A study on diabetes-related self-care plan and its determinants among diabetes patients in a Warangal region, Telangana, India

Abstract The prevalence of epidemiological diseases, including diabetes, has continued to increase because of the adaption of Western culture and the lack of self-care activities among patients with diabetes. Therefore, in this cross-sectional study, we aimed to assess self-care plans and determinants among diabetes outpatients in Warangal. We conducted a prospective observational study among diabetes outpatient clinic in Warangal, India over 6 months from October 2019 to March 2020. We used the expanded Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. A P value of less than < 0.05 was considered statistically significant. Respondents (mean age, 52.3 (standard deviation (SD), 11.01) years) had an overall SDSCA score of 49.18 ± 3.57 (SD). Mean scores for the diet, physical activity, foot care, medication adherence, and blood sugar testing scales were 12.79 (SD, 1.61), 10.24 (SD, 1.77), 15.67 (SD, 1.5), 5.66 (SD, 1.17), and 4.80 (SD, 0.68), respectively. Patients' age, education, disease duration and hemoglobin A1C (HbA1C) levels of <7.5% (P < 0.001)) had significantly higher mean scores for blood sugar testing, diet, physical activity, and adherence (P < 0.001). The employment status is associated with all the domains of Summary of Diabetes Self-Care Activities (P < 0.001). Taken together, our results revealed that patients with diabetes in Warangal had poor self-care planning, highlighting the need for strengthening initiatives that generate awareness regarding diabetes and improving related self-care practices

Outcomes of isoniazid preventive therapy among people living with HIV in Kenya: A retrospective study of routine health care data.

INTRODUCTION: Isoniazid preventive therapy (IPT) taken by People Living with HIV (PLHIV) protects against active tuberculosis (TB). Despite its recommendation, data is scarce on the uptake of IPT among PLHIV and factors associated with treatment outcomes. We aimed at determining the proportion of PLHIV initiated on IPT, assessed TB screening practices during and after IPT and IPT treatment outcomes. METHODS: A retrospective cohort study of a representative sample of PLHIV initiated on IPT between July 2015 and June 2018 in Kenya. For PLHIV initiated on IPT during the study period, we abstracted patient IPT uptake data from the National data warehouse. In contrast, we obtained information on socio-demographic, TB screening practices, IPT initiation, follow up, and outcomes from health facilities' patient record cards, IPT cards, and IPT registers. Further, we assessed baseline characteristics as potential correlates of developing active TB during and after treatment and IPT completion using multivariable logistic regression. RESULTS: From the data warehouse, 138,442 PLHIV were enrolled into ART during the study period and initiated 95,431 (68.9%) into IPT. We abstracted 4708 patients' files initiated on IPT, out of which 3891(82.6%) had IPT treatment outcomes documented, 4356(92.5%) had ever screened for TB at every clinic visit, and 4,243(90.1%) had documentation of TB screening on the IPT tool before IPT initiation. 3712(95.4%) of patients with documented IPT treatment outcomes completed their treatment. 42(0.89%) of the abstracted patients developed active TB,16(38.1%) during, and 26(61.9%) after completing IPT. Follow up for active TB at 6-month post-IPT completion was done for 2729(73.5%) of patients with IPT treatment outcomes. Sex, Viral load suppression, and clinic type were associated with TB development (p<0.05). Levels 4, 5, FBO, and private facilities and IPT prescription practices were associated with IPT completion (p<0.05). CONCLUSION: IPT initiation stands at two-thirds of the PLHIV, with a high completion rate. TB screening practices were better during IPT than after completion. Development of active TB during and after IPT emphasizes the need for a keen follow up.

Prevalence and attitudes to HIV testing among adults visiting public outpatient clinics in Rome: results of the MeDi (Measuring health Disparities in HIV prevention) survey. Part 1.

