[Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings]. Cost-effectiveness of screening and optimal management for diabetes, hypertension, and chronic kidney disease: a modeled analysis. Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol An ICT-Based Diabetes Management System Tested for Health Care Delivery in the African Context Impact of care management processes and integration of care on blood pressure control in diabetes The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial Diabetes decision support: initial experience with the Vermont diabetes information system. Disease management for co-morbid depression and anxiety in diabetes mellitus: design of a randomised controlled trial in primary care Development and evaluation of a Computer-Assisted Management Protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial Readiness of Ugandan health services for the management of outpatients with chronic diseases Collaborative care for patients with depression and chronic illnesses. The Indiana Chronic Disease Management Program. Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors The Cholesterol, Hypertension, and Glucose Education (CHANGE) study for African Americans with diabetes: study design and methodology. Developing ‘high impact’ guideline-based quality indicators for UK primary care: a multi-stage consensus process Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: A pilot study Building equity in chronic disease management in Thailand: a whole-system provincial trial of systematic, pro-active chronic illness care Protocol for a randomised blocked design study using telephone and text-messaging to support cardiac patients with diabetes: a cross cultural international collaborative project Managing Elders With Comorbidities Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience" Picture Good Health: A Church-Based Self-Management Intervention Among Latino Adults with Diabetes The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. Evidence-based management: using serial firm trials to improve diabetes care quality. Cardiovascular risk outcome and program evaluation of a cluster randomised controlled trial of a community-based, lay peer led program for people with diabetes The effectiveness of case management for comorbid diabetes type 2 patients; the CasCo study. Design of a randomized controlled trial Computerized decision support based on a clinical practice guideline improves compliance with care standards. Qualitative evaluation of a mobile phone and web-based collaborative care intervention for patients with type 2 diabetes. A tale of two audits: statistical process control for improving diabetes care in primary care settings. The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health Maintenance Organization The effect of electronic reminders on risk management among diabetic patients in low resourced settings.
UNLABELLED This review should be cited as : Renders CM , Valk GD , Griffin S. Wagner EH , Eijk JThM van , Assendelft WJJ . Interventions to improve the management of  diabetes mellitus  in primary care , outpatient and community setting s ( Cochrane Review ) . In : The Cochrane Library , Issue 2 , 2001 . Oxford : Up date Software . A substantive amendment to this systematic review was last made on 29 June 2000 . Cochrane review s are regularly checked and up date d if necessary . BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care . Different systems have been proposed to manage diabetes care . OBJECTIVES To assess the effects of different interventions , targeted at health professionals or the structure in which they deliver care , on the management of patients with diabetes in primary care , outpatient and community setting s. SEARCH STRATEGY We search ed the Cochrane Effective Practice and Organisation of Care Group specialised register , the Cochrane Controlled Trials Register ( Issue 4 1999 ) , MEDLINE ( 1966 - 1999 ) , EMBASE ( 1980 - 1999 ) , Cinahl ( 1982 - 1999 ) , and reference lists of articles . SELECTION CRITERIA R and omised trials ( RCTs ) , controlled clinical trials ( CCTs ) , controlled before and after studies ( CBAs ) and interrupted time series ( ITS ) analyses of professional , financial and organisational strategies aim ed at improving care for people with Type 1 or Type 2 diabetes . The participants were health care professionals , including physicians , nurses and pharmacists . The outcomes included objective ly measured health professional performance or patient outcomes , and self-report measures with known validity and reliability . DATA COLLECTION AND ANALYSIS Two review ers independently extracted data and assessed study quality . MAIN RESULTS Forty-one studies were included involving more than 200 practice s and 48,000 patients . Twenty-seven studies were RCTs , 12 were CBAs , and two were ITS . The studies were heterogeneous in terms of interventions , participants , setting s and outcomes . The method ological quality of the studies was often poor . In all studies the intervention strategy was multifaceted . In 12 studies the interventions were targeted at health professionals , in nine they were targeted at the organization of care , and 20 studies targeted both . In 15 studies patient education was added to the professional and organisational interventions . A combination of professional interventions improved process outcomes . The effect on patient outcomes remained less clear as these were rarely assessed . Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes . Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes . REVIEW ERS ' CONCLUSION : Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .  Organisational interventions that improve regular prompted recall and review of patients  ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management . The addition of patient-oriented interventions can lead to improved patient health outcomes . Nurses can play an important role in patient-oriented interventions , through patient education or facilitating adherence to treatment OBJECTIVES Chronic kidney disease is , increasingly , both a contributor to premature deaths and a financial burden to the health system , and is estimated to affect between 10 % and 15 % of the adult population in Western countries . Hypertension and , in particular diabetes , are significant contributors to the global burden of chronic kidney disease . Although it might increase costs , screening for , and improved management of , persons at increased risk of progressive kidney disease could improve health outcomes . We therefore sought to estimate the costs and health outcomes of alternative strategies to prevent end-stage kidney disease , compared with usual care . METHODS A Markov model comparing : 1 ) intensive management versus usual care for patients with suboptimally managed diabetes and hypertension ; and 2 ) screening for and intensive treatment of diabetes , hypertension , and proteinuria versus usual care was developed . Intervention effectiveness was based on published meta-analyses and r and omized controlled trial data ; costs were measured from a central health-care funder perspective in 2008 Australian dollars ( $ A ) , and outcomes were reported in quality -adjusted life-years ( QALYs ) . RESULTS Intensive treatment of inadequately controlled diabetes was both less costly ( an average lifetime saving of $ A133 ) and more effective ( with an additional 0.075 QALYs per patients ) than conventional management . Intensive management of hypertension had an incremental cost-effectiveness ratio ( ICER ) $ A2588 per QALY gained . Treating all known diabetics with angiotensin-converting enzyme ( ACE ) inhibitors was both less costly ( an average lifetime saving of $ A825 per patient ) and more effective than current treatment ( result ing in 0.124 additional QALYs per patient ) . Primary care screening for 50- to 69-year-olds plus intensive treatment of diabetes had an ICER of $ A13,781 per QALY gained . Primary care screening for hypertension ( between ages 50 and 69 years ) plus intensive blood pressure management had an ICER of $ A491 per QALY gained . Primary care screening for proteinuria ( between ages 50 and 69 years ) combined with prescription of an ACE inhibitor for all persons showing proteinuria and all known diabetics had an ICER of $ A4793 per QALY gained . CONCLUSIONS Strategies combining primary care screening of 50- to 69-year-olds for proteinuria , diabetes , and hypertension followed by the routine use of ACE inhibitors , and optimal treatment of diabetes and hypertension , respectively , have the potential to reduce death and end-stage kidney disease and are likely to represent good value for money Background Chronic diseases represent a major challenge for health care and social services . A number of people with chronic diseases require more services due to characteristics that increase their vulnerability . Given the burden of increasingly vulnerable patients on primary care , a pragmatic intervention in four Family Medicine Groups ( primary care practice s in Quebec , Canada ) has been proposed for individuals with chronic diseases ( diabetes , cardiovascular diseases , respiratory diseases , musculoskeletal diseases and /or chronic pain ) who are frequent users of hospital services . The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program . The goals of this study are to : ( 1 ) analyze the implementation of the intervention in the participating practice s in order to determine how the various context s have influenced the implementation and the observed effects ; ( 2 ) evaluate the proximal ( self-efficacy , self-management , health habits , activation and psychological distress ) and intermediate ( empowerment , quality of life and health care use ) effects of the intervention on patients ; ( 3 ) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention . Methods / Design The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders ( Family Medicine Group and health centre management , Family Medicine Group practitioners , patients and their families , health centre or community partners ) . The data will be obtained through individual and group interviews , project documentation review s and by documenting the intervention . Evaluation of the effects on patients will be based on a pragmatic r and omized before-after experimental design with a delayed intervention control group ( six months ) . Economic analysis will include cost-effectiveness and