Preconception Counseling in Women with Diabetes by Primary Care Providers and Perceived Barriers to Initiating this Discussion

Objective: To evaluate the frequency that women with diabetes mellitus seen by a primary care provider receive preconception counseling; to identify barriers to preconception counseling; and to determine differences between family medicine, internal medicine, and obstetrics and gynecology.Methods: This was a retrospective cohort study in which medical records were reviewed to determine if preconception counseling was done. An electronic survey evaluated how often preconception counseling was provided and identified perceived barriers to preconception counseling. Characteristics of those who received preconception counseling and those who did not, and survey responses between disciplines, were compared.Results: Women that met inclusion criteria: 577 (18.9% of whom received preconception counseling). A total of 88.7% of primary care providers indicated that preconception counseling was important, but only 39.2% reported that they regularly provide preconception counseling.Conclusion: Women with diabetes mellitus do not regularly receive preconception counseling by primary care providers. Lack of time and knowledge were the most commonly identified barriers to providing preconception counseling.Abbreviations: DM = diabetes mellitus; FM = family medicine; HbA1c = hemoglobin A1c; IM = internal medicine; LVHN = Lehigh Valley Health Network; Ob/Gyn = obstetrics/gynecology; PC = preconception counseling; PCP = primary care provider     

Web-Based Surveillance of Public Information Needs for Informing Preconception Interventions

Background

The risk of adverse pregnancy outcomes can be minimized through the adoption of healthy lifestyles before pregnancy by women of childbearing age. Initiatives for promotion of preconception health may be difficult to implement. Internet can be used to build tailored health interventions through identification of the public''s information needs. To this aim, we developed a semi-automatic web-based system for monitoring Google searches, web pages and activity on social networks, regarding preconception health.

Methods

Based on the American College of Obstetricians and Gynecologists guidelines and on the actual search behaviors of Italian Internet users, we defined a set of keywords targeting preconception care topics. Using these keywords, we analyzed the usage of Google search engine and identified web pages containing preconception care recommendations. We also monitored how the selected web pages were shared on social networks. We analyzed discrepancies between searched and published information and the sharing pattern of the topics.

Results

We identified 1,807 Google search queries which generated a total of 1,995,030 searches during the study period. Less than 10% of the reviewed pages contained preconception care information and in 42.8% information was consistent with ACOG guidelines. Facebook was the most used social network for sharing. Nutrition, Chronic Diseases and Infectious Diseases were the most published and searched topics. Regarding Genetic Risk and Folic Acid, a high search volume was not associated to a high web page production, while Medication pages were more frequently published than searched. Vaccinations elicited high sharing although web page production was low; this effect was quite variable in time.

Conclusion

Our study represent a resource to prioritize communication on specific topics on the web, to address misconceptions, and to tailor interventions to specific populations.     

An Individualized Inpatient Diabetes Education and Hospital Transition Program for Poorly Controlled Hospitalized Patients with Diabetes

ObjectiveTo evaluate predictors of outcomes associated with an inpatient diabetes education and discharge support program for hospitalized patients with poorly controlled diabetes (glycated hemoglobin [HbA1c]>9%).MethodsPatients participated in individualized diabetes education conducted by a certified diabetes educator (CDE) that included an exploration of barriers and goal setting during hospitalization with telephone follow-up and communication with primary providers at discharge. Predictors of HbA1c reduction, successful follow-up, and readmission were analyzed.ResultsThere were 82 subjects, and 48% were insulin naïve. Patients with type 2 diabetes (T2D, n = 58) had a significant decrease in HbAlc at follow-up (-2.8%, P < .0001), while those with type 1 diabetes (T1D, n = 19) did not (+ 0.02%, P = .96). However, after adjustment for other factors, only increasing age, higher baseline HbA1c, earlier education, and initiation of basal insulin were significant predictors of reduction in HbA1c. Higher area level income and empowerment and earlier education were significant predictors of outpatient follow-up within 30 days. While 28% were admitted for severe hyperglycemia, only 1 patient was readmitted with severe hyperglycemia. Successful phone contact was 77% and 57% with and without the support of non-CDE assistants respectively, but all outcomes were similar.ConclusionThe study suggests that an individualized inpatient diabetes education and transition program is associated with a significant reduction in HbA1c that is dependent on baseline HbA1c, older age, initiation of insulin, and earlier enrollment. Additional interventions are needed to ensure better continuity of care. (Endocr Pract. 2014;20:1265-1273)     

