Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study

BACKGROUND

Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes.

METHODS

A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions.

SETTING

Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest.

DESIGN

2 × 2 factorial design.

INTERVENTIONS

Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce.

OUTCOMES

Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months.

DISCUSSION

Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity.

CLINICALTRIALS

gov: NCT05472441.

Socio-economic determinants of attendance at diabetes self-management education program: using Andersen’s behavioral model

Background

Diabetes self-management education is an effective factor for improving outcomes and quality of life in patients with diabetes. However, little information is available on the factors associated with participation or non-participation in self-management education programs in people with diabetes. The aim of this study was to explore the factors affecting on the attendance of patients with diabetes in the diabetes self-management education program.

Methods

A cross-sectional study was conducted in 2019 on 384 patients with diabetes referred to the main comprehensive health centers of Mashhad, Iran. All patients were linked with a diabetes self-management education program that lasted three months and involved 12 sessions. We explore the factors affecting on attending in diabetes self-management education program using Andersen’s behavioral model. Data for independent variables (predisposing, enabling, and need factors) were gathered at the beginning of the training program using registration forms. Dependent variable (attendance of patients with diabetes in the training program) was checked at the end of the program. Univariate and multivariate analysis were done with SPSS v.25.

Results

The results of this study showed that women were less likely to participate in the self-management education program than men (OR=0.414; P<0.05). Also, age, travel time, health status and years with diabetes have negative significantly correlated with participation in the education program (P<0.05). The study showed that patients with diabetes aged≥65 were less participated in the training program than those ≤40 (OR=0.159; P<0.05). Also, patients who lived farther than 40 min away from training center were less likely to participate for this program than patients that live in an area<20 min away from training center (OR=0.196; P<0.05). Odds of attending in training program for patients with poor health status was less than patients with excellent health status (OR=0.282; P<0.05). Participation in training program were low in patients with more than 5-year diabetes duration compared to less than 1 year (OR=0.176; P<0.05).

Conclusion

The implementation of the classes at the right time and online, Reduce the distance between people and the place of the class, providing facilities and providing infrastructure may be appropriate to involve women and the elderly.

SEE-diabetes, a patient-centered diabetes self-management education and support for older adults: Findings and information needs from providers' perspectives

BACKGROUND AND AIMS

Diabetes self-management education and support (DSMES) can improve clinical and health outcomes of people with diabetes. However, DSMES has been underutilized because of many barriers. We aimed to develop a patient-centered educational aid, SEE-Diabetes (Support-Engage-Empower-Diabetes), that facilitates shared decision-making about DSMES between patient and provider during the follow-up visit. We investigated the information needs to inform the design of the SEE-Diabetes from the providers' perspective.

METHODS

We conducted an online survey (N = 42) and three focus groups (N = 13) involving providers who have experience managing diabetes in older patients. Survey collected demographics and assessed knowledge of DSMES. During the subsequent focus groups, participants evaluated the Assessment and Plan section of three clinic notes of older people with diabetes. We also demonstrated the potential workflow of DSMES documentation using SEE-Diabetes during clinical practice.

RESULTS

The survey showed 60% of providers were familiar with DSMES. Focus group findings showed clinic notes should convey concise information at an appropriate reading level, numbered problems, and less medical jargon to improve the readability of clinic notes. Application of SMART (Specific, Measurable, Attainable, Relevant, Time-bound) goals was suggested to deliver effective diabetes self-care information.

CONCLUSIONS

Providers should consider adopting validated DSMES guidelines along with goal-setting strategies to provide patient-centered care. The research team will integrate the provider recommendations when we develop SEE-Diabetes.

Validation of the revised Diabetes Self-Management Questionnaire (DSMQ-R) in the primary care setting

Background

Available tools measuring self-management in diabetes are often improperly validated or do not correlate with glucose metabolism. The Diabetes Self-Management Questionnaire (DSMQ-R) is a valid tool, that showed strong relationship with glucose metabolism in tertiary care among people with mostly type 1 diabetes.

Aim of the study

To validate the translated DSMQ-R questionnaire in a Hungarian sample of people with predominantly type 2 diabetes in primary care.