cost-benefit analysis . Discussion The integration of a case management intervention delivered by nurses and self-management group support into primary care practice s has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care . Decision-makers , managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practice s in the region and elsewhere . Trial Registration Background Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation . There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient population s , but little consensus concerning the optimal model that would best provide such support . We describe the implementation and evaluation of self-management support through an evidence -based ' whole systems ' model involving patient support , training for primary care teams , and service re-organisation , all integrated into routine delivery within primary care . Methods The evaluation involves a large-scale , multi-site study of the implementation , effectiveness , and cost-effectiveness of this model of self-management support using a cluster r and omised controlled trial in patients with three long-term conditions of diabetes , chronic obstructive pulmonary disease ( COPD ) , and irritable bowel syndrome ( IBS ) . The outcome measures include healthcare utilisation and quality of life . We describe the methods of the cluster r and omised trial . Discussion If the ' whole systems ' model proves effective and cost-effective , it will provide decision-makers with a model for the delivery of self-management support for population s with long-term conditions that can be implemented widely to maximise ' reach ' across the wider patient population .Trial registration numberIS RCT N : IS RCT The dem and for new healthcare services is growing rapidly . Improving accessibility of the African population to diabetes care seems to be a big challenge in most countries where the number of care centers and medical staff is reduced . Information and communication technologies ( ICT ) have great potential to address some of these challenges faced by several countries in providing accessible , cost-effective , and high- quality health care services . This paper presents the Mobil Diab system which is a telemedical approach proposed for the management of long-term diseases . The system applies modern mobile and web technologies which overcome geographical barriers , and increase access to health care services . The idea of the system is to involve patients in the therapy process and motivate them for an active participation . For validation of the system in African context , a trial was conducted in the Democratic Republic of Congo . 40 Subjects with diabetes divided r and omly into control and intervention groups were included in the test . Results show that Mobil Diab is suitable for African countries and presents a number of benefits for the population and public health care system . It improves clinical management and delivery of diabetes care services by enhancing access , quality , motivation , reassurance , efficiency , and cost-effectiveness Background Fragmentation within health care systems may negatively impact the quality of chronic disease patient care . We sought to evaluate the relationship between care management processes ( CMP ) , integration of services , and blood pressure  (  BP  ) control among diabetic patients . Methods Retrospective chart review s were performed for a r and om sample of adult diabetic hypertensive patients ( n = 2,162 ) from 28 physician organizations in the United States ( US ) . A modified version of the Physician Practice Connection Readiness Survey ( PPC-RS ) was completed by the chief medical officer at each site . The PPC-RS measured health system organization , delivery system re design , decision support , clinical information systems , and self-management support , and an integration scale measured structure , functions , and financial risk . Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients . Results Approximately 39.9 % of diabetic patients had controlled  BP . Mean total PPC score across sites was 55 , with highest mean scores for health system organization ( 81 ) , followed by design support ( 60 ) , clinical information systems ( 57 ) , self-management support ( 39 ) , and delivery system re design ( 39 ) . Mean integration score was 46 ( SD 27 , range 4–93 ) , and means of subscores were 64 for structure , 33 for financial risk , and 42 for function . Clinical information systems subscore was correlated with uncontrolled BP ( r = −0.38 , p < 0.05 ) , while association with total PPC score was strong but not significant at p < 0.05 ( r = −0.32 ) . Total integration score and the structure subscore were significantly correlated with BP control ( r = 0.38 , p < 0.05 , and r = 0.49 , p < 0.01 ) . Conclusions This study suggests that CMP and service integration may be associated with better outcomes in diabetes , though results were mixed and limited by a small number of participating sites . Primary care implementation of integrated electronic medical records may have a beneficial effect on patient outcomes for diabetes and other chronic diseases OBJECTIVE The Mayo Health System Diabetes Translation Project sought to assess models of community-based diabetes care and use of a diabetes electronic management system ( DEMS ) . Planned care is a re design ed model of chronic disease care that involves guideline implementation , support of self-management , and use of clinical information systems . RESEARCH DESIGN AND METHODS We studied adult diabetic patients attending three primary care practice sites in Wisconsin and Minnesota . We implemented planned care at all sites and DEMS in the practice of 16 primary care providers . We assessed quality of diabetes care using st and ard indicators for 200 patients r and omly selected from each site at baseline and at 24 months of implementation . We used multivariable analyses to estimate the association between planned care and DEMS and each quality indicator . RESULTS Planned care was associated with improvements in measurement of HbA(1c ) ( odds ratio 7.0 [ 95 % CI 4.2 - 11.6 ] ) , HDL cholesterol ( 5.6 [ 4.1 - 7.5 ] ) , and microalbuminuria ( 5.3 [ 3.5 - 8.0 ] ) , as well as the provision of tobacco advice ( 6.9 [ 4.7 - 10.1 ] ) , among other performance measures . DEMS use was associated with improvements in all indicators , including microalbuminuria ( 3.2 [ 1.9 - 5.2 ] ) , retinal examination ( 2.4 [ 1.5 - 3.9 ] ) , foot examinations ( 2.3 [ 1.2 - 4.4 ] ) , and self-management support ( 2.6 [ 1.7 - 3.8 ] ) . Although planned care was associated with improvements in metabolic control , we observed no additional metabolic benefit when providers used DEMS . CONCLUSIONS Planned care was associated with improved performance and metabolic outcomes in primary care . DEMS use augmented the impact of planned care on performance outcomes but not on metabolic outcomes . Optimal identification of the best translation of evidence to diabetes practice will require longer follow-up or new care-delivery models PURPOSE The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes , particularly those physicians not affiliated with an integrated care system that some managed care organizations provide . METHODS Patients with type 2 diabetes were recruited from the general population of a large metropolitan area . Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians ( basic intervention ) . A r and om one-half of patients were additionally assigned to individual counseling , problem identification , care planning , and management recommendations by a nurse care manager ( individualized intervention ) . The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention . Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C , blood pressure , and cholesterol as outcome measures . RESULTS Of 220 patients recruited , 197 had type 2 diabetes , r and omly assigned only the basic intervention ( 102 patients ) or individualized intervention ( 95 patients ) . Postintervention data were obtained on 164 patients ( 83 % ) . Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group . Patients with a systolic blood pressure > or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts . CONCLUSIONS A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes . For those many physicians not affiliated with an integrated care system featured by some managed care organizations , this collaboration could underlie a team approach ( nurse/patient/physician ) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : Interventions that have proven effective in the management of chronic illness have often been difficult to establish in widespread practice . The Chronic Care Model provides a framework for implementing interventions , but it is expensive and difficult to implement . We developed a decision support system based on this model to improve the care of adults who have diabetes and receive primary care in Vermont or adjacent New York . The Vermont Diabetes Information System uses a network of community laboratories for providing data to produce flowsheets , reminders , action alerts , and population reports that are sent to primary care providers by fax and to patients by mail . Currently , 7295 patients are cared for by 124 primary care providers in 62 practice s and are enrolled in a r and omized controlled trial to study its effects Background Depression and anxiety are common co-morbid health problems in patients with type 2 diabetes . Both depression and anxiety are associated with poor glycaemic control and increased risk of poor vascular outcomes and higher mortality rates . Results of previous studies have shown that in clinical practice , treatment of depression and anxiety is far from optimal as these symptoms are frequently overlooked and undertreated . Methods / Design This r and omised controlled trial will examine the effectiveness of a disease management programme treating symptoms of depression and anxiety  in primary care patients with Type 2 diabetes . Patients will be r and omized on patient level in 1:1 ratio . R and om block sizes of 2 and 4 are used . The disease management programme consists of screening , stepped treatment and monitoring of symptoms ( n = 80 ) . This will be compared to care as usual ( n = 80 ) . Discussion The disease management model for co-morbid depression and anxiety in primary care patients with diabetes is expected to result in reduced symptoms of depression and