National standards for diabetes self-management education and support

What works in implementing shared medical appointments for patients with diabetes in primary care to enhance reach: a qualitative comparative analysis from the Invested in Diabetes study

BACKGROUND

Diabetes is a serious public health problem affecting 37.3 million Americans. Diabetes shared medical appointments (SMAs) are an effective strategy for providing diabetes self-management support and education in primary care. However, practices delivering SMAs experience implementation challenges. This analysis examined conditions associated with successful practice implementation of diabetes SMAs in the context of participation in a pragmatic trial.

METHODS

Mixed methods study using qualitative and quantitative data collected from interviews, observations, surveys, and practice-reported data, guided by the practical, robust implementation and sustainability model (PRISM). Data were analyzed using qualitative comparative analysis (QCA). Successful implementation was defined as meeting patient recruitment targets (Reach) during the study period. Participants were clinicians and staff members from 22 primary care practices in Colorado and Missouri, USA.

RESULTS

The first necessary condition identified from the QCA was the presence of additional resources for patients with diabetes in the practice. Within practices that had these additional resources, we found that a sufficiency condition was the presence of an effective key person to make things happen with the SMAs. A second QCA was conducted to determine conditions underlying the presence of the effective key person (often performing functions of an implementation champion), which revealed factors including low or managed employee turnover, a strong baseline practice culture, and previous experience delivering SMAs.

CONCLUSIONS

Identification of key factors necessary and sufficient for implementation of new care processes is important to enhance patient access to evidence-based interventions. This study suggests that practice features and resources have important implications for implementation of diabetes SMAs. There may be opportunities to support practices with SMA implementation by enabling the presence of skilled implementation champions.

TRIAL REGISTRATION

Registered at clinicaltrials.gov under trial ID NCT03590041, registered on July 18, 2018.

Comparative Effectiveness of Patient-Driven versus Standardized Diabetes Shared Medical Appointments: A Pragmatic Cluster Randomized Trial

BACKGROUND

Diabetes self-management education and support can be effectively and efficiently delivered in primary care in the form of shared medical appointments (SMAs). Comparative effectiveness of SMA delivery features such as topic choice, multi-disciplinary care teams, and peer mentor involvement is not known.

OBJECTIVE

To compare effects of standardized and patient-driven models of diabetes SMAs on patient-level diabetes outcomes.

DESIGN

Pragmatic cluster randomized trial.

PARTICIPANTS

A total of 1060 adults with type 2 diabetes in 22 primary care practices.

INTERVENTIONS

Practice personnel delivered the 6-session Targeted Training in Illness Management (TTIM) curriculum using either standardized (set content delivered by a health educator) or patient-driven SMAs (patient-selected topic order delivered by health educators, behavioral health providers [BHPs], and peer mentors).

MAIN MEASURES

Outcomes included self-reported diabetes distress and diabetes self-care behaviors from baseline and follow-up surveys (assessed at 1st and final SMA session), and HbA1c, BMI, and blood pressure from electronic health records. Analyses used descriptive statistics, linear regression, and linear mixed models.

KEY RESULTS

Both standardized and patient-driven SMAs effectively improved diabetes distress, self-care behaviors, BMI (- 0.29 on average), and HbA1c (- 0.45% (mmol/mol) on average, 8.3 to 7.8%). Controlling for covariates, there was a small, significant effect of condition on overall diabetes distress in favor of standardized SMAs (F(1,841) = 4.3, p = .04), attributable to significant effects of condition on emotion and regimen distress subscales. There was a small, significant effect of condition on diastolic blood pressure in favor of standardized SMAs (F(1,5199) = 4.50, p = .03). There were no other differences between conditions.

CONCLUSIONS

Both SMA models using the TTIM curriculum yielded significant improvement in diabetes distress, self-care, and HbA1c. Patient-driven diabetes SMAs involving BHPs and peer mentors and topic selection did not lead to better clinical or patient-reported outcomes than standardized diabetes SMAs facilitated by a health educator following a set topic order.

NIH TRIAL REGISTRY NUMBER

NCT03590041.

Epidemiological parameters and monitoring of analysis of treatment of children and adolescents with type 1 diabetes mellitus in insulin pump therapy with modified educational program

OBJECTIVE

Aim: The aim of the present published work is efficacy evaluation of the modified educational program in achieving the target levels of glycemia in children and adolescents with type 1 diabetes mellitus in pump insulin therapy in Almaty..

PATIENTS AND METHODS

Materials and Methods: This study involved 125 children and adolescents with type 1 DM and evaluated the effectiveness of a modified educational program at the School of Type 1 Diabetes Mellitus. Participants were divided into subgroups based on their method of glycemia evaluation. The program's effectiveness was assessed through pre-and post-training questionnaires and measurement of glycohemoglobin levels. Statistical analysis was conducted using the Statistica application.

RESULTS

Results: The study evaluated the effectiveness of a modified educational program for children and adolescents with type 1 DM. The results indicated that those who participated in the modified program demonstrated significant improvements in their knowledge and ability to manage their diabetes. They were able to correctly answer 80-90% of the questionnaire questions six months to a year after the training. Additionally, those in the modified program exhibited better carbohydrate metabolism rates and achieved higher rates of their individual treatment goals, especially when using the FreeStyle Libre system for continuous monitoring of blood glucose levels. These findings suggest that a modified educational approach can significantly enhance diabetes management and treatment outcomes in children and adolescents.

CONCLUSION

Conclusions: The study concluded that a modified educational program leads to better target therapy levels in children and adolescents with type 1 diabetes mellitus, highlighting the importance of motivated parents and frequent blood glycemia measurements.

Process evaluation of Dulce Digital-Me: an adaptive mobile health (mHealth) intervention for underserved Hispanics with diabetes

Type 2 diabetes disproportionately impacts ethnic minorities and individuals from low socioeconomic status. Diabetes self-management education and support has been shown to improve clinical outcomes in these populations, and mobile health (mHealth) interventions can reduce barriers to access. Dulce Digital-Me (DD-Me) was developed to integrate adaptive mHealth technologies to enhance self-management and reduce disparities in the high-risk, underserved Hispanic population. The objective of the present study was to evaluate reach, adoption, and implementation of an mHealth diabetes self-management education and support intervention in this underrepresented population. The present analysis is a multimethod process evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The study was effective in reaching a sample that was representative of the intended population; only modest but significant differences were observed in sex and age. The DD-Me health coach (HC) cited several important facilitators of intervention adoption, including outreach frequency and personalization, and the automated HC report. Implementation fidelity was high, with participants receiving >90% of intended interventions. Participants who received DD-Me with support from a HC were most engaged, suggesting utility and acceptability of integrating HCs with mHealth interventions. Perceptions of implementation among study participants were positive and consistent across study arms. This evaluation revealed the target population was successfully reached and engaged in the digital health interventions, which was implemented with high fidelity. Further studies should evaluate the efficacy and maintenance of the study following the RE-AIM model to determine whether this intervention warrants expansion to additional settings and populations.

