Increasing Prescribed Office Visits: A Controlled Trial in Patients With Diabetes Mellitus A controlled trial to increase office visits and reduce hospitalizations of diabetic patients Group Visits: Promoting Adherence to Diabetes Guidelines The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review Evaluating Group Visits in an Uninsured or Inadequately Insured Patient Population With Uncontrolled Type 2 Diabetes A Clinical Trial of Chronic Care Diabetic Clinics in General Practice in the United Arab Emirates: A Preliminary Analysis Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Using collaborative learning to improve diabetes care and outcomes: the VIDA project. Further Evaluating the Acceptability of Group Visits in an Uninsured or Inadequately Insured Patient Population With Uncontrolled Type 2 Diabetes Caring for Poorly Controlled Diabetes Mellitus: A Randomized Pharmacist Intervention A randomized controlled trial of the effects of nurse case manager and community health worker team interventions in urban African-Americans with type 2 diabetes. Group visits in medically and economically disadvantaged patients with type 2 diabetes and their relationships to clinical outcomes. Cost analysis of a peer support programme for patients with type 2 diabetes: a secondary analysis of a controlled trial Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial The impact of pharmacist-led medication therapy management on medication adherence in patients with type 2 diabetes mellitus: a randomized controlled study Randomised controlled trial of an automated, interactive telephone intervention to improve type 2 diabetes self-management (Telephone-Linked Care Diabetes Project): study protocol The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial
Patients who fail to show for scheduled visits or who fail to contact their provider when warning symptoms occur pose important problems for the primary care physician . A group of interventions was examined to determine the effectiveness in increasing the number of prescribed office visits in patients with diabetes mellitus . This group of interventions included mailed packets with information on how to use the clinic , providers ' names and phone numbers , after-hours phone numbers , a list of early warning signs , and a booklet on managing diabetes mellitus ; mailed appointment reminders ; and intense followup of visit failures for prompt rescheduling .  Eight hundred fifty-nine patients on drug therapy for diabetes mellitus were stratified by risk of hospitalization and r and omly assigned within strata to control and intervention groups . The intervention group received all interventions . After 1 year , the intervention group averaged 12 % more total contacts than the control group ( 5.8 vs. 5.2 , P = 0.01 ) , due largely to an increase in kept scheduled visits ( 4.1 vs. 3.6 , P = 0.006 ) . These effects were greatest in those patients at higher risk of hospitalization . Also , visit failures were reduced only in high-risk patients . The effect of the interventions did not diminish during the year of study . This systematic and repetitive intervention appears effective in increasing prescribed office visits and is especially effective in patients requiring more frequent care An intervention package was examined to determine its effectiveness in increasing office visits and in reducing the incidence of nonelective hospitalizations ( those for urgent or emergent reasons ) . The intervention included mailings of information , appointment reminders , and intense follow-up by telephone of visit failures for rescheduling .  Eight hundred fifty-four patients receiving drug therapy for diabetes mellitus were stratified by risk of nonelective hospitalization and r and omly assigned to the control group or the intervention group . After two years , the intervention group averaged 9.1 per cent more kept scheduled visits per month than the control group ( 0.371 vs. 0.340 , p=0.02 ) . However , the mean incidence of nonelective hospitalizations per month was not significantly different between intervention and control groups ( 0.040 vs. 0.041 , p=0.9 ) , nor was there a difference in nonelective hospital days per month ( 0.443 vs. 0.425 , p=0.7 ) . The authors conclude that while mailings and telephone calls can increase office visits , the intervention is not sufficient to reduce morbidity necessitating nonelective hospitalizations of diabetic patients BACKGROUND Current diabetes management guidelines offer blueprints for providers , yet type 2 diabetes control is often poor in disadvantaged population s. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems .  