title: Improving primary care in rural Alabama with a pharmacy initiative. Improving Blood Pressure Control Through a Clinical Pharmacist Outreach Program in Patients With Diabetes Mellitus in 2 High-Performing Health Systems: The Adherence and Intensification of Medications Cluster Randomized, Controlled Pragmatic Trial Pharmacist-Led Shared Medical Appointments for Multiple Cardiovascular Risk Reduction in Patients With Type 2 Diabetes Management of type 2 diabetes in Western Australian metropolitan general practice. Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting Effect of case management on glycemic control and behavioral outcomes for chinese people with type 2 diabetes: A 2-year study. Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study The effect of integrated health management model on the health of older adults with diabetes in a randomized controlled trial. A Clinical Trial of Chronic Care Diabetic Clinics in General Practice in the United Arab Emirates: A Preliminary Analysis Effect of Adding Pharmacists to Primary Care Teams on Blood Pressure Control in Patients With Type 2 Diabetes Diabetes specialist nurse as main care provider for patients with type 2 diabetes. Peer support for patients with type 2 diabetes: cluster randomised controlled trial Pharmacist's intervention in the control of blood sugar levels in randomised diabetes patients at a primary health care setting in Benin City. Improving Diabetes Care and Health Measures Among Hispanics Using Community Health Workers Evaluation of a diabetes specialist–guided primary care diabetes treatment program Community health workers improve diabetes care in remote Australian Indigenous communities: results of a pragmatic cluster randomized controlled trial Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. Model of care for the management of complex Type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial Management of type 2 diabetes in China: the Happy Life Club, a pragmatic cluster randomised controlled trial using health coaches Improved control of type 2 diabetes mellitus: a practical education/behavior modification program in a primary care clinic. Caring for Poorly Controlled Diabetes Mellitus: A Randomized Pharmacist Intervention Treatment of type 2 diabetes mellitus in a primary care setting in Taiwan: comparison with secondary/tertiary care. Structured diabetes therapy and education improves the outcome of patients with insulin treated diabetes mellitus. The 10 year follow-up of a prospective, population-based survey on the quality of diabetes care (the JEVIN Trial). Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management Participative decentralization of diabetes care in Davao City (Philippines) according to the Chronic Care Model: a program evaluation. Pharmacist Assisted Medication Program Enhancing the Regulation of Diabetes (PAMPERED) study. An assessment of structured care assistance in the management of patients with type 2 diabetes in general practice. Cardiovascular risk factors in type 2 diabetic patients: multifactorial intervention in primary care. Management of Patients with Type 2 Diabetes by Pharmacists in Primary Care Clinics Lack of insurance coverage for testing supplies is associated with poorer glycemic control in patients with type 2 diabetes A Randomized Controlled Trial to Provide Adherence Information and Motivational Interviewing to Improve Diabetes and Lipid Control Patient-centered outcomes of a value-based insurance design program for patients with diabetes.
abstract: The effect of pharmaceutical care on the prevention , detection , and resolution of medication-related problems in high-risk patients in a rural community was studied . Adult patients who received care at clinics in a medically underserved area of Alabama and who were identified as being at high risk of medication-related adverse events were r and omly assigned to a control group or an intervention group . The control group received st and ard medical care , and the intervention group received pharmaceutical care , including a medical record review , a medication history review , pharmacotherapeutic evaluation , and patient medication education and monitoring over a one-year period .  A total of 69 patients completed the study ( 33 in the intervention group and 36 in the control group ) . The percentage of patients responding to hypertension , diabetes , dyslipidemia , and anticoagulation therapy increased significantly in the intervention group and declined in the control group . Ratings for inappropriate prescribing improved in all 10 domains evaluated in the intervention group but worsened in 5 domains in the control group . There were no significant differences between the groups at 12 months in health-related quality of life or medication misadventures . Medication compliance scores improved in the intervention group but not in the control group . Medication knowledge increased in the intervention group and decreased in the control group . Pharmaceutical care in a rural , community-based setting appeared to reduce inappropriate prescribing , enhance disease management , and improve medication compliance and knowledge without adversely affecting health-related quality of life Background — Even in high-performing health systems , some patients with diabetes mellitus have poor blood pressure ( BP ) control because of poor medication adherence and lack of medication intensification . We examined whether the Adherence and Intensification of Medications intervention , a pharmacist-led intervention combining elements found in efficacy studies to lower BP , improved BP among patients with diabetes mellitus with persistent hypertension and poor refill adherence or insufficient medication intensification in 2 high-performing health systems . Methods and Results — We conducted a prospect i ve , multisite cluster r and omized pragmatic trial with r and omization of 16 primary care teams at 5 medical centers ( 3 Veterans Affairs and 2 Kaiser Permanente ) to the Adherence and Intensification of Medications intervention or usual care . The primary outcome was relative change in systolic BP ( SBP ) , comparing 1797 intervention with 2303 control team patients , from 6 months preceding to 6 months after the 14-month intervention period . We examined shorter-term changes in SBP as a secondary outcome . The mean SBP decrease from 6 months before to 6 months after the intervention period was ≈9 mm Hg in both arms . Mean SBPs of eligible intervention patients were 2.4 mm Hg lower ( 95 % CI : −3.4 to −1.5 ; P<0.001 ) immediately after the intervention than those achieved by control patients . Conclusions — The Adherence and Intensification of Medications program more rapidly lowered SBPs among intervention patients , but usual-care patients achieved equally low SBP levels by 6 months after the intervention period . These findings show the importance of evaluating in different real-life clinical setting s programs found in efficacy trials to be effective before urging their widespread adoption in all setting s. Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00495794 Purpose To assess whether VA MEDIC-E ( Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH ] Extended for 6 months ) , a pharmacist-led shared medical appointments program , could improve attainment of target goals for hypertension , hyperglycemia , hyperlipidemia , and tobacco use in patients with type 2 diabetes compared to st and ard primary care after 6 months of intervention . Methods A r and omized , controlled trial of VA MEDIC-E ( n = 50 ) versus st and ard primary care ( n = 49 ) in veterans with type 2 diabetes , hemoglobin A1c ( A1C ) > 7 % , blood pressure ( BP ) > 130/80 mmHg , and low density lipoprotein cholesterol ( LDL-C ) > 100mg/dl ( 2.59 mmol/l ) in the previous 6 months was conducted . The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions . Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist . Evaluation measures included lab values of A1C , LDL cholesterol , BP , and goal attainment of these values , and diabetes self-care behavior question naires at 6 months . Results The r and omization groups were similar at baseline in all cardiovascular risk factors except for LDL , which was significantly lower in the MEDIC-E arm . At 6 months , significant improvements from baseline were found in the intervention arm for exercise , foot care , and goal attainment of A1C , LDL-C , and BP but not in the control arm . Conclusions The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk The purpose of this study was : ( 1 ) to record GP opinions , practice s and outcomes for the care of Type 2 Diabetes Mellitus ( DM2 ) , ( 2 ) compare practice facilities and process of care with a criterion of recommended competent care and ( 3 ) determine if there were any differences between vocationally registered and non-vocationally registered GPs . A r and om sample of 204 metropolitan doctors from 124 practice s was selected and an audit performed on 467 of their patient records . GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs . Over 80 % regard uncomplicated DM2 as a condition for general practice management . However , only 15 % conducted an annual diabetes check , 9 % had a diabetic register , 6 % a diabetic recall system and 8 % used a diabetic health care checklist for monitoring their patients . The most commonly recorded processes of medical audit in the previous 12 months were : blood pressure ( 94 % ) , duration of diabetes ( 72 % ) , blood glucose ( 70 % ) , diet ( 66 % ) , body weight ( 56 % ) , HBA1c ( 52 % ) and ophthalmoscopy ( 50 % ) . The least commonly recorded processes of care were body mass index ( 5 % ) , inspection of the feet ( 18 % ) , enquiries about vaginitis or impotence ( 23 % ) . The amount of exercise , alcohol and tobacco was recorded in only 34 % of records . Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers .  Vocationally registered ( VR ) doctors had better records , higher process of care scores and more were willing to participate in the study than non-vocationally registered ( NVR ) doctors . However , there was no difference in metabolic control between patients from either group . The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters . The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs Purpose The purpose of this study was to determine whether “ clinical inertia”—inadequate intensification of therapy by the provider — could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site . Methods In a prospect i ve observational study , management was compared in the Medical Clinic , a primary care site supervised by general internal medicine faculty , and the Diabetes Clinic , a specialty site supervised by endocrinologists . These municipal hospital clinics serve a common population that is largely African American , poor , and uninsured . Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age , diabetes duration , body mass index , and gender , but A1C averaged 8.6 % in the Medical Clinic versus 7.7 % in the Diabetes Clinic ( P < .0001 ) . Use of pharmacotherapy  was less intensive in the Medical Clinic ( less use of insulin ) , and when patients had elevated glucose levels during clinic visits , therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic ( P < .0001 ) . Intensification rates were lower in the Medical Clinic regardless of type of therapy ( P < .0001 ) , and intensification of therapy was independently associated with improvement in A1C ( P < .001 ) . Conclusions Medical Clinic patients had worse glycemic control , were less likely to be treated with insulin , and were less likely to have their therapy intensified if glucose levels were elevated . To improve diabetes management and glycemic control nationwide , physicians in training and generalists must learn to overcome clinical inertia , to intensify therapy when appropriate , and to use insulin when clinical ly indicated OBJECTIVE To examine the effect of case management on glycemic control and behavioral outcomes in adults with Type 2 diabetes in China . METHODS Participants were r and omly assigned to a 1-year case management ( CM ) group ( n=60 ) or control group ( n=60 ) . Monthly case management visits included identifying individuals ' diabetes-related problems , setting goals , planning self-care , and evaluating progress . During a 1-year follow-up , all participants attended visits every 3 months without intervention . RESULTS In the CM vs. the control group , HbA1c was reduced at 6 months compared to baseline ( P=0.034 ) , with trends at 12 and 24 months , and empowerment ability improved ( P<0.05 ) . Also in the CM vs. controls , total self-care behaviors , the frequency of exercise , blood glucose testing , and foot care were higher ( P<0.001 ) at 12 months , and the percentage of individuals with HbA1c ≤7.0 % was higher ( P=0.035 ) at 24 months . CONCLUSION The case management intervention in China was effective at 6 months and , based on trends in HbA1c at 12 and 24 months and results for behavioral outcomes , the intervention shows promise and warrants more research . PRACTICE IMPLICATION S A case management approach can enhance behavior change and glycemic control in Chinese with diabetes Summary In primary care it is difficult to treat the growing number of non-insulin-dependent diabetic ( NIDDM ) patients according to (inter)national guidelines . A prospect i ve , controlled cohort study was design ed to assess the intermediate term ( 2 years ) effect of structured NIDDM care in general practice with and without ‘ diabetes service ’ support on glycaemic control , cardiovascular risk factors , general well-being and treatment satisfaction . The ‘ diabetes service ’ , supervised by a diabetologist , included a patient registration system , consultation facilities of a dietitian and diabetes nurse educator , and protocol ized blood glucose lowering therapy advice which included home blood glucose monitoring and insulin therapy . In the study group ( SG ; 22 general practice s ) , 350 known NIDDM patients over 40 years of age ( 206 women ; mean age 65.3 ± SD 11.9 ; diabetes duration 5.9 ± 5.4 years ) were followed for 2 years . The control group ( CG ; 6 general practice s ) consisted of 68 patients ( 28 women ; age 64.6 ± 10.3 ; diabetes duration 6.3 ± 6.4 years ) . Mean HbAlc ( reference 4.3 - 6.1 % ) fell from 7.4 to 7.0 % in SG and rose from 7.4 to 7.6 % in CG during follow-up ( p = 0.004 ) . The percentage of patients with poor control ( HbA1c>8.5 % ) shifted from 21.4 to 11.7 % in SG , but from 23.5 to 27.9 % in CG ( p = 0.008 ) . Good control ( HbAlc > 7.0 % ) was achieved in 54.3 % ( SG ; at entry 43.4 % ) and 44.1 % ( CG ; at entry 54.4 % ) ( p = 0.013  ) . Insulin therapy was started in 29.7 % ( SG ) and 8.8 % ( CG ) of the patients ( p = 0.000 ) with low risk of severe hypoglycaemia ( 0.019/patient year ) . Mean levels of total and HDL-cholesterol ( SG ) , triglycerides ( SG ) and diastolic blood pressure ( SG + CG ) and the percentage of smokers ( SG ) declined significantly , but the prevalence of these risk factors remained high . General well-being ( SG ) did not change during intensified therapy . Treatment satisfaction ( SG ) tended to improve . Implementation of structured care , including education and therapeutic advice , results in sustained good glycaemic control in the majority of NIDDM patients in primary care , with low risk of hypoglycaemia . Lowering cardiovascular risk requires more than reporting results and referral to guidelines . [ Diabetologia ( 1997 ) 40 : 1334 - The objective of this study was to evaluate the effect of integrated health management model on the health of older adults with diabetes . The 100 older adults with diabetes who gave informed consent were r and omly allocated 1:1 into management and control groups . The integrated health management model was applied in the former while the latter was only given usual care . This model included the following components : health record establishment , health evaluation and health management ( such as : diet advice , psychological aspects of health , education/skills training on health self-management , regular blood glucose monitoring , long-term diabetes drug monitoring , etc . ) . After 18 months , differences in three categories of variables ( subjective grading items , objective measurement health indices and health service utilization ) between the two groups before and after the intervention were assessed with t-test , χ(2)-test and mixed model analysis . The management group demonstrated improvement on the following variables : health knowledge score , self-evaluated psychological conditions , overall self-evaluated health conditions , diet score , physical activity duration per week , regular blood sugar monitoring , waist-to-hip ratio , diastolic blood pressure and fasting blood sugar , the days of hospital admissions in the preceding 6 months . Mixed model analysis showed that gender , age , self-evaluated health status , self-evaluated psychological status , education level and resident status were important factors affecting health indices . This study demonstrated that integrated health management model was effectiveness in improving the health of older adults  with diabetes Control of diabetes mellitus is a high priority for primary health care systems . One innovative method of diabetes care delivery is the use of structured diabetes care in primary care . This includes the use of chronic care diabetes clinics or mini-clinics operated by general practitioners in primary care . There is limited experience with this model in non-Western setting s. This study sought to evaluate a multi-component structured approach to diabetes care in primary care including chronic care diabetes clinics in a newly developed country in the Arabian Gulf . The study design used was a controlled before-after methodology . Three primary health centers were chosen for the intervention with six of the remaining clinics in a Health District being used as controls . A multifaceted intervention was initiated in the intervention clinics composed of chronic care diabetes clinics , a diabetic flow chart , and educational programs for clinic nurses and doctors and patients . The study intervention took place over a period of 18 months with three diabetic outcomes ( fasting blood glucose , blood pressure and cholesterol ) and adherence to seven diabetes guidelines being compared for the year prior to the intervention and during the last 12 months of the intervention period . Knowledge and satisfaction question naires were also administered to intervention and control subjects at the end of the study . In this study , 219 subjects were enrolled ( 130 males and 89 females ) . They had a mean age of 51.6 years and a mean of 3.1 years of formal education . Of these 109 were enrolled in one of three clinics that had a chronic care diabetes clinic and 110 were enrolled in one of the six control clinics . Subjects had diabetes for a mean of 7.8 ± 4.8 years and the majority was treated with pharmacological therapy . Baseline characteristics in the intervention and the control clinics were similar with the exception of younger age ( p = 0.01 ) and a trend for more males ( p = 0.06 ) in the intervention clinics . There was a statistically insignificant change noted with the intervention in the three clinical outcomes studied ( fasting blood glucose , blood pressure and cholesterol ) both in comparison to the control group before and after and within the intervention group . However most changes noted were in the expected direction of improvement ; six of the seven guidelines were statistically improved in the intervention group when compared with the control group . Within the intervention group , adherence with five of seven guidelines was also statistically significantly increased with the remaining guidelines showing a trend in favor of improvement ( fasting blood glucose measurements ( p = 0.07 ) and urine determinations for protein ( p = 0.07 ) ) . Knowledge question naire scores were similar between the intervention and control groups on completion of the study but 2 of 4 items on a satisfaction scale were statistically significantly higher in the intervention group . The intervention described in this setting was successful in improving adherence to diabetes guidelines and increased some aspects of satisfaction with diabetes care . The intervention did not result in a statistically significant improvement in clinical outcomes but changes noted were in the expected direction of improvement . The significant improvement in adherence to diabetes guidelines suggests that this intervention is a promising model for diabetes care for newly developed countries OBJECTIVE To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors  in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We conducted a r and omized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton , Canada .  Pharmacists performed medication assessment s and limited history and physical examinations and provided guideline -concordant recommendations to optimize medication management . Follow-up contact was completed as necessary . Control patients received usual care . The primary outcome was a ≥10 % decrease in systolic blood pressure at 1 year . RESULTS A total of 260 patients were enrolled , 57 % were women , the mean age was 59 years , diabetes duration was 6 years , and blood pressure was 129/74 mmHg . Forty-eight of 131 ( 37 % ) intervention patients and 30 of 129 ( 23 % ) control patients achieved the primary outcome ( odds ratio 1.9 [ 95 % CI 1.1–3.3 ] ; P = 0.02 ) . Among 153 patients with inadequately controlled hypertension at baseline , intervention patients ( n = 82 ) were significantly more likely than control patients ( n = 71 ) to achieve the primary outcome ( 41 [ 50 % ] vs. 20 [ 28 % ] ; 2.6 [ 1.3–5.0 ] ; P = 0.007 ) and recommended blood pressure targets ( 44 [ 54 % ] vs. 21 [ 30 % ] ; 2.8 [ 1.4–5.4 ] ; P = 0.003 ) . The 10-year risk of cardiovascular disease , based on changes to the UK Prospect i ve Diabetes Study Risk Engine , were predicted to decrease by 3 % for intervention patients and 1 % for control patients ( P = 0.005 ) . CONCLUSIONS Significantly more patients with type 2 diabetes achieved better blood pressure control  when pharmacists were added to primary care teams , which suggests that pharmacists can make important contributions to the primary care of these patients BACKGROUND The objective of this study was to determine whether the management of type 2 diabetes ( DM2 ) can be transferred from an internist to a nurse specialised in diabetes ( NSD ) . METHODS Ninety-three patients with DM2 referred by their general practitioner were r and omised ; 84 patients completed the study . The intervention group received care from an NSD who treated glycaemia , blood pressure and lipid profile by protocol . The control group received care from an internist . The primary endpoint was the main decrease in HbA1c . Secondary endpoints included blood pressure , lipid profile , healthcare costs , QOL , and patient satisfaction . RESULTS HbA1c , total cholesterol , LDL cholesterol and cholesterol/HDL ratio decreased significantly in both study population s after a follow-up time of 12 months . Cholesterol/HDL ratio decreased by 0.4 and 0.9 in the NSD and control group respectively ( p=0.034 for the difference between groups ) . The decreases ( 95 % confidence interval ) in systolic blood pressure were 8.6 mmHg ( 2.6 , 14.7 ) in the NSD group and 4.0 mmHg ( -0.9 , 8.9 ) in the control group , without a significant difference between groups . After one year , 33.3 % of the patients in the NSD group achieved an HbA1c level . < 7 % compared with 2.2%at baseline ( p=0.002 ) . Healthcare costs were less and patient satisfaction with the NSD s was significantly better(p<0.001 ) , while maintaining the same QOL . CONCLUSION NSD s using treatment protocol s are able to provide effective care for patients with DM 2 , comparable with the care provided by an internist , with respect to clinical parameters , and superior with respect to healthcare costs and patient satisfaction Objective To test the effectiveness of  peer support  for patients with type 2 diabetes . Design Cluster r and omised controlled . Setting 20 general practice s in the east of the Republic of Irel and . Participants 395 patients ( 192 in intervention group , 203 in control group ) and 29 peer supporters with type 2 diabetes . Intervention All practice s introduced a st and ardised diabetes care system . The peer support intervention ran over a two year period and contained four elements : the recruitment and training of peer supporters , nine group meetings led by peer supporters in participant ’s own general practice , and a retention plan for the peer supporters . Main outcome measures HbA1c ; cholesterol concentration ; systolic blood pressure ; and wellbeing score . Results There was no difference between intervention and control patients at baseline . All practice s and 85 % ( 337 ) of patients were followed up . At two year follow-up , there were no significant differences in HbA1c ( mean difference −0.08 % , 95 % confidence interval −0.35 % to 0.18 % ) , systolic blood pressure ( −3.9 mm Hg , −8.9 to 1.1 mm Hg ) , total cholesterol concentration ( −0.03 mmol/L , −0.28 to 0.22 mmol/L ) , or wellbeing scores ( −0.7 , −2.3 to 0.8 ) . While there was a trend towards decreases in the proportion of patients with poorly controlled risk factors at follow-up , particularly for systolic blood pressure ( 52 % ( 87/166 ) > 130 mm Hg in intervention v 61 % ( 103/169 ) > 130 mm Hg in control ) , these changes were not significant . The process evaluation indicated that the intervention was generally delivered as intended , though 18 % ( 35 ) of patients in the intervention group never attended any group meetings . Conclusions A group based peer support intervention is feasible in general practice setting s , but the intervention was not effective when targeted at all patients with type 2 diabetes . While there was a trend towards improvements of clinical outcomes , the results do not support the widespread adoption of peer support . Trial registration Current Controlled Trials IS RCT N42541690 BACKGROUND The extended roles of  pharmacists in Nigeria in the improvement of quality of health care at the primary health care ( PHC ) level is currently poorly executed even though pharmacists have been proven to be involved in interventional activities in health care delivery . OBJECTIVE To evaluate pharmacists ' intervention in the control of blood sugar levels of diabetes patients in a PHC setting in Benin City , Nigeria . METHODS At baseline , the fasting blood sugar ( FBS ) , glycosylated hemoglobin ( HbA1c ) , body mass index ( BMI ) and blood pressure ( BP ) of r and omly selected 170 diabetic patients in a primary health care centre were evaluated . This was followed-up with intervention by the pharmacists through counselling on lifestyle modification , self-medication and drug adherence on monthly basis for three consecutive months after which the FBS , HbA1c , BMI and BP were re-evaluated . RESULTS indicated significant reduction in BMI , HbA1c and FBS from 27.1 + /- 4.2 kg/m2 , 8.1 + /- 3.0 % and 10.0 + /- 4.2 mmol/l to 23.5 + /- 3.5 kg/m2 , 7.1 + /- 1.8 % and 8.5 + /- 2.1 mmol/l , respectively ( p < 0.001 ) was observed following the intervention by the pharmacists . CONCLUSION Direct involvement of pharmacists in the care of diabetic patients in PHC setting s can significantly improve the quality of life provided to these patients and hence reduce mortality result ing from the disease . Recruitment of reasonable number of pharmacists should always be considered in health policies for PHC setting s in developing countries The increasing prevalence of diabetes and obesity , growing health disparities , and shortage of bilingual and culturally trained health care professionals underscore the role of trained community health workers ( CHWs ) to provide economically sustainable and culturally relevant services . This prospect i ve r and omized design evaluated the relative effectiveness of a CHW intervention among Hispanic persons with newly diagnosed type 2 diabetes , as compared with usual clinic practice in three inner-city health centers . In sum , 189 Hispanic patients newly diagnosed with type 2 diabetes were r and omly assigned to one of three 6-month diabetes management approaches — CHW , case management , and st and ard provider care— and assessed for diabetes-related health measures and clinical indicators at baseline and postintervention . Participants in the CHW group achieved greater improvements than did the controls in program measures : health status , emergency department utilization , dietary habits , physical activity , and medication adherence . They also had 2.9 times greater odds of decreasing body mass index 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 Background Health outcomes for Indigenous Australians with diabetes in remote areas remain poor , including high rates of avoidable complications which could be reduced with better primary level care . We aim ed to evaluate the effectiveness of a community-based health-worker led case management approach to the care of Indigenous adults with poorly controlled type 2 diabetes in primary care services in remote northern Australia . Methods Two hundred and thirteen adults with poorly controlled diabetes ( HbA1c > 8.5 % ) and significant comorbidities in 12 remote communities were r and omly assigned by service cluster to receive chronic care co-ordination from a community-based health worker supported by a clinical outreach team , or to a waitlist control group which received usual care . Results At baseline , mean age of participants was 47.9 years , 62.4 % were female , half were Aboriginal and half identified as Torres Strait Isl and er , 67 % had less than 12 years of education , 39 % were smokers , median income was $ 18,200 and 47 % were unemployed .  Mean HbA1c was 10.7 % ( 93 mmol/mol ) and BMI 32.5 . At follow-up after 18 months , HbA1c reduction was significantly greater in the intervention group ( −1.0 % vs −0.2 % , SE ( diff ) = 0.2 , p = 0.02 ) . There were no significant differences between the groups for blood pressure , lipid profile , BMI or renal function . Intervention group participants were more likely to receive nutrition and dental services according to scheduled care plans . Smoking rates were unchanged . Conclusions A culturally safe , community level health-worker led model of diabetes care for high risk patients can be effective in improving diabetes control in remote Indigenous Australian communities where there is poor access to mainstream services . This approach can be effective in other remote setting s , but requires longer term evaluation to capture accrued benefits .Trial registration ANZCTR 12610000812099 , Registered 29 September 2010 AIMS AND OBJECTIVES To determine whether the management of  type 2 diabetes mellitus  in a primary care setting can be safely transferred to practice nurses . BACKGROUND Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients , the dem and type 2 diabetes mellitus patients place on primary health care re sources has become overwhelming . DESIGN R and omised controlled trial . METHODS The patients in the intervention group were cared for by practice nurses who treated glucose levels , blood pressure and lipid profile according to a specified protocol . The control group received conventional care from a general practitioner . The primary outcome measure was the mean decrease seen in glycated haemoglobin ( HbA1c ) levels at the end of the follow-up period ( 14 months ) . RESULTS A total of 230 patients was r and omised with 206 completing the study . The between-group differences with respect to reduction in HbA1c , blood pressure and lipid profile were not significant . Blood pressure decreased significantly in both groups ; 7.4/3.2 mm Hg in the intervention group and 5.6/1.0 mm Hg in the control group . In both groups , more patients met the target values goals for lipid profile compared to baseline . In the intervention group , there was some deterioration in the health-related quality of life and an increase in diabetes-related symptoms . Patients being treated by a practice nurse were more satisfied with their treatment than those being treated by a general practitioner . CONCLUSION Practice nurses achieved results , which were