Association Between Dissatisfaction With Care and Diabetes Self-Care Behaviors, Glycemic Management, and Quality of Life of Adults With Type 2 Diabetes Mellitus.

PURPOSE: The purpose of the study was to examine the associations between patient dissatisfaction and diabetes outcomes among patients with type 2 diabetes. METHODS: Primary data from 615 adults with type 2 diabetes from 2 adult primary care clinics completed validated questionnaires. Patient dissatisfaction was measured by asking participants to what degree over the past 12 months were they very dissatisfied with the care they received from their primary care provider. Diabetes outcomes included self-care behaviors, quality of life, and A1C. A1C was abstracted from the medical record. Multiple linear regression models were used to assess associations between patient dissatisfaction, self-care, blood glucose, and quality of life. RESULTS: After adjusting for covariates, this study demonstrated that higher patient dissatisfaction was significantly associated with poor general diet, worse blood glucose levels, and lower mental component score for quality of life. CONCLUSIONS: In patients with type 2 diabetes, patient dissatisfaction had a significant association with higher blood glucose levels, poor general diet, and low quality of life. Demographic factors driving patient dissatisfaction included young age, low income, and low health literacy. Future studies should investigate how to address patient satisfaction in an effort to improve health outcomes.

Chaos to complexity: leveling the playing field for measuring value in primary care.

RATIONALE, AIMS AND OBJECTIVES: Develop a risk-stratification model that clusters primary care patients with similar co-morbidities and social determinants and ranks 'within-practice' clusters of complex patients based on likelihood of hospital and emergency department (ED) utilization. METHODS: A retrospective cohort analysis was performed on 10 408 adults who received their primary care at the Medical University of South Carolina University Internal Medicine clinic. A two-part generalized linear regression model was used to fit a predictive model for ED and hospital utilization. Agglomerative hierarchical clustering was used to identify patient subgroups with similar co-morbidities. RESULTS: Factors associated with increased risk of utilization included specific disease clusters {e.g. renal disease cluster [rate ratio, RR = 5.47; 95% confidence interval (CI; 4.54, 6.59) P < 0.0001]}, low clinic visit adherence [RR = 0.33; 95% CI (0.28, 0.39) P < 0.0001] and census measure of high poverty rate [RR = 1.20; 95% CI (1.11, 1.28) P < 0.0001]. In the cluster model, a stable group of four clusters remained regardless of the number of additional clusters forced into the model. Although the largest number of high-utilization patients (top 20%) was in the multiple chronic condition cluster (1110 out of 4728), the largest proportion of high-utilization patients was in the renal disease cluster (67%). CONCLUSIONS: Risk stratification enhanced with disease clustering organizes a primary care population into groups of similarly complex patients so that care coordination efforts can be focused and value of care can be maximized.

The association of cumulative discrimination on quality of care, patient-centered care, and dissatisfaction with care in adults with type 2 diabetes.

AIMS: Discrimination is linked to negative health outcomes, but little research has investigated how the cumulative effect of discrimination impacts perceptions of care. This study investigated the influence of cumulative perceived discrimination on quality of care, patient-centeredness, and dissatisfaction with care in adults with type 2 diabetes. METHODS: Six hundred two patients from two primary care clinics in Charleston, SC. Linear regression models assessed associations between perceived discrimination and quality of care, patient-centered care, and dissatisfaction with care. The models control for race, site, age, gender, marital status, duration of diabetes, education, hours worked weekly, income, and health status. RESULTS: The mean age was 61.5years, with 66.3% non-Hispanic blacks, and 41.9% earning less than $20,000 annually. In final adjusted analyses, lower patient-centered care was associated with a higher discrimination score (ß=-0.28; p=0.006), reporting at least 1 category of discrimination (ß=-1.47; p=0.002), and reporting at least 2 categories of discrimination (ß=-1.34; p=0.004). Dissatisfaction with care was associated with at least 2 categories of discrimination (ß=0.45; p=0.002). No significant associations were seen with quality of care indicators. CONCLUSIONS: Increased cumulative discrimination was associated with decreased feeling of patient-centeredness and increased dissatisfaction with care. However, these perceptions of discrimination were not significantly associated with quality indicators.

Advanced Care Directives: Overcoming the Obstacles.

