A Randomized Controlled Trial Testing the Effects of a Social Needs Navigation Intervention on Health Outcomes and Healthcare Utilization among Medicaid Members with Type 2 Diabetes

Health systems are increasingly assessing and addressing social needs with referrals to community resources. The objective of this randomized controlled trial was to randomize adult Medicaid members with type 2 diabetes to receive usual care (n = 239) or social needs navigation (n = 234) for 6 months and compare HbA1c (primary outcome), quality of life (secondary outcome), and other exploratory outcomes with t-tests and mixed-effects regression. Eligible participants had an HbA1c test in claims in the past 120 days and reported 1+ social needs. Data were collected from November 2019 to July 2023. Surveys were completed at baseline and at 3-, 6-, and 12-month follow-up. Health plan data included care management records and medical and pharmacy claims. The sample was from Louisiana, USA, M = 51.6 (SD = 9.5) years old, 76.1% female, 66.5% Black, 29.4% White, and 3.0% Hispanic. By design, more navigation (91.5%) vs. usual care (6.7%) participants had a care plan. Social needs persisted for both groups. No group differences in HbA1c tests and values were observed, though the large amount of missing HbA1c lab values reduced statistical power. No group differences were observed for other outcomes. Proactively eliciting and attempting to provide referrals and resources for social needs did not demonstrate significant health benefits or decrease healthcare utilization in this sample.

Family Support and Type 2 Diabetes Self-management Behaviors in Underserved Latino/a/x Patients

BACKGROUND

Latino/a/x families experience persistent Type 2 diabetes mellitus (T2DM) disparities, including higher rates of diagnosis and mortality due to disease complications than their non-Hispanic White counterparts. Though greater social support is associated with improved disease outcomes for Latino/a/x patients with diabetes, research has yet to identify the specific pathways through which social support, and specifically family support, influences self-management.

PURPOSE

This study tested a theoretical model highlighting the mechanisms and pathways linking social support and physical health. Specifically, self-efficacy and depression were tested as psychological pathways connecting family support to diabetes self-management behaviors and diabetes morbidity in Latino/a/x patients with T2DM.

METHODS

Data from 177 patients were analyzed using structural equation modeling. Measures included diabetes-specific family support needed and received, depressive symptoms, self-efficacy in diabetes management, diabetes self-management behaviors, health appraisal, and hemoglobin A1c.

RESULTS

Greater diabetes-specific family support was significantly associated with more frequent engagement in diabetes self-management behaviors, both directly (p < .001) and through diabetes self-efficacy's partial mediation of this relationship (p = .013). Depression was not significantly associated with either family support (support received, p = .281; support needed, p = .428) or self-management behaviors (p = .349).

CONCLUSIONS

Family support and diabetes self-efficacy may be important modifiable psychosocial factors to target via integrated care interventions aimed at supporting Latino/a/x patients with T2DM. Future research is needed to test empirically based, culturally adapted interventions to reduce T2DM-related health disparities in this population.

A Tailored Intervention for Improving Diabetes Self-care Among Adults With Visual Impairment: A Pilot Study

OBJECTIVES

Our aim in this study was to develop and evaluate a tailored intervention for improving diabetes self-care among people with visual impairment (TID-VI) in South Korea.

METHODS

The TID-VI program was designed around the barriers, resources, and perceptual factors to promote diabetes self-care in those with visual impairment (VI). A single-arm pilot study was conducted to evaluate the feasibility and preliminary effects of the intervention. Diabetes self-efficacy, self-care behaviours, depression, health-related quality of life, and clinical outcomes (fasting blood glucose, glycated hemoglobin [A1C], lipids, and blood pressure) were measured before, and up to 2 months after the 12-week intervention.

RESULTS

All 14 participants completed TID-VI. Diabetes self-efficacy, diabetes self-care behaviours, depression, and health-related quality of life showed improvement from baseline that was sustained at 2 months. Although high- and low-density lipoprotein also improved, there were no differences in blood glucose, A1C, total cholesterol, or blood pressure at 2 months.

CONCLUSIONS

A theory-driven, tailored intervention specific to the needs of adults with VI can produce substantial improvements in patient-reported quality of life and health status outcomes, although the benefits are yet to be confirmed in a controlled study.

The Effectiveness of the Chronic Disease Self-Management Program in Improving Patients' Self-Efficacy and Health-Related Behaviors: A Quasi-Experimental Study

The Stanford Chronic Disease Self-Management Program (CDSMP) is a valuable educational resource for supporting patients' self-management behaviors. However, no evidence supporting its effectiveness in the Saudi Arabian population exists. Therefore, this study aimed to evaluate the effectiveness of the 6-month CDSMP in individuals with chronic conditions in Saudi Arabia within a primary care context. A quasi-experimental design was conducted in 110 adults living with ≥1 chronic disease in Saudi Arabia. The patients in the experimental group (n = 45) participated in a six-session CDSMP, whereas those in the control group (n = 65) continued their usual care. Baseline and 6-month assessments were conducted using relevant questionnaires to assess outcome measures. Analysis of covariance revealed that the participants who underwent the CDSMP had significantly higher self-efficacy levels in managing their conditions (F = 9.80, p < 0.01) and a greater tendency to adopt healthy behaviors to successfully manage their chronic illnesses (F = 11.17, p < 0.01). The participants who underwent the CDSMP also showed significant improvements in all health-related outcomes compared with those in the control group (p < 0.01). These findings indicated that the program had a positive effectiveness in self-efficacy, self-management behaviors, and health-related outcomes among adults with chronic diseases in Saudi Arabia. The CDSMP may be integrated into primary care settings to help patients successfully manage their chronic conditions.

Preventing severe hypoglycemia in adults with type 2 diabetes (PHT2): Design, delivery and evaluation framework for a randomized controlled trial

BACKGROUND

Severe hypoglycemia is a common and feared complication of medications used to lower blood glucose levels in individuals with diabetes. Psychoeducational interventions can prevent severe hypoglycemia in individuals with type 1 diabetes (T1D). We aim to determine the effectiveness of this approach among adults with type 2 diabetes (T2D) at elevated risk for severe hypoglycemia.

METHODS

Preventing Hypoglycemia in Type 2 diabetes (PHT2) is a two-arm, parallel, randomized controlled trial. Participants are eligible if they are adults with T2D receiving care at an integrated group practice in Washington state and have experienced one or more episodes of severe hypoglycemia in the prior 12 months or have impaired awareness of hypoglycemia (Gold score ≥ 4). Participants are randomized to proactive nurse care management with or without my hypo compass, an evidence-based, psychoeducational intervention combining group and individual self-management training. For this study, my hypo compass was adapted to be suitable for adults with T2D and from an in-person to a virtual intervention over videoconference and telephone. The primary outcome is any self-reported severe hypoglycemia in the 12 months following the start of the intervention. Secondary outcomes include biochemical measures of hypoglycemia, self-reported hypoglycemia awareness, fear of hypoglycemia, and emergency department visits and hospitalizations for severe hypoglycemia. The study includes a process evaluation to assess implementation fidelity and clarify the causal pathway.

CONCLUSION

The PHT2 trial will compare the effectiveness of two approaches for reducing severe hypoglycemia in adults with T2D.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT04863872.

Psychosocial Factors and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with poor glycemic control and early onset of complications. Identification of psychosocial factors associated with poor glycemic control is needed to inform efficacious interventions.

Objective

To identify psychosocial factors associated with glycated hemoglobin (HbA1c) levels in young adults with youth-onset type 2 diabetes.

Design, Setting, and Participants

For the iCount cohort study, HbA1c levels were measured twice (at baseline [T1] and at 1 year [T2]) during the last years (2017-2019) of the observational phase of the multicenter Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study. Participants were young adults who had been diagnosed with type 2 diabetes during childhood or adolescence. Data were analyzed from December 2021 to September 2023.

Main Outcomes and Measures

Glycemic control was examined categorically (high [≥8.0%] vs low [<8.0%] HbA1c), continuously (HbA1c level), and over time (change in HbA1c: decreased ≥0.5%, remained stable, or increased ≥0.5%). Psychosocial measures included beliefs about medicines, depression and anxiety symptoms, diabetes distress, diabetes self-efficacy, self-management support, and unmet material needs. Multivariable logistic and linear regression models evaluated the association of each psychosocial factor with the probability of T2 HbA1c of 8.0% or greater, T2 HbA1c level, and change in HbA1c.

