Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of healthcare interventions in primary care and community settings

Predicting control of cardiovascular disease risk factors in South Asia using machine learning

A substantial share of patients at risk of developing cardiovascular disease (CVD) fail to achieve control of CVD risk factors, but clinicians lack a structured approach to identify these patients. We applied machine learning to longitudinal data from two completed randomized controlled trials among 1502 individuals with diabetes in urban India and Pakistan. Using commonly available clinical data, we predict each individual's risk of failing to achieve CVD risk factor control goals or meaningful improvements in risk factors at one year after baseline. When classifying those in the top quartile of predicted risk scores as at risk of failing to achieve goals or meaningful improvements, the precision for not achieving goals was 73% for HbA1c, 30% for SBP, and 24% for LDL, and for not achieving meaningful improvements 88% for HbA1c, 87% for SBP, and 85% for LDL. Such models could be integrated into routine care and enable efficient and targeted delivery of health resources in resource-constrained settings.

The Role of Primary Care in Achieving Life's Essential 8: A Scientific Statement From the American Heart Association

To reduce morbidity and mortality rates of cardiovascular disease, an urgent need exists to improve cardiovascular health among US adults. In 2022, the American Heart Association issued Life's Essential 8, which identifies and defines 8 health behaviors and factors that, when optimized through a combination of primary prevention, risk factor management, and effective treatments, can promote ideal cardiovascular health. Because of its central role in patient care across the life span, primary care is in a strategic position to promote Life's Essential 8 and improve cardiovascular health in the United States. High-quality primary care is person-centered, team-based, community-aligned, and designed to provide affordable optimized health care. The purpose of this scientific statement from the American Heart Association is to provide evidence-based guidance on how primary care, as a field and practice, can support patients in implementing Life's Essential 8. The scientific statement aims to describe the role and functions of primary care, provide evidence for how primary care can be leveraged to promote Life's Essential 8, examine the role of primary care in providing access to care and mitigating disparities in cardiovascular health, review challenges in primary care, and propose solutions to address challenges in achieving Life's Essential 8.

Effectiveness of a multicomponent healthcare intervention on blood pressure and lipids among subjects with poorly controlled type 2 diabetes: Findings from the INTEGRA study

AIM

We aimed to evaluate the impact of a multicomponent healthcare intervention, primarily designed to improve glycemic control, on blood pressure and lipids in individuals with poorly controlled type 2 diabetes mellitus (T2DM) in the Catalonian primary care setting METHODS: A cluster, non-randomized, controlled pragmatic trial was conducted across 11 primary care centers. The intervention group (N=225) received a comprehensive, patient-centered approach, including a dedicated monographic consultation to address therapeutic inertia. The control group (N=181) mirrored the intervention group but lacked the monographic consultation. Secondary endpoints included lipid and blood pressure control assessed at baseline and after a 12-month follow-up.

RESULTS

245 participants completed the study over 12 months. We found no differences in the reduction of lipid laboratory parameters between the groups at the final visit. However, no significant differences were found between the groups for other lipids or the proportion of participants achieving lipid target values. Likewise, no differences were noted between the groups for blood pressure, its target control, and treatment at the final visit. Various clinical factors such as age, sex, diabetes duration, HbA1c levels, BMI, and macrovascular complications among the participants were associated with achieving lipid and blood pressure targets at the final visit.

CONCLUSION

The pragmatic multicomponent intervention proposed in the INTEGRA study, showed that including a component designed to reduce clinical inertia in the management of glycemia did not demonstrate benefits in improving lipids and blood pressure in patients with poorly controlled T2DM.

Healthcare workers' views on type 2 diabetes mellitus management at selected clinics in Mthatha

BACKGROUND

 Diabetes is a non-communicable disease of global public health importance. Healthcare workers play a vital role in the management of this disease.

AIM

 This study aimed to explore healthcare workers' views on managing patients with type 2 diabetes at primary health care facilities.

SETTING

 The study was conducted at two primary health care facilities in Mthatha, South Africa.

METHODS

 This exploratory descriptive qualitative study included 28 primary health care workers. Data were collected through individual interviews and focus group discussions and analysed using a thematic analysis approach.

RESULTS

 Study participants' views of poor control of type 2 diabetes mellitus were categorised under patient- and healthcare system-related factors. The patient-related factors included poor adherence to an ideal diabetic diet, poor medication adherence, a lack of personal glucometers, and dearth of support systems. The healthcare system-related factors identified were inadequate patient education, long waiting times at the health facilities, high patient volumes, limited resources, and delayed service provision. Proposed solutions to address poor control of diabetes included improving patient health education, providing diabetic patients with glucometers, multi-stakeholder management of diabetes, allocating designated areas for patients with chronic illnesses, improved resource allocation, and regular staff training.

CONCLUSION

 Study participants perceived an improved level of control of diabetes among patients managed at the Community Health Centres. When designing interventions for the management of diabetes, both patient and healthcare system-related factors and the proposed solutions should be considered.Contribution: This study's findings could promote better management of diabetes at the primary health care level.

How Would You Manage This Patient With Type 2 Diabetes and Chronic Kidney Disease? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Nearly 15% of U.S. adults have diabetes; type 2 diabetes (T2D) accounts for more than 90% of cases. Approximately one third of all patients with diabetes will develop chronic kidney disease (CKD). All patients with T2D should be screened annually for CKD with both a urine albumin-creatinine ratio and an estimated glomerular filtration rate. Research into strategies to slow the worsening of CKD and reduce renal and cardiovascular morbidity in patients with T2D and CKD has evolved substantially. In 2022, a consensus statement from the American Diabetes Association and the Kidney Disease: Improving Global Outcomes recommended prioritizing the use of sodium-glucose cotransporter-2 inhibitors and metformin and included guidance for add-on therapy with glucagon-like peptide 1 receptors agonists for most patients whose first-line therapy failed. It also recommended nonsteroidal mineralocorticoid receptor antagonists for patients with hypertension that is not adequately controlled with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Here, an endocrinologist and a nephrologist discuss the care of patients with T2D and CKD and how they would apply the consensus statement to the care of an individual patient with T2D who is unaware that he has CKD.

Quality of life, stress, anxiety and depression and associated factors among people with type 2 diabetes mellitus in Western region Saudi Arabia

Introduction

The objective of this study is to evaluate the quality of life (QoL), depression, anxiety, and stress, along with associated factors among individuals with diabetes in Saudi Arabia.

Methods

This survey was conducted at King Abdulaziz University (KAU), Jeddah, Kingdom of Saudi Arabia (KSA). The assessment of depression, anxiety, and stress related to Type 2 Diabetes Mellitus (T2DM) was conducted using the DASS-21 questionnaire, while diabetes-related QoL was evaluated using the revised version of the diabetes QoL questionnaire (RV-DQoL13). Data were analyzed using SPSS-26.

Results

A total of 251 subjects were included in the study (165 [65.7%] males and 86 [34.3%] females, mean age 50.1 ± 14.5 years). The individuals with DM had a mean value of QoL of 29.16 ± 9.23, with 46.9% having poor QoL. Furthermore, in dimensions of QoL, almost half of the individuals reported high worry about the disease (49.6%), followed by a high diabetes impact (46.6%) and low life satisfaction (42.9%). The prevalence of depression, anxiety, and stress was 49.4, 71.7, and 49.8%, respectively. A significant correlation was found between depression, anxiety, and stress and DASS-21 scores with QoL (p < 0.001). The regression analysis indicated an association of distinct factors with QoL like age above 41 years (p = 0.004), being married (p < 0.001), being divorced (p = 0.04), higher education (p = 0.007), regular medicine intake (p = 0.01), regular exercise (p = 0.03), lipid profile (p = 0.01), HbA1c (p < 0.001), and DASS-21 scores (p < 0.001). Poor QoL score (TQoL score > 27) was significantly associated with depression, anxiety, and stress (p < 0.001). The participants with higher monthly income, shorter disease duration, regular medicine use, and altered lipid profile, and older subjects had a lower chance of depression, anxiety, and stress.

Conclusion

Approximately half of individuals with T2DM experienced poor QoL, while the prevalence rates for depression, anxiety, and stress were 49.4, 71.7, and 49.8%, respectively. Scores in the domains of impact, worry, and satisfaction were below optimal levels. Several factors were linked to QoL and depression, anxiety, and stress, and an association was observed between DASS-21 scores and QoL.