comparable to those achieved by a general practitioner with respect to clinical parameters with better patient satisfaction . RELEVANCE TO CLINICAL PRACTICE This study shows that diabetes management in primary care can be safely transferred to practice nurses The aim of this study was to examine whether motivating patients to gain expertise and closely follow their risk parameters will attenuate the course of microvascular and cardiovascular sequelae of diabetes . A r and omized , prospect i ve study was conducted of 165 patients who had type 2 diabetes , hypertension , and hyperlipidemia and were referred for consultation to a diabetes clinic in an academic hospital . Patients were r and omly allocated to st and ard consultation ( SC ) or to a patient participation ( PP ) program . Both groups were followed by their primary care physicians . The mean follow-up was 7.7 yr . The SC group attended eight annual consultations . The PP patients initiated on average one additional consultation per year . There were 80 cardiovascular events ( eight deaths ) in the SC group versus 47 events ( five deaths ) in the PP group ( P = 0.001 ) . The relative risk ( RR ) over 8 yr for a cardiovascular event in the intervention ( PP ) versus the control ( SC ) group was 0.65 ( 95 % confidence interval , 0.89 to 0.41 ) . There were 17 and eight cases of stroke in the SC and PP groups , respectively ( P = 0.05 ) . RR for stroke was 0.47 ( 95 % confidence interval , 0.85 to 0.32 ) . In the SC group , 14 patients developed overt nephropathy ( four ESRD ) versus seven ( one ESRD ) in the PP group ( P = 0.05 ) . Throughout the study period , BP , LDL cholesterol , and hemoglobin A1c were significantly lower in the PP than in the SC patients . Well informed and motivated patients were more successful in obtaining and maintaining good control of their risk factors , result ing in reduced cardiovascular risk and slower progression of microvascular disease AIMS To evaluate patient outcomes for a novel integrated primary /specialist model of community care for complex Type 2 diabetes mellitus management compared with outcomes for usual care at a tertiary hospital for diabetes out patients . METHODS This was a prospect i ve open controlled trial performed in a primary and tertiary care setting in Australia . A total of 330 patients with Type 2 diabetes aged > 18 years were allocated to an intervention ( n=185 ) or usual care group ( n=145 ) . The intervention arm was a community-based model of care led by a general practitioner with advanced skills and an endocrinologist partnership . Usual care was provided via the hospital diabetes outpatient department . The primary end point was HbA(1c ) concentration at 12 months . Secondary end points included serum lipids and blood pressure . RESULTS The mean change in HbA1c concentration in the intervention group was -9 mmol/mol ( -0.8 % ) at 12 months and in the usual care group it was -2 mmol/mol ( -0.2 % ) ( 95 % CI -5,1 ) . The percentage of patients in the intervention group achieving the HbA(1c ) target of ≤53 mmol/mol ( 7 % ) increased from 21 to 42 % ( P<0.001 ) ; for the usual care group there was a 1 % increase to 39 % of patients attaining this target ( P=0.99 ) . Patients in the intervention group experienced significant improvements in blood pressure and total cholesterol compared with those in the usual care group . The percentage of patients achieving clinical targets was greater in the intervention group for the combined target of HbA(1c ) concentration , blood pressure and LDL cholesterol . CONCLUSIONS A community-based , integrated model of complex diabetes care , delivered by general practitioners with advanced skills , produced clinical and process benefits compared with a tertiary diabetes outpatient clinic Objective To evaluate the effectiveness of a structured group education programme on biomedical , psychosocial , and lifestyle measures in people with newly diagnosed type 2 diabetes . Design Multicentre cluster r and omised controlled trial in primary care with r and omisation at practice level . Setting 207 general practice s in 13 primary care sites in the United Kingdom . Participants 824 adults ( 55 % men , mean age 59.5 years ) . Intervention A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care . Main outcome measures Haemoglobin A1c levels , blood pressure , weight , blood lipid levels , smoking status , physical activity , quality of life , beliefs about illness , depression , and emotional impact of diabetes at baseline and up to 12 months . Main results Haemoglobin A1c levels at 12 months had decreased by 1.49 % in the intervention group compared with 1.21 % in the control group . After adjusting for baseline and cluster , the difference was not significant : 0.05 % ( 95 % confidence interval −0.10 % to 0.20 % ) . The intervention group showed a greater weight loss : −2.98 kg ( 95 % confidence interval −3.54 to −2.41 ) compared with 1.86 kg ( −2.44 to −1.28 ) , P=0.027 at 12 months . The odds of not smoking were 3.56 ( 95 % confidence interval 1.11 to 11.45 ) , P=0.033 higher in the intervention group at 12 months . The intervention group showed significantly greater changes in illness belief scores ( P=0.001 ) ; directions of change were positive indicating greater underst and ing of diabetes . The intervention group had a lower depression score at 12 months : mean difference was −0.50 ( 95 % confidence interval −0.96 to −0.04 ) ; P=0.032 . A positive association was found between change in perceived personal responsibility and weight loss at 12 months ( β=0.12 ; P=0.008 ) . Conclusion A structured group education programme for patients with newly diagnosed type 2 diabetes result ed in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A1c levels up to 12 months after diagnosis . Trial registration Current Controlled Trials IS RCT N17844016 ABSTRACT Background Several trials have demonstrated the efficacy of nurse telephone case management for diabetes ( DM ) and hypertension ( HTN ) in academic or vertically integrated systems . Little is known about the real-world potency of these interventions . Objective To assess the effectiveness of nurse behavioral management of DM and HTN in community practice s among patients with both diseases . Design The study was design ed as a patient-level r and omized controlled trial . Participants Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practice s. Subjects were required to have inadequately controlled DM ( hemoglobin A1c [ A1c ] ≥ 7.5 % ) but could have well-controlled HTN . Interventions All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years , for a total of 12 calls . Intervention patients received tailored DM- and HTN- focused behavioral content ; control patients received non-tailored , non-interactive information regarding health issues unrelated to DM and HTN ( e.g. , skin cancer prevention).Main Outcomes and Measures Systolic blood pressure ( SBP ) and A1c were co- primary outcomes , measured at 6 , 12 , and 24 months ; 24 months was the primary time point . Results Three hundred seventy-seven subjects were enrolled ; 193 were r and omized to intervention , 184 to control . Subjects were 55 % female and 50 % white ; the mean baseline A1c was 9.1 % ( SD = 1 % ) and mean SBP was 142 mmHg ( SD = 20 ) . Eighty-two percent of scheduled interviews were conducted ; 69 % of intervention patients and 70 % of control patients reached the 24-month time point . Expressing model estimated differences as ( intervention – control ) , at 24 months , intervention patients had similar A1c [ diff = 0.1 % , 95 % CI ( −0.3 , 0.5 ) , p = 0.51 ] and SBP [ diff = −0.9 mmH g , 95 % CI ( −5.4 , 3.5 ) , p = 0.68 ] values compared to control patients . Likewise , DBP ( diff = 0.4 mmHg , p = 0.76 ) , weight ( diff = 0.3 kg , p = 0.80 ) , and physical activity levels ( diff = 153 MET-min/week , p = 0.41 ) were similar between control and intervention patients . Results were also similar at the 6- and 12-month time points . Conclusions In nine community fee-for-service practice s , telephonic nurse case management did not lead to improvement in A1c or SBP . Gains seen in telephonic behavioral self-management interventions in optimal setting s may not translate to the wider range of primary care setting Objective To assess the effectiveness of a coach-led motivational interviewing ( MI ) intervention in improving glycaemic control , as well as clinical , psychosocial and self-care outcomes of individuals with type 2 diabetes mellitus ( T2DM ) compared with usual care . Design Pragmatic cluster r and omised controlled trial ( RCT ) . Setting Community Health Stations ( CHSs ) in Fengtai district , Beijing , China . Participants Of the 41 r and omised CHSs ( 21 intervention and 20 control ) , 21 intervention CHSs ( 372 participants ) and 18 control CHSs ( 296 participants ) started participation .  