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Quality of diabetes mellitus care by rural primary care physicians.

ABSTRACT: To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes.Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction).Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P = .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P = .16). We observed no differences between degree of rural and reasonable BP or LDL control (P = .42, P = .23, respectively) or optimal A1c or BP control (P = .52, P = .65, respectively). Optimal and mean LDL values worsened as rurality increased (P = .08, P = .029, respectively).In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients' residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted.

SUBMITTER: Tonks SA

PROVIDER: S-EPMC3481192 | biostudies-literature | 2012

REPOSITORIES: biostudies-literature

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Quality of diabetes mellitus care by rural primary care physicians.

Tonks Stephen A SA Makwana Sohil S Salanitro Amanda H AH Safford Monika M MM Houston Thomas K TK Allison Jeroan J JJ Curry William W Estrada Carlos A CA

The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association 20120531 4

<h4>Purpose</h4>To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes.<h4>Methods</h4>Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 ...[more]

PMID: 23083082

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Project description:BackgroundSince 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally.GoalsTo assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care.MethodThe study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians - 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans.Main findingsThe vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried.Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems.ConclusionsThe findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.

Project description:BackgroundType 2 diabetes can be prevented through lifestyle programs like the Diabetes Prevention Programs (DPP), but few people with prediabetes participate in them, in part because their insurance does not reliably cover DPPs. Prior studies have not focused on payor-level barriers.ObjectiveTo understand barriers to DPP uptake that exist and intersect at different levels (patients, PCPs, and payors) to inform strategies to improve diabetes prevention in primary care settings through interviews with PCPs and payors.DesignFrom May 2020 to October 2021, we conducted remote, semi-structured interviews with PCPs and payors.ParticipantsPCPs were from primary care practices affiliated with one mid-Atlantic academic system. Payor leaders were from regional commercial, Medicare, and Medicaid plans.ApproachUsing a standardized interview guide focused on barriers, facilitators, and potential intervention components, interviews were audio-recorded using Zoom and professionally transcribed. Two reviewers double-coded transcripts using the framework analytic approach.Key resultsWe interviewed 16 PCPs from 13 primary care clinics and 7 payor leaders representing 6 insurance plans. Two themes emerged from PCP reports of patient-level barriers: (1) lack of programs and insurance coverage of resources to address nutrition and exercise and (2) inadequate resources to address social determinants of health that impact diabetes prevention. Among barriers PCPs faced, we identified two themes: (1) low PCP knowledge about DPPs and misperceptions of insurance coverage of DPPs and (2) inadequate clinical staff to address diabetes prevention. Barriers common to PCPs and payors included (1) absence of prediabetes quality measures and (2) inadequate engagement of PCPs and patients with payors.ConclusionsDiscussions with PCPs and payors revealed systemic barriers that suggest important priorities to improve prediabetes clinical care, including universal coverage of DPPs, clarity about coverage benefits, data reporting and outreach by payors to PCPs, and adoption of appropriate prediabetes quality measures.

Project description:BackgroundLack of healthcare access to due to physician shortages is a significant driver of telemedicine expansion in rural areas. Telemedicine is effective for management of chronic conditions such as diabetes but its effectiveness in primary care settings is unknown.ObjectiveTo evaluate differences in diabetes care before and after implementation of a longitudinal virtual primary care program.DesignPropensity score-matched cohort study utilizing difference-in-differences analysis.ParticipantsPatients with diabetes who received care at VA primary care clinics between January 2018 and December 2019 where the Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) program was implemented.ExposurePatient participation in at least one V-IMPACT visit while usual care patients did not participate in V-IMPACT.Main measuresThe primary outcome was change in hemoglobin A1C (HbA1C) and secondary outcomes included change in the proportion of patients meeting diabetes quality indicators: blood pressure control, statin use, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEi/ARB) use, and annual microalbuminuria testing.Key resultsOur propensity-matched cohort included 9010 patients split evenly between those who participated in V-IMPACT and those who remained in usual in-person care. Among individuals with diabetes who participated in V-IMPACT, the change in mean HbA1C was - 0.055% (95% CI - 0.088 to - 0.022%) while those in usual care had a - 0.047% (95% CI - 0.080 to - 0.014%) change before and after program implementation. We observed a 5.1% (95% CI 2.4 to 7.7%) absolute increase in the proportion prescribed statins in the V-IMPACT group, a 5.3% (95% CI 2.5 to 8.2%) increase prescribed ACE/ARBs, and a 4.6% (95% 1.7 to 7.5%) increase in completed yearly microalbuminuria testing. V-IMPACT was not associated with a significant difference in the proportion with controlled blood pressure at < 140/90 or < 130/90 mmHg thresholds.ConclusionsQuality of diabetes care delivered by a longitudinal virtual primary care model was similar if not better than traditional in-person care.

