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The major method of controlling recurrent abscesses is the use of antibacterial agents to eradicate staphylococcal carriage. Algorithm 3:A  Empiric Intravenous Antibacterial Therapy for Cellulitis Based on Degree of Immunosuppression. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJC, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. A Treating Diabetic Peripheral Neuropathic PainA  A more recent article on treating diabetic peripheral neuropathy is available. Patient information: See related handout on diabetic peripheral neuropathic pain, written by the authors of this article. Peripheral neuropathy is a common complication of diabetes mellitus, occurring in 30 to 50 percent of patients with the disease.1 It involves the loss of sensation in a symmetric stocking-and-glove distribution, starting in the toes and progressing proximally.
The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities.
The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Diabetes is a major cause of heart disease and stroke among adults in the United States and is the leading cause of nontraumatic lower-extremity amputations, new cases of blindness, and kidney failure (1–3). CCM comprises 6 components that are hypothesized to affect functional and clinical outcomes associated with disease management.
The sum of these CCM component parts are purported to create more effective health care delivery systems that institute mechanisms for decision support, link health care systems to community resources and policies, deliver comprehensive self-management support services for patients, and operate and manage patient-centered clinical information systems. This study identified English-language peer-reviewed research articles describing CCM-based interventions for managing type 1 and type 2 diabetes in US primary care settings (ie, hospital-network outpatient clinics, private practices, and community health centers).
As recommended by the Centre for Reviews and Dissemination systematic review guidelines (8), we created the following categories to systematically assess the 16 studies and gain an understanding of the methods used and the outcomes associated with CCM application: study design, sample size, setting, participant demographics, primary and secondary outcomes measured, data collection instruments used, statistical tests used, and major findings. We found that diabetes self-management education (DSME) generally improved psychosocial and clinical outcomes in patients with diabetes.
Specialized decision support services for diabetes care were provided to PCPs (eg, endocrinologists) and nurse practitioners via telephone and e-mail (18), problem-based learning meetings (11,12,14,16,17), and telemedicine technology (13).
Implementation of ADA standards of care (10–12,14,16,17) and ICSI clinical guidelines (18) resulted in innovative diabetes care delivery in PCP offices. Collaborative clinical information systems using disease registries and electronic medical records enabled multiple health care providers (eg, PCPs, nurse practitioners, nurses, CDEs, physician assistants, medical assistants) to review detailed reports on laboratory and examination results and identify lapses in diabetes care (eg, missed visits, laboratory appointments, and examinations). Seven studies (11,12,16–18,20,24) specified strategies for using community resources and forming public policy. The findings of these studies contribute to a qualitative understanding of the relationship between the application of CCM components and diabetes outcomes in US primary care settings. One meta-analysis (27) determined that no single component of the CCM was imperative for improved outcomes. In several studies, organizational leaders in health care systems initiated system-level reorganizations that facilitated more comprehensive and coordinated diabetes care.
Delivery system design was identified as an important strategy for integrating DSME into primary care settings through addressing patient barriers to care such as accessibility to DSME and availability of staff to assist with diabetes care (10). Finally, community-level partnerships pooled human and fiscal resources to provide diabetes management services (11,12,16–18,20,24). In conclusion, our study provides evidence that CCM is effective in improving the health of people who have diabetes and receive care in primary care settings.
This work was supported in part by the National Institutes for Health National Center for Advancing Translational Sciences Clinical and Translational Science Award to the University of Florida no. Corresponding Author: Krishna Dipnarine, MS, Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, PO Box 118210, FLG 5, Gainesville, FL 32611-8210.
Author Affiliations: Michael Stellefson, Christine Stopka, University of Florida, Gainesville, Florida. Developed the Vermont Diabetes Information System to collect clinical information and provide flow sheets, reminders, and alerts to physicians and their patients with diabetes. Participants and their family members met with team members for five 2-hour group sessions biweekly.
Problem-based learning sessions were used to demonstrate implementation of guidelines into a plan of care. Offered 6 weekly CDE-facilitated DSME sessions based on the University of Michigan DSME curriculum.
