[Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings]. Cost-effectiveness of screening and optimal management for diabetes, hypertension, and chronic kidney disease: a modeled analysis. Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol An ICT-Based Diabetes Management System Tested for Health Care Delivery in the African Context Impact of care management processes and integration of care on blood pressure control in diabetes The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial Diabetes decision support: initial experience with the Vermont diabetes information system. Disease management for co-morbid depression and anxiety in diabetes mellitus: design of a randomised controlled trial in primary care Development and evaluation of a Computer-Assisted Management Protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial Readiness of Ugandan health services for the management of outpatients with chronic diseases Collaborative care for patients with depression and chronic illnesses. The Indiana Chronic Disease Management Program. Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors The Cholesterol, Hypertension, and Glucose Education (CHANGE) study for African Americans with diabetes: study design and methodology. Developing ‘high impact’ guideline-based quality indicators for UK primary care: a multi-stage consensus process Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: A pilot study Building equity in chronic disease management in Thailand: a whole-system provincial trial of systematic, pro-active chronic illness care
UNLABELLED This review should be cited as : Renders CM , Valk GD , Griffin S. Wagner EH , Eijk JThM van , Assendelft WJJ . Interventions to improve the management of  diabetes mellitus  in primary care , outpatient and community setting s ( Cochrane Review ) . In : The Cochrane Library , Issue 2 , 2001 . Oxford : Up date Software . A substantive amendment to this systematic review was last made on 29 June 2000 . Cochrane review s are regularly checked and up date d if necessary . BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care . Different systems have been proposed to manage diabetes care . OBJECTIVES To assess the effects of different interventions , targeted at health professionals or the structure in which they deliver care , on the management of patients with diabetes in primary care , outpatient and community setting s. SEARCH STRATEGY We search ed the Cochrane Effective Practice and Organisation of Care Group specialised register , the Cochrane Controlled Trials Register ( Issue 4 1999 ) , MEDLINE ( 1966 - 1999 ) , EMBASE ( 1980 - 1999 ) , Cinahl ( 1982 - 1999 ) , and reference lists of articles . SELECTION CRITERIA R and omised trials ( RCTs ) , controlled clinical trials ( CCTs ) , controlled before and after studies ( CBAs ) and interrupted time series ( ITS ) analyses of professional , financial and organisational strategies aim ed at improving care for people with Type 1 or Type 2 diabetes . The participants were health care professionals , including physicians , nurses and pharmacists . The outcomes included objective ly measured health professional performance or patient outcomes , and self-report measures with known validity and reliability . DATA COLLECTION AND ANALYSIS Two review ers independently extracted data and assessed study quality . MAIN RESULTS Forty-one studies were included involving more than 200 practice s and 48,000 patients . Twenty-seven studies were RCTs , 12 were CBAs , and two were ITS . The studies were heterogeneous in terms of interventions , participants , setting s and outcomes . The method ological quality of the studies was often poor . In all studies the intervention strategy was multifaceted . In 12 studies the interventions were targeted at health professionals , in nine they were targeted at the organization of care , and 20 studies targeted both . In 15 studies patient education was added to the professional and organisational interventions . A combination of professional interventions improved process outcomes . The effect on patient outcomes remained less clear as these were rarely assessed . Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes . Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes . REVIEW ERS ' CONCLUSION : Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .  Organisational interventions that improve regular prompted recall and review of patients  ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management . The addition of patient-oriented interventions can lead to improved patient health outcomes . Nurses can play an important role in patient-oriented interventions , through patient education or facilitating adherence to treatment OBJECTIVES Chronic kidney disease is , increasingly , both a contributor to premature deaths and a financial burden to the health system , and is estimated to affect between 10 % and 15 % of the adult population in Western countries . Hypertension and , in particular diabetes , are significant contributors to the global burden of chronic kidney disease . Although it might increase costs , screening for , and