Medication reconciliation: comparing a customized medication history form to a standard medication form in a specialty clinic (CAMPII 2).

BACKGROUND: Medication history forms completed by patients are an essential part of the medication reconciliation process. OBJECTIVE: In a crossover prospective study, investigators compared the accuracy and acceptability of a "fill-in-the blank" medication history form (USUAL) to a customized form (CUSTOM) that contained a checklist of the 44 most frequently prescribed diabetes clinic medications. METHODS: The content of both forms was compared to a "gold-standard" medication list compiled by a clinical pharmacist who conducted a medication history and reviewed pharmacy profiles and medical chart. Subject preference and time to complete the forms were also determined. Accurate was defined as complete and correct (name, dose, and frequency) relative to the gold standard. RESULTS: A total of 77 subjects completed both forms. Complete list accuracy was poor; there was no difference in the accuracy between CUSTOM (6.5%) and USUAL (9.1%) (odds ratio [OR], 0.33; P = 0.62). Out of a total of 648 medications, subjects accurately listed 43.7% of medications on CUSTOM and 45.5% on USUAL (OR, 0.88; P = 0.41). The 44 medications on the checklist were more than twice as likely to be accurately reported using CUSTOM than with USUAL (OR, 2.1; P = 0.0002). More subjects preferred CUSTOM (65.7%) compared with USUAL (32.8%, P = 0.007). CONCLUSION: Medication self-report is very poor, and few subjects created an accurate list on either form. Subjects were more likely to report the drugs on the checklist using CUSTOM than when they used USUAL; however, there was no difference in the overall accuracy between CUSTOM and USUAL.

Conceptualizations of patient empowerment among individuals seeking treatment for diabetes mellitus in an urban, public-sector clinic.

OBJECTIVE: The patient empowerment paradigm has been promoted as a critical component of diabetes care. The present study explores how patients in an urban, public-sector clinic perceive patient empowerment as it applies to their treatment, interactions with clinicians, and self-care behaviors. METHODS: Semi-structured interviews were conducted with 29 individuals and analyzed through an inductive approach. RESULTS: Patient empowerment was described as taking responsibility for self-care behaviors. Participants reported they that must be internally driven to maintain their self-care regiment, and placed moral value on their performance. Some participants asked questions during healthcare encounters, but fewer reported setting the agenda or making meaningful decisions regarding their care. CONCLUSION: Gaps in individuals' perception of empowerment were identified, along with barriers such as frustration, fatigue, financial concerns, transportation, and scheduling difficulties. PRACTICE IMPLICATIONS: Increasing patient empowerment in socially disadvantaged settings will require careful communication to elicit questions, present all available treatment choices, and encourage individuals to take responsibility without placing blame on them for instances of poor glycemic control.

Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent population.

PURPOSE: The purpose of this study is to assess the validity of the patient activation construct as measured by the Patient Activation Measure (PAM) survey by correlating PAM scores with diabetes self-management behaviors, attitudes, and knowledge in a predominantly minority and uninsured population. METHODS: A convenience sample of patients presenting to an urban public hospital diabetes clinic was surveyed and contacted by phone 6 months later. The survey included questions about activation, health behaviors, and health care utilization. RESULTS: A total of 287 patients agreed to participate. Most were African American, female, and uninsured. Most respondents (62.2%) scored in the highest category of activation according to the PAM. Activated patients were more likely to perform feet checks, receive eye examinations, and exercise regularly. Activation was consistently associated with less reported difficulty in managing diabetes care but not with A1C knowledge. PAM scores at the initial interview were highly correlated with scores at 6-month follow-up. Activation level did not predict differences in health care utilization during the 6 months following the survey. CONCLUSIONS: Higher scores on the PAM were associated with higher rates of self-care behaviors and ease in managing diabetes; however, the indigent urban population reported higher activation scores than found in previous studies. The relationship between activation and outcomes needs to be explored further prior to expanding use of this measure in this patient population.

Use of a glucose algorithm to direct diabetes therapy improves A1C outcomes and defines an approach to assess provider behavior.

