Comparison of the DM Regular Care Model and the "DM Share Care Disease Management" Model in Eastern

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Comparison of the DM Regular Care Model and the
"DM Share Care Disease Management" Model in
Eastern Taiwan

• ? ? ? ? ?
• ???????????
• Ching-Pei Lee, Cheng-I Chu1,2, Du-An Wu,
  Chen-Chung Fu, Jer-Chuan Li, Yi-Hsuan Wang,
  Hsin-Dean Chen
• Department of Internal Medicine, Buddhist Tzu Chi
  General Hospital, Hualien, Taiwan Department of
  Public Health1, Tzu Chi
• University, Hualien, Taiwan Department of
  Healthcare Administration2, Meiho Institute of
  Technology, Pingtung, Taiwan

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Article Outline

• Introduction
• Methods
• Study population
• Data collection
• DM knowledge assessment
• P't characteristics
• Outcomes
• Analyses
• Results
• Discussion

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Introduction

• According to Taiwan Department of Heath (DOH)
  statistics, since 1987 DM has ranked fifth or
  above among the ten major causes of death, and it
  advanced to fourth in 2000, making it one of the
  most prevalent diseases in Taiwan.
• DM not only adversely affects a person's physical
  condition, but also negatively impacts one's
  level of psychosocial functioning. Indeed, it
  clearly impacts overall life quality.
• The longer the period of affliction(??), the more
  often chronic complications develop. Likewise,
  inadequate control of blood sugar levels results
  in a lower quality of life.

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• For these reasons, in 1996 the DOH introduced the
  paradigm(??) of "shared care", which originated
  in England.
• In November of 2001, the DOH put the "DM medical
  benefit improvement project" of Taiwan's Bureau
  of National Health Insurance into formal
  practice.
• The program was also referred to as the "DSCDM
  (DM share care disease management) program".
• The project utilized health professionals from a
  wide range of medical organizations in providing
  comprehensive and continual health services to
  better control DM and improve their life quality.

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• The mortality rate from DM in Hualien County
  ranked the highest among all counties in Taiwan
  in 2003, with a rate 1.6 times that of the
  national average.
• A diabetic care team at a medical center in
  eastern Taiwan had been practicing a pattern of
  regular diabetic care for several years, and in
  2003 the hospital began applying the DSCDM
  program.
• The effectiveness of DSCDM has been demonstrated
  by much prior research which focused on measuring
  p'ts' disease recognition, selfcare, disease
  control, and life quality, as well as the
  accountability of medical professionals.
• Nonetheless, most of these findings were based on
  comparisons of p'ts who participated in DSCDM vs
  those who were not in any diabetic care program,
  or between those whose care was provided by
  general and those treated in DM clinics.

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• In order to investigate the effectiveness of
  DSCDM, our research team gathered data on care
  accountability(????) (defined as the rates of
  each examination done), laboratory test results,
  and the Taiwan SF-36 life quality scores of DM
  p'ts treated in two different models the regular
  care model and the DSCDM program.
• The findings of this study were used to generate
  clinical suggestions in the hope of upgrading the
  quality of future diabetic care services.

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MATERIALS AND METHODS

• Study subjects
• The subjects in this study were registered type
  II DM p'ts receiving treatment at a medical
  center in eastern Taiwan from January through
  July, 2004.

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Study design

• More than one thousand p'ts consulted physicians
  were assigned into one of the two treatment
  models the regular care model or the DSCDM
  model.
• The p'ts received medical care featuring
  different examination frequencies and different
  health education programs.
• In the regular care group, there were no definite
  rules regulating examination procedures and
  frequencies.
• Blood tests and other related examinations were
  arranged based on each physician's assessment of
  the p'ts needs.
• Despite the absence of a fixed requirement,
  physicians often referred regular care p'ts for
  instruction in diabetic self-care and dietetic
  control at least once, but no more than three
  times, per year.