Results

Of the 411 TODAY2 participants approached, 381 enrolled in the iCount study, and 348 with T1 and T2 HbA1c data comprised the analysis group. The 348 participants had a mean (SD) age of 26.1 (2.5) years and a mean (SD) HbA1c of 9.4% (2.8%). Most participants (229 [65.8%]) were women. In adjusted multivariable regressions, greater beliefs that diabetes medicines are necessary (odds ratio [OR], 1.19 [95% CI, 1.03-1.37]; P = .02), concerns about medicines (OR, 1.20 [95% CI, 1.00-1.45]; P = .049), diabetes distress (OR, 1.08 [95% CI, 1.02-1.15]; P = .006), and high distress (OR, 2.18 [95% CI, 1.15-4.13]; P = .02) increased the odds of high HbA1c at T2. Greater support (OR, 0.67 [95% CI, 0.46-0.97]; P = .04) and diabetes self-efficacy (OR, 0.91 [95% CI, 0.84-0.99]; P = .02) decreased the odds of high HbA1c at T2. Diabetes distress was associated with higher HbA1c level at T2 (coefficient, 0.08 [95% CI, 0.02-0.13]; P = .01). Beliefs that diabetes medicines are necessary (OR, 1.20 [95% CI, 1.03-1.39]; P = .02) and concerns about medicines (OR, 1.22 [95% CI, 1.00-1.47]; P = .048) increased the odds of an HbA1c decrease of at least 0.5% over 1 year.

Conclusions and Relevance

In this cohort study of young adults with youth-onset type 2 diabetes, beliefs about medicines, high diabetes distress, low diabetes self-efficacy, and self-management support were associated with high HbA1c over time. Future research should assess whether interventions that address these factors result in improved glycemic control in this at-risk group.

Feasibility and Acceptability of Home-Delivered Medically Tailored Meals for Treatment of Diabetes in Pregnancy

BACKGROUND

Diabetes complicates ≤7% of pregnancies in the United States. Although medical nutrition therapy is the mainstay of diabetes treatment, many barriers exist to the successful implementation of dietary modifications. Home-delivered medically tailored meals (MTMs) are promising to overcome such barriers.

OBJECTIVE

The objective of this study was to evaluate the feasibility and acceptability of home-delivered MTM in pregnant patients with diabetes.

METHODS

We performed a prospective cohort study of home-delivered MTM for pregnant patients with diabetes using a mixed-methods approach. Participants <35 wk of gestation at the time of enrollment received weekly home delivery of diabetes-specific meals. Qualitative semistructured interviews were conducted to gain insight into participants' experience. Diabetes self-efficacy was assessed pre- and postintervention using the Diabetes Self-Efficacy Scale and 2-Item Diabetes Distress Screening Scale. The difference in mean scores was compared using t-tests with P value of <0.05 considered significant. Feasibility and acceptability were evaluated through participants' attitude toward MTM in qualitative interviews and indirectly evaluated through diabetes self-efficacy surveys.

RESULTS

Twenty pregnant people with diabetes who received home-delivered MTM during pregnancy were interviewed postpartum. Participants found this program convenient for various reasons, including reduced time for grocery shopping and preparing meals. Participants were satisfied with meals, citing a positive impact on diabetes management, accessibility of healthy foods, reduced stress with meal planning, and greater perceived control of blood glucose. Most participants shared meals with their families or received specific meals for their dependents, which was positively received. Reduced financial and mental stress was also widely reported. Diabetes self-efficacy was significantly improved postintervention with MTM.

CONCLUSION

Home-delivered MTM is feasible and acceptable in pregnant patients with diabetes and may improve diabetes self-efficacy. Individual experiences offered insight into various barriers overcome by using this service. Home-delivered MTM may help ensure an accessible, healthy diet for pregnant patients with diabetes.

DiabeText, a mobile health intervention to support medication taking and healthy lifestyle in adults with type 2 diabetes: Study protocol for a randomized controlled trial

AIM

To evaluate the effectiveness of DiabeText, a low-intensity, multifaceted, mobile health (mHealth) intervention to support medication taking and lifestyle change targeted to people with type 2 diabetes (T2D).

DESIGN

Phase III, 12-months, two-arm (1:1 allocation ratio), randomized parallel-group trial.

METHODS

We will recruit 740 adults with glycated hemoglobin (A1c) >8% (>64 mmol/mol) and with at least one prescription of a non-insulin antidiabetic drug. They will be allocated to a control (usual care) group or an intervention (DiabeText messaging intervention) group. The primary outcome measure will be A1c at 12 months follow-up. Secondary outcomes will include medication possession ratio and behavioral and psychological outcomes.

DISCUSSION

Recent trials suggest that digital health interventions can effectively support diabetes self-management improving T2D control and reducing important T2D complications. In Spain this type of interventions is understudied.

IMPACT

This trial will strengthen the evidence base of the impact of mHealth interventions to support diabetes self-management. If effective, DiabeText may offer a low-cost and highly scalable strategy to improve health at the population level in a sustainable way.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05006872; Official Title: Supporting People with Type 2 Diabetes in Effective Use of their Medicine Through a System Comprising Mobile Health Technology Integrated with Clinical Care.

Effectiveness of a culturally tailored diabetes education curriculum with real-time continuous glucose monitoring in a Latinx population with type 2 diabetes: the CUT-DM with CGM for Latinx randomised controlled trial study protocol

INTRODUCTION

The prevalence of type 2 diabetes (T2D) is increasing in the Latinx community. Despite telehealth and technology becoming more available, these resources are not reaching the Latinx population. Diabetes education is a cornerstone of treatment; however, access to culturally tailored content is a barrier to the Latinx population. Real-time continuous glucose monitoring (RT-CGM) is a patient-empowering tool that can improve glycaemic control, but it is not readily available for Latinx patients with T2D. We aim to evaluate a culturally tailored diabetes self-management education and support (DSMES) curriculum, using a team-based approach to improve glycaemic control, promote healthy behaviours and enhance patient access with the use of telehealth in Latinx individuals. The primary aim of the study is to evaluate the additive effectiveness of RT-CGM on glycaemia and behavioural changes among Latinx patients undergoing a culturally tailored DSMES. A sub aim of the study is to evaluate family members' change in behaviours.

METHODS

We propose a randomised controlled trial of blinded versus RT-CGM with 100 Latinx participants with T2D who will receive DSMES via telemedicine over 12 weeks (n=50 per group). The study will be conducted at a single large federally qualified health centre system. The control group will receive culturally tailored DSMES and blinded CGM. The intervention group will receive DSMES and RT-CGM. The DSMES is conducted by community health educators weekly over 12 weeks in Spanish or English, based on participant's language preference. Patients in the RT-CGM group will have cyclical use with a goal of 50 days wear time. The primary outcomes are changes in haemoglobin A1c and CGM-derived metrics at 3 and 6 months. The secondary outcomes include participants' self-management knowledge and behaviour and household members' change in lifestyle.

ETHICS AND DISSEMINATION

The study proposal was approved by the University of Washington ethics/institutional review board (IRB) Committee as minimal risk (IRB ID: STUDY00014396) and the Sea Mar IRB committee.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT05394844.

Feasibility of a food-based diabetes self-management education intervention for food insecure patients with type 2 diabetes: a convergent mixed methods study

OBJECTIVE

To assess the feasibility of a food-based diabetes self-management education and support (DSMES) intervention delivered to persons with type 2 diabetes (T2DM) and food insecurity.

DESIGN

This single arm pre-/post convergent mixed methods study tested the feasibility of a 3-month intervention using food boxes, recipes, DSMES and dietitian visits. Feasibility benchmarks assessed were acceptability (> 50 % participants satisfied), demand (> 50 % used program components) and implementation (75 % adherence, 80 % retention). Assessments included: self-reported food security, health-related quality of life, diabetes self-efficacy, socio-demographic and dietary intake, height, weight, and HbA1c and one in-depth interview with participants and key staff. Enrollment, recruitment and retention rates were summarised; qualitative data were analysed using structured thematic analysis (participant interviews) and key point summaries (staff interviews). Quantitative/qualitative data integration was conducted using a joint display.

SETTING

Food bank and Federally Qualified Health Center in the Southwestern U.S.

PARTICIPANTS

English- or Spanish-speaking adults with T2DM and food insecurity.