BACKGROUND: Advanced care directives (ACDs) and end-of-life discussions are important and typically difficult to initiate because of the sensitive nature of the topic and competing clinical priorities. Resident physicians need to have these conversations but often do not in their continuity clinics. OBJECTIVE: We implemented a program to (1) increase physician opportunity to discuss end-of-life wishes with their patients, and (2) improve residents' confidence in leading discussions regarding ACDs. INTERVENTION: A total of 95 residents in an academic outpatient internal medicine resident continuity clinic participated in a formalized curriculum (didactic sessions, simulations, and academic detailing). Clinic workflow alterations prompted the staff to question if patients had an ACD or living will, and then cued residents to discuss these issues with the patients if they did not. RESULTS: Of the 77% of patients who were asked about ACDs, 74% had no ACD but were interested in discussing this topic. After our intervention, 65% (62 of 95) of our residents reported having at least 1 outpatient discussion with their patients. Residents reported increased confidence directing and discussing advanced care planning with older patients and conducting a family meeting (P < .01). CONCLUSIONS: By delivering a formalized curriculum and creating a clinical environment that supports such discussions, resident physicians had more ACD discussions with their patients and reported increased confidence. When provided information and opportunity, patients consistently expressed interest in talking with their physician about their advanced care wishes.

Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes.

OBJECTIVE: Diabetes fatalism is defined as "a complex psychological cycle characterized by perceptions of despair, hopelessness, and powerlessness" and associated with poor glycemic control. This study examined the association between diabetes fatalism and medication adherence and self-care behaviors in adults with diabetes. METHODS: Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the Southeastern United States were examined. Previously validated scales were used to measure diabetes fatalism, medication adherence, diabetes knowledge and diabetes self-care behaviors (diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of diabetes fatalism on medication adherence and self-care behaviors controlling for relevant covariates. RESULTS: Fatalism correlated significantly with medication adherence (r=0.24, P<.001), diet (r=-0.26, P<.001), exercise (r=-0.20, P<.001) and blood sugar testing (r=-0.19, P<.001). In the linear regression model, diabetes fatalism was significantly associated with medication adherence [ß=0.029, 95% confidence interval (CI) 0.016, 0.043], diabetes knowledge (ß=-0.042, 95% CI -0.001, -0.084), diet (ß=-0.063, 95% CI -0.039, -0.087), exercise (ß=-0.055, 95% CI -0.028, -0.083) and blood sugar testing (ß=-0.055, 95% CI -0.023, -0.087). There was no significant association between diabetes fatalism and foot care (ß=-0.018, 95% CI -0.047, 0.011). The association between diabetes fatalism and medication adherence, diabetes knowledge and diabetes self-care behaviors did not change significantly when depression was added to the models, suggesting that the associations are independent of depression. CONCLUSION: Diabetes fatalism is associated with poor medication adherence and self-care and may be an important target for education and skills interventions in diabetes care. In addition, the effect of diabetes fatalism is independent of depression, suggesting that interventions that target depression may not be sufficient to deal with diabetes fatalism.

Associations between coping, diabetes knowledge, medication adherence and self-care behaviors in adults with type 2 diabetes.

BACKGROUND: Few studies have examined the emotional approach to coping on diabetes outcomes. This study examined the relationship between emotional coping and diabetes knowledge, medication adherence and self-care behaviors in adults with type 2 diabetes. METHODS: Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the southeastern United States were examined. Previously validated scales were used to measure coping, medication adherence, diabetes knowledge and diabetes self-care behaviors (including diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of coping through emotional approach on medication adherence and self-care behaviors while controlling for relevant covariates. RESULTS: Significant correlations were observed between emotional coping [as measured by emotional expression (EE) and emotional processing (EP)] and self-care behaviors. In the linear regression model, EP was significantly associated with medication adherence [ß -0.17, 95% confidence interval (CI) -0.32 to -0.015], diabetes knowledge (ß 0.76, 95% CI 0.29 to 1.24), diet (ß 0.52, 95% CI 0.24 to 0.81), exercise (ß 0.51, 95% CI 0.19 to 0.82), blood sugar testing (ß 0.54, 95% CI 0.16 to 0.91) and foot care (ß 0.32, 95% CI -0.02 to 0.67). On the other hand, EE was associated with diet (ß 0.38, 95% CI 0.13 to 0.64), exercise (ß 0.54, 95% CI 0.27 to 0.82), blood sugar testing (ß 0.42, 95% CI 0.09 to 0.76) and foot care (ß 0.36, 95% CI 0.06 to 0.66), but it was not associated with diabetes knowledge. CONCLUSION: These findings indicate that coping through an emotional approach is significantly associated with behaviors that lead to positive diabetes outcomes.

The use of clinical decision-support tools to facilitate geriatric education.

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision-support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point-of-care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.

Diabetes empowerment, medication adherence and self-care behaviors in adults with type 2 diabetes.