anxiety , improved quality of life , reduced diabetes specific distress and improved glyceamic control , compared to care as usual . Trial Registration Dutch Trial Register Disease-specific st and ards for directing patient management are becoming increasingly important . These st and ards , however , are often not followed because they are not sufficiently integrated into the clinical care setting . In this study we describe the development and evaluation of a Computer-Assisted Management Protocol ( CAMP ) of care guidelines for diabetes mellitus . While other studies have shown improved compliance with rule-based reminders , the CAMP customizes disease-specific care guidelines to individual patients over time . We evaluated the effect of the CAMP on compliance with guidelines in a prospect i ve , r and omized controlled study . The study was performed at a family practice clinic where much of the patient record is maintained electronically on The Medical Record ( TMR ) . The management protocol was developed from st and ards published by the American Diabetes Association . Fifty-eight providers were r and omized to either receive or not receive the CAMP for diabetes . Compliance with st and ards  was assessed by chart audits of all encounters with diabetic patients during the study interval . The following conclusion was made : the Computer-Assisted Management Protocol result ed in a statistically significant improvement in compliance with diabetes care st and ards OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model ( CCM ) . PARTICIPANTS AND METHODS As part of the CCM , 97 primary care physicians at 6 primary care practice s in Rochester , MN , referred 639 patients to an on-site diabetes educator between July 1 , 2001 , and December 31 , 2003 . On first referral , physicians were central ly r and omized to receive a telemedicine intervention ( specialty advice and evidence -based messages regarding medication management for cardiovascular risk ) or no intervention , keeping outcome assessors and data analysts blinded to group assignment . After each subsequent clinical encounter , endocrinologists review ed an abstract from the patient 's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail . Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes . Outcome measures included diabetes care processes ( diabetes test completion ) , outcomes ( metabolic and cardiovascular risk factors , estimated coronary artery disease risk ) , and patient costs ( payer perspective ) . RESULTS During the intervention , 951 ( 70 % ) of the 1361 endocrinology review s detected performance gaps and result ed in a message ; primary care physicians reported using 49 % of messages in patient care . With a mean of 21 months ' follow-up , the intervention , compared with control , did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease ( adjusted mean difference , -1 % ; 95 % confidence interval , -19 % to 17 % ) . The intervention group incurred lower costs ( P=.02 ) but not in diabetes-related costs . CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care ABSTRACT Background : Cardiovascular diseases and diabetes are among the leading causes of premature adult deaths in India . Innovative approaches such as clinical decision support ( CDS ) software could play a major role in improving the quality of hypertension/diabetes care in primary care setting s. Objective : To describe the steps and processes in the development of mWellcare , a complex intervention based on mobile health ( mHealth ) technology . Methods : The Medical Research Council framework was used to develop mWellcare in four steps : ( 1 ) identify gaps in usual care through literature review and health facility assessment s ; ( 2 ) identify the components of the intervention through discussion s and consultations with experts ; ( 3 ) develop intervention ( clinical algorithms and mHealth system ) ; and ( 4 ) evaluate acceptability and feasibility through pilot testing in five community health centers . Results : Lack of evidence -based , integrated , and systematic management of chronic conditions were major gaps identified . Experts in information technology , clinical fields , and public health professionals identified intervention components to address these gaps . Thereafter , clinical algorithm context ualized to primary care setting s were prepared and the mWellcare intervention was developed . During the 2-month pilot , 631 patients diagnosed with hypertension and /or diabetes were registered , with a follow-up rate of 36.2 % . The major barrier was resistance to follow mWellcare recommended patient workflow , and to overcome it , we emphasized onsite training and orientation program to cover all health care team member in each CHC . Conclusion : A pilot-tested mWellcare intervention is an mHealth system with important components , i.e. integrated management of chronic conditions , evidence -based CDS , longitudinal health data and automated short-messaging service to reinforce compliance to drug intake and follow-up visit , which will be used by nurses at primary health care setting s in India . The effectiveness and cost-effectiveness of the intervention will be tested through a cluster r and omized trial ( trial registration number NCT02480062 ) Background : The burden of noncommunicable diseases and their risk factors has rapidly increased worldwide , including in India .  Innovative management strategies with electronic decision support and task sharing have been assessed for hypertension , diabetes mellitus , and depression individually , but an integrated package for multiple chronic condition management in primary care has not been evaluated . Methods : In a prospect i ve , multicenter , open-label , cluster-r and omized controlled trial involving 40 community health centers , using hypertension and diabetes mellitus as entry points , we evaluated the effectiveness of mWellcare , an mHealth system consisting of electronic health record storage and an electronic decision support for the integrated management of 5 chronic conditions ( hypertension , diabetes mellitus , current tobacco and alcohol use , and depression ) versus enhanced usual care among patients with hypertension and diabetes mellitus in India . At trial end ( 12-month follow-up ) , using intention-to-treat analysis , we examined the mean difference between arms in change in systolic blood pressure and glycated hemoglobin as primary outcomes and fasting blood glucose , total cholesterol , predicted 10-year risk of cardiovascular disease , depression score , and proportions reporting tobacco and alcohol use as secondary outcomes . Mixed-effects regression models were used to account for clustering and other confounding variables . Results : Among 3698 enrolled participants across 40 clusters ( mean age , 55.1 years ; SD , 11 years ; 55.2 % men ) , 3324 completed the trial . There was no evidence of difference between the 2 arms for systolic blood pressure ( & Dgr;=−0.98 ; 95 % CI , −4.64 to 2.67 ) and glycated hemoglobin ( & Dgr;=0.11 ; 95 % CI , −0.24 to 0.45 ) even after adjustment of several key variables ( adjusted differences for systolic blood pressure : – 0.31 [ 95 % CI , −3.91 to 3.29 ] ; for glycated hemoglobin : 0.08 [ 95 % CI , −0.27 to 0.44 ] ) . The mean within-group changes in systolic blood pressure in mWellcare and enhanced usual care were −13.65 mm Hg versus −12.66 mm Hg , respectively , and for glycated hemoglobin were −0.48 % and −0.58 % , respectively . Similarly , there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes . Conclusions : We did not find an incremental benefit of mWellcare over enhanced usual care in the management of the chronic conditions studied . Clinical Trial Registration : URL : https://www . clinical trials.gov . Unique identifier : NCT02480062 Abstract Objective Traditionally , health systems in sub‐Saharan Africa have focused on acute conditions . Few data exist on the readiness of African health facilities ( HFs ) to address the growing burden of chronic diseases ( CDs ) , specifically chronic , non‐communicable diseases ( NCDs ) . Methods A stratified r and om sample of 28 urban and rural Ug and an HFs was surveyed to document the burden of selected CDs by analysing the service statistics , service availability and service readiness using a modified WHO Service Availability and Readiness Assessment question naire . Knowledge , skills and practice in the management of CDs of 222 health workers were assessed through a self‐completed question naire . Results Among adult outpatient visits at hospitals , 33 % were for CDs including HIV vs. 14 % and 4 % at medium‐sized and small health centres , respectively . Many HFs lacked guidelines , diagnostic equipment and essential medicines for the primary management of CDs ; training and reporting systems were weak . Lower‐level facilities routinely referred patients with hypertension and diabetes . HIV services accounted for most CD visits and were stronger than NCD services . Systems were weaker in lower‐level HFs . Non‐doctor clinicians and nurses lacked knowledge and experience in NCD care . Conclusion Compared with higher level HFs , lower‐level ones are less prepared and little used for CD care . Health systems in Ug and a , particularly lower‐level HFs , urgently need improvement in managing common NCDs to cope with the growing burden . This should include the provision of st and ard guidelines , essential diagnostic equipment and drugs , training of health workers , supportive supervision and improved referral systems . Substantially better HIV basic service readiness demonstrates that improved NCD care is feasible BACKGROUND Patients with depression and poorly controlled diabetes , coronary heart disease , or both have an increased risk of adverse outcomes and high health care costs . We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients . METHODS We conducted a single-blind , r and omized , controlled trial in 14 primary care clinics in an integrated health care system in Washington State , involving 214 participants with poorly controlled diabetes , coronary heart disease , or both and coexisting depression . Patients were r and omly assigned to the usual-care group or to the intervention group , in which a medically supervised nurse , working with each patient 's primary care physician , provided guideline -based , collaborative care management , with the goal of controlling risk factors associated with multiple