An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7. Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial A controlled before-after trial of structured diabetes care in primary health centres in a newly developed country. Effect of an intervention to improve the management of patients with diabetes in primary care practice. A pilot quality improvement intervention in patients with diabetes and hypertension in primary care settings of Cyprus. Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. The effectiveness of nurse‐led care in general practice on clinical outcomes in adults with type 2 diabetes [Evaluation of a programme to monitor drug therapy in type-2 diabetics]. A new model of integrated primary-secondary care for complex diabetes in the community: study protocol for a randomised controlled trial Individualized electronic decision support and reminders to improve diabetes care in the community: COMPETE II randomized trial Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation - the CASCADE study. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Cardiovascular risk outcome and program evaluation of a cluster randomised controlled trial of a community-based, lay peer led program for people with diabetes A prospective randomized controlled study of a virtual clinic integrating primary and specialist care for patients with Type 2 diabetes mellitus. Practice network-based care management for patients with type 2 diabetes and multiple comorbidities (GEDIMAplus): study protocol for a randomized controlled trial Improving Diabetes Care in Practice
OBJECTIVE Management of diabetes is frequently suboptimal in primary care setting s , where providers often fail to intensify therapy when glucose levels are high , a problem known as clinical inertia . We asked whether interventions targeting clinical inertia can improve outcomes . RESEARCH DESIGN AND METHODS A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center . We studied all patients ( 4,138 ) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were r and omized to be control subjects or to receive one of three interventions . Instead of consultative advice , the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient 's visit , individual face-to-face feedback on performance for 5 min every 2 weeks , or both . RESULTS Over an average patient follow-up of 15 months within the intervention site , improvements in and final HbA1c ( A1C ) with feedback + reminders ( deltaA1C 0.6 % , final A1C 7.46 % ) were significantly better than control ( deltaA1C 0.2 % , final A1C 7.84 % , P < 0.02 ) ; changes were smaller with feedback only and reminders only ( P = NS vs. control ) . Trends were similar but not significant with systolic blood pressure ( sBP ) and LDL cholesterol . Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP . Over a 2-year period , overall glycemic control improved in the intervention site but did not change in other primary care sites ( final A1C 7.5 vs. 8.2 % , P < 0.001 ) . CONCLUSIONS Feedback on performance aim ed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control . Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care setting 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 OBJECTIVE To evaluate the long-term impact of a structured approach to improving the quality of diabetes care in general practice in the United Arab Emirates . DESIGN Controlled before-after trial within a health district with three primary health centres ( PHCs ) in the intervention group and the six remaining serving as controls .  Outcomes and adherence to guidelines were measured over the year before the intervention began and for a second 1-year period at the end of the intervention period . Data were collected by chart abstract ion . SETTING The study was performed in PHCs in the United Arab Emirates , a newly developed country on the Arabian peninsula . STUDY PARTICIPANTS Subjects continuously followed in nine PHCs for diabetes care for the period of the study ( N = 738 ) were included in the study . INTERVENTION Structured diabetes care , including the development of general practice diabetes clinics , a patient education program , a health care professional education program , and improved recording of clinical information , was provided for the 33-month time period . RESULTS There was a statistically significant improvement in three of the process of care variables ( ordering HbA1c , cholesterol , and documenting foot examinations ) whereas the four remaining variables did not improve . There was limited impact on outcome variables . CONCLUSIONS The intervention described in this study demonstrated an improvement in some process of care measures suggesting an impact of this type of delivery model in this environment OBJECTIVE To assess the effect of an intervention targeted at primary care physicians ( PCPs ) in order to improve their management of diabetic patients .  