ABSTRACT
Nurses with advanced training-diabetes resource nurses (DRNs)-can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A(1c) level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A(1c) testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A(1c) <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.
ABSTRACT
BACKGROUND: Tight blood glucose control has been correlated with a reduction in diabetes complications. Adherence to antidiabetic medications is crucial to achieving blood glucose control. OBJECTIVE: To assess the relationship between good glucose control [glycosylated hemoglobin (HbA1c) levels] and adherence to prescribed treatment in patients on a stable medication regimen for type 2 diabetes. METHODS: The Morisky survey, a 4-item questionnaire that predicts patient medication-taking behavior, was used to assess adherence in 301 patients. The relationship of HbA1c to Morisky score was evaluated, controlling for other variables related to patient demographics and clinical characteristics. Data were analyzed using a general linear model on log (HbA1c). RESULTS: Unadjusted mean HbA1c values (capped at 14.0%) for patients with Morisky scores of 0 or 1, 2, 3, and 4 were 8.92%, 8.67%, 7.74%, and 7.60%, respectively. Of all patients, 13.0%, 14.0%, 24.3%, and 48.8% had scores of 0 or 1, 2, 3, and 4, respectively. Good adherence (Morisky score > or = 3) was associated with a 10% lower total HbA1c (p = 0.0003) adjusted for all other factors in the model. Duration of diabetes (5-10 y) and presence of diabetes complications were also significantly associated with HbA1c (p = 0.026 and 0.002, respectively). Adherence was poor in 27% of patients. CONCLUSIONS: This study found that patients with a higher score on the Morisky scale had a lower associated HbA1c measurement. The Morisky score may be an efficient tool for identifying patients with poor medication-taking behavior who can then be targeted for directed adherence counseling services.