Correlates of family involvement before and during medical visits among older adults with high-risk diabetes.

AIMS: To examine the characteristics of patients with diabetes who regularly receive help from a supporter in preparing for and attending medical visits, and the association between this help and clinical risk factors for diabetes complications. METHODS: We linked survey data about family involvement for patients in the Veterans Health Administration system with poorly controlled Type 2 diabetes (n = 588; mean 67 years; 97% male) with health record data on blood pressure, glycaemic control and prescription-fill gaps. We used multivariable regression to assess whether supporter presence and, among patients with supporters, supporter role (visit preparation, accompaniment to medical visit or no involvement) were associated with concurrent trends in clinical risk factors over 2 years, adjusting for sociodemographic and health characteristics. RESULTS: Most patients (78%) had a main health supporter; of these, more had regular support for preparing for appointments (69%) than were regularly accompanied to them (45%). Patients with preparation help only were younger and more educated than accompanied patients. Support presence and type was not significantly associated with clinical risk factors. CONCLUSIONS: Family help preparing for appointments was common among these patients with high-risk diabetes. In its current form, family support for medical visits may not affect clinical factors in the short term. Supporters helping patients engage in medical visits may need training and assistance to have an impact on the clinical trajectory of patients with diabetes.

Generalized anxiety disorder screening scores are associated with greater treatment need among Veterans with depression.

Comorbid anxiety and depression predict a poorer prognosis than either disorder occurring alone. It is unclear whether self-reported anxiety symptom scores identify patients with depression in need of more intensive mental health services. This study evaluated how anxiety symptoms predicted treatment receipt and outcomes among patients with new depression diagnoses in the Veterans Health Administration (VHA). Electronic medical record data from 128,917 VHA patients (71.6% assessed for anxiety, n = 92,237) with new diagnoses of depression were analyzed to examine how Generalized Anxiety Disorder-7 (GAD-7) scores predicted psychotropic medication prescriptions, psychotherapy receipt, acute care service utilization, and follow-up depression symptoms. Patients who reported severe symptoms of anxiety were significantly more likely to receive adequate acute phase and continuation phase antidepressant treatment, daytime anxiolytics/sedatives, nighttime sedative/hypnotics, and endorse more severe depression symptoms and suicidal ideation at follow-up. Patients who reported severe symptoms of anxiety at baseline were less likely to initiate psychotherapy. The GAD-7 may help identify depressed patients who have more severe disease burden and require additional mental health services.

Longitudinal association between medication adherence and glycaemic control in Type 2 diabetes.

AIM: Despite the widespread assumption that adherence drives glycaemic control, there is little published support for this in Type 2 diabetes. The study objective was to determine whether self-reported medication adherence predicts future glycaemic control in Type 2 diabetes, after accounting for baseline control. METHODS: Medication adherence (4-item Morisky scale), glycaemic control (HbA(1c)%), and other variables were assessed in 287 adult primary care patients prescribed oral medication (40% also on insulin) for Type 2 diabetes. Glycaemic control was reassessed 6 months later. Regression analyses examined concurrent and future glycaemic control as a function of baseline medication adherence after adjustment for baseline glycaemia and other potential confounders. RESULTS: Only half of patients reported high adherence. Cross-sectional adjusted analysis replicated prior reports of an adherence-HbA(1c) association (P = 0.011). Even after adjusting for baseline HbA(1c), each one-point increase in baseline Morisky total score was associated with a 1.8 mmol/mol (or 0.16%) increase in HbA(1c) measured 6 months later. Additionally, baseline endorsement of forgetting to take medication was associated with a 4.7 mmol/mol (or 0.43%) increase in 6-month HbA(1c) (P = 0.005). This effect persisted after adjusting for psychological distress and did not vary by key demographic and medical features. CONCLUSIONS: Even after stringent adjustment for baseline glycaemic control, self-reported adherence to diabetes medication predicts long-term glycaemic control. The Morisky scale is an easy-to-use clinical tool to identify patients whose glycaemic control will subsequently worsen, regardless of age, gender and psychological distress.

Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic.

OBJECTIVE: Evaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms. METHOD: Veterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care. RESULTS: A total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated. CONCLUSIONS: Black race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.

Post-discharge tobacco cessation rates among hospitalized US veterans with and without diabetes.

