title: Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Web-based care management in patients with poorly controlled diabetes. Improving diabetes processes of care in managed care. Results of the Medicare Health Support disease-management pilot program. A Randomized Trial of a Church-Based Diabetes Self-management Program for African Americans With Type 2 Diabetes Outcomes of an Intervention to Reduce Uncertainty Among African American Women with Diabetes Impact of active versus usual algorithmic titration of basal insulin and point-of-care versus laboratory measurement of HbA1c on glycemic control in patients with type 2 diabetes: the Glycemic Optimization with Algorithms and Labs at Point of Care (GOAL A1C) trial. A randomized trial comparing intensive and passive education in patients with diabetes mellitus. Translating a Community-Based Motivational Support Program to Increase Physical Activity Among Older Adults With Diabetes at Community Clinics: A Pilot Study of Physical Activity for a Lifetime of Success (PALS) Simulated Physician Learning Intervention to Improve Safety and Quality of Diabetes Care: A Randomized Trial Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving Control with Activity and Nutrition (ICAN) study. Results of a Successful Telephonic Intervention to Improve Diabetes Control in Urban Adults Brief, Computer-Assisted Diabetes Dietary Self-Management Counseling: Effects on Behavior, Physiologic Outcomes, and Quality of Life Case management for patients with poorly controlled diabetes: a randomized trial. An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7. Randomized trial of quality improvement intervention to improve diabetes care in primary care settings. Decreasing the risk of diabetic retinopathy in a study of case management: the California Medi-Cal Type 2 Diabetes Study. Customized Feedback to Patients and Providers Failed to Improve Safety or Quality of Diabetes Care Evaluation of a diabetes specialist–guided primary care diabetes treatment program Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study Spanish Diabetes Self-Management With and Without Automated Telephone Reinforcement Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus Computer-assisted intervention improves patient-centered diabetes care by increasing autonomy support. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Mobile diabetes intervention study: testing a personalized treatment/behavioral communication intervention for blood glucose control. Nurse case management improves blood pressure, emotional distress and diabetes complication screening. Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial Caring for Poorly Controlled Diabetes Mellitus: A Randomized Pharmacist Intervention Randomized trial of a whole-system ayurvedic protocol for type 2 diabetes. Group visits in medically and economically disadvantaged patients with type 2 diabetes and their relationships to clinical outcomes. Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care. A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice. A multifaceted intervention in support of diabetes treatment guidelines: a cont trial. Evaluation of the "Know Your Health" program for type 2 diabetes mellitus and hypertension in a large employer group. Health-related quality of life in the VA Feasibility Study on glycemic control and complications in type 2 diabetes mellitus. Chronic disease management: what will it take to improve care for chronic illness? Telemedicine improved diabetic management. Electronic patient registries improve diabetes care and clinical outcomes in rural community health centers. A randomized, controlled trial of an automated wireless messaging system for diabetes. Outcomes of pharmacist-managed diabetes care services in a community health center. Community Pharmacist–Provided Extended Diabetes Care Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes.
abstract: BACKGROUND African Americans suffer disproportionately from diabetes complications , but little research has focused on how to improve diabetic control in this population . There are also few or no data on a combined primary care and community-based intervention approach . METHODS We r and omly assigned 186 urban African Americans with type 2 diabetes ( 76 % female , mean A SD age 59 A 9 years ) to 1 of 4 parallel arms : ( 1 ) usual care only ; ( 2 ) usual care + nurse case manager ( NCM ) ; ( 3 ) usual care + community health worker ( CHW ) ; ( 4 ) usual care + nurse case manager/community health worker team . Using the framework of the Precede-Proceed behavioral model , interventions included patient counseling regarding self-care practice s and physician reminders . RESULTS The 2-year follow-up visit was completed by 149 individuals ( 84 % ) . Compared to the Usual care group , the NCM group and the CHW group had modest declines in HbA(1c ) over 2 years ( 0.3 and 0.3 % , respectively ) , and the combined NCM/CHW group had a greater decline in HbA(1c ) ( 0.8 % . P = 0.137 ) . After adjustment for baseline differences and /or follow-up time , the combined NCM/CHW group showed improvements in triglycerides ( -35.5 mg/dl ; P = 0.041 ) and diastolic blood pressure , compared to the usual care group ( -5.6 mmHg ; P = 0.042 ) . CONCLUSIONS Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes . Although results were clinical ly important , they did not reach statistical significance . This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans OBJECTIVE To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS For this study , 104 patients with diabetes and HbA(1c ) ( A1C ) > or = 9.0 % who received their care at a Department of Veterans Affairs medical center were recruited . All participants completed a  diabetes education class  and were r and omized to continue with their usual care ( n = 52 ) or receive web-based care management ( n = 52 ) . The web-based group received a notebook computer , glucose and blood pressure monitoring devices , and access to a care management website . The website provided educational modules , accepted uploads from monitoring devices , and had an internal messaging system for patients to communicate with the care manager . RESULTS Participants receiving web-based care management had lower A1C over 12 months ( P < 0.05 ) when compared with education and usual care . Persistent website users had greater improvement in A1C when compared with intermittent users ( -1.9 vs. -1.2 % ; P = 0.051 ) or education and usual care ( -1.4 % ; P < 0.05 ) . A larger number of website data uploads was associated with a larger decline in A1C ( highest tertile -2.1 % , lowest tertile -1.0 % ; P < 0.02 ) . Hypertensive participants in the web-based group had a greater reduction in systolic blood pressure ( P < 0.01 ) . HDL cholesterol rose and triglycerides fell in the web-based group ( P < 0.05 ) . CONCLUSIONS Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes OBJECTIVE To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practice s. RESEARCH DESIGN AND METHODS Nine practice s providing care to managed care patients were r and omly assigned as intervention or comparison sites . Intervention-site subjects had Annual Diabetes Assessment Program ( ADAP ) assessment s ( HbA(1c  ) , blood pressure , lipids , smoking , retinal photos , urine microalbumin , and foot examination ) at years 1 and 2 . Comparison-site subjects had ADAP assessment s at year 2 . At Intervention sites , year 1 ADAP results were review ed with subjects , mailed to providers , and incorporated into electronic medical records with guideline -generated suggestions for treatment and follow-up . Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessment s. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models . RESULTS Of 284 eligible subjects , 103 of 173 ( 60 % ) at the Intervention sites and 71 of 111 ( 64 % ) at the comparison sites participated ; 83 of 103 ( 81 % ) of the intervention-site subjects returned for follow-up at year 2 . Performance of the six recommended assessment s improved in intervention-site subjects at year 2 compared with year 1 ( 5.8 vs. 4.3 , P = 0.0001 ) and compared with comparison-site subjects at year 2 ( 4.2 , P = 0.014 ) . No significant changes were noted in intermediate outcomes . CONCLUSIONS The ADAP significantly improved processes of care but not intermediate outcomes . Additional interventions are needed to improve intermediate outcomes BACKGROUND In the Medicare Modernization Act of 2003 , Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program . METHODS The Medicare Health Support Pilot Program was a large , r and omized study of eight commercial programs for disease management that used nurse-based call centers . We r and omly assigned patients with heart failure , diabetes , or both to the intervention or to usual care ( control )  and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care , acute care utilization , and Medicare expenditures for Medicare fee-for-service beneficiaries . RESULTS The study included 242,417 patients ( 163,107 in the intervention group and 79,310 in the control group ) . The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits , as compared with usual care . We observed only 14 significant improvements in process-of-care measures out of 40 comparisons . These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ( $ 400 million ) , with no demonstrable savings in Medicare expenditures . CONCLUSIONS In this large study , commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality -of-care measures , with no demonstrable reduction in the utilization of acute care or the costs of care Purpose This study developed and tested a culturally appropriate , church-based intervention to improve diabetes self-management . Research Design and Methods This was a r and omized trial conducted at 24 African American churches in central North Carolina . Churches were r and omized to receive the special intervention ( SI ; 13 churches , 117 participants ) or the minimal intervention ( MI ; 11 churches , 84 participants ) . The SI included an 8-month intensive phase , consisting of 1 individual counseling visit , 12 group sessions , monthly phone contacts , and 3 encouragement postcards , followed by a 4-month reinforcement phase including monthly phone contacts . The MI received st and ard educational pamphlets by mail . Outcomes were assessed at 8 and 12 months ; the primary outcome was comparison of 8-month A1C levels . Results At baseline , the mean age was 59 years , A1C 7.8 % , and body mass index 35.0 kg/m2 ; 64 % of participants were female . For the 174 ( 87 % ) participants returning for 8-month measures , mean A1C ( adjusted for baseline and group r and omization ) was 7.4 % for SI and 7.8 % for MI , with a difference of 0.4 % ( 95 % confidence interval [ CI ] , 0.1 - 0.6 , P = .009 ) . In a larger model adjusting for additional variables , the difference was 0.5 % ( 95 % CI , 0.2 - 0.7 , P < .001 ) . At 12 months , the difference between groups was not significant . Diabetes knowledge and diabetes-related quality of life significantly improved in the SI group compared with the MI group . Among SI participants completing an acceptability question naire , intervention components and material s were rated as highly acceptable . Conclusions The church-based intervention was well received by participants and improved short-term metabolic control Poor adjustment to diabetes in older African American women may result from uncertainty , stemming from a lack of information about self-care activities , a complexity of self-care activities , comorbid conditions , and a lack of re sources . This study evaluated a telephone intervention to reduce uncertainty ( through problem-solving strategies , information , cognitive reframing , and improved patient — provider communication)—namely , to measure its effects on diabetes self-care and psychosocial adjustment .  Sixty-eight older African American women were r and omly assigned to an experimental group and a control group . The experimental group received the intervention for 4 weeks , and the control group received usual care .  Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline . The experimental group reported increased participation in exercise ( self-care component ; p < .001 ) and improvement in psychosocial adjustment ( p < .001 ) . Thus , reducing the uncertainty related to diabetes self-care improves self-care exercise , as well as psychosocial adjustment OBJECTIVE The objective of this study was to assess the impact of active versus usual monitoring of algorithmic insulin titration and point-of-care ( POC ) versus laboratory HbA1c ( A1C ) measurement on glycemic control in primary care . RESEARCH DESIGN AND METHODS The Glycemic Optimization with Algorithms and Labs at Point of Care ( GOAL A1C ) study was a 24-week , r and omized , parallel-group , four-arm , open-label study of 7,893 adults with type 2 diabetes uncontrolled by oral antidiabetic agents and requiring insulin . Patients were r and omly assigned by investigators from 2,164 sites in the U.S. to insulin glargine with either 1 ) usual ( no unsolicited contact between visits ) insulin titration using a simple algorithm with laboratory A1C testing , 2 ) usual titration with POC A1C testing , 3 ) active ( weekly monitored ) titration with laboratory A1C testing , or 4 ) active titration with POC A1C testing . Outcome measures included a change in A1C and fasting self-monitoring of blood glucose ( SMBG ) levels , percentage of patients achieving A1C < 7.0 % , and hypoglycemia frequency . RESULTS Significant A1C and SMBG reductions were observed in all arms ( P < 0.0001 ) . Compared with usual insulin titration , active titration achieved greater A1C reduction ( 1.5 vs. 1.3 % ; P < 0.0001 ) , SMBG reduction ( 88 vs. 79 mg/dl ; P < 0.0001 ) , and proportion of patients achieving A1C < 7.0 % ( 38 vs. 30 % ; P < 0.0001 ) . Among patients receiving active titration , POC A1C testing was associated with an increase in the proportion achieving an A1C < 7.0 % ( 41 % for POC vs. 36 % for laboratory ; P < 0.0001 ) . Hypoglycemia rates were low ( usual vs. active groups : 3.7 vs. 6.0 all confirmed episodes/patient-year [ P < 0.001 ] ; 0.09 vs. 0.14 severe episodes/patient-year [ NS ] ) . CONCLUSIONS In a predominantly primary care setting , addition of insulin glargine using a simple algorithm achieved significant improvements in glycemic control in patients with type 2 diabetes in all four study arms . Active titration result ed in significant incremental improvements in glycemic control , and , among patients receiving active titration , POC A1C testing result ed in a greater portion achieving A1C < 7.0 % BACKGROUND Patient education is a cornerstone of treatment in diabetes mellitus , but there is not unanimity of opinion as to how it should be delivered . OBJECTIVE To determine whether a single , intensive group educational program would improve glycosylated hemoglobin ( HbA(1c ) ) levels when compared with passive education . METHODS A total of 106 patients with HbA(1c ) levels greater than 8.5 % were r and omized to either an intensive ( n = 50 ) or a passive education ( n = 56 ) group . The intensive education group received 3.5 days of a structured curriculum involving a physician , nurse , nutritionist , pharmacist , exercise physiologist , and a social worker . The passive education group received material sent by mail every 3 months providing basic information on topics related to diabetes management . Patients continued care with their diabetes care provider during the study period . Levels of HbA(1c ) were measured at baseline and 3 , 6 , and 12 months after r and omization . A matched control group of individuals who declined participation also had HbA(1c ) levels measured at baseline and 12 months . RESULTS Mean + /- SD HbA(1c ) levels fell significantly ( P<.001 ) from baseline ( 9.9 % + /- 1.3 % ) in both the intensive ( -2.0 % ) and passive ( -1.9 % ) education groups at 12 months , and there was no difference between the groups at any evaluation time . Both groups had significantly greater decline ( P<.03 ) in HbA(1c ) levels than a matched control group ( -1.2 % ) with similar baseline HbA(1c ) levels that did not receive education . CONCLUSIONS Patients with elevated HbA(1c ) levels  who were receptive to education had substantial improvement in HbA(1c ) levels after receiving an educational intervention . In this population , intensive or passive methods of delivering patient education seemed to have similar effect on improving glycemic control Background Regular physical activity is an important goal for elders with chronic health conditions . Context This report describes Physical Activity for a Lifetime of Success ( PALS ) , an attempt to translate a motivational support program for physical activity , Active Choices , for use by a group of diverse , low-income , community-dwelling elders with diabetes . Methods PALS linked physical activity assessment and brief counseling by primary care providers with a structured referral to a community-based motivational telephone support program delivered by older adult volunteers . People with diabetes aged 65 years or older who were receiving care at two community clinics were r and omized to receive either immediate or delayed intervention . The main intended outcome measure was physical activity level ; the secondary outcome measure was mean hemoglobin A1c . Consequences One-third of those offered referral to the PALS program in the clinic setting declined . Another 44 % subsequently declined enrollment or were unreachable by the support center . Only 14 ( 21 % ) of those offered referral enrolled in the program . Among these 14 , the percentage who were sufficiently active was higher at follow-up than at enrollment , though not significantly so . Using an intent-to-treat analysis , which included all r and omized clinic patients , we found no significant change in mean hemoglobin A1c for the intervention group compared with controls . Interpretation A community-based referral and support program to increase physical activity  among elderly , ethnically diverse , low-income people with diabetes , many of whom are not English-speaking , may be thwarted by unforeseen barriers . Those who enroll and participate in the PALS program appear to increase their level of physical activity OBJECTIVE To assess two physician learning interventions design ed to improve safety and quality of diabetes care delivered by primary care physicians ( PCPs ) . RESEARCH DESIGN AND METHODS This group r and omized clinical trial included 57 consenting PCPs and their 2,020 eligible adult patients with diabetes . Physicians were r and omized to no intervention ( group A ) , a simulated case-based physician learning intervention ( group B ) , or the same simulated case-based learning intervention with physician opinion leader feedback ( group C ) . Dependent