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Title: Variations in glucocorticoid-induced osteoporosis prevention in a managed care cohort.
Publication: Journal of Rheumatology 2001 Jun;28(6):1298-305.
Authors: Mudano A et al.
Grant No.: HS10389.
Principal Investigator: Kenneth Saag.
Project Officer: Lynn Bosco.
Abstract: OBJECTIVE: To characterize glucocorticoid use and patterns of osteoporosis prevention therapies among a large U.S. national cohort. METHODS: Health maintenance organization (HMO) members who were receiving chronic glucocorticoid therapy (> 90 day supply) within a 3 year observation period were identified along with their prescribing physicians. Receipt of anti-osteoporotic prescription therapies and bone mass measurement was determined. Multivariable analyses were used to define significant predictors of these preventive interventions. RESULTS: We identified 2378 HMO members who filled prescriptions for at least a 90 day supply of glucocorticoids, but had not filled a glucocorticoid prescription in the prior 90 days. In women over age 50, use of anti-osteoporotic therapies and bone mass measurement was 41 percent and 16 percent, respectively. Glucocorticoid-prescribing physicians were identified for 878 (37 percent) of these glucocorticoid users, and internal medicine specialists (39 percent) and rheumatologists (20 percent) wrote the majority of the prescriptions for glucocorticoids. Women age 50 and over were most likely to receive a prescription anti-osteoporotic preventive therapy (OR 4.0; 95 percent CI 1.5-10.8). Patients with a rheumatologist prescribing their glucocorticoids were more likely than those of internists to have a bone mass measurement (OR 2.2; 95 percent CI 1.3-3.6) and receive bisphosphonates (OR 1.9; 95 percent CI 1.1-3.1), but were not more likely to receive preventive treatment overall. CONCLUSION: Although better than in several prior studies, we identified low levels of selected preventive care measures for chronic glucocorticoid users in a large population based cohort. Significant demographic and practice pattern variation suggests opportunities for targeted preventive interventions.
Title: Visual hallucination and tremor induced by sertraline and oxycodone in a bone marrow transplant patient.
Publication: Journal of Clinical Pharmacology 2001 Feb; 41(2):224-7.
Authors: Rosebraugh CJ et al.
Grant No.: HS10385.
Principal Investigator: Raymond Woosley.
Project Officer: Lynn Bosco.
Abstract: The authors report a case of probable serotonin syndrome caused by the coadministration of sertraline and oxycodone. A 34-year-old male patient experienced visual hallucinations and severe tremor after dramatically increasing his dosage of oxycodone while on stable amounts of sertraline and cyclosporin. Discontinuation of cyclosporin did not result in resolution of his symptoms. Consideration of a possible sertraline-oxycodone interaction led to withholding sertraline, which resulted in symptom resolution. Serotonin syndrome has been noted with sertraline in combination with other drugs, but this is the first report in combination with a narcotic analgesic. Possible pharmacological mechanisms are discussed. In complicated patients that are taking multiple medications, physicians should be aware of this possible interaction to avoid delay in the diagnosis of serotonin syndrome.
Title: Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial.
Publication: Journal of American Medical Association 2001 Jun 13;285(22):2871-9.
Authors: Kiefe CI et al.
Grant No.: HS10389.
Principal Investigator: Kenneth Saag.
Project Officer: Lynn Bosco.