Concordance facilitates access in diabetes care-service provider perspectives of service improvement and cultural competency

Aims Inequalities between different ethnic groups in diabetes care and outcomes are well documented in the UK. This research sought to explore and understand how national and local policy interventions impacted upon access and the development of culturally competent diabetes services from the care provider perspective. Methods This paper describes the care provider perspective of access to diabetes care in ethnically mixed populations from a thematic analysis of 14 semi-structured interviews conducted with professionals, at three study sites, with different roles in the diabetes care pathway. Results National policy level initiatives to improve quality have led to quality improvements at a practical level. These achievements, however, have been unable to address all aspects of care that service providers identified as important in facilitating access for all patient groups. Concordance emerged as a key process in improving access to care within local systems and barriers to this exist at different levels and are greater for some groups of patients compared with others. Conclusions Concordance is a key concept that underpins access and cultural competency in diabetes service improvement. A focus on concordance at different levels within local systems may improve access to quality diabetes care for ethnic minority groups.     

How Do Women Prepare for Pregnancy? Preconception Experiences of Women Attending Antenatal Services and Views of Health Professionals

Main objective

To determine the extent to which women plan and prepare for pregnancy.

Methods

Cross-sectional questionnaire survey of pregnant women attending three maternity services in London about knowledge and uptake of preconception care; including a robust measure of pregnancy planning, and phone interviews with a range of health care professionals.

Main results

We recruited 1173/1288 (90%) women, median age of 32 years. 73% had clearly planned their pregnancy, 24% were ambivalent and only 3% of pregnancies were unplanned. 51% of all women and 63% of those with a planned pregnancy took folic acid before pregnancy. 21% of all women reported smoking and 61% reported drinking alcohol in the 3 months before pregnancy; 48% of smokers and 41% of drinkers reduced or stopped before pregnancy. The 51% of all women who reported advice from a health professional before becoming pregnant were more likely to adopt healthier behaviours before pregnancy [adjusted odds ratios for greatest health professional input compared with none were 2.34 (95% confidence interval 1.54–3.54) for taking folic acid and 2.18 (95% CI 1.42–3.36) for adopting a healthier diet before pregnancy]. Interviews with 20 health professionals indicated low awareness of preconception health issues, missed opportunities and confusion about responsibility for delivery of preconception care.

Significance of the findings

Despite a high level of pregnancy planning, awareness of preconception health among women and health professionals is low, and responsibility for providing preconception care is unclear. However, many women are motivated to adopt healthier behaviours in the preconception period, as indicated by halving of reported smoking rates in this study. The link between health professional input and healthy behaviour change before pregnancy is a new finding that should invigorate strategies to improve awareness and uptake of pre-pregnancy health care, and bring wider benefits for public health.     

Neue Interventionsansätze zur Sekundärprävention alkoholbezogener Störungen im Allgemeinkrankenhaus

As individuals with problematic alcohol consumption are hardly reached by the treatment system, measures of early intervention in the primary health care system are promising. However, counseling strategies such as Motivational Interviewing that have been proven to be effective are rarely conducted. Lack of time is mentioned by physicians as a main barrier for conducting brief interventions. New technologies allow the development of economic and individualized prevention strategies. This paper presents the computerized Expert-test and Guide [“Ratgeber”] for Alcohol use (ExtrA), a prevention program for at-risk drinking. Data on the efficacy of this approach in proactively recruited samples are described and possible conclusions for the usability of new technologies for interventions with a high population impact are presented.     

Improving Diabetes Care in Rural Areas: A Systematic Review and Meta-Analysis of Quality Improvement Interventions in OECD Countries

Background and Aims

Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.

Methods

We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.

Results

Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).

Conclusions

This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.     

