Evaluation of provider documentation patterns as a tool to deliver ongoing patient-centred diabetes education and support.

BACKGROUND: Diabetes mellitus (DM) is one of the most common chronic diseases in the world. As a disease with long-term complications requiring changes in management, DM requires not only education at the time of diagnosis, but ongoing diabetes self-management education and support (DSME/S). In the United States, however, only a small proportion of people with DM receive DSME/S, although evidence supports benefits of ongoing DSME/S. The diabetes education that providers deliver during follow-up visits may be an important source for DSME/S for many people with DM. METHODS: We collected 200 clinic notes of follow-up visits for 100 adults with DM and studied the History of Present Illness (HPI) and Impression and Plan (I&P) sections. Using a codebook based on the seven principles of American Association of Diabetes Educators Self-Care Behaviors (AADE7), we conducted a multi-step deductive thematic analysis to determine the patterns of DSME/S information occurrence in clinic notes. Additionally, we used the generalised linear mixed models for investigating whether providers delivered DSME/S to people with DM based on patient characteristics. RESULTS: During follow-up visits, Monitoring was the most common self-care behaviour mentioned in both HPI and I&P sections. Being Active was the least common self-care behaviour mentioned in the HPI section and Healthy Coping was the least common self-care behaviour mentioned in the I&P section. We found providers delivered more information on Healthy Eating to men compared to women in I&P section. Generally, providers delivered DSME/S to people with DM regardless of patient characteristics. CONCLUSIONS: This study focused on the frequency distribution of information providers delivered to the people with DM during follow-up clinic visits based on the AADE7. The results may indicate a lack of patient-centred education when people with DM visit providers for ongoing management. Further studies are needed to identify the underlying reasons why providers have difficulty delivering patient-centred education.

Systematically reviewing the literature: building the evidence for health care quality.

There are important research and non-research reasons to systematically review the literature. This article describes a step-by-step process to systematically review the literature along with links to key resources. An example of a graduate program using systematic literature reviews to link research and quality improvement practices is also provided.

Reducing the risks of diabetes complications through diabetes self-management education and support.

People with diabetes are at risk of developing complications that contribute to substantial morbidity and mortality. In 2011, the American Association of Diabetes Educators convened an invitational Reducing Risks Symposium, during which an interdisciplinary panel of 11 thought leaders examined current knowledge about the reduction and prevention of diabetes-related risks and translated evidence into diabetes care and self-management education. Symposium participants reviewed findings from the literature and engaged in a moderated roundtable discussion. This report summarizes the discussion and presents recommendations to incorporate into practice to improve outcomes. The objective of the symposium was to develop practical advice for diabetes educators and other members of the diabetes care team regarding the reduction of diabetes-related risks. Optimal diabetes management requires patients to actively participate in their care, which occurs most effectively with a multidisciplinary team. Diabetes education is an integral part of this team approach because it not only helps the patient understand diabetes, its progression, and possible complications, but also provides guidance and encouragement to the patient to engage in proactive risk-reduction decisions for optimal health. A variety of tools are available to help the diabetes educator develop an individualized, patient-centered plan for risk reduction. More research is needed regarding intervention efficacy, best practices to improve adherence, and quantification of benefits from ongoing diabetes support in risk reduction. Diabetes educators are urged to stay abreast of evolving models of care and to build relationships with health care providers both within and beyond the diabetes care team.

Heart failure care management programs: a review of study interventions and meta-analysis of outcomes.

BACKGROUND: The objective of this systematic review and meta-analysis was to describe and quantify individual interventions used in multicomponent outpatient heart failure management programs. METHODS: MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials between 1995 and 2008 were searched using 10 search terms. Randomized controlled trials evaluating outpatient programs that addressed comprehensive care to decrease readmissions for patients with heart failure were identified. Forty-three articles reporting on 35 studies that reported readmissions separately from other outcomes were included. Three investigators independently abstracted primary study characteristics and outcomes. RESULTS: In the 35 studies, participants included 8071 subjects who were typically older (mean [SD] age, 70.7 [6.5] years) and male (59%). Using our coding scheme, the number of individual interventions within a program ranged from 1 to 7 within individual studies; the most commonly used interventions were patient education, symptom monitoring by study staff, symptom monitoring by patients, and medication adherence strategies. Most programs had a teaching component with a mean (SD) of 6.4 (3.9) individual topics covered; frequent teaching topics were symptom recognition and management, medication review, and self-monitoring. Fewer than half of the 35 studies reviewed reported adequate data to be included in the meta-analysis. Some outcomes were infrequently reported, limiting statistical power to detect treatment effects. CONCLUSION: A number of studies evaluating multicomponent HF management programs have found positive effects on important patient outcomes. The contribution of the individual interventions included in the multicomponent program on patient outcomes remains unclear. Future studies of chronic disease interventions must include descriptions of recommended key program components to identify critical program components.