diseases . The primary outcome was based on simultaneous modeling of glycated hemoglobin , low-density lipoprotein ( LDL ) cholesterol , and systolic blood-pressure levels and Symptom Checklist-20 ( SCL-20 ) depression outcomes at 12 months ; this modeling allowed estimation of a single overall treatment effect . RESULTS As compared with controls , patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels ( difference , 0.58 % ) , LDL cholesterol levels ( difference , 6.9 mg per deciliter [ 0.2 mmol per liter ] ) , systolic blood pressure ( difference , 5.1 mm Hg ) , and SCL-20 depression scores ( difference , 0.40 points ) ( P<0.001 ) . Patients in the intervention group also were more likely to have one or more adjustments of insulin ( P=0.006 ) , antihypertensive medications ( P<0.001 ) , and antidepressant medications ( P<0.001 ) , and they had better quality of life ( P<0.001 ) and greater satisfaction with care for diabetes , coronary heart disease , or both ( P<0.001 ) and with care for depression ( P<0.001 ) . CONCLUSIONS As compared with usual care , an intervention involving nurses who provided guideline -based , patient-centered management of depression and chronic disease significantly improved control of medical disease and depression . ( Funded by the National Institute of Mental Health ; Clinical Trials.gov number , NCT00468676 . ) The  Indiana Chronic Disease Management Program ( ICDMP ) is intended to improve the quality and cost-effectiveness of care for Medicaid members with congestive heart failure ( chronic heart failure ) , diabetes , asthma , and other conditions . The ICDMP is being assembled by Indiana Medicaid primarily from state and local re sources and has seven components : ( 1 ) identification of eligible participants to create regional registries , ( 2 ) risk stratification of eligible participants , ( 3 ) nurse care management for high-risk participants , ( 4 ) telephonic intervention for all participants , ( 5 ) an Internet-based information system , ( 6 ) quality improvement collaboratives for primary care practice s , and ( 7 ) program evaluation . The evaluation involves a r and omized controlled trial in two inner-city group practice s , as well as a statewide observational design . This article describes the ICDMP , highlights challenges , and discusses approaches to its evaluation PURPOSE New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients . This study ( 1 ) assessed whether chronic disease management differed among 4 models of primary health care delivery and ( 2 ) identified which practice organizational factors were independently associated with high- quality care . METHODS We undertook a cross-sectional survey with nested qualitative case studies ( 2 practice s per model ) in 137 r and omly selected primary care practice s from 4 delivery models in Ontario Canada : fee for service , capitation , blended payment , and community health centers ( CHCs ) .  Practice and clinician surveys were based on the Primary Care Assessment Tool . A chart audit assessed evidence -based care delivery for patients with diabetes , congestive heart failure , and coronary artery disease .  Intermediate outcomes were calculated for patients with diabetes and hypertension . Multiple linear regression identified those organizational factors independently associated with chronic disease management . RESULTS Chronic disease management was superior in CHCs . Clinicians in CHCs found it easier than those in the other models to promote high- quality care through longer consultations and interprofessional collaboration . Across the whole sample and independent of model , high- quality chronic disease management was associated with the presence of a nurse-practitioner . It was also associated with lower patient-family physician ratios and when practice s had 4 or fewer full-time-equivalent family physicians . CONCLUSIONS The study adds to the literature supporting the value of nurse-practitioners within primary care teams and vali date s the contributions of Ontario ’s CHCs . Our observation that quality of care decreased in larger , busier practice s suggests that moves toward larger practice s and greater patient-physician ratios may have unanticipated negative effects on processes of care quality BACKGROUND Cardiovascular disease ( CVD ) and diabetes account for over one third of the mortality difference between African Americans and white patients . The increased CVD risk in African Americans is due in large part to the clustering of multiple CVD risk factors . OBJECTIVES The current study is aim ed at improving CVD outcomes in African-American adults with diabetes by addressing the modifiable risk factors of systolic blood pressure , glycosylated hemoglobin , and low-density lipoprotein cholesterol . METHODS A sample of African American patients with diabetes ( N = 400 ) will receive written education material at baseline and be r and omized to one of 2 arms : ( 1 ) usual primary care or ( 2 ) nurse-administered disease-management intervention combining patient self-management support and provider medication management . The nurse administered intervention is delivered monthly over the telephone . The nurses also interacts with the primary care providers at 3 , 6 , and 9 months to provide concise patient up date s and facilitate changes in medical management . All patients are followed for 12 months after enrollment . The primary outcomes are change in glycosylated hemoglobin , systolic blood pressure , and low-density lipoprotein cholesterol over 12-months . Secondary outcomes include change in overall cardiovascular risk , aspirin use , and health behaviors . CONCLUSION Given the continued racial disparities in CVD , the proposed study could result in significant contributions to cardiovascular risk reduction in African-American patients Background  Quality indicators ( QIs ) are an important tool for improving clinical practice and are increasingly being developed from evidence -based guideline recommendations . We aim ed to identify , select and apply guideline recommendations to develop a set of QIs to measure the implementation of evidence -based practice using routinely recorded clinical data in United Kingdom ( UK ) primary care . Methods We review ed existing national clinical guidelines and QIs and used a four-stage consensus development process to derive a set of ‘ high impact ’ QIs relevant to primary care based upon explicit prioritisation criteria . We then field tested the QIs using remotely extracted , anonymised patient records from 89 r and omly sample d primary care practice s in the Yorkshire region of Engl and . Results Out of 2365 recommendations and QIs originally review ed , we derived a set of 18 QIs ( 5 single , 13 composites – comprising 2–9 individual recommendations ) for field testing . QIs predominantly addressed chronic disease management , in particular diabetes , cardiovascular and renal disease , and included both processes and outcomes of care . Field testing proved to be critical for further refinement and final selection . Conclusions We have demonstrated a rigorous and transparent methodology to develop a set of high impact , evidence -based QIs for primary care from clinical guideline recommendations . While the development process was successful in developing a limited set of QIs , it remains challenging to derive robust new QIs from clinical guidelines in the absence of established systems for routine , structured recording of clinical care There continues to be a need for improved medical management of diabetes patients with hypertension in primary care . While several care models have shown effectiveness in achieving various outcomes among these patients , it remains unclear what care model is most effective in improving blood pressure control in primary care . In this prospect i ve study , 54 patients with type 2 diabetes mellitus and blood pressure of > 140/90 identified through the registry , were r and omized into three groups . Group A attended a nurse educator-conducted class on diabetes and hypertension , group B attended the same class and was asked to monitor their home blood pressure using provided device , and group C served as control ( usual care ) . Of the 24 subjects who completed the study , only 20 % achieved the target blood pressure of < 130/80 and there was no statistical difference in mean systolic and diastolic blood pressures among the three groups ( p > 0.05 ) . Efforts to intensify management of hypertension among type 2 diabetes patients did not result in better blood pressure control compared to usual care . Studies looking into factors which limit patients ’ participation in group classes and determining patients ’ preferences in disease management would be helpful in ensuring success of any chronic disease management program Thail and has a history of implementing innovative and proactive policies to address the health needs of its population . Since 1962 Thail and has implemented initiatives that led to it having a health system characterized by a primary care focus , de central ization and mechanisms to maximize equity and universal access to basic care at the local level . Thai health structures initially evolved to meet challenges including infectious and developmental diseases and later HIV . Early in the 21st century chronic illness rapidly became the greatest cause of morbidity and mortality and the question has arisen how Thail and can adapt its strong health system to deal with the new epidemics . This article describes an effort to reorient provincial health services to meet the needs of the increasing number of people with diabetes and heart disease . It describes measures taken to build on the equity-promoting elements of the Thai health system . The project included ; a situational analysis , development and implementation of a chronic disease self-management intervention implemented by nurses and alignment of provincial health services . The self-management intervention is currently being evaluated within a clustered r and omized control trial . The evaluation has been developed to fit with the focus on equity in relation to both selection criteria and the outcomes that are being assessed Background The prevalence of type 2 diabetes is rising internationally . Patients with diabetes have a higher risk of cardiovascular events accounting for substantial premature morbidity and mortality , and health care expenditure . Given healthcare workforce limitations , there is a need to improve interventions that promote positive self-management behaviours that enable patients to manage their chronic conditions effectively , across different cultural context s. Previous studies have evaluated the feasibility of including telephone and Short Message Service ( SMS ) follow up in chronic disease self-management programs , but only for single diseases or in one specific population . Therefore , the aim of this study is to evaluate the feasibility and short-term efficacy of incorporating telephone and text messaging to support the care of patients with diabetes and cardiac disease , in Australia and in Taiwan . Methods / design A r and omised controlled trial design will be used to evaluate a self-management program for people with diabetes and cardiac disease that incorporates the use of simple remote-access communication technologies .  