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Experiences of Veterans With Diabetes From Shared Medical Appointments
Abstract
Camaraderie and shared narratives, coupled with clinical guidance, may help motivate veterans to better manage their diabetes.
... [13][14][15] Therefore, Veterans have a unique set of life experiences that may influence their perception of T2DM and engagement in T2DM self-management. [16][17][18][19][20] In order to personalize diabetes care to reduce DD, and enhance the effectiveness of this care, ensuring that existing approaches to DD measurement capture Veteran experience is needed. Due to their military experience and training, the etiology of DD may present differently in Veterans than in non-Veterans; therefore, an understanding of how Veterans' experience DD is critical to developing tailored interventions to improve their engagement in T2DM self-management and their health outcomes. ...
... Living with T2DM and engaging in T2DM self-management behaviors can be overwhelming and distressing for Veterans. 16,17 Veterans reported that thinking about T2DM; self-managing T2DM (including incorporating related behaviors into daily activities), and managing DD after specific events involved time and energy. Similar to a previous study 17 , this study's findings indicate that military experience influences Veterans' perspectives on T2DM self-management, engagement with others (e.g., family, friends, health care providers), and participation in recommended T2DM self-management behaviors. ...
... 16,17 Veterans reported that thinking about T2DM; self-managing T2DM (including incorporating related behaviors into daily activities), and managing DD after specific events involved time and energy. Similar to a previous study 17 , this study's findings indicate that military experience influences Veterans' perspectives on T2DM self-management, engagement with others (e.g., family, friends, health care providers), and participation in recommended T2DM self-management behaviors. Prior qualitative research indicates that individuals with DD report diabetesrelated physical burden as well as health care system and comorbid conditions distress. ...
Purpose
The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran’s military-related experience.
Methods
The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes.
Results
The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level <9%, and 67% with prescribed insulin. The DD Scale is readily understood by veterans and interpreted. Thematic analysis indicated additional domains affecting DD and T2DM self-management, including access to care, comorbidities, disruptions in routine, fluctuations in emotions and behaviors, interactions with providers, lifelong nature of diabetes, mental health concerns, military as culture, personal characteristics, physical limitations, physical pain, sources of information and support, spirituality, and stigma.
Conclusions
This study describes how a veteran’s military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.
... Quality of the included studies was generally high; most papers met the majority of the CASP checklist criteria (online supplemental file 2). Weaknesses commonly related to lack of information about participant recruitment [16][17][18][19][20][21][22] and researcher reflexivity, which was missing in all but two studies. 23 24 ...
... 18 28 29 32 Veterans reported that they were using less medication following the group session and were better able to self-manage their condition. 20 Similarly, carers reported that their children had learnt skills to manage their ADHD better. 16 Open access Safe environment to share Some patients reported feeling anxious prior to attending SMAs and ashamed of how they had been controlling their condition. ...
... It was recognised that a skilled facilitator improved enjoyment and engagement, 24 and how providers communicate and interact with patients during the appointment can affect their experience. 20 Others found it difficult to relate to other group members 33 or did not want to talk about their issues, nor hear other patients' issues in a group. 31 Some patients reported they would have liked more individual time with the clinician 26 33 or to have seen their own doctor. ...
Objective
To synthesise the published literature on practitioner, patient and carer views and experiences of shared medical appointments (SMAs) for the management of long-term conditions in primary care.
Design
Systematic review of qualitative primary studies.
Methods
A systematic search was conducted using MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Web of Science, Social Science Premium Collection (Proquest) and Scopus (SciVerse) from database starting dates to June 2019. Practitioner, patient and carer perspectives were coded separately. Deductive coding using a framework approach was followed by thematic analysis and narrative synthesis. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies.
Results
We identified 18 unique studies that reported practitioner (n=11), patient (n=14) and/or carer perspectivs(n=3). Practitioners reported benefits of SMAs including scope for comprehensive patient-led care, peer support, less repetition and improved efficiency compared with 1:1 care. Barriers included administrative challenges and resistance from patients and colleagues, largely due to uncertainties and unclear expectations. Skilled facilitators, tailoring of SMAs to patient groups, leadership support and teamwork were reported to be important for successful delivery. Patients’ reported experiences were largely positive with the SMAs considered a supportive environment in which to share and learn about self-care, though the need for good facilitation was recognised. Reports of carer experience were limited but included improved communication between carer and patient.
