Implementing diabetes care guidelines in long term care

Assessment of Glycemic Control in Nursing Home Residents with Diabetes

OBJECTIVE

To describe glycemic control in nursing home residents with diabetes and to evaluate the relevance of HbA1c in the detection of hypoglycemia risk.

DESIGN AND METHODS

Diabetes treatment, geriatric assessment, blood capillary glucose (n= 24,682), and HbA1c were collected from medical charts of 236 southern France nursing home residents during a 4-month period. Glycemic control was divided into four categories: tight, fair, and moderate or severe chronic hyperglycemia using the High Blood Glucose Index or the analysis of blood glucose frequency distribution. Hypoglycemia episodes were identified by medical or biological records.

RESULTS

Glucose control was tight in 59.3 % and fair in 19.1 % of the residents. Chronic exposure to hyperglycemia was observed in 21.6 % of the residents (severe in 9.7 % and moderate in 11.9 %). Hypoglycemia was noticed in 42/236 (17.8%), in all categories of glycemic control. Relative hypoglycemia risk was significantly (P = 0.0095) higher in residents with moderate chronic hyperglycemia compared with those with tight control. The majority of residents with hypoglycemia (39/42) or chronic hyperglycemia (45/51) were insulin-treated. The relative risk of hypoglycemia was not significantly associated with HbA1c values.

CONCLUSION

Hypoglycemia risk in nursing home residents is observed in all categories of glycemic control. In tight control, the potency of antidiabetic treatment should be reduced. In chronic hyperglycemia, diet and treatment should be reevaluated in order to reduce glucose variability. HbA1c is not sufficient for hypoglycemia risk detection; capillary blood glucose monitoring is warranted for nursing homes residents with diabetes.

Diabetes knowledge in nursing homes and home-based care services: a validation study of the Michigan Diabetes Knowledge Test adapted for use among nursing personnel

BACKGROUND

Providing high-quality diabetes care in nursing homes and home-based care facilities requires suitable instruments to evaluate the level of diabetes knowledge among the health-care providers. Thus, the aim of this study was to examine the psychometric properties of the Michigan Diabetes Knowledge Test adapted for use among nursing personnel.

METHODS

The study included 127 nursing personnel (32 registered nurses, 69 nursing aides and 26 nursing assistants) at three nursing homes and one home-based care facility in Norway. We examined the reliability and content and construct validity of the Michigan Diabetes Knowledge Test.

RESULTS

The items in both the general diabetes subscale and the insulin-use subscale were considered relevant and appropriate. The instrument showed satisfactory properties for distinguishing between groups. Item response theory-based measurements and item information curves indicate maximum information at average or lower knowledge scores. Internal consistency and the item-total correlations were quite weak, indicating that the Michigan Diabetes Knowledge Test measures a set of items related to various relevant knowledge topics but not necessarily related to each other.

CONCLUSIONS

The Michigan Diabetes Knowledge Test measures a broad range of topics relevant to diabetes care. It is an appropriate instrument for identifying individual and distinct needs for diabetes education among nursing personnel. The knowledge gaps identified by the Michigan Diabetes Knowledge Test could also provide useful input for the content of educational activities. However, some revision of the test should be considered.

Management of patients with type 2 diabetes and multiple chronic conditions: A Delphi consensus of the Spanish Society of Internal Medicine

AIMS

To develop consensus-based recommendations for the management of chronic complex patients with type 2 diabetes mellitus using a two round Delphi technique.

METHODS

Experts from the Diabetes and Obesity Working Group (DOWG) of the Spanish Society of Internal Medicine (SEMI) reviewed MEDLINE, PubMed, SCOPUS and Cochrane Library databases up to September 2014 to gather information on organization and health care management, stratification of therapeutic targets and therapeutic approach for glucose control in chronic complex patients with type 2 diabetes mellitus. A list of 6 recommendations was created and rated by a panel of 75 experts from the DOWG by email (first round) and by open discussion (second round). A written document was produced and sent back to DOWG experts for clarification purposes.

RESULTS

A high degree of consensus was achieved for all recommendations summarized as 1) there is a need to redesign and test new health care programs for chronic complex patients with type 2 diabetes mellitus; 2) therapeutic targets in patients with short life expectancy should be individualized in accordance to their personal, clinical and social characteristics; 3) patients with chronic complex conditions and type 2 diabetes mellitus should be stratified by hypoglycemia risk; 4) age and specific comorbidities should guide the objectives for glucose control; 5) the risk of hypoglycemia should be a key factor when choosing a treatment; and 6) basal insulin analogs compared to human insulin are cost-effective options.

CONCLUSION

The assessment and recommendations provided herein represent our best professional judgment based on current data and clinical experience.

Optimal glycaemic control in elderly people with type 2 diabetes: what does the evidence say?

The global prevalence of type 2 diabetes mellitus (T2DM) is rising in an ageing population through a combination of lifestyle changes and greater longevity. However, by excluding participants aged over 70 years, most major interventional trials on which current diabetes therapeutic guidelines are based have failed to provide specific evidence to support the prescribed management of diabetes in elderly people. While diabetes per se has a significant impact on the elderly person, the side effects of medications, particularly hypoglycaemia, prevent optimisation of diabetes treatment. Hypoglycaemia is associated with significant morbidity, to which elderly people are often more vulnerable because of factors such as the effects of ageing, progressive renal impairment, frailty, polypharmacy and cognitive decline. T2DM is associated with accelerated cognitive decline in some individuals, and recurrent severe hypoglycaemia has been implicated as a potential contributory factor. Although the evidence for selection of appropriate glycaemic targets in elderly patients is sparse, it is now acknowledged that prevention of hypoglycaemia must influence individualisation of treatment goals in this vulnerable group. This should also be reflected by the choice of anti-diabetes agents that are initiated when diet and lifestyle advice is ineffective. Recently developed international guidelines, which have specifically addressed the management of diabetes in elderly people, highlight the importance of a pragmatic management approach rather than attempting to achieve a generic glycated haemoglobin goal and are summarised in this article.

Trends in guideline implementation: a scoping systematic review

BACKGROUND

There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers.

METHODS

A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies.

RESULTS

The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies.

CONCLUSIONS

While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.