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Aims To determine the effects of the Diabetes Manual on glycaemic control, diabetes-related distress and confidence to self-care of patients with Type 2 diabetes. Methods A cluster randomized, controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA1c, cardiovascular risk factors, diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale. Outcomes were assessed at baseline and 26 weeks. Results There was no significant difference in HbA1c between the intervention group and the control group [difference −0.08%, 95% confidence interval (CI) −0.28, 0.11]. Diabetes-related distress scores were lower in the intervention group compared with the control group (difference −4.5, 95% CI −8.1, −1.0). Confidence to self-care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%. Conclusions In this population, the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care. [ABSTRACT FROM AUTHOR]

Aims To develop and validate an easy-to-use questionnaire to identify obstacles to self management in Type 2 diabetes. Methods The Diabetes Obstacles Questionnaire (DOQ) was developed from earlier research and the literature. It was completed by 180 people with Type 2 diabetes, recruited from 22 general practices in the UK. Responders also completed a quality-of-life questionnaire (ADDQoL) and the Problem Areas in Diabetes (PAID) scale. Results From analysis of the 176 usable questionnaires, 36 items of the original 113 items were deemed redundant. The remaining 77 items were assembled into eight sub-scales covering Medication, Self Monitoring, Knowledge and Beliefs, Diagnosis, Relationships with Health-Care Professionals, Lifestyle Changes, Coping, and Advice and Support. Each sub-scale had a factor structure of no more than three factors, had Cronbach's alpha of more than 0.75, and a Kaiser–Meyer–Olkin of more than 0.75. Each sub-scale correlated significantly with the PAID scale ( P < 0.01), demonstrating criterion validity. Construct validity was shown by significant correlation between HbA1c and the sub-scales which relate to managing blood glucose levels: Self Monitoring, Relationship with Health-Care Professionals, Lifestyle Changes and Coping. Construct validity was further shown by significant correlation between QoL scores and Medication, Lifestyle Changes and Coping. Discussion The DOQ, comprising eight sub-scales, is a usable, valid instrument for both clinical and research settings. It helps to identify in detail the obstacles which an individual finds in living with Type 2 diabetes. [ABSTRACT FROM AUTHOR]

Background and objective: Pharmacists are now adopting a crucial role in the management of chronic illness in primary care, providing diabetes care and advice. This review aims to show whether a range of diabetes care interventions delivered by pharmacists is successful in improving adherence to medication. Methods: The studies reviewed formed a subgroup of a Cochrane review on interventions to improve adherence to medication in people with type 2 diabetes. Search terms were ‘type 2 diabetes mellitus’ and ‘compliance’ or ‘adherence’. Studies were included if they assessed adherence to medical treatment specifically, rather than other aspects of self-management. Out of the 21 studies selected for review, five described an intervention delivered by a pharmacist. Results and discussion: Two studies reported on attempts to improve adherence focused on the taking of medication. A system of reminders and packaging improved medication adherence, but measuring medicine taking through pill counts or Medication Event Monitoring System was not effective. Three studies evaluated pharmacist-led integrated management and education programmes designed to improve glycaemic control for under-served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. Conclusion: This review indicates a potential benefit of pharmacist interventions to improve medication adherence in diabetes, especially in providing patient education. [ABSTRACT FROM AUTHOR]

Summary Nurses now provide the majority of education and support for people with diabetes both in community and hospital settings. However, there are very few studies on nurse-led interventions to improve adherence to medication, a crucial element of the self-management of diabetes. The four studies reviewed formed a subgroup of a Cochrane review on interventions to improve adherence to medication in people with type 2 diabetes. Search terms were ‘type 2 diabetes mellitus’ and ‘compliance’ or ‘adherence’. Studies were included if they assessed adherence to medical treatment specifically, rather than other aspects of self-management. Out of the 21 studies selected for review, four described an intervention delivered by a nurse. All four studies were from the USA and used an intervention delivered by telephone. Different interventions (two educational programmes, one automated telephone management system, one tracking system for health service and medication use) were backed up by a scripted nurse call. While patients in two studies reported improvements in self-care behaviour, only one measured a significant improvement in blood glucose control. Although some studies asked patients to report on their adherence to medication taking, responses from patients were not explicitly presented. The studies reviewed show the potential for generating evidence for the effectiveness of nurse-led diabetes management programmes. Further high-quality studies into this area are desperately needed, and they should consider new ways of evaluating complex interventions to generate more evidence. Copyright © 2006 FEND. [ABSTRACT FROM AUTHOR]