A sample size of 180 participants from Australia and Taiwan will be recruited and r and omised in a one-to-one ratio to receive either the intervention in addition to usual care ( intervention ) or usual care alone ( control ) . The intervention will consist of in-hospital education as well as follow up utilising personal telephone calls and SMS reminders . Primary short term outcomes of interest include self-care behaviours and self-efficacy assessed at baseline and four weeks . Discussion If the results of this investigation substantiate the feasibility and efficacy of the telephone and SMS intervention for promoting self management among patients with diabetes and cardiac disease in Australia and Taiwan , it will support the external validity of the intervention . It is anticipated that empirical data from this investigation will provide valuable information to inform future international collaborations , while providing a platform for further enhancements of the program , which has potential to benefit patients internationally . Trial registration ACTRN 12611001196932 Carle 's Medicare Coordinated Care Demonstration care/disease management interventional components , based on the chronic care model , are described for elderly patients in 13 counties in Illinois . Patients enrolled in the program are diagnosed with chronic obstructive pulmonary disease , coronary artery disease , diabetes , atrial fibrillation , or congestive heart failure . Primary care teams are made up of a primary care physician , an advanced practice nurse , a nurse case manager , and a case assistant . The patient/family is the cornerstone of the intervention , which is evaluated using a prospect i ve , longitudinal r and omized treatment-control design Background Most research publications on Chronic Care Model ( CCM ) implementation originate from organizations or countries with a well-structured primary health care system . Information about efforts made in countries with a less well-organized primary health care system is scarce . In 2003 , the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting , a setting where the organisational framework for chronic care is mainly hospital-centered . Methods Process evaluation of an action research project ( 2003–2007 ) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients . In consultation with the region a program for type 2 diabetes patients was developed . The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey ( ACIC ) . A multi method approach was used to evaluate the implementation process . The result ing data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process . Results The overall ACIC score improved from 1.45 ( limited support ) at the start of the study to 5.5 ( basic support ) at the end of the study . The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care . The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator . Important barriers were the complexity of the intervention , the lack of quality data , inadequate information technology support , the lack of commitment procedures and the uncertainty about sustainable funding . Conclusion Guided by the CCM , this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure . The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers . Currently primary care providers lack the opportunities to take up full responsibility for chronic care . Trial registration number Clinical Trials.gov Identifier : ABSTRACT BACKGROUND Churches may provide a familiar and accessible setting for chronic disease self-management education and social support for Latinos with diabetes . OBJECTIVE We assessed the impact of a multi-faceted church-based diabetes self-management intervention on diabetes outcomes among Latino adults . DESIGN This was a community-based , r and omized controlled , pilot study .SUBJECTSOne-hundred adults with self-reported diabetes from a Midwestern , urban , low-income Mexican-American neighborhood were included in the study . INTERVENTIONS Intervention participants were enrolled in a church-based diabetes self-management program that included eight weekly group classes led by trained lay leaders . Enhanced usual care participants attended one 90-minute lecture on diabetes self-management at a local church . OUTCOME MEASURES The primary outcome was change in glycosylated hemoglobin ( A1C ) . Secondary outcomes included changes in low-density lipoproteins ( LDL ) , blood pressure , weight , and diabetes self-care practice s . KEY RESULTS Participants ’ mean age was 54 ± 12 years , 81 % were female , 98 % were Latino , and 51 % were uninsured . At 3 months , study participants in both arms decreased their A1C from baseline ( −0.32 % , 95 % confidence interval [ CI ] : -0.62 , -0.02 % ) . The difference in change in A1C , LDL , blood pressure and weight from baseline to 3-month and 6-month follow-up was not statistically significant between the intervention and enhanced usual care groups . Intervention participants reported fewer days of consuming high fat foods in the previous week ( −1.34 , 95 % CI : -2.22 , -0.46 ) and more days of participating in exercise ( 1.58 , 95 % CI : 0.24 , 2.92 ) compared to enhanced usual care from baseline to 6 months . CONCLUSIONS A pilot church-based diabetes self-management intervention did not reduce A1C , but result ed in decreased high fat food consumption and increased participation in exercise among low-income Latino adults with diabetes .  Future church-based interventions may need to strengthen linkages to the healthcare system and provide continued support to participants to impact clinical outcomes OBJECTIVES To explore changes in mortality and hospital usage for chronically ill seniors enrolled in a multidisease care management program , Care Management Plus ( CMP ) .  DESIGN Controlled clinical trial with seven intervention and six control clinics with additional patient-level matching . SETTING Intermountain Health Care , a large health system in Utah ; seven intervention and six control clinics . PARTICIPANTS Three thous and four hundred thirty-two senior patients ( > or=65 ) enrolled in Medicare . INTERVENTION The intervention employed nurse care managers supported by specialized information technology in primary care to manage chronically ill patients ( 2002 - 2005 ) . MEASUREMENTS Mortality and hospitalization data were collected from clinical records and Medicare billing . RESULTS One thous and one hundred forty-four intervention patients were matched to 2,288 controls . Average age was 76.2 ; average comorbidity score was 2.3+/-1.1 ; 75 % of patients had two or more chronic diseases . Survival analyses showed lower mortality and slightly more emergency department visits for care managed patients than for controls . In patients with diabetes mellitus , the intervention result ed in significantly lower mortality at 1 year ( 6.2 % , vs 10.6 % for controls ) and at 2 years ( 12.9 % vs 18.2 % ) . Hospitalization rate was lower ( 21.0 % , vs. 24.2 % for controls ) at 1 year and substantially more so at the 2-year follow-up . CONCLUSION CMP was successful in reducing death for all patients . For complex patients with diabetes mellitus in the intervention group , death and hospital usage were lower . Per clinic , hypothesized savings from decreased hospitalizations was $ 17,384 to $ 70,349 BACKGROUND The design of delivery systems that can truly conduct continuous quality improvement ( CQI ) as a routine part of clinical care provision remains a vexing problem . The effectiveness of the " computerized firm system " approach to chronic disease CQI was examined , with diabetes as the focus of a 5-year case study . METHODS A large family medical center had been divided into two parallel group practice s for reasons of efficiency . These frontline structures ( also known as primary care " firms " ) were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups . Because all the required longitudinal data were contained in a computerized repository , it was possible to conduct these controlled " firm trials " in a matter of months at low cost . RESULTS During a 3-year period , implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin ( HbA1c ) testing by 50 % ( p = 0.02 ) and reduced the number of diabetic patients inadequately controlled by 43 % ( p < 0.01 ) . Following this outcome improvement , patients exhibited a 16 % reduction in ambulatory visit rates ( p = 0.04 ) . The observed outcome improvement , however , was reversed during the subsequent 2 years , when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions . CONCLUSIONS The processes and outcomes of diabetes care were improved , demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence -based management . Health care systems can , by conducting serial firm trials , become learning organizations . CQI programs of all kinds will likely never flourish , however , until quality improvement and reimbursement mechanisms have become better aligned Background The 2013 Global Burden of Disease Study demonstrated the increasing burden of diabetes and the challenge it poses to the health systems of all countries . The chronic and complex nature of diabetes requires active self-management by patients in addition to clinical management in order to achieve optimal glycaemic control and appropriate use of available clinical services . This study is an evaluation of a “ real world ” peer support program aim ed at improving the control and management of type 2 diabetes ( T2DM ) in Australia . Methods The trial used a r and omised cluster design with a peer support intervention and routine care control arms and 12-month follow up . Participants in both arms received a st and ardised session of self-management education at baseline . The intervention program comprised monthly community-based group meetings over 12 months led by trained peer supporters and active encouragement to use primary health care and other community re sources and supports related to diabetes .  