Methods

We enrolled 492 adults from 38 practices in this cross-sectional cohort study, who filled out the self-administered questionnaire, consisting of DSMQ-R and the Summary of Diabetes Self-Care Activities (SDSCA) questionnaires. Family doctors provided clinical data. The translation process was performed in six steps, reaching the expert committee appraisal. The validity of the questionnaire was evaluated by assessing reliability and construct validity.

Results

Cronbach’s alpha showed the questionnaire to reach good reliability (α = 0.845), although subscales had lower alphas. Contrary to the SDSCA questionnaire, the DSMQ-R sum scale differed significantly between persons on target vs not on target (median (interquartile range): 7.23 (6.17–8.44) vs 6.91 (5.91–8.02), and the DSMQ-R sum scale correlated significantly with BMI, HbA1c and SDSCA sum scale. In multivariate analysis higher DSMQ-R scores were significant predictor of achieving glycemic target goal.

Conclusion

The Hungarian translation of the DSMQ-R is a comprehensible tool to assess self-management of persons with diabetes. The questionnaire is valid and reliable in family practice, although its association with achievement of diabetes HbA1c target is weaker in primary than in tertiary care.

Effect of a Primary Care-Based Diabetes Education Model on Provider Referrals and Patient Participation

PURPOSE

The purpose of this study was to evaluate the impact of a primary care (PC)-based delivery model on diabetes self-management education and support (DSMES) referrals and participation. Despite evidence that DSMES is a critical component of diabetes care, referrals and participation remain low.

METHODS

PC practices were assigned to the intervention (n = 6) or usual care (n = 6). Intervention practices had direct access to a diabetes educator (DE) and applied patient-centered medical home elements to DSMES delivery. Usual care practices referred patients to traditional hospital-based outpatient DSMES programs. DSMES referrals and participation were examined for patients with diabetes, 18 to 75 years old, presenting to PC over 18 months (n = 4,894) and compared between groups.

RESULTS

Compared to the usual care group, a higher percentage of patients in the intervention practices were referred to DSMES (18.4% vs 13.4%; P < .0001), and of those referred, a higher percentage of patients in the intervention practices participated in DSMES (34.9% vs 26.1%; P = .02). Patient-level factors predicting referrals were obesity (odds ratio [OR] = 1.6), higher A1C (OR = 1.4), female (OR = 1.3), and younger age (OR = 0.98). The only patient-level factor that predicted DSMES participation was lower A1C (OR = 0.9).

CONCLUSIONS

This study demonstrates the positive influence of a PC-based intervention on DSMES referral and participation. However, modest improvements in DSMES rates, even with targeted efforts to address reported barriers, raise questions as to what is truly needed to drive meaningful change.

Identifying Needs and Barriers to Diabetes Dietary Education in Chinese People with Type 2 Diabetes and Their Family Members in Guangzhou: A Qualitative Study

PURPOSE

The purpose of this exploratory qualitative study was to identify the needs and barriers to diabetes dietary education issues in a Chinese context among people with type 2 diabetes and also their family members.

PATIENTS AND METHODS

Nineteen patients with type 2 diabetes and 15 family members were randomly selected from a larger study in Guangzhou. Descriptive phenomenological qualitative inquiry guided this study.

RESULTS

Both patients and their family members claimed a variety of needs regarding diabetes dietary information and that it should be patient-centered. In addition, both groups identified the effectiveness and helpfulness of diabetes diet-related health education, but family members reported a lack of professional education. Patients reported that the barriers to diabetes diet-related health education were: 1) patients' different faculties of memory and acceptance, 2) educators' methods of explaining the information, 3) lack of advertising and intensity of publicity both inside and outside of the hospital. Family members identified that diabetes diet-related health education assisted them with taking care of patients with diabetes and it was also beneficial for themselves to gain more dietary knowledge and develop healthy dietary habits.

CONCLUSION

It is necessary to make some adjustment to traditional diabetes dietary education. It may be a good strategy to investigate the needs and faculties of memory and acceptance of people with diabetes before starting a diabetes education program. Hospitals should intensify their publicity of diabetes education and make it more attractive to patients with diabetes and their family members. Educators should add information specifically for family members while conducting diabetes education. Tertiary hospitals could provide standardized training regarding diabetes-related health education to community family physicians; in this way, diabetes education could gradually be transferred to them and both groups of clinicians could share in the education.