Monthly support groups focused on foot care, healthful cooking and recipe modification, alternative treatments, and problem-solving skills.
Problem-based learning sessions were held for PCPs, led by an endocrinologist using diabetes management questions.
However, when there is a concern about deep soft tissue infection , surgical consultation should not be delayed. Single dose TMP-SMX or doxycycline for 3 months has also been used, though clinical data is scarce. The etiology of cellulitis without an ulcer is typically staphylococcal (MSSA or MRSA)or beta-hemolytic streptococcus. Approximately 10 to 20 percent of patients with diabetes have diabetic peripheral neuropathic pain, which is a burning, tingling, or aching discomfort that worsens at night.1,2 Patients with diabetic peripheral neuropathic pain may also experience allodynia and hyperalgesia.
Physicians have been using TCAs, such as amitriptyline and nortriptyline (Pamelor), to treat neuropathic pain for years, without approved labeling from the U.S. A 2006 Cochrane review evaluated the use of opiates for general neuropathic pain.14 Methadone, levorphanol, morphine, and controlled-release oxycodone (Oxycontin) were included in the review. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings.
Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. The 6 components (4,5) are 1) health system — organization of health care (ie, providing leadership for securing resources and removing barriers to care), 2) self-management support (ie, facilitating skills-based learning and patient empowerment), 3) decision support (ie, providing guidance for implementing evidence-based care), 4) delivery system design (ie, coordinating care processes), 5) clinical information systems (ie, tracking progress through reporting outcomes to patients and providers), and 6) community resources and policies (ie, sustaining care by using community-based resources and public health policy). Despite evidence indicating widespread application of CCM to multiple illnesses, such as diabetes, congestive heart failure, and asthma (6), no summative reviews have investigated how CCM has been applied in diabetes care. Manuscript selection for systematic review on the Chronic Care Model (CCM) and diabetes management in US primary care settings. We determined which of the 6 CCM components had been applied to each intervention and how the component(s) had been applied.
Study settings included academic-affiliated primary care practices (10,12–14,21,23), private practices (11,16,17,20), community health centers (15,24), safety net clinics (18,19,22), and a hospital (9). Engaging the governing boards of health care systems resulted in support for institutionalizing the CCM approach (18,22), which was associated with HbA1c reductions of at least 1% during 12 months (18,22) and improved foot care (22). Individual patient reports were also provided to health care teams for reviewing clinical trends (eg, HbA1c, blood pressure, lipids) and initiating clinical responses to laboratory results (eg, medication adjustments) (9,10,20,23). These systems helped patients and providers set self-management goals and review progress reports to determine whether patients met their predetermined goals (9,11,12,14,16–18,20,21,23,24).
Collaborations between community leaders and physicians (11,16,17) and between pharmaceutical companies and health plans (20) led to support for PCP training sessions on how to use CCM for diabetes management.

Although the original CCM has been critiqued for not adequately meeting the needs of diverse patient populations with diabetes (7), our systematic review supports the idea that CCM-based interventions are generally effective for managing diabetes in US primary care settings. However, it is important to determine the combination of components that will likely produce optimal patient and provider outcomes. Changing staff roles and responsibilities to more efficiently treat diabetes was 1 strategy that produced clinical benefits. Future studies should examine the effects of continuing education for ADA Standards of Care and ICSI clinical guidelines on CCM decision support among providers. This type of culturally appropriate self-management support was associated with a greater number of participants who had an HbA1c measurement of less than 7% and a fewer number of participants who had an HbA1c measurement of greater than 10% (24). However, strategies for using community resources and developing policies were described in only 7 studies. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011.
National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007.
A survey of leading chronic disease management programs: are they consistent with the literature?
The Vermont Diabetes Information System (VDIS): study design and subject recruitment for a cluster randomized trial of a decision support system in a regional sample of primary care practices. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes nurse case manager and motivational interviewing for change (DYNAMIC): Study design and baseline characteristics in the chronic care model for type 2 diabetes. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Caring for uninsured patients with diabetes: designing and evaluating a novel chronic care model for diabetes care. Improved clinical outcomes for fee-for-service physician practices participating in a diabetes care collaborative.
