Improving access to quality diabetes education in a rural state: the Montana Quality Diabetes Education Initiative.

PURPOSE: Diabetes self-management education (DSME) is an integral component of diabetes care; however, skilled educators and recognized programs are not uniformly available in rural communities. METHODS: To increase access to quality DSME, the Montana Diabetes Control Program and the Montana chapter of the American Association of Diabetes Educators developed a mentoring program with 3 levels: basic, intermediate, and advanced. All participants were assisted by a volunteer certified diabetes educator (CDE) mentor. In addition, the program provided technical support for recognition through the American Diabetes Association and the Indian Health Service. RESULTS: From 2000 to 2005, 90 individuals participated; 76% were nurses and 21% dietitians. Twenty-seven of the 90 enrollees (30%) completed their structured option, and 13 achieved CDE certification. Most provided services in frontier counties (66%). Statewide, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. Twenty-five of the 30 facilities that received technical assistance achieved recognition. Statewide, the number of recognized education programs increased from 2 in 2000 to 22 in 2005. Twelve (55%) of these programs were located in frontier counties. CONCLUSIONS: Mentoring and technical support is an effective method to increase personnel skills for DSME and to increase access to quality education programs in rural areas.

A field-based approach to support improved diabetes care in rural states.

INTRODUCTION: Diabetes care is a challenge in rural areas where primary care practices are faced with limited resources, few clinical information systems, and relative isolation from education programs and diabetes centers with multispecialty teams. This report describes an effective field-based approach to support improved care for patients with diabetes in primary care practices in rural states. METHODS: A collaborative effort between diabetes prevention and control programs in Montana and Wyoming and the University of North Dakota was established to provide support to rural primary care practices for improvement in diabetes care. Field teams from each state diabetes program approached primary care practices. After assessment and orientation of office staff, a computer-based registry was established in each practice. Baseline data were collected in 1997 in Montana and in 1998 in Wyoming; follow-up occurred on July 31, 2004. Health department staff provided ongoing technical support for implementing and evaluating quality-improvement interventions. RESULTS: Forty primary care practices, providing care to more than 7000 patients with diabetes, participated in this quality-improvement effort at follow-up. Of the 37 primary care practices participating in the quality-improvement program for 6 or more months at follow-up, there were significant improvements in Montana in rates of hemoglobin A1c testing, blood glucose control, low-density lipoprotein cholesterol testing, foot and dilated retinal examinations, and pneumococcal vaccinations, and there were significant improvements in pneumococcal vaccinations in Wyoming. CONCLUSION: A field-based approach in which individual practices maintain and use their own registries for both clinical care and quality improvement with ongoing support is a sustainable and an effective strategy for improving diabetes care for rural populations.

Improvements in care and reduced self-management barriers among rural patients with diabetes.

CONTEXT: Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes. PURPOSE: In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care. METHODS: Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management. FINDINGS: In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%). CONCLUSIONS: Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.

Diabetes in Montana's Indians: the epidemiology of diabetes in the Indians of the Northern Plains and Canada.

The prevalence of diabetes is two- to threefold higher in American Indians in Montana compared with the non-Indian population. High rates of diabetes have also been described in Canadian aboriginal populations closely related to the tribes in Montana. Diabetes in pregnancy has increased among Indian mothers and high-birth-weight babies are increasingly likely to be born to Indian mothers with diabetes in pregnancy. Over 70% of the incident cases of diabetes in youth less than 20 years of age on the reservations have the clinical characteristics of type 2 diabetes. Cardiovascular disease mortality rates are high among Indians in Montana, and the prevalence of smoking in the Indian populations of Montana and the neighboring tribes in Canada is remarkably high. Indians in Montana are more likely than non-Indians of similar age to believe that diabetes is preventable and to recall advice about diabetes risk.

Three-year prevalence and incidence of diabetes among American Indian youth in Montana and Wyoming, 1999 to 2001.

OBJECTIVES: To estimate the prevalence and incidence of type 2 diabetes among American Indian youth. STUDY DESIGN: Medical records were reviewed annually for all patients with diabetes who were <20 years of age at 6 Indian Health Service facilities in Montana and Wyoming. All cases < or =5 years of age or weight per age < or =10th percentile at diagnosis or with islet cell antibodies were considered as probable type 1. Among the remaining cases, probable type 2 diabetes was defined when a child had one or more of the following characteristics: weight per age > or =95th percentile or acanthosis nigricans at diagnosis, elevated C-peptide or insulin, family history of type 2 diabetes; treatment with oral agents with or without insulin or no hypoglycemic therapy after 1 year of follow-up. RESULTS: From 1999 to 2001, 53% of prevalent cases and 70% of incident cases were categorized as probable type 2 diabetes. The average annual prevalence of probable type 1 and type 2 diabetes was 0.7 and 1.3 per 1000. The average annual incidence rates for probable type 1, and type 2 diabetes were 5.8, 23.3 per 100,000. CONCLUSIONS: The incidence of probable type 2 diabetes was approximately 4 times higher than type 1 diabetes among American Indian youth in Montana and Wyoming

Testing for microalbuminuria in 2002: barriers to implementing current guidelines.