BACKGROUND: It is estimated that, in Italy, 12 000-18 000 (11-13% of 130 000) HIV-infected subjects are not aware of their serostatus. People in this condition may visit the healthcare system multiple times without being diagnosed. If tested on one of these occasions, they could modify their high-risk behaviours and benefit from treatment, factors that reduce HIV transmission. In Italy, no data on HIV testing in the general population are available so far and little is known on the relationship between socioeconomic determinants (at individual and neighbourhood levels) and testing uptake. METHODS: A large anonymous survey was performed in 2012-2014 on more than 10 000 individuals 18-59 years old who underwent 21 public ambulatories in Rome to determine the proportion of subjects tested for HIV and factors related to testing uptake. Subjects' socio-demographic characteristics, sexual orientation, number of sexual partners, HIV risk behaviour, HIV testing uptake were collected by a self-administered questionnaire. Level of area deprivation was measured at the postal code level by the index of social disadvantage (ISD). Multilevel Poisson regressions were carried out to take heterogeneity between clusters (post code and clinics) into account. RESULTS: Among people participating in the study, 58.1% of subjects self-reported to have been tested at least once for HIV. Those who had one high risk behaviour for HIV-infection were 11% more likely to test than those not reporting any, and subjects who had had a STI (sexually-transmitted-infection) in the past were 12% more likely to test than those who had not had a STI. However only 44% (54% among subjects aged 18-35 years) of those with self-reported risks of contracting HIV had been tested at least once in life. This percentage increases, as expected, with the level of education, but, even so, about 40% of university educated subjects self-reporting risks of contracting HIV had never undergone an HIV test. CONCLUSIONS: This study highlights that, while the percentage of subjects tested is even higher than observed in other western nations, only 44% of subjects, self-reporting risks of contracting HIV, had tested at least once in life and about 40% of university educated subjects self reporting risks of contracting HIV had never tested.

HIV prevalence among adults in Rome: results of the MeDi (Measuring health Disparities in HIV prevention) survey. Part 2.

BACKGROUND: In Italy, out of 60 millions of inhabitants, 3000 (2700-4000) new HIV infections are estimated each year. As combined antiretroviral therapy (ART) prolongs life for HIV sufferers, the prevalence of HIV-infection is likely to increase over time. Few studies have assessed factors associated with being HIV positive in people accessing public outpatient clinics and, in particular, the influence of socio-economic circumstances on HIV prevalence. This study aims to evaluate the association between subjects' serostatus and socio-economic determinants measured at the individual and neighbourhood levels. METHODS: Data from a large anonymous survey performed in 2012-2014 on more than 10 000 individuals 18-59 years old who underwent 21 public ambulatories in Rome were analysed. Subjects' socio-demographic characteristics, sexual orientation, number of sexual partners, HIV risk behaviour and HIV testing uptake were collected by a self-administered questionnaire. Level of area deprivation was measured at the postal code level by the index of social disadvantage (ISD). Multilevel Poisson regressions were carried out to take heterogeneity between clusters (post code and clinics) into account. RESULTS: Self-reported HIV-prevalence was 2.0% among subjects ever been tested (13.7% for the homosexual/lesbians 7.0% for the bisexual and 1.3% for the heterosexual). About 1% of subjects self-identified as low risk was HIV infected. This prevalence increased up to 2% in the age group 18-34 and up to 5% in the non-heterosexuals (i.e. self- identified homosexuals/lesbians and bisexuals). At the individual level, HIV-prevalence decreased linearly from lowest to highest levels of education. Living in a deprived neighbourhood was not associated with HIV-infection. CONCLUSIONS: Our study confirms high HIV prevalences among homosexuals/lesbians. Some infections occur in subjects who do not report high risk behaviours for HIV transmission.

Gaps in Chlamydia Treatment Within California Family Planning Clinics: Are Patients Filling Prescriptions?

