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Abstract Background Management of type 2 diabetes mellitus (T2DM) encompasses intensive glycaemic control, along with treatment of comorbidities and complications to handle the increased risk of cardiovascular disease (CVD). Improved control of LDL-cholesterol (LDL-C) with lipid-lowering medications is associated with reduced CVD risk in T2DM patients. Thus, treatment guidelines recommend lipid-lowering medications for T2DM patients with LDL-C above risk-associated thresholds. This study aimed to assess healthcare provider adherence to guidelines regarding lipid-lowering medication prescription among T2DM patients and to analyse factors associated with lipid-lowering medication prescription. Methods Observations in 2007 − 2014 for T2DM patients age ≥ 18 were collected from the Swedish National Diabetes Register. Observations were excluded if they lacked information about LDL-C, lipid-lowering medication prescription or CVD. Observations with established CVD were attributed to secondary prevention; remaining observations were attributed to primary prevention. The analyses included primary and secondary prevention observations with LDL-C above risk-associated thresholds (LDL-C ≥ 2.5 mmol/l and LDL-C ≥ 1.8 mmol/l respectively). Guideline adherence was analysed as the probability of prescribing lipid-lowering medications using mixed-effect model regression adjusted for potential confounders. Factors associated with prescribing lipid-lowering medications were analysed for patient and healthcare provider characteristics using mixed-effect model regression and odds ratio. Results A total of 1,204,376 observations from 322,046 patients reported by 1352 healthcare providers were included. Primary prevention accounted for 63%; 52% were men, mean age was 64 and mean LDL-C was 3.4 mmol/l. For secondary prevention, 60% were men, mean age was 72 and mean LDL-C was 2.7 mmol/l. During 2007–2014, guideline adherence ranged from 36 to 47% for primary prevention and 59 to 69% for secondary prevention. In general, concomitant prescription of diabetes medications, antiplatelets and antihypertensives along with smoking and specialised care were associated with higher prescription of lipid-lowering medications. Patients age ≥ 80 were associated with lower prescription of lipid-lowering medications. Higher prescription was associated with longer diabetes duration in primary prevention and men in secondary prevention. Conclusions Adherence to treatment guidelines levelled off after an initial increase in both prevention groups. Lipid-lowering medication prescription was based on individualised CVD risk.

Background: Patients with schizophrenia are at least twice as likely to develop diabetes mellitus compared to the general population. This is of significance in Qatar given the high prevalence of obesity and diabetes. Furthermore, the lifespan of people with schizophrenia is shortened by approximately 15 years, partly due to long-term microvascular and macrovascular complications. High quality diabetes care can significantly reduce morbidity and mortality. We assessed the level of diabetes care delivered to patients in Qatar with schizophrenia and diabetes compared to those with diabetes alone. Methods: We performed a retrospective chart review of patients with diabetes mellitus with (n = 73) and without (n = 73) schizophrenia. Demographic information and electronic medical records were reviewed to determine adherence to American Diabetes Association standards of diabetes care in the last 6 and 12 months. Optimal diabetes care was defined as having completed glycated hemoglobin (HbA1c), lipid profile and retinal examination within 12 months. Results: Optimal diabetes care was significantly lower in patients with schizophrenia and diabetes compared to diabetes alone [26.0% (n = 19/73) vs 52.1% (n = 38/73), p = 0.002]. Patients with diabetes and schizophrenia were also significantly less likely to have had body mass index recorded within 6 months (p = 0.008) and HbA1c (p = 0.006), lipid profile (p = 0.015), estimated glomerular filtration rate (eGFR) (p = 0.001) and order for retinal examination (p = 0.004) over 12 months. After adjusting for multiple comparisons, only assessment of eGFR (p = 0.01) and order for retinal examination (p = 0.04) remained significant. Conclusion: Patients in Qatar with schizophrenia and diabetes, receive sub-optimal diabetes care compared to those with diabetes alone. [ABSTRACT FROM AUTHOR]

Objective: To study worldwide differences in childhood diabetes, comparing relevant indicators among five regions within the SWEET initiative. Subjects: We investigated 26 726 individuals with type 1 diabetes (T1D) from 54 centers in the European region; 7768 individuals from 30 centers in the Asia/Middle East/Africa region; 2642 people from five centers in Australia/New Zealand; 10 839 individuals from seven centers in North America, and 1114 patients from five centers in South America. Methods: The SWEET database was analyzed based on the following inclusion criteria: T1D, time period 2015‐2019, and age < 21 years, with analysis of the most recent documented year of therapy. For the statistical analysis, we used multivariable linear and logistic regression models to adjust for age (<6 years, 6‐ < 12 years, 12‐ < 18 years, 18‐ < 21 years), gender, and duration of diabetes (<2 years, 2‐ < 5 years, 5‐ < 10 years, ≥10 years). Results: Adjusted HbA1c means ranged from 7.8% (95%‐confidence interval: 7.6‐8.1) in Europe to 9.5% (9.2‐9.8) in Asia/Middle East/Africa. Mean daily insulin dose ranged from 0.8 units/kg in Europe (0.7‐0.8) and Australia/New Zealand (0.6‐0.9) to 1.0 unit/kg 0.9‐1.1) in Asia/Middle East/Africa. Percentage of pump use was highest in North America (80.7% [79.8‐81.6]) and lowest in South America (4.2% [3.2‐5.6]). Significant differences between the five regions were also observed with regards to body mass index SD scores, frequency of blood glucose monitoring and presence of severe hypoglycaemia. Conclusions: We found significant heterogeneity in diabetes care and outcomes across the five regions. The aim of optimal care for each child remains a challenge. [ABSTRACT FROM AUTHOR]