Patient-centered care and outcomes: a systematic review of the literature.

Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. Three databases were searched for all years through September 2012. We retained 40 articles for the analysis. Results found mixed relationships between PCC and clinical outcomes, that is, some studies found significant relationships between specific elements of PCC and outcomes but others found no relationship. There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC-outcomes relationship.

Strain and satisfaction in caregivers of veterans with chronic illness.

Veterans' health care has shifted towards outpatient treatment, and because of the high prevalence of chronic illness in veterans, more caregiving has been required of their families. The purpose of this study was to identify predictors of caregiver (CG) strain and satisfaction associated with caring for veterans with chronic illness. Data were collected using telephone interviews of 120 dyads. Strain was associated with helping with instrumental activities of daily living, using counseling and prayer for coping, accompanying veteran to appointments, help/advice from friends, paid help, exercising, and depression. Satisfaction was associated with veteran health, CG social support, age, and depression. Innovative and easily accessible interventions are needed to mitigate sources of strain in CGs of chronically ill veterans.

Videogames and Health Improvement: A Literature Review of Randomized Controlled Trials.

OBJECTIVE: There are potential benefits of playing videogames for health improvement such as increasing knowledge about health-related issues by playing educational games and fighting a sedentary lifestyle by playing exergames. The number of systematic review articles about "videogames" and "health improvement" is limited. Therefore, the purpose of this study is to review those randomized controlled trials (RCTs) with the topic of "videogames" and "health improvement." MATERIALS AND METHODS: Several electronic databases were searched for RCTs testing videogames on health outcomes that were published in English between January 2000 and April 2012. RESULTS: Forty-five articles met the eligibility criteria and were categorized into five groups: (1) videogames and patient pain and stress reduction (nine articles), (2) videogames and patient behavioral change (19 articles), (3) videogames and patient rehabilitation (eight articles), (4) videogames as diagnostic tools (three articles), and (5) videogames and cognitive ability (six articles). CONCLUSIONS: Most of the articles have shown promising results in using videogames within various fields of healthcare. Although exergames are the most prominent choice regarding health improvement, videogames have the potential to be used as a pain management tool, diagnostic tool, or educational tool. They also can be used as a facilitator in physical rehabilitation or cognitive loss prevention. More RCTs are needed to fully uncover the benefits of using videogames for improving patients' health.

MedlinePlus-based health information prescriptions: a comparison of email vs paper delivery.

BACKGROUND: The internet can provide evidence-based patient education to overcome time constraints of busy ambulatory practices. Health information prescriptions (HIPs) can be effectively integrated into clinic workflow, but compliance to visit health information sites such as MedlinePlus is limited. OBJECTIVE: Compare the efficacy of paper (pHIP) and email (eHIP) links to deliver HIPs; evaluate patient satisfaction with the HIP process and MedlinePlus information; assess reasons for noncompliance to HIPs. METHOD: Of 948 patients approached at two internal medicine clinics affiliated with an academic medical centre, 592 gave informed consent after meeting the inclusion criteria. In this randomised controlled trial, subjects were randomised to receive pHIP or eHIP for accessing an intermediate website that provided up to five MedlinePlus links for physician-selected HIP conditions. Patients accessing the intermediate website were surveyed by email to assess satisfaction with the health information. Survey non-responders were contacted by telephone to determine the reasons for no response. RESULTS: One hundred and eighty-one patients accessed the website, with significantly more 'filling' eHIP than pHIP (38% vs 23%; P < 0.001). Most (82%) survey respondents found the website information useful, with 77% favouring email for future HIPs delivery. Lack of time, forgot, lost instructions or changed mind were reasons given for not accessing the websites. CONCLUSIONS: Delivery of MedlinePlus-based HIPs in clinic is more effective using email prescriptions than paper. Satisfaction with the HIP information was high, but overall response was low and deserves further investigation to improve compliance and related outcomes.

Data-mining technologies for diabetes: a systematic review.