Diabetes Self-Management Education and Support: Referral and Attendance at a Patient-Centered Medical Home

BACKGROUND

Although evidence shows that diabetes self-management education and support (DSMES) is an effective tool to help individuals with type 2 diabetes (T2DM) improve their health outcomes, there remains a large number of individuals not attending DSMES. Understanding how frequently patients receive referrals to DSMES and the number of DSMES hours they receive is important to determine, as well as patients' health outcomes of utilizing DSMES. This will help us understand patterns of utilization and the outcomes that occur when such a valuable resource is utilized.

METHODS

Secondary data analysis was conducted of patient electronic medical records at a primary healthcare federally qualified clinic and 2 area hospitals. We identified 105 adult patients with a new T2DM diagnosis with at least 2 A1c lab results 3 to 12 months apart during the study period.

RESULTS

Only 53.5% were referred to DSMES. Out of those who were referred, 66% received no DSMES, 17% received 1-hour assessment, 4% received partial DSMES, and 13% received 8 or more hours. Linear regression of percent change in A1c and number of DSMES hours received, revealed that receiving 1 (P = .001) or 8 or more hours of DSMES (P = .022) had a significant negative relationship with the percent difference in A1c compared to the group who received no DSMES. Patients who had an hour of assessment had a similar percent reduction in A1c to those who had partial DSMES.

CONCLUSION

Referral rates and enrollment in DSMES remain low. Those who enrolled often dropped out after the one-hour assessment session. Results suggest making the one-hour assessment session more educationally comprehensive or longer to retain patients. Improving the DSMES referral process and further investing physicians' decisions on whether to refer or not refer patients to DSMES are key for future studies.

A systematic review exploring characteristics of lifestyle modification interventions in newly diagnosed type 2 diabetes for delivery in community pharmacy†

Objectives

The aim of this systematic review was to examine the characteristics of effective lifestyle modification interventions designed for patients with newly diagnosed type 2 diabetes mellitus (T2DM) in order to determine elements that have the potential to be delivered in the community pharmacy setting.

Key findings

Seven studies, comprising three each of the interventions diet and structured education and one of supported exercise, were identified. Interventions were conducted in hospital diabetes clinics and clinics situated in both urban and rural areas. Interventions were delivered face to face by highly skilled personnel including physicians, nurses and dietitians. Duration of interventions ranged from 3 months to 5 years.

Summary

Structured education and dietary interventions in newly diagnosed type 2 diabetes effectively controlled blood glucose levels without pharmacological intervention. Important characteristics included face to face, individualised and multicomponent interventions with a duration of at least 6 months. These characteristics demonstrate potential for delivery in a community pharmacy setting, given its current involvement in delivering face to face, individual services with diet and lifestyle components. Further research is required to provide evidence for ideal intervention duration and frequency as well as training requirements for pharmacists.

Factors Associated with Participation in Diabetes Education: The Korea National Health and Nutrition Examination Survey 2007 to 2009

BACKGROUND

A recent study revealed that the participation rate in diabetes education among diabetic patients was only about 50% in Korea. We investigated the factors associated with participation in diabetes education.

METHODS

The study included 1,255 patients (≥19 years old) diagnosed with diabetes drawn from the total Korea National Health and Nutrition Examination Survey 2007 to 2009 population comprising 30,705 individuals. We compared age, sex, and age- and sex-adjusted clinical characteristics in patients who had received diabetes education versus those who had not.