Facilitators of peer leader retention within a Type 2 diabetes intervention trial for US Latinos/Hispanics of Mexican origin

Peer support is effective in improving self-management behaviors and health outcomes among individuals with Type 2 diabetes. Volunteer peer support programs offer a cost-effective resource for diabetes self-management support; however, factors affecting the retention of volunteer peer leaders remain understudied. Herein, we examined factors associated with volunteer retention and satisfaction among 34 predominantly Mexican-origin peer leaders who assisted patients from a Federally Qualified Health Center located on the US/Mexico border with their diabetes management. Peer leaders completed surveys with open- and close-ended questions at baseline, 6 months and 12 months. Quantitative and qualitative data analyses were guided by the Volunteer Process Model. Using nonparametric Mann-Whitney U tests, self-efficacy as a peer leader at 6 months was most associated with interest to continue volunteering (P = 0.01), and satisfaction with support from the program at 12 months was most associated with interest to continue volunteering (P = 0.01). The qualitative data indicated that the relationship between the peer leaders and their patients was the primary factor for a satisfying volunteer experience. Future research should focus on increasing peer leaders' self-efficacy and satisfaction with program support and examine how organizations can support the development of the patient-peer relationship. Practitioners should consider appealing to volunteer peers' motivations to promote their retention.

Improving Quality Outcomes: The Value of Diabetes Care and Education Specialists

Given the growing prevalence and accelerating cost of diabetes, there is an urgent need to expand strategies in health care that improve access and outcomes and reduce the financial and human burden of the disease. Diabetes care and education specialists (DCESs) are well positioned to assist health care systems with delivery models that enhance diabetes care through evidence-based standards and quality improvement strategies. DCESs have increased opportunities to apply their competencies in primary, specialty, hospital, and acute care settings; accountable care organizations; community settings; research; and academia. Two national certification programs provide an evidence-based foundation for quality in the specialty, with updated competencies guiding practice. This article serves as a call to action for health care systems to integrate specialists in diabetes care and education into diabetes care delivery models and raise awareness of the positive impact these professionals have on the lives of people with diabetes.

The effect of family-based intervention for adults with diabetes on HbA1c and other health-related outcomes: Systematic review and meta-analysis

AIMS AND OBJECTIVES

To evaluate the effectiveness of family-based intervention for adults with diabetes on glycosylated haemoglobin and other health-related outcomes.

BACKGROUND

The impact of family-based intervention on adults with diabetes has been evaluated in various studies, but there is uncertainty about their effect on health-related outcomes for adults with diabetes.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

METHODS

A review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Six relevant databases were searched from inception to 5 March 2021. Heterogeneity between studies was quantified by using Higgins' I² test. Sensibility and subgroup analyses were used to explore potential heterogeneity.

RESULTS

The review included 23 studies (3,114 participants). Family-based intervention had a significant effect on improving glycosylated haemoglobin levels, body mass index, blood pressure, fasting glucose, diabetes self-care, diabetes self-efficacy, diabetes distress and positive family support. Non-significant results were obtained for blood lipid, body weight, depression and negative family support. In particular, subgroup analyses indicated that family-based intervention in Asian regions was more effective in improving glycosylated haemoglobin levels than in other areas.

CONCLUSION

Family-based intervention may improve diabetes control, diabetes self-care, psychological well-being and positive family support in adults with diabetes and is especially effective in Asian regions. Given the limitations in current studies, further studies are recommended to combine family theory with family-based intervention, and to examine the effectiveness of such intervention for family members.

RELEVANCE TO CLINICAL PRACTICE

This review and meta-analysis provides evidence that family-based intervention can improve positive family support, which has a good effect on diabetes control and psychological well-being in adults with diabetes, and it is especially effective in Asian regions. Findings suggested that unreinforced participation by family members and integrating flexible strategies into family-based intervention may be equally effective.

Brazilian version of "The Insulin Delivery System Rating Questionnaire": translation, cross-cultural adaptation and validation

OBJECTIVE

The aim of this study was to translate and cross-culturally adapt the Insulin Delivery System Rating Questionnaire (IDSRQ) for Brazilian users. Validation and reliability analysis of measures were also performed.

METHODS

Methodological study comprising the following stages: forward translation, synthesis, back-translation, assessment by Expert Committee, pre-test and validation. International guidelines for translation and cross-cultural adaptation of measurement tools were followed. Validation data provided information about reliability (internal consistency, test-retest) and construct validity of the IDSRQ.

RESULTS

Content validation by Experts' assessment was successful, with a mean Content Validity Index of 0.87 (±0.2). The IDSRQ validation study involved 113 T1DM patients, 46% male, mean age 32.61 (±12.59) years and mean age at diagnosis of diabetes of 17.51 (±12.41). The scale presented good internal consistency (Cronbach's alpha =0.786). The reliability analysis of the instrument was conducted by calculating the Intra-class Correlation Coefficient 0.885 (0.834-0.921), which indicated adequate concordance in all measures.

CONCLUSION

The translated and cross-culturally adapted Brazilian Portuguese version of the IDSRQ may be used to assess health-related quality of life (HRQOL) and treatment preferences for insulin delivery systems in T1DM Brazilian patients.

Adesão ao autocuidado de pessoas com Diabetes Mellitus na Atenção Primária: estudo de método misto

Resumo Objetivo elaborar um modelo interpretativo sobre a adesão ao autocuidado de pessoas com Diabetes Mellitus na Atenção Primária à Saúde. Método estudo de método misto realizado em quatro Unidades Básicas de Saúde. O estudo quantitativo transversal foi composto por 329 participantes, elegeram-se variáveis sociodemográficas e clínicas e o questionário de atividades de autocuidado. No estudo qualitativo, com 31 participantes, utilizou-se a vertente construtivista da Teoria Fundamentada nos Dados. Os dados foram analisados utilizando-se a estatística descritiva e a codificação inicial e focalizada. Resultados a maioria dos participantes é do sexo feminino, casada, com um a cinco anos de estudo, aposentada e com renda de um a três salários-mínimos. Obteve-se baixa adesão à alimentação saudável, à atividade física e ao monitoramento glicêmico. A adesão desejável foi relacionada ao uso de medicamentos e cuidados com os pés. Na etapa qualitativa, obteve-se como fenômeno: Enfrentando a complexidade do tratamento do Diabetes Mellitus e buscando o autocuidado. Este foi sustentado por duas categorias: Encontrando as dificuldades para seguir o tratamento e Valorizando os aspectos facilitadores do tratamento que deram subsídios para a elaboração do modelo. Conclusões e implicações para a prática foi elaborado um modelo interpretativo cujos elementos demonstram a complexidade do fenômeno e contribuem para a adesão ao autocuidado nessa população.