The effect of close and intensive therapeutic monitoring of patients with poorly controlled type 2 diabetes with different glycemic background

Patients with type 2 diabetes who have HbA1c values ≥ 10% have different previous glycemic trends, including new diagnosis of diabetes. We aimed to assess the efficacy of 3 months of intensive and facilitated antihyperglycemic treatment in patients with different glycemic backgrounds. In this observational study, patients with type 2 diabetes and poor glycemic control (indicated by an HbA1c level of > = 10%) were divided into groups based on their previous HbA1c levels (group 1; newly diagnosed type 2 diabetics, group 2; patients with previously controlled but now deteriorated HbA1c levels, group 3; patients whose HbA1c was not previously in the target range but was now above 10%, and group 4; patients whose HbA1c was above 10% from the start). Patients received intensive diabetes management with close monitoring and facilitated hospital visits. For further analysis, patients who were known to have previously had good metabolic control (either did not have diabetes or had previously had an HbA1c value < =7) and patients who had prior poor metabolic control were analyzed separately. Of the 195 participants [female, n = 84 (43.1%)], the median age was 54 years (inter-quantile range [IQR] = 15, min = 29, max = 80) and the median baseline HbA1c was 11.8% (IQR = 2.6%, min = 10%, max = 18.3%). The median duration of diabetes was 10 years (IQR = 9, min = 1, max = 35) when newly diagnosed patients were excluded. The ≥ 20% reduction in HbA1c at month 3 was observed in groups 1 to 4 in 97%, 88.1%, 69.1%, and 55.4%, respectively. The percentage of patients who achieved an HbA1c level of 7% or less was 60.6%, 38.1%, 16.4%, and 6.2% in the groups, respectively. The rate of those who achieved an HbA1c of 7% or less was nearly 50% of patients with type 2 diabetes mellitus who had previously had good metabolic control, whereas successful control was achieved in only 1 in 10 patients with persistently high HbA1c levels. Patients' glycemic history played an important role in determining their HbA1c levels at 3 months, suggesting that previous glycemic management patterns may indicate future success in diabetes control.

The prevalence of glycemic control in patients with type 2 diabetes treated with insulin: a systematic review and meta-analysis

OBJECTIVES

To estimate the overall prevalence of glycemic control among patients with type 2 diabetes (T2D) treated with insulin.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search was performed in PubMed, EMBASE, Cochrane CENTRAL, and ProQuest Dissertation and Theses from 2000 to January 2022. Cross-sectional studies were included if they were conducted on more than 292 patients with T2D and reported the number of insulin-treated patients who were justified as achieving glycemic control. The Joanna Briggs Institute critical appraisal checklist was used to assess the quality of the included studies. Pooled estimates of the prevalence of glycemic control were calculated and reported with a 95% confidence interval (95% CI) using a random-effects model. All analyses were conducted using RStudio Version 2022.02.0, Build 443 (meta package).

RESULTS

A total of 42 studies (234,345 patients) met the inclusion criteria and were classified as having a low risk of bias. The overall estimated prevalence of glycemic control to insulin therapy among patients with T2D was 26.02% (95% CI: 23.17, 29.08). A subgroup of 34 studies that set the target HbA1c <7% showed that 23.75% (95% CI: 21.47, 26.18) of patients with T2D treated with insulin were justified as achieving good glycemic control.

CONCLUSIONS

This study provided summative evidence that glycemic control among patients with T2D treated with insulin was suboptimal and should be appropriately addressed.

A multicomponent health care intervention is associated with improved glycaemic control in subjects with poorly controlled type 2 diabetes compared with routine care: The INTEGRA study

AIM

The INTEGRA study evaluated whether a specially designed multicomponent health care intervention improved glycaemic control in subjects with poorly controlled type 2 diabetes compared with standard of care practice.

RESEARCH DESIGN AND METHODS

Pragmatic study in subjects from primary care centres with type 2 diabetes and glycated haemoglobin (HbA1c) >9% (75 mmol/mol). The multifaceted intervention (N = 225 subjects) included a diabetes-focused visit encouraging therapeutic intensification by health care professionals. Retrospective data from matched controls (N = 675) were obtained from electronic medical records of a primary care database. The primary outcome was to compare the change in HbA1c values between the groups at 12 months of follow-up.

RESULTS

The mean HbA1c decreased substantially in both groups after 3 months, and the mean reduction was significantly greater in the intervention group than in the usual care group after 12 months [mean difference -0.66% (-7 mmol/mol), 95% CI -0.4, -1.0; p < .001]. A larger percentage of participants in the intervention group achieved HbA1c <7% and <8% goals (15.5% vs. 5.3% and 29.3% vs. 13.5%, respectively; p < .001). The improvement in HbA1c levels was sustained throughout the study only in the intervention arm. Glucose-lowering therapy was more frequently intensified in patients in the intervention group at the initial and final time points of the study (between 0-3 and 6-12 months; p < .001), with a significant increase in the number of patients prescribed ≥2 antidiabetic therapies (p < .001).

CONCLUSIONS

A multifaceted intervention oriented at reducing therapeutic inertia by primary care physicians was associated with greater improvement in glycaemic control compared with patients treated as per usual care.

The impact of health literacy interventions on glycemic control and self-management outcomes among type 2 diabetes mellitus: A systematic review

Diabetes imposes an increasing health and economic burden on individuals living with it and their societies worldwide. Glycemic control is necessary to reduce morbidity and mortality of type 2 diabetes mellitus (T2DM). Self-management is the primary tool for managing diabetes. Health literacy (HL) is the primary driver of self-management activities. The aim of this review is to evaluate the impact of HL interventions on glycemic control and self-management outcomes among T2DM. MEDLINE, CINAHL, PubMed, Cochrane, Scopus, and Web of Science were searched for eligible papers. Fifteen randomized controlled trials published in English between 1997 and 2021, used HL-driven intervention, and measured the level of glycohemoglobin A1c (HbA1c) and self-management of T2DM patients were included in this review. The findings showed that HL-driven intervention had a positive impact on glycemic control and improved self-management behaviors. The level of glycemic control and self-management skills were improved through individual and telephone-based intervention respectively. Community worker-led interventions were effective in improvements in diabetes knowledge and self-care behaviors; however, nurse-led interventions were effective in glycemic control. Better glycemic control is achieved in hospital settings compared to outpatient settings. HL interventions yielded better improvement in self-management among people with longer diabetes duration (more than 7 years). It was possible to achieve a large reduction in HbA1c level after a 3-month intervention in hospital settings. HL-driven interventions are effective in glycemic and diabetes self-management outcomes.

Impact of a multicomponent healthcare intervention on glycaemic control in subjects with poorly controlled type 2 diabetes: The INTEGRA study

AIM

To evaluate whether a specially designed multicomponent healthcare intervention improves glycaemic control in subjects with poorly controlled type 2 diabetes.

MATERIALS AND METHODS

A cluster, non-randomized, controlled, pragmatic trial in subjects from 11 primary care centres with type 2 diabetes and HbA1c of more than 9% (> 75 mmol/mol) was conducted. The intervention (N = 225 subjects) was professional and patient-centred, including a dedicated monographic visit that encouraged therapeutic intensification by physicians. The sham control (N = 181) was identical to that of the intervention group except that the dedicated visit was omitted. The primary outcome was to compare the reductions in HbA1c values between the groups at 12 months of follow-up.

RESULTS

The mean age at baseline was 59.5 years, mean diabetes duration was 10.7 years and mean HbA1c was 10.3% (89.0 mmol/mol). Patients in the intervention arm achieved significantly greater HbA1c reduction than those in the sham control group at 12 months (mean difference -0.62%, 95% CI = -0.2%, -1.04%; P = .002). A larger percentage of intervention participants achieved an HbA1c of less than 8% (44.8% vs. 25.5%; P = .003) and were more frequently treated with more than three antidiabetic therapies (14.4% vs. 3.5%; P = .0008). Intervention was the only variable associated with higher odds of HbA1c less than 8% (odds ratio = 2.52; 95% CI = 1.54-4.12; P < .001).

CONCLUSIONS

A multicomponent intervention including a dedicated visit oriented at reducing therapeutic inertia by primary care physicians can improve glycaemic control in poorly controlled patients with type 2 diabetes.

Characteristics of subjects with type 2 diabetes enrolled in randomized controlled trials and non-randomized controlled trials in Japan: A systematic review

AIMS/INTRODUCTION

This study aimed to understand the characteristics of type 2 diabetes subjects enrolled in randomized controlled trials (RCTs) and non-RCTs according to therapeutic regimens through systematic literature review.

MATERIALS AND METHODS

PubMed and the database of the Japanese Medical Abstract Society (ICHUSHI) were searched for studies published from 2010 to 2019 reporting the efficacy and safety of glucose-lowering drugs in Japanese individuals with suboptimally controlled type 2 diabetes, and therapeutic regimens, demographics and clinical characteristics at the baseline were extracted. We evaluated the treatment arms, not the placebo arms.