New trends in assessing the outcomes of mental health interventions

Assessing the outcomes of interventions in mental health care is both important and challenging. The aim of this paper is to advance the field of outcomes research by proposing a taxonomy of the decisions that clinicians and researchers need to consider when evaluating outcomes. Our taxonomy has eight components, framed as decisions: Whose outcome will be considered? Which scientific stage is being investigated? What outcome domain(s) matter? What level of assessment will be used? Will clinical and/or recovery outcomes be assessed? Whose perspective will be considered? Will deficits and/or strengths be the focus? Will invariant or individualized measures be preferred? We propose a future focus on understanding what matters most to people using mental health services, and on the use of measures rated by service users as the primary approach to evaluating outcome.     

Impacto de las herramientas «Mapas de Conversaciones™» sobre el conocimiento de la diabetes en pacientes españoles con diabetes mellitus tipo 2: un estudio aleatorizado y comparativo

Background and aimThis paper presents results from the Spanish subpopulation of a study comparing Conversation Maps™ (CM)-based education with regular care (RC) in type 2 diabetes mellitus (T2DM).Patients and methodsAdult patients with T2DM who were considered as not demonstrating ideal disease management were randomly assigned to CM or RC with assessments following (Visit 2), and at follow-up 6 months after (Visit 3), the final CM session. The primary endpoint was diabetes knowledge at Visit 3.Results310 patients were randomised to receive CM education (n=148) or RC (n=162). Median knowledge scores were ranked significantly higher in the CM group than the RC group at Visit 2 and Visit 3 (p<0.001). No significant differences in clinical and other outcomes were identified between the interventions, except satisfaction with care (p<0.001, Visit 2; p=0.055, Visit 3) and perception of goal attainment (p<0.001 and p = 0.046, respectively) that were both higher in the CM group.ConclusionsIn these patients from Spain, CM was superior to RC in terms of diabetes knowledge 6 months after education was completed, suggesting that CM should be considered for use in patients requiring diabetes education.     

Prioritisation of clinical research by the example of type 2 diabetes: a caregiver-survey on perceived relevance and need for evidence

Background

The Cochrane Collaboration aims at providing the best available evidence for interventions in health care. We wished to examine to which extent treatments considered relevant by caregivers in type 2 diabetes are covered by Cochrane systematic reviews.

Methodology/Principal Findings

130 different interventions in type 2 diabetes were identified based on a review of clinical practice guidelines and expert opinion (Table S1). 459 members of the German Diabetes Society (diabetologists, general practitioners, diabetic nurses, nutritionists, podologists, others) were surveyed via e-mail-list to rank a) the perceived clinical relevance and b) the perceived need for evidence of interventions, based on an internet survey. In the Cochrane Library, there were, at the time of this evaluation, 56 reviews on interventions in diabetes. Generally, coverage of topics by Cochrane reviews reflected the perceived clinical relevance and perceived need for evidence. As an example, highly ranked treatments such as lifestyle changes or oral antidiabetics were well covered, while low rank treatments such as complementary approaches were not covered. Discrepancies occurred with new treatments such as amylin-analogues (low relevance, high need for evidence, review not yet completed) and interventions with immediate and dramatic effects such as treating hypoglycemia (high relevance, low need for evidence, no review). Also, there was a relative scarcity of reviews concerning specific problems, in particular, treatment of late diabetic complications.

Conclusions/Significance

For most interventions, perceived relevance and perceived need for evidence are reflected by the evidence already available. Prioritizing should aim at improving immediacy and consideration of the treatment of complications.     

Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions

Objective

The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population.

Methods

Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized.

Results

Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient.

Conclusions

The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.     

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high‐income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.     

Patient-Reported Experiences with First-Time Naturopathic Care for Type 2 Diabetes

Differences in the effectiveness of diverse healthcare providers to promote health behavior change and successful diabetes self-care have received little attention. Because training in naturopathic medicine (NM) emphasizes a patient-centered approach, health promotion, and routine use of clinical counseling on wellness and prevention, naturopathic physicians (NDs) may be particularly well-prepared for promoting behavior change. However, patients’ experiences with NM have not been well studied. This study provides the first report of the perceptions of persons with type 2 diabetes of their first experiences with naturopathic care for their diabetes. Following their participation in a one-year prospective cohort study of adjunctive naturopathic care for diabetes, twenty-two patients were interviewed about their experiences working with a naturopathic physician. Using a content analysis approach, nine dominant themes were identified. Three themes characterized the nature of the ND-patient interaction: 1) patient-centered, 2) holistic health rather than diabetes focused, and 3) collaborative. Five themes characterized the content of the clinical encounter: 1) individualized and detailed health promotion, 2) counseling that promoted self-efficacy, 3) pragmatic and practical self-care recommendations, 4) novel treatment options that fostered hopefulness, and 5) patient education that addressed both diabetes self-care and general health. A ninth theme was cross-cutting: the contrast between ND care and conventional medical care. Results indicate that the routine clinical approach used by NDs is consistent with behavior change theory and clinical strategies found most effective in promoting self-efficacy and improving clinical outcomes.     