METHODS Diabetic patients seen by PCPs in King Khalid University Hospital , Riyadh , Kingdom of Saudi Arabia from January 2008 to July 2009 were included in this prospect i ve cohort study . The PCPs were divided into intervention and control groups . The intervention group with the help of an assistant , utilized a customized design ed computer program generating a checklist for the PCPs . The list included clinical and biochemical screening tests needed for the patients current visit , according to evidence -based diabetes guidelines . For the control group , no assistant was used . At the end of one year , an independent review er evaluated the patients ' files in both groups to assess the adherence to diabetes guidelines . RESULTS We enrolled 162 patients in the control group and 517 patients in the intervention group . The intervention significantly improved the percentage of patients being screened for diabetic complications ; retinopathy from 24.7 - 98.5 % , neuropathy from 25.9 - 92 % , and nephropathy from 37.8 - 73.7 % . There was no improvement in glycemic control in both groups and glycosylated hemoglobin level ( HbA1c ) values were still above the 7 % target . CONCLUSION Management of diabetic patients in the primary care clinics is below st and ard . The intervention applied was effective in promoting better adherence to evidence -based diabetes guidelines BACKGROUND The achievement of quality of care constitutes a priority for modern health care systems . The objective of our study was to evaluate a quality improvement intervention in primary care of Cyprus . METHODS In a two-arm non-r and omized controlled study in primary care centres in Cyprus , all patients with hypertension ( HTN ) and diabetes ( n = 539 ) were invited . In one urban and one rural centre , a quality improvement programme was implemented ; two other centres ( one urban and one rural ) served as control practice s. The intervention mainly consisted of the introduction of clinical disease management guidelines and an electronic medical record system . The primary outcome measurement was improvement of specific clinical indicators for HTN and diabetes . Patients ' satisfaction was evaluated using the European Task Force on Patient Evaluations of General Practice ( EUROPEP ) question naire over an 18-month follow-up period . RESULTS Five hundred and four patients completed the study , 278 patients in the intervention practice s and 226 patients in the control practice s.  Mean results for blood pressure , total cholesterol and low density lipoprotein-cholesterol and three annual performance measures ( urine protein testing , dilated eye and foot examination ) had improved at 18-month follow-up in the intervention as compared to the control group . There was no improvement of HbA1c levels . Patients ' satisfaction improved in the intervention practice s ( improvement of 10/23 EUROPEP items ) but decreased in the control group ( decline of 20/23 items ) . CONCLUSIONS A pilot multifaceted quality improvement intervention programme for patients with diabetes and HTN implemented in primary care setting s in Cyprus showed promising results . Future studies need to involve a broader number of practice s and patient population OBJECTIVE Despite good evidence and clinical practice guidelines , studies document that treatment of type 2 diabetes is less than optimal . Lack of re sources or limited access may put patients in rural communities at particular risk for suboptimal care . RESEARCH DESIGN AND METHODS We conducted a prospect i ve , before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service ( intervention ) for improving the quality of care for rural patients with type 2 diabetes . Our intervention consisted of six monthly visits by a traveling team of specialist physicians , nurses , dieticians , and a pharmacist . The core of this service was specialist-to-rural primary care physician academic group detailing . Two comparable regions in Northern Alberta were r and omly allocated to control or intervention . Data were collected before and 6 months after intervention in a representative volunteer sample . The primary outcome was a 10 % improvement in any one of the following : blood pressure , total cholesterol , or HbA(1c ) . RESULTS Our analysis included 200 intervention and 179 control subjects ; 14 subjects were at all three primary outcome targets at baseline . The intervention was associated with a trend toward improvement in primary outcome at 6 months ( 44 % intervention vs. 37 % control ; odds ratio 1.32 , 95 % CI 0.87 - 1.99 ) . The intervention was associated with a significant improvement in blood pressure ( 42 % intervention vs. 25 % control , P = 0.004 ) ; however , there were only small , nonsignificant changes in cholesterol or HbA(1c ) . The intervention was associated with a significant increase in satisfaction with diabetes care . Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results . CONCLUSIONS A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients . Future studies need to involve longer timelines and larger sample sizes PURPOSE To assess the efficacy of a pharmacist-led , primary care-based , disease management program to improve cardiovascular risk factors and glycated hemoglobin ( A(1C ) ) levels in vulnerable patients with poorly controlled diabetes . METHODS A r and omized controlled trial of 217 patients with type 2 diabetes and poor glycemic control ( A(1C ) level > or=8.0 % ) was conducted at an academic general medicine practice from February 2001 to April 2003 . Intervention patients received intensive management from clinical pharmacists , as well as from a diabetes care coordinator who provided diabetes education , applied algorithms for managing glucose control and decreasing cardiovascular risk factors , and addressed barriers to care . Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider . Outcomes were recorded at baseline and at 6 and 12 months . Primary outcomes included blood pressure , A(1C ) level , cholesterol level , and aspirin use . Secondary outcomes included diabetes knowledge , satisfaction , use of clinical services , and adverse events . RESULTS For the 194 patients ( 89 % ) with 12-month data , the intervention group had significantly greater improvement than did the control group for systolic blood pressure ( -9 mm Hg ; 95 % confidence interval [ CI ] : -16 to -3 mm Hg ) and A(1C ) level ( -0.8 % ; 95 % CI : -1.7 % to 0 % ) . Change in total cholesterol level was not significant . At 12 months , aspirin use was 91 % in the intervention group versus 58 % among controls ( P < 0.0001 ) . Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients . There were no significant differences in use of clinical services or adverse events . CONCLUSION Our comprehensive disease management program reduced cardiovascular risk factors and A(1C ) levels among vulnerable patients with type 2 diabetes and poor glycemic control Background In Australia , diabetes was identified as a national health priority area in 1996 ; nevertheless the prevalence of type 2 diabetes has increased dramatically since then . Nurses have been working within Australian general practice s for several decades but only in recent years has the role of the practice nurse in primary health care increased . Objectives This review aims to identify the effectiveness of nurse‐led care in general practice as compared to general practitioner care on clinical outcomes in adults with type 2 diabetes . Inclusion criteria Types of participants Participants were adults ( aged > 18 years ) , with diabetes type 2 attending a general/family practice . Types of intervention Interventions of interest include nurse‐led care in general practice in which the nurse is identified as taking a lead role in the care of patients with type 2 diabetes compared to general practitioner‐led care . Types of studies To evaluate the effectiveness of nurse‐led diabetes care in general practice , this review sought r and omised controlled trials as the study design of choice . Other research design s such as controlled clinical trials , interrupted time series and controlled before and after design s were also considered . Types of outcomes The outcomes of interest were clinical outcomes including changes in systolic and diastolic blood pressure , body mass index , cholesterol levels , HbA1c ( glycated haemoglobin ) and fasting blood glucose . Search strategy A three step literature search was conducted for English language articles from January 1990 to December 2011 . Method ological quality Quantitative papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review using st and ardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument . Data collection Quantitative data was extracted from papers included in the review using the st and ardised data extraction tool from the Joanna Briggs Institute . The data extracted included specific details about the interventions , population s , study methods and outcomes of significance to the review question and specific objectives . Data synthesis Data from quantitative papers , where possible , were pooled in statistical meta‐ analysis using the Meta‐ Analysis of Statistics Assessment and Review Instrument . Additionally , RevMan 5 was used for presenting forest plots of the meta‐ analysis . Results The electronic search yielded 804 potentially relevant papers of which 49 papers appeared to satisfy the criteria for inclusion and full texts of these papers were assessed against the inclusion criteria by two independent review ers . From these papers , five were included in the review , four r and omised control trials and one quasi‐experimental study . These articles provided evidence that nurse‐led care improves blood pressure and cholesterol levels for patients with type 2 diabetes attending a general practice . Conclusions There is some evidence to support the use of nurse‐led care in general practice for patients with type 2 diabetes . Implication s for Practice If nurse‐led care is implemented in the care of people with type 2 diabetes consideration needs to be given to the use of clinical algorithms , goal setting , individualised care plans , self management and follow up of lifestyle risk factors . Implication for Research More r and omised controlled trials are required to assess the efficacy of nurse‐led care including cost effectiveness OBJECTIVES To evaluate the results of pharmaceutical intervention in a programme to monitor the drug therapy of type-2 diabetics ; and to assess the improvement of the indicators , glycosylated haemoglobin , basal glycaemia , lipid profile , albumin/creatinine , blood pressure , BMI , medication-related problems and adherence . DESIGN R and omised clinical trial . SETTING 14 local pharmacies in the province of Pontevedra ( Galicia ) , Spain . SUBJECTS 126 type-2 diabetics , over 18 years old and who joined voluntarily a monitoring programme , distributed 50 - 50 into intervention and