improved management of , persons at increased risk of progressive kidney disease could improve health outcomes . We therefore sought to estimate the costs and health outcomes of alternative strategies to prevent end-stage kidney disease , compared with usual care . METHODS A Markov model comparing : 1 ) intensive management versus usual care for patients with suboptimally managed diabetes and hypertension ; and 2 ) screening for and intensive treatment of diabetes , hypertension , and proteinuria versus usual care was developed . Intervention effectiveness was based on published meta-analyses and r and omized controlled trial data ; costs were measured from a central health-care funder perspective in 2008 Australian dollars ( $ A ) , and outcomes were reported in quality -adjusted life-years ( QALYs ) . RESULTS Intensive treatment of inadequately controlled diabetes was both less costly ( an average lifetime saving of $ A133 ) and more effective ( with an additional 0.075 QALYs per patients ) than conventional management . Intensive management of hypertension had an incremental cost-effectiveness ratio ( ICER ) $ A2588 per QALY gained . Treating all known diabetics with angiotensin-converting enzyme ( ACE ) inhibitors was both less costly ( an average lifetime saving of $ A825 per patient ) and more effective than current treatment ( result ing in 0.124 additional QALYs per patient ) . Primary care screening for 50- to 69-year-olds plus intensive treatment of diabetes had an ICER of $ A13,781 per QALY gained . Primary care screening for hypertension ( between ages 50 and 69 years ) plus intensive blood pressure management had an ICER of $ A491 per QALY gained . Primary care screening for proteinuria ( between ages 50 and 69 years ) combined with prescription of an ACE inhibitor for all persons showing proteinuria and all known diabetics had an ICER of $ A4793 per QALY gained . CONCLUSIONS Strategies combining primary care screening of 50- to 69-year-olds for proteinuria , diabetes , and hypertension followed by the routine use of ACE inhibitors , and optimal treatment of diabetes and hypertension , respectively , have the potential to reduce death and end-stage kidney disease and are likely to represent good value for money Background Chronic diseases represent a major challenge for health care and social services . A number of people with chronic diseases require more services due to characteristics that increase their vulnerability . Given the burden of increasingly vulnerable patients on primary care , a pragmatic intervention in four Family Medicine Groups ( primary care practice s in Quebec , Canada ) has been proposed for individuals with chronic diseases ( diabetes , cardiovascular diseases , respiratory diseases , musculoskeletal diseases and /or chronic pain ) who are frequent users of hospital services . The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program . The goals of this study are to : ( 1 ) analyze the implementation of the intervention in the participating practice s in order to determine how the various context s have influenced the implementation and the observed effects ; ( 2 ) evaluate the proximal ( self-efficacy , self-management , health habits , activation and psychological distress ) and intermediate ( empowerment , quality of life and health care use ) effects of the intervention on patients ; ( 3 ) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention . Methods / Design The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders ( Family Medicine Group and health centre management , Family Medicine Group practitioners , patients and their families , health centre or community partners ) . The data will be obtained through individual and group interviews , project documentation review s and by documenting the intervention . Evaluation of the effects on patients will be based on a pragmatic r and omized before-after experimental design with a delayed intervention control group ( six months ) . Economic analysis will include cost-effectiveness and cost-benefit analysis . Discussion The integration of a case management intervention delivered by nurses and self-management group support into primary care practice s has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care . Decision-makers , managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practice s in the region and elsewhere . Trial Registration Background Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation . There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient population s , but little consensus concerning the optimal model that would best provide such support . We describe the implementation and evaluation of self-management support through an evidence -based ' whole systems ' model involving patient support , training for primary care teams , and service re-organisation , all integrated into routine delivery within primary care . Methods The evaluation involves a large-scale , multi-site study of the implementation , effectiveness , and cost-effectiveness of this model of self-management support using a cluster r and omised controlled trial in