PURPOSE: The purpose of this study was to determine whether an algorithm that recommended individualized changes in therapy would help providers to change therapy appropriately and improve glycemic control in their patients. METHODS: The algorithm recommended specific doses of oral agents and insulin based on a patient's medications and glucose or A1C levels at the time of the visit. The prospective observational study analyzed the effect of the algorithm on treatment decisions and A1C levels in patients with type 2 diabetes. RESULTS: The study included 1250 patients seen in pairs of initial and follow-up visits during a 7-month baseline and/or a subsequent 7-month algorithm period. The patients had a mean age of 62 years, body mass index of 33 kg/m(2), duration of diabetes of 10 years, were 94% African American and 71% female, and had average initial A1C level of 7.7%. When the algorithm was available, providers were 45% more likely to intensify therapy when indicated (P = .005) and increased therapy by a 20% greater amount (P < .001). A1C level at follow-up was 90% more likelyto be <7% in the algorithm group, even after adjusting for differences in age, sex, body mass index, race, duration of diabetes and therapy, glucose, and A1C level at the initial visit (P < .001). CONCLUSIONS: Use of an algorithm that recommends patient-specific changes in diabetes medications improves both provider behavior and patient A1C levels and should allow quantitative evaluation of provider actions for that provider's patients.

An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8.

BACKGROUND: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control. METHODS: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). RESULTS: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both). CONCLUSIONS: Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.

Increasing patient empowerment and improving diabetes care by utilizing a computer-based patient "roadmap".

The 20.8 million Americans with diabetes are at risk of amputation, kidney failure, blindness, and death which could be decreased if glucose control were better. Patients need motivation and empowerment to perform the daily management of diabetes. We are using informatics to help them organize their questions for providers and to generate "road maps" of their progress and future directions of care.

An informatics-supported intervention improves diabetes control in a primary care setting.

Although research has shown that proper management of diabetes can improve outcomes, glucose control is worsening. This partly reflects the failure of providers to intensify diabetes therapy when indicated, termed clinical inertia. Our intervention used (a) decision support reminders which provided patient specific recommendations for management at each visit, and (b) computer generated provider specific feedback on performance. This intervention improved the frequency with which providers intensified the therapy and improved glycemic control.

Diabetes management by residents in training in a municipal hospital primary care site (IPCAAD 2).

PURPOSE: Since diabetes is largely a primary care problem but we know little about management by residents in training--the primary care practitioners of the future--we examined surrogate outcomes reflective of their performance. METHODS: A seven-week observational study was conducted in a typical training site- a municipal hospital internal medicine resident "continuity" (primary care) clinic in a large, academic, university-affiliated training program. We evaluated control of glucose, blood pressure, and lipids; screening for proteinuria; and use of aspirin relative to national standards. RESULTS: Five hundred fifty-six (556) patients were 72% female and 97% African-American, with mean age 63 years, duration of diabetes 12 years, and BMI 34 kg/m2. Patients were managed largely with diet alone (22%) or oral agents alone (40%); 7% used oral agents and insulin in combination, and 30% insulin alone. Hemoglobin A1c (mean 8.2%) was above goal (<7.0%) in 61% of patients. Low density lipoprotein cholesterol (mean 128 mg/dL) was above goal (<100) in 76% of patients, but high density lipoprotein (mean 53 mg/dL) was at goal in 46%, and triglycerides (mean 138 mg/dL) were at goal in 85%. Diastolic pressure (mean 75 mm Hg) was at goal (<85) in 77% of patients, but systolic pressure (mean 143) was at goal (<130) in only 25% of patients. An average of only 53% of the patients had urine protein screening per 12 months, and use of aspirin was documented for only 39% of patients. CONCLUSIONS: Patients with type 2 diabetes in a typical internal medicine resident primary care clinic frequently do not achieve national standard of care goals. Since skills and attitudes developed in residency are likely to carry over into later practice, local diabetes educators may need to work with medical faculty to develop new interventions to improve postgraduate medical education in diabetes management.

An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7.

OBJECTIVE: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.

Clinical inertia contributes to poor diabetes control in a primary care setting.

PURPOSE: The purpose of this study was to determine whether "clinical inertia"-inadequate intensification of therapy by the provider-could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. METHODS: In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. RESULTS: Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). CONCLUSIONS: Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

Little time for diabetes management in the primary care setting.