Aims In order to measure the effectiveness of interventions claiming to improve adherence in diabetes, valid measurement of adherence is necessary. Any measurement must first be based on a definition. This study aimed to identify and categorize definitions and measurements of adherence in living with diabetes, from a review of the literature. Methods Publications were identified from themedline database. Adherence, compliance and concordance were used as terms in the search algorithm, along with diabetes, diabetes mellitus and treatment. Two hundred and ninety-three papers were identified. Abstracts of these papers were read by two researchers independently. Two hundred and thirty-nine papers did not contain definitions or measures of adherence and were discarded. Of the remaining 54 papers, 26 included definitions and 46 described measurements of adherence. Results Definitions and measurements fell into five categories: coincidence of behaviour with professional advice, relationship as part of the process of care, outcome and process targets, taking the medication as prescribed and others. No single definition of adherence emerged. Many authors did not provide definitions of adherence. Glycated haemoglobin was the most common measurement of adherence, although this can raise problems. Conclusion Research which claims to show an intervention has, or has not, improved adherence must be interpreted cautiously. Interventions which appear to fail may actually succeed in aspects of adherence which were not defined or measured in the study. Clinicians and researchers could use clear definitions and measurements, such as the ones presented in this review. [ABSTRACT FROM AUTHOR]

Continuing professional development for healthcare professionals aims to improve care given to patients. The aims are to maintain knowledge and skills, improve existing competencies and learn new competencies. The Warwick Diabetes Care course, which leads to the University of Warwick Certificate in Diabetes Care (CIDC) provides healthcare professionals of all disciplines with the practical knowledge and skills needed to provide a highquality service for people with diabetes. A model for cascading the delivery of this course at local centres throughout the UK was developed (Distance Delivery). Its evaluation is presented in this paper. Twenty-four course leaders gave 26 Distance Delivered CIDC courses with 494 students. Over the same period, teaching fellows of Warwick Diabetes Care delivered 12 CIDC courses with 337 students. CIDC students completed questionnaires at the start and end (nine months later) of their course. The students' mean knowledge scores increased significantly on all courses. A mean of four changes in practice for each student made, or planned, were reported. The increase in knowledge scores and number of changes were the same for Distance Delivered courses and those delivered by Warwick Diabetes Care. The course leaders were trained at the University of Warwick to deliver the CIDC course in their own locality and they completed questionnaires before training, after training and after delivery of the CIDC in their locality. Results showed they increased in confidence in their ability to deliver the course over the period of the training course, and the increase continued after delivery of their courses. The training had been beneficial in preparing them to deliver their courses and their courses had mostly met the stated aims. The delivery of the CIDC course was thought to have had a beneficial effect on local diabetes care. The evidence presented here shows that the Distance Delivered model is an effective method to educate the community of healthcare professionals in diabetes care who are geographically dispersed. This model of professional development has potential to deliver widely distributed, locally available, academically validated and supported education. This model may be suitable for meeting the demand to improve care for people living with diabetes both in the UK and elsewhere. [ABSTRACT FROM AUTHOR]