AIMS: Smoking is a major risk factor for cardiovascular complications among patients with diabetes. Hospitalization has been shown to enhance cessation rates. The purpose of this study was to compare 6-month post-hospitalization tobacco cessation rates among US veterans with and without diabetes. METHODS: This was a longitudinal study among inpatient veterans who used tobacco in the past month (n = 496). Patients were recruited and surveyed from three Midwestern Department of Veterans Affairs hospitals during an acute-care hospitalization. They were also asked to complete a follow-up survey 6 months post-discharge. Bivariate- and multivariable-adjusted analyses were conducted to determine differences in tobacco cessation rates between patients with and without a diagnosis of diabetes. RESULTS: The mean age of patients was 55.2 years and 62% were white. Twenty-nine per cent had co-morbid diabetes. A total of 18.8% of patients with diabetes reported tobacco cessation at 6 months compared with 10.9% of those without diabetes (P = 0.02). Cotinine-verified cessation rates were 12.5 vs. 7.4% in the groups with and without diabetes, respectively (P = 0.07). Controlling for psychiatric co-morbidities, depressive symptoms, age, self-rated health and nicotine dependence, the multivariable-adjusted logistic regression showed that patients with diabetes had three times higher odds of 6-month cotinine-verified tobacco cessation as compared with those without diabetes (odds ratio 3.17, P = 0.005). CONCLUSIONS: Post-hospitalization rates of smoking cessation are high among those with diabetes. Intensive tobacco cessation programmes may increase these cessation rates further.

Association between depression and concurrent Type 2 diabetes outcomes varies by diabetes regimen.

AIMS: Although depression has weak associations with several Type 2 diabetes mellitus (DM) outcomes, it is possible that these associations are concentrated within certain patient subgroups that are more vulnerable to their effects. This study tested the hypothesis that depression is related to glycaemic control and diabetes-related quality of life (DQOL) in patients who are prescribed injected insulin, but not those on oral glucose-lowering agents alone. METHODS: Participants (103 on insulin, 155 on oral glucose-lowering agents alone) with Type 2 DM were recruited from a large US healthcare system and underwent assessment of glycaemic control (glycated haemoglobin; HbA(1c)), medication adherence and diabetes self-care behaviours, DQOL and depression (none, mild, moderate/severe). RESULTS: There was a significant regimen x depression interaction on HbA(1c) (P = 0.002), such that depression was associated with HbA(1c) in patients using insulin (beta = 0.35, P < 0.001) but not in patients using oral agents alone (beta = -0.08, P = NS). There was a similar interaction when quality of life was analysed as an outcome (P = 0.002). Neither effect was mediated by regimen adherence. CONCLUSIONS: The generally weak association between depression and glycaemic control is concentrated among patients who are prescribed insulin. Similarly, the association between depression and illness quality of life is strongest in patients prescribed insulin. Because this is not attributable to depression-related adherence problems, psychophysiological mechanisms unique to this group ought to be carefully investigated. Clinicians might be especially vigilant for depression in Type 2 DM patients who use insulin and consider its potential impact upon their illness course.

The feasibility of automated voice messaging as an adjunct to diabetes outpatient care.

OBJECTIVE: To determine whether automated voice messaging (AVM) systems could be used as an adjunct to primary care for diabetic patients, we examined whether patients were able to respond to AVM queries for clinical information, whether sufficient numbers of problems were identified to warrant the implementation of the service, and whether patients found the system helpful. RESEARCH DESIGN AND METHODS: The AVM system we examined uses specialized computer technology to telephone patients, communicate messages, and collect information. Sixty-five diabetic patients participated. Based on a review of the literature and the input of diabetes clinician-researchers, we developed an AVM monitoring protocol to inquire about patients' symptoms, glucose monitoring, foot care, diet, and medication adherence. Patients also were given the option to listen to health promotion messages and to report their satisfaction with the calls. Patients responded by using their touch-tone telephone keypads. RESULTS: A total of 216 AVM calls were successfully completed, an average of 3.3 out of four calls per patient. Patients reported a variety of health problems that signaled the need for follow-up. Many patients reported not checking their blood glucose or their feet, and one in four reported problems with medication and diet adherence. Health and self-care problems varied across patient subgroups in ways suggesting that the AVM reports were reliable and valid. Overall, 98% of all patients reported that the calls were helpful, 98% reported that they had no difficulty responding to the calls, and 77% reported that receiving AVM calls would make them more satisfied with their health care. CONCLUSIONS: This study demonstrates that diabetic patients can respond to AVM queries and find the calls helpful. Such calls are a feasible strategy for identifying health and self-care problems that would otherwise go unnoticed by clinicians.

Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: a randomized controlled trial.