In Australasia diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease (ESKD), accounting for 47% and 38% of incident patients in New Zealand and Australia respectively. People with DKD also have worse outcomes on dialysis and lower rates of kidney transplantation. To assist in healthcare improvement, we conducted a qualitative study with patients with DKD to better understand their experiences of their diabetes care. In this study, ten participants with DKD were purposively selected and interviewed face to face. Four main themes were identified from the participants' transcripts; the value of education, relationships with healthcare providers, coping with diagnosis and the importance of whānau/family. The study results revealed a standardised approach to diabetes care is required to ensure equity of care for all patients regardless of the service they receive care from. Implementing more specialist nursing models of care in general practice may provide better consistency and continuity for patients as well as enhance collaboration between primary and secondary providers. [ABSTRACT FROM AUTHOR]

Background: Type 2 diabetes mellitus is increasing in rural China and should be managed in primary health care, but knowledge is lacking. Educational interventions have been implemented but not followed up long-term. Objective: The study aimed to assess the long-term impact of an educational intervention on patients’ diabetes knowledge and fasting blood glucose (FBG) level, and whether these outcomes differed between two rural counties. Methods: The study was nested in an educational intervention project in primary health care in Jiangsu province. Patients with type 2 diabetes mellitus from Huaiyin county and Gaochun county were randomly divided into an intervention group receiving an educational intervention and follow-up visits, and a control group with standard care. Questionnaires and medical records, including FBG level and diabetes knowledge score, were compared, at baseline in 2015 and two follow-ups, in 2016, and 2017, respectively. A paired t-test and two mixed-effects linear regression models were used. Results: The diabetes knowledge score increased in the intervention group in 2016 and in 2017, compared with 2015. The FBG level decreased in 2016 compared with 2015 in the intervention and control groups. Comparing data in 2015 and 2017, there was no significant change in FBG level in the intervention or control group, but the diabetes knowledge score increased in the intervention group both in 2016 and 2017. A significant association between FBG level and the interaction of time and group, suggesting a long-term effect, was only found in Gaochun county in 2017. Conclusion: The educational intervention improved the diabetes knowledge score in the intervention group, while no significant improvement was found in the control group in both year 2016 and 2017. Meanwhile, the intervention had a positive impact on FBG level in the intervention group in 2017. Patients in Gaochun county had better improvement in both diabetes knowledge and controlling FBG level, compared with Huaiyin county.

Background: Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention. Description of the care practice: Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification, and 3) the multi-disciplinary virtual clinics in the community. Methods: This paper evaluates the acceptability, feasibility and short-term impact on primary care of implementing a population approach intervention using direct observations of the clinics and surveys of participating clinicians. Results and discussion: Eighteen virtual clinics across seven teams took place over six months between March and July 2017 with organisation, resources, policies, education and approximately 150 individuals discussed. The feedback from primary care was positive with growing knowledge and confidence managing people with complex diabetes in primary care. Conclusion: Taking a population health approach helped to identify groups of people in need of additional diabetes care and deliver a collaborative health intervention across traditional organisational boundaries.

Background: Diabetic retinopathy is the most common microvascular complication of diabetes and it is a leading cause of visual impairment and blindness among patients with diabetes. This study aimed to investigate the effect of educational program based on Theory of Planned Behavior (TPB) on promoting retinopathy preventive behaviors in patients with type 2 diabetes. Methods: The present study is an educational randomized controlled trial research that was conducted on 94 patients with type 2 diabetes who had gone to diabetes clinic. The samples were randomly assigned to the intervention (N = 47) and control groups (N = 47). Data collection instrument was a researcher-made questionnaire based on TPB and FBS and HbA1C tests. Then, educational program was performed for the intervention group through four educational sessions. After 3 months, data collection was repeated for the two groups and FBS, HbA1C testes were done again and data were analyzed. Results: The performance of the intervention group on preventive behaviors of retinopathy increased from 2.48 ± 1.42 to 4.48 45 1.45 after the education (p < 0.001). The mean of FBS and HbA1c in the intervention group also decreased after the intervention (P < 0.05). Conclusion: Applying the TPB model proved is very effective in developing an educational program for patients with diabetes, to control their blood sugar and enhance preventive behaviors of retinopathy. Besides such programs, follow-up education for controlling and monitoring are highly recommended. This theory serves as a helpful theoretical framework for health-related behaviors and can be an appropriate pattern to plan for educational interventions. Trial registration: This trial has been registered at Iranian Registry of Clinical Trials, IRCT20180819040834N1. Prospectively registered 8 Apr 2019, https://en.irct.ir/trial/38401 [ABSTRACT FROM AUTHOR]

Background: This study examined the association between quality of processes of diabetes care in terms of adherence to American Diabetes Association (ADA)‐recommended guidelines and health care utilization in patients with diabetes. Methods: Adults with diabetes were identified from the pool of five panels of the Medical Expenditure Panel Survey, a nationally representative US sample, between 2012 and 2017. The Diabetes Care Survey was used to determine adherence to the ADA‐recommended guidelines for processes of diabetes care if all of the following were performed annually: glycosylated hemoglobin check, foot examination, dilated eye examination, lipid panel, influenza immunization, blood pressure check, and dental examination. Health care utilization in terms of inpatient hospitalization, and emergency department (ED) and outpatient visits were estimated using two‐part hurdle models. Results: An estimated 26.3 million adults with diabetes were derived from the pooled 5‐panel data, of which 7.8% met the ADA‐recommended guidelines for processes of diabetes care, and adherence rates of individual recommendations were generally below 50%. Overall, adults who adhered to the ADA‐recommendations were older, non‐Hispanic white, and married nonsmokers with private insurance and higher income. Mean inpatient hospital stays, ED, and outpatient visits between ADA‐adherent vs nonadherent patients were 0.98 vs 1.62 (P <.001), 0.36 vs 0.39 (P =.074), and 17.9 vs 12.8 (P <.001), respectively. Conclusions: Socioeconomic disadvantage and minority status were linked with nonadherence to the ADA‐recommended processes of diabetes care. Adherence to the ADA recommendation was associated with significant reduction in inpatient hospitalization and a trend toward less ED visits. Our findings may apply to the United States and are likely to be different in other parts of the world. [ABSTRACT FROM AUTHOR]