BACKGROUND: Evidence suggests that empowerment is an important factor to address everyday aspects of dealing with a chronic disease. This study evaluated the effect of diabetes empowerment on medication adherence and self-care behaviors in adults with type 2 diabetes. SUBJECTS AND METHODS: Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the southeastern United States were examined. Previously validated scales were used to measure diabetes empowerment, medication adherence, diabetes knowledge, and diabetes self-care behaviors (including diet, physical activity, blood sugar testing, and foot care). Multiple linear regression was used to assess the independent effect of diabetes empowerment on medication adherence and self-care behaviors controlling for relevant covariates. RESULTS: Eighty-three percent were non-Hispanic blacks, 69% were women, 22% were 65 years or older, 68% were not married, 26% had less than high school education, 60% were unemployed, 39% were uninsured, and 47% had a yearly income <$10,000. Empowerment had significant correlations with medication adherence (r=0.17, P<0.003), diabetes knowledge (r=0.16, P=0.007), diet (r=0.24, P<0.001), exercise (r=0.25, P<0.001), blood sugar testing (r=0.12, P=0.043), and foot care (r=0.18, P=0.002). In the regression model, diabetes empowerment was significantly associated with medication adherence (ß=-0.04, P=0.001), diabetes knowledge (ß=0.09, P=0.012), diet (ß=0.09, P<0.001), exercise (ß=0.10, P<0.001), blood sugar testing (ß=0.07, P=0.016), and foot care (ß=0.08, P=0.001). CONCLUSIONS: In this sample, diabetes empowerment was related to better diabetes knowledge, medication adherence and improved self-care behaviors. Emphasis on empowerment and self-efficacy is relevant to improve outcomes in the management of diabetes.

Aging Q3: an initiative to improve internal medicine residents' geriatrics knowledge, skills, and clinical performance.

A growing number of older adults coupled with a limited number of physicians trained in geriatrics presents a major challenge to ensuring quality medical care for this population. Innovations to incorporate geriatrics education into internal medicine residency programs are needed. To meet this need, in 2009, faculty at the Medical University of South Carolina developed Aging Q(3)-Quality Education, Quality Care, and Quality of Life. This multicomponent initiative recognizes the need for improved geriatrics educational tools and faculty development as well as systems changes to improve the knowledge and clinical performance of residents. To achieve these goals, faculty employ multiple intervention strategies, including lectures, rounds, academic detailing, visual cues, and electronic medical record prompts and decision support. The authors present examples from specific projects, based on care areas including vision screening, fall prevention, and caring for patients with dementia, all of which are based on the Assessing Care of Vulnerable Elders quality indicators. The authors describe the principles driving the design, implementation, and evaluation of the Aging Q(3) program. They present data from multiple sources that illustrate the effectiveness of the interventions to meet the knowledge, skill level, and behavior goals. The authors also address major challenges, including the maintenance of the teaching and modeling interventions over time within the context of demanding primary care and inpatient settings. This organized, evidence-based approach to quality improvement in resident education, as well as faculty leadership development, holds promise for successfully incorporating geriatrics education into internal medicine residencies.

Where are my patients? It is time to automate notification of hospital use to primary care practices.

The hospital-to-community transition is fraught with risks for patients, with 30-day readmission rates of 20% for Medicare patients. Poorly coordinated transitions of care translate to unplanned readmission costs to Medicare of more than $17 billion/year. Calls for better physician communication to improve care coordination abound; however, primary care physicians cannot better coordinate care when, in many cases, they are not even aware that their patients have been admitted to the hospital. During the past 30 years, we have made little progress in systematically improving communication between hospital and posthospital providers to coordinate postdischarge care. Hospitals and physicians need better tools to coordinate care transitions. It is time to automate the hospital discharge notification process, notify practice staff, and stop expecting physician-to-physician communication. Notification can be efficiently supported by computerized systems that do not rely on physicians to "close the loop" back to primary care. We present four clinical programs in which automated notification of primary care staff was used to ensure appropriate follow-up and coordination of care for patients. These automated systems use a secure online Web site or an encrypted e-mail notification system that alerts clinicians and practice staff to hospital registration of the patient. In each program, notification triggers a nurse-directed clinical assessment and care coordination plan and helps ensure timely primary care follow-up. We believe automated notification is a necessary tool to support coordination of care in the new delivery models such as the patient-centered medical home.

Brief report: Trainee provider perceptions of group visits.

OBJECTIVE: To evaluate the effect of observing group visits on trainees' perceptions of group visits as a method of health care delivery. RESEARCH DESIGN AND METHODS: Thirty-two trainees assigned to month-long rotations at an academic Internal Medicine Primary Care Clinic serving underinsured patients were recruited to observe between 1 and 4 group visits. Prior to observation of their first, and subsequent to observation of their last group visit, each trainee completed the Patient-Physician Orientation Scale (PPOS), a validated survey evaluating their tendencies toward being patient-centered or provider-centered. Additionally, they completed a Group Visit Questionnaire (GVQ) evaluating their perceptions of group visits as a method of health care delivery. RESULTS: Trainee gender, type, and level of training were similarly represented across the study population of trainees. While there were no significant differences noted on pre- and postobservation PPOS scores, the postobservation GVQs scores were significantly improved after observing at least one group visit (P<.0001). CONCLUSION: Trainees' perceptions of group visits as a method of health care delivery improved significantly after observation of at least 1 group as measured by the GVQ.