BACKGROUND: The objective of this study is to conduct a systematic review of applications of data-mining techniques in the field of diabetes research. METHOD: We searched the MEDLINE database through PubMed. We initially identified 31 articles by the search, and selected 17 articles representing various data-mining methods used for diabetes research. Our main interest was to identify research goals, diabetes types, data sets, data-mining methods, data-mining software and technologies, and outcomes. RESULTS: The applications of data-mining techniques in the selected articles were useful for extracting valuable knowledge and generating new hypothesis for further scientific research/experimentation and improving health care for diabetes patients. The results could be used for both scientific research and real-life practice to improve the quality of health care diabetes patients. CONCLUSIONS: Data mining has played an important role in diabetes research. Data mining would be a valuable asset for diabetes researchers because it can unearth hidden knowledge from a huge amount of diabetes-related data. We believe that data mining can significantly help diabetes research and ultimately improve the quality of health care for diabetes patients.

Analytical and clinical performance of blood glucose monitors.

BACKGROUND: The objective of this study was to understand the level of performance of blood glucose monitors as assessed in the published literature. METHODS: Medline from January 2000 to October 2009 and reference lists of included articles were searched to identify eligible studies. Key information was abstracted from eligible studies: blood glucose meters tested, blood sample, meter operators, setting, sample of people (number, diabetes type, age, sex, and race), duration of diabetes, years using a glucose meter, insulin use, recommendations followed, performance evaluation measures, and specific factors affecting the accuracy evaluation of blood glucose monitors. RESULTS: Thirty-one articles were included in this review. Articles were categorized as review articles of blood glucose accuracy (6 articles), original studies that reported the performance of blood glucose meters in laboratory settings (14 articles) or clinical settings (9 articles), and simulation studies (2 articles). A variety of performance evaluation measures were used in the studies. The authors did not identify any studies that demonstrated a difference in clinical outcomes. Examples of analytical tools used in the description of accuracy (e.g., correlation coefficient, linear regression equations, and International Organization for Standardization standards) and how these traditional measures can complicate the achievement of target blood glucose levels for the patient were presented. The benefits of using error grid analysis to quantify the clinical accuracy of patient-determined blood glucose values were discussed. CONCLUSIONS: When examining blood glucose monitor performance in the real world, it is important to consider if an improvement in analytical accuracy would lead to improved clinical outcomes for patients. There are several examples of how analytical tools used in the description of self-monitoring of blood glucose accuracy could be irrelevant to treatment decisions.

Healthcare via cell phones: a systematic review.

Regular care and informational support are helpful in improving disease-related health outcomes. Communication technologies can help in providing such care and support. The purpose of this study was to evaluate the empirical evidence related to the role of cell phones and text messaging interventions in improving health outcomes and processes of care. Scientific literature was searched to identify controlled studies evaluating cell phone voice and text message interventions to provide care and disease management support. Searches identified 25 studies that evaluated cell phone voice and text messaging interventions, with 20 randomized controlled trials and 5 controlled studies. Nineteen studies assessed outcomes of care and six assessed processes of care. Selected studies included 38,060 participants with 10,374 adults and 27,686 children. They covered 12 clinical areas and took place in 13 countries. Frequency of message delivery ranged from 5 times per day for diabetes and smoking cessation support to once a week for advice on how to overcome barriers and maintain regular physical activity. Significant improvements were noted in compliance with medicine taking, asthma symptoms, HbA1C, stress levels, smoking quit rates, and self-efficacy. Process improvements were reported in lower failed appointments, quicker diagnosis and treatment, and improved teaching and training. Cost per text message was provided by two studies. The findings that enhancing standard care with reminders, disease monitoring and management, and education through cell phone voice and short message service can help improve health outcomes and care processes have implications for both patients and providers.

Heart failure self-management education: a systematic review of the evidence.