RESULTS

The literature searches identified 2,656 publications, 145 of which met all eligibility criteria and included 282 eligible arms. In the past 10 years, dipeptidyl peptidase-4 inhibitor was the most frequently studied in both RCTs and non-RCTs. Regarding the characteristics of enrolled subjects, sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide-1 receptor agonist have been studied more in relatively obese subjects, and insulin has been studied in higher proportion of subjects with disease duration ≥10 years. Most of the RCTs included subjects aged 55-64 years, whereas a higher proportion of dipeptidyl peptidase-4 inhibitor and insulin arms in the non-RCTs included those aged ≥65 years. Dipeptidyl peptidase-4 inhibitor and sodium-glucose cotransporter 2 inhibitor were evaluated in subjects with no abnormalities in blood pressure or lipid parameters; however, only a few reports of those parameters have been assessed with glucagon-like peptide-1 receptor agonist and insulin.

CONCLUSIONS

As RCTs and non-RCTs differ in the baseline characteristics of type 2 diabetes subjects, it is necessary to integrate and evaluate both to understand the actual treatment status of type 2 diabetes.

Laughter yoga as an enjoyable therapeutic approach for glycemic control in individuals with type 2 diabetes: A randomized controlled trial

BACKGROUND

Laughter has been reported to have various health benefits. However, data on the long-term effects of laughter interventions on diabetes are limited. This study aimed to investigate whether laughter yoga can improve glycemic control among individuals with type 2 diabetes.

METHODS

In a single-center, randomized controlled trial, 42 participants with type 2 diabetes were randomly assigned to either the intervention or the control group. The intervention consisted of a 12-week laughter yoga program. Hemoglobin A1c (HbA1c), body weight, waist circumference, psychological factors, and sleep duration were evaluated at baseline and week 12.

RESULTS

Intention-to-treat analysis showed that participants in the laughter yoga group experienced significant improvements in HbA1c levels (between-group difference: -0.31%; 95% CI -0.54, -0.09) and positive affect scores (between-group difference: 0.62 points; 95% CI 0.003, 1.23). Sleep duration tended to increase in the laughter yoga group with a between-group difference of 0.4 hours (95% CI -0.05, 0.86; P = 0.080). The mean attendance rate for laughter yoga program was high (92.9%).

CONCLUSIONS

A 12-week laughter yoga program is feasible for individuals with type 2 diabetes and improves glycemic control. These findings suggest that having fun could be a self-care intervention. Further studies with larger numbers of participants are warranted to better evaluate the effects of laughter yoga.

CLINICAL TRIAL REGISTRATION

http://www.chinadrugtrials.org.cn, identifier UMIN000047164.

The effect of virtual specialist conferences between endocrinologists and general practitioners about type 2 diabetes: study protocol for a pragmatic randomized superiority trial

BACKGROUND

To support the primary care sector in delivering high-quality type 2 diabetes (T2D), literature reviews emphasize the need for implementing models of collaboration that in a simple and effective way facilitate clinical dialogue between general practitioners (GPs) and endocrinologists. The overall aim of the project is to evaluate if virtual specialist conferences between GPs and endocrinologists about patients living with T2D is clinically effective and improves diabetes competences and organization in general practice in comparison to usual practice.

METHODS

A prospective, pragmatic, and superiority RCT with two parallel arms of general practices in the Municipality of Aarhus, Denmark. All general practices are invited (n = 100). The intervention runs for 12 months and consists of four virtual conferences between endocrinologists and an individual general practice. Before the first conference, an introductory webinar teaches GPs about how to use an IT-platform to identify and manage T2D patients. The main analysis (month 12) concerns the difference between the intervention and control arm. It is expected that the virtual conferences at the patient level will improve adherence to international recommendations on diabetes medication for T2D patients and improve the risk profile with a reduction in glycated haemoglobin, blood pressure, and cholesterol. The study design allows for identifying a significant difference between the intervention (n = 15) and control group (n = 15) regarding the three primary clinical outcomes with a power of 0.8870-0.9941. At the general practice level, it is expected that general practitioners and practice staff in the intervention group will improve self-reported diabetes competence and organization. The control arm will get the intervention when the primary intervention ends (months 12-24), and the intervention arm transitions to a maintenance phase.

DISCUSSION

The potential of virtual conferences is yet to be fully tapped because of methodological limitations. Studies have also not yet systematically evaluated virtual conferences in the context of chronic care using a high-quality research design. Given the nature of this real-life intervention, general practitioners and endocrinologists cannot be blinded to their allocation to either the intervention or comparison arm.

TRIAL REGISTRATION

ClinicalTrials.gov, United States National Institutes of Health trial ID: NCT05268081. Registered on 4 March 2022.

Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis

BACKGROUND

Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes.

METHODS

PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ2 and I2 test statistics. Overall effects were evaluated using Z statistic.

RESULTS

A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI.

CONCLUSIONS

CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA1c is ≥8% and with interventions containing four or more CCM elements.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO  CRD42021273959.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care

PURPOSE

Primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team nurses and pharmacists to improve diabetes care.

METHODS

Using a retrospective, interrupted-time series design, we evaluated the EPCD model's impact on D5, a publicly reported composite quality measure of diabetes care: glycemic control, blood pressure control, low-density lipoprotein control, tobacco abstinence, and aspirin use. We examined 32 primary care practices in an integrated health care system that cares for adults with diabetes; practices were categorized as staff clinician practices (having physicians and advanced practice providers) with access to EPCD (5,761 patients); resident physician practices with access to EPCD (1,887 patients); or staff clinician practices without access to EPCD (10,079 patients). The primary outcome was the percentage of patients meeting the D5 measure, compared between a 7-month preimplementation period and a 10-month postimplementation period.

RESULTS

After EPCD implementation, staff clinician practices had a significant improvement in the percentage of patients meeting the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005; P = .01). Trends in D5 attainment did not change significantly among the resident physician practices with access to EPCD (P = .14) and worsened among the staff clinician practices without access to EPCD (change in incident rate ratio from 1.001 to 0.994; P = .05).

CONCLUSIONS

Implementation of the EPCD team model was associated with an improvement in diabetes care quality in the staff clinician group having access to this model. Further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Glucose trajectory prediction by deep learning for personal home care of type 2 diabetes mellitus: modelling and applying

Glucose management for people with type 2 diabetes mellitus is essential but challenging due to the multi-factored and chronic disease nature of diabetes. To control glucose levels in a safe range and lessen abnormal glucose variability efficiently and economically, an intelligent prediction of glucose is demanding. A glucose trajectory prediction system based on subcutaneous interstitial continuous glucose monitoring data and deep learning models for ensuing glucose trajectory was constructed, followed by the application of personalised prediction models on one participant with type 2 diabetes in a community. The predictive accuracy was then assessed by RMSE (root mean square error) using blood glucose data. Changes in glycaemic parameters of the participant before and after model intervention were also compared to examine the efficacy of this intelligence-aided health care. Individual Recurrent Neural Network model was developed on glucose data, with an average daily RMSE of 1.59 mmol/L in the application segment. In terms of the glucose variation, the mean glucose decreased by 0.66 mmol/L, and HBGI dropped from 12.99 × 10² to 9.17 × 10². However, the participant also had increased stress, especially in eating and social support. Our research presented a personalised care system for people with diabetes based on deep learning. The intelligence-aided health management system is promising to enhance the outcome of diabetic patients, but further research is also necessary to decrease stress in the intelligence-aided health management and investigate the stress impacts on diabetic patients.

Effectiveness of integrated care interventions for patients with long-term conditions: a review of systematic reviews

To examine the effectiveness of integrated care intervention (ICI) models (stand-alone or combination of self-management, discharge management, case management and multidisciplinary teams models) targeting patients with one or more chronic conditions, and to identify outcome measures/indicators of effectiveness, we conducted a systematic review of published systematic reviews and meta-analyses. Included reviews comprise ICIs targeting adult patients with one or more long-term conditions. We searched MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews: 60 reviews were included in the final analysis; 28 reviews evaluated ICIs focused on self-management, 4 on case management, 10 on discharge management and 5 on multidisciplinary teams; 13 reviews assessed multiple interventions that were labelled as complex. Across all reviews, only 19 reviews included intervention with multiple ICIs. Overall, interventions with multiple components, compared with interventions with single components, were more likely to improve hospital use outcomes effectively. Clinical/lifestyle/condition-specific outcomes were more likely to be improved by self-management interventions. Outcome measures identified could be classified into three main categories: organisational, patient-centred and clinical/lifestyle/condition-specific. The findings of this review may provide inputs to future design and evaluation of ICIs.