OBJECTIVE: We evaluated automated telephone disease management (ATDM) with telephone nurse follow-up as a strategy for improving diabetes treatment processes and outcomes in Department of Veterans Affairs (VA) clinics. We also compared the results with those of a prior ATDM trial conducted in a county health care system. RESEARCH DESIGN AND METHODS: A total of 272 VA patients with diabetes using hypoglycemic medications were randomized. During the 1-year study period, intervention patients received biweekly ATDM health assessment and self-care education calls, and a nurse educator followed up with patients based on their ATDM assessment reports. Telephone surveys were used to measure patients' self-care, symptoms, and satisfaction with care. Outpatient service use was evaluated using electronic databases and self-reports, and glycemic control was measured by HbA1c and serum glucose testing. RESULTS: At 12 months, intervention patients reported more frequent glucose self-monitoring and foot inspections than patients receiving usual care and were more likely to be seen in podiatry and diabetes specialty clinics. Intervention patients also were more likely than control patients to have had a cholesterol test. Among patients with baseline HbA1c levels > or =8%, mean end-point values were lower among intervention patients than control patients (8.7 vs. 9.2%, respectively; P = 0.04). Among intervention and control patients with baseline values > or =9%, mean end-point values were 9.1 and 10.2%, respectively (P = 0.04). At follow-up, intervention patients reported fewer symptoms of poor glycemic control than control patients and greater satisfaction with their health care. CONCLUSIONS: This intervention improved the quality of VA diabetes care. Intervention effects for most end points replicated findings from the prior county clinic trial, although intervention-control differences in the current study were smaller because of the relatively good self-care and health status among the current study's enrollees.

Use of automated telephone disease management calls in an ethnically diverse sample of low-income patients with diabetes.

OBJECTIVE: We examined whether low-income patients with diabetes were able and willing to use automated telephone disease management (ATDM) calls to provide health status information that could improve the quality of their care. RESEARCH DESIGN AND METHODS: A total of 252 adults with diabetes, 30 of whom spoke Spanish as their primary language, were enrolled at the time of clinic visits in a Department of Veterans Affairs health care system (n = 132) or a county health care system (n = 120). Patients received ATDM calls for 12 months and responded to queries using their touch-tone telephones. We examined 1) whether patients completed ATDM assessments consistently over the year and used the calls to report their self-monitored blood glucose (SMBG) levels, 2) the characteristics of patients most likely to use the system frequently, 3) whether patients responded consistently within ATDM assessments, and 4) whether ATDM assessments differentiated among groups of patients with different clinical profiles at baseline. RESULTS: Half of all patients completed at least 77% of their attempted assessments, and one-fourth completed at least 91%. Half of all patients reported SMBG levels during at least 86% of their assessments. Patients completed assessments and reported glucose levels consistently over the year. Health status indicators were the most important determinants of assessment completion rates, while socioeconomic factors were more strongly associated with patients' likelihood of reporting SMBG data during assessments. Patients' responses within assessments were consistent, and the information they provided during their initial assessments identified groups with poor glycemic control and other health problems. CONCLUSIONS: Most low-income patients with diabetes can and will use ATDM calls as part of their care. The information they provide is reliable and has clinical significance. ATDM calls could improve the information base for diabetes management while relieving some of the pressures of delivering diabetes care under cost constraints.

Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes?

PURPOSE: We sought to evaluate the effect of automated telephone assessment and self-care education calls with nurse follow-up on the management of diabetes. SUBJECTS AND METHODS: We enrolled 280 English- or Spanish-speaking adults with diabetes who were using hypoglycemic medications and who were treated in a county health care system. Patients were randomly assigned to usual care or to receive an intervention that consisted of usual care plus bi-weekly automated assessment and self-care education calls with telephone follow-up by a nurse educator. Outcomes measured at 12 months included survey-reported self-care, perceived glycemic control, and symptoms, as well as glycosylated hemoglobin (Hb A1c) and serum glucose levels. RESULTS: We collected follow-up data for 89% of enrollees (248 patients). Compared with usual care patients, intervention patients reported more frequent glucose monitoring, foot inspection, and weight monitoring, and fewer problems with medication adherence (all P -0.03). Follow-up Hb A,, levels were 0.3% lower in the intervention group (P = 0.1), and about twice as many intervention patients had Hb A1c levels within the normal range (P = 0.04). Serum glucose levels were 41 mg/dL lower among intervention patients than usual care patients (P = 0.002). Intervention patients also reported better glycemic control (P = 0.005) and fewer diabetic symptoms (P <0.0001 ), including fewer symptoms of hyperglycemia and hypoglycemia. CONCLUSIONS: Automated calls with telephone nurse follow-up may be an effective strategy for improving self-care behavior and glycemic control, and for decreasing symptoms among vulnerable patients with diabetes.

