title: Improving Diabetes Care in Practice Implementation and evaluation of a low-literacy diabetes education computer multimedia application. Medicare payments, healthcare service use, and telemedicine implementation costs in a randomized trial comparing telemedicine case management with usual care in medically underserved participants with diabetes mellitus (IDEATel) Implementation and Evaluation of a Low Health Literacy and Culturally Sensitive Diabetes Education Program The science of improvement. Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience" A patient-centric, provider-assisted diabetes telehealth self-management intervention for urban minorities. Training Community Health Workers as Diabetes Educators for Urban African Americans: Value Added Using Participatory Methods Nurse case management improves blood pressure, emotional distress and diabetes complication screening. Chronic disease management: what will it take to improve care for chronic illness? A web-based diabetes intervention for physician: a cluster-randomized effectiveness trial.
abstract: OBJECTIVE —The purpose of this study was to determine whether implementation of a multicomponent organizational intervention can produce significant change in diabetes care and outcomes in community primary care practice s. RESEARCH DESIGN AND METHODS —This was a group-r and omized , controlled clinical trial evaluating the practical effectiveness of a multicomponent intervention ( TRANSLATE )  in 24 practice s. The intervention included implementation of an electronic diabetes registry , visit reminders , and patient-specific physician alerts . A site coordinator facilitated previsit planning and a monthly review of performance with a local physician champion . The principle outcomes were the percentage of patients achieving target values for the composite of systolic blood pressure ( SBP ) < 130 mmHg , LDL cholesterol < 100 mg/dl , and A1C < 7.0 % at baseline and 12 months . Six process measures were also followed . RESULTS —Over 24 months , 69,965 visits from 8,405 adult patients with type 2 diabetes were recorded from 238 health care providers in 24 practice s from 17 health systems .  Diabetes process measures increased significantly more in intervention than in control practice s , giving net increases as follows : foot examinations 35.0 % ( P < 0.0.001 ) ; annual eye examinations 25.9 % ( P < 0.001 ) ; renal testing 28.5 % ( P < 0.001 ) ; A1C testing 8.1%(P < 0.001 ) ; blood pressure monitoring 3.5 % ( P = 0.05 ) ; and LDL testing 8.6 % ( P < 0.001 ) . Mean A1C adjusted for age , sex , and comorbidity decreased significantly in intervention practice s ( P < 0.02 ) . At 12 months , intervention practice s had significantly greater improvement in achieving recommended clinical values for SBP , A1C , and LDL than control clinics ( P = 0.002 ) . CONCLUSIONS — Introduction of a multicomponent organizational intervention in the primary care setting significantly increases the percentage of type 2 diabetic patients achieving recommended clinical outcomes OBJECTIVE To evaluate a clinic-based multimedia intervention for diabetes education targeting individuals with low health literacy levels in a diverse population . RESEARCH DESIGN AND METHODS Five public clinics in Chicago , Illinois , participated in the study with computer kiosks installed in waiting room areas . Two hundred forty-four subjects with diabetes were r and omized to receive either supplemental computer multimedia use ( intervention ) or st and ard of care only ( control ) . The intervention includes audio/video sequences to communicate information , provide psychological support , and promote diabetes self-management skills without extensive text or complex navigation .  HbA(1c ) ( A1C ) , BMI , blood pressure , diabetes knowledge , self-efficacy , self-reported medical care , and perceived susceptibility of complications were evaluated at baseline and 1 year . Computer usage patterns and implementation barriers were also examined . RESULTS Complete 1-year data were available for 183 subjects ( 75 % ) . Overall , there were no significant differences in change in A1C , weight , blood pressure , knowledge , self-efficacy , or self-reported medical care between intervention and control groups . However , there was an increase in perceived susceptibility to diabetes complications in the intervention group . This effect was greatest among subjects with lower health literacy . Within the intervention group , time spent on the computer was greater for subjects with higher health literacy . CONCLUSIONS Access to multimedia lessons result ed in an increase in perceived susceptibility to diabetes complications , particularly in subjects with lower health literacy . Despite measures to improve informational access for individuals with lower health literacy , there was relatively less use of the computer among these participants Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures , as measured by Medicare cl aims , and to assess the costs of developing and implementing the telemedicine intervention . Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) , a r and omized controlled trial comparing telemedicine case management of diabetes to usual care . Participants were aged 55 years or older , and resided in federally design ated medically underserved areas of New York State . Measurements We analyzed Medicare cl aims payments for each participant for up to 60 study months from date of r and omization , until their death , or until December 31 , 2006 ( whichever happened first ) . We also analyzed study expenditures for the telemedicine intervention over six budget years ( February 28 , 2000- February 27 , 2006 ) . Results Mean annual Medicare payments ( SE ) were similar in the usual care and telemedicine groups , $ 9040 ( $ 386 ) and $ 9669 ( $ 443 ) per participant , respectively ( p>0.05 ) . Sensitivity analyses , including stratification by censored status , adjustment by enrollment site , and semi-parametric weighting by probability of dropping-out , rendered similar results . Over six budget years 28 821 participant/months of telemedicine intervention were delivered , at an estimated cost of $ 622 per participant/month . Conclusion Telemedicine case management was not associated with a reduction in Medicare cl aims in this medically underserved population . The cost of implementing the telemedicine intervention was high , largely representing special purpose hardware and software costs required at the time . Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used & NA ; Low health literacy is more prevalent in persons with limited education , members of ethnic minorities , and those who speak English as a second language , and is associated with multiple adverse diabetes‐related health outcomes . This study examined the effectiveness of a low health literacy and culturally sensitive diabetes education program for economically and socially disadvantaged adult patients with type 2 diabetes . A pre – post prospect i ve study design was used to examine outcomes over 12 months . Outcome measures included diabetes knowledge , self‐efficacy , and self‐care , measured using reliable and valid survey tools , and A1C . Over this period of time 277 patients were enrolled in the program , with 106 participants completing survey data . At the completion of the program patients had significant improvements in diabetes knowledge ( p < .001 ) , self‐efficacy ( p < .001 ) , and three domains of self‐care including diet ( p < .001 ) , foot care ( p < .001 ) , and exercise ( p < .001 ) . There were no significant improvements in the frequency of blood glucose testing ( p = .345 ) . Additionally , A1C values significantly improved 3 months after completing the program ( p = .007 ) . In conclusion , a diabetes education program design ed to be culturally sensitive and meet the needs of individuals with low health literacy improves short‐term outcomes IN THE EARLY 1890S , DR WILLIAM HALSTED DEVELOPED radical mastectomy for breast cancer . Surgeons performed the Halsted procedure for more than 80 years even though there was little systematic evidence for its success . Then a new breed of scholars subjected the procedure to formal methods of evaluation unknown to Halsted . The methods —r and omized controlled trials ( RCTs ) principal among them — led to a surprise : radical mastectomy had no advantage over simpler forms of treatment . This is but 1 example of the hard-won victory of evidence over belief in medicine . The pioneers of the formal evaluation of medical practice s raised questions that traditional practitioners did not welcome . But in time , formal evaluation prevailed . The pioneers developed a hierarchy of evidentiary rigor relating the design of a study to the confidence that could be placed in the findings , from the lowly , nearly valueless anecdote to the royalty of evidence , the RCT . Concurrently , a similar story of hard-won learning unfolded in the so-called quality movement . Scholars illuminated the scale and types of defects in the processes of care and the outcomes , including high rates of unscientific care , inappropriate care , geographic variations in practice , latent disagreements among specialists , and oftenunrecognized medical injury to patients . Like the pioneers of evidence -based medicine , students of medical quality were at first largely ignored , but no longer . In 1999 and 2001 , the Institute of Medicine published 2 l and mark reports on the evidence for quality failures and called urgently for re design of care systems to achieve improvements . The story could end here happily with 2 great streams of endeavor merging into a framework for conjoint action : improving clinical evidence and improving the process of care . Instead , the 2 endeavors are often in unhappy tension . Neither disputes that progress toward health care ’s main goal , the relief of illness and pain , requires research of many kinds : basic , clinical , systems , epidemiologic . The disagreement centers on epistemology — ways to get at “ truth ” and how those ways should vary depending on the knowledge sought . Individuals most involved in day-to-day improvement work fear that if “ evidence ” is too narrowly defined and the approach to gathering evidence too severely constrained , progress may be the victim . For example , the RCT is a powerful , perhaps unequaled , research design to explore the efficacy of conceptually neat components of clinical practice —tests , drugs , and procedures . For other crucially important learning purpose s , however , it serves less well . Recent controversies about the evaluation of rapid response  teams  provide a case in point . These controversies show the importance of adjusting research methods to fit research questions . Although only 10 % to 15 % of in patients resuscitated outside intensive care units survive to hospital discharge , early warning signs are present in a large percentage of patients who ultimately experience cardiac arrest .  