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• In the DSCDM group, physicians adhered to the DM
  treatment guidelines stipulated(??) in the "DM
  medical benefit improvement project of the Bureau
  of National Health Insurance."
• Physicians measured BP, ante cibum (AC) glucose,
  and glycated hemoglobin (A1C) at least four times
  a year.
• Their cholesterol (TCH), TG, LDL-C, HDL-C, and
  urine protein or microalbumin were measured and
  their eyes and feet were examined at least once a
  year.
• P'ts were also required to take four classes in
  diabetic self-care and dietetic control per year.

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Procedures

• From February 2005 to August 2005, we interviewed
  p'ts randomly during outp't services, after they
  had received care for one year within either of
  the care models.
• After explaining the research procedures to the
  p'ts and receiving their informed consent, we
  gathered data on p't characteristics, clinical
  characteristics, Taiwan SF-36 life quality
  scores, the data on care accountability (defined
  as rates each examination performed) on the care
  received for one year.
• We also collected the average laboratory data in
  the pre/post-program, which was defined as the
  average data from p'ts "before" and "after"
  consulting physicians and being assigned into a
  treatment model.
• By the end of the study, we had collected data on
  200 subjects in the regular care model and 300
  subjects in the DSCDM model.

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Methods

• During our study we employed assessment methods
  that included data from face-to-face interviews,
  questionnaires, and medical records. The
  questionnaire contained three sections, with
  queries(??) about the basic p't characteristics,
  disease conditions, and Taiwan SF-36 life quality
  scores. The validity of the questionnaire was
  based on the judgment of five experts, and its
  reliability was measured by Cronbach's a.
• Taiwan SF-36 life quality scores were separated
  into eight scales and grouped into two
  measurements physical and mental. The scales of
  the two measurements were then combined into
  SF-36 total scores at a range of 0-100. A higher
  SF-36 score represents better health perceptions
  and quality of life.
• The literature exhibited an acceptable ( 0.7)
  Cronbach's a for the Taiwan SF-36.

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• Comparison items in our study were based on the
  required evaluation items noted in the
  regulations of the National Committee for Quality
  Assurance (NCQA) DM Physician Recognition Program
  (DPRP), cosponsored by the ADA, and the diabetic
  treatment guidelines of the Bureau of National
  Health Insurance.
• These comparison items included BP, AC glucose,
  A1C, TCH, TG, LDL-C, HDL-C, urine protein,
  microalbumin, eye examination, foot examination,
  and smoking cessation counseling.

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Statistical analysis

• Descriptive statistics, the ?2 test, the t test,
  ANCOVA, and Pearson correlations were analyzed
  using SPSS 10.0 for Windows.

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RESULTS

• Three subjects were eliminated from our regular
  care group because they were counted twice.
• Therefore, 497 questionnaires were collected from
  a total of 500, which included 197 from the
  regular care group and 300 from the DSCDM group,
  which made the overall response rate 99.4.

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P't characteristics

• In the ?2 test, a significant diversity (plt0.05)
  between the two groups was found in both the
  average age and the average duration of DM, and
  both groups had adverse correlations and
  significant variation in the SF-36 measurements.
• In an effort to resolve the disparity between the
  two groups, we made adjustments to the diversity
  of age and the average duration of disease,
  thereby achieving no significant diversity in p't
  characteristics.
• After that, we collected 175 subjects from the
  regular care group and 280 subjects from the
  DSCDM group.
• We gathered data on p't characteristics, clinical
  characteristics, Taiwan SF-36 life quality scores
  and the data on care accountability (defined as
  the rates of each examination done) from care
  received over the previous year.

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• We also collected the average laboratory data in
  the pre/post-program, which was defined as the
  average data of p'ts before and after consulting
  physicians and being assigned into a treatment
  model.
• As shown in Table 1, there were 175 subjects, 79
  men (45.1) and 96 women (54.9), in the regular
  care group, and 280 subjects, 146 men (52.1) and
  134 women (47.9), in the DSCDM group.
• The average ages of the two groups were between
  50 and 59, and average duration of DM was less
  than 5 years.
• Most of the subjects had less than a
  secondary-level education, and were jobless.
  Their personal average income was approximately
  NT5,000 a month, and most had no one to take
  care of them.