Background: Type 2 diabetes mellitus is increasing in rural China and should be managed in primary health care, but knowledge is lacking. Educational interventions have been implemented but not followed up long-term. Objective: The study aimed to assess the long-term impact of an educational intervention on patients' diabetes knowledge and fasting blood glucose (FBG) level, and whether these outcomes differed between two rural counties. Methods: The study was nested in an educational intervention project in primary health care in Jiangsu province. Patients with type 2 diabetes mellitus from Huaiyin county and Gaochun county were randomly divided into an intervention group receiving an educational intervention and follow-up visits, and a control group with standard care. Questionnaires and medical records, including FBG level and diabetes knowledge score, were compared, at baseline in 2015 and two follow-ups, in 2016, and 2017, respectively. A paired t-test and two mixed-effects linear regression models were used. Results: The diabetes knowledge score increased in the intervention group in 2016 and in 2017, compared with 2015. The FBG level decreased in 2016 compared with 2015 in the intervention and control groups. Comparing data in 2015 and 2017, there was no significant change in FBG level in the intervention or control group, but the diabetes knowledge score increased in the intervention group both in 2016 and 2017. A significant association between FBG level and the interaction of time and group, suggesting a long-term effect, was only found in Gaochun county in 2017. Conclusion: The educational intervention improved the diabetes knowledge score in the intervention group, while no significant improvement was found in the control group in both year 2016 and 2017. Meanwhile, the intervention had a positive impact on FBG level in the intervention group in 2017. Patients in Gaochun county had better improvement in both diabetes knowledge and controlling FBG level, compared with Huaiyin county. [ABSTRACT FROM AUTHOR]

In the last four decades, diabetes has become epidemiologically aggressive, threatening the health of millions of people and challenging health systems by increasing costs. Significant changes have been made in many areas of medical and socio - economic life that have become the new world of diabetes. The mission of the lancet commission report is to stimulate the beneficial transformation of diabetes through four major actions. 1. Digital collection of essential data on epidemiology and on the quality of care. 2. Increasing the level of knowledge of doctors and educators. 3. Optimizing the quality of care that can be achieved through adherence to quality standards and the co-participation/activation of patients. It is necessary to gradually approach "precise diabetes" through "personalized management for the right phenotype", where the care of the disease becomes the care of the person with diabetes. 4. Prevention of diabetes and its complications is the last but not the least condition of transformation. The benefits are estimated in terms of increasing the quality of life of people with diabetes, reducing the aggressiveness of the disease, and increasing life expectancy. Conclusion: The transformation of diabetes is necessary and possible and the benefits are huge. Let's participate in its achievement. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of diabetes and its complications in the Innu community of Sheshatshiu is high. We wanted to determine if shared medical appointments (SMAs) could provide culturally appropriate, effective treatment to Innu patients with relatively well-controlled diabetes, as an alternative to standard, 'one-on-one' care. Methods: We conducted a mixed-method study including a randomised controlled trial comparing standard care versus SMAs for patients aged 18--65 years with haemoglobin A1C (HbA1C) of ≤7.5%, followed by a qualitative study using semi-structured interviews with patients who attended SMAs. Results: Among 23 patients, 13 received the intervention. There were no significant differences of HbA1C level or HbA1C percentage of change between intervention and control groups at baseline, 6 months or 12 months. There were no statistical differences between standard care and SMA groups, concerning mortality or the need for haemodialysis. The qualitative analysis found that patients generally enjoyed the SMA model and the peer support and learning benefits of the SMAs. Patients did not believe that the SMA model was more or less culturally appropriate than standard care, but the majority said they felt that the SMAs were good for the community and could be a good venue for incorporating Innu healthy--lifestyle knowledge into medical diabetes care. Conclusions: SMAs may be an efficient way to manage well-controlled diabetic patients in the Innu community of Sheshatshiu and to provide peer support and opportunities for learning and incorporating community-specific knowledge into care. [ABSTRACT FROM AUTHOR]

The coronavirus disease pandemic has created opportunities for innovation in diabetes care that were not possible before. From the lens of this "new normal" state, we have an opportunity to rapidly implement, test, and iterate models of diabetes care to achieve the quadruple aim of improving medical outcomes, patient experience, provider satisfaction, and reducing costs. In this perspective, we discuss several innovative diabetes models of care which promote collaborative care models and improve access to high-quality specialty diabetes care. We discuss ongoing threats to diabetes care innovation, and offer practical solutions to foster evolution and sustain current strides made during the pandemic. [ABSTRACT FROM AUTHOR]

Background: Individuals living with diabetes mellitus (DM) are at an increased risk for multiple serious health complications including diabetic foot disease (DFD). Daily, DFD contributes to increased morbidity, mortality, increased hospitalization, limb amputation, and reduced quality of life. Prevention of DFD is a foundational component of diabetes management., Purpose: The purpose of this study was to explore how individuals manage the care required to protect their feet from DM related foot complications., Methods: This qualitative descriptive study utilized semi structured interviews to explore the perspectives of 23 participants on preventing foot care complications associated with DM. All data were analyzed using reflexive thematic analysis., Results: Participants were challenged to consistently make health choices that were congruent with recommended DM self-management for the prevention of DFD. In addition, participants intuited multiple mixed messages from healthcare providers and workplaces that appeared to diminish their individual responsibility to self-manage their DM. Findings were organized under two main themes: a) Ineffective coping: Distancing self from disease b) Vacillating responsibility: Multiple mixed messages., Conclusions: Nurses are in a unique position to provide the education and support needed to assist individuals in carrying out the many recommended self-care strategies to reduce the risk of DFD. Contextually, nurses must encourage consistent messaging among health care providers and workplaces to prioritize the health needs of individuals living with diabetes and to support the challenging work these individuals must navigate every day. It will take a concerted effort to reinforce the message that diabetes care is a priority for everyone., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

