The TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD): economic analysis.

BACKGROUND: Indigenous populations have increased risk of developing diabetes and experience poorer treatment outcomes than the general population. The FORGE AHEAD program partnered with First Nations communities across Canada to improve access to resources by developing community-driven primary healthcare models. METHODS: This was an economic assessment of FORGE AHEAD using a payer perspective. Costs of diabetes management and complications during the 18-month intervention were compared to the costs prior to intervention implementation. Cost-effectiveness of the program assessed incremental differences in cost and number of resources utilization events (pre and post). Primary outcome was all-cause hospitalizations. Secondary outcomes were specialist visits, clinic visits and community resource use. Data were obtained from a diabetes registry and published literature. Costs are expressed in 2023 Can$. RESULTS: Study population was ~ 60.5 years old; 57.2% female; median duration of diabetes of 8 years; 87.5% residing in non-isolated communities; 75% residing in communities < 5000 members. Total cost of implementation was $1,221,413.60 and cost/person $27.89. There was increase in the number and cost of hospitalizations visits from 8/$68,765.85 (pre period) to 243/$2,735,612.37. Specialist visits, clinic visits and community resource use followed this trend. CONCLUSION: Considering the low cost of intervention and increased care access, FORGE AHEAD represents a successful community-driven partnership resulting in improved access to resources.

Development and validation of a real-world model to predict 1-year Level 3 (severe) hypoglycaemia risk in adults with diabetes (the iNPHORM study, United States).

AIMS: We aimed to develop and internally validate a real-world prognostic model for Level 3 hypoglycaemia risk compatible with outpatient care in the United States. MATERIALS AND METHODS: iNPHORM is a 12-month, US-based panel survey. Adults (18-90 years old) with type 1 diabetes mellitus or insulin- and/or secretagogue-treated type 2 diabetes mellitus were recruited from a nationwide, probability-based internet panel. Among participants completing ≥ 1 follow-up questionnaire(s), we modelled 1-year Level 3 hypoglycaemia risk using Andersen and Gill's Cox survival and penalized regression with multiple imputation. Candidate variables were selected for their clinical relevance and ease of capture at point-of-care. RESULTS: In total, 986 participants [type 1 diabetes mellitus: 17%; men: 49.6%; mean age: 51 (SD: 14.3) years] were analysed. Across follow-up, 035.1 (95% CI: 32.2-38.1)% reported ≥1 Level 3 event(s), and the rate was 5.0 (95% CI: 4.1-6.0) events per person-year. Our final model showed strong discriminative validity and parsimony (optimism corrected c-statistic: 0.77). Numerous variables were selected: age; sex; body mass index; marital status; level of education; insurance coverage; race; ethnicity; food insecurity; diabetes type; glycated haemoglobin value; glycated haemoglobin variability; number, type and dose of various medications; number of SH events requiring hospital care (past year and over follow-up); type and number of comorbidities and complications; number of diabetes-related health care visits (past year); use of continuous/flash glucose monitoring; and general health status. CONCLUSIONS: iNPHORM is the first US-based primary prognostic study on Level 3 hypoglycaemia. Future model implementation could potentiate risk-tailored strategies that reduce real-world event occurrence and overall diabetes burden.

Real-World Incidence and Risk Factors for Daytime and Nocturnal Non-Severe Hypoglycemia in Adults With Type 2 Diabetes Mellitus on Insulin and/or Secretagogues (InHypo-DM Study, Canada).

BACKGROUND: The aim of this study was to estimate the real-world incidence of self-reported non-severe hypoglycemia (NSH) and its related sociodemographic and clinical risk factors in a general population of Canadian adults with type 2 diabetes mellitus (T2DM) taking insulin and/or secretagogues. METHODS: Data for this study were obtained from the InHypo-DM Study. Self-reported data on the frequency of NSH (past 30 days) as well as sociodemographic and clinical characteristics were collected through an online questionnaire. Risk factors for any, daytime and nocturnal NSH were identified using multivariable negative binomial regression with backward selection. RESULTS: Among 432 adults with T2DM (43.8% female, mean age of 53.1 years), 53.9% (95% confidence interval [CI], 49.2% to 58.6%) reported ≥1 event of any (i.e. daytime or nocturnal) NSH in the past 30 days. The 30-day incidence rate of any NSH was 2.3 events per 30 person-days (95% CI, 2.1 to 2.4). Risk factors associated with the increased rate of any NSH were younger age, lower annual household income, being employed, longer duration of diabetes, higher glycated hemoglobin and presence of comorbidity. Risk factors were generally similar for daytime NSH (except for the exclusion of diabetes duration and addition of diabetes medication type) and nocturnal NSH (except for the exclusion of being employed). CONCLUSIONS: This is the largest Canadian investigation to estimate the real-world frequency and distribution of self-reported NSH in T2DM. Events were alarmingly frequent and recurrent. Numerous sociodemographic and clinical risk factors were elucidated. These results highlight the importance of identifying high-risk individuals to minimize future occurrences of hypoglycemia.