Clinical , behavioural and other measures were collected at baseline , 6 and 12 months . The primary outcome was the predicted 5 year cardiovascular disease risk using the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) Risk Equation at 12 months . Secondary outcomes included clinical measures , quality of life , measures of support , psychosocial functioning and lifestyle measures . Results Eleven of 12 planned groups were successfully implemented in the intervention arm . Both the usual care and the intervention arms demonstrated a small reduction in 5 year UKPDS risk and the mean values for biochemical and anthropometric outcomes were close to target at 12 months . There were some small positive changes in self-management behaviours . Conclusions The positive changes in self-management behaviours among intervention participants were not sufficient to reduce cardiovascular risk , possibly because approximately half of the study participants already had quite well controlled T2DM at baseline . Future research needs to address how to enhance community based programs so that they reach and benefit those most in need of re sources and supports to improve metabolic control and associated clinical outcomes .Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) ACTRN12609000469213 . Registered 16 June 2009 Background More than half of the patients with type 2 diabetes ( T2DM ) patients are diagnosed with one or more comorbid disorders . They can participate in several single-disease oriented disease management programs , which may lead to fragmented care because these programs are not well prepared for coordinating care between programs . Comorbid patients are therefore at risk for suboptimal treatment , unsafe care , inefficient use of health care services and unnecessary costs . Case management is a possible model to counteract fragmented care for comorbid patients . It includes evidence -based optimal care , but is tailored to the individual patients ' preferences . The objective of this study is to examine the effectiveness of a  case management program , in addition to a diabetes management program , on the quality of care for comorbid T2DM patients . Methods / Design The study is a r and omized controlled trial among patients with T2DM and at least one comorbid chronic disease ( N = 230 ) , who already participate in a diabetes management program .  R and omization will take place at the level of the patients in general practice s. Trained practice nurses ( case managers ) will apply a case management program in addition to the diabetes management program . The case management intervention is based on the Guided Care model and includes six elements ; assessing health care needs , planning care , create access to other care providers and community re sources , monitoring , coordinating care and recording of all relevant information . Patients in the control group will continue their participation in the diabetes management program and receive care-as-usual from their general practitioner and other care providers . Discussion We expect that the case management program , which includes better structured care based on scientific evidence and adjusted to the patients ' needs and priorities , will improve the quality of care coordination from both the patients ' and caregivers ' perspective and will result in less consumption of health care services . Trial registration Netherl and s Trial Register ( NTR ) : PURPOSE Clinical guidelines are design ed to assist in the management of specific diseases ; however , these guidelines are often neglected in the delivery of care . The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having , at the patient visit , a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient 's electronic medical record . SUBJECTS AND METHODS In a 6-month controlled trial at a primary care clinic , 58 primary care clinicians were r and omized to receive either a special encounter form with the computer-generated guideline recommendations or a st and ard encounter form . The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations . Data from 30 clinicians were analyzed ; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care . RESULTS Availability of patient management recommendations generated by the decision support system result ed in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus ( P = 0.01 ) . Median compliance for the group receiving the recommendations was 32.0 % versus 15.6 % for the control group . CONCLUSION Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients . This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care st and ards . Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care BACKGROUND Drawing on previous web-based diabetes management programs based on the Chronic Care Model , we exp and ed an intervention to include care management through mobile phones and a game console web browser . METHODS The pilot intervention enrolled eight diabetes patients from the University of Washington in Seattle into a collaborative care program : connecting them to a care provider specializing in diabetes , providing access to their full electronic medical record , allowing wireless glucose uploads and e-mail with providers , and connecting them to the program 's web services through a game system . To evaluate the study , we conducted qualitative thematic analysis of semistructured interviews . RESULTS Participants expressed frustrations with using the cell phones and the game system in their everyday lives , but liked the wireless system for collaborating with a provider on uploaded glucoses and receiving automatic feedback on their blood sugar trends . A majority of participants also expressed that their participation in the trial increased their health awareness . DISCUSSION Mobile communication technologies showed promise within a web-based collaborative care program for type 2 diabetes . Future intervention design should focus on integrating easy-to-use applications within mobile technologies already familiar to patients and ensure the system allows for sufficient collaboration with a care provider BACKGROUND Diabetes constitutes a major burden of disease globally . Both primary and secondary prevention need to improve in order to face this challenge . Improving management of diabetes in primary care is therefore of fundamental importance . OBJECTIVE The objective of these series of audits was to find means of improving diabetes management in chronic disease mini-clinics in primary health care . In the process , we were able to study the effect and practical usefulness of different audit design s - those measuring clinical outcomes , process of care , or both . SETTING King Saud City Family and Community Medicine Centre , Saudi National Guard Health Affairs in Riyadh city , Saudi Arabia . METHODS Simple r and om sample s of 30 files were selected every two weeks from a sampling frame of file numbers for all diabetes clients seen over the period . Information was transferred to a form , entered on the computer and an automated response was generated regarding the appropriateness of management , a criterion mutually agreed upon by care providers . The results were plotted on statistical process control charts , p charts , displayed for all employees . Data extraction , archiving , entry , analysis , plotting and design and preparation of p charts were managed by nursing staff specially trained for the purpose by physicians with relevant previous experience . RESULTS Audit series with mixed outcome and process measures failed to detect any changes in the proportion of non-conforming cases over a period of one year . The process measures series , on the other h and , showed improvement in care corresponding to a reduction in the proportion non-conforming by 10 % within a period of 3 months . Non-conformities dropped from a mean of 5.0 to 1.4 over the year ( P < 0.001 ) . CONCLUSION It is possible to improve providers ' behaviour regarding implementation of given guidelines through periodic process audits and feedbacks . Frequent process audits in the context of statistical process control should be supplemented with concurrent outcome audits , once or twice a year Context Little is known about the effects of quality -of-care improvement programs on the process of care and outcomes of diabetes . Contribution The study involved 8661 patients with diabetes , 63 provider groups , and 3 disease management strategies ( provider feedback , reminders , and structured care )  . The quality measures included 8 processes of care , 3 intermediate diabetes outcomes , and medication management of these outcomes . More intense disease management strategies predicted higher measures of many processes of care but only 1 intermediate outcome and 1 medication management outcome . Implication s The disease management strategies improved processes of care but not outcomes . Experts in quality improvement may need to refocus their efforts . The Editors Persons with diabetes continue to receive suboptimal care ( 16 ) . To improve quality , many health systems have implemented disease management programs for diabetes and other chronic conditions ( 79 ) . These programs typically incorporate population -based strategies , such as disease registries , clinical guidelines , performance feedback , physician reminders , self-management support for patients , and targeted case management for high-risk patients ( 10 ) . Evidence for the effectiveness of disease management comes primarily from small efficacy trials ( 1020 ) . Such studies consistently found improved processes of diabetes care ; however , improvements in outcomes ( such as control of cardiovascular disease risk factors ) were less consistent ( 12 , 17 , 18 , 2022 ) . Furthermore , most studies evaluated only 1 or 2 strategies ( instead of multicomponent programs ) in selected clinical setting s. It is unclear how well findings from these smaller studies apply to entire patient population s. Many components of disease management focus on improving processes of care . Early performance