control groups . VARIABLES The main variable was HbA1c . Other variables were : clinical indicators of metabolic control ( mean basal glycaemia , lipid profile ) , blood pressure , BMI , medication-related problems , underst and ing of the illness and its complications , adherence to medical treatment and to changes in life-style , and incidence of complications . METHODS Introduction and r and omisation of patients . Recording of the initial status of the research variables , study and assessment stage , pharmaceutical interventions to detect and resolve any passing medication-related  problems and educational activities . Referral to family doctor if his/her intervention required . Follow-up lasted 12 months with monthly scheduled visits and on-dem and visits , after which the variables were assessed once more . The stages of study , evaluation , intervention and education did not occur in the control group . DISCUSSION The study will enable the role of the chemist in achieving the objectives of controlling type-2 diabetes patients to be achieved through educational intervention and assistance in drug therapy monitoring Background A new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner ( GP ) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting . This study evaluates the health and clinical benefits of the new model of care , assesses the acceptability of the model to patients , GPs and other health professionals , and examines the cost-effectiveness of the model . Methods / Design The study is an open , non-inferiority r and omised controlled trial with data collected at baseline , 6 and 12 months . Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals . Eligible consenting patients are r and omised to either a community practice site ( intervention ) or a hospital site ( usual care ) . In the intervention model , medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist . Quantitative measures include clinical indicators with HbA1c as the primary outcome ; patient-reported outcomes include health-related quality of life , mental health and satisfaction with care . Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care . An economic evaluation will also be undertaken . Discussion This model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes . The study will provide empirical evidence about the impact of the model of care on health outcomes , patient and clinician satisfaction , as well as any economic impacts . Trial registration Clinical Trials Registry Number : Background : Diabetes mellitus is a complex disease with serious complications . Electronic decision support , providing information that is shared and discussed by both patient and physician , encourages timely interventions and may improve the management of this chronic disease . However , it has rarely been tested in community-based primary care . Methods : In this pragmatic r and omized trial , we r and omly assigned adult primary care patients with type 2 diabetes to receive the intervention or usual care .  The intervention involved shared access by the primary care provider and the patient to a Web-based , colour-coded diabetes tracker , which provided sequential monitoring values for 13 diabetes risk factors , their respective targets and brief , prioritized messages of advice . The primary outcome measure was a process composite score . Secondary outcomes included clinical composite scores , quality of life , continuity of care and usability . The outcome assessors were blinded to each patient ’s intervention status . Results : We recruited sequentially 46 primary care providers and then 511 of their patients ( mean age 60.7 [ st and ard deviation 12.5 ] years ) . Mean follow-up was 5.9 months . The process composite score was significantly better for patients in the intervention group than for control patients ( difference 1.27 , 95 % confidence interval [ CI ] 0.79–1.75 , p < 0.001 ) ; 61.7 % ( 156/253 ) of patients in the intervention group , compared with 42.6 % ( 110/258 ) of control patients , showed improvement ( difference 19.1 % , p < 0.001 ) . The clinical composite score also had significantly more variables with improvement for the intervention group ( 0.59 , 95 % CI 0.09–1.10 , p = 0.02 ) , including significantly greater declines in blood pressure ( −3.95 mm Hg systolic and −2.38 mm Hg diastolic ) and glycated hemoglobin ( −0.2 % ) . Patients in the intervention group reported greater satisfaction with their diabetes care . Interpretation : A shared electronic decision-support system to support the primary care of diabetes improved the process of care and some clinical markers of the quality of diabetes care . ( Clinical Trials.gov trial register no. NCT00813085 . BACKGROUND Type 1 diabetes ( T1D ) in children and young people is increasing worldwide with a particular increase in children under the age of 5 years . Fewer than one in six children and young people achieve glycosylated fraction of haemoglobin ( HbA1c ) values in the range identified as providing best future outcomes . There is an urgent need for clinic-based pragmatic , feasible and effective interventions that improve both glycaemic control and quality of life ( QoL ) . The intervention offers both structured education , to ensure young people know what they need to