Development of a Complex Intervention for Effective Management of Type 2 Diabetes in a Developing Country

There has been little focus on designing tailored diabetes management strategies in developing countries. The aim of this study is to develop a theory-driven, tailored and context-specific complex intervention for the effective management of type 2 diabetes at a tertiary care setting of a developing country. We conducted interviews and focus groups with patients, health professionals, and policymakers and undertook thematic analysis to identify gaps in diabetes management. The results of our previously completed systematic review informed data collection. We used the United Kingdom Medical Research Council framework to guide the development of the intervention. Results comprised 48 interviews, two focus groups with 11 participants and three co-design panels with 24 participants. We identified a lack of structured type 2 diabetes education, counselling, and collaborative care of type 2 diabetes. Through triangulation of the evidence obtained from data collection, we developed an intervention called VICKY (patient-centred collaborative care and structured diabetes education and counselling) for effective management of type 2 diabetes. VICKY comprised five components: (1) patient-centred collaborative care; (2) referral system for patients across transitions of care between different health professionals of the diabetes care team; (3) tools for the provision of collaborative care and documentation of care; (4) diabetes education and counselling by trained diabetes educators; and (5) contextualised diabetes education curriculum, educational materials, and documentation tools for diabetes education and counselling. Implementation of the intervention may help to promote evidence-based, patient-centred, and contextualised diabetes care for improved patient outcomes in a developing country.

Continuous Glucose Monitoring With Low-Carbohydrate Nutritional Coaching to Improve Type 2 Diabetes Control: Randomized Quality Improvement Program

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a leading cause of morbidity and mortality globally, with adverse health consequences largely related to hyperglycemia. Despite clinical practice guideline recommendations, effective pharmacotherapy, and interventions to support patients and providers, up to 60% of patients diagnosed with T2DM are estimated to have hemoglobin A_1c (HbA_1c) levels above the recommended targets owing to multilevel barriers hindering optimal glycemic control.

OBJECTIVE

The aim of this study is to compare changes in HbA_1c levels among patients with suboptimally controlled T2DM who were offered the opportunity to use an intermittently viewed continuous glucose monitor and receive personalized low-carbohydrate nutrition counseling (<100 g/day) versus those who received usual care (UC).

METHODS

This was a 12-month, pragmatic, randomized quality improvement program. All adult patients with T2DM who received primary care at a university-affiliated primary care clinic (N=1584) were randomized to either the UC or the enhanced care (EC) group. Within each program arm, we identified individuals with HbA_1c >7.5% (58 mmol/mol) who were medically eligible for tighter glycemic control, and we defined these subgroups as UC-high risk (UC-HR) or EC-HR. UC-HR participants (n=197) received routine primary care. EC-HR participants (n=185) were invited to use an intermittently viewed continuous glucose monitor and receive low-carbohydrate nutrition counseling. The primary outcome was mean change in HbA_1c levels from baseline to 12 months using an intention-to-treat difference-in-differences analysis comparing EC-HR with UC-HR groups. We conducted follow-up semistructured interviews to understand EC-HR participant experiences with the intervention.

RESULTS

HbA_1c decreased by 0.41% (4.5 mmol/mol; P=.04) more from baseline to 12 months among participants in the EC-HR group than among those in UC-HR; however, only 61 (32.9%) of 185 EC-HR participants engaged in the program. Among the EC-HR participants who wore continuous glucose monitors (61/185, 32.9%), HbA_1c was 1.1% lower at 12 months compared with baseline (P<.001). Interviews revealed themes related to EC-HR participants' program engagement and continuous glucose monitor use.

CONCLUSIONS

Among patients with suboptimally controlled T2DM, a combined approach that includes continuous glucose monitoring and low-carbohydrate nutrition counseling can improve glycemic control compared with the standard of care.

Effectiveness and economic impact of a diabetes education program among adults with type 2 diabetes in South Texas

BACKGROUND

The long-term growth and sustained high prevalence of obesity in the US is likely to increase the burden of Type 2 diabetes. Hispanic individuals are particularly burdened by a larger share of diabetes than non-Hispanic White individuals. Given the existing health disparities facing this population, we aimed to examine the effectiveness and potential cost savings of the Diabetes Education Program (DEP) offered as part of Healthy South Texas, a state-legislated initiative to reduce health disparities in 27 counties in South Texas with a high proportion of Hispanic adults.

METHODS

DEP is an 8-h interactive workshop taught in English and Spanish. After the workshop, participants receive quarterly biometric screenings and continuing education with a health educator for one year. Data were analyzed from 3859 DEP participants with Type 2 diabetes living in South Texas at five time points (baseline, 3-months, 6-months, 9-months, 12-months). The primary outcome variable of interest for study analyses was A1c. A series of independent sample t-tests and linear mixed-model regression analyses were used to identify changes over time. Two methods were then applied to estimate healthcare costs savings associated with A1c reductions among participants.

RESULTS

The majority of participants were ages 45-64 years (58%), female (60%), Hispanic (66%), and had a high school education or less (75%). At baseline, the average hemoglobin A1c was 8.57%. The most substantial reductions in hemoglobin A1c were identified from baseline to 3-month follow-up (P < 0.001); however, the reduction in A1c remained significant from baseline to 12-month follow-up (P < 0.001). The healthcare cost savings associated with improved A1c for the program was estimated to be between $5.3 to $5.6 million over a two to three year period.

CONCLUSION

Findings support the effectiveness of DEP with ongoing follow-up for sustained diabetes risk management. While such interventions foster clinical-community collaboration and can improve patient adherence to recommended lifestyle behaviors, opportunities exist to complement DEP with other resources and services to enhance program benefits. Policy makers and other key stakeholders can assess the lessons learned in this effort to tailor and expand similar initiatives to potentially at-risk populations.

TRIAL REGISTRATION

This community-based intervention is not considered a trial by ICMJE definitions, and has not be registered as such.

Evaluation of an mHealth-enabled hierarchical diabetes management intervention in primary care in China (ROADMAP): A cluster randomized trial

BACKGROUND

Glycemic control remains suboptimal in developing countries due to critical system deficiencies. An innovative mobile health (mHealth)-enabled hierarchical diabetes management intervention was introduced and evaluated in China with the purpose of achieving better control of type 2 diabetes in primary care.

METHODS AND FINDINGS

A community-based cluster randomized controlled trial was conducted among registered patients with type 2 diabetes in primary care from June 2017 to July 2019. A total of 19,601 participants were recruited from 864 communities (clusters) across 25 provinces in China, and 19,546 completed baseline assessment. Moreover, 576 communities (13,037 participants) were centrally randomized to the intervention and 288 communities (6,509 participants) to usual care. The intervention was centered on a tiered care team-delivered mHealth-mediated service package, initiated by monthly blood glucose monitoring at each structured clinic visit. Capacity building and quarterly performance review strategies upheld the quality of delivered primary care. The primary outcome was control of glycated hemoglobin (HbA1c; <7.0%), assessed at baseline and 12 months. The secondary outcomes include the individual/combined control rates of blood glucose, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C); changes in levels of HbA1c, BP, LDL-C, fasting blood glucose (FBG), and body weight; and episodes of hypoglycemia. Data were analyzed using intention-to-treat (ITT) generalized estimating equation (GEE) models, accounting for clustering and baseline values of the analyzed outcomes. After 1-year follow-up, 17,554 participants (89.8%) completed the end-of-study (EOS) assessment, with 45.1% of them from economically developed areas, 49.9% from urban areas, 60.5 (standard deviation [SD] 8.4) years of age, 41.2% male, 6.0 years of median diabetes duration, HbA1c level of 7.87% (SD 1.92%), and 37.3% with HbA1c <7.0% at baseline. Compared with usual care, the intervention led to an absolute improvement in the HbA1c control rate of 7.0% (95% confidence interval [CI] 4.0% to 10.0%) and a relative improvement of 18.6% (relative risk [RR] 1.186, 95% CI 1.105 to 1.267) and an absolute improvement in the composite ABC control (HbA1c <7.0%, BP <140/80 mm Hg, and LDL-C <2.6 mmol/L) rate of 1.9% (95% CI 0.5 to 3.5) and a relative improvement of 21.8% (RR 1.218, 95% CI 1.062 to 1.395). No difference was found on hypoglycemia episode and weight gain between groups. Study limitations include noncentralized laboratory tests except for HbA1c, and caution should be exercised when extrapolating the findings to patients not registered in primary care system.

CONCLUSIONS

The mHealth-enabled hierarchical diabetes management intervention effectively improved diabetes control in primary care and has the potential to be transferred to other chronic conditions management in similar contexts.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) IOC-17011325.

Is therapeutic inertia present in hyperglycaemia, hypertension and hypercholesterolaemia management among adults with type 2 diabetes in three health clinics in Malaysia? a retrospective cohort study

BACKGROUND

Good-quality evidence has shown that early glycaemic, blood pressure and LDL-cholesterol control in people with type 2 diabetes (T2D) leads to better outcomes. In spite of that, diseases control have been inadequate globally, and therapeutic inertia could be one of the main cause. Evidence on therapeutic inertia has been lacking at primary care setting. This retrospective cohort study aimed to determine the proportions of therapeutic inertia when treatment targets of HbA1c, blood pressure and LDL-cholesterol were not achieved in adults with T2D at three public health clinics in Malaysia.

