Impact of a computerized system for evidence-based diabetes care on completeness of records: a before-after study.

BACKGROUND: Physicians practicing in ambulatory care are adopting electronic health record (EHR) systems. Governments promote this adoption with financial incentives, some hinged on improvements in care. These systems can improve care but most demonstrations of successful systems come from a few highly computerized academic environments. Those findings may not be generalizable to typical ambulatory settings, where evidence of success is largely anecdotal, with little or no use of rigorous methods. The purpose of our pilot study was to evaluate the impact of a diabetes specific chronic disease management system (CDMS) on recording of information pertinent to guideline-concordant diabetes care and to plan for larger, more conclusive studies. METHODS: Using a before-after study design we analyzed the medical record of approximately 10 patients from each of 3 diabetes specialists (total = 31) who were seen both before and after the implementation of a CDMS. We used a checklist of key clinical data to compare the completeness of information recorded in the CDMS record to both the clinical note sent to the primary care physician based on that same encounter and the clinical note sent to the primary care physician based on the visit that occurred prior to the implementation of the CDMS, accounting for provider effects with Generalized Estimating Equations. RESULTS: The CDMS record outperformed by a substantial margin dictated notes created for the same encounter. Only 10.1% (95% CI, 7.7% to 12.3%) of the clinically important data were missing from the CDMS chart compared to 25.8% (95% CI, 20.5% to 31.1%) from the clinical note prepared at the time (p < 0.001) and 26.3% (95% CI, 19.5% to 33.0%) from the clinical note prepared before the CDMS was implemented (p < 0.001). There was no significant difference between dictated notes created for the CDMS-assisted encounter and those created for usual care encounters (absolute mean difference, 0.8%; 95% CI, -8.5% to 6.8%). CONCLUSIONS: The CDMS chart captured information important for the management of diabetes more often than dictated notes created with or without its use but we were unable to detect a difference in completeness between notes dictated in CDMS-associated and usual-care encounters. Our sample of patients and providers was small, and completeness of records may not reflect quality of care.

Diabetes: foot ulcers and amputations.

INTRODUCTION: Diabetic foot ulceration is full-thickness penetration of the dermis of the foot in a person with diabetes. Severity is classified using the Wagner system, which grades it from 1 to 5. The annual incidence of ulcers among people with diabetes is 2.5% to 10.7% in resource-rich countries, and the annual incidence of amputation for any reason is 0.25% to 1.8%. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent foot ulcers and amputations in people with diabetes? What are the effects of treatments in people with diabetes with foot ulceration? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 50 systematic reviews and RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: debridement, human cultured dermis, human skin equivalent, patient education, pressure off-loading with felted foam or pressure-relief half-shoe, pressure off-loading with total-contact or non-removable casts, screening and referral to foot-care clinics, systemic hyperbaric oxygen for non-infected ulcers, systemic hyperbaric oxygen in infected ulcers, therapeutic footwear, topical growth factors, and wound dressings.

Effect of computer-generated tailored feedback on glycemic control in people with diabetes in the community: a randomized controlled trial.

OBJECTIVE: It is unknown whether computer-generated, patient-tailored feedback leads to improvements in glycemic control in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: We recruited people with type 2 diabetes aged ≥ 40 years with a glycated hemoglobin (A1C) ≥ 7%, living in Hamilton, Canada, who were enrolled in a community-based program (Diabetes Hamilton) that provided regular evidence-based information and listings of community resources designed to facilitate diabetes self-management. After completing a questionnaire, participants were randomly allocated to either receive or not receive periodic computer-generated, evidence-based feedback on the basis of their questionnaire responses and designed to facilitate improved glycemic control and diabetes self-management. The primary outcome was a change in A1C after 1 year. RESULTS: A total of 465 participants (50% women, mean age 62 years, and mean A1C 7.83%) were randomly assigned, and 12-month A1C values were available in 96% of all participants, at which time the A1C level had decreased by an absolute amount of 0.24 and 0.15% in the intervention and control groups, respectively. The difference in A1C reduction for the intervention versus control group was 0.09% (95% CI -0.08 to 0.26; P = 0.3). No between-group differences in measures of quality of life, diabetes self-management behaviors, or clinical outcomes were observed. CONCLUSIONS: Providing computer-generated tailored feedback to registrants of a generic, community-based program that supports diabetes self-management does not lead to lower A1C levels or a better quality of life than participation in the community-based program (augmented by periodic A1C testing) alone.

