Coaching of Physicians by RNs to Improve Diabetes Care

The prevalence of diabetes continues to grow, with the number of people in the U.S. with diagnosed diabetes now reaching 17.5 million. The objectives of this study are to quantify the economic burden of diabetes caused by increased health resource use and lost productivity, and to provide a detailed breakdown of the costs attributed to diabetes. This study uses a prevalence-based approach that combines the demographics of the population in 2007 with diabetes prevalence rates and other epidemiological data, health care costs, and economic data into a Cost of Diabetes Model. Health resource use and associated medical costs are analyzed by age, sex, type of medical condition, and health resource category. Data sources include national surveys and claims databases, as well as a proprietary database that contains annual medical claims for 16.3 million people in 2006. The total estimated cost of diabetes in 2007 is $174 billion, including $116 billion in excess medical expenditures and $58 billion in reduced national productivity. Medical costs attributed to diabetes include $27 billion for care to directly treat diabetes, $58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes, and $31 billon in excess general medical costs. The largest components of medical expenditures attributed to diabetes are hospital inpatient care (50% of total cost), diabetes medication and supplies (12%), retail prescriptions to treat complications of diabetes (11%), and physician office visits (9%). People with diagnosed diabetes incur average expenditures of $11,744 per year, of which $6,649 is attributed to diabetes. People with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than what expenditures would be in the absence of diabetes. For the cost categories analyzed, approximately $1 in $5 health care dollars in the U.S. is spent caring for someone with diagnosed diabetes, while approximately $1 in $10 health care dollars is attributed to diabetes. Indirect costs include increased absenteeism ($2.6 billion) and reduced productivity while at work ($20.0 billion) for the employed population, reduced productivity for those not in the labor force ($0.8 billion), unemployment from disease-related disability ($7.9 billion), and lost productive capacity due to early mortality ($26.9 billion). The actual national burden of diabetes is likely to exceed the $174 billion estimate because it omits the social cost of intangibles such as pain and suffering, care provided by nonpaid caregivers, excess medical costs associated with undiagnosed diabetes, and diabetes-attributed costs for health care expenditures categories omitted from this study. Omitted from this analysis are expenditure categories such as health care system administrative costs, over-the-counter medications, clinician training programs, and research and infrastructure development. The burden of diabetes is imposed on all sectors of society-higher insurance premiums paid by employees and employers, reduced earnings through productivity loss, and reduced overall quality of life for people with diabetes and their families and friends.

Despite significant advances in diagnosis and treatment, the persistence of inadequate metabolic control continues. Poor glycemic control may be reflected by both the failure of diabetes self-management by patients as well as inadequate intervention strategies by clinicians. The purpose of this systematic review is to summarize existing knowledge regarding various barriers of diabetes management from the perspectives of both patients and clinicians. A search of PubMed, CINAHL, ERIC, and PsycINFO identified 1454 articles in English published between 1990 and 2009, addressing type 2 diabetes, patient's barriers, clinician's barriers, and self-management. Patients' adherence, attitude, beliefs, and knowledge about diabetes may affect diabetes self-management. Culture and language capabilities influence the patient's health beliefs, attitudes, health literacy, thereby affecting diabetes self-management. Other influential factors include the patient's financial resources, co-morbidities, and social support. Clinician's attitude, beliefs and knowledge about diabetes also influence diabetes management. Clinicians may further influence the patient's perception through effective communication skills and by having a well-integrated health care system. Identifying barriers to diabetes management is necessary to improve the quality of diabetes care, including the improvement of metabolic control, and diabetes self-management. Further research that considers these barriers is necessary for developing interventions for individuals with type 2 diabetes. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Few studies have explored the contextual dimensions and subsequent interactions that contribute to a lack of adherence in the application of guidelines for diabetes management. The purpose of this qualitative study was to explore family physicians' issues and perceptions regarding the barriers to and facilitators of the management of patients with type 2 diabetes mellitus (DM). Four focus groups composed of family physicians (n= 30) explored the participants' experiences in the management of patients with type 2 DM. A semi-structured interview guide began with questions on family physicians' experience of providing care and included specific probes to stimulate discussion about the various barriers to and facilitators of the management of type 2 DM in family practice. Participants clearly identified type 2 DM as a chronic disease most often managed by family physicians. The findings revealed distinct barriers and facilitators in managing patients with type 2 DM which fell into three domains: patient factors; physician factors; and systemic factors. There was a dynamic interplay among the three factors. The important role of education was common to each. The interactions of patient, physician and systemic factors have implications for the implementation of a diabetes management model. The care of patients with type 2 DM exemplifies the ongoing challenges of caring for patients with a chronic disease in family practice. The findings, while specific to the management of type 2 DM, have potential transferability to other chronic illnesses managed by family physicians.