Intervention Intervention participants received telephone and face-to-face MI health coaching in addition to usual care from their CHS . Control participants received usual care only . Medical fees were waived for both groups . Outcome measures Outcomes were assessed at baseline , 6 and 12 months . Primary outcome measure was glycated haemoglobin ( HbA1c ) . Secondary outcomes included a suite of anthropometric , blood pressure ( BP ) , fasting blood , psychosocial and self-care measures . Results At 12 months , no differential treatment effect was found for HbA1c ( adjusted difference 0.02 , 95 % CI −0.40 to 0.44 , p=0.929 ) , with both treatment and control groups showing significant improvements . However , two secondary outcomes : psychological distress ( adjusted difference −2.38 , 95 % CI −4.64 to −0.12 , p=0.039 ) and systolic BP ( adjusted difference −3.57 , 95 % CI −6.08 to −1.05 , p=0.005 ) were robust outcomes consistent with significant differential treatment effects , as supported in sensitivity analyses . Interestingly , in addition to HbA1c , both groups displayed significant improvements in triglycerides , LDL cholesterol and HDL cholesterol . Conclusions In line with the current Chinese primary healthcare reform , this study is the first large-scale cluster RCT to be implemented within real-world CHSs in China , specifically addressing T2DM . Although a differential treatment effect was not observed for HbA1c , numerous outcomes ( including HbA1c ) improved in both groups , supporting the establishment of regular , free clinical health checks for people with T2DM in China . Trial registration number IS RCT N01010526 ; Pre- results BACKGROUND This study was done to determine the efficacy and ease of administration of education/behavior modification classes , provided by a nurse and a dietitian in a primary care clinic for improving control of type 2 diabetes mellitus .  METHODS Patients were divided r and omly into two groups . Eighteen patients completed 6 months of structured , office-based classes , and 20 similar patients served as control subjects . All were patients of the same group practice and had their usual office visits .  Glycemic control , lipid levels , body weight , knowledge about diabetes , medication requirements , and symptoms were monitored during the 6 months , with follow-up at 12 months . RESULTS At the end of 6 months , the intervention group had significant reductions in mean fasting blood glucose , glycosylated hemoglobin , total cholesterol , and low-density lipoprotein cholesterol ( LDL-C ) values . Their mean body weight was significantly reduced at 12 months , and their knowledge of diabetes was improved . Control patients had significant improvement only in glycosylated hemoglobin and body weight at 6 months . Minimal physician time was required . CONCLUSION The education/behavior modification program was clinical ly worthwhile , and it was easy to administer 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 BACKGROUND This study investigated the status of diabetes control and management in patients treated in a primary healthcare setting and compared the results with data previously obtained for secondary /tertiary care patients in Taiwan . METHODS This study was conducted at 51 primary healthcare stations r and omly selected isl and -wide in Taiwan in 2001 . A total of 1302 type 2 diabetes patients who had been followed-up for more than 1 year were included .  Blood was collected for central ized HbA1c assay . The remaining data and information were collected by review of medical records and patient interview . RESULTS Compared with the results of a previous study on patients treated in a secondary /tertiary care setting , a significantly smaller percentage of primary care patients were receiving insulin therapy . Primary care patients also had a shorter duration of diabetes , a higher HbA1c level , better blood pressure control and a lower prevalence of complications . The proportion of patients achieving optimal control of glycemia and blood pressure was low . Patients aged < 65 years had a significantly shorter duration of diabetes , poorer diabetes control and better blood pressure control than elderly patients aged > or = 65 years . Primary care patients aged > or = 65 years had a significantly higher frequency of stroke than those aged < 65 years . The elderly group of secondary /tertiary care patients had a significantly higher frequency of coronary heart disease and stroke . Duration of diabetes and hypertension were the leading risk factors for complications in diabetes patients treated in both primary and secondary /tertiary care setting s. CONCLUSION Diabetes control was poorer in primary care than in secondary /tertiary care patients , but control of blood pressure was better in primary care patients . The shorter duration of diabetes and better control of blood pressure in primary care patients and in patients aged < 65 years compared with their elderly counterparts might be related to a lower prevalence of complications AIMS /HYPOTHESIS JEVIN ( Jena 's St. Vincent Trial ) is a prospect i ve , 10 year follow-up , population -based survey of all insulin treated patients with type 1 and type 2 diabetes mellitus aged 16 to 60 years and living in the city of Jena ( 100,000 inhabitants ) , Thuringia , Germany . It aims to show the effects of implementation of the St. Vincent Declaration and to evaluate the effect of recent changes in the health care system and new treatment strategies . PATIENTS AND METHODS 190 patients ( 83 % of the target population ) , 244 patients ( 90 % ) and 261 patients ( 90 % ) were studied in 1989/90 , 1994/95 and 1999/2000 , respectively . RESULTS Up to 1994/95 , the HbA1c of patients with type 1 diabetes mellitus increased ( 1994/95 : 8.50+/-1.80 % versus 1989/90 : 7.83+/-1.60 % , p=0.002 ) . For patients with type 2 diabetes mellitus , it remained constant ( 9.01+/-2.06 % versus 9.17+/-1.60 % , n. s. ) . During the period from 1994/95 to 1999/2000 , there was a substantial improvement in the relative HbA1c of both , patients with type 1 ( 7.62+/-1.55 % , p<0.0001 ) , and with type 2 diabetes ( 7.57+/-1.29 % , p<0.0001 ) . Up to 1999/2000 , 87.7 % of the patients with type 1 ( 1989/90 : 0 % , 1994/95 : 73.2 % ) and 96.6 % of the patients with type 2 diabetes ( 1989/90 : 0 % , 1994/95 : 89.7 % ) participated in TTP 's . The incidence of acute and the prevalence of long-term complications remained constant . CONCLUSIONS Results of the population -based , prospect i ve trial to optimise patients ' quality of diabetic control suggest : For patients with insulin treated type 2 diabetes mellitus , excellent treatment can be available by primary care physicians interested , educated and highly engaged in diabetes therapy . Moreover , structured diabetes therapy consisting of treatment and teaching programmes , regular self-monitoring , patients ' insulin dose adjustment and patients ' empowerment , should be offered to all patients with diabetes mellitus BACKGROUND Re source barriers complicate diabetes care management . Support from peers may help patients manage their diabetes . OBJECTIVE To compare a reciprocal peer-support ( RPS ) program with nurse care management ( NCM ) . DESIGN R and omized , controlled trial . ( Clinical Trials.gov registration number : NCT00320112 ) SETTING 2 U.S. Department of Veterans Affairs health care facilities . PATIENTS 244 men with hemoglobin A(1c ) ( HbA(1c ) ) levels greater than 7.5 % during the previous 6 months . MEASUREMENTS The primary outcome was 6-month change in HbA(1c ) level . Secondary outcomes were changes in insulin therapy ; blood pressure ; and patient reports of medication adherence , diabetes-related support , and emotional distress . INTERVENTION Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals , receive peer communication skills training , and be paired with another age-matched peer patient . Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact . These patients could also participate in optional group sessions at 1 , 3 , and 6 months . Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager . RESULTS Of the 244 patients enrolled , 216 ( 89 % ) completed the HbA(1c ) assessment s and 231 ( 95 % ) completed the survey assessment s at 6 months . Mean HbA(1c ) level decreased from 8.02 % to 7.73 % ( change , -0.29 % ) in the RPS group and increased from 7.93 % to 8.22 % ( change , 0.29 % ) in the NCM group . The difference in HbA(1c ) change between groups was 0.58 % ( P = 0.004 ) . Among patients with a baseline HbA(1c ) level greater than 8.0 % , those in the RPS group had a mean decrease of 0.88 % , compared with a 0.07 % decrease among those in the NCM group ( between-group difference , 0.81 % ; P < 0.001 ) . Eight patients in the RPS group started insulin therapy , compared with 1 patient in the NCM group ( P = 0.020 ) . Groups did not differ in blood pressure , self-reported medication adherence , or diabetes-specific distress , but the RPS group reported improvement in diabetes social support . LIMITATION The study included only male veterans and lasted only 6 months . CONCLUSION Reciprocal peer support holds promise as a method for diabetes care management AIM To assess the effectiveness of the  Diabetes Project in Davao City , Philippines , regarding diabetes care access , diabetes management and cardiovascular risk factors . The project was developed in accordance with the Chronic Care Model ( CCM ) framework . METHODS A non-r and omized cross-sectional survey was conducted in nine intervention and five control Barangays ( villages ) . People with diabetes aged ≥20 years were interviewed using a structured question naire ; height , weight , waist circumference , and blood pressure were measured ; HbA1c was tested with a NSGP-certified point-of-care device . Logistic regression models were used to compare the two groups . RESULTS The intervention group ( n=503 ) scored better than the controls ( n=136 ) on the following ( OR , 95 % CI ) : percentage of patients taking metformin ( 1.5 , 1.0 - 2.2 ) ; and in the last 12 months : laboratory test for fasting blood sugar ( 1.6 , 1.1 - 2.3 ) , HbA1c ( 6.0 , 2.4 - 15.1 ) , lipid profile ( 1.7 , 1.1 - 2.5 ) , nutritionist visit ( 1.6 , 1.0 - 2.5 ) and therapeutic education session ( 2.7 , 1.8 - 4.0 ) . Glycemic control ( HbA1c<7 % ) was also better in the intervention Barangays ( 1.6 , 1.0 - 2.4 ) . There were no statistical differences between the two groups for number of visits , and levels of other cardiovascular risk factors . CONCLUSIONS Our findings support the effectiveness of implementing the CCM framework in a low-to-middle income country on glycemic control and diabetes management OBJECTIVES To demonstrate that pharmacists working with physicians and other providers in an ambulatory care setting can improve glucose , blood pressure , and lipid control for patients with type 2 diabetes and to report patient adherence to screening and general preventive measures . DESIGN Prospect i ve , r and omized , clinical practice study . SETTING Burlington , MA , between January 2001 and August 2003 . PATIENTS 164 patients patients with type 2 diabetes older than 18 years with glycosylated hemoglobin ( A1C ) greater than 8 % . INTERVENTION Pharmacist-patient clinic visits included obtaining a comprehensive medication review ; performing targeted physical assessment ; ordering laboratory tests ; review ing , modifying , and monitoring patients ' medication therapy and providing detailed counseling on all therapies ; facilitating self-monitoring of blood glucose ; and providing reinforcement of dietary guidelines and exercise . MAIN OUTCOME MEASURE Effect of clinical pharmacists working with physicians in an ambulatory setting on health measures ( e.g. , A1C , blood pressure , cholesterol ) of patients with diabetes . RESULTS Baseline characteristics were similar between the two groups . After 1 year , significant improvements occurred for A1C and low-density lipoprotein ( LDL ) cholesterol in the intervention group compared with the control group ( A1C , 7.7 % vs. 8.4 % ; LDL , 93.7 vs. 105.1 mg/dL ; P < 0.05 ) . Systolic blood pressure improved for all study patients without a difference between the two groups . Diastolic blood pressure improved significantly in the intervention group compared with the control group ( 73.4 mm Hg vs. 77.6 mm Hg , P < 0.05 ) . Significantly more intervention patients were screened for retinopathy , neuropathy , and microalbuminuria than control patients ( P < 0.05 ) . CONCLUSION For all indices measured , this study demonstrated that collaborative diabetes management with a clinical pharmacist can improve overall care OBJECTIVE To study differences in diabetes-related parameters in type 2 diabetic patients treated with the support of a Diabetes Service compared to conventional general practice care . DESIGN Parallel clinical trial with r and omisation at practice level . SETTING Fifteen general practice s. PATIENTS Type 2 diabetic patients , aged < 76 years , treated by a GP . MAIN OUTCOME MEASURES Level of glycated haemoglobin ( HbA1c ) . RESULTS 246 patients entered the study .  Final mean HbA1c of all evaluable patients allocated to the intervention ( n = 84 ) was 7.1+/-1.2 % , vs 7.5+/-1.8 % in the controls ( n = 140 ) ( p = 0.06 ) . Patients who were initially poorly controlled ( Fasting Blood Glucose > 10 mmol/l ) had a significantly lower final HbA1c if they were in an intervention practice ( p=0.001 ) . Fewer patients in intervention practice s were referred to hospital specialists ( 1 vs 14 ) . CONCLUSIONS Support by the Dutch Diabetes Service did not significantly influence glycated haemoglobin . The subgroup of initially poorly controlled patients developed a significantly lower HbA1c in intervention practice s ( supported by a Diabetes Service ) than in control practice BACKGROUND Cardiovascular disease is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus ( DM ) . Intervention on  cardiovascular risk factors  ( CVRF ) is essential to obtain clinical results reducing the excess of cardiovascular risk ( CVR ) in these patients . METHODS The objective of this study was to describe the association of type 2 DM with modifiable cardiovascular risk factors and the degree of control of these in a population of type 2 diabetics in attendance in primary care clinics , and also to establish prospect ively whether an integral and multifactorial intervention on uncontrolled cardiovascular risk factors , carried out in conditions of routine clinical practice by applying an open protocol , could significantly reduce the estimated CVR according to the Framingham scale . The proposed intervention included both actions aim ed at modifying habits , and pharmacologic intervention to achieve an optimum level of control in accordance with international recommendations for the objectives and treatment for type 2 diabetes . RESULTS A total of 3466 patients with a mean age of 58 + /- 7.5 years were studied and followed-up for 1 year . Of these , 90.4 % of patients had high blood pressure ; 60.1 % of men and 32.7 % of women presented CVR > 20 % in 10 years according to the Framingham scale by categories . Intervention at 1 year of follow-up had achieved statistically significant reductions in blood pressure , glycated hemoglobin , and lipid levels , but not of patients ' body weight . After 1 year of follow-up , 29 % of males and 24 % of women with a high CVR ( > 20 % ) at the start of the study presented reduced risk levels . CONCLUSION The results