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Krall JS, Ng JM, Mehrotra N, Ruppert K, Siminerio LM. Insights into the Feasibility and Acceptability of a Mobile Insulin Titration Application in Clinical Practice and Its Effects on Diabetes Outcomes. TOUCHREVIEWS IN ENDOCRINOLOGY 2024; 20:52-57. [PMID: 38812671 PMCID: PMC11132646 DOI: 10.17925/ee.2024.20.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/02/2023] [Indexed: 05/31/2024]
Abstract
Introduction: Insulin therapy is most effective if patients learn how to properly adjust insulin to achieve glycaemic targets. There is a need for methods and tools that can assist these processes in clinical practice. The purpose of this feasibility study was to evaluate an approach to support insulin dose adjustment in individual patients using a mobile titration application (app). Methods: A cohort of adults (N=36) with type 2 diabetes with suboptimal glycaemia who were starting basal insulin self-titration were trained by a diabetes care and education specialist to use a mobile titration app to guide adjusting insulin doses. Glycaemia, diabetes distress and patient and provider satisfaction were assessed during the first 3 months after initiating basal insulin titration using the mobile app. Results: Mean haemoglobin type A1c (HbA1c) was significantly reduced by an average of 2.1 ± 2.2% from baseline to 3 months (p<0.001). Diabetes distress significantly decreased from baseline to follow-up with scores going down (or improving) across all scales. Both patients and providers reported high levels of satisfaction and positive experiences. Conclusion: The model offers a promising solution to streamline insulin dosage adjustments to achieve specific clinical and self-management goals with high expectations for long-term benefits and warrants further investigation.
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Affiliation(s)
- Jodi S Krall
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jason M Ng
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- niversity of Pittsburgh, Department of Medicine, Division of Endocrinology and Metabolism, Pittsburgh, PA, USA
| | - Neha Mehrotra
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- niversity of Pittsburgh, Department of Medicine, Division of Endocrinology and Metabolism, Pittsburgh, PA, USA
| | - Kristine Ruppert
- University of Pittsburgh School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - Linda M Siminerio
- niversity of Pittsburgh, Department of Medicine, Division of Endocrinology and Metabolism, Pittsburgh, PA, USA
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2
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Leverenz JC, Leverenz B, Prahalad P, Bishop FK, Sagan P, Martinez-Singh A, Conrad B, Chmielewski A, Senaldi J, Scheinker D, Maahs DM. Role and Perspective of Certified Diabetes Care and Education Specialists in the Development of the 4T Program. Diabetes Spectr 2024; 37:153-159. [PMID: 38756427 PMCID: PMC11093765 DOI: 10.2337/ds23-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Affiliation(s)
- Jeannine C. Leverenz
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Brianna Leverenz
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Priya Prahalad
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
| | - Franziska K. Bishop
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
| | - Piper Sagan
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Anjoli Martinez-Singh
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Barry Conrad
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Annette Chmielewski
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - Julianne Senaldi
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
| | - David M. Maahs
- Lucile Packard Children’s Hospital, Division of Pediatric Endocrinology, Palo Alto, CA
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
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3
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Bullock JE. Provider adherence to American Diabetes Association cardiovascular risk-reduction guidelines: An integrative review. J Am Assoc Nurse Pract 2024; 36:17-22. [PMID: 37494065 DOI: 10.1097/jxx.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/05/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) requires comprehensive management to prevent end organ disease. Type 2 diabetes Mellitus (T2DM) effects more than 33.3 million individuals in the United States, the majority managed by primary care providers (PCPs). Type 2 diabetes Mellitus increases lifetime heart attack and stroke risk by 2-4 times. Adherence to the American Diabetes Association (ADA) cardiovascular disease reduction guidelines is associated with decreased morbidity and mortality. PURPOSE This integrative review highlights PCP adherence to ADA cardiovascular risk-reduction guidelines and explores interventions that address adherence. METHODOLOGY The integrative review approach demanded critical examination of the literature following extraction of findings obtained through a rigorous process involving clear inclusion and exclusion criteria. A comprehensive literature search was guided through Johns Hopkins Nursing Evidence-Based Practice Model. Data extraction was documented through Preferred Reporting Items for Systematic Reviews and Meta-Analysis. RESULTS Five articles met inclusion criteria. Articles ranged from 2017 to 2022 and occurred in the United States, Palestine, and one across Europe. Four areas of common content were identified and included the lack of adherence to statin prescribing, lack of adherence to blood pressure management, statin prescribing favoring male patients and those with existing atherosclerotic cardiovascular disease diagnoses, and varying methods to improve adherence. CONCLUSIONS Quality-improvement strategies focused on the improvement of PCP adherence to ADA cardiovascular risk-reduction guidelines are necessary. IMPLICATIONS Improved adherence would significantly improve morbidity and mortality outcomes in T2DM. Adherence interventions include education, electronic health record integration, and oversight by certified diabetes educator nurses. The time is now to reduce the negative sequelae from a disease that effects 11.3% of our population.