RESULTS

Of the 1,255 patients, 19.8% (n=248) had received diabetes education. Patients in the group who received diabetes education were younger, diagnosed at an earlier age, had a longer diabetes duration and were more likely to be using insulin therapy compared with the group who did not receive diabetes education (P<0.001). The group who received diabetes education included fewer manual workers (P<0.001) but more college graduates (P=0.004) compared with the group who did not receive diabetes education. Logistic regression analysis revealed that longer diabetes duration increased the likelihood of receiving diabetes education (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01 to 1.06; P=0.004). Junior high school (OR, 0.47; 95% CI, 0.24 to 0.91; P=0.026) and elementary school education levels (OR, 0.34; 95% CI, 0.17 to 0.65; P=0.001) versus college graduation were inversely correlated with participation in diabetes self-management education. Non-insulin therapy reduced the likelihood of receiving diabetes education (OR, 0.37; 95% CI, 0.21 to 0.64; P<0.001).

CONCLUSION

Longer diabetes duration, insulin therapy, and higher education level were positively associated with the completion of diabetes education.

Characteristics of patients with diabetes who accept referrals for care management services

Introduction:

Patients with chronic conditions can improve their health through participation in self-care programs. However, awareness of and enrollment in these programs are generally low.

Objective:

We sought to identify factors influencing patients’ receptiveness to a referral for programs and services supporting chronic disease management.

Methods:

We analyzed data from 541 high-risk diabetic patients who completed an assessment between 2010 and 2013 from a computer-based, nurse-led Navigator referral program within a large primary care clinic. We compared patients who accepted a referral to those who declined.

Results:

A total of 318 patients (75%) accepted 583 referrals, of which 52% were for self-care programs. Patients who accepted a referral had more primary care visits in the previous year, were more likely to be enrolled in another program, expressed more interest in using the phone and family or friends for support, and were more likely to report recent pain than those who declined a referral.

Discussion:

Understanding what factors influence patients’ decisions to consider and participate in self-care programs has important implications for program design and development of strategies to connect patients to programs. This work informs outreach efforts to identify and engage patients who are likely to benefit from self-care activities.

Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care.

METHODS

We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken.

RESULTS

Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low.

CONCLUSIONS

The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.

Current perspectives on psychological insulin resistance: primary care provider and patient views

BACKGROUND

Psychological insulin resistance (PIR) refers to reluctance of providers to prescribe and patients to take insulin. Processes and tools have been developed to address PIR. The purpose of this qualitative study was to examine current understanding and opinions of insulin therapy of primary care providers (PCPs) and patients with type 2 diabetes (both naive to insulin and insulin users).

SUBJECTS AND METHODS

Providers (n=23 PCPs) and patients (n=96) participated in 1:1 interviews and 12 racially/ethnically diverse focus groups, respectively, conducted by trained qualitative researchers using pilot-tested scripts. Participants examined insulin devices and needles while specific questions were asked about insulin therapy. Recorded sessions were transcribed and analyzed.

RESULTS

Salient themes related to injection resistance, patient adherence, health system barriers, and education emerged during the sessions. Provider knowledge about insulin injection devices and approaches varied and was often limited, particularly regarding needle sizes, which influenced prescribing practices and patient education. Other barriers included limited time and personnel. However, PCPs placed priority on continuing education on devices, needles, insulin adjustment, educational approaches, and cost. Patient focus groups revealed a strong desire for knowledge on injection logistics, particularly by insulin users who felt that they had received inadequate education. Most patients had limited experience with tools like shorter needles but would consider injecting if presented. Those who had self-injection experience were more willing to accept insulin. Cost concerns and need for information were frequently reported.

CONCLUSIONS

Findings reveal that programs and tools designed to address problems associated with PIR have yet to be fully realized.

A web-based intervention to support self-management of patients with type 2 diabetes mellitus: effect on self-efficacy, self-care and diabetes distress

BACKGROUND

Management of diabetes mellitus is complex and involves controlling multiple risk factors that may lead to complications. Given that patients provide most of their own diabetes care, patient self-management training is an important strategy for improving quality of care. Web-based interventions have the potential to bridge gaps in diabetes self-care and self-management. The objective of this study was to determine the effect of a web-based patient self-management intervention on psychological (self-efficacy, quality of life, self-care) and clinical (blood pressure, cholesterol, glycemic control, weight) outcomes.