The Effectiveness of Screening for Diabetes and Cardiovascular Disease Risk Factors in a Community Pharmacy Setting

Risk factors for cardiovascular disease including diabetes have seen a large rise in prevalence in recent years. This has prompted interest in prevention through the identifying individuals at risk of both diabetes and cardiovascular disease and has seen increased investment in screening interventions taking place in primary care. Community pharmacies have become increasingly involved in the provision of such interventions and this systematic review and meta-analysis aims to gather and analyse the existing literature assessing community pharmacy based screening for risk factors for diabetes and those with a high cardiovascular disease risk.

Methods

We conducted systematic searches of electronic databases using MeSH and free text terms from 1950 to March 2012. For our analysis two outcomes were assessed. They were the percentage of those screened who were referred for further assessment by primary care and the uptake of this referral.

Results

Sixteen studies fulfilled our inclusion criteria comprising 108,414 participants screened. There was significant heterogeneity for all included outcomes. Consequently we have not presented summary statistics and present forest plots with I² and p values to describe heterogeneity. We found that all included studies suffered from high rates of attrition between pharmacy screening and follow up. We have also identified a strong trend towards higher rates for referral in more recent studies.

Conclusions

Our results show that pharmacies are feasible sites for screening for diabetes and those at risk of cardiovascular disease. A significant number of previously unknown cases of cardiovascular disease risk factors such as hypertension, hypercholesterolemia and diabetes are identified, however a significant number of referred participants at high risk do not attend their practitioner for follow up. Research priorities should include methods of increasing uptake to follow up testing and early intervention, to maximise the efficacy of screening interventions based in community pharmacies.     

Die Effektivität psychologischer Behandlungsansätze zur Verbesserung der Stoffwechselkontrolle bei Patienten mit Diabetes mellitus

Various reviews have highlighted that despite an increased awareness that psychological care is needed to help optimize diabetes self care, there are difficulties in interpreting the current evidence and translating it into the clinical setting but there seems to be most evidence for CBT techniques delivered by experienced therapists and family interventions for children and adolescents. In the coming years, combining qualitative and quantitative research methodologies should help to refine the techniques, identify what works for whom and for which outcome(s).     

Psychologische Aspekte des Diabetes in Kindheit und Adoleszenz

The intensified insulin therapy of type 1 diabetes imposes considerable demands in everyday life of children, adolescents and their families that often interfere with normal developmental tasks. Accordingly current guidelines on paediatric diabetes stated that psychosocial factors are the most important influences affecting the care and management of the chronic illness. This article reviews the main research findings from studies on psychological coping, family burden and dynamics, neurocognitive functioning, stress, psychosocial risk factors, psychological health and psychiatric disorders. In addition psychological support, age-appropriate educational and behavioural interventions as an integral part of every type 1 diabetes long-term therapy are described. Finally the vital role and the current situation of psychologists and social workers as members of the interdisciplinary paediatric diabetes teams especially in the context of the German Disease –Management Program for type 1 diabetes are discussed.     

Informal education and health promoting approaches in adult cancer survivors

This review looks at the available data relating to the informal education aspects and other health promoting approaches applied by adult cancer survivors to reduce the risk of cancer. The implications of such behavioral interventions on oncology practice are discussed. We also highlight areas of future research to pursue. Available data show that many cancer survivors remain engaged in risky health behaviors post-diagnosis, which are associated with an increased risk of disease's recurrence. However, over the last years patients seem to increasingly receive adequate risk-based medical care. The application of appropriate informal education approaches, such as diet, exercise, and cessation of former unhealthy habits, such as smoking and alcohol has facilitated behavioral changes in cancer survivors, thoroughly improving their well being and overall quality of life (QOL). Most of the research studies published to date have applied structured lifestyle interventions on intensive, individualized counseling sessions delivered by trained personnel or psychosocial-based mediations and reported that these approaches are largely effective in promoting the adoption of a healthier lifestyle in cancer survivors. These interventions have been reported to reduce the risk of cancer recurrence and thus to obtain an obvious positive impact on their well-being and overall QOL. However, there is still insufficient evidence to conclude and support with confidence the effectiveness of any of these behavioral interventions and therefore future interventions should be initiated to assess the long-term effects and validating outcomes of lifestyle and other psychosocial interventions.     