Conclusion
There is insufficient evidence to indicate whether views and experiences vary between staff, medical condition and/or patient characteristics. Participant experiences may be subject to reporting bias. Policies and guidance regarding best practice need to be developed with consideration given to resource requirements. Further research is needed to capture views about wider and co-occurring conditions, to hear from those without SMA experience and to understand which groups of patients and practitioners should be brought together in an SMA for best effect.
PROSPERO registration number
CRD42019141893.
... 19 This is demonstrated when veterans respond positively to peer-support and peer-led efforts to reduce stigma and increase involvement in their health care. 31,32 These findings point to the potential of utilizing shared identity and unity of veterans to strengthen the patient engagement. Although other studies have focused on cohesion at narrower levels of the military unit, 33,34 our findings are novel in that they identify evidence of sense of belonging broadly among veterans. ...
Background:
Health care systems have increasingly focused on patient engagement in efforts to improve patient-centered care. Appointment attendance is an integral component of patient engagement, and missed appointments are an ongoing problem for health care systems. Virtually no studies have examined how the sense of belonging is related to patient engagement within a health care system.
Objective:
To examine patient experiences in the Veterans Health Administration (VA) with outpatient appointment attendance to identify factors that affect sense of belonging and patient engagement.
Research design and participants:
This study draws from qualitative data collected as part of a study to reduce missed appointments through use of enhanced appointment reminder letters. We conducted semistructured interviews with 27 VA patients with primary care or mental health clinic visits, using deductive and inductive analysis to develop themes. More than half of the participants were Vietnam veterans, 24 were over 40 years old, 21 were White, and 18 were men.
Results:
We identified 3 factors that influence sense of belonging within the VA: (1) feelings of camaraderie and commitment toward other veterans were relevant to patient experience in the VA; (2) interactions with all staff influenced the engagement a patient felt with a particular clinic, care team, and the VA; (3) personalized communication and messaging could humanize the VA and demonstrate its interest in engaging with veterans. Lastly, we found (4) sense of belonging appeared to promote appointment attendance and patient engagement.
Conclusions:
There are multiple opportunities to strengthen patients' sense of belonging within the health care system that serves them. For veterans, strategies that build their sense of belonging may be a novel approach to increase appointment attendance and patient engagement in their health care.
... Some Veterans have cited the importance of the patient-provider relationship [39,40] as a primary reason for seeking care at the VA, while others value camaraderiespecifically, the kinship in shared military service and cancer care experiences [39,41]. Together, these factors have been associated with increased patient engagement and adherence with recommended care and improved quality of life [42][43][44][45]. Despite these advantages, there may be a threshold at which distance to a VA facility becomes inconvenient and may lead to barriers to or from CRC care. ...
Background
Transportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits.
Methods
Between November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos.
Results
Of the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman’s ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman’s ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant.
Conclusions
Transportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).
Purpose
The purpose of the study was to explore an understanding of the psychosocial-behavioral impact of diabetes self-management among veterans with diabetes.
Methods
Twenty-six veterans participated in 1 of 9 focus groups that were conducted following a group diabetes self-management education class and prior to a mindfulness intervention as part of a feasibility pilot study. Discussions were guided by open-ended questions that addressed the overarching research question, “How do attitudes and experiences with diabetes inform psychosocial-educational approaches to diabetes self-management education and care for veterans?” Focus groups were audio-recorded and transcribed. The data was then independently coded and thematically analyzed by 2 coders.
Results
Five main themes that reflect veterans’ perceptions of their experiences with diabetes and diabetes self-management were identified: (1) distress and negative emotions, (2) social isolation, (3) perceived lack of control, (4) attitudes toward diabetes support, and (5) desire for information about stress, diabetes, health, and behavior.
Conclusions
Veterans experience emotional distress and have unmet psychosocial needs related to diabetes self-management. Insight gained from these veteran perspectives suggests a framework for integrating psycho-educational interventions like mindfulness into diabetes care that emphasize stress reduction, person-centered communication, and opportunities for peer support.