DIABEO System Combining a Mobile App Software With and Without Telemonitoring Versus Standard Care: A Randomized Controlled Trial in Diabetes Patients Poorly Controlled with a Basal-Bolus Insulin Regimen

Background: The DIABEO^® system (DS) is a telemedicine solution that combines a mobile app for patients with a web portal for health care providers. DS allows real-time monitoring of basal-bolus insulin therapy as well as therapeutic decision-making, integrating both basal and bolus dose calculation. Real-life studies have shown a very low rate of use of mobile health applications by patients. Therefore, we conducted a large randomized controlled trial study to investigate the efficacy of DS in conditions close to real life (TELESAGE study). Methods: TELESAGE was a multicenter, randomized, open study with three parallel arms: arm 1 (standard care), arm 2 (DIABEO alone), and arm 3 (DIABEO+telemonitoring by trained nurses). The primary outcome assessed the reduction in HbA_1c levels after a 12-month follow-up. Results: Six hundred sixty-five patients were included in the study. Participants who used DIABEO once or more times a day (DIABEO users) showed a significant and meaningful reduction of HbA_1c versus standard care after a 12-month follow-up: mean difference -0.41% for arm 2-arm 1 (P = 0.001) and -0.51% for arm 3-arm 1 (P ≤ 0.001). DIABEO users included 25.1% of participants in arm 2 and 37.6% in arm 3. In the intention-to-treat population, HbA_1c changes and incidence of hypoglycemia were comparable between arms. Conclusions: A clinical and statistically significant reduction in HbA_1c levels was found in those patients who used DIABEO at least once a day.

[Diabetic patients, knowledge respectives complications and severity]

Education is at the cornerstone of management of insulin-treated diabetic patient. Previous studies reported that the education of diabetic patients and their entourage was failing, hypothesizing that this lack of education was explained by a lack of knowledge on the disease and its complications and the underestimation of their respective severity. The "Educated Why" suggests that diabetic patients treated with insulin know that hypoglycemia and to a lesser extent diabetes itself are serious or very serious diseases.

The Invested in Diabetes Study Protocol: a cluster randomized pragmatic trial comparing standardized and patient-driven diabetes shared medical appointments

Background

Shared medical appointments (SMAs) have been shown to be an efficient and effective strategy for providing diabetes self-management education and self-management support. SMA features vary and it is not known which features are most effective for different patients and practice settings. The Invested in Diabetes study tests the comparative effectiveness of SMAs with and without multidisciplinary care teams and patient topic choice for improving patient-centered and clinical outcomes related to diabetes.

Methods

This study compares the effectiveness of two SMA approaches using the Targeted Training for Illness Management (TTIM) curriculum. Standardized SMAs are led by a health educator with a set order of TTIM topics. Patient-driven SMAs are delivered collaboratively by a multidisciplinary care team (health educator, medical provider, behavioral health provider, and a peer mentor); patients select the order and emphasis on TTIM topics. Invested in Diabetes is a cluster randomized pragmatic trial involving approximately 1440 adult patients with type 2 diabetes. Twenty primary care practices will be randomly assigned to either standardized or patient-driven SMAs. A mixed-methods evaluation will include quantitative (practice- and patient-level data) and qualitative (practice and patient interviews, observation) components. The primary patient-centered outcome is diabetes distress. Secondary outcomes include autonomy support, self-management behaviors, clinical outcomes, patient reach, and practice-level value and sustainability.

Discussion

Practice and patient stakeholder input guided protocol development for this pragmatic trial comparing SMA approaches. Implementation strategies from the enhanced Replicating Effective Programs framework will help ensure practices maintain fidelity to intervention protocols while tailoring workflows to their settings. Invested in Diabetes will contribute to the literature on chronic illness management and implementation science using the RE-AIM model.

Trial registration

ClinicalTrials.gov, NCT03590041. Registered on 5 July 2018.

Self-Management as a Mediator of the Relationship between Social Support Dimensions and Health Outcomes of African American Adults with Type 2 Diabetes

Social support promotes behavior change and self-management that leads to improved health outcomes. The purpose of this study was to evaluate the role of self-management in mediating the relationship between social support dimensions and health outcomes of African Americans with type 2 diabetes (T2D). Cross-sectional data were collected from 102 African Americans with T2D at an outpatient clinic. The majority of the participants were female, single, unemployed, and having low income. Functional support, the quality of the primary intimate relationship, and the number of support persons were negatively correlated with depression. Functional support and satisfaction with support explained a significant small amount of the variance in self-management. However, self-management did not mediate the relationships between social support dimensions and the health outcomes. The results of this study shed the light on the unique relationships of social support dimensions with health outcomes of African Americans with T2D.

The influence of an eHealth intervention for adults with type 2 diabetes on the patient-nurse relationship: a qualitative study

BACKGROUND

A constructive patient-nurse relationship is beneficial in self-management support approaches. Research indicates eHealth interventions hold a potential for self-management support for adults with type 2 diabetes. However, eHealth may change the patient-nurse relationship. No studies to date have addressed how eHealth self-management support interventions with written asynchronous communication can influence the relationship between patients and nurses.

AIM

The aim of this study was to explore how an eHealth intervention based on the Guided Self-Determination program (eGSD) influences the patient-nurse relationship from the perspective of patients participating and the nurses conducting the intervention.

METHODS

A qualitative approach with individual semi-structured interviews was used. Ten patients with type 2 diabetes who completed the eGSD and four nurses who delivered the intervention participated. The data were transcribed verbatim, and qualitative content analysis was used to analyse the text.

RESULTS

The findings revealed two themes: 'eGSD facilitates a reciprocal understanding and a flexibility in the relationship' and 'eGSD creates a more fragile relationship', reflecting ambiguous experiences with the eGSD.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

The findings indicate that eGSD influences the patient-nurse relationship by facilitating reciprocal understanding and flexibility. Both patients and RNs acknowledged these outcomes as beneficial. Nevertheless, familiar in-person consultations were expressed as integral for the patient-nurse relationship. As written communication in eHealth is a novelty, it demands new knowledge and expertise that RNs must master. Findings from this study may therefore be acknowledged when developing and implementing eHealth interventions. Education programs in written eHealth communication, as well as guidelines and frameworks on how to professionally and effectively conduct eHealth services while maintaining supportive patient-nurse relationships, should be a priority for institutions that educate healthcare personnel, health institutions and other stakeholders.