Abstract: CONTEXT: Performance feedback and benchmarking, common tools for health care improvement, are rarely studied in randomized trials. Achievable Benchmarks of Care (ABCs) are standards of excellence attained by top performers in a peer group and are easily and reproducibly calculated from existing performance data. OBJECTIVE: To evaluate the effectiveness of using achievable benchmarks to enhance typical physician performance feedback and improve care. DESIGN: Group-randomized controlled trial conducted in December 1996, with followup through 1998. SETTING AND PARTICIPANTS: Seventy community physicians and 2,978 fee-for-service Medicare patients with diabetes mellitus who were part of the Ambulatory Care Quality Improvement Project in Alabama. INTERVENTION: Physicians were randomly assigned to receive a multimodal improvement intervention, including chart review and physician-specific feedback (comparison group; n = 35) or an identical intervention plus achievable benchmark feedback (experimental group; n = 35). MAIN OUTCOME MEASURE: Preintervention (1994-95) to postintervention (1997-98) changes in the proportion of patients receiving influenza vaccination; foot examination; and each of 3 blood tests measuring glucose control, cholesterol level, and triglyceride level, compared between the two groups. RESULTS: The proportion of patients who received influenza vaccine improved from 40 percent to 58 percent in the experimental group (P<.001) vs from 40 percent to 46 percent in the comparison group (P =.02). Odds ratios (ORs) for patients of achievable benchmark physicians vs comparison physicians who received appropriate care after the intervention, adjusted for preintervention care and nesting of patients within physicians, were 1.57 (95 percent confidence interval [CI], 1.26-1.96) for influenza vaccination, 1.33 (95 percent CI, 1.05-1.69) for foot examination, and 1.33 (95 percent CI, 1.04-1.69) for long-term glucose control measurement. For serum cholesterol and triglycerides, the achievable benchmark effect was statistically significant only after additional adjustment for physician characteristics (OR, 1.40 [95 percent CI, 1.08-1.82] and OR, 1.40 [95 percent CI, 1.09-1.79], respectively). CONCLUSION: Use of achievable benchmarks significantly enhances the effectiveness of physician performance feedback in the setting of a multimodal quality improvement intervention.
Title: Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data.
Publication: American Journal of Epidemiology 2001 Nov 1;154(9):854-64.
Authors: Schneeweiss S et al.
Grant No.: HS10881/HS09855.
Principal Investigator: Schneweiss/Soumerai.
Project Officer: Lynn Bosco.
Abstract: Comorbidity is an important confounder in epidemiologic studies. The authors compared the predictive performance of comorbidity scores for use in epidemiologic research with administrative databases. Study participants were British Columbia, Canada, residents aged >or=65 years who received angiotensin-converting enzyme inhibitors or calcium channel blockers
at least once during the observation period. Six scores were computed for all 141,161 participants during the baseline year (1995-1996). Endpoints were death and health care utilization during a 12-month followup (1996-1997). Performance was measured by using the c statistic ranging from 0.5 for chance prediction of outcome to 1.0 for perfect prediction. In logistic regression models controlling for age and gender, four scores based on the International Classification of Diseases, Ninth Revision (ICD-9) generally performed better at predicting 1-year mortality (c = 0.771, c = 0.768, c = 0.745, c = 0.745) than medication-based Chronic Disease Score (CDS)-1 and CDS-2 (c = 0.738, c = 0.718). Number of distinct medications used was the best predictor of future physician visits (R(2) = 0.121) and expenditures (R(2) = 0.128) and a good predictor of mortality (c = 0.745). Combining ICD-9 and medication-based scores improved the c statistics (1.7 percent and 6.2 percent, respectively) for predicting mortality. Generalizability of results may be limited to an elderly, predominantly White population with equal access to state-funded health care.
Title: Third-molar removal patterns in an insured population.
Publication: Journal of American Dental Association 2001 Apr;132(4):469-75.
Authors: Eklund SA et al.
Grant Number: HS09554.
Principal Investigator: Stephen Eklund.
Project Officer: Yen-pin Chiang.
Abstract: BACKGROUND: The authors examined third-molar removal patterns in an insured population to see how these patterns compare with recommendations in the literature. METHODS: The source of treatment data was insurance claims for services rendered from July 1991 through December 1999. It included approximately 100 million dental procedures provided to about 7.4 million patients from all 50 states. The insured were public and private employees or retirees and their dependents. RESULTS: The authors found that third molars were the most commonly extracted permanent teeth, and they most often were removed from adolescents. Friday was the day of the week on which most extractions occurred, and the favored month was August, followed by July, December and June. Another important pattern revealed by the authors' analysis was that there was substantial variation among dental practices in whether patients had third molars removed and in the timing of the removal. They found that adolescent patients in some dental practices rarely were referred for third-molar removal, while in other practices, most or all had third molars removed. CONCLUSIONS: Third-molar removal patterns suggest that many third molars are not removed in response to acute pathology, and the observed variation in the likelihood and timing of these extractions reflects the lack of consensus on this topic in the dental literature. CLINICAL IMPLICATIONS: The apparent lack of consensus on third-molar removal should be resolved for the profession to maintain the confidence of the public that the recommended care is based on sound evidence.
Title: Two-year effects of quality improvement programs on medication management for depression.
Publication: Archives of General Psychiatry 2001 Oct;58(10):935-42.
