4.0.0.0 References
- Kindig D, Stoddart G. What is population health? Am J Public Health 2003;93:380–383
- Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century [Internet], 2001. Washington, DC, The National Academies Press. Available from http://www.nap.edu/catalog/10027. Accessed 22 October 2018
- Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med 2013;368:1613–1624
- Wang J, Geiss LS, Cheng YJ, et al. Long-term and recent progress in blood pressure levels among U.S. adults with diagnosed diabetes, 1988-2008. Diabetes Care 2011;34:1579–1581
- Kerr EA, Heisler M, Krein SL, et al. Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? J Gen Intern Med 2007;22:1635–1640
- Fernandez A, Schillinger D, Warton EM, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011;26:170–176
- TRIAD Study Group. Health systems, patients factors, and quality of care for diabetes: a synthesis of findings from the TRIAD study. Diabetes Care 2010;33:940–947
- American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care 2018;41:917–928
- Stellefson M, Dipnarine K, Stopka C. The Chronic Care Model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis 2013;10:E26
- Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28:75–85
- Piatt GA, Anderson RM, Brooks MM, et al. 3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial. Diabetes Educ 2010;36:301–309
- Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363: 2611–2620
- Parchman ML, Zeber JE, Romero RR, Pugh JA. Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study. Med Care 2007;45:1129–1134
- Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet 2012;379:2252–2261
- Schmittdiel JA, Gopalan A, Lin MW, Banerjee S, Chau CV, Adams AS. Population health management for diabetes: health care system-level approaches for improving quality and addressing disparities. Curr Diab Rep 2017;17:31
- O’Connor PJ, Bodkin NL, Fradkin J, et al. Diabetes performance measures: current status and future directions. Diabetes Care 2011;34: 1651–1659
- Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA 2013;310:699–705
- Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603–618
- Raebel MA, Schmittdiel J, Karter AJ, Konieczny JL, Steiner JF. Standardizing terminology and definitions of medication adherence and persistence in research employing electronic databases. Med Care 2013;51(Suppl. 3):S11–S21
- Feifer C, Nemeth L, Nietert PJ, et al. Different paths to high-quality care: three archetypes of top-performing practice sites. Ann Fam Med 2007;5:233–241
- Reed M, Huang J, Graetz I, et al. Outpatient electronic health records and the clinical care and outcomes of patients with diabetes mellitus. Ann Intern Med 2012;157:482–489
- Cebul RD, Love TE, Jain AK, Hebert CJ. Electronic health records and quality of diabetes care. N Engl J Med 2011;365:825–833
- Battersby M, Von Korff M, Schaefer J, et al. Twelve evidence-based principles for implementing self-management support in primary care. Jt Comm J Qual Patient Saf 2010;36:561– 570
- Grant RW, Wald JS, Schnipper JL, et al. Practice-linked online personal health records for type 2 diabetes mellitus: a randomized controlled trial. Arch Intern Med 2008;168:1776– 1782
- Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2126–2140
- Beck J, Greenwood DA, Blanton L, et al.; 2017 Standards Revision Task Force. 2017 National standards for diabetes self-management education and support. Diabetes Care 2017; 40:1409–1419
- Pullen-Smith B, Carter-Edwards L, Leathers KH. Community health ambassadors: a model for engaging community leaders to promote better health in North Carolina. J Public Health Manag Pract 2008;14(Suppl.):S73–S81
- Davidson MB. How our current medical care system fails people with diabetes: lack of timely, appropriate clinical decisions. Diabetes Care 2009;32:370–372
- Selby JV, Uratsu CS, Fireman B, et al. Treatment intensification and risk factor control: toward more clinically relevant quality measures. Med Care 2009;47:395–402
- Raebel MA, Ellis JL, Schroeder EB, et al. Intensification of antihyperglycemic therapy among patients with incident diabetes: a Surveillance Prevention and Management of Diabetes Mellitus (SUPREME-DM) study. Pharmacoepidemiol Drug Saf 2014;23:699– 710
- Grant RW, Pabon-Nau L, Ross KM, Youatt EJ, Pandiscio JC, Park ER. Diabetes oral medication initiation and intensification: patient views compared with current treatment guidelines. Diabetes Educ 2011;37:78–84
- Tamhane S, Rodriguez-Gutierrez R, Hargraves I, Montori VM. Shared decision-making in diabetes care. Curr Diab Rep 2015;15:112
- Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163:83–90
- Rosal MC, Ockene IS, Restrepo A, et al. Randomized trial of a literacy-sensitive, culturally tailored diabetes self-management intervention for low-income Latinos: Latinos en control. Diabetes Care 2011;34:838– 844
