Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study.

BACKGROUND: In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. METHODS: A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. RESULTS: During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). CONCLUSIONS: Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.

The efficacy of single pharmacist medication review among type II diabetic patients who take six chronic medications or more: a case-control study.

BACKGROUND: Pharmacist medication review has been implemented in many health organizations throughout the world in an attempt to alleviate the underlying risk of polypharmacy in elderly patients. These consultations are often frequent and prolonged, and are thus associated with increased costs. To date, data regarding the most effective way to utilize pharmacist consultations for the improvement of health status is scant. AIM: To evaluate the effectiveness of a single pharmacist consultation on changes in chronic medication regimes and on selected outcomes of diabetes 1-year after the consultation. METHODS: A case-control study included an intervention group of 740 patients who had pharmacist consultations and a reference group of 1476 matched patients who did not have a pharmacist consultation. 1-year outcome measures were compared including changes in medications, improved safety, and objective variables such as Hba1c, blood pressure, and lipid profile. RESULTS: In the pharmacist consultation group, there were significantly more treatment changes ([mean 1.5 vs. 0.7, p < 0.001 medications were stopped], and [mean 1.3 vs. 0.4, p < 0.05 medications were started]). Patient safety improved with a general reduction in opiates and benzodiazepines ([50.0% vs. 31.6%, p < 0.05 opioids were stopped] and [58.8% vs 43.8%, p < 0.001 benzodiazepines were stopped]). Sulfonylurea treatment reduced (10.7% vs. 3.6%, p < 0.05 patients who stopped Sulfonylurea) and Glucagon-like peptide-1 receptor agonists (GLP-1) increased (16.4% vs. 11.2%, p < 0.001 patients who started GLP-1). Additionally, HbA1c levels showed a small decrease in the pharmacist consultation group ([- 0.18 ± 1.11] vs. [- 0.051 ± 0.80], p = 0.0058) but no significant differences were found regarding blood pressure or lipids profile. CONCLUSION: A single pharmacist consultation beneficially impacted specific clinical and patient safety outcomes. Pharmacist consultations may thus help resolve polypharmacy complexities in primary care.

Standardized patient-based simulation training as a tool to improve the management of chronic disease.

INTRODUCTION: Patient education is a critical factor in the treatment of chronic disease because it reduces gaps in health care and disease management. We implemented different methods of physician training for patient education of asthma and compared the effects on patients' health. METHOD: Four interventions were administered to groups of primary care physicians in one health care maintenance organization. All physicians received a list of their patients who were classified with uncontrolled asthma. Additional educational methods were implemented as follows: no additional intervention (group 1); lectures on patient education (group 2); standardized patient-based simulation training (group 3); and lectures and standardized patient-based simulations (group 4). We compared among the intervention groups and to a control group changes in rates of patients with uncontrolled asthma at 1 and 2 years after the intervention. RESULTS: During 1 year of follow-up, rates of uncontrolled asthma decreased from 7.2% to 6.2% (by 15%), from 7.5% to 6.5% (by 13%), from 6.4% to 5.1% (by 19%), and from 6.3% to 4.6% (by 27%) in intervention groups 1 to 4, respectively (P<0.01). Rates decreased by approximately 7% more in all intervention groups at 2 years of follow-up. No decrease in rates was observed in the control group. CONCLUSIONS: An intervention for primary care physicians on educating patients with asthma to manage their disease resulted in improved patient health. The most effective intervention was the combination of lectures and standardized patient-based simulation.