The increasing prevalence of chronic conditions has implications for health care provision, particularly primary care which acts as the gatekeeper to other services and provides long-term support for patients with enduring needs. One means of coping with this increasing patient demand centres on enhancing the ability of patients to successfully self-manage the day-to-day realities of their condition in partnership with health care professionals. Hence, it is not surprising that the provision of self-management style programmes has seen a rapid growth in the past five years, primarily in relation to hospital-based programmes led by health professionals. There are exceptions such as the community-based self-management interventions that are organised and delivered by voluntary organisations using peer educators. The value of increasing self-management provision through primary care is discussed in relation to three conditions that form a large part of the primary care caseload: arthritis, asthma, and diabetes. The typical management tasks associated with each condition are considered in terms of differences and commonalities. The implications of such similarities and differences for implementation of self-management on a much wider scale in primary care are discussed. [ABSTRACT FROM AUTHOR]

The increasing prevalence of chronic conditions has implications for health care provision, particularly primary care which acts as the gatekeeper to other services and provides long-term support for patients with enduring needs. One means of coping with this increasing patient demand centres on enhancing the ability of patients to successfully self- manage the day-to-day realities of their condition in partnership with health care professionals. Hence, it is not surprising that the provision of self-management style programmes has seen a rapid growth in the past five years, primarily in relation to hospital-based programmes led by health professionals. There are exceptions such as the community-based self-management interventions that are organised and delivered by voluntary organisations using peer educators. The value of increasing self-management provision through primary care is discussed in relation to three conditions that form a large part of the primary care caseload: arthritis, asthma, and diabetes. The typical management tasks associated with each condition are considered in terms of differences and commonalities. The implications of such similarities and differences for implementation of self-management on a much wider scale in primary care are discussed. [ABSTRACT FROM PUBLISHER]

Objectives. To assess the effectiveness and feasibility of mandatory, multidisciplinary education, in the context of a primary care organisation service development programme for diabetes care. To identify any obstacles to change and to measure changes in knowledge, service organisation and attitudes after a university based course in diabetes care. The course. It was mandated by the primary care group of Ladywood, Birmingham, UK, that one general practitioner and one nurse from each practice should attend a course in diabetes care, which comprised 30 hours spread over 3 months, with three pieces of assessed coursework and a written examination. The programme, led by a shared vision of committed local leaders, also included consultant-led community diabetes clinics, shared software for all providers, and payment for minimum primary care standards. Design. A longitudinal study of the first cohort of the course, using a questionnaire administered at the start of the course and repeated one year later. Setting. Ladywood Primary Care Group, Birmingham, UK, comprising 38 practices in this area of high deprivation. Main outcome measures. Comparison of the mean knowledge scores of 16 general practitioners and 12 nurses in relation to 68 diabetes-related topics before the course and one year later. Measurement of changes in the organisation of diabetes care within practices during the year after the course. Views on the acceptability of mandatory, multidisciplinary education. Results. There was a statistically significant increase in the mean knowledge scores of general practitioners (p0.01) and practice nurses (p0.01) over all topics. There were statistically significant changes in many organisational aspects of diabetes care within practices, for example the proportion undertaking annual reviews and having dedicated time for diabetes clinics. Several obstacles such as time and resources, both human and financial, were identified by participants as barriers to further change. The mandatory course was accepted by most participants. The experience of doctors and nurses learning together was regarded by some as an unexpected benefit of the course. Conclusion. A defined need for education in primary diabetes care as part of a service development programme was met successfully by this course and found acceptable. There were measurable changes in the knowledge of health care professionals one year after the course. Improvements in the organisation of diabetes care were reported, which can be attributed to the whole programme, not only the course, although the usual obstacles to change were found. Future research is needed to identify the persistence of the changes and their presence in a larger sample and in other settings. A mandatory, multidisciplinary education might be usefully adopted by primary care organisations in their service development programmes. In particular this is relevant to the implementation of the UK national service framework for diabetes. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness. With increasing numbers of medications shown to do more good than harm when taken as prescibed, low compliance is a major problem in health care. Relevant studies were retrieved through comprehensive searches of different database systems to enable a thorough assessment of the major issues in compliance to prescribed medical interventions. The term compliance is the main term used in this review because the majority of papers reviewed used this term. Three decades have passed since the first workshop on compliance research. It is timely to pause and to reflect on the accumulated knowledge. The enormous amount of quantitative research undertaken is of variable methodological quality, with no gold standard for the measurement of compliance and it is often not clear which type of non-compliance is being studied. Many authors do not even feel the need to define adherence. Often absent in the research on compliance is the patient, although the concordance model points at the importance of the patient’s agreement and harmony in the doctor–patient relationship. The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy. Recently, some qualitative research has identified important issues such as the quality of the doctor–patient relationship and patient health beliefs in this context. Because non-compliance remains a major health problem, more high quality studies are needed to assess these aspects and systematic reviews/meta-analyses are required to study the effects of compliance in enhancing the effects of interventions. [ABSTRACT FROM AUTHOR]