OBJECTIVE: The objective of this systematic review is to identify educational content and techniques that lead to successful patient self-management and improved outcomes in congestive heart failure education programs. METHODS: MEDLINE, CINAHL and the Cochrane Central Register of Controlled Trials, as well as reference lists of included studies and relevant reviews, were searched. Eligible studies were randomised controlled trials evaluating congestive heart failure self-management education programs with outcome measures. Two of the investigators independently abstracted descriptive information, education content topics and outcomes data. RESULTS: A total of 7413 patients participated in the 35 eligible congestive heart failure self-management education studies. The congestive heart failure self-management programs incorporated 20 education topics in four categories: (i) knowledge and self-management (diagnosis and prognosis, pathophysiology of how congestive heart failure affects the body, aims of treatment, management and symptoms, medication review and discussion of side-effects, knowing when to access/call the general practitioner, communication with the physician, follow up for assessment or reinforcement); (ii) social interaction and support (social interaction and support, stress, depression); (iii) fluids management (sodium restriction, fluid balance, daily measurement of weight, ankle circumference, self-monitoring and compliance relative to fluids); and (iv) diet and activity (dietary assessment and instructions, physical activity and exercise, alcohol intake, smoking cessation). A total of 113 unique outcomes in nine categories (satisfaction, learning, behaviour, medications, clinical status, social functioning, mortality, medical resource utilisation and cost) were measured in the studies. Sixty (53%) of the outcomes showed significant improvement in at least one study. CONCLUSION: Educational interventions should be based on scientifically sound research evidence. The education topic list developed in this review can be used by patients and clinicians to prioritise and personalise education.

A review of health literacy and diabetes: opportunities for technology.

BACKGROUND: The objective of this study was to assess the published literature on health literacy and diabetes, as well as identify opportunities for technology to strengthen information skills and modify behavior to improve diabetes health outcomes. METHODS: Medline (1990-2008), the Cumulative Index to Nursing and Allied Health Literature (1990-2008), and the Education Resources Information Center (1990-2008) were searched, and reference lists from included articles were reviewed to identify additional studies. Articles were included that presented measures of literacy or numeracy specific to diabetes, examined associations between health literacy and diabetes outcomes, or tested a health literacy intervention among persons with diabetes. RESULTS: Twenty-four articles were included in this review. Five articles reported on measures of literacy or numeracy specific to diabetes. Thirteen of the fifteen cross-sectional studies (87%) associated limited health literacy with poorer diabetes outcomes. Two of the four (50%) health literacy intervention studies lead to improved health outcomes. CONCLUSIONS: The cross-sectional studies provide evidence of an association between health literacy and diabetes outcomes; however, there is a need to design and test strategies to improve diabetes health outcomes that consider health literacy. Information and communication technology opportunities could help to mediate the effect that limited health literacy has on diabetes-related health outcomes.

Opportunities for informatics to improve discharge planning: a systematic review of the literature.

The discharge planning process can be successful when information is shared among the patient, caregiver, and provider from admission through post discharge. The objective of this paper was to evaluate the association of information sharing among patients, caregivers, and health care providers and the impact on the discharge process. The authors identified reports of the discharge planning process through systematic electronic database searches. The eligibility criteria were 1) usual discharge planning process, and 2) patient, caregiver, or provider perception or feedback. Of the eligible articles, all voiced concern about a broken discharge planning process that affected the information exchanged among all involved in patient care. Outcomes related to satisfaction, knowledge transfer, and communication were identified. The initial evidence suggests information sharing through interdisciplinary patient care can play a significant role in the future.

Computerized prompting and feedback of diabetes care: a review of the literature.

BACKGROUND: The objective of this study was to assess published literature on computerized prompting and feedback of diabetes care as well as to identify opportunities to strengthen diabetes care processes. METHODS: Medline (1970-2008), Cumulative Index to Nursing and Allied Health Literature (1982-2008), and Cochrane Central Register of Controlled Trials (4th quarter 2008) were searched, and reference lists from included articles were reviewed to identify additional studies. Patient sample, clinician sample, setting, duration of the trial, intervention description, control description, and results were abstracted from each study. RESULTS: Fifteen trials were included in this review. The following elements were observed in the interventions: general prompt for a particular patient to be seen for diabetes-related follow-up (5 studies), specific prompt reminding clinicians of particular tests or procedures related to diabetes (13 studies), feedback to clinicians in addition to prompting (5 studies), and patient reminders in addition to clinician prompts (5 studies). Twelve of the 15 studies (80%) measured a significant process or outcome from the intervention. CONCLUSIONS: The majority of trials identified at least one process or outcome that was significantly better in the intervention group than in the control group; however, the success of the information interventions varied greatly. Providing and receiving appropriate care is the first step toward better outcomes in chronic disease management.

Chronic heart failure consumer information: an exploratory study.

The purpose of this project was to explore how persons with chronic heart failure (CHF) obtain and use health information about their condition and how health literacy might have an impact. We interviewed 28 patients with CHF regarding their quality of life, chronic illness care, literacy level, and knowledge about self-management care for CHF.