patients with three long-term conditions of diabetes , chronic obstructive pulmonary disease ( COPD ) , and irritable bowel syndrome ( IBS ) . The outcome measures include healthcare utilisation and quality of life . We describe the methods of the cluster r and omised trial . Discussion If the ' whole systems ' model proves effective and cost-effective , it will provide decision-makers with a model for the delivery of self-management support for population s with long-term conditions that can be implemented widely to maximise ' reach ' across the wider patient population .Trial registration numberIS RCT N : IS RCT The dem and for new healthcare services is growing rapidly . Improving accessibility of the African population to diabetes care seems to be a big challenge in most countries where the number of care centers and medical staff is reduced . Information and communication technologies ( ICT ) have great potential to address some of these challenges faced by several countries in providing accessible , cost-effective , and high- quality health care services . This paper presents the Mobil Diab system which is a telemedical approach proposed for the management of long-term diseases . The system applies modern mobile and web technologies which overcome geographical barriers , and increase access to health care services . The idea of the system is to involve patients in the therapy process and motivate them for an active participation . For validation of the system in African context , a trial was conducted in the Democratic Republic of Congo . 40 Subjects with diabetes divided r and omly into control and intervention groups were included in the test . Results show that Mobil Diab is suitable for African countries and presents a number of benefits for the population and public health care system . It improves clinical management and delivery of diabetes care services by enhancing access , quality , motivation , reassurance , efficiency , and cost-effectiveness Background Fragmentation within health care systems may negatively impact the quality of chronic disease patient care . We sought to evaluate the relationship between care management processes ( CMP ) , integration of services , and blood pressure  (  BP  ) control among diabetic patients . Methods Retrospective chart review s were performed for a r and om sample of adult diabetic hypertensive patients ( n = 2,162 ) from 28 physician organizations in the United States ( US ) . A modified version of the Physician Practice Connection Readiness Survey ( PPC-RS ) was completed by the chief medical officer at each site . The PPC-RS measured health system organization , delivery system re design , decision support , clinical information systems , and self-management support , and an integration scale measured structure , functions , and financial risk . Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients . Results Approximately 39.9 % of diabetic patients had controlled  BP . Mean total PPC score across sites was 55 , with highest mean scores for health system organization ( 81 ) , followed by design support ( 60 ) , clinical information systems ( 57 ) , self-management support ( 39 ) , and delivery system re design ( 39 ) . Mean integration score was 46 ( SD 27 , range 4–93 ) , and means of subscores were 64 for structure , 33 for financial risk , and 42 for function . Clinical information systems subscore was correlated with uncontrolled BP ( r = −0.38 , p < 0.05 ) , while association with total PPC score was strong but not significant at p < 0.05 ( r = −0.32 ) . Total integration score and the structure subscore were significantly correlated with BP control ( r = 0.38 , p < 0.05 , and r = 0.49 , p < 0.01 ) . Conclusions This study suggests that CMP and service integration may be associated with better outcomes in diabetes , though results were mixed and limited by a small number of participating sites . Primary care implementation of integrated electronic medical records may have a beneficial effect on patient outcomes for diabetes and other chronic diseases OBJECTIVE The Mayo Health System Diabetes Translation Project sought to assess models of community-based diabetes care and use of a diabetes electronic management system ( DEMS ) . Planned care is a re design ed model of chronic disease care that involves guideline implementation , support of self-management , and use of clinical information systems . RESEARCH DESIGN AND METHODS We studied adult diabetic patients attending three primary care practice sites in Wisconsin and Minnesota . We implemented planned care at all sites and DEMS in the practice of 16 primary care providers . We assessed quality of diabetes care using st and ard indicators for 200 patients r and omly selected from each site at baseline and at 24 months of implementation . We used multivariable analyses to estimate the association between planned care and DEMS and each quality indicator . RESULTS Planned care was associated with improvements in measurement of HbA(1c ) ( odds ratio 7.0 [ 95 % CI 4.2 - 11.6 ] ) , HDL cholesterol ( 5.6 [ 4.1 - 7.5 ] ) , and microalbuminuria ( 5.3 [ 3.5 - 8.0 ] ) , as well as the provision of tobacco advice ( 6.9 [ 4.7 - 10.1 ] ) , among other performance measures . DEMS use was associated with improvements in all indicators , including microalbuminuria ( 3.2 [ 1.9 - 5.2 ] ) , retinal examination ( 2.4 [ 1.5 - 3.9 ] ) , foot examinations ( 2.3 [ 1.2 - 4.4 ] ) , and self-management support ( 2.6 [ 1.7 - 3.8 ] ) . Although planned care was associated with improvements in metabolic control , we observed no additional metabolic benefit when providers used DEMS . CONCLUSIONS Planned care was associated with improved performance and metabolic outcomes in primary care . DEMS use augmented the impact of planned care on performance outcomes but not on metabolic outcomes . Optimal identification of the best translation of evidence to diabetes practice will require longer follow-up or new care-delivery models PURPOSE The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes , particularly those physicians not affiliated with an integrated care system that some managed care organizations provide . METHODS Patients with type 2 diabetes were recruited from the general population of a large metropolitan area . Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians ( basic intervention ) . A r and om one-half of patients were additionally assigned to individual counseling , problem identification , care planning , and management recommendations by a nurse care manager ( individualized intervention ) . The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention . Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C , blood pressure , and cholesterol as outcome measures . RESULTS Of 220 patients recruited , 197 had type 2 diabetes , r and omly assigned only the basic intervention ( 102 patients ) or individualized intervention ( 95 patients ) . Postintervention data were obtained on 164 patients ( 83 % ) . Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group . Patients with a systolic blood pressure > or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts . CONCLUSIONS A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes . For those many physicians not affiliated with an integrated care system featured by some managed care organizations , this collaboration could underlie a team approach ( nurse/patient/physician ) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : Interventions that have proven effective in the management of chronic illness have often been difficult to establish in widespread practice . The Chronic Care Model provides a framework for implementing interventions , but it is expensive and difficult to implement . We developed a decision support system based on this model to improve the care of adults who have diabetes and receive primary care in Vermont or adjacent New York . The Vermont Diabetes Information System uses a network of community laboratories for providing data to produce flowsheets , reminders , action alerts , and population reports that are sent to primary care providers by fax and to patients by mail . Currently , 7295 patients are cared for by 124 primary care providers in 62 practice s and are enrolled in a r and omized controlled trial to study its effects Background Depression and anxiety are common co-morbid health problems in patients with type 2 diabetes . Both depression and anxiety are associated with poor glycaemic control and increased risk of poor vascular outcomes and higher mortality rates . Results of previous studies have shown that in clinical practice , treatment of depression and anxiety is far from optimal as these symptoms are frequently overlooked and undertreated . Methods / Design This r and omised controlled trial will examine the effectiveness of a disease management programme treating symptoms of depression and anxiety  in primary care patients with Type 2 diabetes . Patients will be r and omized on patient level in 1:1 ratio . R and om block sizes of 2 and 4 are used . The disease management programme consists of screening , stepped treatment and monitoring of symptoms ( n = 80 ) . This will be compared to care as usual ( n = 80 ) . Discussion The disease management model for co-morbid depression and anxiety in primary care patients with diabetes is expected to result in reduced symptoms of depression and anxiety , improved quality of life , reduced diabetes specific distress and improved glyceamic control , compared to care as usual . Trial Registration Dutch Trial Register Disease-specific st and ards for directing patient management are becoming increasingly important . These st and ards , however , are often not followed because they are not sufficiently integrated into the clinical care setting . In this study we describe the development and evaluation of a Computer-Assisted Management Protocol ( CAMP ) of care guidelines for diabetes mellitus . While other studies have shown improved compliance with rule-based reminders , the CAMP customizes disease-specific care guidelines to individual patients over time . We evaluated the effect of the CAMP on compliance with guidelines in a prospect i ve , r and omized controlled study . The study was performed