Predicting Real-world Hypoglycemia Risk in American Adults With Type 1 or 2 Diabetes Mellitus Prescribed Insulin and/or Secretagogues: Protocol for a Prospective, 12-Wave Internet-Based Panel Survey With Email Support (the iNPHORM [Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models] Study).

BACKGROUND: Hypoglycemia prognostic models contingent on prospective, self-reported survey data offer a powerful avenue for determining real-world event susceptibility and interventional targets. OBJECTIVE: This protocol describes the design and implementation of the 1-year iNPHORM (Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models) study, which aims to measure real-world self-reported severe and nonsevere hypoglycemia incidence (daytime and nocturnal) in American adults with type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues, and develop and internally validate prognostic models for severe, nonsevere daytime, and nonsevere nocturnal hypoglycemia. As a secondary objective, iNPHORM aims to quantify the effects of different antihyperglycemics on hypoglycemia rates. METHODS: iNPHORM is a prospective, 12-wave internet-based panel survey that was conducted across the United States. Americans (aged 18-90 years) with self-reported type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues were conveniently sampled via the web from a pre-existing, closed, probability-based internet panel (sample frame). A sample size of 521 baseline responders was calculated for this study. Prospective data on hypoglycemia and potential prognostic factors were self-assessed across 14 closed, fully automated questionnaires (screening, baseline, and 12 monthly follow-ups) that were piloted using semistructured interviews (n=3) before fielding; no face-to-face contact was required as part of the data collection. Participant responses will be analyzed using multivariable count regression and machine learning techniques to develop and internally validate prognostic models for 1-year severe and 30-day nonsevere daytime and nocturnal hypoglycemia. The causal effects of different antihyperglycemics on hypoglycemia rates will also be investigated. RESULTS: Recruitment and data collection occurred between February 2020 and March 2021 (ethics approval was obtained on December 17, 2019). A total of 1694 participants completed the baseline questionnaire, of whom 1206 (71.19%) were followed up for 12 months. Most follow-up waves (10,470/14,472, 72.35%) were completed, translating to a participation rate of 179% relative to our target sample size. Over 70.98% (856/1206) completed wave 12. Analyses of sample characteristics, quality metrics, and hypoglycemia incidence and prognostication are currently underway with published results anticipated by fall 2022. CONCLUSIONS: iNPHORM is the first hypoglycemia prognostic study in the United States to leverage prospective, longitudinal self-reports. The results will contribute to improved real-world hypoglycemia risk estimation and potentially safer, more effective clinical diabetes management. TRIAL REGISTRATION: ClinicalTrials.gov NCT04219514; https://clinicaltrials.gov/ct2/show/NCT04219514. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33726.

Health Care Providers' Emotional Responses to Their Patients' Hypoglycemic Events: Qualitative Findings From the InHypo-DM Study, Canada.

OBJECTIVE: Hypoglycemia can cause psychological distress in people with diabetes; however, less is understood about the emotional impact of hypoglycemia on their health care providers (HCPs). This article focuses on the experiences and emotions of HCPs caring for patients with diabetes. METHODS: This was a descriptive qualitative study from the InHypo-DM research program. Purposive sampling was used to recruit 20 HCPs from a variety of professions for 30- to 45-minute semi-structured interviews. An iterative analysis was conducted to identify the overarching themes. RESULTS: Three overarching themes encompassed the responses of participants when their patients experienced hypoglycemia. The first was a sense of professional responsibility, as participants felt they must have failed or inadequately fulfilled their professional duties. The second was a more personal range of emotions such as sadness and guilt. The final theme was how these emotions created a "call to action," prompting participants to identify potential strategies to prevent future hypoglycemic events. CONCLUSION: This qualitative study highlights the emotional impact of patients' hypoglycemia on HCPs. Although it may have been expected that HCPs have a strong sense of professional responsibility, it was unexpected that these responses often became personal emotions. To ameliorate the negative impact of these responses on patient care, HCPs should engage in activities that enable them to anticipate and manage their own emotional responses. In addition, strategies to optimize hypoglycemia detection and prevention should be promoted.