Developing and Validating the Educational Materials for a Nurse-Led Self-Management Education in Adults with Type 2 Diabetes

<b><i>Background:</i></b> Diabetes education and self-care are the cornerstones of diabetes management. There are few nurse-led structured diabetes management programs available in Iran. <b><i>Objectives:</i></b> This paper aims to develop and validate a nurse-led diabetes self-management intervention for patients with type 2 diabetes. <b><i>Method:</i></b> The theoretical framework underpinning the intervention was the Bandura’s self-efficacy theory. The seven basic steps of the Taba model were used to develop and validate the study intervention. <b><i>Results:</i></b> The preliminary results from this study suggest that the study intervention was carefully contextualized and linked to the existing diabetes care. Overall, the intervention was very well received and appreciated by the respondents. <b><i>Conclusion:</i></b> This was the first known validated nurse-led diabetes self-management intervention available in the Persian Language.

Self-management behavior concerning physical activity of Japanese type 2 diabetes patients, characterized by sex, daily energy intake and body mass index

Objectives

We assess differences in physical activity self-management behavior in association with dietary intake and BMI between the sexes in patients with type 2 diabetes.

Methods

Patients with type 2 diabetes (n = 145) completed a self-administrated questionnaire. Patients were classified into four groups by BMI and dietary intake: non-obesity and non-overeating (NO/NOE); non-obesity and overeating (NO/OE); obesity and non-overeating (O/NOE); obesity and overeating (O/OE). Differences in physical activity self-management behavior between the four groups were determined by the analysis of variance using a Tukey-Kramer post hoc test.

Results

Male O/OE group showed higher HbA1c (p = 0.001) than the other groups. Male NO/OE group had higher steps/day than O/NOE (p = 0.036) and score of "Exercising to stimulate the enjoyment of eating" was higher than O/OE (p = 0.031). Female NO/OE group showed higher HbA1c (p = 0.001) than NO/NOE and O/NOE.

Conclusions

BMI and dietary intake were associated with frequencies of physical activity self-management strategies in men. Self-management behavior peculiar to male NO/OE group is "Exercising to stimulate the enjoyment of eating". Health professionals should assess sex, BMI, and dietary intake of patients and endeavor to improve individuals' ability to regulate their caloric balance based on physical activity level.

The Relationship between Quality of Life, Activity and Participation among People with Type 2 Diabetes Mellitus

The cross-sectional study investigated the relationship between quality of life, activity, and participation in 93 adults with type 2 diabetes mellitus at a primary care center. Moderately strong correlations were found between quality of life and leisure/work, outdoor and social activities, but not with domestic activities. Leisure/work, outdoor, and social activities accounted for 18% of the variance in the quality of life variables. In a follow-up model, age, depression, and falls efficacy accounted for another 51% of the variance in total quality of life. Findings provide support for the expansion of occupational therapy's role in diabetes self-management, to incorporate leisure, social, and community activities and fall risk management interventions.

Diabetes self-care management practices among insulin-taking patients

BACKGROUND

Diabetes self-care management (DSCM) is complex because various factors and relationships influence its processes.

AIMS

This study aimed to identify the level of DSCM, compare the levels of self care between patients with type 1 and patients with type 2 diabetes, and identify significant predictors of self-care among Jordanian patients with type 1 and type 2 diabetes who were taking insulin.

METHODS

A descriptive cross-sectional design was employed using a convenience sample of 310 Jordanian patients. The Arabic translated version of the 40-item Diabetes Self-Management Scale was used to collect data.

RESULTS

The type of diabetes (t(310) = 4.81; p < .001) and the type of medications (insulin, or insulin and tablets) (t(310) = 4.75; p < .001) significantly affected the level of self-care. Age (t(296) = - 3.41; p = 0.001), gender (t(296) = -4.78; p < 0.001) training in self-care (t(296) = 4.30; p < .001), educational level (t(296) = 2.81, P = .005) and using traditional treatment (herbal therapy) (t(296) = -4.64, p < .001) significantly predicted self-care and explained around 58% of the variance in self-care.

CONCLUSIONS

Various factors were found to influence self-care. Further research is needed to explore the complex nature of DSCM.

Nurse-Led Diabetes Self-Management Education Improves Clinical Parameters in Ethiopia

Background: Unlike in developed countries, the clinical effectiveness of diabetes self-management education (DSME) is not well-studied in the African context. Thus, this study sought to determine effects of DSME on clinical outcomes among type 2 diabetic (T2DM) patients in Ethiopia.

Methods: Before-and-after controlled study design was employed, with random assignment of 116 T2DM adult patients to a nurse-led DSME group and 104 to a treatment-as-usual (comparison) group. A nurse-led DSME with six sessions supported with illustrative pictures handbooks and fliers was customized to local conditions and delivered by trained nurses over 9 months. Our primary outcome was a change in the proportion of people with target glycated hemoglobin (HbA1c ≤ 7%). We used chi-square test and mixed model analysis.

Results: Seventy-eight (67%) and 64 (62%) participants assigned to intervention and comparison, respectively completed the study, and included in the final analysis. Mean HbA1c was significantly reduced by 2.88% within the intervention group and by 2.57% within the comparison group. However, change in the proportion of participants with target HbA1c and end-line mean HbA1c difference between the groups were not significant. Adjusted end-line fasting blood sugar (FBS), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were significantly lower in the intervention group, by 27 ± 9 mg/dL, 12 ± 3, and 8 ± 2 mmHg, respectively.

Conclusion: After 9 months of nurse-led DSME, HbA1c was significantly reduced within both groups but there was no significant difference in HbA1c between groups. The intervention also showed some clinically significant effects on blood pressure and FBS.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03185689, retrospectively registered on June 14, 2017 on ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT03185689.

The impact of inpatient education on self-management for patients with acute coronary syndrome and type 2 diabetes mellitus: a cross-sectional study in China

This study examined the impact of inpatient education on diabetes knowledge, acute coronary syndrome (ACS) symptom management and diabetes self-management on discharge for patients with ACS and type 2 diabetes mellitus (T2DM). A cross-sectional survey and patient health record review of 160 patients was conducted in a major hospital in Shanghai. Patient education received was measured using a visual analogue scale. The survey included valid and reliable measures of diabetes knowledge, self-efficacy, attitudes to ACS and clinical outcomes. Inpatient education contributed to improvements in fasting blood glucose on discharge (P < 0.05). ACS symptom management [Chinese language version of the ACS response index (C-ACSRI) scores] and self-management of T2DM [Chinese version of diabetes management self-efficacy scale (C-DMSES) scores] on discharge differed for the limited education group and sufficient education group (P < 0.001). Based on the multiple regression analyses, increasing scores for the C-ASCRI and C-DMSES could be explained by higher scores for perceived health education. Education relating to ACS and T2DM delivered during an acute admission was associated with improved scores in ACS symptom management and T2DM self-management, preparing some patients to manage both conditions on discharge.