PURPOSE: This study was conducted to determine how time is allocated to diabetes care. METHODS: Patients with type 2 diabetes who were receiving care from the internal medicine residents were shadowed by research nurses to observe the process of management. The amount of time spent with patients and the care provided were observed and documented. RESULTS: The total time patients spent in the clinic averaged 2 hours and 26 minutes: 1 to 9 minutes waiting, 25 minutes with the resident, and 12 minutes with medical assistants and nurses. The residents spent an average of only 5 minutes on diabetes. Glucose monitoring was addressed in 70% of visits; a history of hypoglycemia was sought in only 30%. Blood pressure values were mentioned in 75% of visits; hemoglobin A1c (A1C) values were addressed in only 40%. The need for proper foot care was discussed in 55% of visits; feet were examined in only 40%. Although 65% of patients had capillary glucose levels greater than 150 mg/dL during the visit and their A1C averaged 8.9%, therapy was intensified for only 15% of patients. CONCLUSIONS: During a routine office visit in a resident-staffed general medicine clinic, little time is devoted to diabetes management. Given the time pressures on the primary care practitioner and the need for better diabetes care, it is essential to teach an efficient but systematic approach to diabetes care.

Utility of casual postprandial glucose levels in type 2 diabetes management.

OBJECTIVE: Because readily available glycemic indicators are needed to guide clinical decision-making for intensification of diabetes therapy, our goals were to define the relationship between casual postprandial plasma glucose (cPPG) levels and HbA(1c) in patients with type 2 diabetes and to determine the predictive characteristics of a convenient glucose cutoff. RESEARCH DESIGN AND METHODS: We examined the relationship between cPPG levels (1-4 h post meal) and HbA(1c) levels in 1,827 unique patients who had both determinations during a single office visit. RESULTS: The population studied was predominantly African American and middle-aged, with average cPPG of 201 mg/dl and HbA(1c) of 8.4%. The prevalence of HbA(1c) > or = 7.0% was 67% and HbA(1c) >6.5% was 77%. Overall, cPPG and HbA(1c) were linearly correlated (r = 0.63, P < 0.001). The correlation between cPPG and HbA(1c) was strongest in patients treated with diet alone (n = 348, r = 0.75, P < 0.001) and weaker but still highly significant for patients treated with oral agents (n = 610, r = 0.64, P < 0.001) or insulin (n = 869, r = 0.56, P < 0.001). A cutoff cPPG >150 mg/dl predicted an HbA(1c) level > or = 7.0% in the whole group, with a sensitivity of 78%, a specificity of 62%, and an 80% positive predictive value. The same cPPG cutoff of 150 mg/dl predicted an HbA(1c) level >6.5%, with a sensitivity of 74%, a specificity of 66%, and an 88% positive predictive value. CONCLUSIONS: When rapid-turnaround HbA(1c) determinations are not available, a single cPPG level >150 mg/dl may be used during a clinic visit to identify most inadequately controlled patients and allow timely intensification of therapy.

Rapid A1c availability improves clinical decision-making in an urban primary care clinic.

OBJECTIVE: Failure to meet goals for glycemic control in primary care settings may be due in part to lack of information critical to guide intensification of therapy. Our objective is to determine whether rapid-turnaround A1c availability would improve intensification of diabetes therapy and reduce A1c levels in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: In this prospective controlled trial, A1c was determined on capillary glucose samples and made available to providers, either during ("rapid") or after ("routine") the patient visit. Frequency of intensification of pharmacological diabetes therapy in inadequately controlled patients and A1c levels were assessed at baseline and after follow-up. RESULTS: We recruited 597 subjects. Patients were 79% female and 96% African American, with average age of 61 years, duration of diabetes 10 years, BMI 33 kg/m(2), and A1c 8.5%. The rapid and routine groups had similar clinical demographics. Rapid A1c availability resulted in more frequent intensification of therapy when A1c was >/=7.0% at the baseline visit (51 vs. 32% of patients, P = 0.01), particularly when A1c was >8.0% and/or random glucose was in the 8.4-14.4 mmol/l range (151-250 mg/dl). In 275 patients with two follow-up visits, A1c fell significantly in the rapid group (from 8.4 to 8.1%, P = 0.04) but not in the routine group (from 8.1 to 8.0%, P = 0.31). CONCLUSIONS: Availability of rapid A1c measurements increased the frequency of intensification of therapy and lowered A1c levels in patients with type 2 diabetes in an urban neighborhood health center.

The Improving Primary Care of African Americans with Diabetes (IPCAAD) project: rationale and design.

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.