OBJECTIVE -To determine whether using the chronic care model (CCM) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes. RESEARCH DESIGN AND METHODS-This multilevel, cluster-design, randomized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community. Eleven primary care practices, along with their patients, were randomized to three groups: CCM intervention (n ϭ 30 patients), provider education only (PROV group) (n ϭ 38), and usual care (UC group) (n ϭ 51).RESULTS -A marked decline in HbA 1c was observed in the CCM group (Ϫ0.6%, P ϭ 0.008) but not in the other groups. The magnitude of the association remained strong after adjustment for clustering (P ϭ 0.01). The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group (non-HDL cholesterol: Ϫ10.4 mg/dl, P ϭ 0.24; self-monitor blood glucose: ϩ22.2%, P Ͻ 0.0001), with statistically significant between-group differences in improvement (non-HDL cholesterol: P ϭ 0.05; self-monitor blood glucose: P ϭ 0.03) after adjustment. The CCM group also showed improvement in HDL cholesterol (ϩ5.5 mg/dl, P ϭ 0.0004), diabetes knowledge test scores (ϩ6.7%, P ϭ 0.07), and empowerment scores (ϩ2, P ϭ 0.02).CONCLUSIONS -These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes. Diabetes Care 29:811-817, 2006D iabetes affects ϳ7% of the U.S. population and has reached epidemic proportions (1). Diabetes represents a significant public health burden worldwide by decreasing quality of life and causing death and disability at great economic cost (2). Though quality diabetes care is essential to prevent long-term complications, care often falls below recommended standards regardless of health care setting or patient population, emphasizing the necessity for system change (3-6).The chronic care model (CCM) (3,4,7,8) is a multifaceted framework for enhancing health care delivery. The model is based on a paradigm shift from the current model of dealing with acute care issues to a system that is prevention based (3,5,(7)(8)(9). The premise of the model is that quality diabetes care is not delivered in isolation and can be enhanced by community resources, selfmanagement support, delivery system redesign, decision support, clinical information systems, and organizational support working in tandem to enhance patient-provider interactions (3,4,7-13). Currently, few efforts exist to implement multifaceted approaches to improve quality of care in diabetes despite studies that demonstrate their proven effectiveness (3,4,11,14,15).The objective of the current study was to determine the effectiveness of an intervention based on the CCM in primary care settings. We hypothesized that patient clinical (glycemic, blood pressure, and lipid control), behavioral (selfmonitoring of blood glucose), psychological/psychosocial (qualit...

Implementing systems to support decision support, self-management education, and delivery system redesign has a positive influence on practices and patient outcomes in outlying rural communities.

OBJECTIVE -The objective of this study was to determine if a community-based modified Diabetes Prevention Program Group Lifestyle Balance (GLB) intervention, for individuals with metabolic syndrome, was effective in decreasing risk for type 2 diabetes and cardiovascular disease (CVD) in an urban medically underserved community, and subsequently to determine if improvements in clinical outcomes could be sustained in the short term. RESEARCH DESIGN AND METHODS-This nonrandomized prospective intervention study used a one-group design to test the effectiveness of a community-based GLB intervention. Residents from 11 targeted neighborhoods were screened for metabolic syndrome (n ϭ 573) and took part in a 12-week GLB intervention (n ϭ 88) that addressed safe weight loss and physical activity.RESULTS -A marked decline in weight (46.4% lost Ն5% and 26.1% lost Ն7%) was observed in individuals after completion of the intervention. Of these subjects, 87.5% (n ϭ 28) and 66.7% (n ϭ 12) sustained the 5% and 7% reduction, respectively, at the 6-month reassessment. Over one-third of the population (43.5%, n ϭ 30) experienced improvements in one or more component of metabolic syndrome, and 73.3% (n ϭ 22) sustained this improvement at the 6-month reassessment. Additional improvements occurred in waist circumference (P Ͻ 0.009) and blood pressure levels (P ϭ 0.04) after adjustment for age, sex, race, mean number of GLB classes attended, and time.CONCLUSIONS -Adults in an urban medically underserved community can decrease their risk for type 2 diabetes and CVD through participation in a GLB intervention, and shortterm sustainability is feasible. Future research will include long-term follow-up of these subjects.

OBJECTIVEThe aim of this study was to investigate the presence and correlates of clinically relevant cognitive impairment in middle-aged adults with childhood-onset type 1 diabetes (T1D).RESEARCH DESIGN AND METHODSDuring 2010–2013, 97 adults diagnosed with T1D and aged <18 years (age and duration 49 ± 7 and 41 ± 6 years, respectively; 51% female) and 138 similarly aged adults without T1D (age 49 ± 7 years; 55% female) completed extensive neuropsychological testing. Biomedical data on participants with T1D were collected periodically since 1986–1988. Cognitive impairment status was based on the number of test scores ≥1.5 SD worse than demographically appropriate published norms: none, mild (only one test), or clinically relevant (two or more tests).RESULTSThe prevalence of clinically relevant cognitive impairment was five times higher among participants with than without T1D (28% vs. 5%; P < 0.0001), independent of education, age, or blood pressure. Effect sizes were large (Cohen d 0.6–0.9; P < 0.0001) for psychomotor speed and visuoconstruction tasks and were modest (d 0.3–0.6; P < 0.05) for measures of executive function. Among participants with T1D, prevalent cognitive impairment was related to 14-year average A1c >7.5% (58 mmol/mol) (odds ratio [OR] 3.0; P = 0.009), proliferative retinopathy (OR 2.8; P = 0.01), and distal symmetric polyneuropathy (OR 2.6; P = 0.03) measured 5 years earlier; higher BMI (OR 1.1; P = 0.03); and ankle-brachial index ≥1.3 (OR 4.2; P = 0.01) measured 20 years earlier, independent of education.CONCLUSIONSClinically relevant cognitive impairment is highly prevalent among these middle-aged adults with childhood-onset T1D. In this aging cohort, chronic hyperglycemia and prevalent microvascular disease were associated with cognitive impairment, relationships shown previously in younger populations with T1D. Two additional potentially modifiable risk factors for T1D-related cognitive impairment, vascular health and BMI, deserve further study.

The CCM serves as an effective model for implementing and sustaining DSMT programs.