D iabetes self-management refers to the full range of activities (or “behaviors”) in which patients care for their illness and promote their health. The three broad self-management tasks include 1 ) managing the disease (taking medications, following a diet, engaging in physical activity, self-monitoring); 2 ) maintaining one's daily life while living with chronic illness; and 3 ) dealing with emotional aspects of the disease, such as anger, fear, frustration, and depression.1,2
There is consensus on the key preconditions for effective diabetes self-management. These include 1 ) sufficient knowledge of the condition and its treatment; 2 ) skills to manage the condition and to maintain functioning (ability to identify problems, barriers, and supports and to generate solutions); 3 ) internal, or autonomous, motivation (belief in treatment effectiveness and its relevance to one's goals, values, and priorities);3,4 4 ) confidence in one's ability to successfully execute specific tasks (self-efficacy);5 5 ) adequate environmental support to initiate and sustain behavioral changes (assistance to overcome obstacles, reminders, encouragement, and support from valued people at appropriate times and places); and 6 ) effective affect management (coping with possible depression and other emotional responses to living with diabetes).2,6
Primary care providers can play a key role in multiple ways to help their patients manage their condition, offering informational (therapeutic advice, education), behavioral (realistic self-management goals), emotional (empathy, acceptance, assessment and treatment of depression, recommendation for support groups), and tangible (insulin, test strips) support.7 Many physicians, however, are more comfortable in their role providing information and education than they are providing emotional support and facilitating behavioral changes.8 Although knowledge and information are necessary for patients to manage their disease effectively, they are not sufficient to motivate them to make and sustain behavior changes.9,10
As Robert M. Anderson, PhD, an internationally recognized diabetes …
Objective:
Little is known about how patient-clinician communication leads to better outcomes. Among patients with diabetes, we describe patient-reported use of collaborative goal setting and evaluate whether perceived competency and physician trust mediate the association between collaborative goal setting and glycemic control.
Methods:
Data from a patient survey administered in 2008 to a cohort of insured patients aged 18+ years with diabetes who initiated oral mono-therapy between 2000 and 2005 were joined with pharmaceutical claims data for the prior 12 months and laboratory data for the prior and subsequent 12 months (N=1065). A structural equation model (SEM) was used to test mediation models controlling for baseline HbA1c.
Results:
The hypothesized mediation model was supported. Patient-reported use of more collaborative goal setting was associated with greater perceived self-management competency and increased level of trust in the physician (p<0.05). In turn, both greater perceived competence and increased trust were associated with increased control (p<0.05).
Conclusions:
Findings indicate that engaging patients in collaborative goal setting during clinical encounters has potential to foster a trusting patient-clinician relationship as well as enhance patient perceived competence, thereby improving clinical control.
Practice implications:
Fostering collaborative goal setting may yield payoffs in improved clinical outcomes among patients with diabetes.
The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation.
We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: "chronic care model" (and) "diabet*." We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies.
The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP officd-based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies.
CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making.
Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.
To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.
A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956)
Philadelphia Veterans Affairs Medical Center.
African American veterans aged 50 to 70 years with persistently poor diabetes control.
118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%.
Change in HbA(1c) level at 6 months.
Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group.
The study included only veterans and lasted only 6 months.
Peer mentorship improved glucose control in a cohort of African American veterans with diabetes.
National Institute on Aging Roybal Center.
The "ABCs of Diabetes" are defined as hemoglobin A1c < 7.0%, blood pressure < 130/80 millimeters mercury (mm Hg), and lowdensity lipoprotein cholesterol (LDL-C) < 100 milligrams per deciliter (mg per dL). Assessments of 3-part goal attainment of A1c, blood pressure, and cholesterol have been reported using data from the National Health and Nutrition Examination Survey (NHANES) for several time periods (e.g., 1988-1994, 1999-2000, 1999-2002, and 2003-2004), Look Action for Health in Diabetes (Look AHEAD, 2001-2004), and community-based endocrinology practice (CBEP, 2000-2004). In 2002, an unpublished analysis of data from 2001-2002 at the Iowa City Veterans Affairs (ICVA) Medical Center found less than 50% of patients met each of the 3 individual goals. In the 5 years following the 2001-2002 assessment, the care for veterans with diabetes at the ICVA was enhanced to include (a) an increased number of diabetes classes and clinics, (b) implementation of the diabetes Care Coordination/Home Telehealth (CCHT) program, and (c) clinical reminders for diabetes performance measures that were added to the electronic medical record (EMR).