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Clinical characteristics

• As also shown in Table 1, there were 135 p'ts in
  the regular care group and 203 p'ts in the DSCDM
  group who had chronic diseases after having
  received the care programs for one year.
• These diseases were mainly hypertension (49.5,
  44.0), hyperlipemia (33.7, 31.2) and heart
  disease (24.6, 17.3).
• There were 115 (65.7) in the regular care group
  and 110 (39.6) in the DSCDM group with diabetic
  complications, mainly neuropathy (46.9, 21.9),
  retinopathy (21.7, 10.4), non-healing wounds
  (17.7, 11.2) and nephropathy (9.7, 5.0).
• There were 90 and 139 p'ts with difficulties in
  diabetic control, mainly in exercise control
  (36.6, 27.2), diet control (25.1, 20.1) and
  economic constraints (20.0, 11.1).

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• In general, the "rates of examinations performed
  were all higher in the DSCDM group than in the
  regular care group. The data in Table 2 shows
  differences in BP, blood glucose, A1C, TCH, TG,
  LDL, HDL, urine protein, and microalbumin.
• Table 2 also reveals that the rates of
  examinations performed for the remaining items
  were all higher in the DSCDM group than in the
  regular care group.
• These items include the nephropathy assessment,
  foot examination, eye examination, and smoking
  cessation counseling.

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Improvement in examination values

• In Table 3, the average data for both the
  pre-program and post-program showed better
  examination values in the DSCDM group than in the
  regular care group.
• Examination rates for AC glucose and A1C showed a
  statistically significant variation (plt0.05) on
  ANCOVA analysis.
• Both the regular care group and the DSCDM group
  showed improvement in all of their examination
  values as exhibited in Table 3.
• The data showed a statistically significant
  improvement (plt0.05) in the examination rates for
  AC glucose, A1C, TCH, and LDL-C in both groups,
  and TG in the regular group, based on a paired t
  test.

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Taiwan SF-36 quality of life survey

• In the ?2 test, there was a significant diversity
  (plt 0.05) in diabetic complications, and both
  groups had adverse correlations (plt0.05) and
  significant variation (p lt0.05) in relation to
  the SF-36 quality of life assessment.
• So we made adjustments to achieve no significant
  diversity in diabetic complications.
• After that, life quality was based on analytical
  results from Pearson correlations (plt0.05) and
  independent t tests (plt0.05). The results as
  shown in Table 4, indicate that physical
  functioning (PF), role limitation due to physical
  problems (RP), bodily pain (BP), general health
  (GH), vitality (VT), role limitation due to
  emotional problems (RE) and general mental health
  (MH) were all better in the DSCDM group, with BP,
  GH, VT and MH reaching statistical significance
  (plt0.05).

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• Although social functioning in the DSCDM group
  showed lower scores than in the regular care
  group, the difference did not reach statistical
  significance (pgt0.05).
• The two major measurements of both physical and
  mental health (PH and MH), in the DSCDM group
  showed higher scores than in the regular care
  group and the difference reached statistical
  significance (plt0.05).
• Moreover, the total SF-36 in the DSCDM group
  showed higher scores than the regular care group
  and this difference reached statistical
  significance (plt0.05).

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DISCUSSION

• The results of our study were very similar to
  those found by Chiu in 1998 and Zhang in 1999,
  although the subjects' education level,
  socio-economic level, and income level in our
  study in Hualien were all lower, and the
  self-care behavior of our p'ts was frequently
  worse.
• Our study indicated that the most common diabetic
  complications were neuropathy, retinopathy,
  non-healing wounds and nephropathy.
• This compares well with the results of diabetic
  complications found by the Taiwanese Association
  of DM Educators (TADE) in 2002, wherein
  retinopathy (31.8), nephropathy (26.6) and
  neuropathy (21.2) were most prevalent, even
  though these primary complications did not
  include non-healing wounds.
• The rates of non-healing wounds in our research
  were much higher, indicating that diabetics in
  the eastern region must improve their recognition
  of problems and behavior in taking care of their
  feet and wounds.