at a family practice clinic where much of the patient record is maintained electronically on The Medical Record ( TMR ) . The management protocol was developed from st and ards published by the American Diabetes Association . Fifty-eight providers were r and omized to either receive or not receive the CAMP for diabetes . Compliance with st and ards  was assessed by chart audits of all encounters with diabetic patients during the study interval . The following conclusion was made : the Computer-Assisted Management Protocol result ed in a statistically significant improvement in compliance with diabetes care st and ards OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model ( CCM ) . PARTICIPANTS AND METHODS As part of the CCM , 97 primary care physicians at 6 primary care practice s in Rochester , MN , referred 639 patients to an on-site diabetes educator between July 1 , 2001 , and December 31 , 2003 . On first referral , physicians were central ly r and omized to receive a telemedicine intervention ( specialty advice and evidence -based messages regarding medication management for cardiovascular risk ) or no intervention , keeping outcome assessors and data analysts blinded to group assignment . After each subsequent clinical encounter , endocrinologists review ed an abstract from the patient 's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail . Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes . Outcome measures included diabetes care processes ( diabetes test completion ) , outcomes ( metabolic and cardiovascular risk factors , estimated coronary artery disease risk ) , and patient costs ( payer perspective ) . RESULTS During the intervention , 951 ( 70 % ) of the 1361 endocrinology review s detected performance gaps and result ed in a message ; primary care physicians reported using 49 % of messages in patient care . With a mean of 21 months ' follow-up , the intervention , compared with control , did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease ( adjusted mean difference , -1 % ; 95 % confidence interval , -19 % to 17 % ) . The intervention group incurred lower costs ( P=.02 ) but not in diabetes-related costs . CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care ABSTRACT Background : Cardiovascular diseases and diabetes are among the leading causes of premature adult deaths in India . Innovative approaches such as clinical decision support ( CDS ) software could play a major role in improving the quality of hypertension/diabetes care in primary care setting s. Objective : To describe the steps and processes in the development of mWellcare , a complex intervention based on mobile health ( mHealth ) technology . Methods : The Medical Research Council framework was used to develop mWellcare in four steps : ( 1 ) identify gaps in usual care through literature review and health facility assessment s ; ( 2 ) identify the components of the intervention through discussion s and consultations with experts ; ( 3 ) develop intervention ( clinical algorithms and mHealth system ) ; and ( 4 ) evaluate acceptability and feasibility through pilot testing in five community health centers . Results : Lack of evidence -based , integrated , and systematic management of chronic conditions were major gaps identified . Experts in information technology , clinical fields , and public health professionals identified intervention components to address these gaps . Thereafter , clinical algorithm context ualized to primary care setting s were prepared and the mWellcare intervention was developed . During the 2-month pilot , 631 patients diagnosed with hypertension and /or diabetes were registered , with a follow-up rate of 36.2 % . The major barrier was resistance to follow mWellcare recommended patient workflow , and to overcome it , we emphasized onsite training and orientation program to cover all health care team member in each CHC . Conclusion : A pilot-tested mWellcare intervention is an mHealth system with important components , i.e. integrated management of chronic conditions , evidence -based CDS , longitudinal health data and automated short-messaging service to reinforce compliance to drug intake and follow-up visit , which will be used by nurses at primary health care setting s in India . The effectiveness and cost-effectiveness of the intervention will be tested through a cluster r and omized trial ( trial registration number NCT02480062 ) Background : The burden of noncommunicable diseases and their risk factors has rapidly increased worldwide , including in India .  