Beyond the Sick Role: The Many Roles of Adults With Type 1 and Type 2 Diabetes in the Management of Hypoglycemia-The InHypo-DM Study, Canada.

OBJECTIVES: Hypoglycemia is a common adverse event for people with type 1 and type 2 diabetes mellitus. In this article, we explore the specific roles that individuals assume to prevent or treat hypoglycemia. METHODS: A descriptive qualitative study from the UnderstandINg the impact of HYPOglycemia on Diabetes Management Study (InHypo-DM) research program. A purposive sample of people with type 1 and type 2 diabetes were recruited for semistructured interviews. There were 16 participants (women and men), who were, on average, 53 years old. Average time since diagnosis was 15 (type 1) and 21 (type 2) years; all patients had at least 1 hypoglycemic event in the past year. Individual and team analysis of interviews were conducted to identify overarching themes. RESULTS: Participants articulated 4 roles in preventing or treating hypoglycemia. The first role was being a manager by assuming ownership and accountability for their own glycemic control. The second role, being a technician, used both subjective and objective information and employed specific strategies to respond to hypoglycemic events. The third role, educator, extended beyond self-management to increase others' awareness of hypoglycemia. The fourth role, advocate, involved championing one's own needs during a hypoglycemic event. These 4 roles were, in turn, influenced by the contexts of work, social settings, exercise and travel. CONCLUSIONS: These findings demonstrate that strategies that individuals use to avoid or reduce the severity of a hypoglycemic event extend beyond merely making impromptu decisions during events. Instead, these 4 roles of manager, technician, educator and advocate, embedded in specific contexts, enhanced their mastery in managing hypoglycemia in daily life.

Living With Hypoglycemia: An Exploration of Patients' Emotions: Qualitative Findings From the InHypo-DM Study, Canada.

Hypoglycemia is one of the most common adverse events for people living with type 1 or type 2 diabetes. To gain a deeper understanding of patients' emotions regarding hypoglycemia, we conducted a descriptive qualitative study. Purposive sampling was used to recruit participants for a 30- to 45-minute semi-structured interview. The 16 participants included both women and men with either type 1 or type 2 diabetes, with a mean age of 53 years and mean time since diagnosis of 21 years. All participants had experienced more than one hypoglycemia event in the past year, ranging from nonsevere to severe. Data collection and analysis occurred in an iterative manner. Individual and team analyses of interviews were conducted to identify overarching themes and sub-themes. Thematic analysis revealed the unique interconnection among the emotions experienced by participants, including fear, anxiety, frustration, confidence, and hope. Time, experience, and reflection helped to build participants' confidence in their ability to manage a hypoglycemia event. Patients' emotions regarding hypoglycemia provide valuable insights into life with diabetes. Although hypoglycemia continues to evoke feelings of fear and anxiety, the role of hope may temper these emotions. Understanding the complex interplay of emotions concerning hypoglycemia can guide health care providers in improving clinical practice and promoting patient-centered interventions. Ultimately, health care providers can build patients' hypoglycemia-related confidence by using a strengths-based approach.

A qualitative enquiry of hypoglycemia and the social determinants of health: The InHypo-DM study, Canada.

INTRODUCTION: A significant body of research exists on the impact of the social determinants of health (SDoHs) on diabetes care and general health outcomes. However, less is known about health care practitioners' (HCPs') perspectives and experiences regarding the impact of the SDoHs on their patients with Type I and Type 2 diabetes mellitus and how this affects the prevention and treatment of hypoglycemia. METHOD: A descriptive qualitative study, derived from the InHypo-DM (Canada) research program. A purposive sampling technique was used to recruit participants residing in southwestern Ontario, Canada, for a 30- to 45-min semistructured interview. Individual and team analysis of interviews was conducted to identify overarching and subthemes. Twenty HCP participants, including endocrinologists, family physicians, and allied health care practitioners, were recruited. Seven were Certified Diabetes Educators. RESULTS: Participants articulated 2 overarching components of the SDoHs: patients' socioeconomic issues and psychosocial issues. They highlighted two socioeconomic issues: occupation type and poverty. Participants also emphasized 3 areas pertaining to patients' psychosocial issues: stage in the life cycle (e.g., elderly), social isolation, and mental health. DISCUSSION: This study emphasizes the need for conducting detailed and comprehensive social histories during clinical diabetes assessments, as well as the necessity of adequate clinical time and resources for HCPs and patients to address these issues in the context of hypoglycemia management. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study.