of the study demonstrate that an integrated and multifactorial intervention in type 2 diabetic patients can achieve clinical ly significant reductions in CVR . However , conducted in effective conditions , it is not able to achieve optimum levels of control in spite of the initial proposal , possibly due to some degree of inertia in routine clinical practice OBJECTIVE : To determine the impact of clinical pharmacists involved in direct patient care on the glycemic control of patients with type 2 diabetes mellitus . DESIGN : Eligible patients included those with type 2 diabetes who received insulin or were initiated on insulin therapy by the pharmacists and were willing to perform self-monitoring of blood glucose . The pharmacists provided diabetes education , medication counseling , monitoring , and insulin initiation and /or adjustments . All initial patient interactions with the pharmacists were face-to-face . Thereafter , patient – pharmacist interactions were either face-to-face or telephone contacts . SETTING : Two primary care clinics in a university-affiliated Veterans Affairs Medical Center . PARTICIPANTS : Study subjects were patients with type 2 diabetes who were referred to the pharmacists by their primary care providers for better glycemic control . OUTCOME MEASURES : Primary outcome variables were changes from baseline in glycosylated hemoglobin , fasting blood glucose , and r and om blood glucose measurements . Secondary outcomes were the number and severity of symptomatic episodes of hypoglycemia , and the number of emergency room visits or hospitalizations related to diabetes . Twenty-three veterans aged 65 ± 9.4 years completed the study . Fifteen ( 65 % ) patients were initiated on insulin by the pharmacists ; 8 ( 35 % ) were already using insulin . Patients were followed for a mean ± SD of 27 ± 10 weeks . Glycosylated hemoglobin , fasting blood glucose concentrations , and r and om blood glucose concentrations significantly decreased from baseline by 2.2 % ( p = 0.00004 ) , 65 mg/dL ( p < 0.01 ) , and 82 mg/dL ( p = 0.00001 ) , respectively . Symptomatic hypoglycemic episodes occurred in 35 % of patients . None of these episodes required physician intervention . CONCLUSIONS : This study demonstrates that pharmacists working as members of interdisciplinary primary care teams can positively impact glycemic control in patients with type 2 diabetes requiring insulin Background : Public insurance for testing supplies for self-monitoring of blood glucose is highly variable across Canada . We sought to determine if insured patients were more likely than uninsured patients to use self-monitoring and whether they had better glycemic control . Methods : We used baseline survey and laboratory data from patients enrolled in a r and omized controlled trial examining the effect of paying for testing supplies on glycemic control . We recruited patients through community pharmacies in Alberta and Saskatchewan from Nov. 2001 to June 2003 . To avoid concerns regarding differences in provincial coverage of self-monitoring and medications , we report the analysis of Alberta patients only . Results : Among our sample of 405 patients , 41 % had private or public insurance coverage for self-monitoring testing supplies . Patients with insurance had significantly lower hemoglobin A1c concentrations than those without insurance coverage ( 7.1 % v. 7.4 % , p = 0.03 ) . Patients with insurance were younger , had a higher income , were less likely to have a high school education and were less likely to be married or living with a partner . In multivariate analyses that controlled for these and other potential confounders , lack of insurance coverage for self-monitoring testing supplies was still significantly associated with higher hemoglobin A1c concentrations ( adjusted difference 0.5 % , p = 0.006 ) . Interpretation : Patients without insurance for self-monitoring test strips had poorer glycemic control Purpose The purpose of this study was to assess whether providing medication adherence information with or without motivational interviewing improves diabetes and lipid control . Methods Study participants were adult members of a health system in southeast Michigan , were using both oral diabetes and lipid-lowering medications , and had glycated hemoglobin ( A1C ) or low-density lipoprotein cholesterol ( LDL-C ) levels not at goal . Participants were r and omly assigned to receive usual care ( UC ) , n = 567 ; have medication adherence information ( AI ) provided to their physician , n = 569 ; or have AI and receive motivational interviewing ( MI ) though trained staff ( AI + MI ) , n = 556 . Primary outcomes were A1C and LDL-C levels at 18 months post r and omization . Results Primary outcomes were not significantly different between patients in the AI or AI + MI study arms when compared with UC . Similarly , neither oral diabetes nor lipid-lowering medication adherence was significantly different between groups . Patient participation in the AI + MI arm was low and limit the interpretation of the study results , but post hoc analysis of the AI + MI study arm showed that the number of MI  sessions received was positively associated with only oral diabetes medication adherence . Conclusion Neither AI nor MI significantly improved diabetes and lipid control when compared with UC . Moreover , patient participation appeared to be a particular barrier for MI Value-based insurance design ( VBID ) initiatives have been associated with modest improvements in adherence based on evaluations of administrative cl aims data . The objective of this prospect i ve cohort study was to report the patient-centered outcomes of a VBID program that eliminated co-payments for diabetes-related medications and supplies for employees and dependents with diabetes at a large health system . The authors compared self-reported values of medication adherence , cost-related nonadherence , health status , and out-of-pocket health care costs for patients before and 1 year after program implementation . Clinical metrics and satisfaction with the program also are reported . In all , 188 patients completed the follow-up evaluation . Overall , patients reported a significant reduction in monthly out-of-pocket costs ( P<0.001 ) , which corresponded to a significant reduction in cost-related nonadherence from 41 % to 17.5 % ( P<0.001 ) . Self-reported medication adherence increased for hyperglycemic medications ( P=0.011 ) , but there were no apparent changes in glycemic control . Overall , 89 % of participants agreed that the program helped them take better care of their diabetes . The authors found that a  VBID program for employees and dependents with diabetes was associated with self-reported reductions in cost-related nonadherence and improvements in medication adherence . Importantly , the program was associated with high levels of satisfaction among participants and strongly perceived by participants to facilitate medication utilization and self-management for diabetes . These findings suggest that VBID programs can accomplish the anticipated goals for medication utilization and are highly regarded by participants . Patient-centered outcomes should be included in VBID evaluations to allow decision makers to determine the true impact of VBID programs on participants
target: Through this review , we found two key health system barriers to effective T2DM care and management : financial constraints faced by the patient and limited access to health services and medication .
  This review points to the importance of reducing , or possibly eliminating , out-of-pocket costs for diabetes medication and self-monitoring supplies .
background: BACKGROUND Type 2 Diabetes Mellitus ( T2DM ) is reported to affect one in 11 adults worldwide , with over 80 % of T2DM patients residing in low-to-middle-income countries .
  Health systems play an integral role in responding to this increasing global prevalence , and are key to ensuring effective diabetes management .
  We conducted a systematic review to examine the health system-level factors influencing T2DM awareness , treatment , adherence , and control .