METHODS

For this cohort study we used repeated-measures modelling and qualitative individual interviews. We invited patients with type 2 diabetes to use a self-management website and asked them to complete questionnaires assessing self-efficacy (primary outcome) every three weeks for nine months before and nine months after they received access to the website. We collected clinical outcomes at three-month intervals over the same period. We conducted in-depth interviews at study conclusion to explore acceptability, strengths and weaknesses, and mediators of use of the website. We analyzed the data using a qualitative descriptive approach and inductive thematic analysis.

RESULTS

Eighty-one participants (mean age 57.2 years, standard deviation 12) were included in the analysis. The self-efficacy score did not improve significantly more than expected after nine months (absolute change 0.12; 95% confidence interval -0.028, 0.263; p = 0.11), nor did clinical outcomes. Website usage was limited (average 0.7 logins/month). Analysis of the interviews (n = 21) revealed four themes: 1) mediators of website use; 2) patterns of website use, including role of the blog in driving site traffic; 3) feedback on website; and 4) potential mechanisms for website effect.

CONCLUSIONS

A self-management website for patients with type 2 diabetes did not improve self-efficacy. Website use was limited. Although its perceived reliability, availability of a blog and emailed reminders drew people to the website, participants' struggles with type 2 diabetes, competing priorities in their lives, and website accessibility were barriers to its use. Future interventions should aim to integrate the intervention seamlessly into the daily routine of end users such that it is not seen as yet another chore.

Pilot trial of diabetes self-management education in the hospital setting

AIMS

Diabetes self-management education (DSME) is recommended for all patients with diabetes. Current estimates indicate that <50% of patients receive DSME, increasing risk for hospitalization which occurs more frequently with diabetes. Hospitalization presents opportunities to provide DSME, potentially decreasing readmissions. To address this, we investigated the feasibility of providing DSME to inpatients with diabetes.

METHODS

Patients hospitalized on four medicine units were randomized to receive DSME (Education Group) (n=9) prescribed by a certified diabetes educator and delivered by a registered nurse, or Usual Care (n=12). Participants completed Diabetes Knowledge Tests (DKT), Medical Outcomes Short Form (SF-36), Diabetes Treatment Satisfaction Questionnaire (DTSQ), and the DTSQ-inpatient (DTSQ-IP). Bedside capillary blood glucoses (CBG) on day of admission, randomization and discharge were compared.

RESULTS

There were no group differences in demographics, diabetes treatment, admission CBG (186±93 mg/dL vs. 219±84 mg/dL, p=0.40), DKT scores (Education vs. Usual Care 48±25 vs. 68±19, p=0.09), SF-36, and DTSQ scores (28±6 vs. 25±7, p=0.41). Patients receiving education reported more satisfaction with inpatient treatment (83±13 vs. 65±19, p=0.03), less hyperglycemia prior to (2.7±4.5 vs. 4.5±1.4, p=0.03) and during hospitalization (3.9±1.9 vs. 5.5±1.2, p=0.04); and had lower mean discharge CBG (159±38 mg/dL vs. 211±67 mg/dL, p=0.02).

CONCLUSIONS

Inpatient diabetes education has potential to improve treatment satisfaction, and reduce CBG.

Strategies for improving participation in diabetes education. A qualitative study

Objective

Diabetes mellitus is highly prevalent and can lead to serious complications and mortality. Patient education can help to avoid negative outcomes, but up to half of the patients do not participate. The aim of this study was to analyze patients' attitudes towards diabetes education in order to identify barriers to participation and develop strategies for better patient education.

Methods

We conducted a qualitative study. Seven GP practices were purposively selected based on socio-demographic data of city districts in Hamburg, Germany. Study participants were selected by their GPs in order to increase participation. Semi-structured face-to-face interviews were conducted with 14 patients. Interviews were audiotaped and transcribed verbatim. The sample size was determined by data saturation. Data were analysed by qualitative content analysis. Categories were determined deductively and inductively.

Results

The interviews yielded four types of barriers: 1) Statements and behaviour of the attending physician influence the patients' decisions about diabetes education. 2) Both, a good state of health related to diabetes and physical/psychosocial comorbidity can be reasons for non-participation. 3) Manifold motivational factors were discussed. They ranged from giving low priority to diabetes to avoidance of implications of diabetes education as being confronted with illness narratives of others. 4) Barriers also include aspects of the patients' knowledge and activity.