BACKGROUND: Compared with receiving medication dispensed in a health center, patients receiving prescriptions must take additional steps for treatment. Few clinics have protocols for ensuring prescriptions are filled. This study evaluated prescription fill rates for chlamydia treatment based on claims data in California Title X clinics and examined fill rates by patient demographics and clinic type. METHODS: We collected treatment information during Title X site audits for a convenience sample of patients with a positive chlamydia test between January 2008 and March 2013. We categorized patients as receiving treatment on-site versus via prescription and matched prescriptions to pharmacy billing claims within 90 days of test date. We examined treatment rates by patient age, gender, and race/ethnicity, and by clinic type, and assessed the median time to treatment. RESULTS: Among 790 patients diagnosed with chlamydia across 79 clinics, 65% (n = 513) were treated on-site and 33% (n = 260) via prescription; 17 (2%) did not have treatment information. Sixty-seven percent of prescriptions had confirmed receipt of treatment. Prescription fill rates were lower for patients age 18 years and younger (47% vs. 71%, P < 0.01) and for patients attending federally qualified health centers compared with stand-alone family planning clinics (63% vs. 88%, P < 0.01). Median time to treatment was similar for patients treated on-site (5 days) or via prescription (4 days). CONCLUSIONS: Delays in chlamydia treatment increase risk of complications and ongoing transmission. Providing medications on-site can improve treatment rates, especially among younger patients. These insights can inform clinic treatment protocols and efforts to improve quality of chlamydia care.

Infections after pediatric ambulatory surgery: Incidence and risk factors.

OBJECTIVE: To describe the epidemiology of surgical site infections (SSIs) after pediatric ambulatory surgery. DESIGN: Observational cohort study with 60 days follow-up after surgery. SETTING: The study took place in 3 ambulatory surgical facilities (ASFs) and 1 hospital-based facility in a single pediatric healthcare network.ParticipantsChildren <18 years undergoing ambulatory surgery were included in the study. Of 19,777 eligible surgical encounters, 8,502 patients were enrolled. METHODS: Data were collected through parental interviews and from chart reviews. We assessed 2 outcomes: (1) National Healthcare Safety Network (NHSN)-defined SSI and (2) evidence of possible infection using a definition developed for this study. RESULTS: We identified 21 NSHN SSIs for a rate of 2.5 SSIs per 1,000 surgical encounters: 2.9 per 1,000 at the hospital-based facility and 1.6 per 1,000 at the ASFs. After restricting the search to procedures completed at both facilities and adjustment for patient demographics, there was no difference in the risk of NHSN SSI between the 2 types of facilities (odds ratio, 0.7; 95% confidence interval, 0.2-2.3). Within 60 days after surgery, 404 surgical patients had some or strong evidence of possible infection obtained from parental interview and/or chart review (rate, 48 SSIs per 1,000 surgical encounters). Of 306 cases identified through parental interviews, 176 cases (57%) did not have chart documentation. In our multivariable analysis, older age and black race were associated with a reduced risk of possible infection. CONCLUSIONS: The rate of NHSN-defined SSI after pediatric ambulatory surgery was low, although a substantial additional burden of infectious morbidity related to surgery might not have been captured by standard surveillance strategies and definitions.

Area-level poverty, race/ethnicity & dialysis star ratings.

The Centers for Medicare and Medicaid Services recently released a five star rating system as part of 'Dialysis Facility Compare' to help patients identify and choose high performing clinics in the US. Eight dialysis-related measures determine ratings. Little is known about the association between surrounding community sociodemographic characteristics and star ratings. Using data from the U.S. Census and over 6000 dialysis clinics across the country, we examined the association between dialysis clinic star ratings and characteristics of the local population: 1) proportion of population below the federal poverty level (FPL); 2) proportion of black individuals; and 3) proportion of Hispanic individuals, by correlation and regression analyses. Secondary analyses with Quality Incentive Program (QIP) scores and population characteristics were also performed. We observed a negligible correlation between star ratings and the proportion of local individuals below FPL; Spearman coefficient, R = -0.09 (p<0.0001), and a stronger correlation between star ratings and the proportion of black individuals; R = -0.21 (p<0.0001). Ordered logistic regression analyses yielded adjusted odds ratio of 0.91 (95% confidence interval [0.80-1.30], p = 0.12) and 0.55 ([0.48-0.63], p<0.0001) for high vs. low level of proportion below FPL and proportion of black individuals, respectively. In contrast, a near-zero correlation was observed between star ratings and the proportion of Hispanic individuals. Correlations varied substantially by country region, clinic profit status and clinic size. Analyses using clinic QIP scores provided similar results. Sociodemographic characteristics of the surrounding community, factors typically outside of providers' direct control, have varying levels of association with clinic dialysis star ratings.