To (a) describe the prevalence of veterans meeting the ABC goals of diabetes in 1 VA medical center; (b) differentiate the proportion of diabetes patients who met the individual targets for A1c, blood pressure, and LDL-C and compare the results for 2008 through September 2009 with the earlier data from this facility (2001-2002); and (c) examine results reported previously in the literature for NHANES, Look AHEAD, and CBEP data sources.
Single-center, retrospective analysis of veterans at the ICVA for dates of service from January 1, 2008, through September 30, 2009, who (a) filled at least 1 prescription for an antidiabetic medication and (b) had each of the 3 biomarker values recorded in the EMR for A1c, blood pressure, and LDL-C after the antidiabetic prescription fill date.
Of the 5,426 (97.6% male) patients meeting inclusion criteria in 2008-2009, 17.3% (n = 936) achieved the 3-part ABC goal. In this managed care setting, achievement of the 3-part ABC goal surpassed the proportions reported in previous studies in NHANES data (5.2% in 1988-1994, 7.3% in 1999-2000, 7.0% in 1999-2002, 13.2% in 2003-2004), and 10.1% in Look AHEAD 2001-2004, but fell short of the 22.0% reported in CBEP 2000- 2004. When compared with the 2001-2002 results at ICVA, the proportion of patients achieving the individual A1c goal in 2008-2009 increased by 10.8 percentage points (from 43.2% to 54.0%), 12.6 percentage points for blood pressure (from 29.2% to 41.8%), and 17.1 percentage points for LDL-C (from 49.5% to 66.6%, P < 0.001) for the 3 individual comparisons.
The proportion of patients achieving each of the 3 goals for A1c, blood pressure, and LDL-C improved significantly in 2008-2009 compared with the 2001-2002 assessment in this medical center, following implementation of yearly clinical reminders for diabetes care, enhanced patient education, and other program changes that included home-based telephone monitoring with diabetes case management for some patients. Achievement of the 3-part ABC goal in 2008-2009 (17.3%) surpassed 5 assessments reported in the literature but was lower than the CBEP (2000- 2004) performance (22.0%).
Resource barriers complicate diabetes care management. Support from peers may help patients manage their diabetes.
To compare a reciprocal peer-support (RPS) program with nurse care management (NCM).
Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00320112)
2 U.S. Department of Veterans Affairs health care facilities.
244 men with hemoglobin A(1c) (HbA(1c)) levels greater than 7.5% during the previous 6 months.
The primary outcome was 6-month change in HbA(1c) level. Secondary outcomes were changes in insulin therapy; blood pressure; and patient reports of medication adherence, diabetes-related support, and emotional distress.
Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals, receive peer communication skills training, and be paired with another age-matched peer patient. Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact. These patients could also participate in optional group sessions at 1, 3, and 6 months. Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager.
Of the 244 patients enrolled, 216 (89%) completed the HbA(1c) assessments and 231 (95%) completed the survey assessments at 6 months. Mean HbA(1c) level decreased from 8.02% to 7.73% (change, -0.29%) in the RPS group and increased from 7.93% to 8.22% (change, 0.29%) in the NCM group. The difference in HbA(1c) change between groups was 0.58% (P = 0.004). Among patients with a baseline HbA(1c) level greater than 8.0%, those in the RPS group had a mean decrease of 0.88%, compared with a 0.07% decrease among those in the NCM group (between-group difference, 0.81%; P < 0.001). Eight patients in the RPS group started insulin therapy, compared with 1 patient in the NCM group (P = 0.020). Groups did not differ in blood pressure, self-reported medication adherence, or diabetes-specific distress, but the RPS group reported improvement in diabetes social support.
The study included only male veterans and lasted only 6 months.
Reciprocal peer support holds promise as a method for diabetes care management.
Knowledge of one's actual and target health outcomes (such as HbA(1c) values) is hypothesized to be a prerequisite for effective patient involvement in managing chronic diseases such as diabetes. We examined 1) the frequency and correlates of knowing one's most recent HbA(1c) test result and 2) whether knowing one's HbA(1c) value is associated with a more accurate assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control.