Disparity in Crohn's disease activity between home and clinics is associated with unscheduled hospital visits due to disease flares

BACKGROUND/AIMS

E-health technologies have been implemented for the management of Crohn's disease (CD). We aimed to identify differences between patient activities at home and at routine clinic visits using a web-based self-reporting CD symptom diary (CDSD) and to determine the impact of this disparity on clinical outcomes.

METHODS

Patients with CD from three tertiary hospitals were invited to assess their symptoms at least once a week using CDSD. We identified patients who showed disparities in disease activity (high activity at home but normal at the next hospital visit) and evaluated clinical outcomes of these patients such as unscheduled visits due to flares using Kaplan-Meier analyses.

RESULTS

One hundred and forty-three patients recorded their symptoms weekly for at least 3 consecutive months and were included. Forty-eight patients (33.6%) showed disparate disease activities between at home and at the next outpatient clinic visit. The cumulative risk of unscheduled visits was significantly higher in this disparity group than in the concordant group (p = 0.001). Disparity in activity (p = 0.003), and anti-tumor necrosis factor use (p = 0.002) were independent risk factors of unscheduled visits due to disease flares.

CONCLUSION

Disparity in disease activity is considerable in CD patients and is related to the risk of unscheduled hospital visit.

Beliefs and Practices of Patients with Diabetes toward the Use of Herbal Therapy

This study aimed to assess the prevalence of using herbal therapy and the beliefs toward the use of this type of therapy among patients with diabetes. It also aimed to identify the significant predictors of these beliefs and the factors that increase the likelihood of using herbal therapy. A descriptive cross-sectional design was used. A convenience sample comprised 310 patients with diabetes. Sixty-seven (21.6%) of the participants used herbal therapy. The mean beliefs score was 3.72 and ranged from (0–12). Linear regression showed that beliefs were significantly predicted by self-care, attending workshops, education level, and number of complications. The logistic regression showed that the lower the self-care and the higher the beliefs, the more likelihood the patient uses herbal therapy. Informing patient through individualized diabetes education influences the patient's beliefs and promotes self-care. This education program should target mainly those patients with low self-care, high number of complications, lower educational level and having more complications.

Identification of Family Factors That Affect Self-Management Behaviors Among Patients With Type 2 Diabetes: A Qualitative Descriptive Study in Chinese Communities

INTRODUCTION

In the past 30 years, the prevalence of diabetes in China has increased from 0.67% to 11.6%. Self-management behaviors (SMBs) are significant to improve health outcomes for diabetics. However, little is known about self-management experiences of Chinese diabetic patients. The purpose of this study was to explore family factors affecting SMBs.

METHODOLOGY

A qualitative descriptive study was used. Purposive samples were recruited from Chinese communities. Semistructured interviews were conducted, and audio-recordings transcripts were analyzed using content analysis methods.

RESULTS

Twenty participants were interviewed, including 8 with well-controlled HbA1c while 12 were poorly controlled. Facilitators that promote patients' SMBs were responsibility toward children and commitment to spouse; barriers that hinder patients' SMBs were family experiences about starvation, seeking harmony-eating in a big family, living in an "empty nest," and family financial burden.

DISCUSSION

This study provides insight into SMBs of Chinese diabetic patients. Professionals can develop tailored interventions in a Chinese cultural context according to patients' perceptions of family responsibility, early experience, activities, and resources.

Development of the IMB Model and an Evidence-Based Diabetes Self-management Mobile Application

Objectives

This study developed a diabetes self-management mobile application based on the information-motivation-behavioral skills (IMB) model, evidence extracted from clinical practice guidelines, and requirements identified through focus group interviews (FGIs) with diabetes patients.

Methods

We developed a diabetes self-management (DSM) app in accordance with the following four stages of the system development life cycle. The functional and knowledge requirements of the users were extracted through FGIs with 19 diabetes patients. A system diagram, data models, a database, an algorithm, screens, and menus were designed. An Android app and server with an SSL protocol were developed. The DSM app algorithm and heuristics, as well as the usability of the DSM app were evaluated, and then the DSM app was modified based on heuristics and usability evaluation.

Results

A total of 11 requirement themes were identified through the FGIs. Sixteen functions and 49 knowledge rules were extracted. The system diagram consisted of a client part and server part, 78 data models, a database with 10 tables, an algorithm, and a menu structure with 6 main menus, and 40 user screens were developed. The DSM app was Android version 4.4 or higher for Bluetooth connectivity. The proficiency and efficiency scores of the algorithm were 90.96% and 92.39%, respectively. Fifteen issues were revealed through the heuristic evaluation, and the app was modified to address three of these issues. It was also modified to address five comments received by the researchers through the usability evaluation.

Conclusions

The DSM app was developed based on behavioral change theory through IMB models. It was designed to be evidence-based, user-centered, and effective. It remains necessary to fully evaluate the effect of the DSM app on the DSM behavior changes of diabetes patients.

DIABEO App Software and Telemedicine Versus Usual Follow-Up in the Treatment of Diabetic Patients: Protocol for the TELESAGE Randomized Controlled Trial

Background

Self-management of diabetes minimizes the risk of macrovascular and microvascular complications, but understanding and/or adherence to self-management recommendations is often suboptimal. DIABEO is a smartphone app (downloaded via the internet) used to calculate bolus insulin doses. A previous study (TELEDIAB 1) showed that the use of DIABEO was associated with a significant improvement in glycemic control in patients with poorly controlled type 1 diabetes mellitus, particularly when combined with teleconsultations with physicians.

Objective

Here, we present the protocol for a new study (Suivi A Grande Echelle d’une cohorte de diabétiques de type 1 et de type 2 sous schéma insulinique basal bolus par la TELEmédecine; abbreviated TELESAGE), conducted in a larger population of diabetic patients with poorly controlled basal-bolus insulin levels.

Methods

TELESAGE is a multicenter, double-randomized, open-label, three parallel–arms study, conducted in approximately 100 centers in France. The study will compare a control group (arm 1: usual follow-up) with two DIABEO telemedicine systems: (1) physician-assisted telemedicine (arm 2), and (2) nurse-assisted telemonitoring and teleconsultations by a diabetologist’s task delegation (arm 3). Initial randomization will allocate the study arms in 12 French regions. A second randomization will assign patients in the groups allocated to each studied region. The primary objective of TELESAGE will be to investigate the effect of the DIABEO telemedicine system versus usual follow-up, with respect to improvements in the glycated hemoglobin levels of approximately 696 diabetic patients with poorly controlled basal-bolus insulin levels.

Results

The TELESAGE study is sponsored by Sanofi (Gentilly, France). A primary completion date is expected in June 2018, and publication of results is expected within 6 months of work completion.

Conclusions

The TELESAGE study is expected to confirm the previous results of the TELEDIAB 1 study using a larger sample of diabetic patients. It is also expected to evaluate a nurse-assisted telemonitoring system. We will assess the potential of the DIABEO telemedicine service in terms of its utility and explore whether it can become an integral part of diabetes care for patients.

