Kimberly S. Davis

Diabetes Empowerment, Medication Adherence and Self-Care Behaviors in Adults with Type 2 Diabetes

BACKGROUND Evidence suggests that empowerment is an important factor to address everyday aspects of dealing with a chronic disease. This study evaluated the effect of diabetes empowerment on medication adherence and self-care behaviors in adults with type 2 diabetes. SUBJECTS AND METHODS Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the southeastern United States were examined. Previously validated scales were used to measure diabetes empowerment, medication adherence, diabetes knowledge, and diabetes self-care behaviors (including diet, physical activity, blood sugar testing, and foot care). Multiple linear regression was used to assess the independent effect of diabetes empowerment on medication adherence and self-care behaviors controlling for relevant covariates. RESULTS Eighty-three percent were non-Hispanic blacks, 69% were women, 22% were 65 years or older, 68% were not married, 26% had less than high school education, 60% were unemployed, 39% were uninsured, and 47% had a yearly income <

Associations between Coping, Diabetes Knowledge, Medication Adherence, and Self-Care Behaviors in Adults with Type 2 Diabetes

10,000. Empowerment had significant correlations with medication adherence (r=0.17, P<0.003), diabetes knowledge (r=0.16, P=0.007), diet (r=0.24, P<0.001), exercise (r=0.25, P<0.001), blood sugar testing (r=0.12, P=0.043), and foot care (r=0.18, P=0.002). In the regression model, diabetes empowerment was significantly associated with medication adherence (β=-0.04, P=0.001), diabetes knowledge (β=0.09, P=0.012), diet (β=0.09, P<0.001), exercise (β=0.10, P<0.001), blood sugar testing (β=0.07, P=0.016), and foot care (β=0.08, P=0.001). CONCLUSIONS In this sample, diabetes empowerment was related to better diabetes knowledge, medication adherence and improved self-care behaviors. Emphasis on empowerment and self-efficacy is relevant to improve outcomes in the management of diabetes.

The Use of Clinical Decision‐Support Tools to Facilitate Geriatric Education

BACKGROUND Few studies have examined the emotional approach to coping on diabetes outcomes. This study examined the relationship between emotional coping and diabetes knowledge, medication adherence and self-care behaviors in adults with type 2 diabetes. METHODS Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the southeastern United States were examined. Previously validated scales were used to measure coping, medication adherence, diabetes knowledge and diabetes self-care behaviors (including diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of coping through emotional approach on medication adherence and self-care behaviors while controlling for relevant covariates. RESULTS Significant correlations were observed between emotional coping [as measured by emotional expression (EE) and emotional processing (EP)] and self-care behaviors. In the linear regression model, EP was significantly associated with medication adherence [β -0.17, 95% confidence interval (CI) -0.32 to -0.015], diabetes knowledge (β 0.76, 95% CI 0.29 to 1.24), diet (β 0.52, 95% CI 0.24 to 0.81), exercise (β 0.51, 95% CI 0.19 to 0.82), blood sugar testing (β 0.54, 95% CI 0.16 to 0.91) and foot care (β 0.32, 95% CI -0.02 to 0.67). On the other hand, EE was associated with diet (β 0.38, 95% CI 0.13 to 0.64), exercise (β 0.54, 95% CI 0.27 to 0.82), blood sugar testing (β 0.42, 95% CI 0.09 to 0.76) and foot care (β 0.36, 95% CI 0.06 to 0.66), but it was not associated with diabetes knowledge. CONCLUSION These findings indicate that coping through an emotional approach is significantly associated with behaviors that lead to positive diabetes outcomes.

Aging Q3: an initiative to improve internal medicine residents' geriatrics knowledge, skills, and clinical performance.

Innovative methods are needed to incorporate effective geriatric education into internal medicine residency programs. The purpose of this report is to describe the development and use of clinical decision‐support (CDS) tools to facilitate geriatric education and improve the care delivered to older adults in an academic internal medicine residency ambulatory care clinic. Starting in 2009, CDS tools were implemented as a major strategy of an initiative to improve resident physician clinical competencies in geriatrics and improve the quality of care and quality of life of older adults. These tools, designed to improve resident assessment and action for each of three educational modules (falls, vision, and dementia) were embedded within the ambulatory electronic medical record (EMR) and provided a method of point‐of‐care training to residents caring for older adults. One hundred internal medicine residents supervised by 17 general internal medicine faculty members participated. Data regarding CDS use and associated outcomes were recorded and extracted from the ambulatory clinic EMR. Residents screened between 67% and 88% of eligible patients using CDS algorithms; rates of additional assessment and referral or further examination reflected the prevalence of the condition in the patient population. Although further development may be necessary, CDS tools are a promising modality to supplement geriatric postgraduate education while simultaneously improving patient care.

Where are my patients? It is time to automate notification of hospital use to primary care practices.

A growing number of older adults coupled with a limited number of physicians trained in geriatrics presents a major challenge to ensuring quality medical care for this population. Innovations to incorporate geriatrics education into internal medicine residency programs are needed. To meet this need, in 2009, faculty at the Medical University of South Carolina developed Aging Q(3)-Quality Education, Quality Care, and Quality of Life. This multicomponent initiative recognizes the need for improved geriatrics educational tools and faculty development as well as systems changes to improve the knowledge and clinical performance of residents. To achieve these goals, faculty employ multiple intervention strategies, including lectures, rounds, academic detailing, visual cues, and electronic medical record prompts and decision support. The authors present examples from specific projects, based on care areas including vision screening, fall prevention, and caring for patients with dementia, all of which are based on the Assessing Care of Vulnerable Elders quality indicators. The authors describe the principles driving the design, implementation, and evaluation of the Aging Q(3) program. They present data from multiple sources that illustrate the effectiveness of the interventions to meet the knowledge, skill level, and behavior goals. The authors also address major challenges, including the maintenance of the teaching and modeling interventions over time within the context of demanding primary care and inpatient settings. This organized, evidence-based approach to quality improvement in resident education, as well as faculty leadership development, holds promise for successfully incorporating geriatrics education into internal medicine residencies.