South Korea is one of many countries that has implement national chronic disease management programs. These programs comprise “A pilot program for the registration and management of cardiocerebrovascular high-risk groups” in 2007, “A pilot program for community primary medical care” in 2014, “A pilot program for chronic care charges” in 2016, and “Primary medical chronic disease management pilot project” in 2019. For establishing and implementing policies to strengthen chronic care management in primary medical care, a virtuous cycle, in which experiences in various programs are monitored and achievements are accumulated in aid of policy development, is important. That is, objective evaluation indices and systems should be designed as programs are carried forward, and program quality should be improved through of evaluation results and feedback. This study highlight the problems with existing programs and the necessary steps to achieve the expected effects. [ABSTRACT FROM AUTHOR]

Objective: To examine how the teach-back, interactive communication loop between patient and provider, is utilized and its role in diabetes care delivery.Methods: This was a cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) 2011-2016. The study sample included US adults aged 18 or older with diabetes. Survey-design adjusted analyses were used to examine patterns of teach-back utilization across patient socioeconomic/clinical characteristics, patient-provider interactions, and diabetes care education.Results: Analysis of 2901 US adults with diabetes showed that 25.0 % reported patient teach-back experience during their visit to care. Compared with patients without teach-back, those with teach-back experience had higher scores on interaction quality with their providers (composite score: 90.8 vs. 55.8, P < .001). Those with teach-back were also more to receive additional advice on diet and exercise from providers (67.0 % vs. 60.9 %, P = 0.03) and to report that they were confident in diabetes self-care management (75.7 % vs. 70.3 %, P =0.03).Conclusion: Teach-back communication appears to be effective in patient-provider interaction and diabetes care education, leading to higher confidence in self-care management.Practice Implications: Despite its potential, the utilization of teach-back communication is suboptimal. More effort is needed to promote effective use of teach-back communication in routine diabetes care. [ABSTRACT FROM AUTHOR]

People with diabetes who are housebound often fall between services and, therefore, do not always receive all of their key care processes, including insulin delivery. As part of a review of all such patients within a clinical commissioning group (CCG) in Kent, this project was conducted to train unregistered practitioners to carry out annual review. The aim was to improve knowledge and competencies among unregistered practitioners in order for them to be able to carry out some components of the diabetes annual review. Six unregistered practitioners employed by the GP practice or the community health trust participated in the project. Each practitioner achieved nine competencies, based on the TREND-UK competency framework. Competencies were achieved through classroom-based learning delivered by a nurse consultant in diabetes, as well as practical supervision of tasks and skills associated with carrying out an annual review. Reflective work and discussion demonstrated not only new skills learned but also how to put these into practice. It is hoped that the training of unregistered practitioners as part of the overall project not only improved their understanding and knowledge but also improved the standard of care delivered to this vulnerable group of people with diabetes. [ABSTRACT FROM AUTHOR]

Introduction Considering limited global access to affordable insulin, we evaluated insulin access in public and private health sectors in Bengaluru, India. Methods Employing modified WHO/HAI methodology, we used mixed-methods analysis to study insulin access and factors influencing insulin supply and demand in Bengaluru in December 2017. We assessed insulin availability, price and affordability in a representative sample of 5 public-sector hospitals, 5 private-sector hospitals and 30 retail pharmacies. We obtained insulin price data from websites of government Jan Aushadhi scheme (JAS) and four online private-sector retail pharmacies. We interviewed wholesalers in April 2018 to understand insulin market dynamics. Results Mean availability of insulins on India’s 2015 Essential Medicine List was 66.7% in the public sector, lower than private-sector retail (76.1%) and hospital pharmacies (93.3%). Among private retailers, mean availability was higher among chain (96.7%) than independent pharmacies (68.3%). Non-Indian companies supplied 67.3% products in both sectors. 79.1% products were manufactured in India, of which 60% were marketed by non-Indian companies. In private retail pharmacies, median consumer prices of human insulin cartridges and pens were 2.5 and 3.6 times, respectively, that of human insulin vials. Analogues depending on delivery device were twice as expensive as human insulin. Human insulin vials were 18.3% less expensive in JAS pharmacies than private retail pharmacies. The lowest paid unskilled worker would pay 1.4 to 9.3 days’ wages for a month’s supply, depending on insulin type and health sector. Wholesaler interviews suggest that challenges constraining patient insulin access include limited market competition, physicians’ preference for non-Indian insulins, and the ongoing transition from human to analogue insulin. Rising popularity of online and chain pharmacies may influence insulin access. Conclusion Insulin availability in Bengaluru’s public sector falls short of WHO’s 80% target. Insulin remains unaffordable in both private and public sectors. To improve insulin availability and affordability, government should streamline insulin procurement and supply chains at different levels, mandate biosimilar prescribing, educate physicians to pursue evidence-based prescribing, and empower pharmacists with brand substitution. Patients must be encouraged to shop around for lower prices from subsidized schemes like JAS. While non-Indian companies dominate Bengaluru’s insulin market, rising market competition from Indian companies may improve access.

Abstract Background Novel telemedicine platforms have expanded access to critical retinal screening into primary care settings. This increased access has contributed to improved retinal screening uptake for diabetic patients, particularly those treated in Federally Qualified Health Centers (‘safety net’ clinics). The aim of this study was to understand how the implementation of telemedical screening for diabetic retinopathy within primary care settings is improving the delivery of critical preventative services, while also introducing changes into clinic workflows and creating additional tasks and responsibilities within resource-constrained clinics. Methods A qualitative approach was employed to track workflows and perspectives from a range of medical personnel involved in the telemedicine platform for diabetic retinopathy screening and subsequent follow-up treatment. Data were collected through semi-structured interviews and participant observation at three geographically-dispersed Federally Qualified Health Centers in California. Qualitative analysis was performed using standard thematic analytic approaches within a qualitative data analysis software program. Results The introduction of telemedicine platforms, such as diabetic retinopathy screening, into primary care settings is creating additional strain on medical personnel across the diabetes eye care management spectrum. Central issues are related to scheduling patients, issuing referrals for follow-up care and treatment, and challenges to improving adherence to treatment and diabetes management. These issues are overcome in many cases through workarounds, or when medical staff work outside of their job descriptions, purview, and permission to move patients through the diabetes management continuum. Conclusions This study demonstrates how the implementation of a novel telemedical platform for diabetic retinopathy screening contributes to the phenomenon of workarounds that account for additional tasks and patient volume. These workarounds should not be considered a sustainable model of health care delivery, but rather as an initial step to understanding where issues are and how clinics can adapt to the inclusion of telemedicine and ultimately increase access to care. The presence of workarounds suggests that as telemedicine is expanded, adequate resources, as well as collaborative, cross-sectoral co-design of new workflows must be simultaneously provided. Systematic bolstering of resources would contribute to more consistent success of telemedicine screening platforms and improved treatment and prevention of disease-related complications.