BACKGROUND: In Ontario, a province-wide quality-improvement program (Quality Improvement and Innovation Partnership [QIIP]) was implemented between 2008 and 2010 to support improved outcomes in Family Health Teams, a care model that includes many features of the patient-centred medical home. We assessed the impact of this program on diabetes management, colorectal and cervical cancer screening and access to health care. METHODS: We used comprehensive linked administrative data sets to conduct a population-based controlled before-and-after study. Outcome measures included diabetes process-of-care measures (test ordering, retinal examination, medication prescribing and completion of billing items specific to diabetes management), colorectal and cervical cancer screening measures and use of health care services (emergency department visits, hospital admission for ambulatory-care-sensitive conditions and rates of readmission to hospital). The control group consisted of Family Health Team physicians with at least 100 assigned patients during the study follow-up period (November 2009-February 2013). RESULTS: There were 53 physicians in the intervention group and 1178 physicians in the control group. Diabetes process-of-care measures improved more in the intervention group than in the control group: hemoglobin A1c testing 4.3% (95% confidence interval [CI] 1.2-7.5) more, retinal examination 2.5% (95% CI 0.8-4.4) more and preventive care visits 8.9% (95% CI 2.9-14.9) more. Medication prescribing also improved for use of statins (3.4% [95% CI 0.8-6.0] more) and angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers (4.1% [95% CI 1.8-6.4] more). Colorectal cancer screening improved 5.4% (95% CI 3.1-7.8) more in the intervention group than in the control group, and cervical cancer screening improved 2.7% (95% CI 0.9-4.6) more. There were no significant differences in any of the measures of use of health care services. INTERPRETATION: This large controlled evaluation of a broadly implemented quality-improvement initiative showed improvement for diabetes process of care and cancer screening outcomes, but not for proxy measures of access related to use of health care services.

Impact of a primary healthcare quality improvement program on diabetes in Canada: evaluation of the Quality Improvement and Innovation Partnership (QIIP).

OBJECTIVE: Primary healthcare (PHC) quality improvement (QI) initiatives are designed to improve patient care and health outcomes. We evaluated the Quality Improvement and Innovation Partnership (QIIP), an Ontario-wide PHC QI program on access to care, diabetes management and colorectal cancer screening. This manuscript highlights the impact of QIIP on diabetes outcomes and associated vascular risk factors. RESEARCH DESIGN AND METHODS: A cluster matched-control, retrospective prechart and postchart audit was conducted. One physician per QIIP-PHC team (N=34) and control (N=34) were recruited for the audit. Eligible charts were reviewed for prespecified type 2 diabetes mellitus clinical process and outcome data at baseline, during (intervention range: 15-17.5 months) and post. Primary outcome measures were the A1c of patients above study target and proportion of patients with an annual foot exam. Secondary outcome measures included glycemic, hypertension and lipid outcomes and management, screening for diabetes-related complications, healthcare utilization, and diabetes counseling, education and self-management goal setting. RESULTS: More patients in the QIIP group achieved statistically improved lipid testing, eye examinations, peripheral neuropathy exams, and documented body mass index. No statistical differences in A1c, low-density lipoprotein or systolic/diastolic blood pressure values were noted, with no significant differences in medication prescription, specialist referrals, or chart-reported diabetes counseling, education or self-management goals. Patients of QIIP physicians had significantly more PHC visits. CONCLUSION: The QIIP-learning collaborative program evaluation using stratified random selection of participants and the inclusion of a control group makes this one of the most rigorous and promising efforts to date evaluating the impact of a QI program in PHC. The chart audit component of this evaluation highlighted that while QIIP improved some secondary diabetes measures, no improvements in clinical outcomes were noted. This study highlights the importance of formalized evaluation of QI initiatives to provide an evidence base to inform future program planning and scale-up.