Innovative management strategies with electronic decision support and task sharing have been assessed for hypertension , diabetes mellitus , and depression individually , but an integrated package for multiple chronic condition management in primary care has not been evaluated . Methods : In a prospect i ve , multicenter , open-label , cluster-r and omized controlled trial involving 40 community health centers , using hypertension and diabetes mellitus as entry points , we evaluated the effectiveness of mWellcare , an mHealth system consisting of electronic health record storage and an electronic decision support for the integrated management of 5 chronic conditions ( hypertension , diabetes mellitus , current tobacco and alcohol use , and depression ) versus enhanced usual care among patients with hypertension and diabetes mellitus in India . At trial end ( 12-month follow-up ) , using intention-to-treat analysis , we examined the mean difference between arms in change in systolic blood pressure and glycated hemoglobin as primary outcomes and fasting blood glucose , total cholesterol , predicted 10-year risk of cardiovascular disease , depression score , and proportions reporting tobacco and alcohol use as secondary outcomes . Mixed-effects regression models were used to account for clustering and other confounding variables . Results : Among 3698 enrolled participants across 40 clusters ( mean age , 55.1 years ; SD , 11 years ; 55.2 % men ) , 3324 completed the trial . There was no evidence of difference between the 2 arms for systolic blood pressure ( & Dgr;=−0.98 ; 95 % CI , −4.64 to 2.67 ) and glycated hemoglobin ( & Dgr;=0.11 ; 95 % CI , −0.24 to 0.45 ) even after adjustment of several key variables ( adjusted differences for systolic blood pressure : – 0.31 [ 95 % CI , −3.91 to 3.29 ] ; for glycated hemoglobin : 0.08 [ 95 % CI , −0.27 to 0.44 ] ) . The mean within-group changes in systolic blood pressure in mWellcare and enhanced usual care were −13.65 mm Hg versus −12.66 mm Hg , respectively , and for glycated hemoglobin were −0.48 % and −0.58 % , respectively . Similarly , there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes . Conclusions : We did not find an incremental benefit of mWellcare over enhanced usual care in the management of the chronic conditions studied . Clinical Trial Registration : URL : https://www . clinical trials.gov . Unique identifier : NCT02480062 Abstract Objective Traditionally , health systems in sub‐Saharan Africa have focused on acute conditions . Few data exist on the readiness of African health facilities ( HFs ) to address the growing burden of chronic diseases ( CDs ) , specifically chronic , non‐communicable diseases ( NCDs ) . Methods A stratified r and om sample of 28 urban and rural Ug and an HFs was surveyed to document the burden of selected CDs by analysing the service statistics , service availability and service readiness using a modified WHO Service Availability and Readiness Assessment question naire . Knowledge , skills and practice in the management of CDs of 222 health workers were assessed through a self‐completed question naire . Results Among adult outpatient visits at hospitals , 33 % were for CDs including HIV vs. 14 % and 4 % at medium‐sized and small health centres , respectively . Many HFs lacked guidelines , diagnostic equipment and essential medicines for the primary management of CDs ; training and reporting systems were weak . Lower‐level facilities routinely referred patients with hypertension and diabetes . HIV services accounted for most CD visits and were stronger than NCD services . Systems were weaker in lower‐level HFs . Non‐doctor clinicians and nurses lacked knowledge and experience in NCD care . Conclusion Compared with higher level HFs , lower‐level ones are less prepared and little used for CD care . Health systems in Ug and a , particularly lower‐level HFs , urgently need improvement in managing common NCDs to cope with the growing burden . This should include the provision of st and ard guidelines , essential diagnostic equipment and drugs , training of health workers , supportive supervision and improved referral systems . Substantially better HIV basic service readiness demonstrates that improved NCD care is feasible BACKGROUND Patients with depression and poorly controlled diabetes , coronary heart disease , or both have an increased risk of adverse outcomes and high health care costs . We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients . METHODS We conducted a single-blind , r and omized , controlled trial in 14 primary care clinics in an integrated health care system in Washington State , involving 214 participants with poorly controlled diabetes , coronary heart disease , or both and coexisting depression . Patients were r and omly assigned to the usual-care group or to the intervention group , in which a medically supervised nurse , working with each patient 's primary care physician , provided guideline -based , collaborative care management , with the goal of controlling risk factors associated with multiple diseases . The primary outcome was based on simultaneous modeling of glycated hemoglobin , low-density lipoprotein ( LDL ) cholesterol , and systolic blood-pressure levels and Symptom Checklist-20 ( SCL-20 ) depression outcomes at 12 months ; this modeling allowed estimation of a single overall treatment effect . RESULTS As compared with controls , patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels ( difference , 0.58 % ) , LDL cholesterol levels ( difference , 6.9 mg per deciliter [ 0.2 mmol per liter ] ) , systolic blood pressure ( difference , 5.1 mm Hg ) , and SCL-20 depression scores ( difference , 0.40 