Improving quality of care for urban older people with diabetes mellitus and cardiovascular disease. Establishing diabetes self-management in a community health center serving low-income Latinos. Enough of the problem: a review of time for health care transition solutions for young adults with a chronic illness.
Using exploratory focus groups to inform the development of targeted COPD self-management education DVDs for rural patients. The system also generates population reports so that physicians can view the progress of their patients with diabetes. Each group consisted of 5 to 10 participants who learned goal-setting strategies based on the empowerment approach, problem-solving skills, and behavioral change strategies. Patients can realistically expect a 30 to 50 percent reduction in discomfort with improved functionality. Diabetic peripheral neuropathic pain interferes with sleep quality, mood, and activity level.
Pregabalin is one of only two medications approved by the FDA for the treatment of diabetic peripheral neuropathic pain.
Nine intermediate-term (28-day average) studies involving 460 participants demonstrated the superiority of opiates over placebo.
Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care.
Comprehensive models of care, such as the original Chronic Care Model (CCM) (4,5), advocate for evidence-based health care system changes that meet the needs of growing numbers of people who have chronic disease. The objective of this study was to determine how CCM has been applied in US primary care settings to provide care for people who have diabetes and also to describe outcomes of CCM implementation.
We excluded studies that took place outside of the United States, reported secondary data, or represented an editorial, commentary, or a literature review. We then qualitatively assessed the outcomes of each component that was applied in each study.
Two studies (19,20) revised the health care system to redefine health care team roles (eg, nurses, instead of PCPs, became responsible for conducting foot examinations). Training PCPs on evidence-based guidelines and methods for implementing CCM resulted in improved PCP adherence to clinical guidelines, including the American Diabetes Association (ADA) Standards of Care (10–12,14,16,17) and Institute for Clinical Systems Improvement (ICSI) Clinical Guidelines for Hypertension, Diabetes, and Hyperlipidemia (18).
Hospital and PCP collaborations within the community, such as partnerships between the University of Pittsburgh Medical Center and western Pennsylvania community hospitals and PCP offices (12), provided greater access to funding, information systems, and administrative support for CCM implementation (11,12,16,17). Our review suggested that incorporating multiple components together in the same intervention can help facilitate better CCM implementation (eg, using the decision-support component to train providers on guidelines such as the ADA Standards of Care and using the delivery system design component to remodel the care delivery process to provide self-management support through DSME in PCP offices).
Reorganized care can also support better training programs for patients to help them self-manage diabetes.
It is important to determine whether provider training delivered through telecommunication and distance learning technologies can provide ample decision-support training to PCPs. DSME fostered learning about proactive diabetes self-care practices and self-management skills. Other culturally tailored non-CCM interventions (29) have demonstrated larger absolute reductions in HbA1c than nontailored interventions.
Many studies (9,10,12,14,18,20, 21,23,24) used disease registries and electronic medical records to establish patient goals, monitor patient progress, and determine lapses in patient care. A meta-analysis (27) also found that few studies addressed the community resources and policies component of CCM.
The main classes of agents used to treat diabetic peripheral neuropathic pain include tricyclic antidepressants, anticonvulsants, serotonin-norepinephrine reuptake inhibitors, opiates and opiate-like substances, and topical medications. One in five patients discontinues therapy because of adverse effects.8 Potential drug interactions must be reviewed.
In a 2008 meta-analysis of seven trials, pregabalin was used to treat diabetic peripheral neuropathic pain in 1,510 patients, and the results showed effectiveness with a dose-related response.10 When compared with placebo, measurable pain relief was achieved with 150, 300, or 600 mg per day, divided into three doses.
However, further studies are needed to investigate the effectiveness of venlafaxine for diabetic peripheral neuropathic pain specifically.Duloxetine is the second drug approved for the treatment of diabetic peripheral neuropathic pain. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. CCM was developed (4,5) to provide patients with self-management skills and tracking systems.