Patient education via automated calls: a study of English and Spanish speakers with diabetes.

INTRODUCTION: Using diabetes as a prototype, we examined whether automated telephone disease management (ATDM) calls can improve chronically ill patients' access to self-care and dietary information. METHODS: Two-hundred-twenty-six English-speaking patients and 30 Spanish-speaking patients who were recruited from outpatient clinics received bi-weekly ATDM calls for 1 year, in which they were given the opportunity to access patient education messages. We compared the proportion of English-speaking and Spanish-speaking patients who selected brief self-care tips and interactive dietary education modules. Within each language group, we examined trends in patients' likelihood of selecting the messages over time. RESULTS: On average, Spanish-speaking patients selected self-care tips during 64% of their ATDM calls compared to 36% for English speakers (p < 0.0001). Spanish speakers also selected dietary education modules more often (52% versus 28%, p < 0.0001). Patients were less likely to select each type of message over the course of their participation in the study. However, after 12 months, most Spanish speakers and roughly one fourth of English speakers continued to select each message type. As a result, participants in both language groups received a substantial amount of patient education. CONCLUSIONS: Patients with diabetes are receptive to self-care and dietary education via ATDM. Spanish speakers especially are willing to use ATDM calls to access patient education.

The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction.

OBJECTIVE: To examine whether patients admitted for treatment of a myocardial infarction (MI) who live farther from their source of care are less likely to be followed in an outpatient clinic, and whether patients who receive follow-up care are less likely to die or to have a subsequent acute care admission. DATA SOURCE: Department of Veterans Affairs (VA) databases to identify a national sample of 4,637 MI patients discharged in 1992, their use of care, and vital status within the subsequent year. Sociodemographics, comorbid diagnoses, invasive cardiac procedures, hospital teaching status, and distance to patients' admitting hospital were determined. STUDY DESIGN: Using these longitudinal data, we examined the relationship between patient characteristics, distance to care, and use of outpatient care after discharge. We then examined the relationship between the use of ambulatory care and subsequent death and readmission. PRINCIPAL FINDINGS: Patients living more than 20 miles from their admitting hospital were less likely to use ambulatory services. Patients receiving ambulatory care were 79 percent as likely to die within the year as those without any follow-up care (95% C.I. = 0.66, 0.94). Patients living more than 20 miles from their admitting hospital were more likely to die independent of their likelihood of receiving VA outpatient follow-up. Among patients who did not die in the subsequent year, those receiving ambulatory care were 33 percent more likely to be readmitted to a VA hospital with a cardiac diagnosis (95% C.I. = 1.12, 1.57). CONCLUSIONS: Distance may pose a barrier to outpatient follow-up for some VA patients after a MI. It also may limit patients' ability to access medical care quickly in the event of a recurrent acute event. Ambulatory care after discharge may be an important factor determining survival for patients with cardiac disease.

Interactive voice response systems in the diagnosis and management of chronic disease.

OBJECTIVE: To assess the feasibility, reliability, validity, and potential clinical impact of interactive voice response (IVR) systems in the diagnosis and management of chronic disease. STUDY DESIGN: Literature review. RESULTS: Interactive voice response assessment systems have been implemented in the treatment of patients with chronic health problems such as heart failure, diabetes, hypertension, and mental health disorders. The information patients report during IVR assessments is at least as reliable as information obtained via structured clinical interviews or medical record reviews. Patients often are more inclined to report health problems to an IVR system than directly to a clinician. The few outcome evaluations of IVR-supported chronic illness management services indicate that they can have moderate impacts on some health and health behavior outcomes. CONCLUSIONS: Future research should evaluate the extent to which IVR assessment data can improve the prediction of clinical problems over and above what is possible using data usually available to primary care providers. Studies also should evaluate the outcomes of IVR-supported chronic disease management and the use of IVR assessments to measure variation in patient-centered treatment outcomes.

Moving diabetes management from clinic to community: development of a prototype based on automated voice messaging.

The purpose of this study is twofold. First, it provides a review of the literature supporting the development of a new service to help patients with diabetes and their providers manage their care. This service, automated voice messaging (AVM) with nurse follow-up, allows for systematic and intensive patient monitoring and diabetes education as well as a means of focusing clinical resources where they are most needed. Second, it provides a description of a prototype AVM-based diabetes management service that has been developed as part of two ongoing, randomized, controlled trials to test the efficacy of AVM care for patients with Type 2 diabetes. Preliminary findings from implementing this service in two large public healthcare systems suggest that AVM-supported care is feasible, desirable by clinicians and patients with diabetes, and may identify serious health problems that otherwise would go unnoted through standard means of clinic-based patient care.