Background and Objectives: Improving the sensitivity of general practice to patients' needs demands a good understanding of patients' expectations and priorities in care provision. Insight into differences in expectations of patients in different cultures and health care systems may support decision-making on desirable models for care provision in general practice. An international study was conducted to determine priorities of patients in general practice care: which views do patients in different countries have in common and which views differ?Methods: Written surveys in general practices in the UK, Norway, Sweden, Denmark, The Netherlands, Germany, Portugal and Israel were performed. Samples of patients from at least 12 practices per country, stratified according to area and type of practice, were included. Patients rated the importance of 38 different aspects of general practice care, selected on the basis of literature analysis, qualitative studies and consensus discussions. Rankings between countries were compared.Results: A total number of 3540 patients (response rate on average 55%) completed the questionnaire. Patients in different countries had many opinions in common. Aspects that got the highest ranking were: getting enough time during the consultation; quick services in case of emergencies; confidentiality of information on patients; telling patients all they want to know about their illness; making patients feel free to talk about their problems; GPs going to courses regularly; and offering preventive services. However, differences between opinions of patients in different countries were also found for some of the selected aspects. A confounding effect of patients' characteristics may have played a role in these differences.Discussion: The study provides information on what patients expect of and value in general practice care. It shows that patients in different cultures and health care systems may have different views on some aspects of care, but most of all that they have many views in common, particularly as far as doctor-patient communication and accessibility of services are concerned. [ABSTRACT FROM AUTHOR]

The preweaning growth of the progeny of mature cows grazing high, medium or low quality pasture was evaluated. The cows were 5–9 years of age at the beginning of the study and were either purebred Hereford (H x H), first-cross Brahman x Hereford (B x H), Simmental x Hereford (S x H) or Friesian x Hereford (F x H). Hereford and Brahman bulls were mated to these cows for three mating seasons commencing in 1982, at Grafton, New South Wales, Australia. Records on 634 calves born over three consecutive years were used.Most traits were subject to significant sire breed or dam breed effects or their interactions with one or more of the other main effects (pasture, year of birth of calf, cow age and sex of calf). The incidences of calving difficulty and stillbirths were exceptions. Stillbirths (mean of 3·8%) were not affected by any of the effects studied, while calving difficulty was affected only by sex of calf effect (males, 3·9%; females, 0·8%). The mean calving date of Brahman-sired calves was 11·4 days later (P < 0·05) than that of Hereford-sired calves. Differences between Brahman-sired and Hereford-sired calves for weaning weight were not significant for S x H (Brahman, 237 kg; Hereford, 232 kg) and FxH (Brahman, 238kg; Hereford, 238kg) dams. For HxH dams however, calves sired by Brahman were heavier at weaning (205 kg) than those sired by Hereford (193 kg) bulls, while for B x H dams the reverse was true (Brahman, 222 kg; Hereford, 231 kg). For calves with B x H dams average daily gain (ADG) was the same (957 g/day) for each sire breed, while for the other dam breeds, Brahman-sired calves had a higher ADG than Hereford-sired calves (862 v. 779, 1014 v. 946 and 1022 v. 950 g/day for H x H, S x H and FxH, respectively). Calves sired by Brahman bulls had > 90% eyelid pigmentation while Hereford-sired calves had 44–74%. On high quality pasture, the weaning weights and ADG of calves of F x H and S x H dams were higher than those of B x H and HxH dams. On medium quality pasture, weaning weight of calves of crossbred dams (B x H, S x H and FxH) were similar but higher than those of H x H dams. On low quality pasture, mean weaning weight of calves of B x H was higher than those of S x H and F x H dams, which in turn, were higher than that of H x H dams. [ABSTRACT FROM PUBLISHER]