METHODS

The index prescriptions were those that when the annual blood tests were reviewed. Prescriptions of medication were verified, compared to the preceding prescriptions and classified as 1) no change, 2) stepping up and 3) stepping down. The treatment targets were HbA1c < 7.0% (53 mmol/mol), blood pressure (BP) < 140/90 mmHg and LDL-cholesterol < 2.6 mmol/L. Therapeutic inertia was defined as no change in the medication use in the present of not reaching the treatment targets. Descriptive, univariable, multivariable logistic regression and sensitive analyses were conducted.

RESULTS

A total of 552 cohorts were available for the assessment of therapeutic inertia (78.9% completion rate). The mean (SD) age and diabetes duration were 60.0 (9.9) years and 5.0 (6.0) years, respectively. High therapeutic inertia were observed in oral anti-diabetic (61-72%), anti-hypertensive (34-65%) and lipid-lowering therapies (56-77%), and lesser in insulin (34-52%). Insulin therapeutic inertia was more likely among those with shorter diabetes duration (adjusted OR 0.9, 95% CI 0.87, 0.98). Those who did not achieve treatment targets were less likely to experience therapeutic inertia: HbA1c ≥ 7.0%: adjusted OR 0.10 (0.04, 0.24); BP ≥ 140/90 mmHg: 0.28 (0.16, 0.50); LDL-cholesterol ≥ 2.6 mmol/L: 0.37 (0.22, 0.64).

CONCLUSIONS

Although therapeutic intensifications were more likely in the presence of non-achieved treatment targets but the proportions of therapeutic inertia were high. Possible causes of therapeutic inertia were less of the physician behaviours but might be more of patient-related non-adherence or non-availability of the oral medications. These observations require urgent identification and rectification to improve disease control, avoiding detrimental health implications and costly consequences.

TRIAL REGISTRATION

Number NCT02730754 , April 6, 2016.

Shared decision making and patient-centeredness for patients with poorly controlled type 2 diabetes mellitus in primary care-results of the cluster-randomised controlled DEBATE trial

Background

We investigate whether an educational intervention of GPs increases patient-centeredness and perceived shared decision making in the treatment of patients with poorly controlled type 2 diabetes mellitus?

Methods

We performed a cluster-randomized controlled trial in German primary care. Patients with type 2 diabetes mellitus defined as HbA1c levels ≥ 8.0% (64 mmol/mol) at the time of recruitment (n = 833) from general practitioners (n = 108) were included. Outcome measures included subjective shared decision making (SDM-Q-9; scale from 0 to 45 (high)) and patient-centeredness (PACIC-D; scale from 1 to 5 (high)) as secondary outcomes. Data collection was performed before intervention (baseline, T0), at 6 months (T1), at 12 months (T2), at 18 months (T3), and at 24 months (T4) after baseline.

Results

Subjective shared decision making decreased in both groups during the course of the study (intervention group: -3.17 between T0 and T4 (95% CI: -4.66, -1.69; p < 0.0001) control group: -2.80 (95% CI: -4.30, -1.30; p = 0.0003)). There were no significant differences between the two groups (-0.37; 95% CI: -2.20, 1.45; p = 0.6847). The intervention's impact on patient-centeredness was minor. Values increased in both groups, but the increase was not statistically significant, nor was the difference between the groups.

Conclusions

The intervention did not increase patient perceived subjective shared decision making and patient-centeredness in the intervention group as compared to the control group. Effects in both groups might be partially attributed to the Hawthorne-effect. Future trials should focus on patient-based intervention elements to investigate effects on shared decision making and patient-centeredness.

Trial registration

The trial was registered on March 10^th, 2011 at ISRCTN registry under the reference ISRCTN70713571.

Population Health Management in Diabetes Care: Combining Clinical Audit, Risk Stratification, and Multidisciplinary Virtual Clinics in a Community Setting to Improve Diabetes Care in a Geographically Defined Population. An Integrated Diabetes Care Pilot in the North East Locality, Oxfordshire, UK

BACKGROUND

Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention.

DESCRIPTION OF THE CARE PRACTICE

Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification, and 3) the multi-disciplinary virtual clinics in the community.

METHODS

This paper evaluates the acceptability, feasibility and short-term impact on primary care of implementing a population approach intervention using direct observations of the clinics and surveys of participating clinicians.

RESULTS AND DISCUSSION

Eighteen virtual clinics across seven teams took place over six months between March and July 2017 with organisation, resources, policies, education and approximately 150 individuals discussed. The feedback from primary care was positive with growing knowledge and confidence managing people with complex diabetes in primary care.

CONCLUSION

Taking a population health approach helped to identify groups of people in need of additional diabetes care and deliver a collaborative health intervention across traditional organisational boundaries.

Determinants of glycaemic control among patients with type 2 diabetes: testing a process model based on self-determination theory

Aims

To investigate a hypothesised process model based on self-determination theory (SDT) in a population of people with type 2 diabetes. The model suggests that autonomy support from healthcare professionals is an important determinant of autonomous motivation and perceived competence in diabetes, which correlate positively in turn with wellbeing and negatively with HbA1c.

Methods

This cross-sectional study used baseline questionnaire data and HbA1c levels from a randomised controlled trial investigating the effects of a person-centred consultation program. The questionnaire used validated scales and items assessing autonomy support, wellbeing, motivation, self-care activities, diabetes distress and perceived competence. Pearson correlations were calculated, and mediation analysis was conducted by multivariate linear regression analysis.

Results

116 participants completed the questionnaire. Autonomy support was significantly correlated with perceived competence and controlled motivation. Perceived competence correlated negatively with diabetes distress and positively with self-care activities. Diabetes distress correlated negatively with wellbeing. Controlled motivation correlated positively with autonomous motivation, which correlated positively with both wellbeing and self-care activities. Self-care activities correlated negatively with HbA1c.

Conclusion

As suggested by the hypothesised SDT process model, autonomy support, autonomous motivation and perceived competence are associated with better wellbeing and improved HbA1c.

Immediate and Long-Term Effects of an 8-Week Digital Mental Health Intervention on Adults With Poorly Managed Type 2 Diabetes: Protocol for a Randomized Controlled Trial

Background

Diabetes is a leading cause of years of life lost and accounts for approximately one-fourth of health care dollars spent in the United States. Many of these costs are related to poor medication adherence and lack of self-care behaviors and are thus preventable. Depression, which is more prevalent among people with diabetes than in the general population, predicts poorer management of one’s diabetes, whereas positive affect predicts engaging in more positive health behaviors. Consequently, interventions that improve depression and positive affect may also improve diabetes-related outcomes among people with diabetes. Although preliminary research on the impact of such interventions among people with diabetes is promising, these studies focused primarily on in-person interventions, have had small samples, and lack long-term follow-up.

Objective

This study aims to examine the short- and long-term effects of a digital therapeutic platform focused on mental health among adults with poorly managed type 2 diabetes and elevated levels of depression.

Methods

This is a randomized controlled trial in which adults with a type 2 diabetes diagnosis, elevated hemoglobin A_1c (HbA_1c) levels (≧7), and moderate to severe depressive symptoms will be randomly assigned to a positive emotion regulation skills intervention group or a sham digital intervention with only psychoeducational content. The study will take place over 14 months, including the 8-week intervention (or control) delivered via a digital therapeutic platform (Happify Health) and follow-up assessments at 3, 6, and 12 months postintervention. Throughout the intervention and for 1 week at each postintervention follow-up, participants will complete daily assessments of diabetes-related distress, diabetes regimen adherence, and mood. Our primary outcome, HbA_1c, will be self-reported every 3 months throughout the study. Secondary and exploratory outcomes will be assessed at baseline; at 8 weeks; and at 3, 6, and 12 months postintervention.

Results

Recruitment is expected to begin in June 2020. Participants will begin the study as they are recruited and will finish in waves. The final wave of data collection from the 8-week intervention is expected for winter 2020, with the completion of the 12-month follow-up in winter 2021.

Conclusions

Although previous research suggests that in-person psychological interventions have promising effects on both psychological and physical outcomes among adults with diabetes, digital interventions can be advantageous because they are easily scalable and reduce many barriers that prevent people from seeking treatment. This trial will provide important information about the effects of a digital mental health intervention among adults with type 2 diabetes, assessing both short- and long-term effects of this intervention on HbA1c, depressive symptoms, and other diabetes-specific outcomes. If successful, this may introduce a scalable intervention that would help reduce some of the preventable costs associated with diabetes.

Trial Registration

ClinicalTrials.gov NCT04068805; https://clinicaltrials.gov/ct2/show/NCT04068805.