Does this patient with diabetes have large-fiber peripheral neuropathy?

CONTEXT: Diabetic peripheral neuropathy predisposes patients to foot ulceration that heals poorly and too often leads to amputation. Large-fiber peripheral neuropathy (LFPN), one common form of diabetic neuropathy, when detected early prompts aggressive measures to prevent progression to foot ulceration and its associated morbidity and mortality. OBJECTIVE: To systematically review the literature to determine the clinical examination findings predictive of asymptomatic LFPN before foot ulceration develops. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: MEDLINE (January 1966-November 2009) and EMBASE (1980-2009 [week 50]) databases were searched for articles on bedside diagnosis of diabetic peripheral neuropathy. Included studies compared elements of history or physical examination with nerve conduction testing as the reference standard. DATA SYNTHESIS: Of 1388 articles, 9 on diagnostic accuracy and 3 on precision met inclusion criteria. The prevalence of diabetic LFPN ranged from 23% to 79%. A score greater than 4 on a symptom questionnaire developed by the Italian Society of Diabetology increases the likelihood of LFPN (likelihood ratio [LR], 4.0; 95% confidence interval [CI], 2.9-5.6; negative LR, 0.19; 95% CI, 0.10-0.38). The most useful examination findings were vibration perception with a 128-Hz tuning fork (LR range, 16-35) and pressure sensation with a 5.07 Semmes-Weinstein monofilament (LR range, 11-16). Normal results on vibration testing (LR range, 0.33-0.51) or monofilament (LR range, 0.09-0.54) make LFPN less likely. Combinations of signs did not perform better than these 2 individual findings. CONCLUSIONS: Physical examination is most useful in evaluating for LFPN in patients with diabetes. Abnormal results on monofilament testing and vibratory perception (alone or in combination with the appearance of the feet, ulceration, and ankle reflexes) are the most helpful signs.

Diabetes: foot ulcers and amputations.

INTRODUCTION: Diabetic foot ulceration is full-thickness penetration of the dermis of the foot in a person with diabetes. Severity is classified using the Wagner system, which grades it from 1 to 5. The annual incidence of ulcers among people with diabetes is 2.5-10.7% in resource-rich countries, and the annual incidence of amputation for any reason is 0.25-1.8%. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent foot ulcers and amputations in people with diabetes? What are the effects of treatments in people with diabetes with foot ulceration? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 41 systematic reviews and RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: debridement, human cultured dermis, human skin equivalent, patient education, pressure off-loading with felted foam or pressure-relief half-shoe, pressure off-loading with total-contact or non-removable casts, screening and referral to foot care clinics, systemic hyperbaric oxygen for non-infected ulcers, systemic hyperbaric oxygen in infected ulcers, therapeutic footwear, topical growth factors, and wound dressings.

Annual incidence and relative risk of diabetes in people with various categories of dysglycemia: a systematic overview and meta-analysis of prospective studies.