- Osborn CY, Cavanaugh K, Wallston KA, et al. Health literacy explains racial disparities in diabetes medication adherence. J Health Commun 2011;16(Suppl. 3):268–278
- Garg AX, Adhikari NKJ, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293: 1223–1238
- Smith SA, Shah ND, Bryant SC, et al.; Evidens Research Group. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Mayo Clin Proc 2008; 83:747–757
- Stone RA, Rao RH, Sevick MA, et al. Active care management supported by home telemonitoring in veterans with type 2 diabetes: the DiaTel randomized controlled trial. Diabetes Care 2010;33:478–484
- Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care 2011; 34:1047–1053
- American Telemedicine Association. About telemedicine [Internet]. Available from http:// www.americantelemed.org/ main/about/about-telemedicine/ telemedicine-faqs. Accessed 2 October 2018
- Lee SWH, Chan CKY, Chua SS, Chaiyakunapruk N. Comparative effectiveness of telemedicine strategies on type 2 diabetes management: a systematic review and network meta-analysis. Sci Rep 2017;7:12680
- Faruque LI, Wiebe N, Ehteshami-Afshar A, et al.; Alberta Kidney Disease Network. Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials. CMAJ 2017;189:E341–E364
- Marcolino MS, Maia JX, Alkmim MBM, Boersma E, Ribeiro AL. Telemedicine application in the care of diabetes patients: systematic review and meta-analysis. PLoS One 2013;8:e79246
- Heitkemper EM, Mamykina L, Travers J, Smaldone A. Do health information technology self-management interventions improve glycemic control in medically underserved adults with diabetes? A systematic review and meta-analysis. J Am Med Inform Assoc 2017;24:1024–1035
- Myerson R, Laiteerapong N. The Affordable Care Act and diabetes diagnosis and care: exploring the potential impacts. Curr Diab Rep 2016;16:27
- Casagrande SS, McEwen LN, Herman WH. Changes in health insurance coverage under the Affordable Care Act: a national sample of U.S. adults with diabetes, 2009 and 2016. Diabetes Care 2018;41:956–962
- Doucette ED, Salas J, Scherrer JF. Insurance coverage and diabetes quality indicators among patients in NHANES. Am J Manag Care 2016;22: 484–490
- Stiefel M, Nolan K. Measuring the triple aim: a call for action. Popul Health Manag 2013;16: 219–220
- Agency for Healthcare Research and Quality. About the National Quality Strategy [Internet], 2017. Available from https://www.ahrq.gov/ workingforquality/ about/index.html. Accessed 22 October 2018
- National Quality Forum. Home page [Internet], 2017. Available from http://www.qualityforum.org/home.aspx. Accessed 22 October 2018
- Burstin H, Johnson K. Getting to better care and outcomes for diabetes through measurement [article online], 2016. Available from http://www.ajmc.com/journals/evidence-based-diabetes-management/2016/march-2016/getting-to-better-care-and-outcomes-for-diabetes-through-measurement. Accessed 22 October 2018
- National Institute of Diabetes and Digestive and Kidney Diseases. Practice transformation for physicians & health care teams [Internet]. Available from https://www.niddk.nih.gov/ health-information/health-communication-programs/ndep/health-care-professionals/ practice-transformation/Pages/resourcedetail.aspx. Accessed 22 October 2018
- National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes care and quality: past, present, and future[Internet]. Available from https://www.niddk.nih.gov/health-information/ health-communication-programs/ndep/health-care-professionals/practice-transformation/ defining-quality-care/diabetes-care-quality/Pages/default.aspx. Accessed 22 October 2018
- O’Connor PJ, Sperl-Hillen JM, Fazio CJ, Averbeck BM, Rank BH, Margolis KL. Outpatient diabetes clinical decision support: current status and future directions. Diabet Med 2016;33:734–741
- Centers for Medicare & Medicaid Services. CMS Equity Plan for Medicare [Internet]. Available from https://www.cms.gov/About-CMS/ Agency-Information/OMH/equity-initiatives/equity-plan.html. Accessed 22 October 2018
- Rosenthal MB, Cutler DM, Feder J. The ACO rules–striking the balance between participation and transformative potential. N Engl J Med 2011;365:e6
- Washington AE, Lipstein SH. The PatientCentered Outcomes Research Institute–promoting better information, decisions, and health. N Engl J Med 2011;365:e31
- Hutchinson RN, Shin S. Systematic review of health disparities for cardiovascular diseases and associated factors among American Indian and Alaska Native populations. PLoS One 2014;9: e80973
- Borschuk AP, Everhart RS. Health disparities among youth with type 1 diabetes: a systematic review of the current literature. Fam Syst Health 2015;33:297–313