International Registered Report Identifier (IRRID)

PRR1-10.2196/18578

Community Outreach for Navajo People Living with Diabetes: Who Benefits Most?

INTRODUCTION

The Community Outreach and Patient Empowerment (COPE) intervention provides integrated outreach through community health representatives (CHRs) to people living with diabetes in Navajo Nation. The aim of this study was to identify groups for whom the intervention had the greatest effect on glycated hemoglobin A_1c (HbA_1c).

METHODS

We analyzed de-identified data extracted from routine health records dated from December 1, 2010, through August 31, 2014, to compare net change in HbA_1c among COPE patients and non-COPE patients. We used linear mixed models to assess whether the intervention was modified by age, sex, preferred language, having a primary care provider, baseline HbA_1c, or having a mental health condition.

RESULTS

Age, having a primary care provider, and baseline HbA_1c significantly modified HbA_1c levels. Among patients aged 64 or younger, COPE participation was associated with a net decrease in HbA_1c of 0.77%; among patients aged 65 or older, the net decrease was 0.49% (P = .03). COPE participation was associated with a steeper decrease in HbA_1c among patients without a primary care physician (net decrease, 0.99%) than among patients with a primary care provider (net decrease, 0.57%) (P = .03). COPE patients with a baseline HbA_1c >9% had a net decrease of 0.70%, while those with a baseline HbA_1c ≤9% had a net decrease of 0.34% (P = .01). We found no significant differences based on sex, preferred language, or having a mental health condition.

CONCLUSION

Findings suggest that the COPE intervention was robust and equitable, benefiting all groups living with diabetes in Navajo Nation, but conferring the greatest benefit on the most vulnerable.

Evaluation of a Community-Based Cardiovascular Prevention Program in Patients With Type 2 Diabetes

PURPOSE

An outcomes' evaluation of a community-based cardiovascular disease (CVD) prevention program in persons with newly diagnosed type 2 diabetes.

DESIGN

A prospective, observational study.

SETTING

A community-setting in Ireland.

PARTICIPANTS

Persons with newly diagnosed type 2 diabetes, aged 40 years or older, and 2 or more cardiovascular risk factors.

INTERVENTION

A 16-week community-based, cardiovascular prevention program, with health promotion seminars, group exercise, and individual consultations, delivered by a multidisciplinary team.

MEASURES

Medical, lifestyle, and well-being measures.

ANALYSIS

Changes in categorical and continuous variables were analyzed using the paired exact test and the t test/Wilcoxin matched-pairs test, respectively.

RESULTS

In total, 218 persons (134 men) participated, mean age was 59.8 (10.2) years. Completion rate was 75.2% (n = 164). The proportion achieving target glycosylated hemoglobin (HbA_1c) increased from 53% at baseline to 75% (P < .001) at end of program. Systolic and diastolic blood pressures reduced by 8.8 mm Hg (95% CI: -11.2 to -6.4, P < .001) and 5.2 mm Hg (95% CI: -6.9 to -3.5, P < .001), respectively. Mean low-density lipoprotein cholesterol reduced from 2.45 to 2.05 mmol/L (P < .001). Significantly higher proportions met recommended targets in diet (6.9% vs 43.4%, P < .001) and physical activity (9.2% vs 56.6%, P < .001). Psychosocial measures significantly improved at end of program. The majority of improvements were sustained at 1 year.

CONCLUSION

Participation in this CVD prevention program was associated with significant improvements in glycemia and CVD risk factors in newly diagnosed patients with type 2 diabetes.

A Mixed Methods Evaluation of a Randomized Control Trial to Evaluate the Effectiveness of the Pure Prairie Living Program in Type 2 Diabetes Participants

The primary objective of this randomized control trial was to evaluate the effectiveness of the Pure Prairie Living Program (PPLP) in a primary care setting. Adults with type 2 diabetes were randomized into intervention (PPLP, n = 25) and wait-listed controls (CON, n = 24). The PPLP group participated in education sessions. The intervention yielded no significant within-group changes in HbA1c at three-month (-0.04 (-0.27 to 0.17) and -0.15 (-0.38 to 0.08)) or six-month (-0.09 (-0.41 to 0.22) and 0.06 (-0.26 to 0.38)) follow ups in either CON or PPLP groups, respectively. Dietary adherence scores improved in the PPLP group (p < 0.05) at three and six months but were not different in the between-group comparison. No changes in diabetes self-efficacy scores were detected. In the qualitative analysis, participants described the program as clear and easy to understand. Knowledge acquired influenced their everyday decision making but participants faced barriers that prevented them from fully applying what they learned. Healthcare professionals enjoyed delivering the program but described the "back-stage" workload as detrimental. In conclusion, while some positive effects of the PPLP intervention were observed, they were not comparable to those previously attained by our group in an academic setting or to what the guidelines recommend, which reflects the challenge of translating lifestyle intervention to real-world settings.

Cardiovascular risk factor control in British adults with diabetes mellitus: Retrospective cohort study

Using primary care electronic medical records (the United Kingdom Health Improvement Network Database 2003-2015), we examined the control of cardiovascular risk factors in the first year after diagnosis in British adults with diabetes mellitus. Among 292 170 individuals with diabetes receiving frequent outpatient management (median of 16 primary care visits in the prior year), control of cardiovascular risk factors a median of 354 days after diagnosis was suboptimal: 14.7% had HbA1C < 7%, SBP < 140 mm Hg, LDL cholesterol ≤1.8 mmol/L or taking a statin, and were nonsmokers (the proportion dropped to 7.5% if the SBP target was defined as <130 mm Hg). While 90.4% had an LDL cholesterol ≤1.8 mmol/L or were taking a statin, and 86.0% were nonsmokers, only 52.0% had HbA1C < 7% and 53.1% had SBP < 140 mm Hg (29.8% had SBP < 130 mm Hg) despite 71.4% taking antihypertensive agents. Thus, there is still a need for quality improvement strategies that target all atherosclerotic risk factors in individuals with diabetes and not just glycaemic control.

Improving empowerment, motivation, and medical adherence in patients with poorly controlled type 2 diabetes: A randomized controlled trial of a patient-centered intervention

OBJECTIVE

To test whether an intervention consisting of four patient-centered consultations improves glycemic control and self-management skills in patients with poorly regulated type 2 diabetes (T2DM), compared to a control group receiving usual care.

METHODS

Unblinded parallel randomized controlled trial including 97 adults diagnosed with T2DM ≥ 1 year and hemoglobin A1c (HbA1c) levels ≥ 8.0% (64 mmol/mol). Consultations incorporated tools supporting self-reflection, learning processes, and goal setting. Primary outcome was HbA1c. Secondary outcomes were autonomy support, motivation, self-management skills, and well-being.

RESULTS

Average HbA1c decreased slightly in both groups. Autonomy support and frequency of healthy eating were significantly higher in the intervention group. Most participants in the intervention group chose to set goals related to diet and physical exercise. Implementation of the intervention was inconsistent.

CONCLUSION

Despite increased autonomy support and individual goal-setting, the intervention was not superior to usual care in terms of glycemic control. More research is needed on how individual preferences and goals can be supported in practice to achieve sustainable behavior changes.

PRACTICE IMPLICATIONS

The intervention promoted participant engagement and supported exploration of participants' challenges and preferences. Further exploration of more flexible use of tools adapted to individual contexts is recommended.

The effects of an empowerment-based self-management intervention on empowerment level, psychological distress, and quality of life in patients with poorly controlled type 2 diabetes: A randomized controlled trial

BACKGROUND

There is considerable interest in advocating empowerment in diabetes care. Health professionals, however, often fail to realize empowerment in clinical practice, especially in patients with poorly controlled type 2 diabetes.

OBJECTIVES

To evaluate the effectiveness of an empowerment-based intervention on empowerment level, psychological distress, and quality of life among patients with poorly controlled type 2 diabetes.

DESIGN

An analysis of secondary outcomes of a prospective multi-center, randomized, parallel, investigator-blinded controlled trial.

METHODS

A total of 242 adult patients with poorly controlled type 2 diabetes [Hemoglobin A1c (HbA1c)≥ 58 mmol/mol in the recent six months] were randomly allocated to either intervention (n = 121) or attentional control (n = 121) groups. The design of the intervention was based on the Empowerment Process Model. The intervention group received a 6-week empowerment-based transitional care program, with significant emphasis on establishing personally meaningful goals, facilitating collaborative partnership and shared decision-making, resolving life-disease conflicts via situational reflection. Participants in the attentional control group received two general health education classes and post-discharge social calls on top of routine care. Outcomes of interest include empowerment level, diabetes distress, and quality of life. Participants were invited to complete a set of questionnaires before randomization, one-week, and three-month post-intervention. Statistical analyses were performed using the generalized estimating equations based on the intention-to-treat principle.