Group visits offer promise for delivering care to diabetic patients , as visits are lengthier and can be more frequent , more organized , and more educational . OBJECTIVE To evaluate the effect of group visits on clinical outcomes , concordance with 10 American Diabetes Association ( ADA ) guidelines [ American Diabetes Association , Diabetes Care , 28:S4–36 , 2004 ] and 3 United States Preventive Services Task Force ( USPSTF ) cancer screens [ U.S. Preventive Services Task Force , http://www.ahrq.gov/clinic/uspstf/re source .htm , 2003 ] . RESEARCH DESIGN AND METHODS A 12-month r and omized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient – physician dyad . Clinical outcomes ( HbA1c , blood pressure [ BP ] , lipid profiles ) were assessed at 6 and 12 months and quality of care measures ( adherence to 10 ADA guidelines and 3 USPSTF cancer screens ) at 12 months . RESULTS At both measurement points , HbA1c , BP , and lipid levels did not differ significantly for patients attending group visits versus those in usual care . At 12 months , however , patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators ( p < .0001 ) and higher screening rates for cancers of the breast ( 80 vs. 68 % , p = .006 ) and cervix ( 80 vs 68 % , p = .019 ) . CONCLUSIONS Group visits can improve the quality of care for diabetic patients , but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes Background The prevalence of diabetes mellitus is ubiquitous . Complications and costs of diabetes are rising and are depleting limited re sources . It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions . An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit . Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting . Objectives The review objective was to conduct a systematic review and meta‐ analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c , blood pressure and cholesterol measurements /levels for adult patients with type II diabetes in outpatient setting s. Search strategy A three‐step literature search for studies in English language from 1990 to 2010 was conducted utilising ( a ) a primary search of Medline , CINAHL , PsycINFO and Cochrane Central Register of Controlled Trials , ( b ) a secondary search of non‐indexed data bases , and ( c ) a search of the grey literature . In addition , a manual review of the reference lists of all identified reports and articles was performed to identify additional studies . Inclusion criteria All r and omised and quasi‐experimental studies of adult patients ( > 18 ) with type II diabetes mellitus seen in outpatient health setting s were considered if they met one or more of the following diagnostic outcome measurements : haemoglobin A1c , systolic and diastolic blood pressure , and low density lipoprotein cholesterol . Critical appraisal , data collection and analysis Each of the eligible articles was review ed by two independent review ers . Disagreements between the review ers were resolved through discussion , or with a third review er . Studies that met the inclusion criteria were assessed for method ological quality using the JBI st and ardized critical appraisal tools . Data extraction was undertaken using the st and ardised data extraction tool from JBI‐MAStARI . Main results The search strategy identified 2,040 articles in the published and unpublished literature . Of these , 11 r and omised controlled trials and 4 quasi‐experimental trials met the inclusion criteria and represented 2240 patients included in the final review . There are clear benefits of group medical visits for patients ' HbA1c levels which are consistent in the post‐intervention and change from baseline effect sizes . The most significant effect observed is with the change from baseline results . Some evidence suggests post‐intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe . There is no evidence that group visits improve LDL cholesterol values of the group visit participants . Conclusions Group medical visits should be considered by clinicians as an effective non‐pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure . Implication s for practice The evidence suggests that the most powerful model of Group medical visits ( GMV ) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs . Implication s for research Future research should include this GMV intervention in r and omised controlled trials across different health systems and socio‐economic and ethnic groups PURPOSE this study was conducted to evaluate the feasibility and acceptability of a managed-care approach ( group visits ) on delivering care to uninsured or inadequately insured patients with type 2 diabetes . METHODS One hundred twenty patients with uncontrolled type 2 diabetes were r and omly assigned to receive care in group visits or usual care for 6 months . At baseline , 3 months , and 6 months , the feasibility and acceptability of this model of healthcare delivery were assessed through the patients ' responses to the Primary Care Assessment Tool and the Trust in Physician Scale . Attendance records were kept for each group . RESULTS Patients who received care in group visits showed an improved sense of trust in their physician compared with patients who continued to receive usual care . There was a tendency for patients in groups to report better coordination of their care , better community orientation , and more culturally competent care . Patient attendance at the groups also indicated good acceptance of this form of healthcare delivery . CONCLUSIONS Group visits were feasible and acceptable to these uninsured and inadequately insured patients with uncontrolled type 2 diabetes and fostered an improved sense of trust in their physician Control of diabetes mellitus is a high priority for primary health care systems . One innovative method of diabetes care delivery is the use of structured diabetes care in primary care . This includes the use of chronic care diabetes clinics or mini-clinics operated by general practitioners in primary care . There is limited experience with this model in non-Western setting s. This study sought to evaluate a multi-component structured approach to diabetes care in primary care including