measurement projects , such as the Health Plan Employer Data Information System ( 23 ) and the Diabetes Quality Improvement Program ( 5 ) , emphasized the importance of such processes as annual retinal screening or hemoglobin A1c determination . Particularly for health plans , process measures are more readily available than are outcomes data . However , if disease management is to improve patient outcomes , it must also improve intermediate outcomes , such as hemoglobin A1c levels , systolic blood pressure , and serum low-density lipoprotein ( LDL ) cholesterol levels . Translating Research into Action for Diabetes ( TRIAD ) ( 24 ) is a multicenter study of diabetes care in managed care . The TRIAD study 's central hypothesis is that health care systems features can affect quality of care . Here , we examine how 3 disease management strategies vary in intensity across physician groups and whether physician groups with more intensive disease management have higher quality of diabetes care . We assess quality by processes of care , by levels of intermediate outcomes , and by current clinical management of these outcomes . Methods Overview of the TRIAD Study and Sample The TRIAD study 's sampling frame , methods , key hypotheses , and power calculations are detailed elsewhere ( 24 ) . The study comprised 6 collaborating translational research centers that were partnered with 10 managed care health plans in 7 states . Of the 10 plans , 7 contracted with 1 to 26 physician groups ( total , 68 groups ) , whereas 4 plans directly contracted with individual physicians . A st and ard algorithm was applied to automated pharmacy , laboratory utilization , and inpatient and outpatient diagnostic data ( 25 ) to identify all community-dwelling patients with diabetes who were 18 years of age and older and who had been continuously enrolled in the TRIAD health plan for at least 18 months . The study cohort was r and omly sample d from this population . Sample d patients were recruited between July 2000 and October 2001 by using computer-assisted telephone interviews or written surveys that were conducted in English or Spanish . Eligibility was confirmed if patients verified that they had had diabetes for at least 12 months and had received most of their diabetes care through the TRIAD health plan . Permission was sought from all respondents to request copies of their outpatient medical records for the previous 18 months . All health plan and physician group directors received mailed surveys ( Appendix Figure ) during the same interval . Face-to-face or telephone interviews were used to complete and clarify responses . Each director was offered $ 100 for completing the survey . Appendix Figure . Translating Research into Action for Diabetes ( TRIAD ) Physician Group Survey . The TRIAD study was review ed and approved by the institutional review boards of each research center and by the Centers for Disease Control and Prevention ( CDC ) . Informed consent was obtained from all survey respondents . Data Sources Patient surveys included questions on health status , diabetes duration , current diabetes treatment , and demographic characteristics .  Of 13086 contacted and eligible persons , 11927 ( 91 % ) completed the survey ( 56.6 % by computer-assisted telephone interview and 43.4 % by written survey ) ( Figure ) . We were unable to contact many individuals . Using a practice that is endorsed by the Council of American Survey Research Organizations ( 26 ) , we assumed that persons whom we could not contact or for whom we could not confirm eligibility had the same eligibility rate as those contacted . Under that assumption , the response rate was 69 % . Figure . Description of sampling and response rate . xx Of 11927 patients who completed a survey , 8661 ( 73 % ) consented to medical record review and subsequently had charts available for review . Central ly trained review ers used st and ardized data collection software to abstract process measures , most recent levels of hemoglobin A1c , upper limits of normal for hemoglobin A1c measurements that were recorded , serum LDL cholesterol levels , systolic blood pressure , current medications , and comorbid conditions . Interrater reliability ( ) for the main quality measures ranged from 0.86 to 0.94 . All 10 health plan directors and 52 of 68 physician group directors completed surveys . Surveys assessed organizational age , size , structure , profit status , insurance products , contracting arrangements , history of involvement with managed care , and detailed information on the organization 's use of diabetes disease management strategies . Of the physician groups that did not respond ( 443 participants ) , 11 existed solely for the purpose of contracting with plans and had no diabetes disease management . These physician groups were assumed to have no care management strategies and were included in the analyses , as were patient groups ( 1150 participants ) from the 4 health plans that contracted directly with physicians . The remaining 5 groups ( 159 participants ) did not respond and were excluded from analyses ( Figure ) . Consequently , the result ing sample included a total of 8661 survey respondents with charts available for review and data from 63 physician groups and 4 additional health plans ( Figure ) . Mean duration of diabetes , body mass index , and health status did not meaningfully differ between persons whose medical records and physician group variables were available to the study team and those whose records were unavailable . Predictors , End Points , and Covariates The primary predictors were 3 measures of the intensity of disease management strategies : physician reminders , performance feedback , and structured care .  These were calculated for physician groups and health plans from multiple survey items . A detailed description of the methods used to calculate composite intensity scores is provided in Appendix 2 . Selected item-level responses for physician groups in the most intense versus least intense tercile of each strategy are displayed in Table 1 . Table 1 . Selected Item-Level Responses for Provider Groups for Each Disease Management Strategy * The physician reminders intensity score was derived from 2 questions , which detailed the types and content of the reminders physicians received . Groups whose use of reminders represented the upper tercile of intensity were found to have reminded physicians about 4 care processes on average . Most groups in the upper tercile delivered reminders electronically at the point of care . Performance feedback intensity was obtained by tallying responses to a checklist of possible diabetes process and outcome feedback items . A total of 86 % and 82 % of groups in the upper tercile included levels of hemoglobin A1c and serum LDL cholesterol , respectively , in feedback to physicians ( Table 1 ) . Physician feedback focused on many of the same elements of care as reminders . The use of formal case management , diabetes guidelines , patient reminders , and diabetes education correlated highly in physician groups ( Pearson correlation coefficients ranged from 0.63 to 0.88 ) ; therefore , we could not look at these approaches independently . Consequently , we combined the 4 approaches into a single composite score for structured diabetes care management . Use of formal case management was assessed by the  proportion of patients with diabetes who were enrolled  , the  number of case managers per 10000 patients  , the extent to which the program targeted high-risk patients , and a checklist of case management activities . The clinical guidelines were scored to reflect the extent of implementation . The highest score was assigned to physician groups that incorporated guidelines into automated physician or patient reminders . Patient reminder intensity incorporated the number , type , and frequency of reminders sent . On average , physician groups in the upper tercile had diabetes education as a covered benefit , whereas those in the lowest tercile generally did not have these programs . Because of the differing numbers of questions and wide range of possible values within each intensity score , each question was z-transformed to a mean of 0.0 and st and ard deviation near or equal to 1.0 to facilitate comparison . The Diabetes Control and Complications Trial ( DCCT ) and the Kumamoto study [ 1 , 2 ] showed that near-normal glycemic control reduces the development and progression of microvascular and neuropathic complications by approximately 50 % in type 1 and type 2 diabetes mellitus . Additional analyses [ 3 - 5 ] indicate that therapy to achieve near normalization of blood glucose levels is cost-effective compared with other treatments . Thus , the American Diabetes Association has recommended that all persons with diabetes attempt to achieve near normalization of blood glucose levels [ 6 ] . This recommendation is not routinely followed in medical practice . In a 1989 national survey of physician practice behaviors in the United States , 64 % of physicians agreed that achieving target HbA1c values is very important but only 18 % reported that they ordered HbA1c tests every 2 to 3 months for patients with type 1 diabetes [ 7 ] . Although 98 % agreed that patient education improves glucose control , only 55 % reported that they routinely used a dietitian or a diabetes educator in patient care . Studies indicate that bringing clinical practice into line with scientific knowledge can be difficult . Methods used to achieve diabetes control in clinical trials are re source intensive . The American Diabetes Association currently recommends that patients with diabetes see their primary care physicians two to four times per year . Data from the National Health Interview Survey , a nationally representative survey [ 8 ] , indicate that most patients with diabetes are seen by nonspecialists and that 69 % of physician visits last less than 15 minutes . Algorithms for diabetes care exist but may be complex and difficult for physicians to follow , given patient load , diversity of patients seen , lack of information systems , and time constraints . Simple , low-cost methods of translating guidelines into clinical care are required . One solution may be to make greater use of personnel other than physicians . Nurse case management was an integral part of intensive therapy in the DCCT and has proven to be effective in reducing smoking and cholesterol levels after acute myocardial infa