The use and effectiveness of electronic clinical decision support tools in the ambulatory/primary care setting: a systematic review of the literature.

BACKGROUND: The 1999 Institute of Medicine (IOM) report To Err is Human alerted the healthcare industry and the public to the lack of consistency in the delivery of quality care to the US population. Clinical decision support systems (CDSS) have become a leading response to this report, and to the growing demand for the promotion of standards-based care delivery. The objective of this paper is to evaluate the recent literature for both the types and effectiveness of electronic CDSS in the primary care setting. METHODS: An electronic search of the literature was conducted utilising MEDLINE (1996-2006), CINAHL (1982-2006) and all EBM Reviews--Cochrane DSR, ACP Journal Club, DARE and CCTR. The search included various combinations of the MeSH search terms 'clinical decision support systems', 'primary health care', 'ambulatory care' and 'practice guidelines' and was limited to articles published from 2000 to 2006. Studies were selected for review if they involved either non-randomised observational or randomised controlled trials (RCTs) utilising CDSS as a single intervention, were performed in an ambulatory primary care setting and included quantifiable outcome measures. RESULTS: Seventeen studies were included in the review, including five non-randomised observational studies and 12 RCTs. Thirteen studies (76%) found either positive or variable outcomes related to CDSS intervention with four studies (24%) showing no significant effect. CONCLUSION: Although there is validation that CDSS has the potential to produce statistically significant improvement in outcomes, there is much variability among the types and methods of CDSS implementation and resulting effectiveness. As CDSS will likely continue to be at the forefront of the march toward effective standards-based care, more work needs to be done to determine effective implementation strategies for the use of CDSS across multiple settings and patient populations.

The role of the electronic medical record (EMR) in care delivery development in developing countries: a systematic review.

OBJECTIVE: Most countries in Europe and the USA are increasingly using an electronic medical record (EMR) to help improve healthcare quality. Unfortunately, most developing countries face many challenges ranging from epidemics and civil wars to disasters: they also lack a robust healthcare infrastructure in the form of information and communications technology (ICT) to ensure continuity of patient health which many research studies consider a lifesaving resource. The aim of this systematic review is to examine the benefits of an EMR and its contribution to the development of healthcare delivery in developing countries. METHODS: We searched MEDLINE, PubMed, CINAHL, COMPENDEX and Academic Search Premier as well as systematically searching the reference lists of included studies and relevant reviews. Inclusion criteria were that studies should relate to the importance and challenges of an EMR system, paper-based medical records, development and implementation of an EMR system in developing countries or EMR impact on care delivery in developing countries. RESULTS: A total of 23 articles were identified that met the eligibility criteria. Articles identified were grouped into five non-exclusive areas: EMR benefits (n=4), challenges (n=6), transition from paper-based to EMR (n=5), EMR in developing countries (n=8) and pilot projects (n=5). Nine articles were excluded because three were not published in English and six were studies on EMR in developed countries. CONCLUSIONS: The potential of EMR systems to transform medical care practice has been recognised over the past decades, including the enhancement of healthcare delivery and facilitation of decision-making processes. Some benefits of an EMR system include accurate medication lists, legible notes and prescriptions and immediately available charts. In spite of challenges facing the developing world such as lack of human expertise and financial resource, most studies have shown how feasible it could be with support from developed nations to design and implement an EMR system that fits into this environment.

Computerized learning technologies for diabetes: a systematic review.

BACKGROUND: The objective of this study was to evaluate computerized learning technology interventions that can empower patients in the self-management of diabetes and support diabetes education over a distance. METHODS: We searched Medline (1966-2006), CINAHL (1982-2006), and the Cochrane Central Register of Controlled Trials (first quarter 2007) databases. We also reviewed reference lists from included studies to identify additional studies. We included 25 articles representing 21 randomized controlled trials that evaluated a computerized learning technology and measured the outcome of patient care. We extracted patient sample, intervention, educational content topics, outcome measures, and statistical significance. RESULTS: Of 21 eligible trials, 18 trials (85.7%) reported significant positive outcomes. Almost 44% (43.8%) of the outcomes demonstrated significant improvements (49 of 112 outcomes). CONCLUSIONS: Patient self-management behaviors are important in chronic disease management, and initial evidence suggests that computerized learning technology interventions can play a significant role in the future.