Trial Registration

ClinicalTrials.gov NCT02287532; https://clinicaltrials.gov/ct2/show/NCT02287532 (Archived by WebCite at http://www.webcitation.org/6ykajhJKd)

Team composition and chronic disease management within primary healthcare practices in eastern Ontario: an application of the Measuring Organizational Attributes of Primary Health Care Survey

BACKGROUND

Various organizational-level attributes are being implemented in primary healthcare to improve healthcare delivery. There is a need to describe the distribution and nature of these attributes and explore differences across practices.AimThe aim of this study was to better understand organizational attributes of primary care teams, focusing specifically on team composition, nursing roles, and strategies that support chronic disease management.

METHODS

We employed a cross-sectional survey design. Team composition, nursing roles, availability of health services, and chronic disease management activities were described using the 'Measuring Organizational Attributes of Primary Health Care Survey.'FindingsA total of 76% (n=26 out of 34) of practice locations completed the survey, including family health teams (FHT; n=21) and community health centers (CHC; n=4). Nurse practitioners (NPs) and registered nurses (RNs) were the most common non-physician providers, and CHCs had a greater proportion of non-physician providers than FHTs. There was overlap in roles performed by NPs and RNs, and registered practical nurses engaged in fewer roles compared with NPs and RNs. A greater proportion of FHTs had systematic chronic disease management services for hypertension, depression and Alzheimer's disease compared with CHC practices. The 'Measuring Organizational Attributes of Primary Health Care Survey' was a useful tool to highlight variability in organizational attributes across PHC practices. Nurses are prominent within PHC practices, engaging in a wide range of roles related to chronic disease management, suggesting a need to better understand their contributions to patient care to optimize their roles.

The effectiveness of theory- and model-based lifestyle interventions on HbA1c among patients with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVES

The prevalence of type 2 diabetes is rising rapidly around the world. A number of systematic reviews have provided evidence for the effectiveness of lifestyle interventions on diabetic patients. The effectiveness of theory- and model-based education-lifestyle interventions for diabetic patients are unclear. The systematic review and meta-analysis aimed to evaluate and quantify the impact of theory-based lifestyle interventions on type 2 diabetes.

STUDY DESIGN

A literature search of authentic electronic resources including PubMed, Scopus, and Cochrane collaboration was performed to identify published papers between January 2002 and July 2016.

METHODS

The PICOs (participants, intervention, comparison, and outcomes) elements were used for the selection of studies to meet the inclusion and exclusion criteria. Mean differences and standard deviations of hemoglobin A1c (HbA1c [mmol/mol]) level in baseline and follow-up measures of studies in intervention and control groups were considered for data synthesis. A random-effects model was used for estimating pooled effect sizes. To investigate the source of heterogeneity, predefined subgroup analyses were performed using trial duration, baseline HbA1c (mmol/mol) level, and the age of participants. Meta-regression was performed to examine the contribution of trial duration, baseline HbA1c (mmol/mol) level, the age of participants, and mean differences of HbA1c (mmol/mol) level. The significant level was considered P < 0.05.

RESULTS

Eighteen studies with 2384 participants met the inclusion criteria. The pooled main outcomes by random-effects model showed significant improvements in HbA1c (mmol/mol) -5.35% (95% confidence interval = -6.3, -4.40; P < 0.001) with the evidence of heterogeneity across studies.

CONCLUSION

The findings of this meta-analysis suggest that theory- and model-based lifestyle interventions have positive effects on HbA1c (mmol/mol) indices in patients with type 2 diabetes. Health education theories have been applied as a useful tool for lifestyle change among people with type 2 diabetes.

Types and sources of social support among adults living with type 2 diabetes in rural communities in the Dominican Republic

Type 2 diabetes management hinges on various determinants, including the role of interpersonal relationships in self-management behaviours. The aim of this study was to explore the types and sources of social support received by adults in the diabetes diagnosis and self-management processes. We conducted qualitative interviews with 28 men and women at two rural clinics in the Dominican Republic and used a combination of narrative and thematic analytic techniques to identify key sources and types of social support in their diabetes experiences. Participants described three stages in their diabetes experience: diagnosis, programme-enrolment, and long-term management. During diabetes diagnosis, most participants described receiving no support. At the programme-enrolment stage, friends and neighbours frequently provided informational or instrumental support to get to the clinic. In long-term management, cohabiting partners provided the most support, which was often assistance with their diet. Our findings highlight he need to assess and leverage distinct types and sources of social support at different stages of the diabetes experience.

The Gestational Diabetes Group Program

The purpose of the Gestational Diabetes Group Program (GDGP) was to provide patients with diabetes self-management education that occurs in a supportive, prenatal group care setting. The Centering Pregnancy Interdisciplinary Model of Empowerment and the Chronic Care Model guided the program. The pilot project took place at an urban clinic that cares for a diverse, underserved population. The GDGP, a series of four prenatal group sessions after the diagnosis of gestational diabetes and one postpartum group, used an interprofessional/interdisciplinary approach to care with the groups cofacilitated by certified nurse-midwives, certified diabetes nurse-educators, and other community partners. The program was able to show statistically significant changes in knowledge and empowerment, optimal pregnancy outcomes, and high patient satisfaction.

Grieving the Loss of Self: Challenges in Type 2 Diabetes Mellitus Self-Management

The aim of this study was to understand and describe the experience of diabetes self-management among patients not meeting glycemic control (A1C > 9). Type 2 diabetes mellitus (T2DM) is a complex chronic disease process. Diabetes self-management is equally complex and critical to patient outcomes and quality of life. The components for self-management include: knowledge, skills/abilities, and support. Few studies have reported on the experiences of self-management for patients with T2DM to reach and sustain glycemic control. This study used a qualitative descriptive design. Semistructured interviews were conducted with 13 patients receiving care at a diabetic clinic at a major health-care system in New York City. An interview guide was developed based on diabetes self-management which guided the interviews. All data were analyzed using qualitative content analysis. Initially, three themes that describe each component of diabetes mellitus self-management (DMSM) and impact the patients' reaching the desired outcome were identified: acceptance of knowledge, motivation for skills and abilities, and variability and vulnerability of support. Further analysis of the three themes led to the identification of an overarching, theme: loss of self. This overarching theme helped to explain the stages of grief illustrated across the themes in the participants DMSM experiences. The participants in this study identified loss of self, and the accompanying grief and grieving process related to the loss of self in response to their T2DM diagnosis. Participants were "stuck" in a stage of loss of self, which presented challenges to acceptance of their diagnosis, barriers to DMSM, and optimizing glycemic control.