rct ion [ 3 , 9 ] . A nonr and omized study [ 10 ] of more than 700 patients with diabetes in a health maintenance organization suggests that nurse case management may be effective in improving metabolic control . Other studies [ 11 , 12 ] show a strong association between algorithm-directed nurse interventions and improved glycemic control . To our knowledge , no r and omized , controlled clinical trial of nurse case management in diabetes has yet been published . In a 12-month r and omized , controlled trial , we compared a nurse case management model of diabetes care with usual diabetes management in a primary care setting . Methods Patients Our study was approved by the institutional review board of the Prudential Center for Health Care Research , and all patients gave written informed consent . Participants were recruited from two of the largest clinics within the Jacksonville Health Care Group , which is the largest provider of primary care services for the Prudential HealthCare HMO plan of Jacksonville , Florida . The Jacksonville Health Care Group is a group of 43 primary care physicians who provide care in eight clinics to more than 75 000 Prudential HealthCare plan members . Potential study participants were identified through a data base used to support quality -improvement activities . Prudential HealthCare HMO members who had diabetes were included in the data base if they had visited a physician for diabetes ( International Classification of Diseases , 9th Revision , codes 250.0 to 250.9 ) , had had a hospital cl aim processed for diabetes , had been seen by the utilization management nurse , or had been referred to an ophthalmologist for a diabetic retinal examination . This data base is up date d regularly . A list with each member 's name , address , telephone number , medical record number , member identification number , age , sex , physician , and clinic was generated by merging the data from the data base with enrollment information . In addition , a list of members who may have had diabetes was created by using pharmacy data . Adult members with diabetes who were potential study participants each received a recruitment call and were invited to schedule an appointment with a research assistant to discuss participation in the study . We made a total of 14 calls at different times and on different days before coding a member as unavailable . After consent was given and the eligibility assessment was completed , baseline information was obtained and an HbA1c test was ordered if the result of one given within the previous 60 days was not available . Patients were ineligible for the study if they had a recent HbA1c value less than 7.0 % ; had uncontrolled hypertension ( blood pressure > 180/110 mm Hg ) ; had unstable angina ( class 4 ) ; had had a myocardial infa rct ion in the past 3 months ; had had two or more episodes of seizures ; had alcoholism or drug abuse documented in the chart ; had late-stage complications of diabetes or other chronic conditions , such as severe immunodeficiency or cirrhosis ; were pregnant or were planning to become pregnant in the next 12 months ; or were unable to perform self-management . Patients were r and omly assigned in blocks to either the nurse case management ( intervention ) group or the usual care group . R and omization was based on a 1:1 allocation ratio and a block size of three . Each block contained six patients , three in each study group . This r and omization scheme ensured that the desired allocation ratio-one intervention patient to one usual care patient-was maintained after sequential enrollment of every sixth patient . Outcome Measures Change in HbA1c value was the primary outcome measure . Decreased HbA1c values correlate directly with reduced risk for diabetes-related microvascular and neuropathic complications in type 1 and type 2 diabetes [ 1 , 3 ] . We also assessed health-related quality of life by using four generic questions developed by the Centers for Disease Control and Prevention for the Behavioral Risk Factor Surveillance System ( BRFSS ) [ 13 , 14 ] . These questions evaluate key conceptual domains of health-related quality of life : 1 ) patient-perceived general health status , 2 ) patient-perceived physical dysfunction during the previous 30 days , 3 ) patient-perceived mental dysfunction during the previous 30 days , and 4 ) patient-perceived functional incapacity during the previous 30 days for either mental or physical reasons . The BRFSS quality -of-life measures have been vali date d in a national sample of adults in the United States [ 15 ] . Patient-perceived health was found to be a good proxy indicator for chronic disease conditions . The other three domains further characterize general health functioning and quality of life [ 15 ] . In this analysis , we report findings related to the patient-perceived general health status domain . Intervention and Follow-up The nurse case manager was a registered nurse and a certified diabetes educator . She was trained to follow a set of detailed management algorithms under the direction of a board-certified family medicine physician and an endocrinologist who were responsible for all diabetes management decisions for patients in the intervention group but were not primary care providers for these patients . The algorithms were specific for type of diabetes and were developed by a multidisciplinary team on which endocrinology , family medicine , nursing , pharmacy , health services research , and epidemiology were represented . The algorithms progressively moved a patient toward improvement of glycemic control through adjustments in medication , meal planning , and reinforcement of exercise ( Figure 1 ) . Figure 1 . Algorithm for management of type 2 diabetes mellitus . Patients assigned to receive nurse case management met with the nurse for an initial assessment , were instructed about a blood glucose monitoring schedule , and returned for a follow-up visit 2 weeks later . The initial visit with the nurse averaged 45 minutes . At the 2-week follow-up visit , the nurse review ed the patient 's blood glucose log ; explained the algorithm step to which the patient had been assigned ; and used this information as the baseline for subsequent medication adjustments , meal planning , and exercise reinforcement . Patients receiving nurse case management  were also referred to a 5-week , 12-hour diabetes education program that included individual counseling by a dietitian , individual counseling by an exercise therapist , and group diabetes education classes . Subsequent in-person follow-up visits occurred quarterly . Patients in the nurse case management group  who were taking insulin  received weekly follow-up telephone calls . After the nurse review ed the blood glucose log and discussed glucose values with the patient , medication regimens were adjusted as needed and meal planning and exercise were reinforced . Patients treated with oral agents or diet and exercise  received follow-up telephone calls every 2 weeks . The nurse case manager met at least biweekly with the family medicine physician and the endocrinologist to review patient progress , medication adjustments , and other issues related to diabetes care . All medication adjustments or changes were communicated to the patients ' regular primary care physicians . Patients assigned to receive usual care were given blood glucose meters and strips , were encouraged to discuss enrollment in the diabetes education class with their physicians if they had not done so in the past year , and continued to receive diabetes care and follow-up from their primary care physicians . The 5-week diabetes education program is a st and ard , free-of-charge benefit for all HMO members with diabetes . All Jacksonville Health Care Group primary care physicians participate in an annual diabetes care seminar and undergo regular peer review of their adherence to published diabetes care st and ards . Tests to BACKGROUND Information technology has potential to improve health care delivery particularly among individuals with chronic diseases such as diabetes in low and middle-income countries ( LMIC ) . Research on the usefulness of information technology to manage persons living with chronic diseases is scarce in LMIC . We sought to evaluate the effect of an electronic reminder system on cardiovascular risk factors ( blood pressure , heart rate , and fasting plasma glucose ) and adherence to clinical appointments among persons living with diabetes . RESEARCH DESIGN AND METHODS A r and omized controlled design was used to recruit 200 diabetic patients ( intervention n=100 , control n=100 ) from the National Diabetes Management Research Centre , Accra . All patients received usual diabetes care . The intervention group was given electronic reminders for their clinical appointments and their physicians were prompted with abnormal laboratory results for six months . RESULTS Baseline characteristics were largely similar for both groups . At six months follow up , the mean reductions of all the cardiovascular risk factors in the intervention group were significantly greater than in the control group : -1.7 kg/m(2 ) versus -1.1 kg/m(2)(p=0.002 ) for BMI ; -4.7 mmHg versus -2.8 mmHg ( p=0.002 ) for SBP ; -5.3 mmH versus -3.1 mmHg ( p=0.001 ) for DBP ; -1.7 bpm versus -0.1 bpm ( p=0.001 ) for heart rate and -2.3 mmol/L versus -1.6 mmol/L ( p=0.001 ) for fasting plasma glucose , respectively . Adherence to appointment schedules was also significantly higher in the intervention group compared with the control group ( 97.8 % versus 89.4 % , p=0.010 ) . CONCLUSIONS Locally developed electronic initiatives such as this result ed in improved cardiovascular risk factors and effective compliance to clinical practice s and improved quality of care for persons living with diabetes
The effect on patient outcomes remained less clear as these were rarely assessed .
Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes .
Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes .
REVIEW ER 'S CONCLUSIONS Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .
Organisational interventions that improve regular prompted recall and review of patients ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management .
The addition of patient-oriented interventions can lead to improved patient health outcomes .
BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care .
Different systems have been proposed to manage diabetes care .