Boon-How Chew,1 Aaron Fernandez,2 Sazlina Shariff-Ghazali1 1Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia; 2Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia Abstract: Psychological aspects of a person, such as the personal value and belief systems, cognition and emotion, form the basis of human health behaviors, which, in turn, influence self-management, self-efficacy, quality of life, disease control and clinical outcomes in people with chronic diseases such as diabetes mellitus. However, psychological, psychosocial and behavioral interventions aimed at these groups of patients have yielded inconsistent effects in terms of clinical outcomes in clinical trials. This might have been due to differing conceptualization of health behavioral theories and models in the interventions. Assimilating different theories of human behavior, this narrative review attempts to demonstrate the potential modulatory effects of intrinsic values on cognitive and affective health-directed interventions. Interventions that utilize modification of cognition alone via education or that focuses on both cognitive and emotional levels are hardly adequate to initiate health-seeking behavior and much less to sustain them. People who are aware of their own personal values and purpose in life would be more motivated to practice good health-related behavior and persevere in them. Keywords: behavioral medicine, psychological theory, long-term care, diabetes care, self-management, self-efficacy, chronic diseases

Abstract Background The aim of this study was to determine if the achievement of control targets in patients with type 2 diabetes was associated with personal socioeconomic factors and if these associations were sex-dependent. Methods This cross-sectional, population-based study was conducted in Spain. Glycated haemoglobin (HbA1c) level and other clinical parameters were obtained from electronic primary care records (n = 32,638 cases). Socioeconomic status was determined using education level and yearly income. Among patients, having their HbA1c level checked during the previous year was considered as an indirect measure of the process of care, whereas tobacco use and clinical parameters such as HbA1c, low-density lipoprotein cholesterol (LDL-c) and blood pressure (BP) were considered intermediate control outcomes. General linear mixed effect models were used to assess associations. Results The achievement of metabolic and cardiovascular control targets in patients with type 2 diabetes was associated with educational level and income, and socioeconomic gradients differed by sex. The probability of having had an HbA1c test performed in the previous year was higher in patients with lower education levels. Patients in the lowest income and education level categories were less likely to have reached the recommended HbA1c level. Males in the lowest education level categories were less likely to be non-smokers or to have achieved the blood pressure targets. In contrast, patients within the low income categories had a higher probability of reaching the recommended LDL-c level. Conclusions Our results suggest the presence of socioeconomic inequalities in the achievement of cardiovascular and metabolic control that differed in direction and magnitude depending on the measured outcome and sex of the patient. These findings may help health professionals focus on high-risk individuals to decrease health inequalities.

Buddhist philosophy is a way of life that transcends the borders of religion and focuses on the alleviation of suffering. The core teaching of Buddha was the Four Noble Truths: there is suffering, suffering is caused by clinging and ignorance, there is a way out of suffering and that way is the Noble Eightfold Path. The medical analogy in diabetes care would include identification of diabetes, understanding its etiopathogenesis, and how prognosis can be improved with appropriate care and management of this chronic disorder. Gaining awareness about the cause of illness and conducting our lives in a manner that nourishes and maintains long-term good health leads to improved outcomes for individuals living with diabetes and improve their overall well-being. The Noble Eightfold Path in Buddhism constitutes of right view, right resolve, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration. These elements of the Eightfold Path can be taken as guiding principles in diabetes care. Buddhist meditation techniques, including mindfulness meditation-based strategies, have been used for stress reduction and management of chronic disorders such as chronic pain, depression, anxiety, hypertension, and diabetes. In this article, we focus on how Buddhist philosophy offers several suggestions, precepts, and practices that guide a diabetic individual toward holistic health.

BackgroundAlthough preventing diabetes complications requires long-term management, little is known about which patients persistently fail to get recommended care.ObjectiveTo determine the frequency and correlates of persistent, long-term gaps in diabetes care.Method: The study population included 8392 patients with diabetes. Patient surveys and medical records from 10 health plans over 3 years provided data on socioeconomic characteristics, access to care, social support, and mental and physical health, and diabetes preventive care services. We defined a "persistent gap" as a participant's missing a preventive care service for the entire 3 years. Services considered included hemoglobin A1c, cholesterol, and albuminuria tests, and foot and dilated eye examinations.ResultsThirty percent of participants had at least 1 persistent gap. The most common gaps were lipid testing (11.6%), microalbuminuria testing (9.7%), and eye examinations (9.0%). Persistent gaps were 18% to 42% higher for young patients, lean persons, those with low income, employed persons, smokers, those with diabetes less than 5 years, and patients with none or 1 comorbid conditions. Sex, education, marital status, family demands, transportation, trust in physicians, and mental health were not associated with gaps in care.ConclusionsPersistent gaps in diabetes care are common even among insured patients. Patients with lower income, younger age, fewer years of diabetes, having fewer comorbidities, taking fewer medications, and poor health behaviors are vulnerable to persistent gaps in care and a group who warrant targeted interventions to improve preventive diabetes care.