Rapid response team systems bring expert clinicians to the bedsides of deteriorating patients before arrest occurs . In the mid 1990s , based largely on reports from Australian investigators , the Institute for Healthcare Improvement and others began introducing the concept to willing hospitals . Local experience strongly suggested that these systems often , although not always , were associated with improved outcomes , including reduced anxiety among nursing staff ; increased interdisciplinary teamwork ; decreased cardiac arrests outside of intensive care units ; and , in some cases , declines in mortality . The evidence base took a turn in June 2005 with the publication of the Medical Early Response Intervention and Therapy ( MERIT ) Study , a cluster r and omized prospect i ve trial that cl aim ed to find no beneficial effect of these teams on several primary outcomes . Controversy has continued since then regarding the scientific evidence for rapid response systems . In fact , the MERIT trial was not negative ; it was inconclusive . The study team encountered an array of serious problems in execution , common in social science . For example , although the study ’s power calculation assumed a baseline rate of 30 events per 1000 admissions , the actual rate proved to be fewer than 7 events per 1000 admissions ; thus , the study was ef fect ively underpowered by 500 % . Crosscontamination abounded ; some control hospitals implemented rapid response protocol s , and several study Background Type 2 diabetes mellitus is a complex , progressive disease which requires a variety of quality improvement strategies . Limited information is available on the feasibility and effectiveness of interdisciplinary diabetes care teams ( IDCT ) operating on the interface between primary and specialty care . A first study hypothesis was that the implementation of an IDCT is feasible in a health care setting with limited tradition in shared care . A second hypothesis was that patients who make use of an IDCT  would have significantly better outcomes compared to non-users of the IDCT after an 18-month intervention period . A third hypothesis was that patients who used the IDCT in an Advanced quality Improvement Program ( AQIP ) would have significantly better outcomes compared to users of a Usual Quality Improvement Program ( UQIP ) . Methods This investigation comprised a two-arm cluster r and omized trial conducted in a primary care setting in Belgium . Primary care physicians ( PCPs , n = 120 ) and their patients with type 2 diabetes mellitus ( n = 2495 ) were included and subjects were r and omly assigned to the intervention arms . The IDCT acted as a cornerstone to both the intervention arms , but the number , type and intensity of IDCT related interventions varied depending upon the intervention arm . Results Final registration included 67 PCPs and 1577 patients in the AQIP and 53 PCPs and 918 patients in the UQIP . 84 % of the PCPs made use of the IDCT .  The expected participation rate in patients ( 30 % ) was not attained , with 12,5 % of the patients using the IDCT .  When comparing users and non-users of the IDCT ( irrespective of the intervention arm ) and after 18 months of intervention the use of the IDCT was significantly associated with improvements in HbA1c , LDL-cholesterol , an increase in statins and anti-platelet therapy as well as the number of targets that were reached . When comparing users of the IDCT in the two intervention arms no significant differences were noted , except for anti-platelet therapy . Conclusion IDCT 's operating on the interface between primary and specialty care are associated with improved outcomes of care . More research is required on what team and program characteristics contribute to improvements in diabetes care . Trial registration NTR 1369 Background Most research publications on Chronic Care Model ( CCM ) implementation originate from organizations or countries with a well-structured primary health care system . Information about efforts made in countries with a less well-organized primary health care system is scarce . In 2003 , the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting , a setting where the organisational framework for chronic care is mainly hospital-centered . Methods Process evaluation of an action research project ( 2003–2007 ) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients . In consultation with the region a program for type 2 diabetes patients was developed . The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey ( ACIC ) . A multi method approach was used to evaluate the implementation process . The result ing data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process . Results The overall ACIC score improved from 1.45 ( limited support ) at the start of the study to 5.5 ( basic support ) at the end of the study . The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care . The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator . Important barriers were the complexity of the intervention , the lack of quality data , inadequate information technology support , the lack of commitment procedures and the uncertainty about sustainable funding . Conclusion Guided by the CCM , this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure . The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers . Currently primary care providers lack the opportunities to take up full responsibility for chronic care . Trial registration number Clinical Trials.gov Identifier : This article describes the design and implementation of an online diabetes self-management intervention for a sample of inner-city African Americans with diabetes . Study participants were r and omly assigned to the treatment ( 26 ) and control ( 21 ) conditions . The results indicate that treatment group participants were more likely to achieve positive outcomes in terms of lowered hemoglobin A1c and body mass index measurements than were control group members . These findings support the development of telehealth interventions to promote effective chronic disease management in medically underserved communities Background : With growing use of Community Health Workers ( CHWs ) to reach underserved population s , there is a need for more information on training methods to prepare CHWs , particularly in a health educator role . Objectives : To describe procedures used to recruit , train , and evaluate CHWs in Project Sugar 2 , a r and omized controlled trial of a nurse case manager and CHW team intervention design ed to improve diabetes care and control in a sample of 542 urban African Americans with type 2 diabetes . Methods : CHWs received a Core Training on guidelines and procedures , didactic diabetes self-management education , and research protocol training . However , barriers to CHW implementation of the intervention were encountered , including CHW attrition , job performance and satisfaction issues , low self-confidence in knowledge and skills as educators , difficulties with maintaining a large caseload , and inefficiencies experienced in conducting home visits . To address barriers , the initial training was modified and Results : The supplemental training result ed in CHW retention , satisfaction , confidence in skills , and feelings of ownership of the intervention . Participant satisfaction with care received from the CHWs and the Project Sugar 2 intervention was rated as high by 97 % and 93 % of responders , respectively . Conclusion : Core training in research intervention policies , procedures , and protocol s , combined with an extended participatory training , led to effective preparation of laypersons to serve as CHWs 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 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 OBJECTIVE To determine the effectiveness of a provider-based education and implementation intervention for improving diabetes control . DESIGN Cluster-r and omized trial with baseline and follow-up cross sections of diabetes patients in each participating physician 's practice . SETTING Eleven US Southeastern states , 2006 - 08 . PARTICIPANTS Two hundred and five rural primary care physicians . INTERVENTION Multi-component interactive intervention including Web-based continuing medical education , performance feedback and quality improvement tools . Primary Outcome Measures ' Acceptable control ' [ hemoglobin A1c ≤9 % , blood pressure ( BP ) < 140/90 mmHg , low-density lipoprotein cholesterol ( LDL ) < 130 mg/dl ] and ' optimal control ' ( A1c < 7 % , BP < 130/80 mmHg , LDL < 100 mg/dl ) . RESULTS Of 364 physicians attempting to register , 205 were r and omized to the intervention ( n= 102 ) or control arms ( n= 103 ) . Baseline and follow-up data were provided by 95 physicians ( 2127 patients ) .  The proportion of patients with A1c ≤9 % was similar at baseline and follow-up in both the control [ adjusted odds ratio ( AOR ) : 0.94 ; 95 % confidence interval ( CI ) : 0.61 , 1.47 ] and intervention arms [ AOR : 1.16 ( 95 % CI : 0.80 , 1.69 ) ] ; BP < 140/90 mmHg and LDL < 130 mg/dl were also similar at both measurement points ( P= 0.66 , P= 0.46 ; respectively ) . We observed no significant effect on diabetes control attributable to the intervention for any of the primary outcome measures . Intervention physicians engaged with the Website over a median of 64.7 weeks [ interquartile range ( IQR ) : 45.4 - 81.8 ) for a median total of 37 min ( IQR : 16 - 66 ) . CONCLUSIONS A wide-reach , low-intensity , Web-based interactive multi-component intervention did not improve control of glucose , BP or lipids for patients with diabetes of physicians practicing in the rural Southeastern US
target: It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level , especially by increasing staff involvement and satisfaction .
background: Background Integrated care interventions for chronic conditions can lead to improved outcomes , but it is not clear when and why this is the case .
  This study aims to answer the following two research questions : First , what are the context , mechanisms and outcomes of integrated care for people with type 2 diabetes ?
  Second , what are the relationships between context , mechanisms and outcomes of integrated care for people with type 2 diabetes ?