Redesigning the system of care for the management of patients with type 2 diabetes mellitus has not been well studied in rural communities with a significant minority population and limited health care resources. This study assesses the feasibility and potential for cost-effectiveness of restructuring care in rural fee-for-service practices for predominantly minority patients with diabetes mellitus.
This was a feasibility study of implementing case management, group visits, and electronic registry in 5 solo or small group primary care practices in rural North Carolina. The subjects were 314 patients with type 2 diabetes mellitus (mean age = 61 years; 72% African American; 54% female). An advanced practice nurse visited each practice weekly for 12 months, provided intensive diabetes case management, and facilitated a 4-session group visit educational program. An electronic diabetes registry and visit reminder systems were implemented.
There was an improvement in the percentage of patients achieving diabetes management goals and an improvement in productivity and billable encounters. The percentage of patients with a documented self-management goal increased from 0% to 42%, a currently documented lipid panel from 55% to 76%, currently documented aspirin use from 25% to 37%, and currently documented foot examination from 12% to 54%. The average daily encounter rate improved from 20.17 to 31.55 on intervention days.
A redesigned care delivery system that uses case management with structured group visits and an electronic registry can be successfully incorporated into rural primary care practices and appears to significantly improve both care processes and practice productivity.
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"The model includes practice changes to provide the family with self-management support using relationship-focused methods such as MI; provider decision support for evidence-based care; delivery-system redesign to promote better care and follow-up; and clinical information systems to provide data to evaluate the progress made toward meeting goals. Indirect evidence from the National Health Disparities Collaboratives on Asthma, Diabetes, and Depression suggests that practice-based changes made at the system level will improve patient outcomes (Bodenheimer, 2003; Bodenheimer, Wagner, & Grumbach, 2002a, 2002b Bray et al., 2005; Hupke, Camp, Chaufournier, Langley, & Little, 2004; McCullough, Davis, Austin, & Wagner, 2004; Norris & Olson, 2004). The proposed model recognizes that children live in the context of their family, school, and community and that culture and environment have an impact on the child's health. "
"Seven interventions were initially included in the meta- analysis [31,36373847,51]. The remaining interventions were excluded as they employed a study design other than RCT3233343539,41424344454648,49,52] or did not measure HbA1c . A first meta-analysis was conducted to assess possible baseline HbA1c differences between intervention and control groups, observing no statistically significant differences (HbA 1c mean difference = -0.065% "
[Show abstract][Hide abstract]ABSTRACT: Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.
We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.
Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).
This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.
"Assessing human capital needs—It is important to assess human capital needs to implement and maintain health IT interventions in under-resourced settings. Although some of the studies we reviewed commented on the need for nursing staff, case managers, or staff to assist in maintaining health IT interventions, no studies reported the type of staff and number of staff needed to support health IT interventions in under-resourced settings (Bray, Thompson et al., 2005; Chin et al., 2007). Studies in EMR process measurement have noted the importance of a health IT champion, yet this concept still needs testing in underresourced settings and in addressing diabetes (Zandieh et al., 2008). "
[Show abstract][Hide abstract]ABSTRACT: Differences in rates of diabetes-related lower extremity amputations represent one of the largest and most persistent health disparities found for African Americans and Hispanics compared with Whites in the United States. Since many minority patients receive care in underresourced settings, quality improvement (QI) initiatives in these settings may offer a targeted approach to improve diabetes outcomes in these patient populations. Health information technology (health IT) is widely viewed as an essential component of health care QI and may be useful in decreasing diabetes disparities in underresourced settings. This article reviews the effectiveness of health care interventions using health IT to improve diabetes process of care and intermediate diabetes outcomes in African American and Hispanic patients. Health IT interventions have addressed patient, provider, and system challenges in the provision of diabetes care but require further testing in minority patient populations to evaluate their effectiveness in improving diabetes outcomes and reducing diabetes-related complications.
Full-text · Article · Oct 2010 · Medical Care Research and Review