RESULTS

In total, 247 patients with T2DM and food insecurity were recruited, seventy-one expressed interest and twenty-five consented. Twenty-one participants completed study measurements. 71 % (n 15) received six home food deliveries and ≥ 1 dietitian visit. A priori benchmarks were approached or met within each feasibility criterion - most participants found the intervention to be acceptable, used most or all intervention components, and reported some challenges within intervention implementation (e.g. timing of food deliveries). Data integration provided deeper understanding of reported intervention implementation challenges, yet high adherence to the intervention.

CONCLUSIONS

The intervention was feasible. Next steps include a clinical trial to establish intervention efficacy.

Psychosocial Factors Predicting Healthcare Usage in Young Adults with Youth-Onset Type 2 Diabetes: The TODAY2 iCount Observational Study

BACKGROUND

Established diabetes care ("diabetes home") and regular healthcare visits are important to achieve optimal health. Nothing is known about psychosocial factors that predict healthcare usage (HCU) in young adults with youth-onset type 2 diabetes, at risk for early complications.

OBJECTIVE

To identify psychosocial predictors of HCU in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

DESIGN

Longitudinal, measured at T1 (baseline) and T2 (1 year later). Logistic and linear regressions, adjusted for potential confounders, identified predictors of sub-optimal HCU (defined as no diabetes home, 0 visits for routine care, or  ≥ 1 urgent care visit in prior 6 months).

PARTICIPANTS

N = 366 TODAY2 participants with T1 and T2 data (381 consented). Mean age = 26.0 years, 67.8% female, 37.7% non-Hispanic Black, 35.8% Hispanic, 20.2% non-Hispanic white, 6.3% "other," mean HbA1c = 9.4%.

MAIN MEASURES

HCU survey; reliable and valid measures of diabetes self-efficacy, depressive symptoms, anxiety symptoms, diabetes distress, beliefs about medicines, diabetes attitudes, material need insecurities, self-management support.

KEY RESULTS

25.4% had no diabetes home, 23.7% had 0 routine care visits, 46% had  ≥ 1 urgent care visit (prior 6 months). Beliefs in the necessity of (adjusted odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.12, 1.46, p < 0.001), and concerns about (OR = 1.29;CI = 1.08,1.54, p = 0.004), diabetes medicines, and its negative psychosocial impacts (OR = 1.57;CI = 1.04, 2.38, p = 0.03), predicted higher odds of having a diabetes home at T2. Beliefs that medicines are harmful predicted lower odds of a diabetes home (OR = 0.56;CI = 0.37,0.85, p = 0.006). Necessity beliefs (OR = 1.2;CI = 1.06,1.36, p = 0.004), and self-management support (OR = 1.5;CI = 1.08,2.07, p = 0.01) predicted higher odds of having  ≥ 1 diabetes care visit, harm beliefs predicted lower odds (OR = 0.6;CI = 0.41,0.88, p = 0.01).

CONCLUSIONS

Sub-optimal healthcare usage, common in young adults with youth-onset type 2 diabetes, is predicted by beliefs about medicines, diabetes impact, and self-management support. We must address these factors to help this vulnerable group establish stable diabetes care.

Antihypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with early development of chronic complications. Treatment of elevated blood pressure (BP), nephropathy, and dyslipidemia are critical to reduce morbidity. Data are needed on adherence to BP- and lipid-lowering medications in young adults with youth-onset diabetes.

Objective

To assess adherence and factors associated with adherence to BP- and lipid-lowering medications in young adults with youth-onset type 2 diabetes and diagnoses of hypertension, nephropathy, or dyslipidemia.

Design, Setting, and Participants

This cohort study measured medication adherence with 3 monthly unannounced pill counts at 2 time points 1 year apart during iCount, conducted during the last years (2017-2019) of the observational phase of the Treatment Options for Type 2 Diabetes in Adolescents and Youth study. Psychosocial factors associated with medication adherence were examined. Participants included individuals with youth-onset type 2 diabetes with hypertension, nephropathy, or dyslipidemia receiving diabetes care in their communities. Data were analyzed from September 2022 to September 2023.

Main Outcomes and Measures

The main outcome was BP- and lipid-lowering medication adherence, with low adherence defined as using less than 80% of pills and high adherence, at least 80% of pills. Psychosocial factors were measured using the Beliefs about Medicines Questionnaire and Material Needs Insecurities Survey.

Results

Of 381 participants in iCount, 243 participants (mean [SD] age, 26.12 [2.51] years; 159 [65.43%] women) with hypertension, nephropathy, or dyslipidemia were included in analysis. Among 196 participants with hypertension or nephropathy, 157 (80.1%) had low adherence. Participants with low adherence, compared with those with high adherence, were younger (mean [SD] age, 25.99 [2.41] vs 27.26 [2.41] years; P = .005), had higher glycated hemoglobin A1c (mean [SD], 10.33% [2.66 percentage points] vs 8.85% [2.39 percentage points]; P = .001), shorter diabetes duration (mean [SD], 12.32 [1.49] vs 12.90 [1.46] years; P = .03), and less education (eg, 17 participants [10.83%] vs 0 participants with no high school diploma; P = .004). Of 146 participants with dyslipidemia, 137 (93.8%) had low adherence and only 9 participants (6.2%) had high adherence. Of 103 participants with low adherence to BP-lowering medications and using oral hypoglycemic agents, 83 (80.58%) had low adherence to oral hypoglycemic agents. Beliefs that medications are necessary were higher for participants with high adherence to BP-lowering medications than those with low adherence in unadjusted analyses (mean [SD] necessity score, 16.87 [6.78] vs 13.89 [9.15]; P = .03). In adjusted multivariable analyses of participants with hypertension or nephropathy, having at least 1 unmet social need (odds ratio [OR], 0.20; 95% CI, 0.05-0.65; P = .04) and medication concerns (OR, 0.63; 95% CI, 0.40-0.96; P = .01) were associated with worse medication adherence 1 year follow-up. Diabetes distress, self-efficacy, depressive and anxiety symptoms, and self-management support were not associated with 1-year medication adherence.

Conclusions and Relevance

These findings suggest that adherence to BP- and lipid-lowering medications was very poor in this cohort. To improve medication adherence and prevent early vascular events, approaches that identify and address medication concerns and unmet social needs are needed.

The psychometric properties of the Diabetes Self-Efficacy Scale in Saudis with type 2 diabetes

AIM

To assess the psychometric properties of the Arabic version of the Diabetes Self-Efficacy Scale (A-DSES).

DESIGN

This study used a cross-sectional design.

METHODS

This study recruited 154 Saudi adults with type 2 diabetes at two primary healthcare centres in Riyadh, Saudi Arabia. Its instruments were the Diabetes Self-Efficacy Scale and the Diabetes Self-Management Questionnaire. The psychometric properties of the A-DSES were assessed for reliability, including internal consistency and validity using exploratory factor analysis, confirmatory factor analysis and criterion validity.

RESULTS

The item-total correlation coefficients were >0.30 for all items, ranging from 0.46 to 0.70. The Cronbach's alpha for internal consistency was 0.86. One factor was extracted from the exploratory factor analysis (self-efficacy for diabetes self-management), and the one-factor model showed an acceptable fit to the data in the confirmatory factor analysis. Diabetes self-efficacy levels were positively correlated with diabetes self-management skills (r = 0.40, p < 0.001), indicating criterion validity.

CONCLUSIONS

The results indicate that the A-DSES is a reliable and valid instrument for assessing self-efficacy related to diabetes self-management.

RELEVANCE TO CLINICAL PRACTICE

The A-DSES could be used in clinical practice and research to provide a reference for assessing self-efficacy levels in areas of diabetes self-management.

NO PATIENT OR PUBLIC CONTRIBUTION

Participants were not involved in the design, conduct, reporting or dissemination plans of this research.

Emergency Department Use in Black Individuals With Diabetes

Objective

The prevalence of diabetes is higher in Black than in White individuals, and Blacks seek emergency department (ED) care for diabetes more often than Whites. This randomized controlled trial compared the efficacy of a novel intervention called the Diabetes Interprofessional Team to Enhance Adherence to Medical Care (DM I-TEAM) to usual medical care (UMC) to prevent return diabetes-related ED visits and hospitalizations over 12 months in 200 Black individuals with diabetes after an ED visit. The trial also identified baseline variables associated with return ED visits and hospitalizations.

Methods

The DM I-TEAM provided diabetes education and behavioral activation services delivered by race-concordant research assistants, telehealth visits with a diabetes care and education specialist and primary care physicians, and clinical pharmacist recommendations.