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Affiliation(s)
- Jamie Eve Bullock
- Johns Hopkins University School of Nursing, Baltimore, Maryland
- University of New England, Portland, Maine
- Martin's Point Health Care, Portland, Maine
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4
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Siminerio L, Krall J, Johnson P, Ruppert K, Hammoudeh R, Bandi A, Ng JM. Examining a Diabetes Self-Management Education and Support Telemedicine Model With High-Risk Patients in a Rural Community. J Diabetes Sci Technol 2023; 17:1190-1197. [PMID: 37338130 PMCID: PMC10563533 DOI: 10.1177/19322968231180884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Ongoing support is critical to diabetes self-management education and support (DSMES) effectiveness, but difficult to realize, particularly in areas with limited resources. The objective of this feasibility study was to assess the impact of a virtual support model on diabetes outcomes and acceptability with high-risk patients with type 2 diabetes in a rural community. METHODS In a 12-month nonrandomized trial in federally qualified health centers (FQHCs), patients with hemoglobin A1c (HbA1c) >9% were referred to the Telemedicine for Reach, Education, Access, Treatment, and Ongoing Support (TREAT-ON) program where a Diabetes Care and Education Specialist provided DSMES through videoconferencing. HbA1c change was compared in 30 patients in the intervention group (IG) to a propensity score-matched retrospective control group (CG) of patients who received in-person DSMES delivered by a DCES. Changes in HbA1c, diabetes distress, empowerment, self-care and acceptability were assessed within the intervention group (IG) between those who did and did not meet self-management goals. RESULTS The IG experienced similar significant reductions in HbA1c as the CG. Most (64%) IG participants achieved their self-management goal. Goal attainers had a significant HbA1c decrease of 0.21% every 3 months as well as significant reduction in diabetes distress and improvement in general dietary intake. Regardless of goal attainment, IG participants reported high levels of acceptability with TREAT-ON. CONCLUSIONS This feasibility study suggests that TREAT-ON was well-received and as effective as traditional in-person DSMES. While findings augment ample evidence regarding DSMES benefits, the TREAT-ON model offers additional advantages and provides validation for telehealth to inform future practice in reaching and supporting self-management for high-risk patients in underserved areas. TRIAL REGISTRATION Clinicaltrials.gov, # NCT04107935.
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Affiliation(s)
- Linda Siminerio
- Division of Endocrinology and
Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,
USA
| | - Jodi Krall
- University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | | | - Kristine Ruppert
- Department of Epidemiology, University
of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Rawan Hammoudeh
- Division of Endocrinology and
Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,
USA
- University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Archana Bandi
- Division of Endocrinology and
Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,
USA
- Veterans Affairs Pittsburgh Health
System, Pittsburgh, PA, USA
| | - Jason M. Ng
- Division of Endocrinology and
Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,
USA
- University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
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5
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Konnyu KJ, Yogasingam S, Lépine J, Sullivan K, Alabousi M, Edwards A, Hillmer M, Karunananthan S, Lavis JN, Linklater S, Manns BJ, Moher D, Mortazhejri S, Nazarali S, Paprica PA, Ramsay T, Ryan PM, Sargious P, Shojania KG, Straus SE, Tonelli M, Tricco A, Vachon B, Yu CH, Zahradnik M, Trikalinos TA, Grimshaw JM, Ivers N. Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes. Cochrane Database Syst Rev 2023; 5:CD014513. [PMID: 37254718 PMCID: PMC10233616 DOI: 10.1002/14651858.cd014513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors. Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted. Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three. Combinations of the three most effective QI strategies were estimated to lead to the below effects: - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%; - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg; - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.
