XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

D iabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. Specifically titled sections of the standards address children with diabetes, pregnant women, and people with prediabetes. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A large number of these interventions have been shown to be cost-effective (4). A grading system (Table 1), developed by the American Diabetes Association (ADA) andmodeled after existingmethods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence. For the current revision, committee members systematically searched Medline for human studies related to each subsection and published since 1 January 2010. Recommendations (bulleted at the beginning of each subsection and also listed in the “Executive Summary: Standards of Medical Care in Diabetesd2012”) were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strength of the wording to the strength of the evidence. A table linking the changes in recommendations to new evidence can be reviewed at http:// professional.diabetes.org/CPR_Search. aspx. Subsequently, as is the case for all Position Statements, the standards of care were reviewed and approved by the ExecutiveCommittee of ADA’s Board ofDirectors, which includes health care professionals, scientists, and lay people. Feedback from the larger clinical community was valuable for the 2012 revision of the standards. Readers who wish to comment on the “Standards of Medical Care in Diabetesd2012” are invited to do so at http://professional.diabetes.org/ CPR_Search.aspx. Members of the Professional Practice Committee disclose all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the standards revisionmeeting. Members of the committee, their employer, and their disclosed conflicts of interest are listed in the “Professional PracticeCommitteeMembers” table (see pg. S109). The AmericanDiabetes Association funds development of the standards and all its position statements out of its general revenues and does not utilize industry support for these purposes.

https://www.science-open.com/document_file/bb04d9d0-b3df-4133-9494-e71e300f4279/PubMedCentral/bb04d9d0-b3df-4133-9494-e71e300f4279.pdf

Standards of Medical Care in Diabetes—2012

https://www.scienceopen.com/document_file/57689460-a74a-45be-b1a0-a3e9cd0c5d62/PubMedCentral/57689460-a74a-45be-b1a0-a3e9cd0c5d62.pdf

Standards of Medical Care in Diabetes—2013

Statistical Analysis With Missing Data (2nd ed.) (Book)

CAROLÉ MENSING, RN, MA, CDE (TASK FORCE CHAIR) JACKIE BOUCHER, MS, RD, LD, CDE MARJORIE CYPRESS, MS, C-ANP, CDE KATIE WEINGER, EDD, RN KATHRYN MULCAHY, MSN, RN, CDE PATRICIA BARTA, RN, MPH, CDE GWEN HOSEY, MS, ARNP, CDE WENDY KOPHER, RN, C, CDE, HTP ANDREA LASICHAK, MS, RD, CDE BETTY LAMB, RN, MSN MAVOURNEEN MANGAN, RN, MS, ANP, C, CDE JAN NORMAN, RD, CDE JON TANJA, BS, MS, RPH LINDA YAUK, MS, RD, LD, CDE KIMBERLYDAWN WISDOM, MD, MS CYNTHIA ADAMS, PHD

National Standards for Diabetes Self-Management Education

OBJECTIVE —To determine whether using the chronic care model (CCM) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes. RESEARCH DESIGN AND METHODS —This multilevel, cluster-design, randomized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community. Eleven primary care practices, along with their patients, were randomized to three groups: CCM intervention ( n = 30 patients), provider education only (PROV group) ( n = 38), and usual care (UC group) ( n = 51). RESULTS —A marked decline in HbA 1c was observed in the CCM group (−0.6%, P = 0.008) but not in the other groups. The magnitude of the association remained strong after adjustment for clustering ( P = 0.01). The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group (non-HDL cholesterol: −10.4 mg/dl, P = 0.24; self-monitor blood glucose: +22.2%, P P = 0.05; self-monitor blood glucose: P = 0.03) after adjustment. The CCM group also showed improvement in HDL cholesterol (+5.5 mg/dl, P = 0.0004), diabetes knowledge test scores (+6.7%, P = 0.07), and empowerment scores (+2, P = 0.02). CONCLUSIONS —These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes.

https://care.diabetesjournals.org/content/diacare/29/4/811.full.pdf

Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention

PurposeThe purpose of this pilot study was to determine the impact of implementing elements of the chronic care model (CCM; decision support, self-management, and delivery system redesign) on provi...

Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice.

We read Belalcazar and Swank’s response (1) to our article with great interest. They have valid concerns regarding potentially biased estimates of treatment effects in small translational research studies where circumstances and environments are not as easily controlled as they are in efficacy-based research (2).

Our study (3) was a pilot, randomized, controlled trial of a multifaceted diabetes care intervention. Eleven primary care practices and their patients ( n = 762), all from the same underserved community, were block randomized to one of three study groups before the …

https://care.diabetesjournals.org/content/diacare/29/12/2762.2.full.pdf

Translating the Chronic Care Model Into the Community: Results From a Randomized Controlled Trial of a Multifaceted Diabetes Care Intervention Response to Belalcazar and Swank

Objective: The objective of this study was to determine if a community-based, modified DPP Group Lifestyle Balance (GLB) intervention, for individuals with Metabolic Syndrome (MetS), was effective in decreasing risk for type 2 diabetes (T2D) and cardiovascular disease (CVD) in an urban, medically underserved community; and subsequently to determine if improvements in clinical outcomes could be sustained in the short-term. Research Design and Methods: This non-randomized prospective intervention study utilized a one group design to test the effectiveness of a community-based GLB intervention. Residents from eleven targeted neighborhoods were screened for MetS (n=573) and took part in a 12 week GLB intervention (n=88) that addressed safe weight loss and physical activity. Results: A marked decline in weight (46.4% lost ≥ 5% and 26.1% lost ≥ 7%) was observed in individuals following completion of the intervention. 87.5% (28) and 66.7% (12) of these subjects sustained the 5% and 7% reduction, respectively, at the 6-month reassessment. Over 1/3 of the population (43.5%, n=30) experienced improvements in ≥ one component of MetS, and 73.3% (22) sustained this improvement at the 6-month reassessment. Additional improvements occurred in waist circumference (p Conclusions: Adults in an urban, medically underserved community can decrease their risk for T2D and CVD through participation in a GLB intervention and short-term sustainability is feasible. Future research will include long-term follow-up of these subjects.

https://care.diabetesjournals.org/content/diacare/31/4/684.full.pdf

Translating the Diabetes Prevention Program Into an Urban Medically Underserved Community: A nonrandomized prospective intervention study

OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA 1c over 12 months after a 6-month diabetes self-management education (DSME) program. RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited from a federally qualified health center and randomized to 1 ) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2 ) a 6-month DSME program followed by 12 months of monthly telephone outreach delivered by CHWs. The primary outcome was HbA 1c . Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months. RESULTS After DSME, the PL group achieved a reduction in mean HbA 1c (8.2–7.5% or 66–58 mmol/mol, P P = 0.009]). The CHW group also showed a reduction in HbA 1c (7.8 vs. 7.3% or 62 vs. 56 mmol/mol, P = 0.0004) post–6 month DSME; however, it was attenuated at 18 months (−0.3% or −3.3 mmol/mol from baseline, within-group P = 0.234). Only the PL group maintained improvements achieved in blood pressure at 18 months. At the 18-month follow-up, both groups maintained improvements in waist circumference, diabetes support, and diabetes distress, with no significant differences between groups. CONCLUSIONS Both low-cost maintenance programs led by either a PL or a CHW maintained improvements in key patient-reported diabetes outcomes, but the PL intervention may have additional benefit in sustaining clinical improvements beyond 12 months.

https://care.diabetesjournals.org/content/diacare/37/6/1525.full.pdf

Gretchen A. Piatt

Papers

Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention

Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice.

Translating the Chronic Care Model Into the Community: Results From a Randomized Controlled Trial of a Multifaceted Diabetes Care Intervention Response to Belalcazar and Swank

Translating the Diabetes Prevention Program Into an Urban Medically Underserved Community: A nonrandomized prospective intervention study

Comparative Effectiveness of Peer Leaders and Community Health Workers in Diabetes Self-management Support: Results of a Randomized Controlled Trial