Assessing the association of diabetes self-management education centers with age-adjusted diabetes rates across U.S.: Aspatial cluster analysis approach

The purpose of this study is to identify regions with diabetes health-service shortage. American Diabetes Association (ADA)-accredited diabetes self-management education (DSME) is recommended for all those with diabetes. In this study, we focus on demographic patterns and geographic regionalization of the disease by including accessibility and availability of diabetes education resources as a critical component in understanding and confronting differences in diabetes prevalence, as well as addressing regional or sub-regional differences in awareness, treatment and control. We conducted an ecological county-level study utilizing publicly available secondary data on 3,109 counties in the continental U.S. We used a Bayesian spatial cluster model that enabled spatial heterogeneities across the continental U.S. to be addressed. We used the American Diabetes Association (ADA) website to identify 2012 DSME locations and national 2010 county-level diabetes rates estimated by the Centers for Disease Control and Prevention and identified regions with low DSME program availability relative to their diabetes rates and population density. Only 39.8% of the U.S. counties had at least one ADA-accredited DSME program location. Based on our 95% credible intervals, age-adjusted diabetes rates and DSME program locations were associated in only seven out of thirty five identified clusters. Out of these seven, only two clusters had a positive association. We identified clusters that were above the 75th percentile of average diabetes rates, but below the 25th percentile of average DSME location counts and found that these clusters were all located in the Southeast portion of the country. Overall, there was a lack of relationship between diabetes rates and DSME center locations in the U.S., suggesting resources could be more efficiently placed according to need. Clusters that were high in diabetes rates and low in DSME placements, all in the southeast, should particularly be considered for additional DSME programming.

Self-management of type 2 diabetes in gulf cooperation council countries: A systematic review

Aims

This study aimed to systematically review intervention studies on self-management of type 2 diabetes in Gulf Cooperation Council (GCC) countries to determine the most effective self-management strategies for individuals with type 2 diabetes in this region.

Methods

A search strategy was developed using multiple databases: Medline and Embase (via Ovid), CINAHL (via EBSCO), and PubMed. Study and intervention characteristics, intervention structure, content, cultural adaptation, and outcomes were extracted from the included studies. To be included in the review the studies should have met the following criteria: have examined the effectiveness of at least one intervention involving a type 2 DSME programme, have involved participants over 18 years old diagnosed with type 2 diabetes, have taken place to in a GCC country, have a study design that was observational, quasi-experimental or controlled, have reported at least one individual and have a quantitative outcome. A narrative data synthesis was used to describe the studies and comment on their methodological quality.

Results

Of the 737 retrieved papers, only eight met the inclusion criteria. Only one study was a randomised controlled trial. A statistically significant improvement in HbA1c was reported in five of the eight studies. There was a significant improvement in physical activity levels as reported in four of the eight studies. Only three studies referred to aspects of cultural design or adaptation of the intervention implemented.

Conclusions

Self-management interventions may have a positive impact on HbA1 levels in patients with type 2 diabetes in the GCC area. A greater emphasis placed on culturally appropriate self-management programmes may improve the effectiveness of self-management interventions for adults with type 2 diabetes in the GCC.

Quality of Care Improves for Patients with Diabetes in Medicare Shared Savings Accountable Care Organizations: Organizational Characteristics Associated with Performance

Accountable care organizations (ACOs), a primary care-centric delivery and payment model, aim to promote integrated population health, which may improve care for those with chronic conditions such as diabetes. Research has shown that, overall, the ACO model is effective at reducing costs, but there is substantial variation in how effective different types of ACOs are at impacting costs and improving care delivery. This study examines how ACO organizational characteristics - such as composition, staffing, care management, and experiences with health reform - were associated with quality of care delivered to patients with diabetes. Secondary data were analyzed retrospectively to examine Medicare Shared Savings Program (MSSP) ACOs' performance on diabetes metrics in the first 2 years of ACO contracts. Ordinary least squares was used to analyze 162 MSSP ACOs with publicly available performance data and the National Survey of ACOs. ACOs improved performance significantly for patients with diabetes between contract years 1 and 2. In year 1, also having a private payer contract and an increased number of services within the ACO were positively associated with performance, while having a community health center or a hospital were negatively associated with performance. Better performance in year 1 was negatively associated with improved performance in year 2. This study found that ACOs substantively improved diabetes management within initial contract years. ACOs may need different types of support throughout their contracts to ensure continued improvements in performance.

Health professionals' knowledge and attitudes to healthcare-seeking practices and complementary alternative medicine usage in Ugandans with diabetes: a cross-sectional survey

INTRODUCTION

Healthcare-seeking behaviour among persons with diabetes has been investigated to a limited extent, and not from professionals' perspective. The aim of the study was to describe healthcare professionals' knowledge, attitudes and practice concerning healthcare-seeking behaviour and the use of complementary and alternative medicine among persons with diabetes.

METHODS

A cross-sectional, self-administered questionnaire was conducted in western Uganda. Nurses, midwives or nurse assistants 72.2%, physicians 12% and clinical officers 10% volunteered to participate in the study with a total 108 (93% response rate) response rate. Descriptive statistics were used to analyse data with frequencies, percentages and summarized in tables.

RESULTS

Most of the healthcare providers perceived more uneducated people to be at risk of developing complications related to diabetes (66.7%) and that most of the patients with diabetes were not knowledgeable about signs and symptoms of diabetes before being diagnosed (75.9%). The main reasons inducing persons with diabetes to seek care outside the health care sector were reported to be seeking a cure for the condition, influence from the popular sector, the accessibility of the place and signs of complications of diabetes related to poor glycaemic control. Healthcare providers had relatively positive attitudes towards using complementary and alternative medicine.

CONCLUSION

Insufficient knowledge about diabetes, compromised healthcare-seeking practices including drug procurement for diabetes seem to be barriers to diabetes management. Patients were thus reported to be burdened with co-morbidities of complications of diabetes related to poor glycaemic control.

The Effect of Group Discussion-based Education on Self-management of Adults with Type 2 Diabetes Mellitus Compared with Usual Care: A Randomized Control Trial

Objectives

We sought to determine the effect of group discussion-based education on the self-management capability of patients with type 2 diabetes in Iran.

Methods

This randomized control trial was conducted on 90 patients with type 2 diabetes. Participants were allocated randomly into one of two groups; intervention and control. The intervention group received the group discussion-based education while the control group received routine care only. The Lin's self-management questionnaire was completed at baseline and three months post-intervention.

Results

Statistical analysis, including the use of independent t-test, identified that in comparison to the control group, significant increases were observed in the scores of self-organization (t =11.24, p < 0.001), self-adjustment (t = 7.53, p < 0.001), interaction with health experts (t = 7.31, p < 0.001), blood sugar self-monitoring (t = 6.42, p < 0.001), adherence to the proposed diet (t = 5.22, p < 0.001), and total self-management (t = 10.82, p < 0.001) in the intervention group.

Conclusions

Sharing experiences through group discussions and receiving instructive feedback can improve the ability to self-manage diabetes.

