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

According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

From the Publisher: 
A Question of Identity 
Life on the Screen is a fascinating and wide-ranging investigation of the impact of computers and networking on society, peoples' perceptions of themselves, and the individual's relationship to machines. Sherry Turkle, a Professor of the Sociology of Science at MIT and a licensed psychologist, uses Internet MUDs (multi-user domains, or in older gaming parlance multi-user dungeons) as a launching pad for explorations of software design, user interfaces, simulation, artificial intelligence, artificial life, agents, "bots," virtual reality, and "the on-line way of life." 
Turkle's discussion of postmodernism is particularly enlightening. She shows how postmodern concepts in art, architecture, and ethics are related to concrete topics much closer to home, for example AI research (Minsky's "Society of Mind") and even MUDs (exemplified by students with X-window terminals who are doing homework in one window and simultaneously playing out several different roles in the same MUD in other windows). Those of you who have (like me) been turned off by the shallow, pretentious, meaningless paintings and sculptures that litter our museums of modern art may have a different perspective after hearing what Turkle has to say. 
This is a psychoanalytical book, not a technical one. However, software developers and engineers will find it highly accessible because of the depth of the author's technical understanding and credibility. Unlike most other authors in this genre, Turkle does not constantly jar the technically-literate reader with blatant errors or bogus assertions about how things work. Although I personally don't have time or patience for MUDs,view most of AI as snake-oil, and abhor postmodern architecture, I thought the time spent reading this book was an extremely good investment.

스크린 위의 삶 = Life on the screen : identity in the age of the internet

Background Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective. Objectives To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies. Selection criteria Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. Main results We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice. Reviewer's conclusions Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Audit and feedback: effects on professional practice and healthcare outcomes

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

https://www.jhsph.edu/sebin/k/a/2005_MQ_Starfield.pdf

Contribution of Primary Care to Health Systems and Health

OBJECTIVE--To evaluate the influence of continuity of care on patient satisfaction with consultations. DESIGN--Direct and episodic specific evaluation of patient satisfaction with recent consultation. SETTING AND SUBJECTS--A representative sample of 3918 Norwegian primary care patients were asked to evaluate their consultations by filling in a questionnaire. The response rate was 78%. MAIN OUTCOME MEASURES--The patient's overall satisfaction with the consultation was rated on a six point scale. Continuity of care was recorded as the duration and intensity of the present patient-doctor relationship and as patients' perception of the present doctor being their personal doctor or not. RESULTS--The multivariate analysis indicated that an overall personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4.9 to 9.9) as compared with consultations where no such relationships existed. The duration of the patient-doctor relationship had a weak but significant association with patient satisfaction, while the intensity of contacts showed no such association. CONCLUSION--Personal, continuous care is linked with patient satisfaction. If patient satisfaction is accepted as an integral part of quality health care, reinforcing personal care may be one way of increasing this quality.

https://www.bmj.com/content/bmj/304/6837/1287.full.pdf

Continuity of care in general practice: effect on patient satisfaction.

BACKGROUND: Patients' evaluations can be used to improve health care and compare general practice in different health systems. AIM: To identify aspects of general practice that are generally evaluated positively by patients and to compare opinions of patients in different European countries on actual care provision. METHOD: An internationally-validated questionnaire was distributed to and completed by patients in 10 European countries. A stratified sample of 36 practices per country, with at least 1080 patients per country, was included. A set of 23 validated questions on evaluations of different aspects of care was used, as well as questions on age, sex, overall health status, and frequency of visiting the GP. RESULTS: The patient sample included 17,391 patients in 10 different countries; the average response rate was 79% (range = 67% to 89%). In general, patients visiting their general practitioner (GP) were very positive about the care provided. For most of the 23 selected aspects of care more than 80% viewed care as good or excellent; in particular, keeping records confidential, GP listening to patients, time during consultations, and quick services in case of urgent problems were evaluated positively. Patients were relatively negative about organisational aspects of care. The evaluations in different countries were largely similar, with some interesting differences; for instance, service and organisational aspects were evaluated more positively in fee-for-service health systems. CONCLUSIONS: Patients in Europe are positive about general practice but improvements in practice management in some countries are requested. More research is needed to study the complex field of differences in expectations and evaluations between countries with different health systems.