Influence of a quality improvement learning collaborative program on team functioning in primary healthcare.

Quality improvement (QI) programs are frequently implemented to support primary healthcare (PHC) team development and to improve care outcomes. In Ontario, Canada, the Quality Improvement and Innovation Partnership (QIIP) offered a learning collaborative (LC) program to support the development of interdisciplinary team function and improve chronic disease management, disease prevention, and access to care. A qualitative study using a phenomenological approach was conducted as part of a mixed-method evaluation to explore the influence of the program on team functioning in participating PHC teams. A purposive sampling strategy was used to identify PHC teams (n = 10), from which participants of different professional roles were selected through a purposeful recruitment process to reflect maximum variation of team roles. Additionally, QI coaches working with the interview participants and the LC administrators were also interviewed. Data were collected through semistructured telephone interviews that were audiotaped and transcribed verbatim. Thematic analysis was conducted through an iterative and interpretive approach. The shared experience of participating in the program appeared to improve team functioning. Participants described increased trust and respect for each other's clinical and administrative roles and were inspired by learning about different approaches to interdisciplinary care. This appeared to enhance collegial relationships, collapse professional silos, improve communication, and increase interdisciplinary collaboration. Teamwork involves more than just physically grouping healthcare providers from multiple disciplines and mandating them to work together. The LC program provided opportunities for participants to learn how to work collaboratively, and participation in the LC program appeared to enhance team functioning.

Impact of a quality improvement program on primary healthcare in Canada: a mixed-method evaluation.

PURPOSE: Rigorous comprehensive evaluations of primary healthcare (PHC) quality improvement (QI) initiatives are lacking. This article describes the evaluation of the Quality Improvement and Innovation Partnership Learning Collaborative (QIIP-LC), an Ontario-wide PHC QI program targeting type 2 diabetes management, colorectal cancer (CRC) screening, access to care, and team functioning. METHODS: This article highlights the primary outcome results of an external retrospective, multi-measure, mixed-method evaluation of the QIIP-LC, including: (1) matched-control pre-post chart audit of diabetes management (A1c/foot exams) and rate of CRC screening; (2) post-only advanced access survey (third-next available appointment); and (3) post-only semi-structured interviews (team functioning). RESULTS: Chart audit data was collected from 34 consenting physicians per group (of which 88% provided access data). Between-group differences were not statistically significant (A1c [p=0.10]; foot exams [p=0.45]; CRC screening [p=0.77]; advanced access [p=0.22]). Qualitative interview (n=42) themes highlighted the success of the program in helping build interdisciplinary team functioning and capacity. CONCLUSION: The rigorous design and methodology of the QIIP-LC evaluation utilizing a control group is one of the most significant efforts thus far to demonstrate the impact of a QI program in PHC, with improvements over time in both QIIP and control groups offering a likely explanation for the lack of statistically significant primary outcomes. Team functioning was a key success, with team-based chronic care highlighted as pivotal for improved health outcomes. Policy makers should strive to endorse QI programs with proven success through rigorous evaluation to ensure evidence-based healthcare policy and funding.

Does a patient-managed insulin intensification strategy with insulin glargine and insulin glulisine provide similar glycemic control as a physician-managed strategy? Results of the START (Self-Titration With Apidra to Reach Target) Study: a randomized noninferiority trial.

OBJECTIVE Diabetes self-management is universally regarded as a foundation of diabetes care. We determined whether comparable glycemic control could be achieved by self-titration versus physician titration of a once-daily bolus insulin dose in patients with type 2 diabetes who are unable to achieve optimal glycemia control with a basal insulin. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes, an HbA1c level >7% (53 mmol/mol), and either nocturnal hypoglycemia episodes or an insufficient basal insulin glargine level (with or without oral agents) to achieve a fasting plasma glucose level ≤6 mmol/L (108 mg/dL) were studied. Participants all had bolus insulin glulisine added at breakfast and were allocated to either algorithm-guided patient self-titration or physician titration. The primary outcome was an HbA1c level ≤7% (53 mmol/mol) without severe hypoglycemia. RESULTS After a mean (SD) follow-up of 159.4 days (36.2 days), 28.4% of participants in the self-titration arm vs. 21.2% in the physician titration arm achieved an HbA1c level of ≤7% (53 mmol/mol) without severe hypoglycemia (between-group absolute difference 7.2%; 95% CI -3.2 to 17.7). The lower end of this 95% confidence interval was within the predetermined noninferiority boundary of -5% (P noninferiority = 0.011). CONCLUSIONS In stable patients with type 2 diabetes who are receiving doses of basal insulin glargine who require bolus insulin, a simple bolus insulin patient-managed titration algorithm is as effective as a physician-managed algorithm.