Diabetes care improvement in pharmacist- versus nurse-supported patient-centered medical homes

OBJECTIVES

In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models.

STUDY DESIGN

Longitudinal cohort study.

METHODS

We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C]).

RESULTS

In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years.

CONCLUSIONS

Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.

Dulce Digital: An mHealth SMS-Based Intervention Improves Glycemic Control in Hispanics With Type 2 Diabetes

OBJECTIVE

Type 2 diabetes is growing in epidemic proportions and disproportionately affects lower-income, diverse communities. Text messaging may provide one of the most rapid methods to overcome the "digital divide" to improve care.

RESEARCH DESIGN AND METHODS

A randomized, nonblinded, parallel-groups clinical trial design allocated N = 126 low-income, Hispanic participants with poorly controlled type 2 diabetes to receive the Dulce Digital intervention or usual care (UC). Dulce Digital participants received up to three motivational, educational, and/or call-to-action text messages per day over 6 months. The primary outcome was HbA_1c; lipids, blood pressure, and BMI were secondary outcomes. Satisfaction and acceptability were evaluated via focus groups and self-report survey items.

RESULTS

The majority of patients were middle-aged (mean age 48.43 years, SD 9.80), female (75%), born in Mexico (91%), and uninsured (75%) and reported less than a ninth-grade education level (73%) and mean baseline HbA_1c 9.5% (80 mmol/mol), SD 1.3, and fasting plasma glucose 187.17 mg/dL, SD 64.75. A statistically significant time-by-group interaction effect indicated that the Dulce Digital group achieved a significantly greater reduction in HbA_1c over time compared with UC (P = 0.03). No statistically significant effects were observed for secondary clinical indicators. The number of blood glucose values texted in by participants was a statistically significant predictor of month 6 HbA_1c (P < 0.05). Satisfaction and acceptability ratings for the Dulce Digital intervention were high.

CONCLUSIONS

Use of a simple, low-cost text messaging program was found to be highly acceptable in this sample of high-risk, Hispanic individuals with type 2 diabetes and resulted in greater improvement in glycemic control compared with UC.

Implementation of collaborative goal setting for diabetes in community primary care

Collaborative goal setting (CGS) is a cornerstone of diabetes self-management support, but little is known about its feasibility and effectiveness during routine care. The aim of this study was to evaluate the implementation of an existing CGS intervention when integrated by primary care staff. Using a mixed-methods approach guided by the RE-AIM framework, intervention adoption, implementation, reach, and effectiveness were evaluated over 12 months. Three of four sites adopted the CGS intervention, in which 521 patients with type 2 diabetes (9-29 % of those targeted) received CGS. For those with suboptimal glycemic control (A1C ≥ 7.5 %), %A1C decreased by 1.1 for those receiving CGS (n = 204, p < 0.001) compared to 0.4 for a group who did not (n = 41, p = 0.23). Practice characteristics influenced adoption and implementation, while isolation of CGS from the remainder of clinical care likely influenced reach and effectiveness. CGS may benefit patients with diabetes, but a lack of integration by practice staff is a key barrier to overcome during implementation.

The effect of guided self-determination on self-management in persons with type 1 diabetes mellitus and HbA1c ≥64 mmol/mol: a group-based randomised controlled trial

OBJECTIVES

To determine whether the impact of guided self-determination (GSD) applied in group training (GSD-GT) in people with chronically elevated HbA_1c and type 1 diabetes mellitus (DM) was superior to 'care as usual' in improving HbA_1c and psychological functioning.

SETTING

An outpatient clinic at a university hospital in Western Norway.

PARTICIPANTS

A total of 178 adults (all Caucasian) aged 18-55 (mean age 36.7±10.7, 62% women) with type 1 DM for at least 1 year and HbA_1c ≥64 mmol/mol (8.0%) were randomly assigned to participate in either GSD-GT or a control group (CG). Exclusion criteria were severe comorbidity, major psychiatric disorder, cognitive deficiency/language barriers and pregnancy.

INTERVENTION

Intervention group met seven times for 2 hours over 14 weeks to promote patient autonomy and intrinsic motivation using reflection sheets and advanced professional communication in accordance with the GSD methodology.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was HbA_1c and secondary outcomes (all outcomes 9 months post intervention) were self-monitored blood glucose frequency, self-reported diabetes competence, autonomy support by healthcare providers (Health Care Climate Questionnaire), autonomous versus controlled diabetes motivation (Treatment Self-Regulation Questionnaire), diabetes distress (Problem Areas In Diabetes Scale (PAID) and Diabetes Distress Scale (DDS)), self-esteem (Rosenberg Self-Esteem Scale) and psychological well-being (World Health Organization five-item Well-Being Index scale).

RESULTS

Among participants allocated to the GSD-GT (=90) 48 completed the study, whereas 83 completed in the CG (n=88). With 95% CIs GSD-GT did not have effect on HbA_1c (B -0.18, CI (-0.48, 0.12), p=0.234). GSD-GT improved autonomy-motivated behaviour (B 0.51, CI (0.25, 0.77), p<0.001), diabetes distress (PAID, B -6.96, CI (-11.40, -2.52), p=0.002), total DDS (B -5.15, CI (-9.34, -0.96), p=0.016), DDS emotional burden (B -7.19, CI (-13.20, -1.19), p=0.019) and self-esteem (B 1.43, CI (0.34, 2.52), p=0.011).

CONCLUSIONS

Results from this behavioural intervention must be interpreted cautiously because of recruitment and attrition problems. Medical outcomes did not improve. Psychological outcomes improved, especially reduced diabetes distress.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov NCT 01317459.

Effects of a Family-based Diabetes Intervention on Behavioral and Biological Outcomes for Mexican American Adults

Purpose The purpose of the study was to investigate the effects of a family-based self-management support intervention for adults with type 2 diabetes (T2DM). Methods Using a 2-group, experimental repeated measures design, 157 dyads (participant with T2DM and family member) were randomly assigned to an intervention (education, social support, home visits, and telephone calls) or a wait list control group. Data were collected at baseline, postintervention (3 months), and 6 months postintervention. A series of 2 × 3 repeated measures ANOVAs were used to test the hypotheses with interaction contrasts to assess immediate and sustained intervention effects. Results Significant changes over time were reported in diet self-management, exercise self-management, total self-management, diabetes self-efficacy for general health and total diabetes self-efficacy, physician distress, regimen distress, interpersonal distress, and total distress. There were likewise sustained effects for diet self-management, total self-management, diabetes self-efficacy for general health, total self-efficacy, physician distress, regimen distress, and interpersonal distress. Conclusions Results support and extend prior research documenting the value of culturally relevant family-based interventions to improve diabetes self-management and substantiate the need for intensive, longer, tailored interventions to achieve glycemic control.