points ) ( P<0.001 ) . Patients in the intervention group also were more likely to have one or more adjustments of insulin ( P=0.006 ) , antihypertensive medications ( P<0.001 ) , and antidepressant medications ( P<0.001 ) , and they had better quality of life ( P<0.001 ) and greater satisfaction with care for diabetes , coronary heart disease , or both ( P<0.001 ) and with care for depression ( P<0.001 ) . CONCLUSIONS As compared with usual care , an intervention involving nurses who provided guideline -based , patient-centered management of depression and chronic disease significantly improved control of medical disease and depression . ( Funded by the National Institute of Mental Health ; Clinical Trials.gov number , NCT00468676 . ) The  Indiana Chronic Disease Management Program ( ICDMP ) is intended to improve the quality and cost-effectiveness of care for Medicaid members with congestive heart failure ( chronic heart failure ) , diabetes , asthma , and other conditions . The ICDMP is being assembled by Indiana Medicaid primarily from state and local re sources and has seven components : ( 1 ) identification of eligible participants to create regional registries , ( 2 ) risk stratification of eligible participants , ( 3 ) nurse care management for high-risk participants , ( 4 ) telephonic intervention for all participants , ( 5 ) an Internet-based information system , ( 6 ) quality improvement collaboratives for primary care practice s , and ( 7 ) program evaluation . The evaluation involves a r and omized controlled trial in two inner-city group practice s , as well as a statewide observational design . This article describes the ICDMP , highlights challenges , and discusses approaches to its evaluation PURPOSE New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients . This study ( 1 ) assessed whether chronic disease management differed among 4 models of primary health care delivery and ( 2 ) identified which practice organizational factors were independently associated with high- quality care . METHODS We undertook a cross-sectional survey with nested qualitative case studies ( 2 practice s per model ) in 137 r and omly selected primary care practice s from 4 delivery models in Ontario Canada : fee for service , capitation , blended payment , and community health centers ( CHCs ) .  Practice and clinician surveys were based on the Primary Care Assessment Tool . A chart audit assessed evidence -based care delivery for patients with diabetes , congestive heart failure , and coronary artery disease .  Intermediate outcomes were calculated for patients with diabetes and hypertension . Multiple linear regression identified those organizational factors independently associated with chronic disease management . RESULTS Chronic disease management was superior in CHCs . Clinicians in CHCs found it easier than those in the other models to promote high- quality care through longer consultations and interprofessional collaboration . Across the whole sample and independent of model , high- quality chronic disease management was associated with the presence of a nurse-practitioner . It was also associated with lower patient-family physician ratios and when practice s had 4 or fewer full-time-equivalent family physicians . CONCLUSIONS The study adds to the literature supporting the value of nurse-practitioners within primary care teams and vali date s the contributions of Ontario ’s CHCs . Our observation that quality of care decreased in larger , busier practice s suggests that moves toward larger practice s and greater patient-physician ratios may have unanticipated negative effects on processes of care quality BACKGROUND Cardiovascular disease ( CVD ) and diabetes account for over one third of the mortality difference between African Americans and white patients . The increased CVD risk in African Americans is due in large part to the clustering of multiple CVD risk factors . OBJECTIVES The current study is aim ed at improving CVD outcomes in African-American adults with diabetes by addressing the modifiable risk factors of systolic blood pressure , glycosylated hemoglobin , and low-density lipoprotein cholesterol . METHODS A sample of African American patients with diabetes ( N = 400 ) will receive written education material at baseline and be r and omized to one of 2 arms : ( 1 ) usual primary care or ( 2 ) nurse-administered disease-management intervention combining patient self-management support and provider medication management . The nurse administered intervention is delivered monthly over the telephone . The nurses also interacts with the primary care providers at 3 , 6 , and 9 months to provide concise patient up date s and facilitate changes in medical management . All patients are followed for 12 months after enrollment . The primary outcomes are change in glycosylated hemoglobin , systolic blood pressure , and low-density lipoprotein cholesterol over 12-months . Secondary outcomes include change in overall cardiovascular risk , aspirin use , and health behaviors . CONCLUSION Given the continued racial disparities in CVD , the proposed study could result