Authors: Unutzer J et al.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: BACKGROUND: Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression. METHODS: A total of 1356 patients with depressive symptoms (60 percent with depressive disorders and 40 percent with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In theQI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists. RESULTS: Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52 percent in the QI-medications group, 40 percent in the QI-therapy group, and 33 percent in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group. CONCLUSIONS: Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active followup by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such followup.
Title: Problematic Substance Use, Depressive Symptoms, and Gender in Primary Care.
Publication: Psychiatric Services 2001 Sep;52(9): 1251-53.
Authors: Roeloffs CA et al.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: This study determined the frequency of problematic substance use and of counseling about drug and alcohol use among 867 women and 320 men who reported symptoms of depression in managed primary care clinics. Seventy-two (8.3 percent) of the women and 61 (19 percent) of the men reported hazardous drinking; 228 (26.3 percent) of the women and 94 (29.4 percent) of the men reported problematic drug use, including use of illicit drugs and misuse of prescription drugs. Only 17 (13.9 percent) of the patients who reported hazardous drinking and 18 (6.6 percent) of those who reported problematic drug use received counseling about drug or alcohol use during their last primary care visit. Men were significantly more likely than women to have received counseling about drug or alcohol use from their primary care practitioner.
Title: Can Quality Improvement Programs for Depression in Primary Care Address Patient Preferences for Treatment?
Publication: Medical Care 2001 Sep;39(9):934-44.
Authors: Dwight-Johnson M et al.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: BACKGROUND: Depression is common in primary care, but rates of adequate care are low. Little is known about the role of patient treatment preferences in encouraging entry into care. OBJECTIVES: To examine whether a primary care based depression quality improvement (QI)intervention designed to accommodate patient and provider treatment choice increases the likelihood that patients enter depression treatment and receive preferred treatment. METHODS: In 46 primary care clinics, patients with current depressive symptoms and either lifetime or current depressive disorder were identified through screening. Treatment preferences, patient characteristics, and use of depression treatments were assessed at baseline and 6 months by patient self-report. Matched clinics were randomized to usual care (UC) or one of two QI interventions. Data were analyzed using logistic regression models. RESULTS: For patients not in care at baseline, the QI interventions increased rates of entry into depression treatment compared with usual care (adjusted percentage: 50.0 percent +/- 5.3 and 33.0 percent +/- 4.9 for interventions vs. 15.9 percent +/- 3.6 for usual care; F = 12.973, P <0.0001). Patients in intervention clinics were more likely to get treatments they preferred compared with those in usual care (adjusted percentage: 54.2 percent +/- 3.3 and 50.7 percent +/- 3.1 for interventions vs. 40.5 percent +/- 3.1 for usual care; F = 6.034, P <0.003); however, in all clinics less than half of patients preferring counseling reported receiving it. CONCLUSIONS: QI interventions that support patient choice can improve the likelihood of patients receiving preferred treatments. Patient treatment preference appears to be related to likelihood of entering depression treatment, and patients preferring counseling may require additional interventions to enhance entry into treatment.
Title: Long-term effectiveness of disseminating quality improvement for depression in primary care.
Publication: Archives of General Psychiatry 2001;58:696-703.
Authors: Sherbourne CD et.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: BACKGROUND: This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC). METHODS: The sample included 1,299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or one of two QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication followup (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years. RESULTS: For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (e.g., a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively). CONCLUSIONS: While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.
Title: Are better ratings of the patient-provider relationship associated with higher quality care for depression?
Publication: Medical Care Apr 2001;39(4):349-60.
