XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

人教版高中英语新课程教材中,语言运用（Using Language）是每个单元必不可少的部分,提供了围绕单元中心话题的听、说、读、写的综合性练习,是单元中心话题的延续和升华.如何设计Using Language部分的教学,使自己的教学模式既不落俗套,又能真正体现新课程标准所倡导的教学理念,正是广大一线英语教师一直努力探索的问题.

打磨Using Language,倡导新理念

SummaryWhat is known and objective
With the increasing prevalence of diabetes, the physician-centred model is challenged to deliver holistic care in Asia. Diabetes may be managed effectively within a multidisciplinary collaborative care model; however, evidence on its effectiveness in Asian patients is lacking. Therefore, the primary objective was to evaluate the clinical outcomes of multidisciplinary collaborative care vs physician-centred care in diabetes. The secondary objectives were to evaluate humanistic and economic outcomes among the two types of care.

Methods
This 6-month prospective, open-label, parallel-arm, randomized, controlled study was conducted at four outpatient healthcare institutions. High-risk patients aged ≥21 years with uncontrolled type 2 diabetes, polypharmacy and comorbidities were included. Patients with type 1 diabetes or those who were unable to communicate independently were excluded. The control arm received usual care with referrals to nurses and dietitians as needed. The intervention arm (multidisciplinary collaborative care) was followed up with pharmacists regularly, in addition to receiving the usual care. The primary outcomes included HbA1c, systolic blood pressure, low-density lipoprotein and triglycerides. The secondary outcomes included scores from the Problem Areas in Diabetes (PAID) and the Diabetes Treatment Satisfaction Questionnaires (DTSQ), and diabetes-related health service utilization rates and costs.

Results and discussion
Of 411 eligible patients, 214 and 197 patients were randomized into the intervention and control arms, respectively. At 6 months, 141 patients in the intervention arm (65.9%) and 189 patients in the control arm (95.9%) completed the study. Mean HbA1c reduced from 8.6%±1.5% at baseline to 8.1%±1.3% at 6 months in the intervention arm (P=.04), with up to mean HbA1c improvement of 0.8% in patients with greater levels of uncontrolled glycemia. Whereas the mean HbA1c in the control arm remained unchanged (8.5%±1.4%) throughout the 6-month period. Improvements in PAID and DTSQ scores, reduction in physician workload and an average cost savings of US$91.01 per patient were observed in the intervention arm over 6 months.

What is new and conclusions
The positive clinical, humanistic and economic outcomes highlighted the value of multidisciplinary collaborative care for Asian diabetic patients, thereby supporting the effectiveness of this approach in managing chronic diseases.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jcpt.12536

Impact of pharmacist-involved collaborative care on the clinical, humanistic and cost outcomes of high-risk patients with type 2 diabetes (IMPACT): a randomized controlled trial

The purpose of this review is to summarise the existing evidence about the association of health literacy (HL) with type 2 diabetes mellitus self-management. The PubMed, Medline, CINHAL, Scopus and Web of Science databases were searched for randomised control trials of type 2 diabetes mellitus (T2DM) self-management and HL published between 2009 and 2018. Fourteen randomised control trials were included in this review. Our findings showed that HL was instrumental in improving diabetes knowledge, physical activity, self-efficacy and quality of life; however, its associations with glycaemic control, self-monitoring of blood glucose, foot care and medication adherence was inconclusive. Customized and community-based HL interventions were more efficient compared to patient-focused HL interventions. This review concludes that HL is key for T2DM self-management, but customised, structured and community-based interventions are more likely to yield better outcomes.

/pdf/association-of-health-literacy-and-diabetes-self-management-26tpb35bbt.pdf

Association of health literacy and diabetes self-management: a systematic review.

This systematic review identified studies of nonmedical interventions designed to reduce risk for and improve clinical outcomes for type 2 diabetes. Specifically, this review sought to identify interventions that target structural racism and social determinants of health. To be included, studies were published in English; published between database initiation and January 2022; conducted in the United States; measured an intervention effect using a clinical trial, quasi-experimental, or pre-post design; included a population of adults at risk for or with type 2 diabetes; and targeted hemoglobin A1c levels, blood pressure, lipids, self-care, or quality of life as outcomes. The findings of our review indicate that interventions with targeted, multicomponent designs that combine both medical and nonmedical approaches can reduce risk for and improve clinical outcomes for type 2 diabetes. HbA1c levels improved significantly with the use of food supplementation with referral and diabetes support; the use of financial incentives with education and skills training; the use of housing relocation with counseling support; and the integration of nonmedical interventions into medical care using the electronic medical record. Our findings demonstrate that the literature on nonmedical interventions designed to address relevant social factors and target structural racism is limited. The article offers actionable strategies and identifies policy opportunities for targeting structural inequalities and decreasing social risk among adults with type 2 diabetes.

Nonmedical Interventions For Type 2 Diabetes: Evidence, Actionable Strategies, And Policy Opportunities.

Background:Health literacy is the ability of patients to obtain, process, and understand information needed to make health decisions. Health literacy is a stronger predictor of a person's health than is age, income, employment status, educational level, or race. The Medtable is a paper-based tool that is designed to support comprehension of medication information by patients. A collaborative tool such as the Medtable might facilitate the comprehension of medication information by low-literacy patients and increase communication regarding medications between healthcare pers and their patients. Before evaluating the efficacy of the Medtable to improve health outcomes, it is important to confirm that patients find the tool easy to use and helpful in relevant clinical settings.Objective:To investigate whether patients think that the Medtable is a helpful and easy-to-use tool for organizing daily medication regimens.Methods:Sixty outpatients participated in this usability study. Patients filled in the Medtable...

Outpatient Perceptions of the Medtable: A Medication Scheduling Tool

Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.

/pdf/effects-of-a-patient-provider-collaborative-medication-3vmxu66en9.pdf

Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial.

Patient knowledge about the purpose of medications is crucial to ensure safe and correct use, so it is an important index of adherence in patients with chronic illness. We examined how health literacy and its components (processing capacity and knowledge about illness) influence memory for medication purposes. We conducted a cross-sectional study to examine memory for medication purposes in relation to health literacy, processing capacity, and illness knowledge among patients with diabetes in outpatient clinics. Six hundred seventy-four adults who were diagnosed with type II diabetes mellitus, age 40 years or older, taking 5 or more current medications, native speakers of English, and with glycosylated hemoglobin (HbA1c) of 6.0 or more, were recruited to the study. We included measures of processing capacity, illness knowledge, health literacy, and actionable memory for medication taking (memory for medication purpose). Results suggested an association between health literacy and both processing capacity and health knowledge, with some evidence that knowledge can compensate for limited processing capacity in order to maintain health literacy. Furthermore, health literacy was associated with memory for medication purposes, with processing capacity and health knowledge partly mediating this association. This pattern of results supports the process-knowledge model of health literacy. Our findings establish the role of health literacy in medication taking, in relation to broader cognitive abilities and knowledge. Implications for improving the learning of medication purpose among diverse older adults with chronic illness are discussed. NIH trial registry number: NCT01296633

Health Literacy, Processing Capacity, Illness Knowledge, and Actionable Memory for Medication Taking in Type 2 Diabetes: Cross-Sectional Analysis.

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Outpatient Perceptions of the Medtable: A Medication Scheduling Tool

Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial.

Health Literacy, Processing Capacity, Illness Knowledge, and Actionable Memory for Medication Taking in Type 2 Diabetes: Cross-Sectional Analysis.