Brief report: Trainee provider perceptions of group visits

Abstract The hospital-to-community transition is fraught with risks for patients, with 30-day readmission rates of 20% for Medicare patients. Poorly coordinated transitions of care translate to unplanned readmission costs to Medicare of more than

Acute Care Utilization in Patients With Concurrent Mental Health and Complex Chronic Medical Conditions

17 billion/year. Calls for better physician communication to improve care coordination abound; however, primary care physicians cannot better coordinate care when, in many cases, they are not even aware that their patients have been admitted to the hospital. During the past 30 years, we have made little progress in systematically improving communication between hospital and posthospital providers to coordinate postdischarge care. Hospitals and physicians need better tools to coordinate care transitions. It is time to automate the hospital discharge notification process, notify practice staff, and stop expecting physician-to-physician communication. Notification can be efficiently supported by computerized systems that do not rely on physicians to “close the loop” back to primary care. We present four clinical programs in which automated notification of primary care staff was used to ensure appropriate follow-up and coordination of care for patients. These automated systems use a secure online Web site or an encrypted e-mail notification system that alerts clinicians and practice staff to hospital registration of the patient. In each program, notification triggers a nurse-directed clinical assessment and care coordination plan and helps ensure timely primary care follow-up. We believe automated notification is a necessary tool to support coordination of care in the new delivery models such as the patient-centered medical home.

The association of cumulative discrimination on quality of care, patient-centered care, and dissatisfaction with care in adults with type 2 diabetes.

AbstractOBJECTIVE: To evaluate the effect of observing group visits on trainees’ perceptions of group visits as a method of health care delivery. RESEARCH DESIGN AND METHODS: Thirty-two trainees assigned to month-long rotations at an academic Internal Medicine Primary Care Clinic serving underinsured patients were recruited to observe between 1 and 4 group visits. Prior to observation of their first, and subsequent to observation of their last group visit, each trainee completed the Patient-Physician Orientation Scale (PPOS), a validated survey evaluating their tendencies toward being patient-centered or provider-centered. Additionally, they completed a Group Visit Questionnaire (GVQ) evaluating their perceptions of group visits as a method of health care delivery. RESULTS: Trainee gender, type, and level of training were similarly represented across the study population of trainees. While there were no significant differences noted on pre- and postobservation PPOS scores, the postobservation GVQs scores were significantly improved after observing at least one group visit (P<.0001). CONCLUSION: Trainees’ perceptions of group visits as a method of health care delivery improved significantly after observation of at least 1 group as measured by the GVQ.

Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes.

Objectives: Patients with coexisting mental health disorder and chronic disease are more at risk for poor outcomes, including increased acute care utilization. This study was performed to assess the association of mental health disorders on acute care utilization (emergency department [ED] use, hospitalization, and rehospitalization within 30 days) using disease clustering. Methods: A retrospective cohort analysis was performed on 10 408 patients. Adult patients >18 years of age were included in the study if they were seen at least twice in University Internal Medicine primary care clinic at the Medical University of South Carolina from October 10, 2010 through September 30, 2013. The main outcome measure was a count of acute care use (hospital or ED). A linear regression model was used to fit a predictive model for ED and hospital utilization, and agglomerative hierarchical clustering was used to identify patients with similar comorbidities. Results: Covariates associated with increased risk of ED and hospital utilization include non-white race (rate ratio [RR] = 1.35, P < .0001), resident physician (RR = 1.30, P < .0001), and public insurance (RR = 1.56, P < .0001). Patients within the multiple chronic conditions (MCC), chronic obstructive pulmonary disease (COPD)/asthma, or renal disease clusters had 1.80 (P < .0001), 1.50 (P < .0001), and 2.57 (P < .0001) times, respectively, the amount of predicted utilization compared with healthy patients, whereas patients with a mental health diagnosis had 1.41 (P < .0001) times the predicted utilization. There was a significant association with increased utilization in patients with coexisting mental health disorder and chronic disease within the COPD/asthma (RR = 1.20, P = .0038), renal disease (RR = 1.27, P < .0001), and MCC (RR = 1.34, P < .0001) clusters. Conclusions: Patients with co-occurring chronic medical conditions and mental health disorders have higher rates of acute care utilization compared with patients with chronic medical conditions alone. Improving access to mental health care at the primary care clinic may have a positive impact on utilization.

Advanced Care Directives: Overcoming the Obstacles

AIMS Discrimination is linked to negative health outcomes, but little research has investigated how the cumulative effect of discrimination impacts perceptions of care. This study investigated the influence of cumulative perceived discrimination on quality of care, patient-centeredness, and dissatisfaction with care in adults with type 2 diabetes. METHODS Six hundred two patients from two primary care clinics in Charleston, SC. Linear regression models assessed associations between perceived discrimination and quality of care, patient-centered care, and dissatisfaction with care. The models control for race, site, age, gender, marital status, duration of diabetes, education, hours worked weekly, income, and health status. RESULTS The mean age was 61.5years, with 66.3% non-Hispanic blacks, and 41.9% earning less than