Artificial intelligence/Machine learning (AI/ML) is transforming all spheres of our life, including the healthcare system. Application of AI/ML has a potential to vastly enhance the reach of diabetes care thereby making it more efficient. The huge burden of diabetes cases in India represents a unique set of problems, and provides us with a unique opportunity in terms of potential availability of data. Harnessing this data using electronic medical records, by all physicians, can put India at the forefront of research in this area. Application of AI/ML would provide insights to our problems as well as may help us to devise tailor-made solutions for the same.

Copyright of Public Health Forum is the property of De Gruyter and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Public Health Forum is the property of De Gruyter and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Continuing professional development (CPD) is a widely used and evolving set of complex interventions that seeks to update and improve the knowledge, skills, and performance of health care professionals to ultimately improve patient care and outcomes. While synthesized evidence shows CPD in general to be effective, effects vary, in part due to variation in CPD interventions and limited understanding of CPD mechanisms of action. We introduce two behavioral science tools--the Behavior Change Technique Taxonomy version 1 and the Theoretical Domains Framework--that can be used to characterize the content of CPD interventions and the determinants of behaviour potentially targeted by the interventions, respectively. We provide a worked example of the use of these tools in coding the educational content of 43 diabetes quality improvement trials containing clinician education as part of their multicomponent intervention. Fourteen (of a possible 93; 15%) behavior change techniques were identified in the clinician education content of the quality improvement trials, suggesting a focus of addressing the behavioral determinants beliefs about consequences, knowledge, skills, and social influences, of diabetes care providers' behavior. We believe that the Behavior Change Technique Taxonomy version 1 and Theoretical Domains Framework offer a novel lens to analyze the CPD content of existing evidence and inform the design and evaluation of future CPD interventions. [ABSTRACT FROM AUTHOR]

Objective: In this study, we assessed school nurses' perception of barriers to caring for a child with Type 1 diabetes in the school setting. Methods: Four semi-structured focus group interviews were conducted with 29 school nurses from 4 Appalachian locations in Ohio. The researchers used purposeful sampling for the study and invited the participants by an email flyer sent through a state school nurse listserv. The focus groups ranged in size from 5-9 participants in each group and a research guide of 14 open-ended questions was used to guide the interview. The transcripts were transcribed verbatim by a research assistant and independently analyzed by 2 researchers for categories and themes. Results: Emerging themes from the interview data were: (1) nurse workload, (2) need for diabetes training for school nurses, and (3) lack of support from parent/guardians and healthcare providers. Conclusions: Our findings provide direction for school nurse staffing models, policies for diabetes management, and strategies for enhancing relationships between parents and healthcare providers. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of an educational intervention for type 2 diabetes mellitus (T2DM) in primary care in rural China, on fasting blood glucose (FBG) level and diabetes knowledge.Methods: Patients with T2DM (n = 1,589) in 18 township health centres in three counties in Jiangsu Province were randomly divided into an intervention group receiving educational intervention and follow-up visits, and a control group with standard care. Questionnaires and medical records, including FBG level and diabetes knowledge score, were compared, at baseline and follow-up. Propensity score matching and Difference-in-Difference analysis were used.Results: The FBG level decreased significantly in the intervention group compared to the control group, DID=-0.53 mmol/l, (CI95 % -0.90 to -0.16). The diabetes knowledge score increased significantly in the intervention group compared to the control group, DID = 0.91, (CI95 % 0.64-1.18). The FBG level and diabetes knowledge score improved significantly in the intervention group in all counties.Conclusions: The educational intervention and increased collaboration between hospitals and primary care improved the FBG level and diabetes knowledge score in the intervention group compared to the control group after one year.Practice Implications: Educational intervention and increased collaboration between hospitals and primary care may improve diabetes care in rural China. [ABSTRACT FROM AUTHOR]

While diabetes centers are well established by the Ministry of Health, there is no separate specialized diabetes clinics for COVID-19 patients (SDCs). There are several clinical diabetes centers throughout the Kingdom of Saudi Arabia, several of which have been developed through philanthropy funding; nevertheless, it is not obvious what distinguishes SDCs from a therapeutic viewpoint and what the potential would be for such centers. Through this context, we suggest a structure to direct the progress of SDCs. Defining protocols for wider adoption of SDCs as a means to enhance public safety and COVID-19 patient care efficiency (including consistency and satisfaction) and minimize health care expenses becomes increasingly essential when moving towards value-based sales and reimbursements away from service charges. It is wise to introduce innovative financial mechanisms to pay for diabetes that cannot be covered by fiscally limited private and university medical centers. We foresee potential clinical SDCs to be made up of a well-defined framework and six areas or foundations that act as basic guiding principles for the advancement of diabetes treatment skills that can be easily illustrated by stakeholders, including insurance facilities, consumers, payers and government departments. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a chronic disease characterized by high social, economic and health burden, mostly due to the high incidence and morbidity of diabetes complications. Numerous studies have shown that optimizing metabolic control may reduce the risk of micro and macrovascular complications related to the disease, and the algorithms suggest that an appropriate and timely step of care intensification should be proposed after 3 months from the failure to achieve metabolic goals. Nonetheless, many population studies show that glycemic control in diabetic patients is often inadequate. The phenomenon of clinical inertia in diabetology, defined as the failure to start a therapy or its intensification/de-intensification when appropriate, has been studied for almost 20 years, and it is not limited to diabetes care, but also affects other specialties. In the present manuscript, we have documented the issue of inertia in its complexity, assessing its dimensions, its epidemiological weight, and its burden over the effectiveness of care. Our main goal is the identification of the causes of clinical inertia in diabetology, and the quantification of its social and health-related consequences through the adoption of appropriate indicators, in an effort to advance possible solutions and proposals to fight and possibly overcome clinical inertia, thus improving health outcomes and quality of care. [ABSTRACT FROM AUTHOR]