We conducted a cross-sectional survey of a sample of 686 U.S. adults with type 2 diabetes in five health systems who had HbA(1c) checked in the previous 6 months. Independent variables included patient characteristics, health care provider communication, and health system type. We examined bivariate and multivariate associations between each variable and the respondents' knowledge of their last HbA(1c) values and assessed whether knowledge of HbA(1c) was associated with key diabetes care attitudes and behaviors.
Of the respondents, 66% reported that they did not know their last HbA(1c) value and only 25% accurately reported that value. In multivariate analyses, more years of formal education and high evaluations of provider thoroughness of communication were independently associated with HbA(1c) knowledge. Respondents who knew their last HbA(1c) value had higher odds of accurately assessing their diabetes control (adjusted odds ratio 1.59, 95% CI 1.05-2.42) and better reported understanding of their diabetes care (P < 0.001). HbA(1c) knowledge was not associated with respondents' diabetes care self-efficacy or reported self-management behaviors.
Respondents who knew their HbA(1c) values reported better diabetes care understanding and assessment of their glycemic control than those who did not. Knowledge of one's HbA(1c) level alone, however, was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve patients' diabetes self-management. Strategies to provide information to patients must be combined with other behavioral strategies to motivate and help patients effectively manage their diabetes.
Content analysis is a widely used qualitative research technique. Rather than being a single method, current applications of content analysis show three distinct approaches: conventional, directed, or summative. All three approaches are used to interpret meaning from the content of text data and, hence, adhere to the naturalistic paradigm. The major differences among the approaches are coding schemes, origins of codes, and threats to trustworthiness. In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, analysis starts with a theory or relevant research findings as guidance for initial codes. A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context. The authors delineate analytic procedures specific to each approach and techniques addressing trustworthiness with hypothetical examples drawn from the area of end-of-life care.
The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8-20) are seen by a multi-disciplinary team in a 1-2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk.
Primary care clinic at a tertiary care academic medical center.
Patients with diabetes with one or more of the following: A1c >9%, SBP blood pressure >160 mm Hg and LDL-c >130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05.
Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used).
SMA system redesign. ANALYTICAL METHODS: Paired and independent t tests, chi(2) tests and Fisher Exact tests.
Each group had up to 8 patients. Patients participated in 1-7 visits. At the initial visit, 83.3% had A1c levels >9%, 30.6% had LDL-cholesterol levels >130 mg/dl, and 34.1% had SBP >or=160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p<0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p<0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs -0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29).
We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.
Incorporating shared medical appointments (SMAs) or group visits into clinical practice to improve care and increase efficiency has become a popular intervention, but the processes to implement and sustain them have not been well described. The purpose of this study was to describe the process of implementation of SMAs in the local context of a primary care clinic over time.
The setting was a primary care clinic of an urban academic medical center of the Veterans Health Administration. We performed an in-depth case analysis utilizing both an innovations framework and a nested systems framework approach. This analysis helped organize and summarize implementation and sustainability issues, specifically: the pre-SMA local context; the processes of tailoring and implementation of the intervention; and the evolution and sustainability of the intervention and its context.
Both the improvement intervention and the local context co-adapted and evolved during implementation, ensuring sustainability. The most important promoting factors were the formation of a core team committed to quality and improvement, and the clinic leadership that was supported strongly by the team members. Tailoring had to also take into account key innovation-hindering factors, including limited resources (such as space), potential to alter longstanding patient-provider relationships, and organizational silos (disconnected groups) with core team members reporting to different supervisors.
Although interventions must be designed to meet the needs of the sites in which they are implemented, specific guidance tailored to the practice environment was lacking. SMAs require complex changes that impact on care routines, collaborations, and various organizational levels. Although the SMA was not envisioned originally as a form of system redesign that would alter the context in which it was implemented, it became clear that tailoring the intervention alone would not ensure sustainability, and therefore adjustments to the system were required. The innovation necessitated reconfiguring some aspects of the primary care clinic itself and other services from which the patients and the team were derived. In addition, the relationships among different parts of the system were altered.
The implementation of a pharmacist-managed Veterans Affairs (VA) clinic for high-risk patients with type 2 diabetes is described, including a review of first-year performance data.