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Affiliation(s)
- Kristin J Konnyu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sharlini Yogasingam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Johanie Lépine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katrina Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Sathya Karunananthan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - John N Lavis
- McMaster Health Forum, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Braden J Manns
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sameh Mortazhejri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Peter Sargious
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Kaveh G Shojania
- University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Marcello Tonelli
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Andrea Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
- Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Occupational Therapy Program, University of Montreal, Montreal, Canada
| | - Catherine Hy Yu
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Michael Zahradnik
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
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Lewinski AA, Jazowski SA, Goldstein KM, Whitney C, Bosworth HB, Zullig LL. Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review. PATIENT EDUCATION AND COUNSELING 2022; 105:3381-3388. [PMID: 36002348 PMCID: PMC9675717 DOI: 10.1016/j.pec.2022.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain. METHODS We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia. RESULTS Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices. CONCLUSION To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs. PRACTICE IMPLICATIONS Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.
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Affiliation(s)
- Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Duke University School of Nursing, Box 3322 DUMC, Durham, NC 27710, USA.
| | - Shelley A Jazowski
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599‑7400, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA; Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC 27701, USA.
| | - Colette Whitney
- Cascades East Family Medicine Residency, Oregon Health & Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA.
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Duke University School of Nursing, Box 3322 DUMC, Durham, NC 27710, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599‑7400, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, P.O. Box 102508, Durham, NC 27710, USA.
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA.
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7
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Benson G, Hayes J, Bunkers-Lawson T, Sidebottom A, Boucher J. Leveraging Registered Dietitian Nutritionists and Registered Nurses in Medication Management to Reduce Therapeutic Inertia. Diabetes Spectr 2022; 35:491-503. [PMID: 36561653 PMCID: PMC9668720 DOI: 10.2337/ds21-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective To conduct a systematic review of studies that used registered dietitian nutritionists (RDNs) or registered nurses (RNs) to deliver pharmacological therapy using protocols for diabetes, dyslipidemia, or hypertension. Research Design and Methods A database search of PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and the Cumulative Index to Nursing and Allied Health Literature was conducted of literature published from 1 January 2000 to 31 December 2019. Results Twenty studies met the inclusion criteria, representing randomized controlled trials (12), retrospective (1) and prospective cohort design studies (6), and time series (1). In all, the studies include 7,280 participants with a median study duration of 12 months (range 6-25 months). Fifteen studies were led by RNs alone, two by RDNs, and three by a combination of RDNs and RNs. All demonstrated improvements in A1C, blood pressure, or lipids. Thirteen studies provided a lifestyle behavior change component in addition to medication protocols. Conclusion This systematic review provides evidence that RDN- and RN-led medication management using physician-approved protocols or treatment algorithms can lead to clinically significant improvements in diabetes, dyslipidemia, and hypertension management and is as good or better than usual care.
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Affiliation(s)
| | - Joy Hayes
- Minneapolis Heart Institute Foundation, Minneapolis, MN
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8
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Heisler M, Simmons D, Piatt GA. Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes. Endocrinol Metab Clin North Am 2021; 50:e1-e20. [PMID: 34763822 DOI: 10.1016/j.ecl.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To translate improvements in diabetes management into improved outcomes, it is essential to improve care delivery. To help guide clinicians and health organizations in their efforts to achieve these improvements, this article briefly describes key components underpinning effective diabetes care and six categories of innovations in approaches to improve diabetes care delivery: (1) team-based clinical care; (2) cross-specialty collaboration/integration; (3) virtual clinical care/telehealth; (4) use of community health workers (CHWs) and trained peers to provide pro-active self-management support; (5) incorporating screening for and addressing social determinants of health into clinical practice; and (6) cross-sectoral clinic/community partnerships.