These changes improved the quality of diabetes care and rates of eye examinations, and were associated with improved HbA1c levels, blood pressure, cholesterol, and weight (19,20). Follow-up telephone calls allowed clinicians to monitor patient progress toward meeting diabetes-management goals that were set during individual office visits (10,15,18,21). For example, the Medical Archival Retrieval System (MARS) stored data and generated robust reports for providers on laboratory results, visits, medications, health insurance, comorbid conditions, medical procedures, and billing charges (12). Future system-level CCM reorganizations should create clear access points for providers to intervene with patients who are at risk for diabetes complications. Another area worth investigating is whether the longitudinal use of decision support in different primary care practice settings (eg, private practices, community health centers, hospitals) improves patient outcomes. When ADA-accredited DSME occurs in primary care settings, PCPs are able to provide patients with personalized access to CDEs, who are likely funded through third-party health insurers (12). Assimilating clinical information systems into user-friendly, portable digital technologies (ie, smartphones, iPads) may enable patients and providers to view and respond to laboratory results more regularly.

More public-private partnerships need to be developed between providers and community organizations to address barriers to care and explore culturally appropriate community-based services (eg, cooking classes, exercise programs, nutrition counseling, self-monitoring assistance) for underserved populations and neighborhoods. Future studies should use the multiple-rater approach for study selection and data extraction as outlined by the Centre for Reviews and Dissemination systematic review guidelines (8). Far less emphasis has been placed on measuring the process outcomes of CCM that help lead to functional and clinical improvements. Physicians should ask patients whether they have tried complementary and alternative medicine therapies for their pain.
Any cardiac history, including heart failure, arrhythmias, or recent myocardial infarction, is a contraindication for TCAs.
It acts centrally at the muopioid receptors and weakly inhibits the central neuronal reuptake of norepinephrine and serotonin. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. The model represents a well-rounded approach to restructuring medical care through partnerships between health systems and communities. First we reviewed the abstracts; 76 manuscripts met inclusion criteria, and 79 were excluded. Health system reorganization also helped to establish diabetes self-management training programs (12,16,17) that identified and intervened with patients at risk for developing complications (17) and improved clinical and behavioral outcomes (12,16). For example, Schillinger et al (15) found that weekly automated (prerecorded) tailored telephone calls from nurses were associated with improvements in interpersonal processes of care, physical activity and function, and slightly better metabolic outcomes (eg, HbA1c, blood pressure, cholesterol). One study (12) even noted that providing DSME programs in PCP offices instead of hospital settings resulted in a 2- to 3-fold increase in the number of patients reached with diabetes education. MARS also served as a tool for administrators to gauge fiscal outcomes associated with placing CDEs in primary care sites to deliver DSME (12).
Offering DSME in primary care settings, rather than solely hospital settings, enhances the reach of such programs in a more intimate, socially supportive venue. Cultural factors (eg, food preparation, views of illness) should be considered when designing, implementing, and evaluating DSME for these underserved groups (31). For older populations of chronic disease patients (the age group sampled in most of the reviewed studies), training programs on the use of digital technologies for diabetes self-management may reduce the anxiety and barriers to access that may currently exist (23,34).
Other models have sought to improve the community resources and policies component of the CCM.
We did not conduct a meta-analysis because we did not have access to primary data, and the variability in study design did not allow us to pool data.
Process outcomes (eg, self-efficacy for disease management and clinical decision making, perceived social support, knowledge of diabetes self-care practices) are all indicators that need to be assessed.
Only two medications are approved specifically for the treatment of diabetic peripheral neuropathic pain: pregabalin and duloxetine. Because of the anticholinergic effects of TCAs, physicians should be cautious when prescribing them for patients with narrow-angle glaucoma, benign prostatic hypertrophy, orthostasis, urinary retention, impaired liver function, or thyroid disease.
However, the review concluded that although gabapentin is effective for neuropathic pain, physicians should consider the cost before prescribing.