As part of VA's ongoing initiative to improve chronic disease management by creating multidisciplinary Patient-Aligned Care Teams (PACTs) that include clinical pharmacy specialists, an outpatient diabetes treatment clinic was implemented at a VA site in Massachusetts. Operated two days weekly, the clinic provides continuity of care between physician visits by applying standard protocols and procedures for insulin therapy; oral medication and insulin doses are adjusted according to self-monitored blood glucose values and other health data transmitted by patients via telephone or secure messaging system. The clinic pharmacist monitors patients' progress toward attainment of glycosylated hemoglobin (HbA1c) goals and provides frequent followup and education to prevent hypoglycemia. During its first year of operation, the clinic enrolled 160 veterans. Among 85 patients included in a three-month review of outcomes data, the mean ± S.D. HbA1c concentration declined by more than one percentage point (from 9.12% ± 1.41% to 7.94% ± 1.18%). Further HbA1c improvements were documented in a subset of 46 patients followed for six months after clinic enrollment, with no episodes of severe hypoglycemia.
An outpatient clinic successfully integrated a pharmacist into a multidisciplinary PACT focused on veterans with poorly controlled type 2 diabetes. The clinic's initial experience suggests that frequent pharmacist interventions have a positive impact in promoting appropriate insulin use in this high-risk patient population.
Self-determination theory was applied to explore the motivational basis of adherence to long-term medication prescriptions. Adult outpatients with various diagnoses who had been on a medication for at least 1 month and expected to continue (a) completed questionnaires that assessed their autonomous regulation, other motivation variables, and perceptions of their physicians' support of their autonomy by hearing their concerns and offering choice; (b) provided subjective ratings of their adherence and a 2-day retrospective pill count during an interview with a clinical psychologist; and (c) provided a 14-day prospective pill count during a subsequent, brief telephone survey. LISREL analyses supported the self-determination model for adherence by confirming that patients' autonomous motivation for adherence did mediate the relation between patients' perceptions of their physicians' autonomy support and their own medication adherence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Professional and patient groups have called for increased participation of patients' informal support networks in chronic disease care, as a means to improve clinical care and self-management. Little is known about the current level of participation of family and friends in the physician visits of adults with chronic illnesses or how that participation affects the experience of patients and physicians.
Written survey of 439 functionally independent adults with diabetes or heart failure and 88 of their primary care physicians (PCPs). Patients were ineligible if they had a memory disorder, needed help with activities of daily living, or were undergoing cancer treatment.
Nonprofessional friends or family ("companions") regularly participated in PCP visits for nearly half (48%) of patients. In multivariable models, patients with low health literacy (adjusted odds ratio [AOR]: 2.9, confidence interval [CI]: 1.4-5.7), more depressive symptoms (AOR: 1.3, CI: 1.1-1.6), and 4 or more comorbid illnesses (AOR: 3.7, CI: 1.3-10.5) were more likely to report companion participation. Patients reported that they were more likely to understand PCP advice (77%) and discuss difficult topics with the physician (44%) when companions participated in clinic visits. In multivariable models, companion participation was associated with greater patient satisfaction with their PCP (AOR: 1.7, CI: 1.1-2.7). Most PCPs perceived visit companions positively, however 66% perceived 1 or more barriers to increasing companion participation, including increased physician burden (39%), inadequate physician training (27%), and patient privacy concerns (24%).
Patients' companions represent an important source of potential support for the clinical care of functionally independent patients with diabetes or heart failure, particularly for patients vulnerable to worse outcomes. Companion participation in care was associated with positive patient and physician experiences. Physician concerns about companion participation are potentially addressable through existing training resources.
Group interaction is put forward as the principal advantage for focus group research, although rarely reported on. The aim of the article is to contribute to the methodological knowledge regarding focus group research by providing an empirical example of the application of the Lehoux, Poland, and Daudelin template suggested for analysis of the interaction in focus groups. The data source was 18 focus groups' performance in Sweden: 12 with older patients and 6 with general practitioners (GPs). GPs found common ground in belonging to the same profession, whereas the older patients, instead of constituting a group in the word's real sense, started just sharing a common focus. We found the template easy to understand and use, except for identifying participants' explicit and implicit purposes for participating. Furthermore, adding an interaction analysis to the content analysis helped us appreciate and clarify the contexts from which these data were created.
Interprofessional practice has increasingly been recognized as important for chronic illness care. Recently, several health care professional-accrediting bodies have called for integration of interprofessional care and education. The shared medical appointment (SMA) is an interprofessional practice model that provides an educational opportunity.