RESULTS

Comparing with the attention control group, participants in the intervention group showed significant improvements on empowerment level [(β= 0.163; 95% confidence interval (CI): 0.011 to 0.316, p = 0.036) at one-week post-intervention and (β= 0.176; 95% CI: 0.020 to 0.331, p = 0.027) at three-month post-intervention, respectively]. This group of patients also displayed significant reduction in terms of emotional-distress (β= -0.424, 95% CI: -0.798 to -0.049, p = 0.027) and regimen-distress (β= -0.397, 95% CI: -0.702 to -0.091, p = 0.011) at three-month post-intervention and physician-related distress (β= -0.236, 95% CI: -0.466 to -0.006, p = 0.044) at one-week post-intervention. Significant improvement in quality of life (β= 4.151, 95% CI: 1.291, 7.012, p = 0.004) at three-month post-intervention was also observed in the intervention group.

CONCLUSIONS

Findings provide empirical evidence for the values of an empowerment-based intervention program for patients with poorly controlled type 2 diabetes in increasing the empowerment level and perceived quality of life and reducing diabetes distress. Long-term effects of the intervention and its underlying mechanisms need further investigation.

Patient-centered communication and shared decision making to reduce HbA1c levels of patients with poorly controlled type 2 diabetes mellitus - results of the cluster-randomized controlled DEBATE trial

Background

Does an intervention designed to foster patient-centered communication and shared decision making among GPs and their patients with poorly controlled type 2 diabetes mellitus reduce the level of HbA1c.

Methods

The DEBATE trial is a cluster-randomized controlled trial conducted in German primary care and including patients with type 2 diabetes mellitus having an HbA1c level of 8.0% (64 mmol/mol) or above at the time of recruitment. Data was measured before intervention (baseline, T0), 6–8 months (T1), 12–14 months (T2), 18–20 months (T3), and 24–26 months (T4) after baseline. Main outcome measure is the level of HbA1c.

Results

In both, the intervention and the control group the decline of the HbA1c level from T0 to T4 was statistically significant (− 0.67% (95% CI: − 0.80,-0.54%; p < 0.0001) and − 0.64% (95% CI: − 0.78, − 0.51%; p < 0.0001), respectively). However, there was no statistically significant difference between both groups.

Conclusions

Although the DEBATE trial was not able to confirm effectiveness of the intervention tested compared to care as usual, the results suggest that patients with poorly controlled type 2 diabetes are able to improve their blood glucose levels. This finding may encourage physicians to stay on task to regularly approach this cohort of patients.

Trial registration

The trial was registered at ISRCTN registry under the reference ISRCTN70713571.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0977-9) contains supplementary material, which is available to authorized users.

Person-Centered Primary Care and Type 2 Diabetes: Beyond Blood Glucose Control

With an estimated 9% of persons in the United States diagnosed with diabetes, primary care providers such as midwives and nurse practitioners are increasingly working with persons who have diabetes and are seeking primary care services. This article reviews the current literature with regard to the initial evaluation of individuals who are diagnosed with diabetes, and what is entailed in comprehensive continuing management of care. A person-centered interprofessional approach to care of the person with diabetes is presented. Recommendations are given that address dietary habits, activities of daily living, medication regimens, and potential alternative therapies. Social constructs related to effective care of individuals with diabetes also are addressed. Knowledge of current research that has identified effective care practices for individuals with diabetes is imperative to ensuring their well-being, and promoting a person-centered and interprofessional approach is best for offering optimal care to those diagnosed with diabetes.

Patterns of Glycemic Variability During a Diabetes Self-Management Educational Program

Background: Variations in blood glucose levels over a given time interval is termed as glycemic variability (GV). Higher GV is associated with higher diabetes-related complications. The current study was done with the aim of detecting the sensitivity of various GV indices among individuals with type 2 diabetes mellitus of different glycemic control status. Methods: We performed a longitudinal study among individuals with type 2 diabetes mellitus (T2DM) who were participating in a two-week diabetes self-management education (DSME) program. Participants were categorized by their HbA1c as poor (≥8%), acceptable (7%–8%), and optimal control (<7%). Continuous glucose monitoring (CGM) sensors recorded interstitial glucose every 15 min from day 1. The evaluated GV measures include standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic excursion (MAGE), continuous overlapping net glycemic action (CONGA), mean of daily difference for inter-day variation (MODD), high blood glucose index (HBGI), and low blood glucose index (LBGI). Results: A total of 41 study participants with 46347 CGM values were available for analysis. Of 41 participants, 20 (48.7%) were in the poor, 10 (24.3%) in the acceptable, and 11 (26.8%) in the optimal control group. The GV indices (SD; CV; MODD; MAGE; CONGA; HBGI) of poorly controlled (77.43; 38.02; 45.82; 216.63; 14.10; 16.62) were higher than acceptable (50.02; 39.32; 30.79; 138.01; 8.87; 5.56) and optimal (34.15; 29.46; 24.56; 126.15; 8.67; 3.13) control group. Glycemic variability was reduced in the poorly and acceptably controlled groups by the end of the 2-week period. There was a rise in LBGI in the optimally controlled group, indicating pitfalls of tight glycemic control. Conclusion: Indices of glycemic variability are useful complements, and changes in it can be demonstrated within short periods.

Diabetes Canada 2018 clinical practice guidelines: Key messages for family physicians caring for patients living with type 2 diabetes

OBJECTIVE

To summarize the 2018 Diabetes Canada clinical practice guidelines, focusing on high-priority recommendations for FPs managing people who live with type 2 diabetes.

QUALITY OF EVIDENCE

A prioritization process was conducted to focus the efforts of Diabetes Canada's guideline dissemination and implementation efforts. The resulting identified key messages for FPs to consider when managing patients with type 2 diabetes are described. Evidence supporting the guideline recommendations ranges from levels I to IV and grades A to D.

MAIN MESSAGE

Three key messages were identified from the 2018 guidelines as priorities for FPs: discussing opportunities to reduce the risk of diabetes complications, discussing opportunities to ensure safety and prevent hypoglycemia, and discussing progress on self-management goals and addressing barriers. A theme cutting across these key messages was the need to tailor discussions to the needs and preferences of each person. These important guideline recommendations are highlighted, along with information about relevant tools for implementing the recommendations in real-world practice.

CONCLUSION

High-quality diabetes care involves a series of periodic conversations about self-management and about pharmacologic and nonpharmacologic treatments that fit with each patient's goals (ie, shared decision making). Incorporating these conversations into regular practice provides FPs with opportunities to maximize likely benefits of treatments and decrease the risk of harms, to support patients in initiating and sustaining desired lifestyle changes, and to help patients cope with the burdens of diabetes and comorbid conditions.

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Objectif

Résumer les lignes directrices de pratique clinique 2018 de Diabète Canada en s’attardant aux recommandations prioritaires pour les médecins de famille qui traitent des personnes vivant avec le diabète de type 2.

Qualité des données

Un processus de priorisation a été réalisé dans le but de canaliser les efforts de dissémination et de mise en oeuvre des lignes directrices de Diabète Canada. Il en a résulté une description des principaux messages à l’intention des médecins de famille qui soignent des patients de diabète de type 2. Les données étayant les recommandations des lignes directrices varient des niveaux I à IV, et des catégories A à D.

Message principal

Trois principaux messages prioritaires pour les médecins de famille ont été relevés dans les lignes directrices 2018 : parler des occasions de réduire le risque de complications du diabète, parler des occasions d’assurer la sécurité et de prévenir l’hypoglycémie, et parler des progrès vers l’atteinte des objectifs d’autoprise en charge et de l’élimination des obstacles. Ces principaux messages ont fait ressortir un thème : celui d’adapter les conversations aux besoins et aux préférences de chacun. Ces importantes recommandations sont mises en lumière, de même que l’information sur les outils pertinents pour mettre en oeuvre les recommandations en pratique réelle.

Conclusion

Les soins du diabète de grande qualité comprennent une série de conversations périodiques sur l’autoprise en charge, et sur les traitements pharmacologiques et non pharmacologiques adaptés aux objectifs de chaque patient (c.-à-d. prise de décision partagée). Lorsque les médecins de famille incorporent ces conversations dans la pratique régulière, ils ont la chance d’optimiser les bienfaits possibles du traitement et de réduire le risque d’effets nuisibles, d’encourager les patients à instaurer et à maintenir les modifications désirées du mode de vie, et de les aider à composer avec le fardeau du diabète et des comorbidités.

Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes

OBJECTIVE

Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A_1c (HbA_1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined.

RESEARCH DESIGN AND METHODS

The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA_1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA_1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices.

RESULTS

A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA_1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA_1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US$3086 annually per participant for averted hospitalizations were calculated.

CONCLUSIONS

Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes.

