Organizational Factors Associated With Self-management Behaviors in Diabetes Primary Care Clinics

Department of Health Care Administration, Trinity University, San Antonio, TX 78212-7200, USA.
The Diabetes Educator (Impact Factor: 1.79). 09/2009; 35(5):843-50. DOI: 10.1177/0145721709342901
Source: PubMed


The purpose of this article is to examine the relationship between organizational characteristics as measured by the Chronic Care Model (CCM) and patient self-management behaviors among patients with type 2 diabetes.
The study design was cross-sectional. The study setting included 20 primary care clinics from South Texas. The sample included approximately 30 consecutive patients that were enrolled from each clinic for a sample of 617 patients. For the data collection procedures, the CCM survey was completed by caregivers in the clinic. Self-management behaviors were obtained from patient exit surveys. For measures, the CCM consisted of 6 structural dimensions: (1) organization support, (2) community linkages, (3) self-management support, (4) decision support system, (5) delivery system design, and (6) clinical information systems. Patient self-management behavior included whether the patient reported always doing all 4 of the following behaviors as they were instructed: (1) checking blood sugars, (2) following diabetes diet, (3) exercising, and (4) taking medications. For data analyses, to account for clustering of patients within clinics, hierarchical logistic regression models were used.
Self-management support was positively associated with medication adherence, while decision support system was positively associated with exercise and all 4 self-management behaviors. Surprisingly, community linkages were negatively associated with medication adherence, while clinical information system was negatively associated with diet and all 4 behaviors. A total score, including all dimensions, was positively associated with only exercise.
Health care providers and diabetes educators in primary care clinics should consider how organizational characteristics of the clinic might influence self-management behaviors of patients. The focus should be on better access to evidence-based information at the point of care and self-management needs and activities.

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    • "Some may question non-clinicians’ ability to accurately judge the quality of chronic illness care; however, the present findings suggest that several subscales of the ACIC as rated by diverse teams of practice members ranging from physicians to front office staff are weakly associated with patients’ own perceptions of their chronic illness care. These results build upon prior literature suggesting that the ACIC is a valid measure of chronic illness care that is associated with a broad array of patient, provider, and organizational outcomes [3-5,24,28-32]. "
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    ABSTRACT: Little is known as to whether primary care teams' perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients' own experience of chronic illness care. We examined the extent to which practice members' perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients' perceptions of the chronic illness care they have received. Analysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice "members" (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire. Two sets of hierarchical linear regression models accounting for nesting of practice members (N = 283) and patients (N = 1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients' perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales [Self-management Support (p < 0.05); Community Linkages (p < 0.02), Delivery System Design (p < 0.02), and Organizational Support (p < 0.02)] were consistently associated with PACIC summary score and the majority of PACIC subscale scores after controlling for patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak. The ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care.Trial registration: NCT00482768.
    BMC Family Practice 03/2014; 15(1):57. DOI:10.1186/1471-2296-15-57 · 1.67 Impact Factor
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    • "Inadequate training for our physicians on the principles of evidence based guidelines and health system that support these guidelines adherence may be another [41-43]. Failure to individualise treatment according to the needs of the patient and the lack of a team approach involving nurses, medical assistants, pharmacists, nutritionists/dietitians may be another factor [40,44,45]. Providing guidelines, having appropriate protocols and knowledge instruments that has been validated for use in this country should be put in place and then, perhaps the medical care for diabetic hypertensive would improve [42,46]. "
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    ABSTRACT: Background Uncontrolled blood pressure (BP) is a significant contributor of morbidity and even mortality in type 2 diabetes (T2D) patients. This study was done to determine the significant determinants of uncontrolled blood pressure in T2D patients in Malaysia. Methods Between 1st January 2009 to 31st December 2009, data from 70 889 patients with Type 2 diabetes was obtained from the Adult Diabetes Control and Management Registry for analysis; 303 centers participated in the study. Their demographic characteristics, the nature of their diabetes, their state of hypertension, treatment modalities, risk factors, and complications are described. Based on their most recent BP values, subjects were divided into controlled BP and uncontrolled BP and their clinical determinants compared. Independent determinants were identified using multivariate logistic regression. Results The mean age of patients at diagnosis of diabetes was 52.3 ± 11.1 years old. Most were women (59.0 %) and of Malay ethnicity (61.9 %). The mean duration of diabetes was 5.9 ± 5.6 years. A total of 57.4 % were hypertensive. Of the 56 503 blood pressure (BP) measured, 13 280 (23.5 %) patients had BP <130/80 mmHg. Eighteen percent was on > two anti-hypertensive agents. Health clinics without doctor, older age (≥ 50 years old), shorter duration of diabetes (< 5 years), Malay, overweight were determinants for uncontrolled blood pressure (BP ≥130/80 mmHg). Patients who were on anti-hypertensive agent/s were 2.7 times more likely to have BP ≥130/80 mmHg. Type 2 diabetes patients who had ischaemic heart disease or nephropathy were about 20 % and 15 % more likely to have their blood pressure treated to target respectively. Conclusions Major independent determinants of uncontrolled BP in our group of T2D patients were Malay ethnicity, older age, recent diagnosis of diabetes, overweight and follow-up at health clinics without a doctor and possibly the improper use of anti hypertensive agent. More effort, education and resources, especially in the primary health care centres are needed to improve hypertensive care among our patients with diabetes.
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