Results

Participants had a mean age of 64.9 years, and 73.0% were women. There was no treatment group difference in return diabetes-related ED visits or hospitalizations over 12 months (DM I-TEAM n = 39 [45.3%] vs. UMC n = 37 [38.5%], χ2 = 0.864, P = 0.353). Baseline variables that were associated with return diabetes-related ED visits or hospitalizations were longer duration of diabetes, higher number of chronic health conditions, higher number of previous ED visits or hospitalizations, greater anticholinergic medication burden, lower satisfaction with primary care physicians, and lower trust in physicians (all P ≤0.05).

Conclusion

Among Black individuals with diabetes, the DM I-TEAM interprofessional intervention was no better than UMC at preventing return diabetes-related ED visits or hospitalizations. High medical morbidity, greater anticholinergic medication burden, low satisfaction with primary care physicians, and physician mistrust were associated with diabetes-related ED visits or hospitalizations independent of treatment. Before clinical interventions such as the DM I-TEAM can be effective, reducing system-level barriers to health, improving physician-patient relationships and medication prescribing, and building community health care capacity will be necessary.

Diabetes distress in a Medicaid sample: The role of psychosocial and health-related factors

AIMS

Diabetes-related distress can negatively affect disease management leading to worse complications, especially among marginalized populations. Prior studies mostly focus on distress' impact on diabetes outcomes, with few examining distress predictors. The current study examined the impact of social needs on distress on its own and after controlling for other socio-demographic, psychosocial, and health factors.

METHODS

Adult Medicaid beneficiaries with type 2 diabetes and a recent HbA1c test documented in claims data (<120 days) were recruited for a 12-month social needs intervention trial. Baseline survey data assessed diabetes distress, social needs, psychosocial factors and health factors. Descriptive statistics were obtained, and bivariate and multivariable logistic regression analyses were used to identify predictors of moderate to severe distress.

RESULTS

Bivariate analyses revealed social needs, stress, depression, comorbidity and comorbidity burden, poor self-rated health, insulin use, a self-reported HbA1c ≥ 9.0, and difficulty remembering to take diabetes medications were all positively associated with greater odds of diabetes distress; greater social support, diabetes self-efficacy, and age were negatively associated. Four variables remained significant in the multivariate model: depression, diabetes self-efficacy, self-reported HbA1c ≥ 9.0, and younger age.

CONCLUSIONS

Targeted distress screening efforts might prioritize people with HbA1c values >9.0, greater depression, and worse diabetes self-efficacy.

Diabetes and Depression: Strategies to Address a Common Comorbidity Within the Primary Care Context

Diabetes and depression represent a prevalent, bidirectional, and impactful comorbidity that affects patient and family quality of life, glycemic self-management, long-term diabetes complications, usage of medical services, medical costs, and early mortality. Primary care providers (PCPs) are frequently the first medical providers to observe changes in mood and diabetes management, as well as the primary point of contact for making referrals to specialty providers (e.g. endocrinology, psychiatry). PCPs play a critical role in screening, evaluating, and treating these conditions. Critical to fostering and maintaining a position of trust and patient engagement in medication recommendations is the use of person-centered, nonjudgmental language used by the provider within the clinical encounter. Key strategies for the management of these conditions include the following: routine screening for depressive symptoms, securing access to behavioral health professionals, either within or beyond the primary care setting, collaboration with diabetes care and education specialists to support problem-solving of diabetes self-management, and monitoring the use and effectiveness of antidepressant medications.

Stories for change protocol: A randomized controlled trial of a digital storytelling intervention for Hispanic/Latino individuals with type 2 diabetes

BACKGROUND

Hispanic/Latino adults are disproportionately impacted by type 2 diabetes mellitus (T2D). The Stories for Change (S4C) Diabetes digital storytelling intervention promotes T2D self-management among Hispanic/Latino people. We describe the S4C protocol and participant baseline characteristics.

METHODS

Study eligibility criteria: Hispanic or Latino, age 18-70 years, ≥1 office visit within a year at a participating clinic, T2D diagnosis for ≥6 months, HbA1c ≥ 8%, and intention to continue care at the recruitment clinic. We used a two-group, parallel randomized controlled trial design and an intervention derived through a community-based participatory research approach. All participants received usual diabetes care and two cards describing how to engage healthcare teams and access diabetes-related resources. At baseline, the intervention group additionally viewed the 12-min, intervention video (four stories about diabetes self-management). To encourage subsequent video viewing, participants received five monthly text messages. The messages prompted them to self-rate their motivation and self-efficacy for T2D management. The control group received no additional intervention. Bilingual (English/Spanish) staff collected data at baseline, six weeks, three months, and six months including biometric measurements and a survey on diabetes self-management outcomes, theory-based measures, and the number of video views. We reviewed the number of diabetes-related appointments attended using electronic medical record data.

RESULTS

Participants (n = 451; 70% women, mean age = 53 years) had an average HbA1C ≥9%. Intervention participants reported identifying with the storytellers and engaging with the stories.

CONCLUSION

We present a digital storytelling intervention protocol that provides a template for future health promotion interventions prioritizing health disparity populations.

CLINICALTRIAL

gov#NCT03766438.

Psychosocial factors predict medication adherence in young adults with youth-onset type 2 diabetes: Longitudinal results from the TODAY2 iCount study

AIM

To identify psychosocial predictors of medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

METHODS

Participants (mean age: 26 years) completed validated psychosocial measures. Unannounced telephone pill counts were completed at T1 (baseline) and T2 (follow-up, approximately 1 year later) to assess adherence to oral hypoglycaemia agents (OHAs). Adherence to insulin was assessed by self-report. Logistic and linear regressions identified factors that predicted 'low adherence' (<80% of pills/insulin) and per cent adherence, adjusted for potential confounders.

RESULTS

Of 171 participants with OHA adherence scores at T1 and T2 (65% women, 43% Hispanic and 35% non-Hispanic Black), 65.4% were low adherent. After adjustment (including T1 adherence), concerns about diabetes medicines (adverse effects, dependence) at T1 predicted higher odds of being low adherent (categorical) at T2 (p = 0.019). Housing insecurity (p = 0.045) and reporting ≥2 need insecurities (p = 0.027) at T1 predicted lower per cent adherence (continuous) at T2. Of 157 participants with insulin adherence scores at T1 and T2 (69% women, 38% Hispanic and 38% non-Hispanic Black), 36.3% were low adherent. After adjustment (including T1 adherence), beliefs that medicines are overused predicted higher odds of insulin low adherence at T2 (p = 0.013), and beliefs that medicines are harmful (p = 0.004) and overused (p = 0.010) predicted lower per cent insulin adherence at T2.

CONCLUSIONS

Suboptimal medication adherence, common in young adults with youth-onset type 2 diabetes, is predicted by interfering beliefs about medicines and social factors. We must address these beliefs and unmet needs to develop tailored interventions for this vulnerable group.

Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes

Black individuals with diabetes have high rates of emergency department (ED) use. This randomized controlled trial compared the efficacy of Diabetes Interprofessional Team to Enhance Adherence to Medical Care (DM I-TEAM) versus Usual Medical Care (UMC) to reduce number of return ED visits/hospitalizations over 12 months in 200 Black individuals with diabetes after an ED visit. DM I-TEAM consisted of community health worker-delivered diabetes education and behavior activation, telehealth visits with a diabetes nurse educator and primary care physicians, and clinical pharmacist recommendations to reduce potentially inappropriate medications (PIMs). Secondary outcomes included glycemic control, PIMs use, diabetes self-management, diabetes self-efficacy, depression, and medical trust. Participants had a mean age of 64.9 years and 73.0% were women. The 2 treatment groups were similar in baseline characteristics. Sixty-eight (69.4%) DM I-TEAM participants and 69 (67.6%) UMC participants had at least 1 incident ED visit/hospitalization over 12 months. The adjusted incidence rate ratio for DM I-TEAM versus UMC was 1.11 (95% confidence interval 0.79-1.56; P = 0.54). DM I-TEAM participants attained significantly better diabetes self-management, diabetes self-efficacy, and institutional trust than UMC participants. There were no treatment group differences in hemoglobin A1c level nor PIMs use. Among Black individuals with diabetes, a novel culturally relevant intervention was no better than usual care at preventing return ED visits/hospitalizations over 1 year. Before reasonable clinical interventions such as DM I-TEAM can be effective, reducing system-level barriers to health, building community health care capacity, and designing interventions that better align with the everyday realities of patients' lives are necessary. clinicaltrials.gov NCT03393338.