chronic care diabetes clinics in a newly developed country in the Arabian Gulf . The study design used was a controlled before-after methodology . Three primary health centers were chosen for the intervention with six of the remaining clinics in a Health District being used as controls . A multifaceted intervention was initiated in the intervention clinics composed of chronic care diabetes clinics , a diabetic flow chart , and educational programs for clinic nurses and doctors and patients . The study intervention took place over a period of 18 months with three diabetic outcomes ( fasting blood glucose , blood pressure and cholesterol ) and adherence to seven diabetes guidelines being compared for the year prior to the intervention and during the last 12 months of the intervention period . Knowledge and satisfaction question naires were also administered to intervention and control subjects at the end of the study . In this study , 219 subjects were enrolled ( 130 males and 89 females ) . They had a mean age of 51.6 years and a mean of 3.1 years of formal education . Of these 109 were enrolled in one of three clinics that had a chronic care diabetes clinic and 110 were enrolled in one of the six control clinics . Subjects had diabetes for a mean of 7.8 ± 4.8 years and the majority was treated with pharmacological therapy . Baseline characteristics in the intervention and the control clinics were similar with the exception of younger age ( p = 0.01 ) and a trend for more males ( p = 0.06 ) in the intervention clinics . There was a statistically insignificant change noted with the intervention in the three clinical outcomes studied ( fasting blood glucose , blood pressure and cholesterol ) both in comparison to the control group before and after and within the intervention group . However most changes noted were in the expected direction of improvement ; six of the seven guidelines were statistically improved in the intervention group when compared with the control group . Within the intervention group , adherence with five of seven guidelines was also statistically significantly increased with the remaining guidelines showing a trend in favor of improvement ( fasting blood glucose measurements ( p = 0.07 ) and urine determinations for protein ( p = 0.07 ) ) . Knowledge question naire scores were similar between the intervention and control groups on completion of the study but 2 of 4 items on a satisfaction scale were statistically significantly higher in the intervention group . The intervention described in this setting was successful in improving adherence to diabetes guidelines and increased some aspects of satisfaction with diabetes care . The intervention did not result in a statistically significant improvement in clinical outcomes but changes noted were in the expected direction of improvement . The significant improvement in adherence to diabetes guidelines suggests that this intervention is a promising model for diabetes care for newly developed countries 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 UNLABELLED The prevalence of diabetes in Mexico among those 20 - 64 years of age has increased from 7.2 % in 1993 to 10.7 % in 2000 . National population -based surveys in Mexico demonstrated that 50 % of the total population with diabetes had blood glucose levels of 200mg/dl or higher . Thus , diabetes care has become one of the most important public health challenges in this country . The aim of the study was to improve the quality of diabetes care in primary health care centers using the chronic care model and the breakthrough series ( BTS ) collaborative methodology . METHODS Ten public health centers in the cities of Xalapa and Veracruz were r and omly selected to participate in the project . Five of the health centers were r and omly assigned to receive the intervention ( intervention group ) and the other five followed usual care ( usual care group ) . The intervention was evaluated by A1c test before and after the intervention in both groups of patients . Patients were followed for 18 months from November 2002 to May 2004 . Results were adjusted for the clustering of patients within practice s and baseline measure . RESULTS The proportion of people with good glycemic control ( A1c<7 % ) among those in the intervention group increased from 28 % before the intervention to 39 % after the intervention . The proportion of patients achieving three or more quality improvement goals increased from 16.6 % to 69.7 % ( p<0.001 ) among the intervention group while the usual care group experienced a non-significant decrease from 12.4 % to 5.9 % ( p=0.118 ) . The focus on the primary care team and the participation of people with diabetes were strategic elements incorporated into the methodology , expected to ensure sustainability of continued improvement of health outcomes . CONCLUSIONS The intervention introduced modifications to solve problems identified by health teams in their practice and improved process and outcome measures of quality diabetes care . Most of the actions were directed at four components of the chronic care model : self-management support , decision support , delivery system design , and clinical information systems PURPOSE The purpose of the study was to evaluate perceptions of care delivered through group visits to disadvantaged patients with type 2 diabetes . METHODS One hundred eighty-six patients with uncontrolled type 2 diabetes were r and omly assigned to receive care in group visits or usual care for 12 months . Their perceptions of the care they received were measured at baseline and 6 and 12 months by the  Primary Care Assessment Tool ( PCAT ) , the Diabetes-Specific Locus of Control ( DLC ) survey , and the Trust in Physician Scale ( TPS ) .  