BACKGROUND: Several estimates of the risk of progression to diabetes in people with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) have been reported. OBJECTIVE: To provide an estimate of the risk of progression to diabetes and regression to normoglycemia in these populations. DESIGN: Systematic overview and meta-analysis of prospective cohort studies published from 1979 until 2004. SETTING: Global cohort studies. PATIENTS: People with IFG or IGT detected by a screening oral glucose tolerance test. MEASUREMENTS: Fasting and post-load plasma glucose levels. RESULTS: The absolute annual incidence of diabetes in individuals with various categories of IFG or IGT varied from 5 to 10%. Compared to normoglycemic people the meta-analyzed relative risk and 95% confidence interval for diabetes was: 6.35 (4.87-7.82) in people with IGT; 5.52 (3.13-7.91) in people with isolated IGT; 4.66 (2.47-6.85) in people with IFG; 7.54 (4.63-10.45) in people with isolated IFG; and 12.13 (4.27-20.00) in people with both IFG and IGT. People with IGT were 0.33 times as likely to be normoglycemic after 1 year compared to people with normal glucose tolerance (95% CI 0.23-0.43). LIMITATIONS: Studies that used differing criteria for IFG and IGT were included, and participants were classified on the basis of only one test. CONCLUSION: IFG and IGT are associated with similar, high relative risk for incident diabetes. The combined abnormality of IFG plus IGT is associated with the highest relative risk.

Reproducibility of impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) classification: a systematic review.

BACKGROUND: The classifications of impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) represent glucose levels above normal, but below the decision threshold for diabetes. We sought to determine what the reproducibility of these classifications was when repeat tests were performed by conducting a systematic review of the literature. METHODS: All primary studies published in English of any study design were included. Studies were excluded if they did not follow the World Health Organization or American Diabetes Association diagnostic criteria, used whole blood as the specimen type, a glucose meter for analysis, or performed repeat testing greater than 8 weeks apart. RESULTS: Five papers had reproducibility data for IGT or IFG, two of which where from the same population but sampled differently. The kappa coefficients, indicating agreement between repeat tests that exceeded chance, indicated poor to fair agreement for IGT (0.04, 0.22, 0.38, 0.42) and moderate agreement for IFG (0.44 and 0.56). Similarly, the observed reproducibility was slightly lower for IGT (33%, 44%, 47%, 48%) compared to IFG (51%, 64%). In two studies for which data were available for both IGT and IFG, the average reproducibility was lower (49%) for the prediabetes group compared to the diabetes group (73%) or the normal group (93%). CONCLUSIONS: Poor reproducibility of IGT and IFG classification suggests caution should be exercised when interpreting a single test result.

The Diabetes Continuity of Care Scale: the development and initial evaluation of a questionnaire that measures continuity of care from the patient perspective.

The purpose of the present study was to develop and pilot test a questionnaire to assess continuity of care from the perspective of patients with diabetes. Seven patient and two healthcare-provider focus groups were conducted. These focus groups generated 777 potential items. This number was reduced to 56 items after item reduction, face validity testing and readability analysis, and to 47 items after a preliminary factor analysis. Readability was assessed as requiring 7-8 years of schooling. Sixty adult patients with diabetes completed the draft Diabetes Continuity of Care Scale (DCCS) at a single point in time to assess the validity of the instrument. Patients completed the draft DCCS again 2 weeks later to assess test-retest reliability. A provisional factor analysis and grouping according to clinical sense yielded five domains: access and getting care, care by doctor, care by other healthcare professionals, communication between healthcare professionals, and self-care. The internal consistency (Cronbach's alpha) for the whole scale was 0.89. The test-retest reliability was r = 0.73. The DCCS total score was moderately correlated with some of the measures used to establish construct validity. The DCCS could differentiate between patients who did and did not achieve specific process and clinical indicators of good diabetes care (e.g. Hba1c tested within 6 months). The development of the DCCS was centred on the patient's perspective and revealed that the patient perspective regarding continuity of care extends beyond the concept of seeing one doctor. Initial testing of this instrument demonstrates that it has promise as a reliable and valid measure in this area.

Using evidence in practice. Foot care in diabetes.

Foot ulceration and amputation remain all too common complications for people with diabetes mellitus. Overcoming this, however, requires considerable effort. Improved implementation of patient education programs is essential, along with increased access to resources to support optimal foot care and the acquisition of optimal footwear for patients at highest risk of these complications. Well-coordinated screening programs are likely to be highly beneficial. Multidisciplinary care must be available for patients with established lower extremity disease. Equally important, further research into foot ulcer prevention and management is critical. The total number of studies completed to date in the field remains low, especially considering the frequency and devastating nature of lower extremity complications.