variables included A1C values , LDL cholesterol values , pharmacotherapy intensification rates in patients not at clinical goals , and risky prescribing events . RESULTS Groups B and C had substantial reductions in risky prescribing of metformin in patients with renal impairment ( P = 0.03 ) . Compared with groups A and C , physicians in group B achieved slightly better glycemic control ( P = 0.04 ) , but physician intensification of oral glucose-lowering medications was not affected by interventions ( P = 0.41 ) . Lipid management improved over time ( P < 0.001 ) but did not differ across study groups ( P = 0.67 ) . CONCLUSIONS A simulated , case-based learning intervention for physicians significantly reduced risky prescribing events and marginally improved glycemic control in actual patients . The addition of opinion leader feedback did not improve the learning intervention . Refinement and further development of this approach is warranted OBJECTIVE To assess the efficacy of a lifestyle intervention program that can be readily translated into clinical practice for obese patients with type 2 diabetes . RESEARCH DESIGN AND METHODS The study consisted of a 12-month r and omized controlled trial of 147 health plan members with type 2 diabetes and obesity ( BMI > or=27 kg/m(2 ) ) . Participants were r and omized to lifestyle case management or usual care . Case management entailed individual and group education , support , and referral by registered dietitians ; intervention cost was US dollars 350 per person . Individuals treated with usual care received educational material . Both groups received ongoing primary care . Outcomes were difference between groups for change in weight ( kilograms ) , waist circumference ( centimeters ) , HbA(1c ) , fasting lipid levels , use of prescription medications , and health-related quality of life . RESULTS Case management result ed in greater weight loss ( P < 0.001 ) , reduced waist circumference ( P < 0.001 ) , reduced HbA(1c ) level ( P = 0.02 ) , less use of prescription medications ( P = 0.03 ) , and improved health-related quality of life ( P < 0.001 ) compared with usual care . The 12-month group difference in weight loss and waist circumference was 3.0 kg ( 95 % CI -5.4 to -0.6 ) and -4.2 cm ( -6.8 to -1.6 ) . HbA(1c ) differences were greatest at 4 months ( -0.59 % , P = 0.006 ) but not significant by 12 months ( -0.19 % , P = 0.45 ) . Participants in the case management group lowered their use of medications , primarily diabetes medications , by 0.8 medications per day more than participants treated with usual care ( P = 0.03 ) . In seven of nine quality -of-life domains , the case management group improved compared with usual care ( P < 0.05 ) . CONCLUSIONS Moderate-cost dietitian-led lifestyle case management may improve diverse health indicators among obese patients with type 2 diabetes OBJECTIVE To compare the effectiveness of a telephonic and a print intervention over 1 year to improve  diabetes control in low-income urban adults . RESEARCH DESIGN AND METHODS A r and omized trial in Spanish and English comparing a telephonic intervention implemented by health educators with a print intervention .  Participants ( N = 526 ) had an A1C ≥7.5 % and were prescribed one or more oral agents . All were members of a union/employer jointly sponsored health benefit plan . Health coverage included medications . Primary outcomes were A1C and pharmacy cl aims data ; secondary outcomes included self-report of two medication adherence measures and other self-care behaviors . RESULTS Participants were 62 % black and 23 % Hispanic ; 77 % were foreign born , and 42 % had annual family incomes < $ 30 thous and . Baseline median A1C was 8.6 % ( interquartile range 8.0–10.0 ) . Insulin was also prescribed for 24 % of participants . The telephone group had mean ± SE decline in A1C of 0.23 ± 0.11 % over 1 year compared with a rise of 0.13 ± 0.13 % for the print group ( P = 0.04 ) . After adjusting for baseline A1C , sex , age , and insulin use , the difference in A1C was 0.40 % ( 95 % CI 0.10–0.70 , P = 0.009 ) . Change in medication adherence measured by cl aims data , but not by self-report measures , was significantly associated with change in A1C ( P = 0.01 ) . Improvement in medication adherence was associated ( P = 0.005 ) with the telephonic intervention , but only among those not taking insulin . No diabetes self-care activities were significantly correlated with the change in A1C . CONCLUSIONS A 1-year tailored telephonic intervention implemented by health educators was successful in significantly , albeit modestly , improving diabetes control compared with a print intervention in a low-income , insured , minority population Objectives .The objective of this work was to evaluate the reach , effectiveness , adoption , and implementation of a brief behavioral dietary intervention and 2 supplemental components of diabetes self-management support : telephone follow-up calls and community re sources enhancement . Design and Subjects . This was a 2 × 2 r and omized , controlled trial investigating the incremental effects of telephone follow-up and community re sources enhancement with 320 adult type 2 diabetes out patients . Methods .Key outcomes included behavioral ( dietary patterns , fat intake ) , physiologic ( HbA1C , lipids ) , and quality -of-life/patient satisfaction measures and were collected at baseline and 3- and 6-month follow-up . Results .Despite high reach ( 76 % patient participation ) , excellent adoption ( all 12 primary care practice s approached participated ) , and good implementation , there were few outcome differences among treatment conditions . There was significant improvement across conditions in most outcomes in each category at both follow-ups . Conclusions .A brief , computer-assisted , dietary goal – setting intervention basic treatment condition was moderately successful in producing dietary improvements but less so in producing biologic or quality -of-life outcomes . Additions of follow-up phone calls or a community re sources enhancement component did not produce incremental improvements over this basic intervention PURPOSE To evaluate the effects of a collaborative case management intervention for patients with poorly controlled type 2 diabetes on glycemic control , intermediate cardiovascular outcomes , satisfaction with care , and re source utilization . METHODS We conducted a r and omized controlled trial at two Department of Veterans Affairs Medical Centers involving 246 veterans with diabetes and baseline hemoglobin A(1C ) ( HbA(1C ) ) levels > or=7.5 % . Two nurse practitioner case managers worked with patients and their primary care providers , monitoring and coordinating care for the intervention group for 18 months through the use of telephone contacts , collaborative goal setting , and treatment algorithms . Control patients received educational material s and usual care from their primary care providers . RESULTS At the conclusion of the study , both case management and control patients remained under poor glycemic control and there was little difference between groups in mean exit HbA(1C ) level ( 9.3 % vs. 9.2 % ; difference = 0.1 % ; 95 % confidence interval : -0.4 % to 0.7 % ; P = 0.65 ) . There was also no evidence that the intervention result ed in improvements in low-density lipoprotein cholesterol level or blood pressure control or greater intensification in medication therapy . However , intervention patients were substantially more satisfied with their diabetes care , with 82 % rating their providers as better than average compared with 64 % of patients in the control group ( P = 0.04 ) . CONCLUSION An intervention of collaborative case management did not improve key physiologic outcomes for high-risk patients with type 2 diabetes . The type of patients targeted for intervention , organizational factors , and program structure are likely critical determinants of the effectiveness of case management . Health systems must underst and the potential limitations before expending substantial re sources on case management , as the expected improvements in outcomes and downstream cost savings may not always be realized OBJECTIVE Management of diabetes is frequently suboptimal in primary care setting s , where providers often fail to intensify therapy when glucose levels are high , a problem known as clinical inertia . We asked whether interventions targeting clinical inertia can improve outcomes . RESEARCH DESIGN AND METHODS A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center . We studied all patients ( 4,138 ) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were r and omized to be control subjects or to receive one of three interventions . Instead of consultative advice , the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient 's visit , individual face-to-face feedback on performance for 5 min every 2 weeks , or both . RESULTS Over an average patient follow-up of 15 months within the intervention site , improvements in and final HbA1c ( A1C ) with feedback + reminders ( deltaA1C 0.6 % , final A1C 7.46 % ) were significantly better than control ( deltaA1C 0.2 % , final A1C 7.84 % , P < 0.02 ) ; changes were smaller with feedback only and reminders only ( P = NS vs. control ) . Trends were similar but not significant with systolic blood pressure ( sBP ) and LDL cholesterol . Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP . Over a 2-year period , overall glycemic control improved in the intervention site but did not change in other primary care sites ( final A1C 7.5 vs. 8.2 % , P < 0.001 ) . CONCLUSIONS Feedback on performance aim ed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control . Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care setting OBJECTIVE To assess the impact of a quality improvement ( QI ) intervention on the quality of diabetes care at primary care clinics . RESEARCH DESIGN AND METHODS Twelve primary care medical practice s were matched by size and location and r and omized to intervention or control conditions . Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care . Surveys and medical record review s of 754 patients , surveys of 329 clinic staff , interviews with clinic leaders , and analysis of training session videotapes evaluated compliance with and impact of the intervention . Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention . RESULTS All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and , compared with control clinics , had broader staff participation in QI activities ( P = 0.04 ) , used patient registries more often ( P = 0.03 ) , and had better test rates for HbA(1c ) ( A1C ) , LDL , and blood pressure ( P = 0.02 ) . Other processes of diabetes care were unchanged . The intervention did not improve A1C ( P = 0.54 ) , LDL ( P = 0.46 ) , or blood pressure ( P = 0.69 ) levels or a composite of these outcomes ( P = 0.35 ) . CONCLUSIONS This QI change process was successfully implemented but failed to improve A1C , LDL , or blood pressure levels . Data suggest that to be successful , such a QI change process should direct more attention to specific clinical actions , such as drug intensification and patient activation OBJECTIVE Diabetic retinopathy affects > 60 % of people with type 2 diabetes during the first 2 decades of the disease and is ameliorated by good glycemic control . This study tested whether intensive diabetes case management could prevent or delay diabetic retinopathy in patients with established type 2 diabetes . RESEARCH DESIGN AND METHODS This study was part of a r and omized , controlled clinical trial of diabetes case management  in type 2 diabetes in southern California counties serving low income ethnic minority population s. Subjects were r and omized to intervention ( diabetes case management ) or control ( traditional treatment ) groups . Subjects with at least two retinal photographs ( n = 149 ) were included in this analysis to assess the effect of intervention on development or progression of diabetic retinopathy . RESULTS Progression of retinopathy in the intervention group was not significantly less than in the control group ( P = 0.226 ) . However , those in the intervention group with no evidence of retinopathy at baseline were less likely to develop diabetic retinal changes ( 5/48 ) during a mean follow-up of 23.1 months than those in the control group ( 10/34 , chi(2 ) = 4.805 , P = 0.028 ) . This difference remained significant in a logistic regression model that controlled for potential confounders ( odds ratio 5.35 [ 95 % CI 1.14 - 25.12 ] ) . CONCLUSIONS This study shows that a relatively short duration of case management instituted before the onset of clinical ly identifiable retinopathy significantly diminished the risk of developing retinopathy in patients with type 2 diabetes . The findings also emphasized the retinal disease burden in this population , with development and progression of retinopathy occurring in < 2 years OBJECTIVE To assess whether providing customized clinical information to patients and physicians  improves safety or quality of diabetes care . RESEARCH DESIGN AND METHODS Study subjects included 123 primary care physicians and 3,703 eligible adult diabetic patients with elevated A1C or LDL cholesterol , who were r and omly assigned to receive customized feedback of clinical information as follows : 1 ) patient only , 2 ) physician only , 3 ) both the patient and physician , or 4 ) neither patient nor physician . In the intervention groups , patients received customized mailed information or physicians received printed , prioritized lists of patients with recommended clinical actions and performance feedback . Hierarchical models were used to accommo date group r and om assignment . RESULTS Study interventions did not improve A1C test ordering ( P = 0.35 ) and negatively affected LDL cholesterol test ordering ( P < 0.001 ) in the 12 months postintervention . Interventions had no effect on LDL cholesterol values ( P = 0.64 ) , which improved in all groups over time . Interventions had a borderline unfavorable effect on A1C values among those with baseline A1C ≥7 % ( P = 0.10 ) and an unfavorable effect on A1C values among those with baseline A1C ≥8 % ( P < 0.01 ) . Interventions did not reduce risky prescribing events or increase treatment intensification . Time to next visit was longer in all intervention groups compared with that for the control group ( P < 0.05 ) . CONCLUSIONS Providing customized decision support to physicians and /or patients did not improve quality or safety of diabetes care and worsened A1C control in patients with baseline A1C ≥8 % . Future research ers should consider providing point-of-care decision support with re design of office systems and /or incentives to increase appropriate actions in response to decision-support information Purpose An initial pilot program demonstrated promising results in improvements in glycosylated hemoglobin ( HbA1c ) , low-density lipoprotein cholesterol ( LDL-C ) , and systolic blood pressure ( SBP ) and prompted us to test these findings in a controlled trial . The purpose of the Diabetes-focused , Algorithm-directed care , Midlevel practitioner – administered , Electronically coached , Treatment ( DAMET-2 ) program clinical trial was to investigate the benefits of a novel program for disseminating guidance in the treatment of diabetes from a central specialist clinic to primary care centers with access to midlevel provider services . Data sources DAMET-2 included st and ardized treatment algorithms and education disseminated through computer-assisted and traditional methods associated with distance medicine . Two primary care practice s were selected and subjects with diagnosed type 2 diabetes ≥6 months , ≥18 years of age with one or more cardiovascular risk factors ( identified by chart review ) were eligible for inclusion . Midlevel practitioners for subjects in the experimental group ( N= 34 ) received training in American Diabetes Association treatment algorithms , had telephone consultations at 2- to 4-week intervals and bimonthly visits with diabetes specialists , and received treatment guidance within 24 h from remote diabetes specialists . Weekly diabetes clinics were made available to subjects in the experimental group . After 12 months , the last available subject data were extracted from the subjects ' charts and compared to 12-month chart data from a control group ( N= 101 ) that did not receive additional study services . Conclusions Mean HbA1c values decreased from baseline by 0.46 % in the active treatment group versus 0.06 % in the control group ; however , reductions in HbA1c did not achieve statistical significance potentially because of the small sample size of the experimental group . Mean SBP values were significantly reduced in both groups ; however , LDL-C was only significantly reduced in the control group , where more aggressive use of statins may have had an effect . Implication s for practice Despite the inconsistencies in risk factor reduction from the pilot program , the DAMET-2 program provided insights regarding the importance of electronic records and provider notifications , patient adherence , prioritization of provider re sources by risk factor level among patients , and access to self-management education CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 OBJECTIVE —To determine 1 ) whether participants in the Spanish Diabetes Self-Management Program ( SDSMP ) , when compared at 6 months to r and omized control subjects , would demonstrate improvements in health status , health behaviors , and self-efficacy ; and 2 ) whether SDSMP participants receiving monthly automated telephone reinforcement would maintain improvements at 18 months better than those not receiving reinforcement . RESEARCH DESIGN AND METHODS —A total of 567 Spanish-speaking adults with type 2 diabetes were r and omized to a usual-care control group or 6-week community-based , peer-led SDSMP . SDSMP participants were re-r and omized to receive 15 months of automated telephone messages or no reinforcement . A1C was measured at baseline and 6 and 18 months . All other data were collected by self-administered question naires . RESULTS —At 6 months SDSMP participants compared with control subjects demonstrated improvements in A1C ( −0.4 % ) , health distress , symptoms of hypo- and hyperglycemia , and self-efficacy ( P < 0.05 ) . At 18 months all improvements persisted ( P < 0.05 ) . SDSMP participants also demonstrated improvements in self-rated health and communication with physicians , had fewer emergency room visits ( −0.18 visits in 6 months , P < 0.05 ) , and trended toward fewer visits to physicians . At 18 months the only difference between reinforced and nonreinforced participants was increased glucose monitoring for the reinforcement group . CONCLUSIONS —The SDSMP  demonstrated effectiveness in lowering A1C and improving health status . Reinforcement did not add to its effectiveness . Given the high needs of the Spanish-speaking population , the SDSMP deserves consideration for implementation Introduction Detection and response to medically urgent situations in patients with diabetes mellitus can improve the process and outcomes of care and potentially decrease morbidity and mortality . We examined the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes . Methods In the setting of a r and omized trial , 338 patients in the intervention group and living in upstate New York received a home telemedicine unit to transmit blood glucose and blood pressure values to a nurse case manager , videoconference with a nurse or dietitian every 4–6 weeks and access educational websites . The educators met with a supervising endocrinologist 4–5 times weekly and clinical recommendations were proposed to the primary care providers via mail , fax , or phone . Results Over a 36 month period , 67 medically urgent situations were identified and addressed ( 1.9 events/month ) . Some of these situations were potentially life-threatening , including major drug contraindications ( N = 24 ) , other medically urgent situations ( N = 19 ) , and medical urgent conditions ( ie , unstable angina ) ( N = 24 ) . Conclusion The interaction via telemedicine in rural upstate New York between patients with diabetes mellitus , a diabetes care team , and primary care providers can successfully identify and remediate medically urgent situations OBJECTIVE To determine if a patient-centered , computer-assisted diabetes care intervention increased perceived autonomy support , perceived competence ( from self-determination theory ) , and if these constructs mediated the effect of the intervention on ADA/NCQA recommended diabetes care outcomes . DESIGN A r and omized controlled trial of 866 adult type 2 diabetes patients in heterogeneous primary care setting s in Colorado . MAIN OUTCOME MEASURES Perceived autonomy support , perceived competence , patient satisfaction , glycemic control ( HbA1c ) , ratio of total to HDL cholesterol , diabetes distress , and depressive symptoms . RESULTS The computer-assisted intervention increased patient perception of autonomy support relative to a computer-based control condition ( p = .05 ) . Change in perceived competence partially mediated the effects of increased autonomy support on the change in lipids , diabetes distress , and depressive symptoms . The construct of autonomy support was found to be separate from that of patient satisfaction . CONCLUSIONS A patient-centered , computer-assisted intervention was effective in improving diabetes self-management outcomes , in part , because it increased patients ' perception that their autonomy was supported which changed perceived competence . These findings support the self-determination model for health behavior change and the chronic care model and support the further study of the use of these technologies to motivate patients to improve their health outcomes OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model ( CCM ) . PARTICIPANTS AND METHODS As part of the CCM , 97 primary care physicians at 6 primary care practice s in Rochester , MN , referred 639 patients to an on-site diabetes educator between July 1 , 2001 , and December 31 , 2003 . On first referral , physicians were central ly r and omized to receive a telemedicine intervention ( specialty advice and evidence -based messages regarding medication management for cardiovascular risk ) or no intervention , keeping outcome assessors and data analysts blinded to group assignment . After each subsequent clinical encounter , endocrinologists review ed an abstract from the patient 's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail . Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes . Outcome measures included diabetes care processes ( diabetes test completion ) , outcomes ( metabolic and cardiovascular risk factors , estimated coronary artery disease risk ) , and patient costs ( payer perspective ) . RESULTS During the intervention , 951 ( 70 % ) of the 1361 endocrinology review s detected performance gaps and result ed in a message ; primary care physicians reported using 49 % of messages in patient care . With a mean of 21 months ' follow-up , the intervention , compared with control , did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease ( adjusted mean difference , -1 % ; 95 % confidence interval , -19 % to 17 % ) . The intervention group incurred lower costs ( P=.02 ) but not in diabetes-related costs . CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care OBJECTIVE To evaluate the effect of case management by a clinical pharmacist on glycemic control and preventive measures in patients with type 2 diabetes mellitus . STUDY DESIGN R and omized controlled trial in a university-affiliated primary care internal medicine clinic . METHODS We recruited 80 patients with poorly controlled type 2 diabetes mellitus . A clinical pharmacist provided evaluation and modification of pharmacotherapy , self-management diabetes education , and reinforcement of diabetes complications screening processes through clinic visits and telephone follow-up . The main clinical outcome was hemoglobin A1C ( HbA1C ) level ; process measures included HbA1C and low-density lipoprotein measurement , retinal examination , urine microalbumin testing ( or use of angiotensin-converting enzyme inhibitors ) , and monofilament screening for diabetic neuropathy . RESULTS Patients in the intervention and control groups were similar in age , sex , mean HbA1C levels ( 10.1 % and 10.2 % , respectively ; P = .65 ) , and current treatment regimens at baseline . Patients who received case management by the clinical pharmacist achieved greater reduction in HbA1C levels than those in the control group ( 2.1 % vs 0.9 % , P = .03 ) . Three of the 5 process measures were conducted more frequently in the intervention group than the control group , including low-density lipoprotein measurement ( 100.0 % vs 85.7 % , P = .02 ) , retinal examination ( 97.3 % vs 74.3 % ) , and monofilament foot screening ( 92.3 % vs 62.9 % ) . CONCLUSIONS Proactive diabetes case management by a pharmacist substantially improved glycemic control and diabetes process-of-care measures . This approach , integrated with and based in the primary care setting , was an effective and efficient approach to improving care , especially for those with poor glycemic control at baseline BACKGROUND National data find glycemic control is within target ( A1c<7.0 % ) for 37 % of patients with diabetes , and only 7 % meet recommended glycemic , lipid , and blood pressure goals . OBJECTIVES To compare active interventions and usual care for  glucose control  in a r and omized clinical trial ( RCT ) among persons with diabetes cared for by primary care physicians ( PCPs ) over the course of 1 year . METHODS Physician practice s ( n=36 ) in 4 geographic areas are r and omly assigned to 1 of 4 study groups . The intervention is a diabetes communication system , using mobile phones and patient/physician portals to allow patient-specific treatment and communication . All physicians receive American Diabetes Association ( ADA ) Guidelines for diabetes care . Patients with poor diabetes control ( A1c > or = 7.5 % ) at baseline ( n=260 ) are enrolled in study groups based on PCP r and omization . All study patients receive blood glucose ( BG ) meters and a year 's supply of testing material s. Patients in three treatment groups select one of two mobile phone models , receive one-year unlimited mobile phone data and service plan , register on the web-based individual patient portal and receive study treatment phone software based on study assignment . Control group patients  receive usual care from their PCP . The primary outcome is mean change in A1c over a 12-month intervention period . CONCLUSION Traditional methods of disease management have not achieved adequate control for BG and other conditions important to persons with diabetes . Tools to improve communication between patients and PCPs may improve patient outcomes and be satisfactory to patients and physicians . This RCT is ongoing We studied the impact of  nurse case management ( NCM ) on  blood pressure ( BP ) , hemoglobin A1C , lipids , and diabetes complication screening . A 1-year r and omized-controlled trial was conducted in two primary care clinics of the Penn State Hershey Medical Center . Diabetes patients were r and omized to control group ( CG ) ( n=182 ) who received usual care by their primary care provider and intervention group ( IG ) ( n=150 ) who received additional NCM care , including self-management education , and implementation of diabetes guidelines .  Primary outcomes included BP , A1C , lipid , process measures , and secondary outcome was diabetes-related emotional distress as assessed by Problem Areas in Diabetes ( PAID ) . BP significantly decreased from 137/77 to 129/72 in IG as compared to an increase from 136/77 to 138/79 in CG after 1 year . PAID scores improved significantly in IG ( from 23 to 10 ) due to reduced emotional stress . A1C ( 7.4 ) and LDL ( 105 ) were unaffected . Complications screening significantly improved in IG compared to CG : opthalmologic exam 26 to 68 % , foot exam 47 to 64 % , and nephropathy screening 34 to 72 % . NCM improved BP , diabetes-related emotional distress , and process measures in primary care . Unchanged A1C and lipids might be due to a threshold effect . Intervention based upon initial risk assessment may prove more cost-effective PURPOSE The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes , particularly those physicians not affiliated with an integrated care system that some managed care organizations provide . METHODS Patients with type 2 diabetes were recruited from the general population of a large metropolitan area . Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians ( basic intervention ) . A r and om one-half of patients were additionally assigned to individual counseling , problem identification , care planning , and management recommendations by a nurse care manager ( individualized intervention ) . The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention . Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C , blood pressure , and cholesterol as outcome measures . RESULTS Of 220 patients recruited , 197 had type 2 diabetes , r and omly assigned only the basic intervention ( 102 patients ) or individualized intervention ( 95 patients ) . Postintervention data were obtained on 164 patients ( 83 % ) . Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group . Patients with a systolic blood pressure > or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts . CONCLUSIONS A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes . For those many physicians not affiliated with an integrated care system featured by some managed care organizations , this collaboration could underlie a team approach ( nurse/patient/physician ) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level BACKGROUND : There is limited information from r and omized controlled studies about the influence of pharmacist interventions on diabetes control . OBJECTIVE : To evaluate the effect of a pharmacist intervention on improving diabetes control ; secondary endpoints were medication appropriateness and self-reported adherence . METHODS : A r and omized , controlled , multi-clinic trial was conducted in the University of Washington Medicine Neighborhood Clinics . Seventy-seven subjects , ⩾18 years old with a hemoglobin ( Hb ) A1c ⩾9 % at baseline and taking at least one oral diabetes medication , were r and omized to receive a pharmacist intervention ( n = 43 ) or usual care ( n = 34 ) for 6 months followed by a 6-month usual-care observation period for both groups . Subjects met with a clinical pharmacist to establish and initiate a diabetes care plan followed by weekly visits or telephone calls to facilitate diabetes management and adherence . HbA1c , medication appropriateness , and self-reported adherence were assessed at baseline , 6 months , and 12 months . RESULTS : The mean HbA1c did not differ between groups over the 12-month period ( p = 0.61 ) . A reduction in HbA1c was noted for both groups over time compared with baseline ( p = 0.001 ) ; however , control subjects relied more heavily on provider visits . Medication appropriateness was not improved for diabetes medications ( p = 0.65 ) . Self-reported adherence was not significantly improved by the intervention . CONCLUSIONS : This pharmacist intervention did not significantly improve diabetes control , but did allow for similar HbA1c control with fewer physician visits . Medication appropriateness and self-reported adherence compared with usual care in individuals with poorly controlled diabetes were not changed CONTEXT Though complementary and alternative medicine ( CAM ) treatments are popular , evidence to support their application to diabetes care is scarce . Previous CAM diabetes research has generally focused on single modalities , but CAM practitioners more commonly prescribe complex , multimodality interventions . OBJECTIVES The aims of this study were to determine the feasibility and clinical impact of a whole-system , Ayurvedic intervention for newly diagnosed people with type 2 diabetes . DESIGN Patients were r and omly assigned to either an experimental or control arm . SETTING Group model health maintenance organization . PARTICIPANTS We recruited 60 adult patients with baseline glycosylated hemoglobin ( HbA1c ) values between 6.0 and 8.0 . INTERVENTION Treatment for the experimental group included exercise , an Ayurvedic diet , meditation instruction , and an Ayurvedic herb supplement ( MA 471 ) . Control patients attended st and ard diabetes education classes with primary care clinician follow-up . MEASUREMENTS Clinical outcomes were assessed at 3 and 6 months and included HbA1c , fasting glucose , lipids , blood pressure , and weight . RESULTS Ninety-two percent of r and omized patients completed the study , and there were no significant adverse study -related events . Using analysis of co-variance ( ANCOVA ) , we found no significant differences for clinical outcomes at 6 months between on- study patient groups , though trends favored the Ayurvedic group . When we included a factor measuring how much baseline HbA1c exceeded the mean ( 6.5 % ) , however , we found statistically significant improvements in the Ayurvedic group for HbA1c ( P = .006 ) , fasting glucose ( P = .001 ) , total cholesterol ( P = .05 ) , low-density lipoprotein ( LDL ) cholesterol ( P = .04 ) , and weight ( P = .035 ) . CONCLUSIONS These results suggest that the Ayurvedic intervention may benefit patients with higher baseline HbA1c values , warranting further research To evaluate group visits in the management of underinsured patients with uncontrolled type 2 diabetes , 120 eligible patients enrolled were r and omly assigned to receive care in groups or continue usual care .  Feasibility , acceptability , and concordance with American Diabetes Association st and ards of care ( Diab Camre . 25[suppl 1]:533 - 549 ) were evaluated . Patients who received care in groups exhibited improvement in American Diabetes Association st and ards of care ( p < .001 ) , improved sense of trust in physician ( p = .02 ) , and tended to report better coordination of care ( p = .07 ) , better community orientation ( p = .09 ) , and more culturally competent care ( p = .09 ) . Group visits offer a promising model for delivering health care to these patients OBJECTIVE There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care setting s. This report presents 12-month follow-up results from a computer-assisted , patient-centered intervention to improve the level of recommended services patients received from a variety of primary care setting s. RESEARCH DESIGN AND METHODS A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program . Physicians were stratified and r and omized to intervention or control conditions and evaluated on two primary outcomes : number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program ( PRP ) . Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale , lipid and HbA1c levels , and the Patient Health Question naire-9 depression scale . RESULTS The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition . There was overall improvement on secondary outcomes of lipids , HbA1c , quality of life , and depression scores ; between-condition differences were not significant . CONCLUSIONS Staff in small , mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care . Alternative explanations for why these process improvements did not lead to improved outcomes , and suggested directions for future research are discussed BACKGROUND Disease registries are powerful tools with the potential to transform the way chronic diseases are managed . To date , however , little work has been done to determine how to optimize the implementation of a chronic disease registry in practice . METHODS Twenty-nine physicians and their nurse teams in a large community internal medicine practice participated in this 6-month prospect i ve r and omized trial in 2000 . Teams were assigned to one of three implementation strategies using information from a diabetes registry .  Process and outcome measures for diabetes management were analyzed . Process measures included the percentage of patients completing glycosylated hemoglobin ( Hgb ) testing within 6 months and low-density lipoprotein ( LDL ) testing within 12 months . Outcome measures included the percentage of patients with a glycosylated Hgb > 9.3 % ( equivalent to a HgbA1c > 8.0 % ) , the percentage of patients with an LDL cholesterol > 130 mg/dl , and the percentage of patients with controlled blood pressure , defined as < 130/85 millimeters of mercury . Mean change in LDL and glycosylated Hgb values was also measured . RESULTS Teams r and omized to an intervention strategy that included direct letters to patients showed significant improvement across a number of measures . The improvement was most apparent among patients without recent testing or with poorly controlled disease . The two interventions that did not include direct patient letters result ed in limited improvement . DISCUSSION Disease registries can be used to improve outcomes in the management of diabetes and other chronic diseases . Better outcomes were seen in patients who received letters based on registry-generated data . This strategy should be included as part of a comprehensive chronic disease management plan . Further refinements in the use of registries should result in further incremental improvement OBJECTIVE in an academic family practice clinic , we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes . Providers received didactic training and computerized compliance feedback to support staged diabetes management , an evidence