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Affiliation(s)
- Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School; Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System; Department of Health Behavior and Health Education, School of Public Health, University of Michigan.
| | - David Simmons
- School of Medicine, Western Sydney University, Sydney, Australia; Macarthur Clinical School, Campbelltown Hospital, Therry Road, Campbelltown, New South Wales 2560, Australia
| | - Gretchen A Piatt
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan; Department of Learning Health Sciences, University of Michigan Medical School, 1111 E. Catherine Street, Victor Vaughan Building, Room 225, Ann Arbor, MI 48109, USA
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9
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Powell RE, Zaccardi F, Beebe C, Chen XM, Crawford A, Cuddeback J, Gabbay RA, Kissela L, Litchman ML, Mehta R, Meneghini L, Pantalone KM, Rajpathak S, Scribner P, Skelley JW, Khunti K. Strategies for overcoming therapeutic inertia in type 2 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2021; 23:2137-2154. [PMID: 34180129 DOI: 10.1111/dom.14455] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 01/14/2023]
Abstract
AIMS To systematically investigate the effect of interventions to overcome therapeutic inertia on glycaemic control in individuals with type 2 diabetes. MATERIALS AND METHODS We electronically searched for randomized controlled trials or quasi-experimental studies published between January 1, 2004 and December 31, 2019 evaluating the effect of interventions on glycated haemoglobin (HbA1c) control. Characteristics of included studies and HbA1c difference between intervention and control arms (main outcome) were extracted. Interventions were grouped as: care management and patient education; nurse or certified diabetes educator (CDE); pharmacist; or physician-based. RESULTS Thirty-six studies including 22 243 individuals were combined in nonlinear random-effects meta-regressions; the median (range) duration of intervention was 1 year (0.9 to 36 months). Compared to the control arm, HbA1c reduction ranged from: -17.7 mmol/mol (-1.62%) to -4.4 mmol/mol (-0.40%) for nurse- or CDE-based interventions; -13.1 mmol/mol (-1.20%) to 3.3 mmol/mol (0.30%) for care management and patient education interventions; -9.8 mmol/mol (-0.90%) to -6.6 mmol/mol (-0.60%) for pharmacist-based interventions; and -4.4 mmol/mol (-0.40%) to 2.8 mmol/mol (0.26%) for physician-based interventions. Across the included studies, a reduction in HbA1c was observed only during the first year (6 months: -4.2 mmol/mol, 95% confidence interval [CI] -6.2, -2.2 [-0.38%, 95% CI -0.56, -0.20]; 1 year: -1.6 mmol/mol, 95% CI -3.3, 0.1 [-0.15%, 95% CI -0.30, 0.01]) and in individuals with preintervention HbA1c >75 mmol/mol (9%). CONCLUSIONS The most effective approaches to mitigating therapeutic inertia and improving HbA1c were those that empower nonphysician providers such as pharmacists, nurses and diabetes educators to initiate and intensify treatment independently, supported by appropriate guidelines.
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Affiliation(s)
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Leicester Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | - Xin Mei Chen
- American Diabetes Association, Arlington, Virginia, USA
| | | | - John Cuddeback
- AMGA (American Medical Group Association), Alexandria, Virginia, USA
| | - Robert A Gabbay
- American Diabetes Association, Arlington, Virginia, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Rajesh Mehta
- Healthagen, a CVS Health Company, Scottsdale, Arizona, USA
| | - Luigi Meneghini
- UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Kevin M Pantalone
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Paul Scribner
- American Diabetes Association, Arlington, Virginia, USA
| | - Jessica W Skelley
- Samford University, Department of Pharmacy Practice, Birmingham, Alabama, USA
| | - Kamlesh Khunti
- Leicester Real World Evidence Unit, Leicester Diabetes Research Centre, University of Leicester, Leicester, UK
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10
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Wrzal PK, Bunko A, Myageri V, Kukaswadia A, Neish CS, Ivers NM. Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review. Can J Diabetes 2020; 45:273-281.e13. [PMID: 33160883 DOI: 10.1016/j.jcjd.2020.08.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 12/17/2022]
Abstract
The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.
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Affiliation(s)
- Paulina K Wrzal
- Medical Affairs, Novo Nordisk Canada, Inc, Mississauga, Ontario, Canada.
| | - Andrean Bunko
- Real World Solutions, IQVIA, Mississauga, Ontario, Canada
| | - Varun Myageri
- Real World Solutions, IQVIA, Mississauga, Ontario, Canada
| | | | - Calum S Neish
- Real World Solutions, IQVIA, Mississauga, Ontario, Canada
| | - Noah M Ivers
- Department of Family Medicine, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada
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Abstract
Diabetes educators can be challenged by therapeutic inertia, as has been documented with other health care providers. There are many contributing factors related to the educators themselves, their patients, and the health care system in which they operate. To address this potentially significant barrier to quality patient care, diabetes educators can adopt numerous strategies to maximize their impact and address the factors contributing to therapeutic inertia in their practices.