Authors: Meredith LS et al.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: BACKGROUND: The interpersonal patient-provider relationship (PPR) is an essential part of health care quality, particularly for patients with depression, yet little is known neither about how to measure this relationship nor about its association with quality of care. OBJECTIVES: To evaluate properties of patient rating measures, understand the relation between two types of ratings, and determine the association of ratings with quality depression care. SETTING AND PARTICIPANTS: 1,104 patients with current depressive symptoms and lifetime or 12-month disorder identified through screening 27,332 consecutive primary care visitors in six managed care organizations participating in Partners in Care (PIC). DESIGN: Cross-sectional analysis of 18-month data (collected in 1998) after the start of PIC depression quality improvement (QI) interventions (in which clinics were randomized to one of two QI interventions or usual care). MEASURES: Patient ratings of the interpersonal relationship with the primary care provider and satisfaction with health care, and qualit y of depression care indicators. ANALYSIS: Factor analysis and multitrait scaling to evaluate the psychometric properties of multiitem constructs and analysis of covariance to evaluate associations between patient ratings and quality. RESULTS: Patient ratings had high internal consistency and met criteria for discriminant validity tapping unique aspects of care. Patients receiving quality care, especially for medication use, had significantly higher ratings of the interpersonal relationship (by 22 percent to 27 percent of a SD) and were more satisfied (by 26 percent to 34 percent of a SD) than patients who did not receive quality care. CONCLUSIONS: Ratings of the interpersonal relationship and satisfaction measure distinct aspects of care and are positively associated with quality care for depression.
Title: Utility elicitation using single-item questions compared with a computerized interview.
Publication: Medical Decision Making 2001 Mar-Apr; 21(2):97-104.
Authors: Lenert LA et al.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: BACKGROUND: The use of a simpler procedure for the measurement of utilities could affect primarily the variance or both the mean and the variance of measurements. In the former case, simpler methods would be useful for population studies of preferences; however, in the latter, their use for such studies might be problematic. PURPOSE: The purpose of this study was to compare the results of utility elicitation using single-item questions to computer elicitation using the Ping-Pong search procedure. METHODS: In a convenience sample of 149 primary care patients with symptoms of depression, the authors measured and compared standard gamble (SG) utilities elicited using a single-item "open question" to SG elicitations performed using a computerized interview procedure. Elicitations were performed 1 to 2 weeks apart to minimize memory effects. RESULTS: More than 90 percent of persons with utilities of 1.0 to the single-item standard gamble had utilities of less than 1.0 on the computer SG instrument. Consistent with this finding, the mean utilities were lower in computer interviews (0.80 vs. 0.90; P < 0.0001 for differences). Within subjects, utility measures had only a fair degree of correlation (r = 0.54). CONCLUSIONS: Use of single-item questions to elicit utilities resulted in less precise estimates of utilities that were upwardly biased relative to those elicited using a more complex search rocedure.
Title: Affective Disorders in Children and Adolescents: Addressing Unmet Need in Primary Care Settings.
Publication: Biological Psychiatry 2001 Jun 15;49(12):1111-20.
Authors: Wells K et al.
Grant No.: HS09908.
Principal Investigator: Joan Asarnow.
Project Officer: Charlotte Mullican.
Abstract: Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, due to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve (1) more systematic implementation of programs that offer coverage for uninsured children, (2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders, and (3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluations of their impacts.
Title: The cost-effectiveness of practice initiated quality improvement for depression: Results of a randomized, controlled trial.
Publication: Journal of American Medical Association 2001 Sep 19;286(11):1325-30.
Authors: Schoenbaum M et al.
Grant No.: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: CONTEXT: Depression is a leading cause of disability worldwide, but treatment rates in primary care are low. OBJECTIVE: To determine the cost-effectiveness from a societal perspective of two quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment. DESIGN: Group-level randomized controlled trial conducted June 1996 to July 1999. SETTING: Forty-six primary care clinics in six community-based managed care organizations. PARTICIPANTS: One hundred eighty-one primary care clinicians and 1,356 patients with positive screening results for current depression. INTERVENTIONS: Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication followup (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment. MAIN OUTCOME MEASURES: Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions. RESULTS: Relative to usual care, average health care costs increased $419 (11 percent) in QI-meds (P =.35) and $485 (13 percent) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period. CONCLUSIONS: Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.
Title: Effects of Cost Containment Strategies within Managed Care on Continuity of the Relationship Between Depressed Patients and their Primary Care Providers.
Publication: Medical Care 2001 Oct;39(10):1075-85.
Authors: Meredith LS et al.
Grant Number: HS08349.
Principal Investigator: Kenneth Wells.
Project Officer: Charlotte Mullican.