Objective: The objectives of this study is to assess the quality of diabetic care at AlManhal PHCC based on CBAHI standards. Methods: This audit was conducted during 2018 at Al_Manhal PHCC through assessment all aspects of DM care (structures, processes and outcomes) using CBAHI standards. Data entry and analysis were managed used SPSS. Results: Most of DM structures were available at the PHCC , however, health educational program , lab relevant facilities were partially met the standards. Records of 429 patients were assessed for process of care which were satisfactory except for laboratory investigations and eye examination which were partially met. Good DM metabolic control was (28%) , HTN control (71%) and lipid control(54%), good compliance with appointment was 85%. The most common documented complications were retinopathy(14%), nephropathy (4.5%) and CHD(4%). Conclusion and Recommendations: This audit revealed that using of CBAHI standards for DM care at PHCC is simple and practical and could help to identify the weak areas that needs improvement. The present care of DM in our PHCC has acceptable infrastructures except for health education program , laboratory and referral system which should be scaled up to improve the processes and outcomes. DM control is still a big challenge and needs more collaborative effort between health care providers and patients. [ABSTRACT FROM AUTHOR]

Introduction: Despite treatment with oral antidiabetic drugs (OADs), achieving effective glycaemic control in type 2 diabetes (T2D) remains a challenge. The objective of this post hoc analysis of data from the SUSTAIN 2, 3, 4 and 10 active-controlled trials was to assess the efficacy and safety of the once-weekly glucagon-like peptide 1 receptor agonist (GLP-1RA) semaglutide in patients on background treatment with metformin (MET), with or without a sulphonylurea (SU). Methods: Data from the randomised phase 3 trials SUSTAIN 2, 3, 4 and 10 for subjects who received background MET alone or MET + SU were analysed. Change from baseline in HbA1c and body weight at the end of treatment visit (week 30 in SUSTAIN 4 and 10, week 56 in SUSTAIN 2 and 3), and rates of hypoglycaemia and adverse events leading to premature treatment discontinuation were assessed. Results: In total, 3411 subjects were included in the full analysis set (3410 in the safety analysis set). Across the four trials, semaglutide significantly reduced HbA1c (estimated treatment difference [ETD] − 0.32 to − 0.79%-points for semaglutide 0.5 mg, and − 0.38 to − 1.07%-points for semaglutide 1.0 mg vs comparators; p < 0.01) in subjects receiving both MET and MET + SU. Regardless of background OAD, semaglutide significantly reduced body weight (ETD − 2.35 to − 4.72 kg for semaglutide 0.5 mg, and − 2.96 to − 6.76 kg for semaglutide 1.0 mg vs comparators; p < 0.0001). Across the trials, hypoglycaemic events were more common with background MET + SU than MET alone, in subjects receiving either semaglutide or a comparator. The rate of adverse events (AEs) leading to premature treatment discontinuations in subjects treated with semaglutide were generally consistent regardless of background therapy. Conclusion: Semaglutide 0.5 mg and 1.0 mg significantly improve glycaemic control (HbA1c) and body weight in subjects with T2D, with a similar tolerability profile, regardless of whether they receive background MET or MET + SU. Trial Registration: Clinicaltrials.gov: NCT01930188 (SUSTAIN 2), NCT01885208 (SUSTAIN 3), NCT02128932 (SUSTAIN 4) and NCT03191396 (SUSTAIN 10). [ABSTRACT FROM AUTHOR]

Background: Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings.Objective: The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients.Design: Cluster randomized controlled trial.Patients: Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN.Interventions: A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics).Main Measures: Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care.Key Results: Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses.Conclusions: Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting. [ABSTRACT FROM AUTHOR]

Background: Diabetes is the most prevalent disease resulted from metabolic disorders. This study aimed to investigate the effect of training based on health belief model (HBM) on oral hygiene-related behaviors in patients with type 2 diabetes mellitus.Methods: This study was conducted as an educational randomized controlled trial (single blind) on 120 patients with type 2 diabetes referring to a diabetes clinic selected through systematic sampling, who were assigned to two groups of control (N = 60) and intervention (N = 60). The data collection tool was a valid and reliable questionnaire based on HBM which was completed by both groups before the intervention. Then, the intervention group received 4 sessions of educational program based on HBM in 1 month, and the same questionnaire was completed again after 3 months and the data were analyzed through SPSS version 20 software with inferential statistics, t-test, paired t-tests, Chi square, Mann-Whitney test, and Wilcoxon test analysis.Results: Three months after the intervention, awareness of the patients and perceived susceptibility, benefits, self-efficacy, internal cue to action, and performance in oral and dental hygiene-related behaviors had a significant increase in the intervention group (p < 0.05). So that the performance of oral and dental hygiene in the intervention group increased from 2.16 ± 0.71 to 3.25 ± 0.49 (p = 0.001) after the education.Conclusion: Our results suggest that training patients with diabetes based on HBM as well as through active follow-up can enhance their skills in oral and dental hygiene-related behaviors. Controlling, monitoring and follow-up during the program are also recommended.Trial Registration: Iranian Registry of Clinical Trials, IRCT 2017050733847N1. Prospectively registered 14 June 2017, http://en.irct.ir/trial/26011. [ABSTRACT FROM AUTHOR]

Background: International comparisons of diabetes-related lower extremity amputation rates are still hampered by different criteria used for data collection and analysis. We aimed to evaluate trends and variation of major/minor amputations, using agreed definitions adopted by the Organization for Economic Cooperation and Development in 2015. Methods: Direct age–sex standardized rates were calculated per 100,000 subjects per year between 2000 and 2013, using major/minor amputations with diabetes diagnosis as numerators and the total population or number of people with diabetes as denominators. Longitudinal trends were investigated using generalized estimating equations. Results: Twenty-one countries reported major amputations referred to the general population, showing a mean reduction from 10.8 to 7.5 per 100,000 (− 30.6%). Eleven countries also reported major amputations among people with diabetes, showing a mean reduction from 182.9 to 128.3 per 100,000 (− 29.8%). Minor amputations remained stable over the study period. Longitudinal trends showed a significant average annual decrease of − 0.19 per 100,000 in the general population (95% CI − 0.36 to − 0.02; p =.03) and − 4.52 per 100,000 among subjects with diabetes (95% CI − 6.09 to − 2.94; p <.001). The coefficient of variation of major amputation rates between countries was fairly high (64%—in the total population, 67% among people with diabetes). Conclusions: The study highlighted a clinically significant reduction of major amputations, in both the general population and among people with diabetes. The use of standardized definitions, while increasing the comparability of multinational data, highlighted remarkable differences between countries. These results can help identifying and sharing best practices effectively on a global scale. [ABSTRACT FROM AUTHOR]