know , and a delivery model design ed to motivate self-management . OBJECTIVE To assess the feasibility of providing a clinic-based structured educational group programme incorporating psychological approaches to improve long-term glycaemic control , QoL and psychosocial functioning in a diverse range of young people . DESIGN The study was a pragmatic , cluster r and omised control trial with integral process and economic evaluation . SETTING Twenty-eight paediatric diabetes services across London , south-east Engl and and the Midl and s. R AND OMISATION Minimised by clinic size , age ( paediatric or adolescent ) and specialisation ( district general hospital clinic or teaching hospital/tertiary clinic ) . ALLOCATION Half of the sites were r and omised to the intervention arm and half to the control arm . Allocation was concealed until after clinics had consented and the first participant was recruited . Where possible , families were blind to allocation until recruitment finished . PARTICIPANTS Forty-three health-care practitioners ( 14 teams ) were trained in the intervention . The study recruited 362 children aged 8 - 16 years , diagnosed with T1D for > 12 months , with a mean 12-month HbA1c level of ≥ 8.5 % . INTERVENTION Two 1-day workshops taught intervention delivery . A detailed manual and re sources were provided . The intervention consists of four group education sessions led by a paediatric diabetes specialist nurse with another team member . OUTCOMES The primary outcome was glycaemic control , assessed at the individual level using venous HbA1c values , measured at baseline , 12 and 24 months . Secondary outcomes were directly and indirectly related to diabetes management , including hypoglycaemic episodes , hospital admissions , diabetes regimen , knowledge , skills and responsibility for diabetes management , intervention compliance , clinic utilisation , emotional and behavioural adjustment , and general and diabetes-specific QoL. PROCESS EVALUATION Question naires , semistructured interviews , informal discussion following observation sessions , fieldwork notes and case note review were used to collect qualitative and quantitative data from key stakeholder groups at specific time points in the trial . STATISTICAL ANALYSES Primary and secondary analyses were intention-to-treat comparisons of outcomes at 12 and 24 months , using analysis of covariance with a r and om effect for clinic . Prespecified subgroup analyses based on age , gender , initial HbA1c value and socioeconomic status were estimated from models that included an interaction term . The economic analysis compared long-term costs and predicted quality -adjusted life-years ( QALYs ) . RESULTS The intervention did not improve HbA1c at 12 months [ intervention effect 0.11 ; 95 % confidence interval ( CI ) -0.28 to 0.50 ; p = 0.584 ] or 24 months ( intervention effect 0.03 ; 95 % CI -0.36 to 0.41 ; p = 0.891 ) . A total of 298/362 patients ( 82.3 % ) provided blood sample s at 12-month follow-up , and 284/362 ( 78.5 % ) provided blood sample s at 24-month follow-up . Follow-up question naires were completed by 307 patients ( 85.3 % ) at 12 months and by 295 patients ( 81.5 % ) at 24 months . Intervention group parents at 12 months ( 95 % CI 0.74 ; 0.03 to 1.52 ) and young people at 24 months ( 0.85 ; 95 % CI 0.03 to 1.61 ) had higher scores on the diabetes family responsibility question naire . Young people reported reduced happiness with body weight at 12 months ( -0.56 ; 95 % CI -1.03 to -0.06 ) . Only 68 % of groups were run . Of the 180 families recruited , 96 ( 53 % ) attended at least one module . Reasons for low uptake included difficulties organising groups , and work and school commitments . Young people with higher HbA1c levels were less likely to attend . Parents and young people who attended groups described improved family relationships , improved knowledge and underst and ing , greater confidence and increased motivation to manage diabetes . Twenty-four months after the intervention , nearly half of the young people reported that the groups had made them want to try harder and that they had carried on trying . A high- quality , complex , pragmatic trial of structured education can be delivered alongside st and ard care in NHS diabetes clinics . Health-care providers benefited from behaviour change skill training and can deliver pragmatic aspects of a National Institute for Health and Care Excellence (NICE)-compliant structured education programme after relatively brief training . The process evaluation provides insight into aspects of the model , and highlights strengths and aspects that may have contributed to the failure to influence primary and secondary outcomes . Current NHS practice dominates CASCADE ( Child and Adolescent Structured Competencies Approach to Diabetes Education ) in that it achieves the same number of QALYs at a lower cost . The mean cost of providing the intervention was £ 5098 per site or £ 683 per child . Members of paediatric diabetes services trained to deliver the CASCADE structured education package using behaviour change techniques did not improve glycaemic control in patients compared with control subjects 1 and 2 years after the intervention . The training workshops for practitioners were well evaluated ; however , more