Hereford (H × H), Brahman × Hereford (B × H), Simmental × Hereford (S × H) and Friesian × Hereford (F × H) females born over a 5-year period (1973–77) were placed on pastures of high, medium or low nutritive value at Grafton, New South Wales, Australia, at weaning (7–8 months of age). The first mating of heifers on high pasture was at 15 months (1974) while that on medium and low pastures was delayed until 27 months of age (1975). This paper reports the reproductive performance of these cows up to 5 years of age and the preweaning growth of their calves which were sired by Hereford bulls at Grafton, Australia. In total, 1222 calving records were analysed.Most traits were subject to interaction between genotype and other main effects (pasture, year of birth of cow, cow age and sex of calf). Eyelid pigmentation was an exception, with calves from B × H cows having more than calves of other genotypes (73 v. 43%). There were significant genotype differences in calving difficulty among 2-year-old heifers only, with H × H (33%) requiring more assistance than F × H (15%) and SxH (10%) heifers, while B × H heifers did not require any assistance. Genotype differences in percentage of calves born and weaned were observed on low pastures only, where B × H (66% born, 65% weaned) exceeded H × H (48%, 39%) and S × H (39%, 38%) cows, with F × H (58%, 50%) cows being intermediate. Calves by H × H cows were the slowest-growing and were the lightest at weaning on all pastures, with mean gains of 759, 604 and 340 g/day, and mean weaning weights of 212, 188 and 110 kg, on high, medium and low quality pastures, respectively. F × H and S × H cows produced the fastest-growing calves on high quality pasture (966 and 936 g/day, respectively) while B × H cows produced the fastest-growing calves on medium (823 g/day) and low (679 g/day) quality pastures. F × H cows weaned the heaviest calves on high quality pasture (274 kg) while F × H and B × H weaned the heaviest calves on medium (230 and 229 kg, respectively) and low (162 and 169 kg, respectively) quality pastures. Differences in body measurements followed a pattern similar to weaning weight. [ABSTRACT FROM PUBLISHER]

Background: Patient views are important in the evaluation of the quality of health care. The use of surveys needs to be evaluated to determine their cost-effectiveness and benefits.Objectives: To determine the costs of conducting patient opinion surveys in general practice and to find out how effective patient surveys are in stimulating changes which are beneficial for patient care.Method: Postal questionnaire to all 102 medical audit advisory groups (MAAGs) and 98 family health services authorities (FHSAs) in England and Wales, followed by postal questionnaire to 302 general practices reported to have conducted surveys, sampled by the type or questionnaire used. Numbers of MAAGs and FHSAs reporting surveys in general practice; types of questionnaire used; estimated costs; changes made; and benefits identified were measured.Results: Eighty-five (83%) MAAGs and 75 (77%) FHSAs responded. One hundred and fifty-four (96%) of MAAGs or FHSAs reported survey activity. Types of questionnaire used were 1) designed by the practice, 2) designed by the MAAG or FHSA, possibly in collaboration with a practice, or 3) standard 'off-the-shelf'. One hundred and thirty-three (44%) practices responded. Total costs to a practice of conducting a survey ranged from nothing to over 2200 Pounds. Questionnaires designed by the practice are likely to be more costly than other designs. Some practices had surveys provided free of charge by MAAG or FHSA. Sixty-one per cent of practices said changes had been implemented and a further 22% of practices said changes were planned. The most common change was to appointment systems. Benefits were identified for patients, staff, the practice, the MAAG or FHSA and the NHS. Surveys also brought benefits in relationships and understanding. Only 8.2% of practices felt the costs of surveys outweighed the benefits.Conclusions: Many practices are surveying patients' opinions. Surveys can be costly but MAAGs and FHSAs can provide expertise and resources. Surveys using any of the types of questionnaire are likely to lead to changes and identifiable benefits. Benefits of surveys are perceived by the majority of practices to outweigh the costs. [ABSTRACT FROM AUTHOR]