Project description:BACKGROUND:Due to the perennial shortage of diabetes specialists, primary care physicians (PCPs) constitute the largest diabetes care manpower in Nigeria. However, the competence of the PCPs to undertake this task is not known. This study was aimed at evaluating diabetes care knowledge and practice among PCPs in Southeastern part of Nigeria. METHODS:This was a cross-sectional study among PCPs in Southeastern Nigeria. Diabetes care knowledge and practices were evaluated using a structured self administered questionnaire. RESULTS:A total of 64 PCPs with mean duration of practice of 17.3 ± 11.6 years completed the study. 65.6% were in private practice and 50% attended to between 11 and 20 persons living with diabetes (PLWD) weekly. Majority (78.1%) had not participated in any diabetes training since graduation from medical school and 79.9% were not aware of any diabetes clinical practice guideline. The PCPs had adequate knowledge of classical symptoms of diabetes. However, they had very poor knowledge of glycemic thresholds for diagnosis of diabetes which was 26.6, 45.3 and 10.9% for fasting blood glucose (FBG), random blood glucose (RBG) and glycated hemoglobin (A1c) respectively. We observed serious gaps in diabetes care practice such that only 18.8% of the respondents performed foot examination on newly diagnosed PLWD while 28.1 and 39.1% provided counseling on foot care and hypoglycemia respectively. Annual comprehensive foot examination was conducted by only 12.5%, none of the physicians ever screened for microalbuminuria and only 21.9% conducted annual dilated eye examination. Majority (57.8%) rated their confidence in prescribing insulin as "low" and only 23.4% had ever prescribed outpatient insulin for type 2 diabetes in their practice. Glycemic monitoring was largely limited to FBG and only 17.2% monitored A1c. Duration of practice more than 10 years (OR 10.1; P 0.034) and non participation in diabetes training (OR 6.5; P 0.027) were significant predictors of poor diabetes care knowledge. CONCLUSION:Diabetes care knowledge and practice were poor among PCPs in Southeast Nigeria. There is an urgent need to improve their capacity to provide diabetes care through periodic training.

Project description:IntroductionMeasuring the performance of a primary care system is one of the very first steps to find out whether there is room for improvement. To obtain an objective and comprehensive view, this measurement should come from both the supply and demand sides of the system. Patients' experiences of primary care have been studied around the world, but much less energy has been invested in researching providers' perspectives. This research aims to explore how primary care physicians working at commune health centers in Vietnam evaluate their performance and their opinions on how to improve the quality of primary care services.Materials and methodsFirst, a quantitative study was conducted using the validated Vietnamese PCAT questionnaire-provider expanded version (VN PCAT PE) targeting all primary care physicians (PCPs) working at commune health centers in a province of Central Vietnam. Next, a qualitative study was carried out, consisting of in-depth interviews with PCPs, to better understand the results of the quantitative survey and gain insight on barriers of primary care services and how to overcome them.ResultsIn the quantitative portion of our study, 150 PCPs rated the quality of ongoing care and first contact in CHCs as the best (3.09 and 3.11 out of 4, respectively), and coordination as the worst performing core domain (2.53). Twenty-two PCPs also participated in our qualitative research. In regards to challenges that primary care physicians face during their daily practice, three central themes emerged: 1) patient factors such as client attitude and knowledge, 2) provider factors such as the burden of administrative work and lack of training opportunities, and 3) contextual factors such as low income and lack of resources including medicines and diagnostics. Participants recommended more health promotion campaigns in the media, increasing the number of services available at CHCs (such as being able to take blood samples), reducing the workload related to administration for CHC leaders, greater government subsidies, and providing more training courses for PCPs.ConclusionsFindings from this study offer a valuable view from the supply-side of the primary care system, specifically those who directly deliver primary care services. Along with the earlier study on consumers' evaluation of the Vietnamese primary care system, and literature from other low and middle-income countries, these findings offer emerging evidence for policymakers to improve the quality of primary care in Vietnam.

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Quality of diabetes mellitus care by rural primary care physicians.

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Quality of diabetes mellitus care by rural primary care physicians.

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