BACKGROUND: Testing for microalbuminuria is recommended to detect early kidney damage in patients with diabetes or other diseases. However, few studies have examined laboratory practices for microalbuminuria testing in the general community. METHODS: In 2002, all laboratories in Montana and reference laboratories used by Montana laboratories for microalbuminuria measurement were surveyed by mail to ascertain if they provided testing for microalbuminuria, specific tests performed, and units and cutoff values used to report microalbuminuria results. RESULTS: One hundred three of 126 laboratories (82%) responded to the survey. Overall, 79% of laboratories offered quantitative testing for microalbuminuria, either on site or through a reference laboratory. Twenty-five laboratories (24%) surveyed provided quantitative testing for microalbuminuria on site. Only 14 of 23 laboratories offering albumin-creatinine ratios on site reported results in units and cutoff values consistent with current recommendations. Fewer laboratories provided 24-hour (6 of 17 laboratories) or other timed (2 of 7 laboratories) testing, and many of these laboratories did not report results using recommended units and cutoff values. Overall, only 11 of 25 laboratories (44%) with on-site testing reported microalbuminuria values from 1 or more types of specimens exclusively using recommended units and cutoff values. CONCLUSION: Quantitative testing for microalbuminuria is not offered universally, and results often are reported in units and cutoff values that differ from current clinical recommendations.

Cardiovascular risk factors in Montana American Indians with and without diabetes.

BACKGROUND: Cardiovascular disease (CVD) and diabetes are prevalent and of major concern for American-Indian communities in the United States. Health professional counseling is effective in increasing patient awareness and inducing lifestyle modification. The objective of this study was to compare the prevalence of CVD, modifiable risk factors and counseling for smoking cessation, physical activity, and a healthy diet in adult American Indians with and without diabetes. METHODS: A random sample of adult American Indians living on or near the seven Montana reservations was interviewed through an adapted Behavioral Risk Factor Surveillance System telephone survey in 1999 (N=1000) and 2001 (N=1006). RESULTS: Respondents with diabetes, compared to those without, had a significantly higher prevalence of CVD (27% vs 8%); overweight (89% vs 71%); high blood pressure (57% vs 24%); and high cholesterol (44% vs 22%). There were no differences for insufficient physical activity (60% vs 51%) or smoking (34% vs 41%) after adjustment for age, gender, and survey year. Respondents with diabetes, compared to respondents without diabetes, were significantly more likely to report health professional counseling for smoking cessation (83% vs 58%); physical activity (73% vs 37%); and reduced fat consumption (57% vs 24%). CONCLUSIONS: The prevalence of modifiable CVD risk factors was alarmingly high among adult American Indians with and without diabetes. Strategies to increase health professional counseling for healthy diet and smoking cessation are needed.

Measuring and improving preventive care for patients with diabetes in primary health centers.

Diabetes care among medically underserved patients is suboptimal. Few studies, however, have described successful strategies to improve diabetes care in these patient populations. To address this issue, 4 Montana community health centers and 1 urban Indian health center implemented quality improvement efforts along with an office-based electronic system for monitoring diabetes care. After a median of 17 months follow-up, preventive services and clinical outcomes were assessed for all patients at baseline (N = 332) and follow-up (N = 590), and for a cohort (N = 164) who had 1 or more visits 6 months after baseline. In cross-sectional analyses, there were increases from baseline to follow-up in the percent of patients who had received an annual foot examination (50% to 68%), microalbuminuria testing (34% to 62%), annual retinal examination (14% to 30%), pneumococcal immunization (30% to 61%), and smoking assessment (77% to 91%). But neither HbA1c testing in the previous 6 months (64% to 55%) nor annual LDL-C testing (59% to 61%) showed any improvement. There were no significant changes from baseline to follow-up in the median hemoglobin A1c (HbAlc), low density lipoprotein-cholesterol (LOL-C), or in systolic and diastolic blood pressure values. Similar improvements in preventive care were seen in the cohort of patients with diabetes. But overall outcomes were not improved. Our findings suggest that office-based monitoring systems can support systems' changes to improve the delivery of preventive services to patients with diabetes in primary care facilities for the underserved, but outcomes are more difficult to enhance over a short period of follow-up. Also, our findings suggest that over a relatively short-term period, cross-sectional and cohort analyses of quality improvement measures do yield similar measures of diabetes care in such settings.

Do persons with diabetes know their (A1C) number?

PURPOSE: The objective of this study was to compare self-reported knowledge about A1C testing with information from the medical record. METHODS: A telephone survey was conducted among patients with diabetes in a rural fee-for-service practice and a community health center. Self-reported information regarding A1C testing, the last A1C value, and perceived blood glucose control was compared with the most current A1C value documented in the medical record. RESULTS: Seventy five percent of survey respondents reported having 1 or more A1C tests in the past year, which generally agreed with information from their medical records. However, only 24% of those who reported having a test remembered the actual value, and the self-reported values correlated weakly with the last A1C on the medical record. Among those with a documented A1C value, half described their blood glucose as very well controlled. The last A1C value, however, was < 7.0% in only half of those respondents. CONCLUSIONS: Persons with diabetes were aware of their previous A1C testing but did not interpret the values accurately in relation to their own glycemic control. If clinicians expect patient knowledge and understanding of glycemic control measures to improve outcomes of care, patient education will need to emphasize the meaning of these values.