Abstract: BACKGROUND: Continuity of the relationship between patients and primary care providers (PCPs) is an important component of care from the consumer perspective that may be affected by variation in cost containment strategies within managed care. OBJECTIVE: To evaluate the effects of cost containment strategies on the continuity of the relationship between their patients with depression and their PCPs. DESIGN: Observational analysis of a 2-year panel of depressed patients who participated in a quality improvement intervention trial in 46 managed care practices. PARTICIPANTS: One thousand two hundred four patients with current depression who enrolled in a longitudinal study, completed the baseline survey, and were followed for 2 years. MAIN MEASURES: The dependent variable is probability of continuing the relationship between patients and their PCPs; explanatory variables include individual patient mental health benefits and cost-sharing, individual provider financial incentives, supply-side managed care policies, and patient ratings of the care received. RESULTS: The average duration of the patient-PCP relationship was significantly longer among depressed patients who initially had less generous benefits for specialty care (higher copays, P = 0.02 and fewer visits covered, P = 0.002) and for patients whose PCPs received a performance-based salary bonus from a risk pool (P = 0.07). CONCLUSIONS: For depressed patients, cost containment strategies, such as limits on specialty benefits and presence of clinician bonus payments typically used within managed care may increase, rather than decrease, PCP continuity. Whether increased PCP continuity is a desirable outcome depends on whether health care systems can provide high quality primary care and this merits further study.
Title: Depression in youth: psychosocial interventions.
Publication: Journal of Clinical Child Psychology 2001 Mar;30(1):33-47.
Authors: Asarnow JR et al.
Grant No.: HS09908.
Principal Investigator: Joan Asarnow.
Project Officer: Charlotte Mullican.
Abstract: Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.
Title: Clinical inertia.
Publication: Ann Intern Med 2001 Nov 6; 135(9):825-34.
Authors: Phillips LS et al.
Grant No.: HS09722.
Principal Investigator: Lawrence Phillips.
Project Officer: Yen-Pin chiang.
Abstract: Medicine has traditionally focused on relieving patient symptoms. However, in developed countries, maintaining good health increasingly involves management of such problems as hypertension, dyslipidemia, and diabetes, which often have no symptoms. Moreover, abnormal blood pressure, lipid, and glucose values are generally sufficient to warrant treatment without
further diagnostic maneuvers. Limitations in managing such problems are often due to clinical inertia-failure of health care providers to initiate or intensify therapy when indicated. Clinical inertia is due to at least three problems: overestimation of care provided; use of "soft" reasons to avoid
intensification of therapy; and lack of education, training, and practice organization aimed at achieving therapeutic goals. Strategies to overcome clinical inertia must focus on medical students, residents, and practicing physicians. Revised education programs should lead to assimilation of three concepts: the benefits of treating to therapeutic targets, the practical complexity of treating to target for different disorders, and the need to structure routine practice to facilitate effective management of disorders for which resolution of patient symptoms is not sufficient to guide care.
Physicians will need to build into their practice a system of reminders and performance feedback to ensure necessary care.
Title: Evidence-based guidelines meet the real world: the case of diabetes care.
Publication: Diabetes Care 2001 Oct;24(10):1728-33.
Authors: Larme AC, Pugh JA.
Grant No.: HS07397.
Principal Investigator: Jacqueline Pugh.
Project Officer: Heddy Hubbard.
Abstract: OBJECTIVE: Improving diabetes care in the United States is critical because diabetes rates are increasing dramatically, particularly among minority and low-income populations. Although evidence-based practice guidelines for diabetes have been widely disseminated, many physicians fail to implement them. The objective of this study was to explore what happens to diabetes practice guidelines in real-world clinical settings. RESEARCH DESIGN AND METHODS: A qualitative research design was used. Open-ended semistructured interviews lasting 1-2 hour were conducted with 32 key informants (physicians, certified diabetes educators, researchers, and agency personnel) selected for their knowledge of diabetes care in South Texas, an area with a high diabetes prevalence and a large proportion of minority and low-income patients. RESULTS: Health professionals stress that contextual factors are more important barriers to optimal diabetes care than physician knowledge and attitudes. Barriers exist at multiple levels and are interrelated in a complex manner. Examples include the following: time constraints and practice economics in the private practice setting; the need to maintain referral relationships and maldistribution of professionals in the practice community; low awareness and low socioeconomic status among patients; and lack of access for low-income patients, low reimbursement, and insufficient focus on prevention in the U.S. health care system. CONCLUSIONS: Contextual barriers must be addressed in order for diabetes practice guidelines to be implemented in real-world clinical practice. Suggested changes include an increased focus on prevention, improvements in health care delivery for chronic diseases, and increased attention to the special needs of minority and low-income populations.