Implementation of Self-Care Deficits Assessment and a Nurse-Led Supportive Education Program in Community Hospitals for Behavior Change and HbA1c Reduction: A Cluster Randomized Controlled Trial

BACKGROUND

The prevalence of uncontrolled type 2 diabetes has been increasing, and the nurse is a primary healthcare provider to patients when health professionals are scarce in the community setting. A feasible intervention delivered by nurses is necessary to fulfill patients' needs to help them achieve glycemic control.

AIM

To investigate whether Thai adults with uncontrolled diabetes in community hospitals lack self-care competency and whether a nurse-led supportive education program can enhance their self-care skills, change behavior, and control HbA1C levels.

METHODS

We employed a multi-community hospital cluster randomized controlled trial design. Participants were randomly selected in the experimental group (2 hospitals) and control group (2 hospitals), with 30 patients from each hospital. One hundred twenty adults with HbA1c 7-10% treated by oral glycemic medication were recruited. Using Orem's Theory as a framework, nurses implemented self-care deficit assessments and supportive-educative nursing programs into their work. Participants in the control group received usual care, and those in the experimental group underwent a nurse assessment and supportive education measures. Data were collected at baseline, with 4-week and 12-week follow-ups. Data analysis were a repeated measures ANOVA with post hoc analysis, and Independent t-test.

RESULTS

One hundred three patients completed the trial (51 in the experimental group and 52 in the control group). At 12 weeks, there were statistically significant improvements in HbA1c (P < .001), fasting plasma glucose (P = .03), knowledge (P < .001), diabetes self-care agency (P < .001), diet consumption (P < .001), physical activity (P < .001), and medical adherence (P = .03) in the experimental group significantly greater than those in the control group. Also, the between-group effect sizes were 0.49 or greater.

CONCLUSION

The self-care deficit assessment and supportive education program were essential to the nursing intervention that effectively improved knowledge, changed behavior, and HbA1c levels among adults with uncontrolled blood glucose.

Naturalizing digital and quality of life in chronic diseases: Systematic review to research perspective into technological advancing and personalized medicine

The increasing of chronic diseases and related health management are the main clinical and public health challenges. The long-term nature and the need for continuous monitoring in chronic disease management gave rise to early technological innovations (mobile Health) to improve care management plans, therapeutic adherence, and psychological support to the patient. This review aimed to map the literature on the impact of the use of wearable device on quality of life in patients with chronic diseases. We performed a systematic search of MEDLINE through PubMed, Web of Science, and Scopus of all scientific literature published until January 2022. Based on inclusion and exclusion criteria, a total of 10 papers were included. This review pointed out the relevant focus on the use of wearable device in chronic disease patients highlighting the wearable device impact on several domains including quality of life, Self-Efficacy, Self-Management, and feelings on patients with chronic diseases. The available scientific literature related to the impact of the use of wearable device on quality of life and psychological features in patients with chronic diseases, general underline a need to develop professional healthcare guidelines and tailored intervention on patients with a chronic condition, using mobile Health solutions and trying to fill the lack of knowledge about the topic.

Association of psychosocial factors with medication adherence in emerging adults with youth-onset type 2 diabetes: The iCount study

AIMS

To assess associations of psychosocial factors with medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

METHODS

Participants (mean age 26 years) completed validated psychosocial measures. Adherence to oral hypoglycemia agents (OHAs) was assessed with 3-monthly unannounced phone pill counts; insulin adherence by self-report. Logistic and linear regressions identified factors associated with "low-adherence" (<80% of pills/insulin) controlling for confounders.

RESULTS

Of 212 participants taking OHAs (67% female, 39% Hispanic, 36% non-Hispanic Black), 69.8% were low-adherent. After adjustment, beliefs that medicines are necessary was associated with lower odds of low-adherence (p = 0.040, dichotomous). Less self-management support (p = 0.008), no healthcare coverage (p = 0.001), ≥1 (p = 0.008)/≥2 (p = 0.045) need insecurities were associated with higher odds of low-adherence. Factors associated with lower % adherence (continuous) were beliefs that medicines are harmful (p < 0.001)/overused (p = 0.007)/less necessary (p = 0.022), low self-management support (p = 0.003), food insecurity (p = 0.036), no healthcare coverage (p < 0.001), ≥1 (p = 0.003)/≥2 (p = 0.018) need insecurities. Of 192 taking insulin (69% female, 36% Hispanic, 41% non-Hispanic Black, 16% non-Hispanic white), 37.0% were low-adherent. Beliefs that medicines are overused (p = 0.009), that diabetes is not serious (p = 0.010), low diabetes self-efficacy (p = 0.035), high distress (p = 0.027), low self-management support (p = 0.001), food insecurity (p = 0.020), ≥1 (p = 0.011)/≥2 (p = 0.015) insecurities increased odds of insulin low-adherence.

CONCLUSIONS

Poor medication adherence, common in young adults with youth-onset type 2 diabetes, is associated with interfering beliefs, diabetes distress and social factors. We must address these factors to develop tailored interventions for this vulnerable group.

Prenatal Depressive Symptoms, Self-Rated Health, and Diabetes Self-Efficacy: A Moderated Mediation Analysis

BACKGROUND

Diabetes leads to risk for pregnant persons and their fetuses and requires behavioral changes that can be compromised by poor mental health. Poor self-rated health (SRH), a reliable predictor of morbidity and mortality, has been associated with depressive symptoms and lower self-efficacy in patients with diabetes. However, it is unclear whether SRH mediates the association between depressive symptoms and self-efficacy in pregnant patients with diabetes and whether the healthcare site moderates the mediation. Thus, we sought to test these associations in a racially and ethnically diverse sample of pregnant individuals diagnosed with diabetes from two clinical settings.

MATERIALS AND METHODS

This was an observational, cross-sectional study of 137 pregnant individuals diagnosed with diabetes at two clinical study sites. Participants self-administered a demographic questionnaire and measures designed to assess depressive symptoms, SRH in pregnancy, and diabetes self-efficacy. A moderated mediation model tested whether these indirect effects were moderated by the site.

RESULTS

The results show that SRH mediated the association between depressive symptoms and diabetes self-efficacy. The results also showed the site moderated the mediating effect of SRH on depressive symptoms and diabetes self-efficacy.

CONCLUSIONS

Understanding the role of clinical care settings can help inform when and how SRH mediates that association between prenatal depressive symptoms and self-efficacy in diabetic patients.

Sleep optimization to improve glycemic control in adults with type 1 diabetes: study protocol for a randomized controlled parallel intervention trial

BACKGROUND

Despite improvements in treatment regimens and technology, less than 20% of adults with type 1 diabetes (T1D) achieve glycemic targets. Sleep is increasingly recognized as a potentially modifiable target for improving glycemic control. Diabetes distress, poor self-management behaviors, and reduced quality of life have also been linked to sleep variability and insufficient sleep duration. A significant gap of knowledge exists regarding interventions to improve sleep and the effects of sleep optimization on glycemic control in T1D. The purpose of this study is to determine the efficacy of a T1D-specific sleep optimization intervention (Sleep-Opt) on the primary outcomes of sleep variability, sleep duration, and glycemic control (A1C); other glycemic parameters (glycemic variability, time-in-range [TIR]); diabetes distress; self-management behaviors; quality of life; and other patient-reported outcomes in adults with T1D and habitual increased sleep variability or short sleep duration.

METHODS

A randomized controlled parallel-arm study will be employed in 120 adults (aged 18 to 65 years) with T1D. Participants will be screened for habitual sleep variability (> 1 h/week) or insufficient sleep duration (< 6.5 h per night). Eligible subjects will be randomized to the Sleep-Opt intervention group or healthy living attention control group for 12 weeks. A 1-week run-in period is planned, with baseline measures of sleep by actigraphy (sleep variability and duration), glycemia (A1C and related glycemic measures: glycemic variability and TIR using continuous glucose monitoring), and other secondary outcomes: diabetes distress, self-management behaviors, quality of life, and additional patient-reported outcomes. Sleep-Opt is a technology-assisted behavioral sleep intervention that we recently developed that leverages the rapidly increasing public interest in sleep tracking. Our behavioral intervention employs four elements: a wearable sleep tracker, didactic content, an interactive smartphone application, and brief telephone counseling. The attention control group will participate in a healthy living information program. Baseline measures will be repeated at midpoint, program completion, and post-program (weeks 6, 12, and 24, respectively) to determine differences between the two groups and sustainability of the intervention.