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• In 2005, the Bureau of Health at Hualien County
  established standards in DM care requiring that
  foot examination rates should reach 80.
• Table 2 revealed that the foot examination rate
  in our subjects was only 54.9 in the regular
  care group, compared to 95 in the DSCDM model.
• Thus, the rate of foot examinations in the
  regular care group was lower than the standard
  set by the government.
• This factor alone demonstrates that the DSCDM
  model had much better care accountability.
• Based on this evidence, the regular care model
  should reinforce care accountability.

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• This study found that, our subjects (in both
  models) encountered difficulties with diabetic
  control, mainly in exercise control, diet control
  and economic constraints.
• Hence, the affected clinical staff should
  encourage broader consultation and hygiene
  lessons, seek out the reasons that p'ts had
  difficulties with diabetic control, and learn how
  best to resolve problems in improving p'ts'
  self-care capabilities and disease control.
• In comparison with the seven examination items
  from a survey of 80 health institutes made in
  2004 by the TADE, which included A1C, BP, lipid
  profile, nephropathy assessment, foot
  examination, eye examination and smoking
  cessation counseling, our results for the
  nephropathy assessment and eye examination in the
  regular care group were better than those of the
  TADE.

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• Furthermore, our results for all seven items were
  better than those found by the DPRP in
  measurements of nine managed organizations with
  Medicare participation in 2000.
• In addition, our results for eye examination and
  smoking cessation counseling were also better
  than those of the care standards required by the
  National Committee for Quality Assurance in the
  USA.
• Moreover, the DSCDM group displayed the highest
  care accountability, as the frequencies of all
  seven examinations were higher than those in the
  regular care group, as well as in the other three
  surveys.

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• From the data shown in Table 2, we determined
  that the care accountability examination rates in
  the DSCDM group were not only higher than those
  in the regular care group, but were also better
  than the results of nationwide investigations,
  done by the TADE in 2004, the DPRP in 2000, and
  the DPRP in 2004.
• In the regular care group, the rates for BP and
  LDL-C (lt130 mg/dL) also outperformed the TADE in
  2004, DPRP in 2000 and DPRP in 2004.
• Although the regular care group's values for
  A1Cgt9.0 and A1Clt7.0 were better than that of
  the TADE in 2004, and its A1Cgt9.0was better than
  that of the DPRP in 2000, the measures of
  A1Cgt9.0, A1Clt7.0 and LDL-Clt100 mg/dL were all
  worse than those in the DSCDM group, as well as
  in the DPRP in 2004.

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• On the whole, the results of the Taiwan SF-36
  assessment in the DSCDM group were better than in
  the regular care group.
• Thus, the quality of life in the DSCDM group
  surpassed that of the regular care group.
• In addition, the BP and MH scores of both groups,
  and the VT score of the DSCDM group, were higher
  than those of a previous Taiwan SF-36 survey
  collected in 2002 from 175,558 subjects in
  Taiwan.
• Previous research indicated that the DSCDM model
  could upgrade the care accountability and
  significantly improve the quality of regional
  diabetic medical care systems.
• Practicing DSCDM can also improve p'ts
  physiological examination values.

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• Our study demonstrated similar, in some
  instances, even better results than previous
  surveys and research.
• Throughout the study, the DSCDM model
  outperformed the regular care model in the values
  for each examination, the rates of development of
  both chronic diseases and diabetic complications,
  difficulties in diabetic control, and care
  accountability.
• Both groups of p'ts showed worse physical health,
  mental health and quality of life when faced with
  increases in chronic disease, diabetic
  complications, and difficulties in diabetic
  control (plt0.05).
• This result is similar to that found by Goldney
  et al in 2004.