Socioeconomic Status of Counties Where Dialysis Clinics Are Located Is an Important Factor in Comparing Dialysis Providers.

This study assessed the hypothesis that the clinic site of service socioeconomic status (SES) represents an unmeasured confounder for clinical outcome comparisons between dialysis clinics and provider types, using data from the federal pay-for-performance program for end-stage renal disease. A total of 6506 dialysis facilities were categorized by clinic SES status (rurality and poverty status). Clinics were then grouped by provider type (chain size and tax status). Lastly, performance penalties were determined by each of these classifications. Findings were that 7.4% of dialysis clinics could be classified as being in rural locations, and 20.6% could be classified as being in high-poverty locations. Large dialysis organizations served more rural (65%) and high-poverty areas (metropolitan, 69%; micropolitan, 75%; rural, 75%) compared to other providers (medium, small, hospital/university). For-profit providers accounted for a majority of dialysis clinics in rural areas (78%) and high poverty areas (metropolitan, 84%; micropolitan, 85%; rural, 90%). This study found that dialysis clinic performance penalties did vary by SES, with poorer outcomes observed for clinic locations with lower SES. This finding, along with the nonrandom distribution of provider types by SES status, suggests that clinic and provider location SES may need to be considered when comparing providers.

Perceptions of healthcare professionals and managers regarding the effectiveness of GP-led walk-in centres in the UK.

OBJECTIVES: This study aimed to identify the perceptions of healthcare professionals regarding the effectiveness and the impact of a new general practitioner-led (GP-led) walk-in centre in the UK. SETTING: This qualitative study was conducted in a large city in the North of England. In the past few years, there has been particular concern about an increase in the use of emergency department (ED) services provided by the National Health Service and part of the rationale for introducing the new GP-led walk-in centres has been to stem this increase. The five institutes included in the study were EDs, a minor injuries unit, a primary care trust, a GP-led walk-in centre and GP surgeries. PARTICIPANTS: Semistructured interviews were conducted with healthcare providers at an adult ED, an ED at a children's hospital, a minor injuries unit, a GP-led walk-in centre, GPs from surrounding surgeries and GPs. RESULTS: 11 healthcare professionals and managers were interviewed. Seven key themes were identified within the data: the clinical model of the GP-led walk-in centre; public awareness of the services; appropriate use of the centre; the impact of the centre on other services; demand for healthcare services; choice and confusion and mixed views (positive and negative) of the walk-in services. There were discrepancies between the managers and healthcare professionals regarding the usefulness of the GP-led walk-in centre in the current urgent care system. CONCLUSIONS: Participants did not notice declines in the demand for EDs after the GP-led walk-in centre. Most of the healthcare professionals believed that the GP-led walk-in centre duplicated existing healthcare services. There is a need to have a better communication system between the GP-led walk-in centres and other healthcare providers to have an integrated system of urgent care delivery.

Patient perception of care received by students at the Jackson Free Clinic.

INTRODUCTION: Little has been done to examine the role of student-run free clinics in patient care. In this study we examine patient perceptions of care provided by medical students in comparison to that provided by licensed physicians. Care providers were judged on perceived exam thoroughness, trust, and overall patient satisfaction. METHODS: Patients were asked to complete a 37 question survey after being examined by either medical students or by a physician. RESULTS: Differences between physicians and students were not observed for perceived thoroughness, trust, or overall satisfaction scores. Patients who reported never being married gave lower satisfaction scores (p = 0.024); however, all patients reported being satisfied with their care. CONCLUSIONS: Patients are satisfied with the care they received at the Jackson Free Clinic regardless of the provider's level of training. Patients did not report students to be less thorough in their exams than physicians. Furthermore, patients reported equal trust in students and physicians.