/pdf/patients-in-europe-evaluate-general-practice-care-an-1kcfgwwtho.pdf

Patients in Europe evaluate general practice care: an international comparison.

BACKGROUND AND OBJECTIVES Improving the sensitivity of general practice to patients' needs demands a good understanding of patients' expectations and priorities in care provision. Insight into differences in expectations of patients in different cultures and health care systems may support decision-making on desirable models for care provision in general practice. An international study was conducted to determine priorities of patients in general practice care: which views do patients in different countries have in common and which views differ? METHODS Written surveys in general practices in the UK, Norway, Sweden, Denmark, The Netherlands, Germany, Portugal and Israel were performed. Samples of patients from at least 12 practices per country, stratified according to area and type of practice, were included. Patients rated the importance of 38 different aspects of general practice care, selected on the basis of literature analysis, qualitative studies and consensus discussions. Rankings between countries were compared. RESULTS A total number of 3540 patients (response rate on average 55%) completed the questionnaire. Patients in different countries had many opinions in common. Aspects that got the highest ranking were: getting enough time during the consultation; quick services in case of emergencies; confidentiality of information on patients; telling patients all they want to know about their illness; making patients feel free to talk about their problems; GPs going to courses regularly; and offering preventive services. However, differences between opinions of patients in different countries were also found for some of the selected aspects. A confounding effect of patients' characteristics may have played a role in these differences. DISCUSSION The study provides information on what patients expect of and value in general practice care. It shows that patients in different cultures and health care systems may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as doctor-patient communication and accessibility of services are concerned.

/pdf/patients-priorities-with-respect-to-general-practice-care-an-3vfr4yywml.pdf

Patients' priorities with respect to general practice care: an international comparison

OBJECTIVE--To examine the relation between general practitioners' knowledge about their patients and the use of resources in consultations. DESIGN--A cross sectional evaluation of consultations. SETTING AND SUBJECTS--A representative sample of 133 Norwegian general practitioners were each asked to record 30 consecutive consultations. 131 did so, and of 3990 possible registrations, 3918 (98%) were evaluated. MAIN OUTCOME MEASURES--The influence, as assessed by the doctor, of accumulated knowledge on the use of laboratory tests, expectant management, prescriptions, sickness certification, referrals, and time spent in the consultation. RESULTS--Accumulated knowledge was a substantial factor in saving time, especially in consultations with children, the elderly, patients with psychosocial problems, and those with chronic diseases. It also influenced the overall use of laboratory tests, expectant management, sickness certification, and referrals, and to a lesser degree the use of medication. CONCLUSION--The findings imply strong but complex associations between accumulated knowledge and the use of resources in the consultation.

https://www.bmj.com/content/bmj/303/6811/1181.full.pdf

Continuity of care: influence of general practitioners' knowledge about their patients on use of resources in consultations.

Continuity of care has had many definitions,1 but in the context of general practice it is still virtually synonymous with care from one doctor, usually spanning an extended time and more than one episode of illness.2 Although this longitudinal continuity, with its implied personal relationship, is seen by many as a core feature of the discipline, there is little supporting evidence. Seeing the same doctor does not guarantee a good patient-doctor relationship, and in any case such continuity can no longer be taken for granted. In many countries it is being abandoned under pressure from modern developments in medicine, in organisation of practices, and in society generally. A recent report from the British General Medical Services Committee suggested that it is being replaced by continuity within the primary care team.3

The practical question is whether patients should be enabled as far as possible to see the doctor of their choice or whether to go further and state that they should normally see only one general practitioner because this is better for them. We think that current evidence does not support this last view. Instead general practitioners, primary care teams, managers, politicians, and the public need to develop a shared understanding of the strengths and drawbacks of continuity, which when allied with good communication we call personal continuity (box).

#### Definitions of continuity of care

Longitudinal continuity 

Personal continuity 

Longitudinal continuity is a simple concept with strong face …

/pdf/what-future-for-continuity-of-care-in-general-practice-2cqxrstzgf.pdf

Per Hjortdahl

Papers

Continuity of care in general practice: effect on patient satisfaction.

Patients in Europe evaluate general practice care: an international comparison.

Patients' priorities with respect to general practice care: an international comparison

Continuity of care: influence of general practitioners' knowledge about their patients on use of resources in consultations.

What future for continuity of care in general practice