DISCUSSION

A better understanding of strategies to improve sleep in persons with T1D has the potential to be an important component of diabetes.

TRIAL REGISTRATION

Clinical Trial Registration: NCT04506151 .

Text Message Intervention for Latino Adults to Improve Diabetes Outcomes

Introduction: Determine the effectiveness of a diabetes text message intervention to improve diabetes outcomes in Latino adults at a free clinic in the southeastern United States. Methods: A pre-post, one-group design was used with a convenience sample (n = 24) of Latino adults with type 2 diabetes and A1C ≥ 7 who consented to participate. Over 8 weeks, participants were sent 23 educational and motivational text messages that were based on the American Association of Diabetes Educators (AADE) 7 self-care tasks and the American Diabetes Association (ADA) Standards of Medical Care in Diabetes Mellitus (DM). Diabetes knowledge, self-efficacy, self-care, and A1C were measured. Results: Diabetes knowledge, self-efficacy, self-care, and A1C improved after 8 weeks. Statistically significant results (p < .05) were seen in two of the four evaluation instruments administered (Spoken Knowledge in Low Literacy in Diabetes Scale [SKILLD], p = .001, Diabetes Self-Efficacy Scale [DSES], p = .000). A1C improvements were significant (0.86 or 10 mmol/mol) from the pre-intervention (M = 9.06 [76 mmol/mol], SD = 1.49) to the post-intervention (M = 8.20 [66 mmol/mol], SD = 1.27, t [23] = 3.02, p = .006). Conclusion: Personalized communication, education, and follow-up via text messages improved diabetes knowledge, self-efficacy, self-care, and A1C among pilot project participants. Text messages are a useful tool for diabetes management.

Effects of an integrated mindfulness intervention for veterans with diabetes distress: a randomized controlled trial

INTRODUCTION

US military veterans have disproportionately high rates of diabetes and diabetes-related morbidity in addition to being at risk of comorbid stress-related conditions. This study aimed to examine the effects of a technology-supported mindfulness intervention integrated into usual diabetes care and education on psychological and biobehavioral outcomes.

RESEARCH DESIGN AND METHODS

Veterans (N=132) with type 1 or 2 diabetes participated in this two-arm randomized controlled efficacy trial. The intervention arm received a one-session mindfulness intervention integrated into a pre-existing program of diabetes self-management education and support (DSMES) plus one booster session and 24 weeks of home practice supported by a mobile application. The control arm received one 3-hour comprehensive DSMES group session. The primary outcome was change in diabetes distress (DD). The secondary outcomes were diabetes self-care behaviors, diabetes self-efficacy, post-traumatic stress disorder (PTSD), depression, mindfulness, hemoglobin A1C (HbA1C), body weight, and blood pressure. Assessments were conducted at baseline, 12 weeks, and 24 weeks. Participant satisfaction and engagement in home practice were assessed in the intervention group at 12 and 24 weeks.

RESULTS

Intention-to-treat group by time analyses showed a statistically significant improvement in DD in both arms without significant intervention effect from baseline to 24 weeks. Examination of distal effects on DD between weeks 12 and 24 showed significantly greater improvement in the intervention arm. Improvement in DD was greater when baseline HbA1C was <8.5%. A significant intervention effect was also shown for general dietary behaviors. The secondary outcomes diabetes self-efficacy, PTSD, depression, and HbA1C significantly improved in both arms without significant intervention effects. Mindfulness and body weight were unchanged in either group.

CONCLUSIONS

A technology-supported mindfulness intervention integrated with DSMES showed stronger distal effects on DD compared with DSMES control. Examination of longer-term outcomes, underlying mechanisms, and the feasibility of virtual delivery is warranted.

TRIAL REGISTRATION NUMBER

NCT02928952.

Changes in quality of life following hypoglycaemia in adults with type 2 diabetes: A systematic review of longitudinal studies

AIM

To conduct a systematic review of published studies reporting on the longitudinal impacts of hypoglycaemia on quality of life (QoL) in adults with type 2 diabetes.

METHOD

Database searches with no restrictions by language or date were conducted in MEDLINE, Cochrane Library, CINAHL and PsycINFO. Studies were included for review if they used a longitudinal design (e.g. cohort studies, randomised controlled trials) and reported on the association between hypoglycaemia and changes over time in patient-reported outcomes related to QoL.

RESULTS

In all, 20 longitudinal studies published between 1998 and 2020, representing 50,429 adults with type 2 diabetes, were selected for review. A descriptive synthesis following Synthesis Without Meta-analysis guidelines indicated that self-treated symptomatic hypoglycaemia was followed by impairments in daily functioning along with elevated symptoms of generalised anxiety, diabetes distress and fear of hypoglycaemia. Severe hypoglycaemic events were associated with reduced confidence in diabetes self-management and lower ratings of perceived health over time. Frequent hypoglycaemia was followed by reduced energy levels and diminished emotional well-being. There was insufficient evidence, however, to conclude that hypoglycaemia impacted sleep quality, depressive symptoms, general mood, social support or overall diabetes-specific QoL.

CONCLUSIONS

Longitudinal evidence in this review suggests hypoglycaemia is a common occurrence among adults with type 2 diabetes that impacts key facets in the physical and psychological domains of QoL. Nonetheless, additional longitudinal research is needed-in particular, studies targeting diverse forms of hypoglycaemia, more varied facets of QoL and outcomes assessed using hypoglycaemia-specific measures.

Type 2 Diabetes Self-Management Variables and Predictors

Guided by the Self and Family-Management framework, relationships between diabetes distress, self-efficacy, resilience and outcomes of A1c, quality of life and health status were explored. A cross sectional descriptive design was used. 78 individuals were enrolled from US clinics. Data were analyzed to test for associations, main effects and interactions and predictors of self-management. Results indicated low diabetes distress (M = 20.53), high self-efficacy (M = 7.32), moderate resilience (M = 80.27), and mean A1c 7.35%/56.88 mmol/mol. 76% scored above the mental health norm, 46% scored above the physical health norm. Average weighted quality of life = -1.74. Diabetes distress was negatively associated with self-efficacy, resilience, physical health, mental health, and quality of life. Self-efficacy was positively associated with resilience, physical health and quality of life. Resilience was positively associated with physical health, mental health and quality of life. Positive associations were found between quality of life, physical and mental health. No associations were found between A1c and variables in the study. Multiple significant interactions were found with A1c, mental health and quality of life outcomes. Terms in the model included treatment regimen, years since diagnosis, provider collaboration and history of diabetes self-management education. Distress was a significant predictor of health status and quality of life. The results confirm self-management facilitators self-efficacy and resilience and barrier diabetes distress and their relationships with outcomes in the framework. This study contributes to the understanding of the emotional aspect of diabetes. Continuing this work will allow researchers to better understand self-management, support self-management efforts and better outcomes.

Feasibility and Acceptability of a Digital Patient-Reported Outcome Tool in Routine Outpatient Diabetes Care: Mixed Methods Formative Pilot Study

Background

Improvements in the digital capabilities of health systems provide new opportunities for the integration of patient-reported outcome (PRO) solutions in routine care, which can facilitate the delivery of person-centered diabetes care. We undertook this study as part of our development of a new digital PRO diabetes questionnaire and clinical dialog support tool for use by people with diabetes and their health care professionals (HCPs) to improve person-centered diabetes care quality and outcomes.

Objective

This study evaluates the feasibility, acceptability, and perceived benefits and impacts of using a digital PRO diabetes tool, DiaProfil, in routine outpatient diabetes care.

Methods

Overall, 12 people with diabetes scheduled for routine medical diabetes visits at the outpatient clinic were recruited. Purposive sampling was used to optimize heterogeneity regarding age, gender, duration, type of diabetes, treatment modality, and disease severity. Participants filled out a PRO diabetes questionnaire 2 to 5 days before their visit. During the visit, HCPs used a digital PRO tool to review PRO data with the person with diabetes for collaborative care planning. Participants completed evaluation forms before and after the visit and were interviewed for 30 to 45 minutes after the visit. HCPs completed the evaluation questionnaires after each visit. All visits were audio-recorded and transcribed for analysis. Data were analyzed using quantitative, qualitative, and mixed methods analyses.