[Consensus paper of the German Migraine and Headache Society on the structure of headache care facilities in Germany]. / Konsensuspapier der Deutschen Migräne- und Kopfschmerzgesellschaft zur Struktur von Kopfschmerzzentren und Kopfschmerzschwerpunktpraxen in Deutschland.

This consensus paper introduces a classification of headache care facilities on behalf of the German Migraine and Headache Society. This classification is based on the recommendations of the International Association for the Study of Pain (IASP) and the European Headache Federation (EHF) and was adapted to reflect the specific situation of headache care in Germany. It defines three levels of headache care: headache practitioner (level 1), headache outpatient clinic (level 2) and headache centers (level 3). The objective of the publication is to define and establish reliable criteria in the field of headache care in Germany.

Outcomes of dialytic modalities in a large incident registry cohort from Eastern Europe: the Romanian Renal Registry.

BACKGROUND: Studies comparing survival in hemodialysis (HD) or peritoneal dialysis (PD) patients reported controversial results, mainly during the first 2 years of treatment. Moreover, there is a significant geographic variation in the use of these modalities. We aimed to compare the survival of HD and PD patients using data from the Romanian Renal Registry. METHODS: In an intention-to-treat analysis using Kaplan-Meier and Cox proportional hazard (CPH) models, survival was compared between 8,252 incident HD patients and 1,000 incident PD patients treated between 2008 and 2011. The patients were followed from the dialysis initiation and stratified by modality on day 90. The time on dialysis was separated into four periods (3-12, 12-24, 24-36 and >36 months), and outcome comparisons were made. RESULTS: Mean survival time was 46.3 (44.9-47.6) months in PD group and 45.8 (45.3-46.3) months in HD group (p = 0.9, log-rank test). In the multivariate CPH models, age, diabetes-associated kidney disease (DM), primary renal disease and center size significantly influenced survival. In the first year of therapy, the mortality was higher in HD than in PD patients (HR = 1.34 (1.12-1.60), p = 0.001), while in the second and third year, HD patients survived better (HR = 0.69 (0.53-0.89), p = 0.005); HR = 0.56 (0.41-0.78), p = 0.001) and after 36 months, the survival difference was not statistically significant (HR = 0.63 (0.34-1.13), p = 0.1), respectively. CONCLUSIONS: Despite the survival advantage for PD patients during the first year and that of HD in the next 2 years of dialysis, the overall survival in HD and PD patients was similar and was influenced by age, DM and center size.

Do differences in profiling criteria bias performance measurements? Economic profiling of medical clinics under the Korea National Health Insurance program: an observational study using claims data.

BACKGROUND: With a greater emphasis on cost containment in many health care systems, it has become common to evaluate each physician's relative resource use. This study explored the major factors that influence the economic performance rankings of medical clinics in the Korea National Health Insurance (NHI) program by assessing the consistency between cost-efficiency indices constructed using different profiling criteria. METHODS: Data on medical care benefit costs for outpatient care at medical clinics nationwide were collected from the NHI claims database. We calculated eight types of cost-efficiency index with different profiling criteria for each medical clinic and investigated the agreement between the decile rankings of each index pair using the weighted kappa statistic. RESULTS: The exclusion of pharmacy cost lowered agreement between rankings to the lowest level, and differences in case-mix classification also lowered agreement considerably. CONCLUSIONS: A medical clinic may be identified as either cost-efficient or cost-inefficient, even when using the same index, depending on the profiling criteria applied. Whether a country has a single insurance or a multiple-insurer system, it is very important to have standardized profiling criteria for the consolidated management of health care costs.

Patient's assessment of primary care of medical institutions in South Korea by structural type.