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• More supportive evidence for the DSCDM model and
  similar team care programs can be found in the
  books, "Team Care Comprehensive Lifetime
  Management for DM" from "DM Control and
  Complications Trial" (DCCT) and "United Kingdom
  Prospective DM Study" (UKPDS).
• These references show that short- and long-term
  benefits of employing DM team care, including
  improved health outcomes, greater glycemic
  control, higher p't satisfaction, lower risks of
  complications, better quality of life, and
  decreased health costs, are possible through
  providing intensive management involving
  multi-disciplinary care, frequent p't follow-ups,
  additional counseling, and ongoing p't education.

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• At the end of our one-year care study, both the
  regular care group and the DSCDM group subjects
  showed significant improvement in nearly all
  examination values as exhibited in Table 3.
• Inexplicably(?????), at the beginning of our
  study, the subjects in the regular care group had
  much worse blood analysis examination values than
  those in the DSCDM group.
• This factor might have caused measurements of
  their improvement margins to be higher than those
  seen among the DSCDM subjects.

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• Despite this initial disparity, the DSCDM group
  still had better final examination values at the
  end of the program, and greater achievement of
  the desired goals.
• Variations in the improvement of examination
  results may have also been affected by other
  causes, such as the medication level, the
  cooperation of p'ts, the efforts of physicians,
  or the pre-existing health conditions of p'ts.
• It is worth further study, using a longitudinal
  approach, to evaluate the long-term effect of
  different care models.

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• In addition, it may be interesting to perform
  studies similar to ours in different regions of
  Taiwan to scrutinize(??) the impact of geographic
  variables.
• This research focused on accountability,
  improvement in examination results, and the
  quality of life of diabetic p'ts to investigate
  whether practicing DSCDM had a positive effect on
  p'ts' quality of care and quality of life.
• The results of this study showed that pts in the
  DSCDM model fared better(????) than those in the
  regular care model, and the DSCDM model is
  therefore worth promoting and practicing on a
  broader scale.

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ABSTRACT

• Objective
• Previously documented studies found
  that hospitals which practiced "DM share care
  disease management" program (DSCDM) achieved
  positive results in the quality of p't care among
  diabetics. However, most of these studies
  compared p'ts who participated in the DSCDM vs
  those who were not in any diabetic care program.
  This study particulary focused on comparing care
  accountability, laboratory results, and the
  Taiwan SF-36 life quality scores in DM p'ts who
  were treated in two different models the regular
  care model and the DSCDM program. Based on the
  findings of this study, we hope to provide
  clinical recommendations and upgrade the quality
  of DM care.
• Materials and Methods
• The data from 175 regular care group
  subjects and 280 DSCDM group subjects were
  collected from February 2005 to August 2005 at a
  medical center in eastern Taiwan via multiple
  approaches, which included face-to-face
  interviews, questionnaires, and medical records.
  Analysis of the data was performed on SPSS10.0
  for Windows.

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• Results
• After one year, the average rates of
  chronic disease, chronic complications, and
  difficulties in diabetic control were showed
  better in the DSCDM group than those of the
  regular care group. Both groups exhibited
  noticeable improvement in all clinical
  examination criteria, and the laboratory data in
  the DSCDM group were lower and more close to
  control target, while the care accountability and
  life quality elevels also showed better than
  those of the regular care group.
• Conclusions
• This research demonstrated that practicing
  DSCDM generated positive results and improved
  both the care and life quality of p'ts.
  Therefore, DSCDM should be promoted and practiced
  on a broader scale. (Tzu Chi Med J 2007
  1966-73)
• Key words regular care, DM share care disease
  management (DSCDM), accountability, life quality,
  Taiwan SF-36

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THANK YOU FOR YOUR ATTENTION !
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