- Walker RJ, Strom Williams J, Egede LE. Influence of race, ethnicity and social determinants of health on diabetes outcomes. Am J Med Sci 2016;351:366–373
- Patel MR, Piette JD, Resnicow K, Kowalski-Dobson T, Heisler M. Social determinants of health, cost-related nonadherence, and costreducing behaviors among adults with diabetes: findings from the National Health Interview Survey. Med Care 2016;54:796–803
- Steve SL, Tung EL, Schlichtman JJ, Peek ME. Social disorder in adults with type 2 diabetes: building on race, place, and poverty. Curr Diab Rep 2016;16:72
- World Health Organization Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health [Internet], 2008. Geneva, Switzerland, World Health Organization. Available from http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf. Accessed 22 October 2018
- Hill JO, Galloway JM, Goley A, et al. Socioecological determinants of prediabetes and type 2 diabetes. Diabetes Care 2013;36:2430– 2439
- National Academies of Sciences, Engineering, and Medicine. A Framework to Address the Social Determinants of Health [Internet], 2016. Washington, DC, The National Academies Press. Available from https://www.nap.edu/ catalog/21923/a-framework-for-educating-healthprofessionals- to-address-the-social-determinantsof- health. Accessed 22 October 2018
- Institute of Medicine. Capturing social and behavioral domains and measures in electronic health records: phase 2 [Internet], 2014. Washington, DC, The National Academies Press. Available from https://www.nap.edu/catalog/18951/capturing-social-and-behavioral-domains-and-measures-in-electronic-health-records. Accessed 22 October 2018
- Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med 2012;27:992–1000
- National Quality Forum. National voluntary consensus standards for ambulatory cared measuring healthcare disparities [Internet], 2008. Available from https://www.qualityforum.org/ Publications/2008/03/National_Voluntary_ Consensus_Standards_for_Ambulatory_Care% E2%80%94Measuring_Healthcare_Disparities.aspx. Accessed 22 October 2018
- Piette JD, Heisler M, Wagner TH. Costrelated medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health 2004;94:1782–1787
- Laiteerapong N, Karter AJ, Liu JY, et al. Correlates of quality of life in older adults with diabetes: the Diabetes & Aging Study. Diabetes Care 2011;34:1749–1753
- Heerman WJ, Wallston KA, Osborn CY, et al. Food insecurity is associated with diabetes selfcare behaviours and glycaemic control. Diabet Med 2016;33:844–850
- Silverman J, Krieger J, Kiefer M, Hebert P, Robinson J, Nelson K. The relationship between food insecurity and depression, diabetes distress and medication adherence among low-income patients with poorly-controlled diabetes. J Gen Intern Med 2015;30:1476–1480
- Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics 2010;126:e26–e32
- Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med 2010;363:6–9
- Montgomery AE, Fargo JD, Kane V, Culhane DP. Development and validation of an instrument to assess imminent risk of homelessness among veterans. Public Health Rep 2014;129:428–436
- U.S. Department of Health and Human Services. Think cultural health [Internet]. Available from https://www.thinkculturalhealth.hhs.gov/. Accessed 22 October 2018
- Agency for Healthcare Research and Quality. Clinical-community linkages [Internet]. Available from http://www.ahrq.gov/professionals/ prevention-chronic-care/improve/community/index.html. Accessed 22 October 2018
- Shah M, Kaselitz E, Heisler M. The role of community health workers in diabetes: update on currentliterature. Curr Diab Rep 2013;13:163–171
- Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Ann Intern Med 2010;153:507–515
- Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial. Ann Intern Med 2012;156:416–424
- Fisher EB, Boothroyd RI, Elstad EA, et al. Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews. Clin Diabetes Endocrinol 2017;3:4
- Foster G, Taylor SJC, Eldridge SE, Ramsay J, Griffiths CJ. Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database Syst Rev 2007;4: CD005108
- Rosenthal EL, Rush CH, Allen CG; Project on CHW Policy & Practice. Understanding scope and competencies: a contemporary look at the United States community health worker field: progress report of the Community Health Worker (CHW) Core Consensus (C3) Project: building national consensus on CHW core roles, skills, and qualities [Internet], 2016. Available from http://files.ctctcdn.com/a907c850501/1c1289f0-88cc-49c3-a238-66def942c147.pdf. Accessed 22 October 2018
- U.S. Department of Health and Human Services. Community health workers help patients manage diabetes [Internet]. Available from https://www.thecommunityguide.org/content/ community-health-workers-help-patients-manage- diabetes. Accessed 22 October 2018