Diabetes mellitus (DM) is a chronic progressive metabolic disorder characterized by hyperglycemia mainly due to absolute (Type 1 DM) or relative (Type 2 DM) deficiency of insulin hormone. World Health Organization estimates that more than 346 million people worldwide have DM. This number is likely to more than double by 2030 without any intervention. The needs of diabetic patients are not only limited to adequate glycemic control but also correspond with preventing complications; disability limitation and rehabilitation. There are seven essential self-care behaviors in people with diabetes which predict good outcomes namely healthy eating, being physically active, monitoring of blood sugar, compliant with medications, good problem-solving skills, healthy coping skills and risk-reduction behaviors. All these seven behaviors have been found to be positively correlated with good glycemic control, reduction of complications and improvement in quality of life. Individuals with diabetes have been shown to make a dramatic impact on the progression and development of their disease by participating in their own care. Despite this fact, compliance or adherence to these activities has been found to be low, especially when looking at long-term changes. Though multiple demographic, socio-economic and social support factors can be considered as positive contributors in facilitating self-care activities in diabetic patients, role of clinicians in promoting self-care is vital and has to be emphasized. Realizing the multi-faceted nature of the problem, a systematic, multi-pronged and an integrated approach is required for promoting self-care practices among diabetic patients to avert any long-term complications.

/pdf/role-of-self-care-in-management-of-diabetes-mellitus-1cbfwoht8u.pdf

Role of self-care in management of diabetes mellitus.

Objective This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care. Data sources We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO. Review methods All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision. Results Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men. Conclusions The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.

Closing the quality gap: revisiting the state of the science (vol. 3: quality improvement interventions to address health disparities).

Diabetes Self-Management Education Core Outcomes Measures:

OBJECTIVE —To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers. RESEARCH DESIGN AND METHODS —One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews. RESULTS —The performance of several key processes of care assessed by chart review increased, including rates of HbA 1c measurement (80–90%; adjusted odds ratio 2.1, 95% CI 1.6–2.8), eye examination referral (36–47%; 1.6, 1.1–2.3), foot examination (40–64%; 2.7, 1.8–4.1), and lipid assessment (55–66%; 1.6, 1.1–2.3). Mean value of HbA 1c tended to improve (8.5–8.3%; difference −0.2, 95% CI −0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management. CONCLUSIONS —The Health Disparities Collaborative improved diabetes care in health centers in 1 year.

https://care.diabetesjournals.org/content/diacare/27/1/2.full.pdf

Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative

A short message service by cellular phone in type 2 diabetic patients for 12 months.

OBJECTIVE — We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards.

RESEARCH DESIGN AND METHODS — In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbAlc tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA).

RESULTS — Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbAlc testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers.

CONCLUSIONS — Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.

https://care.diabetesjournals.org/content/diacare/24/2/268.full.pdf

Anita G. Harrand

Papers

Barriers to Providing Diabetes Care in Community Health Centers