Results

People with diabetes found the PRO diabetes questionnaire to be relevant, acceptable, and feasible to complete from home. People with diabetes and HCPs found the digital PRO tool to be feasible and acceptable for use during the diabetes visit and would like to continue using it. HCPs were able to use the tool in a person-centered manner, as intended. For several people with diabetes, completion of the questionnaire facilitated positive reflection and better preparation for the visit. The use of the PRO tool primarily improved the quality of the dialog by improving the identification and focus on the issues most important to the person with diabetes. People with diabetes did not report any negative aspects of the PRO tool, whereas HCPs highlighted that it was demanding when the person with diabetes had many PRO issues that required attention within the predefined time allocated for a visit.

Conclusions

The Danish PRO diabetes questionnaire and the digital tool, DiaProfil, are feasible and acceptable solutions for routine diabetes visits, and this tool may generate important benefits related to advancement of person-centered care. Further research is now required to corroborate and expand these formative insights on a larger scale and in diverse health care settings. The results of this study are therefore being used to define research hypotheses and finalize real-world PRO evaluation tools for a forthcoming large-scale multisector implementation study in Denmark.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Identification of diabetes self-management profiles in adults: A cluster analysis using selected self-reported outcomes

The present study describes adult diabetes self-management (DSM) profiles using self-reported outcomes associated with the engagement in diabetes care activities and psychological adjustment to the disease. We used self-reported data from a community-based cohort of adults with diabetes (N = 316) and conducted a cluster analysis of selected self-reported DSM outcomes (i.e., DSM behaviors, self-efficacy and perceived empowerment, diabetes distress and quality of life). We tested whether clusters differed according to sociodemographic, clinical, and care delivery processes variables. Cluster analysis revealed four distinct DSM profiles that combined high/low levels of engagement in diabetes care activities and good/poor psychological adjustment to the disease. The profiles were differently associated with the variables of perceived financial insecurity, taking insulin treatment, having depression, and the congruence of the care received with the Chronic Care Model. The results could help health professionals gain a better understanding of the different realities facing people living with diabetes, identify patients at risk of poor outcomes related to their DSM, and lead to the development of profile-specific DSM interventions.

General Behavioral Engagement and Changes in Clinical and Cognitive Outcomes of Patients with Type 2 Diabetes Using the Time2Focus Mobile App for Diabetes Education: Pilot Evaluation

Background

Type 2 diabetes affects 30 million Americans, representing a significant cause of morbidity and mortality. Self-management support is an important component of chronic illness care and is a key pillar of the chronic care model. Face-to-face teaching and patient education materials suffer from being static or incompatible with mobile lifestyles. Digital apps provide a self-management support alternative that is convenient and scalable.

Objective

This pilot study tested the real-world deployment of a self-guided mobile app for diabetes education (Time2Focus app; MicroMass Communications Inc, Cary, NC), which utilizes evidence-based content and gamification to deliver an interactive learning experience.

Methods

Primary care providers were approached for permission to invite their patients to participate. Eligible patients were 18 to 89 years of age, had a diagnosis of type 2 diabetes, hemoglobin A1c (HbA1c) ≥8% and <12% in the past 3 months, an active online patient portal account (tied to the electronic health record), and access to an iOS or Android smartphone. Interested patients were emailed a baseline survey, and once this was completed, were sent instructions for downloading the Time2Focus app. After completing all 12 levels, participants were sent a follow-up survey. The primary outcome was the change in HbA1c. Secondary outcomes included medication adherence, self-care activities, self-reporting of physical activities, diabetes self-efficacy, illness perceptions, diabetes distress scale, and users’ engagement with and rating of the app.

Results

Of 1355 potentially eligible patients screened, 201 were consented. Of these 201 patients, 101 (50.2%) did not download the app. Of the 100 participants (49.8%) who downloaded the app, 16 (16.0%) completed 0 levels, 26 (26.0%) completed 1 to 4 levels, 10 (10.0%) completed 5 to 11 levels, and 48 (48.0%) completed all 12 levels of the app and the follow-up survey. Those completing one or more levels had a mean pre/post-HbA1c change of –0.41% (compared to –0.32% among those who completed zero levels); however, the unadjusted two-tailed t test indicated no significant difference between the two groups (P=.73). Diabetes self-efficacy showed a large and significant increase during app usage for completers (mean change 1.28, P<.001, d=.83). Severity of illness perceptions showed a small but significant decrease during app usage for completers (mean change –0.51, P=.004, d=.43). Diabetes distress showed a small but significant decrease during app usage for completers (mean change –0.45, P=.006, d=.41). The net promoter score was 62.5, indicating that those who completed all levels of the app rated it highly and would recommend it to others.

Conclusions

Participants who engaged in all 12 levels of the Time2Focus mobile app showed an improvement in diabetes self-efficacy and a decrease in severity of illness perceptions. The decrease in HbA1c observed in app users relative to nonusers during this limited pilot study was not statistically significant. However, uptake and application of lessons learned from self-management support may be delayed. Further research is needed to address how to increase engagement through self-management support and to investigate if follow up over a longer period demonstrates a significant change in outcomes such as HbA1c.

Feasibility of Using Mobile Technology to Improve Physical Activity Among People Living with Diabetes in Asia

Background: Chronic conditions such as diabetes (DM) and cardiovascular disease are associated with disability and poor quality of life. Asians are 30% more likely than non-Hispanic Whites to develop type 2 DM. The important roles of wearable technological applications or devices in maintaining individuals' motivation to attain their physical activity (PA) goal have been reported. However, evidence of the feasibility and impact of the mobile technology on the PA in Thailand is limited. This study aims to examine the feasibility and the impact of the immediate performance feedback feature of the wearable device on PA. Methods: This pilot study recruited persons aged 18 or older with diabetes from two diabetes clinics in Chiang Mai, Thailand. Participants were randomly assigned into three groups: the aware group (AW: can see the step count on the device screen), the unaware group (UW: the device screen was completely covered), and the control group (usual care). Participants in the AW and UW groups were asked to wear the device for 2 full days while the usual care group did not wear the device. All participants completed a questionnaire package at their first study visit. Data analysis of univariate and multivariate general linear models were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC). All significance levels were set at 5%. Results: One hundred and fourteen participants age ranged from 39 to 75 years old were included in this analysis. The majority were female (n = 86, 69%) and married (n = 103, 82%). No adverse events were reported among device users. Within 2 days, there were less than 10% missing data and more than 70% of participants liked the devices mainly because they could see the step count. More than 63% of participants who wore the device had an average of steps greater than 10,000 per day. Although the number of steps and sleep hours were not significantly different between the AW and UW groups, 68% of the AW participants found that the device help them with their exercise. Discussion: The results demonstrate the feasibility of the use of the wearable device among people living with chronic conditions. Participants found that the step count screen provided immediate physical performance feedback that was helpful with their exercise. The behavioral changes, however, could not be examined due to the short duration of the usage. Future studies that require longer device usage in larger sample sizes are needed.

Self-efficacy instruments for type 2 diabetes self-care: A systematic review of measurement properties

AIMS

To identify currently available self-efficacy instruments for type 2 diabetes self-care and to evaluate the evidence for their measurement properties.

DESIGN

Systematic review of measurement properties.

DATA SOURCES

The PubMed, Embase and CINAHL databases were searched from their inception to 27 May 2019.

REVIEW METHODS

The updated COnsensus-based Standards for the selection of health Measurement INstruments methodology were applied.

RESULTS

Twelve instruments were identified from 3,665 records. Eight instruments were related to self-efficacy in performing a comprehensive set of the tasks/behaviours for diabetes self-care and the other four addressed specific behaviours related to diabetes self-care, such as insulin management. Most of the 12 instruments were developed based on Bandura's self-efficacy theory as their theoretical background. Overall, sufficient high-quality evidence for measurement properties was seldom identified. The Diabetes Management Self-Efficacy Scale is currently the best instrument, with particularly the 4-factor, 16-item version being demonstrated to have sufficient high-quality evidence for structural and internal consistency and sufficient moderate-quality evidence for reliability and convergent validity.

CONCLUSIONS

None of the instruments evaluated all of the relevant measurement properties. The Diabetes Management Self-Efficacy Scale is currently the most suitable instrument for potential use in practice and research. The measurement invariance across languages, measurement error and responsiveness of this instrument still need be evaluated.

IMPACT

This systematic review provides clinicians and researchers with a comprehensive list of available instruments for measuring self-efficacy in diabetes self-care, as well as evidence for helping them to select the most appropriate instrument. Using a psychometrically sound instrument will accurately inform practitioners about the levels of self-efficacy in self-care among patients with type 2 diabetes in practice and avoid threatening the credibility of research studies on self-efficacy in diabetes self-care.