RESULTS Compared to patients in usual care , group visit patients ' PCAT scores were higher in the domains of ongoing care ( P = .001 ) , community orientation ( P < .0001 ) , and cultural competence ( P = .022 ) . In addition , group patients had higher scores for the Powerful-Other Health Professional subscale of the DLC survey ( P = .010 ) . CONCLUSIONS Patients assigned to group visits had generally more positive perceptions about their care in the areas of ongoing care , community orientation of care , and cultural competence of care than did those in usual care . The perception that one 's health professional is powerful , however , has been associated with a reluctance of patients to make medication changes on their own in previous studies . These findings suggest the need for modification in the way that group visits are conducted to empower and activate patients while still delivering continuous , culturally competent , and community-oriented care BACKGROUND : There is limited information from r and omized controlled studies about the influence of pharmacist interventions on diabetes control . OBJECTIVE : To evaluate the effect of a pharmacist intervention on improving diabetes control ; secondary endpoints were medication appropriateness and self-reported adherence . METHODS : A r and omized , controlled , multi-clinic trial was conducted in the University of Washington Medicine Neighborhood Clinics . Seventy-seven subjects , ⩾18 years old with a hemoglobin ( Hb ) A1c ⩾9 % at baseline and taking at least one oral diabetes medication , were r and omized to receive a pharmacist intervention ( n = 43 ) or usual care ( n = 34 ) for 6 months followed by a 6-month usual-care observation period for both groups . Subjects met with a clinical pharmacist to establish and initiate a diabetes care plan followed by weekly visits or telephone calls to facilitate diabetes management and adherence . HbA1c , medication appropriateness , and self-reported adherence were assessed at baseline , 6 months , and 12 months . RESULTS : The mean HbA1c did not differ between groups over the 12-month period ( p = 0.61 ) . A reduction in HbA1c was noted for both groups over time compared with baseline ( p = 0.001 ) ; however , control subjects relied more heavily on provider visits . Medication appropriateness was not improved for diabetes medications ( p = 0.65 ) . Self-reported adherence was not significantly improved by the intervention . CONCLUSIONS : This pharmacist intervention did not significantly improve diabetes control , but did allow for similar HbA1c control with fewer physician visits . Medication appropriateness and self-reported adherence compared with usual care in individuals with poorly controlled diabetes were not changed The objective of the study was to determine the effectiveness and cost-effectiveness of primary care and community-oriented interventions in managing HbA1c , blood pressure , and lipids , and reducing hospitalizations and emergency room visits over 2 years . We describe an ongoing , r and omized controlled trial of 542 urban African-Americans with type 2 diabetes ages 25 years and older who are members of a university-affiliated managed-care organization in Baltimore , MD . The participants are 74 % female , have a mean age of 58 years , and 35 % have yearly incomes greater than 7500 US dollars . Participants were r and omized to one of two intervention groups for a period of 2 years : ( 1 ) usual medical care plus minimal telephone intervention implemented by a trained lay health educator ( control group ) or ( 2 ) usual medical care plus intensive intervention implemented by a nurse case manager (NCM)/community health worker ( CHW ) team . The intensive NCM/CHW team executes individual plans of care using evidence -based algorithms that focus on traditional diabetes self-management , screening and management of diabetes-related complications , and social issues surrounding diabetes care . Face-to-face NCM visits are conducted in the clinic once per year and CHW visits are conducted in the participant 's home one to three times per year , both with additional follow-up contacts as needed . Written and verbal feedback ( when necessary ) is provided to the participant 's primary care physician . All participants are expected to attend a 24-month follow-up visit where data are collected by interviewers blinded to intervention assignment . As of May 1 , 2003 , recruitment is complete , interventions are being fully implemented , and 24-month follow-up visits are beginning . Baseline sociodemographic characteristics , health-care utilization , health behaviors , and clinical characteristics of the study population are reported . This study is design ed to test the hypothesis that a primary -care-based NCM plus CHW team approach is an effective , practical , and economically feasible strategy for translating current knowledge about type 2 diabetes into high- quality health care for urban African-Americans To evaluate group visits in the management of underinsured patients with uncontrolled type 2 diabetes , 120 eligible patients enrolled were r and omly assigned to receive care in groups or continue usual care .  