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Affiliation(s)
- Carla Cox
- Mountain Vista Medicine, South Jordan, UT
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12
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Siminerio L, Hamm M, Kanter J, Cameron FDA, Krall J. A Diabetes Education Model in Primary Care: Provider and Staff Perspectives. DIABETES EDUCATOR 2019; 45:498-506. [DOI: 10.1177/0145721719865181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this qualitative study was to explore the effectiveness of Glucose to Goal (G2G), a diabetes self-management education and support (DSMES) model for primary care (PC). Methods PC providers and staff were recruited from 5 PC practices participating in the 18-month intervention to participate in focus groups and interviews, which were used to gain insights about their perspectives on DSMES and how G2G was implemented across the intervention. Data were collected by qualitative researchers at baseline, midpoint, and study completion. Results At baseline, PC participants held a favorable view of DSMES and welcomed having a diabetes educator (DE) in their practice. Most participants suggested DEs would be helpful in meeting patients’ nutrition needs but should give therapeutic advice only with a doctor’s oversight. Participants anticipated that having a DE onsite would mitigate transportation, scheduling, communication, and cost barriers. Participant viewpoints about G2G remained unchanged from midpoint to study end, while barriers regarding location and transportation were perceived as being reduced by having a DE in the practice. Despite referral rates remaining low in some practices, many concerns stated at earlier timepoints appeared to have been attenuated by G2G components (eg, bringing the DE onsite, preidentifying patients, and DE ability to communicate and make diabetes management recommendations). Conclusions This study demonstrates that G2G, providing DSMES in PC, appeared to be a welcome service where acceptance of and enthusiasm for the model grew over the course of the intervention.
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Affiliation(s)
| | - Megan Hamm
- University of Pittsburgh, Pittsburgh, Pennsylvania
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13
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Benson GA, Sidebottom A, Hayes J, Miedema MD, Boucher J, Vacquier M, Sillah A, Gamam S, VanWormer JJ. Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes. J Acad Nutr Diet 2019; 119:585-598. [DOI: 10.1016/j.jand.2018.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
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14
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Ni Y, Liu S, Li J, Dong T, Tao L, Yuan L, Yang M. The Effects of Nurse-Led Multidisciplinary Team Management on Glycosylated Hemoglobin, Quality of Life, Hospitalization, and Help-Seeking Behavior of People with Diabetes Mellitus. J Diabetes Res 2019; 2019:9325146. [PMID: 31934593 PMCID: PMC6942811 DOI: 10.1155/2019/9325146] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/13/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the effect of community-nurse-led multidisciplinary team management on glycosylated hemoglobin (HbA1c), quality of life (QOL), hospitalization, and help-seeking behavior in people with type 2 diabetes mellitus (DM). METHODS A quasi-experimental trial was conducted among people with type 2 DM from two community centers in China. The intervention group (n = 88) received community-nurse-led multidisciplinary team management for 2 years, while the control group (n = 91) received usual care. Data regarding HbA1c, QOL (assessed by the SF-36), hospitalization, and help-seeking behavior were collected at baseline and at 6, 12, and 24 months. RESULTS During the 24-month project, the intervention group demonstrated 1.08% reduction in HbA1c, whereas the control group achieved an increase of 0.45%. The differences between the two groups were statistically significant (P < 0.001). The intervention group showed greater increased in QOL scores (from 66.43 to 70.47, P < 0.001), more decrease in hospitalization (OR = 2.981, 95% CI: 1.016, 8.752 versus OR = 1.189, 95% CI: 0.411, 3.444; P = 0.028) when compared with the control group. The percentage increase of seeking help from nurses in the intervention group (from 12.5% to 57.3%, P < 0.001) was significantly greater than that in the control group after the intervention. CONCLUSIONS Nurse-led multidisciplinary team management is an effective intervention for improving glycemic control, QOL, hospitalization, and help-seeking behavior for people with DM in a community.
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Affiliation(s)
- Yunxia Ni
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Suzhen Liu
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Jiping Li
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Ting Dong
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Lin Tao
- West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Li Yuan
- Department of Endocrinology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Meilan Yang
- Yulin Community Health Service Center, Chengdu, Sichuan Province, China
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