d-based approach to diabetes care . RESEARCH DESIGN AND METHODS one firm of the clinic practice received the intervention , the other served as the control group  during a 14-month baseline period and a 14-month study period . HbA1(c ) was the principal outcome measure . RESULTS there was a significant 0.71 % difference in change in HbA1(c ) values between the intervention and control firms ( P=0.02 ) . The subgroup with the greatest improvement in HbA1(c ) was those subjects who started the intervention with a HbA1(c ) above 8 % . The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy . There were no changes in healthcare utilization or costs between the two firms . CONCLUSION in an academic family practice clinic , a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs . The improvement was mostly due to mitigation of the natural deterioration in control usually seen . Further efforts are required to involve all patients in co-managing their diabetes OBJECTIVE To evaluate the effect of an educational intervention program on clinical outcomes and on compliance with medical therapy in patients with type 2 diabetes mellitus ( DM ) , hypertension , or both . STUDY DESIGN Six-month r and omized unblinded study . METHODS Three hundred fifty-two patients were screened , and 347 were r and omized to the intervention group  ( education through the Know Your Health [ KYH ] program [ n = 174 ] ) or to the  control group ( usual care [ n = 173 ] ) . Evaluation of the effectiveness of the KYH program was based on the cohort of patients who were not at goal at baseline ( 124 in the intervention group and 115 in the control group ) . The primary research interests were to assess patient acceptance of the KYH material s and to compare the clinical outcomes of the intervention group with those of the control group . RESULTS After 6 months , significantly more patients in the intervention group than in the control group were at goal ( 44.2 % vs 29.2 % , P = .046 ) . Among patients with hypertension , reductions in the mean diastolic blood pressure were significantly greater in the intervention group compared with the control group at month 6 ( -6.7 vs -3.6 mm Hg , P = .04 ) . The groups did not differ significantly on other primary end points ( percentage of patients with DM who were at goal , change from baseline glycosylated hemoglobin level , and change in Morisky score ) . CONCLUSIONS Participation in the KYH educational program during a 6-month period improved clinical outcomes in patients with type 2 DM or hypertension . The KYH material s were well received and were considered informative and easily comprehensible by patients who completed the program OBJECTIVE The Veterans Affairs Cooperative Study in Diabetes Mellitus Type 2 Feasibility Trial ( VA CSDM ) studied st and ard and intensive glycemic treatment groups , achieving and maintaining for 27 months a difference in HbA1c of 2.1 % ( 9.2 % vs. 7.1 % , respectively ) . A sub study planned in advance examined health status as assessed by a health status question naire obtained at baseline and 24 months . DESIGN AND METHODS A r and omized , prospect i ve trial was carried out at five VA Medical Centers from 1990 to 1993 . The sample involved 153 male veterans 40 - 69 years of age and with diabetes duration of 8+/-4 years , who were suboptimally controlled with st and ard glucose lowering treatment .  The participants were r and omized to  intensive and st and ard treatment groups . In addition to a variety of indicators of glycemic control and complications , health-related qualify of life data were assessed using a 20- question version of the Medical Outcome Study instrument . Scores were evaluated at baseline and 24 months for changes between the treatment groups . RESULTS The two groups were similar at baseline with respect to age , duration of diabetes , complications , comorbidities , and reported physical activity . The intensive treatment group had more frequent , m and atory self-glucose monitoring ( vs. occasional measurement in the st and ard ) and received two or more daily insulin injections  ( only one in the st and ard ) . This group had three times the number of clinic visits and 10-fold higher reported incidence of mild/moderate hypoglycemia . There were no significant changes in the health status over time in either the st and ard or intensive treatment groups , nor was there a difference between the two groups . CONCLUSIONS Intensive glucose control in advanced Type 2 diabetes mellitus ( DM ) has no effect on health status over 2 years . The successful lowering of glycemia does not improve health-related quality of life nor do the increased dem and s of an intensive therapy regimen worsen it M eeting the complex needs of patients with chronic illness or impairment is the single greatest challenge facing organized medical practice . Usual care is not doing the job ; dozens of surveys and audits have revealed that sizable proportions of chronically ill patients are not receiving effective therapy , have poor disease con- trol , and are unhappy with their care ( 1 ) . Results of r and omized trials also show that effective disease management programs can achieve substantially better outcomes than usual care , the control intervention . These trials , along with the ideas and efforts for improvement discussed in this issue , show that we can improve care and outcomes . As the articles suggest , these improvements will not come easily . If we are to improve care for most patients with chronic illness , the evidence strongly suggests that we reshape our ambulatory care systems for this purpose . Pri- mary care practice was largely design ed to provide ready access and care to patients with acute , varied problems , with an emphasis on triage and patient flow ; short appointments ; diagnosis and treatment of symptoms and signs ; reliance on laborato- ry investigations and prescriptions ; brief , didactic patient education ; and patient- initiated follow-up . Patients and families struggling with chronic illness have differ- ent needs , and these needs are unlikely to be met by an acute care organization and culture . They require planned , regular interactions with their caregivers , with a focus on function and prevention of exacerbations and complications . This interac- tion includes systematic assessment s , attention to treatment guidelines , and behav- iorally sophisticated support for the patient 's role as self-manager . These interactions must be linked through time by clinical ly relevant information systems and continu- ing follow-up initiated by the medical practice . Comprehensive System Effective control of diabetes is known to delay or prevent the end-organ complications of this disease . Can telemedicine improve a patient 's ability to self-manage diabetes  ? Twenty-eight patients entered a study comparing home telemedicine consultation with st and ard outpatient care . A nurse case manager contacted the telemedicine group once a week under the direction of a primary care physician , who contacted the telemedicine group once a month . Laboratory studies and total body weight were measured at the beginning and at the end of the 3-month study . The hemoglobin A1c ( HbA1c ) and total body weight improved significantly in the intervention ( telemedicine ) group , as shown by a 16 % reduction in mean HbA1c level ( from 9.5 to 8.2 % ) and a 4 % mean weight reduction ( from 214.3 to 206.7 pounds ) . Based on our experience , we present a functionally based telemedicine classification system to improve the application of electronic medicine in future studies CONTEXT Diabetes care is challenging in rural areas . Research has shown that the utilization of electronic patient registries improves care ; however , improvements generally have been described in combination with other ongoing interventions . The level of basic registry utilization sufficient for positive change is unknown . PURPOSE The goal of the current study was to examine differential effects of basic registry utilization on diabetes care processes and clinical outcomes according to level of registry use in a rural setting . METHODS Patients with diabetes ( N = 661 ) from 6 Federally Qualified Health Centers in rural West Virginia were entered into an electronic patient registry . Data from pre- and post-registry were compared among 3 treatment and control groups that had different levels of registry utilization : low , medium , or high ( for example , variations in the use of registry-generated progress notes examined at the point-of-care and in the accuracy of registry-generated summary reports to track patients ' care ) . Data included care processes ( annual exams , screens to promote wellness , education , and self-management goal - setting ) and clinical outcomes ( HbA1c , LDL , HDL , cholesterol , triglycerides , blood pressure ) . FINDINGS The registry assisted in significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes ( HbA1c , LDL , cholesterol ) for patients exposed to at least medium levels of registry utilization , but not for the controls . For example , the percent of patients who had received an annual eye exam at follow-up was 11 % , 34 % , and 38 % for the low , medium , and high utilization groups , respectively ; only the latter groups improved . CONCLUSIONS As an initial step to achieving control of diabetes , basic registry utilization may be sufficient to drive improvements in provider-patient care