Proteomic analysis of adipose tissue: informing diabetes research

Diabetes, one of the most common endocrine diseases worldwide, results from complex pathophysiological mechanisms that are not fully understood. Adipose tissue is considered a major endocrine organ and plays a central role in the development of diabetes. The identification of the adipose tissue-derived factors that contribute to the onset and progression of diabetes will hopefully lead to the development of preventive and therapeutic interventions. Proteomic techniques may be useful tools for this purpose. In the present review, we have summarized the studies conducting adipose tissue proteomics in subjects with diabetes and insulin resistance, and discussed the proteins identified in these studies as candidates to exert important roles in these disorders.     

Pre-Conception Dyslipidemia Is Associated with Development of Preeclampsia and Gestational Diabetes Mellitus

IntroductionThe association between glucose intolerance, elevated blood pressure and abnormal lipid levels is well established and comprises the basis of metabolic syndrome pathophysiology. We hypothesize that abnormal preconception lipid levels are associated with the increased risk of severe pregnancy complications such as preeclampsia and gestational diabetes mellitus.MethodsWe included all singleton deliveries (n = 27,721) of women without known cardiovascular morbidity and preeclampsia and gestational diabetes mellitus during previous pregnancies. Association between preconception low high density lipoprotein cholesterol (HDLc level≤50 mg/dL), high triglycerides (level≥150 mg/dL) and the primary outcome (composite of gestational diabetes mellitus/or preeclampsia) was assessed using Generalized Estimation Equations.ResultsPrimary outcome of preeclampsia and/or gestational diabetes was observed in a total of 3,243 subjects (11.7%). Elevated triglycerides and low HDLc were independently associated with the primary outcome: with odds ratio (OR) of 1.61 (95% CI 1.29–2.01) and OR = 1.33 (95% CI 1.09–1.63), respectively, after adjusting for maternal age, weight, blood pressure, repeated abortions, fertility treatments and fasting glucose. There was an interaction between the effects of HDLc≤50 mg/dL and triglycerides≥150 mg/dL with an OR of 2.69 (95% CI 1.73–4.19).ConclusionsOur analysis showed an increased rate of preeclampsia and/or gestational diabetes in women with low HDLc and high triglycerides values prior to conception. In view of the severity of these pregnancy complications, we believe this finding warrants a routine screening for the abnormal lipid profile among women of a child-bearing age.     

Optimizing the therapeutic benefits of exercise in Type 2 diabetes.

Other than diet and medication, exercise is considered one of the three cornerstones of good diabetes treatment. Nevertheless, current clinical guidelines on Type 2 diabetes provide no detailed information on the modalities of effective exercise intervention in the treatment of Type 2 diabetes. Based on a review of currently available literature, exercise modalities are being identified to maximize the benefits of exercise intervention in the treatment of different Type 2 diabetes subpopulations. Both endurance and resistance types of exercise have equal therapeutic strength to improve metabolic control in patients with Type 2 diabetes. When applying endurance-type exercise, energy expenditure should be equivalent to approximately 1.7-2.1 MJ/exercise bout on 3 but preferably 5 days/wk. In sarcopenic or severely deconditioned patients with Type 2 diabetes, focus should lie on the implementation of resistance-type exercise to attenuate and/or reverse the decline in skeletal muscle mass and strength. Before choosing the most appropriate exercise modalities, the patient's disease stage should be well characterized, and an ECG-stress test should be considered. Based on baseline aerobic fitness, level of co-morbidities, body composition, and muscle strength, patients should be provided with an individually tailored exercise intervention program to optimize therapeutic value. A multidisciplinary individualized approach and continued exercise training under personal supervision is essential to enhance compliance and allow long-term health benefits of an exercise intervention program.