A description of this innovative educational model, the challenges associated with the implementation, and the evaluation are presented.
Mixed quantitative and qualitative analysis were utilized.
Preliminary evaluation suggests that SMAs promote improved trainee/student understanding of both the complexity of diabetes care and the seriousness of the illness, along with an increased confidence in the ability to communicate with providers from other disciplines.
Further research to determine the efficacy of SMAs as an interprofessional training venue is needed that focuses on comprehensive assessment, necessary dose of exposure, and identification of barriers to overcome operational issues.
The purpose of this qualitative study was to explore perceptions of people with diabetes about their experience of living with and managing their diabetes.
This study was part of a larger study of patients with diabetes who used a novel computer portal system for access to information about diabetes and to their health care providers for enhanced communication. The research method used for this portion of the study was grounded theory methodology, a particular kind of qualitative research method.
A central theme generated from the data was "normalizing an identity as a person with diabetes." The participants described themselves as diabetic; they took on an identity in which having diabetes was central. They struggled with how to become "a person with diabetes" rather than a "diabetic person."
For people who are diagnosed with diabetes, there is a struggle to become a person with diabetes rather than a diabetic person and to manage the lifestyle changes that are mandated by this role/identity. One way of dealing or coping with this new identity is to begin to "normalize" these lifestyle changes-to view them as healthy living for all people, those with and without diabetes. This will then have implications for interventions-encouraging healthy lifestyles among people with diabetes rather than emphasizing that people with diabetes are "different from" the general population.
In this study, the social theory of identity was used to gain a better understanding of the complex process of how individuals adjust to having insulin-requiring diabetes. Semistructured interviews were conducted with 30 individuals to explore issues related to their personal experience with diabetes. Narrative methods were used to analyze the data. An exploration of participants' stories revealed significant identity issues underlying their interpretation and management of diabetes. The diagnosis of diabetes was conceptualized as an assault on personal identity. This initial disruption was followed by a process of negotiation whereby individuals grappled with identity issues to adapt to the condition and integrate it into their lives. This process was socially shaped and influenced individuals' perceptions of their diabetes management. The main concepts examined in this paper are diagnosis and identity, identity and treatment management, and identity and the ongoing nature of adjustment. The implications for diabetes education are presented.
The Veterans Health Administration (VHA) is a unique laboratory for using the electronic health record (EHR) to transform health care and accelerate discovery. This is particularly evident in the care of veterans with diabetes, who constitute a quarter of those served by the VHA. Although EHRs have enabled rapid learning, additional factors were necessary, including the lead participation of clinician-investigators, accountability through performance measurement, a delivery system focused on population health, and favorable economic externalities. "Off-the-shelf" technology is unlikely to generate similar benefits if these attributes are not in place.
Studies that focus on patient empowerment tend to address more specifically two issues of patients' experience of illness: managing regimens and relating to health-care providers. Other aspects of illness experience, such as coming to terms with disrupted identities, tend to be overlooked. The outcome of empowerment is therefore usually referred to as achieving self-efficacy, mastery and control. We conducted an inductive exploratory study, based on individual in-depth interviews with 40 chronically ill patients in Belgium and Italy, in order to understand the process of empowerment as it may occur in patients whose experience of illness has at some point induced a feeling of powerlessness, which we conceptualised as a threat to their senses of security and identity. Our findings show that empowerment and control are not one and the same thing. We describe patient empowerment as a process of personal transformation which occurs through a double process of (i) "holding on" to previous self-representations and roles and learning to control the disease and treatment, so as to differentiate one's self from illness on the one hand, and on the other hand (ii) "letting go", by accepting to relinquish control, so as to integrate illness and illness-driven boundaries as being part of a reconciled self. Whereas the process of separating identities ("holding on") was indeed found to be linked to efforts aimed at taking control and maintaining or regaining a sense of mastery, the process of reconciling identities ("letting go") was found to be linked to a need for coherence, which included a search for meaning and the acceptance that not everything is controllable. We argue that the process of relinquishing control is as central to empowerment as is the process of gaining control. As a "successful" process of empowerment occurs when patients come to terms with their threatened security and identity, not only with their treatment, it may be facilitated by health-care providers through the use of narratives.
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