¡Sí, Yo Puedo Vivir Sano con Diabetes! A Self-Management Randomized Controlled Pilot Trial for Low-Income Adults with Type 2 Diabetes in Mexico City

BACKGROUND

Type 2 diabetes (T2D) is a worldwide epidemic and a leading cause of death in Mexico, with a prevalence of 15.9%, and >70% of diagnosed adults have poor glycemic control [glycated hemoglobin (HbA1c) >7.5%]. We developed a diabetes self-management education program contextualized to the study population, including dietary preferences, health literacy, and health system.

OBJECTIVES

We aimed to evaluate the efficacy of a self-management + text message program (¡Sí, Yo Puedo Vivir Sano con Diabetes!) on primary (HbA1c), and secondary behavioral (self-management), clinical, and psychosocial outcomes in adults with T2D in Mexico City.

METHODS

Participants were recruited at public primary healthcare centers (Seguro Popular), and randomly allocated to treatment (n = 26) or wait-list control groups (n = 21) with data collected at 3 and 6 mo. The program included 7 weekly sessions and 6 mo of daily text/picture messages. Descriptive statistics and a generalized linear mixed model with intent-to-treat analysis were calculated.

RESULTS

Participants were 55.5 ± 8.8 y of age (mean ± SD), 68% female, 88.6% overweight/obese, and 57% lived in food-insecure households. Mean ± SD T2D duration was 11.9 ± 7.8 y and HbA1c was 9.2% ± 1.5%. There was 89% attendance at sessions and 6.4% attrition across both groups at 6 mo. Group-by-time effects were seen in self-monitoring of blood glucose (P < 0.01) and diabetes self-efficacy (P < 0.04); and a trend for lower HbA1c was seen in the intervention group at 6 mo (P = 0.11). Significant improvements in dietary behavior (P < 0.01) were demonstrated in the intervention group over time, but this did not reach statistical significance compared with the control group.

CONCLUSIONS

The program was associated with clinically significant improvements in T2D self-management, self-efficacy, and HbA1c over time. Thus, T2D self-management skills, including diet, were improved in a vulnerable metropolitan population.This trial was registered at clinicaltrials.gov as NCT03159299.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Feasibility study of automated interactive voice response telephone calls with community health nurse follow-up to improve glycaemic control in patients with type 2 diabetes

BACKGROUND

Thailand has a shortage of community health nurses for supporting the self-management of type 2 diabetes, which is prevalent and poorly controlled.

AIM

This study examined the feasibility and acceptability of a self-care assistance programme for poorly controlled type 2 diabetes mellitus. The SukapapNet programme consisted of automated interactive voice response calls to patients and automated follow-up email notifications to their nurses.

DESIGN

Single-arm pre-post trial.

METHODS

Six nurses and 35 type 2 diabetes patients were recruited from primary care settings in suburban provinces in Thailand. The study was conducted from June 2017 to November 2017. We assessed patients before and after 12 weeks of the SukapapNet intervention.

RESULTS

Mean glycated haemoglobin decreased by 0.9%. Patients reported reduced carbohydrate consumption, increased physical activity, increased medication adherence, improved sleep quality, and more frequent foot care. Patients and nurses both recommended using the intervention, although nurses expressed concerns regarding increased workload.

CONCLUSIONS

The study programme could improve outcomes in Thai type 2 diabetes patients. Further study of the impact of technology upon nurses' workload is warranted.

Efficacy of a self-management education programme on patients with type 2 diabetes in primary care: A randomised controlled trial

AIM

The purpose of this study was to assess the efficacy of the Spanish Diabetes Self-Management Program (SDSMP) versus usual care in adults with type 2 diabetes mellitus (T2DM) residing in a Spanish region.

METHODS

A two-year follow-up randomised controlled trial. The intervention consisted of 6 weekly structured peer-to-peer workshops. The primary outcome was change in HbA1c levels. Secondary outcomes included other clinical measures, quality of life, self-efficacy, life-style changes, medication and use of healthcare services. Mixed effect models were fitted.

RESULTS

n=297 patients were recruited in each study arm. Baseline HbA1c levels were comparable in both groups with an overall mean 7.1 (SD=1.2). The intervention did not significantly modify HbA1c, or other cardiovascular variables. Significant improvements were seen in self-efficacy, and in particularly its disease control component. Certain differences were also observed in the use of healthcare resources and medication consumption. High workshop participation and satisfaction rates were achieved.

CONCLUSION

HbA1c reductions are difficult to obtain in adequately controlled patients. On the other hand, raising awareness on one's disease can increase disease control self-efficacy. This finding, accompanied by reduced medication consumption and healthcare use rates, highlights that usual care would be benefited by incorporating certain SDSMP aspects.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01642394.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

2017 National Standards for Diabetes Self-Management Education and Support

Purpose

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

Methods

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

Results

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

Conclusion

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Baseline Characteristics and Technology Training of Underserved Adults With Type 2 Diabetes in the Mobile Diabetes Detective (MoDD) Randomized Controlled Trial

Purpose The purpose of this study is to describe the characteristics and technology training needs of underserved adults with type 2 diabetes mellitus (T2DM) who participated in a health information technology (HIT) diabetes self-management education (DSME) intervention. Methods The baseline physiological, psychosocial, and technology use characteristics for 220 adults with poorly controlled T2DM were evaluated. Intervention participants received a 1-time intervention training, which included basic technology help, introduction to the Mobile Diabetes Detective (MoDD) website and text message features, and account activation that included subject-specific tailoring. Four additional on-site sessions for participants needing computer or Internet access or technology support were made available based on need. Data regarding on-site visits for usual care were collected. Data were analyzed using descriptive statistics and bivariate analysis. Results The participants were predominately Hispanic and female with a baseline mean A1C of 10% (86 mmol/mol). Only half of the participants regularly used computers or text messages in daily life. The average introductory MoDD training session lasted 73.6 minutes. Following training, approximately one-third (35%) of intervention participants returned for basic and MoDD-specific technology assistance at their federally qualified health center. The most frequently reported duration for the extra training sessions was 30 to 45 minutes. Conclusions Training and support needs were greater than anticipated. Diabetes educators should assess technology abilities prior to implementing health information technology (HIT) diabetes self-management education (DSME) in underserved adults. Future research must invest resources in technology access, anticipate subject training, and develop new training approaches to ensure HIT DSME use and engagement.

2017 National Standards for Diabetes Self-Management Education and Support

This article was copublished in Diabetes Care 2017;40:1409-1419 and The Diabetes Educator 2017;43:449-464 and is reprinted with permission. The previous version of this article, also copublished in Diabetes Care and The Diabetes Educator, can be found at Diabetes Care 2012;35:2393-2401 (https://doi.org/10.2337/dc12-1707).

2017 National Standards for Diabetes Self-Management Education and Support

Purpose The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. Methods The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Results Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Conclusion Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study

Background

Diabetes self-management education has been shown to be effective in controlled trials. However, few programs that meet American Association of Diabetes Educators standards have been translated into widespread practice.

Objective

This study examined the translation of the evidence-based Better Choices, Better Health-Diabetes program in both Internet and face-to-face versions.

Methods

We administered the Internet program nationally in the United States (n=1010). We conducted face-to-face workshops in Atlanta, Georgia; Indianapolis, Indiana; and St. Louis, Missouri (n=232). Self-report questionnaires collected health indicator, health behavior, and health care utilization measures. Questionnaires were administered on the Web or by mail. We determined hemoglobin A_1c (HbA_1c) from blood samples collected via mailed kits. Paired t tests determined whether changes between baseline and 6 months differed significantly from no change. Subgroup analyses determined whether participants with specific conditions benefited (high HbA_1c, depression, hypoglycemia, nonadherence to medication taking, and no aerobic exercise). We calculated the percentage of participants with improvements of at least 0.4 effect size in at least one of the 5 above measures.

Results

Of the 1242 participants, 884 provided 6-month follow-up questionnaires. There were statistically significant improvements in 6 of 7 health indicators (including HbA_1c) and in 7 of 7 behaviors. For each of the 5 conditions, there were significant improvements among those with the condition (effect sizes 0.59–1.1). A total of 662 (75.0%) of study participants improved at least 0.4 effect size in at least one criterion, and 327 (37.1%) improved in 2 or more.

Conclusions

The Diabetes Self-Management Program, offered in two modes, was successfully disseminated to a heterogeneous national population of members of either insured or administered health plans. Participants had small but significant benefits in multiple measures. The program appears effective in improving diabetes management.