Results of a mixed-methods evaluation of partnerships for health: a quality improvement initiative for diabetes care.

PURPOSE: Quality improvement (QI) initiatives have been implemented to facilitate transition to a chronic disease management approach in primary health care. However, the effect of QI initiatives on diabetes clinical processes and outcomes remains unclear. This article reports the effect of Partnerships for Health, a QI program implemented in Southwestern Ontario, Canada, on diabetes clinical process and outcome measures and describes program participants' views of elements that influenced their ability to reach desired improvements. METHODS: Part of an external, concurrent, comprehensive, mixed-methods evaluation of Partnerships for Health, a before/after audit of 30 charts of patient of program physicians (n = 35) and semistructured interviews with program participants (physicians and allied health providers) were conducted. RESULTS: The proportion of patients (n = 998) with a documented test/examination for the following clinical processes significantly improved (P ≤ .005): glycosylated hemoglobin (A1c), cholesterol, albumin-to-creatinine ratio, serum creatinine, glomerular filtration rate, electrocardiogram, foot/eye/neuropathy examination, body mass index, waist circumference, and depression screening. Data showed intensification of treatment and significant improvement in the number of patients at target for low-density lipoprotein (LDL) and blood pressure (BP) (P ≤ .001). Mean LDL and BP values decreased significantly (P ≤ .01), and an analysis of patients above glycemic targets (A1c >7% at baseline) showed a significant decrease in mean A1c values (P ≤ .01). Interview participants (n = 55) described using a team approach, improved collaborative and proactive care through better tracking of patient data, and increased patient involvement as elements that positively influenced clinical processes and outcomes. CONCLUSIONS: QI initiatives like Partnerships for Health can result in improved diabetes clinical process and outcome measures in primary health care.

Can community retail pharmacist and diabetes expert support facilitate insulin initiation by family physicians? Results of the AIM@GP randomized controlled trial.

BACKGROUND: Limited evidence exists on the effectiveness of external diabetes support provided by diabetes specialists and community retail pharmacists to facilitate insulin-prescribing in family practice. METHODS: A stratified, parallel group, randomized control study was conducted in 15 sites across Canada. Family physicians received insulin initiation/titration education, a physician-specific 'report card' on the characteristics of their type 2 diabetes (T2DM) population, and a registry of insulin-eligible patients at a workshop. Intervention physicians in addition received: (1) diabetes specialist/educator consultation support (active diabetes specialist/educator consultation support for 2 months [the educator initiated contact every 2 weeks] and passive consultation support for 10 months [family physician initiated as needed]); and (2) community retail pharmacist support (option to refer patients to the pharmacist(s) for a 1-hour insulin-initiation session). The primary outcome was the insulin prescribing rate (IPR) per physician defined as the number of insulin starts of insulin-eligible patients during the 12-month strategy. RESULTS: Consenting, eligible physicians (n = 151) participated with 15 specialist sites and 107 community pharmacists providing the intervention. Most physicians were male (74%), and had an average of 81 patients with T2DM. Few (9%) routinely initiated patients on insulin. Physicians were randomly allocated to usual care (n = 78) or the intervention (n = 73). Intervention physicians had a mean (SE) IPR of 2.28 (0.27) compared to 2.29 (0.25) for control physicians, with an estimated adjusted RR (95% CI) of 0.99 (0.80 to 1.24), p = 0.96. CONCLUSIONS: An insulin support program utilizing diabetes experts and community retail pharmacists to enhance insulin prescribing in family practice was not successful. Too few physicians are appropriately intensifying diabetes management through insulin initiation, and aggressive therapeutic treatment is lacking.

Teleconferenced educational detailing: diabetes education for primary care physicians.

INTRODUCTION: Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed. METHODS: A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated. RESULTS: Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians. DISCUSSION: CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.

Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study).