processes and in patient outcomes in rural clinics with few re sources BACKGROUND Aggressive management of blood glucose reduces future diabetes-related complications , but this is difficult to achieve . METHODS This r and omized , controlled study tested the effect of using a wireless two-way pager-based automated messaging system to improve diabetes control through facilitated self-management . The system sent health-related messages to patients , with automatic forwarding of urgent patient responses to the health care team . RESULTS Participants in both the experimental ( pager ) and the control groups experienced an average hemoglobin A1c decrease of 0.1 - 0.3 % . More patients in the pager group were  normotensive  , and more felt that their health care was better by the end of the study . A total of 79 % of participants enjoyed using the pager , and 68 % wanted to continue using the system . CONCLUSIONS Utilizing a wireless , automated messaging system in clinical practice is a feasible , low-cost , interactive way to facilitate diabetes self-management , which is acceptable to patients . While providing a convenient way for patients and providers to communicate , this system can support automated recording and ready retrieval of these real-time interactions PURPOSE The outcomes of pharmacist-managed diabetes care services in a community health center were studied . METHODS Eligible patients were over age 18 years and had a diagnosis of type 2 diabetes mellitus . Patients were r and omly assigned by the clinical pharmacist and nurse to the intervention group ( n = 76 ) or control group ( n = 73 ) . Patients in the intervention group were enrolled in a pharmacist-managed diabetes care program . Patients in the control group received the st and ard diabetes care . The primary endpoint was reduction in glycosylated hemoglobin ( HbA(1c ) ) ; secondary outcome measures included weight loss , an improved body mass index , decreased blood pressure , and an improved lipid panel . Quality -of-life measures ( health level , satisfaction , impact , worry about disease , and worry about social and vocational issues ) were also assessed . RESULTS Demographic differences between groups were not remarkable . Mean HbA(1c ) levels fell significantly ( p < 0.05 ) from baseline to nine months in both groups . A difference of 1.0 was reported between the groups ' HbA(1c ) levels ( 95 % confidence interval , 0.08 - 1.78 ; p < 0.05 ) . Satisfaction level improved from 63.7 to 77.4 in the intervention group , which was significant when compared with the control group , whose satisfaction score improved from 57.0 to 63.4 ( p < 0.05 ) . CONCLUSION Patients with type 2 diabetes mellitus who received pharmacist-managed diabetes care  demonstrated improved HbA(1c ) , systolic blood pressure , and low-density-lipoprotein cholesterol levels and quality -of-life measures and met treatment goals more often than patients receiving st and ard care Background Pharmacists in various setting s have been effective in initiating diabetes treatment . Patients with diabetes require ongoing disease management , and community pharmacists are in a strategic position to provide such extended care . Little is known , however , about the effects of community pharmacist – provided interventions beyond the initial treatment period . Objective To evaluate the effect of community pharmacist – provided extended diabetes care service on primary clinical outcomes , including hemoglobin A1c ( A1C ) , low-density lipoprotein cholesterol ( LDL-C ) , and blood pressure , and on patients ' reported self-care activities . Methods A r and omized controlled trial was conducted in patients with diabetes . Participants had already completed at least 2 diabetes education sessions at a local diabetes education center .  Nine specially trained pharmacists administered interventions during up to 4 quarterly visits per patient . Interventions included discussing medications , clinical goals , and self-care activities with patients and recommending medication changes to physicians when appropriate . The main outcome measures were 12-month changes in A1C , LDL-C , blood pressure , and self-report of self-care activities . Results Seventy-eight patients participated in the study ( 36 intervention , 42 control ) ; 66 were included in the final analysis ( 31 intervention , 35 control ) . Compared with changes in the control group , patients who received interventions significantly increased the number of days per week that they engaged in a set of diet and diabetes self-care activities ( 1.25 and 0.73 more days/wk , respectively ) . The mean 12-month changes for A1C , LDL-C , and blood pressure were not significantly different between the 2 study groups . Conclusions Although pharmacist-provided interventions did not demonstrate statistically significant improvements in clinical outcomes over the study period , study results did show that pharmacists were effective at increasing the number of days that patients spent engaging in healthy diet and diabetes self-care activities . Addressing lifestyle and self-care behaviors can be a beneficial component of a pharmacist-provided extended diabetes care service OBJECTIVE Disparities exist in the diabetes health status of ethnic minority and /or low-income population s relative to other groups . A primary objective of diabetes management is to improve glycemic control . The feasibility of implementing intensive diabetes case management in disparate population s remains largely untested . RESEARCH DESIGN AND METHODS Clinical sites in three southern California counties serving low-income , ethnic minority population s participated in our study . We r and omized 362 Medicaid ( called Medi-Cal in California ) recipients with type 2 diabetes for at least 1 year to intervention ( diabetes case management ) or control ( traditional primary care treatment ) groups . Fifty-five percent of participants were minorities . Participants with HbA(1c ) levels less than 7.5 % , serious diabetes-related complications , or other serious medical conditions were excluded . We assessed the effect of the intervention ( ongoing diabetes case management added to primary care ) on glycemic control using serial HbA(1c ) measurements over several years . RESULTS The mean duration of follow-up was 25.3 months . HbA(1c ) decreased substantially in both groups from an average of 9.54 - 7.66 % ( a reduction of 1.88 % ) in the intervention group and from an average of 9.66 - 8.53 % ( a reduction of 1.13 % ) in the control group . This improvement was sustained throughout the study . The reduction in HbA(1c ) was consistently greater in the intervention group at each time point ( P < 0.001 ) , ranging between 0.65 at 6 months and 0.87 at study end . CONCLUSIONS Diabetes case management , added to primary care , substantially improved glycemic control compared with the control group . Diabetes case management can help reduce disparities in diabetes health status among low-income ethnic population PURPOSE To assess the efficacy of a pharmacist-led , primary care-based , disease management program to improve cardiovascular risk factors and glycated hemoglobin ( A(1C ) ) levels in vulnerable patients with poorly controlled diabetes . METHODS A r and omized controlled trial of 217 patients with type 2 diabetes and poor glycemic control ( A(1C ) level > or=8.0 % ) was conducted at an academic general medicine practice from February 2001 to April 2003 . Intervention patients received intensive management from clinical pharmacists , as well as from a diabetes care coordinator who provided diabetes education , applied algorithms for managing glucose control and decreasing cardiovascular risk factors , and addressed barriers to care . Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider . Outcomes were recorded at baseline and at 6 and 12 months . Primary outcomes included blood pressure , A(1C ) level , cholesterol level , and aspirin use . Secondary outcomes included diabetes knowledge , satisfaction , use of clinical services , and adverse events . RESULTS For the 194 patients ( 89 % ) with 12-month data , the intervention group had significantly greater improvement than did the control group for systolic blood pressure ( -9 mm Hg ; 95 % confidence interval [ CI ] : -16 to -3 mm Hg ) and A(1C ) level ( -0.8 % ; 95 % CI : -1.7 % to 0 % ) . Change in total cholesterol level was not significant . At 12 months , aspirin use was 91 % in the intervention group versus 58 % among controls ( P < 0.0001 ) . Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients . There were no significant differences in use of clinical services or adverse events . CONCLUSION Our comprehensive disease management program reduced cardiovascular risk factors and A(1C ) levels among vulnerable patients with type 2 diabetes and poor glycemic control
target: Less frequently reported were quality of life , patient satisfaction , self-care , and healthcare utilization .
  Most care management modalities were carved out from primary care .
  Conclusions Most care management programs for patients with type 2 diabetes are ' carved-out ' , accomplish limited effects on metabolic outcomes , and have unknown effects on patient important outcomes .
background: Background This systematic review and meta- analysis aims at assessing the composition and performance of care management models evaluated in the last decade and their impact on patient important outcomes .