TRIAL REGISTRATION NUMBER

NCT02925312.

Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Supporting general practitioner-based care for poorly controlled type 2 diabetes mellitus (the DECIDE study): feasibility study and protocol for a pilot cluster randomised controlled trial

BACKGROUND

Poorly controlled type 2 diabetes mellitus (T2DM) is associated with significant morbidity, mortality and healthcare costs. Control of T2DM can be challenging for healthcare professionals for a number of reasons, including poor concordance with medications, difficulties modifying lifestyle behaviour and also clinical inertia, which is defined as a reluctance among health professionals to intensify medications. A complex intervention, called ComputeriseD dECisIonal support for poorly controlleD typE 2 Diabetes mellitus in Irish General Practice (DECIDE), was developed, identifying T2DM patients with poor glycaemic and blood pressure control and aiming to target clinical inertia, by supporting therapeutic action, including GP-led medication intensification where appropriate. A small-scale, uncontrolled, non-randomised feasibility study highlighted the acceptability of the DECIDE intervention within Irish General Practice. This paper presents a protocol for a pilot cluster randomised controlled trial (RCT) of the DECIDE intervention.

METHODS/DESIGN

The pilot cluster RCT will involve 14 practices and 140 patients in Irish General Practice. Intervention GPs will participate in the DECIDE intervention, comprising (a) a training programme for the practices and (b) a web-based clinical decision support system supporting treatment escalation, tailored to specific patient information. Only patients who have poorly controlled T2DM (defined as HbA1c > 70 mmol/mol and/or BP > 150/95) will be included. The primary outcomes will include measures of feasibility such as recruitment and retention of practices and acceptability of the intervention and also HbA1c. Secondary outcomes will include medication intensification, blood pressure and lipids. Control GPs will continue to provide usual care. A process evaluation will be performed to determine whether the intervention is delivered as intended and treatment fidelity assessed to monitor and enhance the reliability and validity of interventions. An exploratory health economic analysis will examine the potential costs and cost effectiveness of the intervention relative to the control.

DISCUSSION

A pilot cluster RCT will establish the feasibility of a complex intervention which aims to support primary care for patients with poorly controlled T2DM in Irish General Practice.

TRIAL REGISTRATION

The protocol for the pilot cluster RCT is registered on the ISRCTN Registry at: ISRCTN69498919.

Gut microbiome and type 2 diabetes: where we are and where to go?

Type 2 diabetes mellitus (T2D) is a highly prevalent metabolic disorder characterized by an imbalance in blood glucose level, altered lipid profile and high blood pressure. Genetic constituents, high-fat and high-energy dietary habits, and a sedentary lifestyle are three major factors that contribute to high risk of T2D. Several studies have reported gut microbiome dysbiosis as a factor in rapid progression of insulin resistance in T2D that accounts for about 90% of all diabetes cases worldwide. The gut microbiome dysbiosis may reshape intestinal barrier functions and host metabolic and signaling pathways, which are directly or indirectly related to the insulin resistance in T2D. Thousands of the metabolites derived from microbes interact with the epithelial, hepatic and cardiac cell receptors that modulate host physiology. Xenobiotics including dietary components, antibiotics and nonsteroidal anti-inflammatory drugs strongly affect the gut microbial composition and can promote dysbiosis. Any change in the gut microbiota can shift the host metabolism towards increased energy harvest during diabetes and obesity. However, the exact mechanisms behind the dynamics of gut microbes and their impact on host metabolism at the molecular level are yet to be deciphered. We reviewed the published literature for better understanding of the dynamics of gut microbiota, factors that potentially induce gut microbiome dysbiosis and their relation to the progression of T2D. Special emphasis was also given to understand the gut microbiome induced breaching of intestinal barriers and/or tight junctions and their relation to insulin resistance.

Medicare utilization, screening, and costs among participants in the Southeastern Diabetes Initiative: A population-based evaluation

AIMS

Type 2 diabetes mellitus imposes significant burdens on patients and health care systems. Population-level interventions are being implemented to reach large numbers of patients at risk of or diagnosed with diabetes. We describe a population-based evaluation of the Southeastern Diabetes Initiative (SEDI) from the perspective of a payer, the Centers for Medicare & Medicaid Services (CMS). The purpose of this paper is to describe the population-based evaluation approach of the SEDI intervention from a Medicare utilization and cost perspective.

METHODS

We measured associations between the SEDI intervention and receipt of diabetes screening (i.e., HbA1c test, eye exam, lipid profile), health care resource use, and costs among intervention enrollees, compared with a control cohort of Medicare beneficiaries in geographically adjacent counties.

RESULTS

The intervention cohort had slightly lower 1-year screening in 2 of 3 domains (4% for HbA1c; 9% for lipid profiles) in the post-intervention period, compared with the control cohort. The SEDI intervention cohort did not have different Medicare utilization or total Medicare costs in the post-intervention period from surrounding control counties.

CONCLUSIONS

Our analytic approach may be useful to others evaluating CMS demonstration projects in which population-level health is targeted for improvement in a well-defined clinical population.

Influencing Pathways to Quality of Life and HbA1c in Patients With Diabetes: A Longitudinal Study That Inform Evidence-Based Practice

BACKGROUND

Determining possible associated factors and the influencing pathways to hemoglobin A1C (HbA1C) levels and quality of life (QoL) will facilitate the development of effective interventions to improve the physical and psychosocial health of patients with type 2 diabetes mellitus (T2DM).

OBJECTIVES

To test a hypothesized model that addressed the pathways among personal characteristics, social support, diabetes distress, and self-care behaviors to HbA1C and QoL.

METHODS

A total of 382 adults with T2DM were recruited. Self-reported questionnaires and medical records were used to collect data regarding personal characteristics, diabetes distress, and social support at baseline. The self-care behaviors characters were collected 6 months later, as well as QoL and HbA1C levels 1 year later.

RESULTS

The 12-month QoL directly affected 12-month HbA1C levels. The 6-month self-care behaviors directly affected 12-month QoL, and indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline diabetes distress directly affected 12-month QoL. Moreover, baseline diabetes distress indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline social support directly affected baseline diabetes distress and 6-month self-care behaviors. In addition, baseline social support indirectly affected 12-month QoL through baseline diabetes distress. Baseline social support also indirectly affected 12-month QoL through 6-month self-care behaviors.

LINKING EVIDENCE TO ACTION

Enhancing QoL is important to improve HbA1C levels. Enhancing self-care behaviors is essential to improve subsequent HbA1C control and QoL. Reducing diabetes distress is crucial to improve subsequent QoL. Improving social support is suggested a favorable strategy to reduce diabetes distress and enhance subsequent self-care behaviors in patients with T2DM.

The role of telenursing in the management of Diabetes Type 1: A randomized controlled trial

BACKGROUND

Diabetes Mellitus type 1 (T1DM) is a chronic disease that requires patients' self-monitoring and self-management to achieve glucose targets and prevent complications. Telenursing implicates technology in the interaction of a specialized nurse with patients with chronic diseases in order to provide personalized care and support.

OBJECTIVE

To evaluate the effect of telenursing on T1DM patients' compliance with glucose self-monitoring and glycemic control.

DESIGN

Randomized controlled study.

SETTINGS

Outpatient Department of Diabetes, Endocrinology and Metabolism of a University Hospital in Northern Greece.

METHODS

Ninety-four T1DM patients were recruited and randomized in two groups by a random number generator. The intervention group (N = 48) was provided with telenursing services. A specialized nurse made a weekly contact via telephone motivating patients to frequently measure blood glucose and adopt a healthy lifestyle. The control group (N = 46) received standard diabetes advice and care in the clinic. The primary outcome was the effect of the intervention in glucose control and glucose variability. The secondary outcome was the effect on frequency of self-monitoring. SPSS 20.0 was used for data analysis.

RESULTS

The two groups did not differ in age, sex, physical activity or initial HbA1c. In the intervention group, blood glucose significantly decreased at the end of the study in all predefined measurements, compared to control group: morning (93.18 ± 13.30 mg/dl vs. 105.17 ± 13.74 mg/dl, p < 0.005), pre-prandial (114.76 ± 9.54 mg/dl vs. 120.84 ± 4.05 mg/dl, p < 0.005), post-prandial (193.35 ± 25.36 mg/dl vs. 207.84 ± 18.80 mg/dl, p < 0.005), and HbA1c decreased significantly over time in the intervention group (8.3 ± 0.6% at the beginning of the study vs. 7.8 ± 1% at the end of the study, p = 0.03). In the intervention group there were also fewer omitted glucose measurements than in the control group.

CONCLUSIONS

Patients in the intervention group achieved better glucose control and more frequent self-monitoring than patients in routine care in the clinic. The findings of our study indicate that telenursing can motivate T1DM patients to better control their disease.