Satisfaction with automated telephone disease management calls and its relationship to their use.

PURPOSE: This paper reports the results of an assessment of automated telephone disease management (ATDM) among patients in 2 randomized trials evaluating ATDM as an adjunct to usual care. METHODS: During the 12-month follow-up interview, 256 low-income adults with diabetes from the intervention groups of 2 randomized trials were asked to respond to questions about their satisfaction with the ATDM process. Variation in satisfaction was examined across groups, and satisfaction reports were correlated with the extent to which patients completed ATDM assessments and used them to report glycemic levels or access educational messages. RESULTS: Overall, 85% of patients reported that they were satisfied with the ATDM calls, 82% reported that they would be more satisfied with their health care if such calls were available to patients, and 76% reported that they personally would choose to receive such calls in the future. Most patients reported few difficulties completing ATDM assessments and found the calls to be a useful adjunct to their care. Some, however, found the calls intrusive; 16% reported that the calls were a bother. CONCLUSIONS: Patients were satisfied with ATDM calls as part of their diabetes care. Satisfaction played some part in determining patients' use of ATDM assessment and health education, although other barriers also contributed to less than optimal usage rates.

The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management?

BACKGROUND: The RE-AIM framework is used as a method of systematically considering the strengths and weaknesses of chronic illness management interventions in order to guide program planning. METHOD: The RE-AIM dimensions of Reach, Efficacy, Adoption, Implementation, and Maintenance are used to rate one-on-one counseling interventions, group sessions, interactive computer-mediated interventions, telephone calls, mail interventions, and health system policies. RESULTS: The RE-AIM ratings suggest that, although often efficacious for those participating, traditional face-to-face intervention modalities will have limited impact if they cannot be delivered consistently to large segments of the target population. Interventions using new information technologies may have greater reach, adoption, implementation, and maintenance, and thereby greater public health impact. Policy changes received high ratings across a variety of RE-AIM dimensions. CONCLUSIONS: Program planners should make decisions regarding implementing and funding health services based on multiple dimensions, rather than only considering efficacy in randomized clinical trials. Doing so may improve the resulting public health impact. Directions for future chronic illness management research related to RE-AIM, and implications for decision making, are described.

First-time admissions with alcohol-related medical problems: a 10-year follow-up of a national sample of alcoholic patients.

OBJECTIVE: We estimated the rate of first-time hospital admission over 10 years with alcohol-related medical problems among a large national sample of patients with diagnosed alcohol abuse disorders. METHOD: We identified a nationwide cohort of all patients (N = 46,680) discharged in 1980 from all Department of Veterans Affairs (VA) medical centers with alcohol-related diagnoses. Two comparison cohorts also were identified: patients with musculoskeletal disorders (N = 18,231) and a random sample of nonalcoholic patients (N = 45,204). Using secondary databases, ICD-9-CM coded diagnostic information was collected for all VA inpatient admissions these patients experienced over the decade following their index hospitalizations. Admission rates within age strata and age/race standardized rates were computed. Adjusted rate ratios were estimated using Poisson regression. RESULTS: Alcoholic patients were at substantial risk of admission for multiple medical disorders. Admission rates varied for patients of different ages. Those who were between 50 and 59 years of age during their index hospital stay were at the highest risk of admission with an alcohol-related medical disease over the subsequent decade. CONCLUSIONS: The admission rates for these medical disorders among alcoholic patients provide an important baseline estimate of individual patients' risk profiles and may help providers set priorities among diagnostic tests.

Sampling and accessing people with AIDS. Implications for program evaluation.

This article describes issues that arose in attempting to conduct a survey of people with acquired immune deficiency syndrome (AIDS) as part of an evaluation of a program to deliver health and social services to this population. Demands to maintain the confidentiality of people with human immunodeficiency virus (HIV) infection posed a large impediment to randomly sampling and accessing program recipients. Efforts to contact people with AIDS through the mediation of health service providers encountered problems of nonimplementation and slow accrual. Comparisons of the obtained sample with a more comprehensive data base of program clients suggest that clients who were more accessible and compliant were overrepresented in the sample. People with AIDS themselves, however, were willing to be interviewed, as demonstrated by refusal rates less than 11%. Future studies of people with AIDS must overcome direct service providers' lack of time to contact and recruit respondents; it may be wise to allocate funds to support recruitment activities conducted by an administrative staff person in the service delivery agency.