Richelle J. Koopman

Changes in Age at Diagnosis of Type 2 Diabetes Mellitus in the United States, 1988 to 2000

PURPOSE The prevalence of diabetes in the United States is increasing. There is also concern that diabetes may be occurring at a greater frequency in youth and in young adults. We describe US population trends in self-reported age at diagnosis of type 2 diabetes mellitus. METHODS We undertook a secondary analysis of data from the National Health and Nutrition Examination Survey (NHANES) 1999–2000 and NHANES III (1988–1994). Both surveys are stratified, multistage probability samples targeting the civilian, noninstitutionalized US population, which allow calculation of population estimates. We included adults aged 20 years and older. We compared self-reported age at diagnosis of type 2 diabetes between the 2 survey periods. RESULTS The mean age at diagnosis decreased from 52.0 to 46.0 years (P <.05). Racial and ethnic differences in age at diagnosis found in 1988 to 1994 are no longer found in 1999 to 2000. CONCLUSIONS The age at diagnosis of type 2 diabetes mellitus has decreased with time. This finding likely represents a combination of changing diagnostic criteria, improved physician recognition of diabetes, and increased public awareness. Younger age at diagnosis may also reflect a true population trend of earlier onset of type 2 diabetes.

Relationship between continuity of care and diabetes control: Evidence from the Third National Health and Nutrition Examination Survey

OBJECTIVES We examined the relationship between continuity of care and diabetes control. METHODS We analyzed data on 1400 adults with diabetes who took part in the Third National Health and Nutrition Examination Survey. We examined the relationship of continuity of care with glycemic, blood pressure, and lipid control. RESULTS Continuity of care was associated with both acceptable and optimal levels of glycemic control. Continuity was not associated with blood pressure or lipid control. There was no difference between having a usual site but no usual provider and having a usual provider in any of the investigated outcomes. CONCLUSIONS Continuity of care is associated with better glycemic control among people with diabetes. Our results do not support a benefit of having a usual provider above having a usual site of care.

Information needs and information-seeking behaviour analysis of primary care physicians and nurses: a literature review

BACKGROUND The increase in the adoption of electronic health records (EHR) has contributed to physicians and nurses experiencing information overload. To address the problem of information overload, an assessment of the information needs of physicians and nurses will assist in understanding what they view as useful information to make patient care more efficient. OBJECTIVE To analyse studies that assessed the information needs and information-seeking behaviour of physicians and nurses in a primary care setting to develop a better understanding of what information to present to physicians when they making clinical decisions. METHOD A literature review of studies was conducted with a comprehensive search in PubMed, cinahl, scopus, as well as examination of references from relevant papers and hand-searched articles to identify articles applicable to this review. RESULTS Of the papers reviewed the most common information needs found among physicians and nurses were related to diagnoses, drug(s) and treatment/therapy. Colleagues remain a preferred information source among physicians and nurses; however, a rise in Internet usage is apparent. CONCLUSION Physicians and nurses need access to the Internet and job-specific resources to find practitioner-oriented information. In addition, effective usage of resources is important for improving patient care.

Information needs of informal caregivers of older adults with chronic health conditions

OBJECTIVE To systematically examine current evidence pertaining to information needs of informal caregivers of older adults with chronic health conditions. METHODS Structured search of MEDLINE, MEDLINE IN-PROCESS, CINAHL, and PsycINFO databases to identify studies of caregiver information needs, followed by data extraction and syntheses. RESULTS The 62 articles that met the stated inclusion criteria highlighted extensive needs among informal caregivers for practical, accessible, timely information. CONCLUSION The identified information needs of informal caregivers can inform organizations and agencies that seek to provide disease and illness-related information. PRACTICE IMPLICATIONS Existing evidence supports the implementation of a health information delivery system designed to meet the needs of informal caregivers of older adults with chronic health conditions.

A Diabetes Dashboard and Physician Efficiency and Accuracy in Accessing Data Needed for High-Quality Diabetes Care

PURPOSE We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care. METHODS We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and “think-aloud” interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology. RESULTS The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again. CONCLUSIONS Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies.