intensive training was needed . The intervention cost £ 683 per patient but was not cost-effective because it did not improve metabolic control . CONCLUSIONS A high- quality , complex , pragmatic trial of structured education can be successfully conducted alongside st and ard care in NHS diabetes clinics . Pragmatic components of a NICE-compliant structured education programme can be successfully delivered following a relatively brief 2-day training while paediatric health-care professionals benefit from training in behaviour change skills . The study provides invaluable information on barriers and opportunities regarding future , similar interventions . A low dropout rate and good attendance for the subgroup that attended the intervention suggests there might be improved uptake if offered to young people with lower HbA1c . Testing whether this approach can be more successful with a robust ongoing supervisory element should be a target of further research . TRIAL REGISTRATION Current Controlled Trials IS RCT N52537669 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 18 , No. 20 . See the NIHR Journals Library website for further project information OBJECTIVE To evaluate the impact of primary care group visits ( chronic care clinics ) on the process and outcome of care for diabetic patients . RESEARCH DESIGN AND METHODS We evaluated the intervention in primary care practice s r and omized to intervention and control groups in a large-staff model health maintenance organization ( HMO ) . Patients included diabetic patients > or = 30 years of age in each participating primary care practice , selected at r and om from an automated diabetes registry . Primary care practice s were r and omized within clinics to either a chronic care clinic ( intervention ) group or a  usual care ( control ) group . The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor 's practice .  Chronic care clinics consisted of st and ardized assessment s ; visits with the primary care physician , nurse , and clinical pharmacist ; and a group education/peer support meeting . We collected  self-report question  naires from patients and data from administrative systems . The question naires were mailed , and telephoned interviews were conducted for nonrespondents , at baseline and at 12 and 24 months ; we queried the process of care received , the satisfaction with care , and the health status of each patient . Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems . RESULTS In an intention-to-treat analysis at 24 months , the intervention group had received significantly more recommended preventive procedures  and helpful patient education .  Of five primary health status indicators examined , two ( SF-36 general health and bed disability days ) were significantly better in the intervention group . Compared with control patients , intervention patients had slightly more primary care visits , but significantly fewer specialty and emergency room visits . Among intervention participants , we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes , including patient satisfaction and HbA1c levels . CONCLUSIONS Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes 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 AIMS To investigate the effectiveness of a diabetes virtual clinic to enhance diabetes in primary care by developing clinical management plans for patients with suboptimal metabolic control and /or case complexity . METHODS A prospect i ve study with r and omized allocation to virtual clinic or usual care .  Patients with Type 2 diabetes ( n = 208 ) were recruited from six general practice s in South London . The primary outcome for the study was glycaemic control , secondary outcomes included : lipids , blood pressure , weight ( kg and BMI ) and renal function ( eGFR ) . Data were collected from participants ' records at baseline and 12 months . We also considered process measures including therapy optimization . RESULTS The 12-month data show equivalence between the virtual clinic and control groups for glycaemic control with both achieving clinical ly significant reductions in HbA1c of 8 mmol/mol ( 0.6 ± 1.7 % ) and 10 mmol/mol ( 0.8 ± 1.9 % ) , respectively ( P = 0.4 ) . The virtual clinic group showed superiority over the intervention group for blood pressure control with a mean reduction in systolic blood pressure of 6 ± 16 mmHg compared with an increased of 2 ± 18 mmHg in the control group ( P = 0.008 ) . There were no significant differences between the groups in terms of cholesterol , weight and renal function . Process measures showed an increased level of therapy adjustment in the virtual clinic group . CONCLUSION The virtual clinic model explored in this study showed a clinical ly important improvement in glycaemic control . Although this improvement was not superior to that observed in the control participants , this might be attributable to the systemic impact of the virtual clinic on the practice as a whole Background Care management interventions in the German health-care system have been evaluated with promising results , but further research is necessary to explore their full potential in the context of multi-morbidity . Our aim in this trial is to assess the efficacy of a primary care practice network – based care management