Feasibility , acceptability , and concordance with American Diabetes Association st and ards of care ( Diab Camre . 25[suppl 1]:533 - 549 ) were evaluated . Patients who received care in groups exhibited improvement in American Diabetes Association st and ards of care ( p < .001 ) , improved sense of trust in physician ( p = .02 ) , and tended to report better coordination of care ( p = .07 ) , better community orientation ( p = .09 ) , and more culturally competent care ( p = .09 ) . Group visits offer a promising model for delivering health care to these patients Background This study aim ed to explore if group-based peer support as an additional component to a disease management programme ( DMP ) in type 2 diabetes can reduce the number of prescribed drugs ; hospital admissions ; and length of hospital stay and therefore be a cost-effective model . Methods Controlled study based on a secondary data analysis of a cluster r and omized trial . Our study population was general practitioners and patients in the province of Salzburg . The 24-months intervention consisted of regular group meetings facilitated by trained peer supporters . The groups exercised together , discussed diabetes related topics , and received support by professionals . Data was anonymously collected on clusters through the statutory health insurance . Results Data were available of 118 ( 82.5%,17 clusters of the patients in the original r and omized trial ) participants in the intervention and 143 ( 77.3%,19 clusters ) in the control groups .  The length of hospital stay was shorter in the intervention groups compared with controls . The mean difference during the 24-month study period was -40.13 days ( 95 % CI - 78.54 to - 1.71 , P = 0.041 ) in favour of the intervention groups . No differences were seen in the number of prescribed drugs and hospital admission . Estimated yearly savings by reducing the length of hospital stay was € 1660.60 per patient . Conclusion A group-based peer support programme as an additional component of a DMP in type 2 diabetes is a promising approach to optimize diabetes care and to enhance lifestyle interventions in primary care . Peer support seems to reduce length of hospital stay and could therefore be a cost-effective model PURPOSE The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes , particularly those physicians not affiliated with an integrated care system that some managed care organizations provide . METHODS Patients with type 2 diabetes were recruited from the general population of a large metropolitan area . Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians ( basic intervention ) . A r and om one-half of patients were additionally assigned to individual counseling , problem identification , care planning , and management recommendations by a nurse care manager ( individualized intervention ) . The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention . Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C , blood pressure , and cholesterol as outcome measures . RESULTS Of 220 patients recruited , 197 had type 2 diabetes , r and omly assigned only the basic intervention ( 102 patients ) or individualized intervention ( 95 patients ) . Postintervention data were obtained on 164 patients ( 83 % ) . Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group . Patients with a systolic blood pressure > or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts . CONCLUSIONS A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes . For those many physicians not affiliated with an integrated care system featured by some managed care organizations , this collaboration could underlie a team approach ( nurse/patient/physician ) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level BACKGROUND Poor adherence to antidiabetic medications leads to a higher rate of hospital admissions and adverse health outcomes in type 2 diabetes mellitus patients . OBJECTIVE This study aims to evaluate whether a pharmacist-led medication therapy management , compared to the usual care , could enhance medication adherence and reduce hospital admission in patients with type 2 diabetes mellitus . METHODS A prospect i ve r and omized controlled study was conducted in patients with type 2 diabetes mellitus from February 1 to July 30 , 2016 . Patients in the control group ( n=65 ) received the usual care while patients in the intervention group ( n=62 ) received a personalized pharmacotherapeutic care plan and diabetes education . The two groups were compared by repeated measure ANOVA at 3 and 6-months with medication adherence ( using Morisky medication adherence scale ) and number of hospital admissions as the main outcome variables . RESULTS A total of 127 patients were included in the study . A marked and statistically significant increase in medication adherence from baseline to 3 and 6 months were noted in the intervention group ( increased from 9.2 % at baseline to 61 % at 6 month ) compared with the control group ( increased from 13.2 % at baseline ( to 30.2 % at 6 month ; p-value<0.01 ) . Furthermore , at the 6-month follow-up , only 23 patients in MTM group with poorly controlled blood glucose levels result ed in hospital admissions compared to 48 patients in non-MTM group , result ing in a 52.1 % fewer hospital admissions ( p < 0.001 ) . CONCLUSIONS The