in significant contributions to cardiovascular risk reduction in African-American patients Background  Quality indicators ( QIs ) are an important tool for improving clinical practice and are increasingly being developed from evidence -based guideline recommendations . We aim ed to identify , select and apply guideline recommendations to develop a set of QIs to measure the implementation of evidence -based practice using routinely recorded clinical data in United Kingdom ( UK ) primary care . Methods We review ed existing national clinical guidelines and QIs and used a four-stage consensus development process to derive a set of ‘ high impact ’ QIs relevant to primary care based upon explicit prioritisation criteria . We then field tested the QIs using remotely extracted , anonymised patient records from 89 r and omly sample d primary care practice s in the Yorkshire region of Engl and . Results Out of 2365 recommendations and QIs originally review ed , we derived a set of 18 QIs ( 5 single , 13 composites – comprising 2–9 individual recommendations ) for field testing . QIs predominantly addressed chronic disease management , in particular diabetes , cardiovascular and renal disease , and included both processes and outcomes of care . Field testing proved to be critical for further refinement and final selection . Conclusions We have demonstrated a rigorous and transparent methodology to develop a set of high impact , evidence -based QIs for primary care from clinical guideline recommendations . While the development process was successful in developing a limited set of QIs , it remains challenging to derive robust new QIs from clinical guidelines in the absence of established systems for routine , structured recording of clinical care There continues to be a need for improved medical management of diabetes patients with hypertension in primary care . While several care models have shown effectiveness in achieving various outcomes among these patients , it remains unclear what care model is most effective in improving blood pressure control in primary care . In this prospect i ve study , 54 patients with type 2 diabetes mellitus and blood pressure of > 140/90 identified through the registry , were r and omized into three groups . Group A attended a nurse educator-conducted class on diabetes and hypertension , group B attended the same class and was asked to monitor their home blood pressure using provided device , and group C served as control ( usual care ) . Of the 24 subjects who completed the study , only 20 % achieved the target blood pressure of < 130/80 and there was no statistical difference in mean systolic and diastolic blood pressures among the three groups ( p > 0.05 ) . Efforts to intensify management of hypertension among type 2 diabetes patients did not result in better blood pressure control compared to usual care . Studies looking into factors which limit patients ’ participation in group classes and determining patients ’ preferences in disease management would be helpful in ensuring success of any chronic disease management program Thail and has a history of implementing innovative and proactive policies to address the health needs of its population . Since 1962 Thail and has implemented initiatives that led to it having a health system characterized by a primary care focus , de central ization and mechanisms to maximize equity and universal access to basic care at the local level . Thai health structures initially evolved to meet challenges including infectious and developmental diseases and later HIV . Early in the 21st century chronic illness rapidly became the greatest cause of morbidity and mortality and the question has arisen how Thail and can adapt its strong health system to deal with the new epidemics . This article describes an effort to reorient provincial health services to meet the needs of the increasing number of people with diabetes and heart disease . It describes measures taken to build on the equity-promoting elements of the Thai health system . The project included ; a situational analysis , development and implementation of a chronic disease self-management intervention implemented by nurses and alignment of provincial health services . The self-management intervention is currently being evaluated within a clustered r and omized control trial . The evaluation has been developed to fit with the focus on equity in relation to both selection criteria and the outcomes that are being assessed
The effect on patient outcomes remained less clear as these were rarely assessed .
Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes .
Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes .
REVIEW ER 'S CONCLUSIONS Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .
Organisational interventions that improve regular prompted recall and review of patients ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management .
The addition of patient-oriented interventions can lead to improved patient health outcomes .
BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care .
Different systems have been proposed to manage diabetes care .