Evidence of Nephropathy and Peripheral Neuropathy in US Adults With Undiagnosed Diabetes

PURPOSE Nearly one third of diabetes cases in the United States is undiagnosed, with mounting evidence that complications accrue even before clinical diagnosis. We wanted to determine whether persons with undiagnosed diabetes have signs of nephropathy and peripheral neuropathy METHODS We examined the prevalence of positive screening tests for nephropathy and peripheral neuropathy in adults aged ≥40 years with undiagnosed diabetes using secondary analysis of survey and examination data from the population-based United States National Health and Nutrition Examination Survey 1999-2002. We defined a positive screening test for nephropathy as a spot urine albumin-creatinine ratio >30.0 mg/g, representing at least microalbuminuria. We defined ≥1 insensate area on Semmes-Weinstein monofilament testing as a positive finding for neuropathy. Undiagnosed diabetes was defined as a combination of no history of diagnosed diabetes and a measured fasting glucose ≥126 mg/dL. We used SUDAAN for χ2 and regression analyses. RESULTS The prevalence of a positive test when screening for nephropathy among those with undiagnosed diabetes was 26.5% compared with 7.1% in those with no diabetes (χ2, P <.01). After adjusting for age and diagnosed or undiagnosed hypertension, the association of undiagnosed diabetes with nephropathy persisted (odds ratio = 2.35; 95% confidence interval, 1.38–4.01). For peripheral neuropathy, 21.5% with undiagnosed diabetes had positive screening tests compared with 10.1% with no diabetes (χ2, P <.01); however, this effect was not significant after adjustment for age. There was no significant difference in positive screening tests for nephropathy or neuropathy when comparing those with undiagnosed and diagnosed diabetes. CONCLUSIONS A significant proportion of adults with undiagnosed diabetes have signs of nephropathy and peripheral neuropathy. These findings may influence policies about early screening for diabetes.

Automated Technology to Speed Recognition of Signs of Illness in Older Adults

Our team has developed a technological innovation that detects changes in health status that indicate impending acute illness or exacerbation of chronic illness before usual assessment methods or self-reports of illness. We successfully used this information in a 1-year prospective study to alert health care providers so they could readily assess the situation and initiate early treatment to improve functional independence. Intervention participants showed significant improvements (as compared with the control group) for the Short Physical Performance Battery gait speed score at Quarter 3 (p = 0.03), hand grip-left at Quarter 2 (p = 0.02), hand grip-right at Quarter 4 (p = 0.05), and the GAITRite functional ambulation profile score at Quarter 2 (p = 0.05). Technological methods such as these could be widely adopted in older adult housing, long-term care settings, and in private homes where older adults wish to remain independent for as long as possible.

Issues and questions to consider in implementing secure electronic patient–provider web portal communications systems

PURPOSE Patients are increasingly interested in using Internet-based technologies to communicate with their providers, schedule clinic visits, request medication refills, and view their medical records electronically. However, healthcare organizations face significant challenges in providing such highly personal and sensitive communication in an effective and user-friendly manner. METHODS Based on the literature and our experience in providing a secure web-based patient-provider communication portal in primary care clinics, a framework was developed that identifies key issues and questions to consider in implementing secure electronic patient-provider communications systems. RESULTS The framework serves to categorize the many lessons learned from our implementation process and the specific issues and questions healthcare organizations need to consider in implementing such systems related to seven areas: strategic fit and priority; selection process & implementation team; integration into communications and workflows; HIPAA issues & clinic policies; systems implementation & training; marketing & enrollment; on-going performance monitoring. CONCLUSION The framework provides a useful guide for organizations looking to implement secure electronic patient-provider communication systems.

Diabetes management in the USA and England : comparative analysis of national surveys

OBJECTIVES To compare diabetes management in adults between England and the United States, particularly focusing on the impact of a universal access health insurance system. DESIGN Analysis of the nationally-representative surveys Health Survey of England, 2003 (unweighted n =14 057) and the National Health and Nutrition Examination Survey, 2001-2002 (unweighted n =5411). SETTING AND PARTICIPANTS Adults 20-64 years of age; individuals >65. MAIN OUTCOME MEASURES Glycaemic, lipid and blood pressure control and medication use among individuals with previously diagnosed diabetes. RESULTS Among those aged 20-64 the prevalence of diagnosed diabetes was lower in England (2.7%) than in the USA (5.0%). The proportion with diabetes receiving treatment was similar for the two countries. However, the mean HbA1c in England was 7.6%: in the USA it was 7.5% for those with insurance and 8.6% for those without insurance. The proportion of individuals on ACE inhibitors in England was 39%: in USA it was 39% for those with insurance, and 14% for those without. CONCLUSIONS Individuals in a healthcare system providing universal access have better managed diabetes than those in a market based system once one accounts for insurance.

Using sensor networks to detect urinary tract infections in older adults

Integrated sensor networks have been installed in apartments of volunteer residents at TigerPlace, an aging in place retirement community that allows residents to remain in their apartments even if their health deteriorates. The sensor networks supplement registered nurse (RN) care coordination provided by Sinclair Home Care by alerting the RN care coordinator about changes in the normal sensor patterns. In several cases, the alerts have prompted the care coordinator to have the resident tested for urinary tract infections. Importantly, the sensor network detected signs of illness earlier than traditional health care assessment.