Conclusions

First, physicians should encourage patients to participate in diabetes education and argue that they can profit even if actual treatment and examination results are promising. Second, patients with other priorities, psychic comorbidity or functional limitations might profit more from continuous individualized education adapted to their specific situation instead of group education. Third, it might be justified that patients do not participate in diabetes education if they have slightly increased blood sugar values only and no risk for harmful consequences or if they already have sufficient knowledge on diabetes.

Disparities in attendance at diabetes self-management education programs after diagnosis in Ontario, Canada: a cohort study

BACKGROUND

Patients newly-diagnosed with diabetes require self-management education to help them understand and manage the disease. The goals of the study were to determine the frequency of diabetes self-management education program utilization by newly-diagnosed patients, and to evaluate whether there were any demographic or clinical disparities in utilization.

METHODS

Using population-level health care data, all 46,553 adults who were diagnosed with any type of non-gestational diabetes in Ontario, Canada between January and June 2006 were identified. They were linked with a diabetes self-management education program registry to identify those who attended within 6 months of diagnosis. The demographic and clinical characteristics of attendees and non-attendees were compared.

RESULTS

A total of 9,568 (20.6%) patients attended a diabetes self-management education program within 6 months of diagnosis. Younger age, increasing socioeconomic status, and the absence of mental health conditions or other medical comorbidity were associated with attendance. Patients living in rural areas, where access to physicians may be limited, were markedly more likely to attend. Recent immigrants were 40% less likely to attend self-management education programs than longer-term immigrants or nonimmigrants.

CONCLUSION

Only one in five newly-diagnosed diabetes patients attended a diabetes self-management education program. Demographic and clinical disparities in utilization persisted despite a publicly-funded health care system where patients could access these services without direct charges. Primary care providers and education programs must ensure that more newly-diagnosed diabetes patients receive self-management education, particularly those who are older, poorer, sicker, or recent immigrants.

Better self-perceived health is associated with lower odds of physical inactivity in older adults with chronic disease

Poor self-perceived health (SPH) is associated with lower levels of physical activity (PA) and the presence of chronic disease in older adults. The purpose of this study was to determine whether SPH is associated with PA levels in older adults with existing chronic disease and whether this differs by disease. Using logistic regressions on data from the Canadian Community Health Survey (N = 33,168) it was found that adjusted logistic regressions revealed that odds of physical inactivity were similar in those with good SPH who reported having respiratory, musculoskeletal, or other chronic disease compared with those with good SPH without these diseases. Those with good SPH who reported having cardiometabolic disease were at significantly greater risk of physical inactivity than those with good SPH without cardiometabolic disease. It is apparent from the current analysis that SPH plays an important role in PA levels of older adults with chronic disease and should be targeted in future interventions.

Shortcomings in public and private insurance coverage of diabetes self-management education and support

The objective of this study is to present preliminary data to characterize public and private insurance coverage for diabetes self-management education (DSM Education) and diabetes self-management support (DSM Support). Representatives from Medicaid and 2 private insurance providers in 10 states provided coverage information for their insurance plans. Two states (the most populous state from the East and West coasts) were sampled purposively and 8 additional states from 4 geographic regions (northeast, southeast, northwest, southwest) were sampled at random. Representatives from each private insurer described both a premium and basic coverage plan. Thus, 10 Medicaid programs and 40 private insurance plans were represented. Information about Medicare coverage was accessed from publicly available documents. Restricted by physician certification of patient eligibility, Medicare coverage included 10 hours of DSM Education plus 3 hours of medical nutrition therapy (MNT) within a continuous 12-month period, and 4 hours of follow-up (2 hours DSM Education and 2 hours MNT) for each subsequent year. Only 22 of 40 sampled private insurance and 5 of 10 Medicaid plans covered DSM Education, which ranged from 7 to 20 hours of education per year. Medicaid and private plans often limited the amount of DSM Education or required patients to obtain a physician certification of eligibility. Other than on-demand access features, coverage of DSM Support was minimal. Public and private insurance coverage of DSM Education was neither widespread nor uniform, while coverage of DSM Support was scarce.