OBJECTIVE: To compare patient's assessment of primary care of medical institutions by structural type. DESIGN: Cross-sectional study. SETTING: Primary care clinics where family physicians work in South Korea (nine private clinics, three health cooperative clinics, three public health center clinics and five teaching hospital clinics). We collected data by questionnaire survey from April 2007 to June 2007. PARTICIPANTS: Study subjects were patients who had visited their primary care clinic on six or more occasions over a period of more than 6 months as a usual source of care. MAIN OUTCOME MEASURES: Scores in each domain of primary care, evaluated by the Korean Primary Care Assessment Tool. RESULTS: A total of 968 subjects were surveyed. The median of primary care average scores was the highest (78) in health cooperative clinics, the second in teaching hospitals clinics, the third in private clinics and the lowest (62) in public health center clinics. When compared with private clinics, the odds ratio for having a high primary care average score was 2.1 (95% confidence interval 1.3-3.3) for health cooperative clinics, and 0.55 (95% confidence interval 0.34-0.88) for public health center clinics. CONCLUSION: Among medical institutions where family physicians work in South Korea, health cooperative clinics showed the highest primary care average score, and public health center clinics the lowest. To reinforce primary care in South Korea, where medical service delivery systems are only loosely established, health cooperative clinics could serve as an alternative.

Clinic visits and prescribing patterns among Veterans Affairs Maryland Health Care System dementia patients.

OBJECTIVE: Our objective was to determine how patient demographics and outpatient referrals to specialized dementia (DEM) or mental health (MH) clinics influence receipt of anti-dementia (AD), antidepressant (ADEP), antipsychotic (APSY) and sedative-hypnotic (SEDH) medications among veterans with dementia. DESIGN: Retrospective, cross-sectional observational study. SETTING: Veterans Affairs Maryland Health Care System (VAMHCS). PARTICIPANTS: Veterans aged ≥ 60 years with Alzheimer's or related dementia diagnosis after 1999 with minimum of one-year follow-up or death were included. MEASUREMENTS: Retrospective analysis of VAMHCS electronic medical records were used to determine predictors of AD, ADEP, APSY, and SEDH prescribing using logistic regression models that examined visits to DEM or MH clinics, patient age, follow-up time, race/ethnicity and marital status. RESULTS: Among 1209 veterans with average follow-up of 3.2 (SD 1.9) years, 36% percent had MH visits, 38% had DEM visits and 19% visited both clinics. DEM visits were associated with AD and ADEP but not APSY medication receipt (OR(AD:DEM) = 1.47, 95% CI = (1.052, 2.051); OR(ADEP:DEM) = 1.66, 95% CI = (1.193, 2.302); OR(APSY:DEM) = 1.35, 95% CI = (0.941, 1.929)). MH visit was associated with ADEP and APSY medication receipt (OR(AD:MH)\ = 1.16, 95% CI = (0.821, 1.631); OR(ADEP:MH) = 2.83, 95% CI = (2.005, 4.005); OR (APSY:MH) = 4.41, 95% CI = (3.109, 6.255)). CONCLUSION: In the VAMHCS dementia population, visits to DEM or MH specialty clinics increase the odds of receiving AD, ADEP, and APSY medications.

Structures of care in the clinics of the HIV Research Network.

As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.

[Efficiency of outpatient clinics in Matanzas, Cuba, using data envelopment analysis]. / Niveles de eficiencia de las policlínicas de Matanzas, Cuba, según el método de análisis envolvente de datos.

OBJECTIVES: To rate the efficiency of all the outpatient clinics in Matanzas, Cuba; identify the best-performing clinics; and find opportunities for improvement at the others. METHODS: A descriptive study of the 40 outpatient clinics in the province of Matanza was carried out during the first trimester of 2006. Clinics were grouped according to the complexity of services they offer and the socioeconomic level of the municipality in which they are located. Five output and six input variables were analyzed. Calculations were performed using data envelopment analysis, including optimization of results and constant and variable returns-to-scale. RESULTS: In general, the clinics studied had high efficiency rates, with a mean of 0.95 +/- 0.11. Eleven (27.5%) clinics studied were rated inefficient (0.77 +/- 0.12). The following Three key areas for improvement were identified: increasing tuberculosis detection rates in the community, reducing rates of preventable infant mortality, and expanding immunization coverage. Among the 11 clinics rated as inefficient, there were resource gaps in at least one indicator. CONCLUSIONS: By recognizing successful clinics, best practices were identified that could be used to improve the weaker clinics. The resource distribution process should be reviewed to ensure that additional, unneeded resources are not used to improve efficiency.