intervention in improving self-care behaviour among patients with type 2 diabetes mellitus and multiple co-occurring chronic conditions . Methods / Design The study is design ed as a prospect i ve , 18-month , multicentre , investigator-blinded , two-arm , open-label , individual-level , r and omized parallel-group superiority trial . We will enrol 582 patients with type 2 diabetes mellitus and at least two severe chronic conditions and one informal caregiver per patient . Data will be collected at baseline ( T0 ) , at the primary endpoint after 9 months ( T1 ) and at follow-up after 18 months ( T2 ) . The primary outcome will be the differences between the  intervention and control groups  in changes of diabetes-related self-care behaviours from baseline to T1 using a German version of the revised Summary of Diabetes Self-Care Activities ( SDSCA-G ) . The secondary outcomes will be the differences between the intervention and control groups in : changes in scores on the SDSCA-G subscales , glycosylated haemoglobin A level , health-related quality of life , self-efficacy , differences in ( severe ) symptomatic hypoglycaemia , cost-effectiveness and financial family burden . The intervention will be delivered by trained health-care assistants as an add-on to usual care and will consist of three main elements : ( 1 ) three home visits , including structured assessment of medical and social needs ; ( 2 ) 24 structured telephone monitoring contacts ; and ( 3 ) self-monitoring of blood glucose levels after T1 in 3-month intervals . The control group will receive usual care . The confirmatory primary analysis will be performed following the intention-to-treat ( ITT ) principle . The efficacy of the intervention will be quantified using two-level linear regression stratified by type of medical treatment adjusted for baseline values on the SDSCA-G. Secondary analyses will be performed according to the ITT principle . In health economic evaluations , we will estimate the incremental cost-effectiveness ratios . Discussion We hope that the results of this study will provide insights into the efficacy of practice network – based care management among patients with complex health-care needs . Trial registration Current Controlled Trials IS RCT N83908315 ( IS RCT N assigned 25 February 2014 ) OBJECTIVE —The purpose of this study was to determine whether implementation of a multicomponent organizational intervention can produce significant change in diabetes care and outcomes in community primary care practice s. RESEARCH DESIGN AND METHODS —This was a group-r and omized , controlled clinical trial evaluating the practical effectiveness of a multicomponent intervention ( TRANSLATE )  in 24 practice s. The intervention included implementation of an electronic diabetes registry , visit reminders , and patient-specific physician alerts . A site coordinator facilitated previsit planning and a monthly review of performance with a local physician champion . The principle outcomes were the percentage of patients achieving target values for the composite of systolic blood pressure ( SBP ) < 130 mmHg , LDL cholesterol < 100 mg/dl , and A1C < 7.0 % at baseline and 12 months . Six process measures were also followed . RESULTS —Over 24 months , 69,965 visits from 8,405 adult patients with type 2 diabetes were recorded from 238 health care providers in 24 practice s from 17 health systems .  Diabetes process measures increased significantly more in intervention than in control practice s , giving net increases as follows : foot examinations 35.0 % ( P < 0.0.001 ) ; annual eye examinations 25.9 % ( P < 0.001 ) ; renal testing 28.5 % ( P < 0.001 ) ; A1C testing 8.1%(P < 0.001 ) ; blood pressure monitoring 3.5 % ( P = 0.05 ) ; and LDL testing 8.6 % ( P < 0.001 ) . Mean A1C adjusted for age , sex , and comorbidity decreased significantly in intervention practice s ( P < 0.02 ) . At 12 months , intervention practice s had significantly greater improvement in achieving recommended clinical values for SBP , A1C , and LDL than control clinics ( P = 0.002 ) . CONCLUSIONS — Introduction of a multicomponent organizational intervention in the primary care setting significantly increases the percentage of type 2 diabetic patients achieving recommended clinical outcomes
Educational interventions did not seem to have a positive impact on HbA1c , systolic blood pressure or lipid profiles .
The use of telemedicine , clinician reminders and feedback showed mixed results but there was a level of consistency in improvement in HbA1c when multifaceted interventions on multidisciplinary teams were implemented .
Targeting general or family physicians was largely ineffective in improving the cardiovascular risk factors considered , except when using a computer application on insulin h and ling of type 2 diabetes or customised simulated cases with feedbacks .
Similarly , interventions targeting nurses did not improve outcomes compared to st and ard care .
Multifaceted professional interventions were more effective than single interventions targeting single primary or community care professionals in improving glycaemic control
OBJECTIVE To review the interventions targeting primary care or community based professionals on glycaemic and cardiovascular risk factor control in people with diabetes .