Cattle sired by Piedmontese or Wagyu bulls were bred and grown within pasture-based nutritional systems followed by feedlot finishing. Effects of low (mean 28.6 kg, n = 120) and high (38.8 kg, n = 120) birthweight followed by slow (mean 554 g/day, n = 119) or rapid (875 g/day, n = 121) growth to weaning on beef primal cut weights at ~30 months of age were examined. Cattle of low birthweight or grown slowly to weaning had smaller primal cuts at 30 months as a result of reduced liveweight and smaller carcasses compared with their high birthweight or rapidly grown counterparts. Hence they require additional nutritional and economic inputs to reach target market weights. At equivalent carcass weights (380 kg), cattle restricted in growth from birth to weaning yielded slightly more beef and were somewhat leaner than their rapidly grown counterparts, resulting in primal cuts being up to 4% heavier in the slowly grown compared with the rapidly grown cattle. Compositional differences due to birthweight were less apparent at the same carcass weight, although low birthweight cattle had a slightly (~2%) heavier forequarter and slightly lower (~1%) hindquarter retail yield, and less shin-shank meat (~2 %) than high birthweight cattle, suggesting only minor effects on carcass tissue distribution. There were few interactions between sire genotype and birthweight or preweaning growth, and interactions between birthweight and preweaning growth were not evident for any variables. However, variability between cohorts in their long-term responses to growth early in life suggests other environmental factors during early-life and/or subsequent growth influenced carcass yield characteristics. Overall, this study shows that effects of birthweight and preweaning growth rate on carcass compositional and yield characteristics were mostly explained by variation in carcass weight and, hence, in whole body growth to 30 months of age. [ABSTRACT FROM AUTHOR]

Consequences of low (mean 28.0 kg, n = 77) and high (mean 38.4 kg, n = 77) birthweight followed by slow (mean 548 g/day, n = 75) or rapid (mean 859 g/day, n = 79) growth to weaning for feedlot growth, intake and efficiency from 26 to 30 months of age were determined in Wagyu x Hereford (n = 81) and Piedmontese x Hereford (n = 73) cattle. Cattle were selected for study based on birthweight and preweaning growth rate, from multi-modal distributions achieved by imposition of low or high maternal nutrition during pregnancy and lactation, with the objective of achieving as close as possible to a 30% difference in birthweight and a 2-fold difference in preweaning growth rate between progeny groups. High birthweight cattle entered the intake test 57 kg heavier, grew 100 g/day more rapidly, and ate 1.0 kg dry matter /day more than the low birthweight cattle. The high birthweight cattle tended to have a higher feed conversion ratio than low birthweight cattle, but net feed intake did not differ due to birthweight group. Cattle grown rapidly to weaning entered the intake test 29 kg heavier, grew at an equivalent rate, and ate 0.7 kg dry matter/day more than the cattle grown slowly to weaning. No differences in feed conversion ratio or net feed intake were observed between the preweaning groups. When assessed at the same liveweight, differences in dry matter intake and/or feed conversion ratio due to birthweight or preweaning growth were no longer apparent. Interactions between prenatal and preweaning growth, or between sire genotype and early-life growth, were not evident for feedlot growth, intake or efficiency. It is concluded that severely restricted growth during prenatal life or from birth to weaning results in cattle that are smaller and consume less feed at the same age as their well grown counterparts; however, long-term effects of growth during early life on efficiency of utilisation of feed are not evident. [ABSTRACT FROM AUTHOR]