The objective of this scoping review was to create an up-to-date descriptive overview of published Disease-Management-Program evaluations conducted within Europe. We also assessed the methodological quality of the evaluation and the comparability of the included studies. The Databases Pub Med via Medline and Embase via Ovid were searched for thematically fitting publications. Out of 649 initial titles and abstracts, 45 full-texts were screened for inclusions. Finally, 21 publications met all inclusion criteria. DMPs from Germany, Austria, Italy, the Netherlands and Great Britain were included. The results are tabulated in the results section and discussed descriptively. Due to the heterogeneity of the included studies and the application of sometimes potentially biased study design comparisons were difficult. A uniform European-wide evaluation strategy and common quality features would be desirable. [ABSTRACT FROM AUTHOR]

• Paper reviews the extant literature for appropriateness of telemedicine in healthcare. • The study identifies various components of diabetes care. • The study identifies various factors affecting the adoption of telemedicine in diabetes care. • The study provides the new approach for implementation of telemedicine in diabetes care. Chronic diseases like diabetes are becoming major health care challenges in various parts of the world. The treatment of diabetes requires an integrated approach in which a team of various health care professionals works under the guidance of a diabetes specialist. If implemented appropriately, telemedicine has the potential to solve the dual problem of availability and affordability associated with health care. This paper aims to provide a phased approach to the implementation of telemedicine in diabetes care. The study used an unstructured interview of a diabetes specialist to find out the major components of diabetes care. Once the various components of diabetes care were identified, a focus group of two physicians, two diabetes educators, and one dietician was formed to identify the various factors affecting telemedicine adaptation. The same focus group was used to find the rating of 13 identified components for three identified factors. Finally, components of diabetes care were divided into homogeneous groups, using the hierarchical clustering method. This study identifies thirteen components of diabetes care and rates these components based on three factors, namely (1) importance (2) physical presence, and (3) frequency. k -means clustering was used to divide these components into two groups, (1) appropriate for telemedicine (ATM) and (2) not appropriate for telemedicine (NATM). The components of diabetes care, which are appropriate for telemedicine, can be delivered using telemedicine first. The paper gives a phased approach for the adaptation of telemedicine in case of a chronic disease like diabetes. The phased approach reduces the risks associated with implementation and provides the ability to make timely adaptations. [ABSTRACT FROM AUTHOR]

It is estimated that there were 1.73-2.20 million people with diabetes in Taiwan in 2014-2015. The executive summary briefly introduced recommendations from the Diabetes Association of Republic of China (DAROC) clinical practice guidelines for diabetes care- 2018. We described the diagnostic criteria for diabetes, pre-diabetes and gestational diabetes, and the screening methods for diabetes in asymptomatic subjects. Treatment goals for adults with diabetes, older adults with diabetes, children and adolescents with type 1 diabetes, women with gestational diabetes and inpatients were recommended. For people with type 2 diabetes, we suggested an algorithm including lifestyle modification, weight control, as well as the consideration and selection of anti-diabetic medications. Besides, we also recommended laboratory tests for metabolic monitoring, examinations for the screening of diabetic complications and the suggested testing intervals for these tests and examinations. [ABSTRACT FROM AUTHOR]

Pay-for-performance is a relatively new payment model that offers financial remuneration to physicians based on the results that they have achieved during the treatment of their patients. It aims at improving the quality of health care for chronically ill patients by addressing patients’ needs at an earlier stage, when some complications could still be preventable, and thus reduce hospitalization costs. The initiation of the model should lead to an improvement in the intermediate and long-term outcomes for patients, to improved quality of life, reduced all-cause and specific- mortality rates as well as to improvements in the physicians’ performance by promoting adherence to international clinical guidelines resulting in positive outcomes for all involved parties. The aim of this review is, by analyzing the existing literature, to assess the advantages and limitations of this financial model as part of an integrated diabetes care. We searched the Pub Med database using the key words “pay for performance” and “diabetes” and identified a total of 210 search results in the last 10 years. We based this review on the best 174 articles relevant to the topic and selected 68 references. There are many factors which may influence the effectiveness of the pay-for-performance model. Data on intermediate and long-term outcomes for diabetes patients are inconclusive, with only a moderate improvement noticed in intermediate outcomes and only for a limited period of time. All-cause mortality and hospitalization rates are slightly reduced. Publications examining the cost-effectiveness of the model produced conflicting results. Publications differ by country with the vast majority of positive messages coming from Taiwan; while research in the UK, Canada and other countries showed that the primary goals of this financial model were not completely met. In conclusion, more extensive research and longer follow-up periods of patients with diabetes participating in this pay-for-performance model are needed in order to make more precise conclusions about its long-term benefits. [ABSTRACT FROM AUTHOR]

Purpose of this study is to develop a customized service quality assessment model for diabetes care. The research identifies factors important for the quality of diabetes care. The study further uses factor analysis to identify the factors representing a single underlying construct. The Interpretative Structural Modelling was used to find out whether and how factors are related. In the end, research finds the priority weight of the factors using Analytic Hierarchy Process (AHP). The six factors identified from the study were (1) Employee Attitude (2) Care Delivery (3) Cost of Care (4) Cleanliness & Privacy (5) Customer Relationship and (6) Process Flexibility. The factors having the highest importance for the implementation of quality practices was employee attitude while the factor at lowest level was the cost of care. The weight calculated using AHP concurs with earlier findings using ISM Model. [ABSTRACT FROM AUTHOR]