The objective of this national, cross-sectional study was to provide insight into the care and treatment of type 2 diabetes (T2DM) in the Canadian primary care setting. Specifically, the study examines glycemic control, management and morbidity load among T2DM patients, and investigates the relationship of glycemic control and morbidity load with duration of diabetes. Participating primary care physicians (PCPs) (N=243) completed a chart audit for the first 10 patients with T2DM attending their clinics (2473 eligible patient records). The mean A1C was 7.3% with 49% of patients not at target (A1C>or=7.0%). Glycemic control eroded significantly with increasing duration of diabetes in spite of increasing therapeutic intervention. T2DM patients experienced a high morbidity load (hypertension 63%; dyslipidemia 59%; macrovascular complications 28%; microvascular complications 38%) each of which increased significantly with duration of diabetes. For 79% of patients not at target, PCPs identified lifestyle intervention as the strategy for achieving glycemic targets while more aggressive treatment plans were identified for only 56%. These results underscore the complexity of primary care management of T2DM and suggest that current treatment approaches are not intensive enough for a large proportion of patients especially those with longer duration of disease.

Is the Health Utilities Index valid in total hip arthroplasty patients?

PURPOSE: The purpose of the study was to examine the construct validity of the Health Utilities Index Mark 2 (HU12) and Mark 3 (HU13) in patients with osteoarthritis (OA) needing total hip arthroplasty (THA). BACKGROUND: One hundred and fourteen OA patients (mean age = 69.2; SD = 8.9) who were waiting to see a surgeon for an evaluation for THA completed baseline measures that included the HU12, HU13, SF-36, Harris Hip Scale, WOMAC, MACTAR, State-Trait Anxiety Inventory, and the 6-min walk test. METHODS: We examined 87 a priori hypotheses by correlating (one-tailed zero-order correlations) the single-attribute utility scores for the pain, emotion, mobility, ambulation, self-care, dexterity, vision, hearing, and speech attributes of the HU12 and HU13 and the overall HU12 and HU13 utility scores to specified subscales of the other measures. RESULTS: The zero-order correlations confirmed 75% of our a priori hypotheses suggesting that the constructs within the HU12 and HU13 were, in general, related to similar constructs in other measures as expected. CONCLUSIONS: The evidence suggests that HU12 and HU13 are valid for use in OA and THA studies.

Is the Health Utilities Index responsive in total hip arthroplasty patients?

OBJECTIVE: The purpose is to examine the responsiveness of the Health Utilities Index Mark 2 (HUI2), Mark 3 (HUI3), and other generic and disease-specific measures in osteoarthritis patients undergoing total hip arthroplasty (THA). METHODS: Ninety patients (mean age=68.13; SD=8.15) on a waiting list for THA completed measures that included the standard gamble, HUI2, HUI3, SF-36, Harris Hip Scale, WOMAC, and MACTAR. before and after THA. Responsiveness statistics (effect size, standardized response mean, Guyatt's responsiveness statistic, paired-sample t-tests, and relative efficiency statistic) were calculated. RESULTS: The disease-specific measures were more responsive than the generic measures. Rankings of the degree of responsiveness varied depending on the responsiveness statistic used. CONCLUSIONS: Disease-specific measures are the most responsive in THA patients. However, the SF-36, HUI2, and HUI3 had summary scores and domain/attributes scores that were also responsive and provided additional information. Among the generic measures, HUI3 was the most responsive.

Type 2 diabetes in family practice. Room for improvement.

OBJECTIVE: To further knowledge of diabetes management in family practice. DESIGN Retrospective, observational chart audit study. SETTING: Southwestern Ontario. PARTICIPANT: A random sample of non-academic family physicians and a random selection of their patients with type 2 diabetes mellitus. MAIN OUTCOME MEASURES: Glycemic control as measured by HbA1c and adherence to recommendations in clinical practice guidelines (CPGs). RESULTS: Eighty-four percent of patients had at least one HbA1c test ordered in the previous year. Overall mean HbA1c was 0.079 and half-the patients had levels deemed acceptable by 1992 CPGs. Screening for microvascular complications was disappointing; only 28% were tested for microalbuminuria, and 15% were examined for diabetes-related foot conditions. Screening for macrovascular complications was more comprehensive; blood pressure was measured in 88%, and lipid profiles documented in 48%, of patient charts. CONCLUSION: Management of glycemic control and screening for microvascular and macrovascular disease in family practice can be improved.