Family Medicine Update

“Damm Sokkor”* Factors associated with the quality of care of patients with diabetes: A study in primary care in Tunisia (*Damm = blood pressure, Sokkor = diabetes, in Arabic).

Diabetes Care. 2007 May 16;

Authors: Alberti H, Boudriga N, Nabli M

Objective To identify the organisational, physician and patient factors associated with the quality of care of patients with diabetes in a low/middle income country. Research Design and Methods Data from 2160 randomly selected patients with diabetes were extracted from the manual medical records of a nationwide sample of 48 randomly selected health centres. Physician and organisational characteristics were collected from national reports, questionnaires, interviews and observation at the centres. Univariate and multivariate regression analyses were undertaken to identify associations with four quality of care scores, based on processes and intermediate outcomes of care, and 53 potential explanatory factors. Results The mean age of the study population was 62.4years, mean duration of diabetes was 8.4years, 62% were female and 94% had type 2 diabetes. In the final multivariate models, factors independently and significantly associated with higher process of care scores were regional affluence, doctor motivation and the use of chronic disease clinics (p<0.05). Health centres with younger patients and increased availability of medication were independently and significantly associated with improved outcome of care scores (p<0.05). The final models of the 4 quality of care scores explained 55-71% of the variations in scores. Conclusions Use of chronic disease clinics, availability of medication and possibly doctor motivation, appear to be the most strongly related modifiable factors influencing diabetes care. These findings will be used to develop and implement culturally appropriate, quality improvement interventions to improve the quality of diabetes care. We recommend our findings be taken into account in other low/middle income countries.

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Prediction and prevention of type 1 diabetes: progress, problems, and prospects.

Clin Pharmacol Ther. 2007 May;81(5):768-71

Authors: Skyler JS

Type 1 diabetes mellitus (T1D) arises from selective immunologically mediated destruction of the insulin-producing beta-cells in the pancreatic islets of Langerhans with consequent insulin deficiency. This occurs in genetically susceptible individuals and is a cellular-mediated process, presumably a specific reaction to one or more beta-cell proteins (autoantigens), although probably initiated by some environmental factor(s). There is consequent progressive impairment of beta-cell function and decline in beta-cell mass. A secondary humoral immune response is characterized by the appearance of autoantibodies that serve as markers of the immune damage to beta-cells. This insidious T1D disease process evolves over a period of years. The decline in beta-cell function and mass is evidenced metabolically by loss of first-phase insulin response to an intravenous glucose challenge, and later by the appearance of impairment in glycemic regulation, manifested as dysglycemia–usually as impaired glucose tolerance, but occasionally as impaired fasting glucose. Ultimately, the clinical syndrome of T1D becomes evident when the majority of beta-cells have been destroyed and frank hyperglycemia supervenes. Given this sequence of events, for which it is possible to envision intervention to interdict the process, it is not surprising that much research effort has been expended to identify individuals at risk of the disease.

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Value of recruitment strategies used in a primary care practice-based trial.

Contemp Clin Trials. 2007 May;28(3):258-67

Authors: Ellis SD, Bertoni AG, Bonds DE, Clinch CR, Balasubramanyam A, Blackwell C, Chen H, Lischke M, Goff DC

PURPOSE: “Physicians-recruiting-physicians” is the preferred recruitment approach for practice-based research. However, yields are variable; and the approach can be costly and lead to biased, unrepresentative samples. We sought to explore the potential efficiency of alternative methods. METHODS: We conducted a retrospective analysis of the yield and cost of 10 recruitment strategies used to recruit primary care practices to a randomized trial to improve cardiovascular disease risk factor management. We measured response and recruitment yields and the resources used to estimate the value of each strategy. Providers at recruited practices were surveyed about motivation for participation. RESULTS: Response to 6 opt-in marketing strategies was 0.40% (53/13290), ranging from 0% to 2.86% by strategy; 33.96% (18/53) of responders were recruited to the study. Of those recruited from opt-out strategies, 8.68% joined the study, ranging from 5.35% to 41.67% per strategy. A strategy that combined both opt-in and opt-out approaches resulted in a 51.14% (90/176) response and a 10.80% (19/90) recruitment rate. Cost of recruitment was $613 per recruited practice. Recruitment approaches based on in-person meetings (41.67%), previous relationships (33.33%), and borrowing an Area Health Education Center’s established networks (10.80%), yielded the most recruited practices per effort and were most cost efficient. Individual providers who chose to participate were motivated by interest in improving their clinical practice (80.5%); contributing to CVD primary prevention (54.4%); and invigorating their practice with new ideas (42.1%). CONCLUSIONS: This analysis provides suggestions for future recruitment efforts and research. Translational studies with limited funds could consider multi-modal recruitment approaches including in-person presentations to practice groups and exploitation of previous relationships, which require the providers to opt-out, and interactive opt-in approaches which rely on borrowed networks. These approaches can be supplemented with non-relationship-based opt-out strategies such as cold calls strategically targeted to underrepresented provider groups.

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