Lyles et al (23) found that the use of a secure e-mail connection and a smartphone to upload glucose readings via a wireless Bluetooth device allowed some participants to feel better connected with their nurse case manager. For example, the Rockwood Clinic Foundation revised its mission statement to include fundraising for research and development in new methods of chronic care delivery, which has resulted in increased funding for training materials, glucometers, blood pressure monitors, and laboratories (20).
Future DSME for primary care patients should continue to cover the ADA content areas (28) for diabetes self-management, and strategies for delivering DSME should be evaluated by assessing the comparative effectiveness of group- and individual-level DSME approaches.
It is also noteworthy that none of the reviewed studies addressed the needs of pediatric patients diagnosed with either type 1 or type 2 diabetes.
Involving patients in exploratory focus groups to inform the development of assistive technologies can customize educational technology and address usability concerns among unique patient populations (35). The Innovative Care for Chronic Conditions (ICCC) model espoused by the World Health Organization (33,37) is comparable to the Expanded Chronic Care Model proposed by Barr and colleagues (7); it introduces prevention efforts, social determinants of health, and enhanced community participation as core components of chronic disease care. Future research could include a meta-analysis of data (27) from randomized controlled trials to evaluate the methodological quality of quantitative studies that have tested the effectiveness of CCM for managing diabetes. These assessments could enable health care administrators and professionals to determine how CCM could become further integrated into primary health care initiatives in diabetes. However, evidence supports the use of other therapies, and unless there are contraindications, tricyclic antidepressants are the first-line treatment.
However, some participants found this communication system to be unstructured and preferred regular interaction (eg, face-to-face) with their nurse case manager; some participants found the smartphones to be frustrating because of technical difficulties associated with these unfamiliar technologies (23).
Diabetes is becoming more common in children and adolescents (32); Rapley and Davidson (33) have advocated for the adoption of CCM programs aimed at adolescent patients with diabetes to help bridge the gap between pediatric and adult care. Future studies on diabetes self-management support within the broader CCM framework should attempt to refine the use of information and communications technologies to empower, engage, and educate patients (36).
Patients who received DSME showed gains in all areas of empowerment: psychological, readiness to change, and goal setting.
Because patients often have multiple comorbidities, physicians must consider potential adverse effects and possible drug interactions before prescribing a medication. One Cochrane review examined 12 studies including 404 participants with a variety of types of neuropathic pain. Future studies should investigate how different derivations of CCM components contribute to changes in diabetes care within primary care settings. This study provides support for CDEs to receive financial reimbursement for services.Piatt et al (11)Study design (no. Before beginning treatment, the patient's blood urea nitrogen, creatinine, transaminase, and iron levels should be checked, and a complete blood count (including platelets), reticulocyte count, liver function test, and urinalysis should be performed.
A 2- to 3-fold greater proportion of patients reached when DSME was available at primary care practices compared to hospital-based programs. Few studies have examined the effects of diabetic peripheral neuropathic pain on quality of life.
Having DSME programs at primary care practices resulted in improvements in HbA1c levels and better communication and use of resources among PCPs and CDEs. Patients reported comfort with location and ease of approaching CDEs.Smith et al (13)Study design (no. Baseline survey scores of the patient population showed a high level of depression and a slightly positive effect of diabetes on self-confidence and that diabetes had most negative effect on enjoyment of vacations and on enjoyment of food and drinks.Schillinger et al (15)Study design (no. ATSM group was less likely than GMV and usual care groups to report that diabetes prevented them from carrying out daily activities. No significant changes in HbA1c were found in ATSM, GMV, and usual-care groups.Piatt et al (16)Study design (no. Having higher baseline HbA1c values, older age, and being in the CCM group were each associated with improved glycemic control.Stroebel et al (18)Study design (no.
Patients felt more aware of and engaged in their own care through monitoring their glucose, sharing their glucose readings with the nurse case manager, and communicating with the nurse case manager via the secure e-mail system; uploading glucose readings and receiving feedback was easy.
However, half of the patients found the use of smartphones to be frustrating (unfamiliar technology).
Using the Nintendo Wii to access electronic medical records was not useful (unfamiliar technology).Liebman et al (24)Study design (no.

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