findings of this study implied that pharmacist-led medication therapy management might improve medication adherence and reduce number of hospitalizations in patients with type 2 diabetes mellitus . Hence , policies and guidelines should be in place in order for clinical pharmacists to fully engage in patient care and improve the medication therapy outcomes Background An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030 . For the year 2010 , it is estimated that 3.96 million excess deaths in the age group 20 - 79 years are attributable to diabetes around the world . Self-management is recognised as an integral part of diabetes care . This paper describes the protocol of a r and omised controlled trial of an automated interactive telephone system aim ing to improve the uptake and maintenance of essential diabetes self-management behaviours . Methods / Design A total of 340 individuals with type 2 diabetes will be r and omised , either to the routine care arm , or to the intervention arm in which participants receive the  Telephone-Linked Care ( TLC ) Diabetes program in addition to their routine care . The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months . They receive the study h and book and a glucose meter linked to a data uploading device . The TLC system consists of a computer with software design ed to provide monitoring , tailored feedback and education on key aspects of diabetes self-management , based on answers voiced or entered during the current or previous conversations . Data collection is conducted at baseline ( Time 1 ) , 6-month follow-up ( Time 2 ) , and 12-month follow-up ( Time 3 ) . The primary outcomes are glycaemic control ( HbA1c ) and quality of life ( Short Form-36 Health Survey version 2 ) . Secondary outcomes include anthropometric measures , blood pressure , blood lipid profile , psychosocial measures as well as measures of diet , physical activity , blood glucose monitoring , foot care and medication taking . Information on utilisation of healthcare services including hospital admissions , medication use and costs is collected . An economic evaluation is also planned . Discussion Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes . Furthermore , the study will provide insight into the potential for more widespread uptake of automated telehealth interventions , globally . Trial Registration Background Diabetes is a major challenge for the health care system and especially for the primary care provider . The Chronic Care Model represents an evidence -based framework for the care for chronically ill . An increasing number of studies showed that implementing elements of the Chronic Care Model improves patient relevant outcomes and process parameters . However , most of these findings have been performed in setting s different from the Swiss health care system which is dominated by single h and ed practice s. Methods / Design CARAT is a cluster r and omized controlled trial with general practitioners as the unit of r and omization ( trial registration : IS RCT N05947538 ) . The study challenges the hypothesis that implementing several elements of the Chronic Care Model via a specially trained practice nurse improves the HbA1c level of diabetes type II patients significantly after one year ( primary outcome ) . Furthermore , we assume that the intervention increases the proportion of patients who achieve the recommended targets regarding blood pressure ( < 130/80 ) , HbA1c ( = < 6.5 % ) and low-density lipoprotein-cholesterol ( < 2.6 mmol/l ) , increases patients ' quality of life ( SF-36 ) and several evidence -based quality indicators for diabetes care . These improvements in care will be experienced by the patients ( PACIC-5A ) as well as by the practice team ( ACIC ) . According to the power calculation , 28 general practitioners will be r and omized either to the intervention group or to the control group . Each general practitioner will include 12 patients suffering from diabetes type II . In the intervention group the general practitioner as well as the practice nurse will be trained to perform care for diabetes patients according to the Chronic Care Model in teamwork . In the control group no intervention will be applied at all and patients will be treated as usual . Measurements ( pre- data - collection ) will take place in months II-IV , starting in February 2010 . Follow-up data will be collected after 1 year . Discussion This study challenges the hypothesis that the Chronic Care Model can be easily implemented by a practice nurse focused approach . If our results will confirm this hypothesis the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to re design care in Switzerl and
The most significant effect observed is with the change from baseline results .
Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe .
There is no evidence that group visits improve LDL cholesterol values of the group visit participants .
IMPLICATION S FOR PRACTICE The evidence suggests that the most powerful model of Group medical visits ( GMV ) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs .
BACKGROUND The prevalence of diabetes mellitus is ubiquitous .
Complications and costs of diabetes are rising and are depleting limited re sources .
It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions .
An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit .
Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting .