Participation in a diabetes education and care program: experience from the diabetes care for older adults project

Patient Experience in Older Adults with Diabetes: A Narrative Review on Interventions to Improve Patient Experience and Research Gaps

Patient experience is a critical healthcare quality indicator, evolving from Patient Satisfaction (PS) and encompassing patients' concrete healthcare experiences. It is increasingly vital in aging societies where collaborative efforts among patients, families, and healthcare professionals are essential. Studies suggest that enhanced patient experience leads to better adherence, outcomes, and patient safety. This paper reviews patient experience evaluations in older adults with diabetes through randomized controlled trial (RCT)-based findings. The author searched PubMed/MEDLINE, Embase, AMED, and CINAHL. The review focused on RCTs examining interventions affecting patient experience and PS in T2D/T1D patients aged ≥65. A total of 13 RCTs were eligible for this review. This review highlights studies on diabetes management in older adults, assessing the impact of health education, diabetes management programs, treatments, mHealth, and advanced insulin delivery systems. Early studies showed that education improved self-care but had a limited impact on glycemic control. Key findings include the effectiveness of experience-based education in improving HbA1c, the benefits of insulin therapy for elderly patients, and the value of structured peer-to-peer diabetes management programs in enhancing satisfaction. Patient adherence, satisfaction, and personalized support emerged as critical factors influencing diabetes management across various interventions. More recent trials involving mHealth demonstrated improvements in glycemic control and PS through automated data sharing and app-based support. Closed-loop insulin delivery studies reported reduced mental strain, improved glycemic control, and better quality of life, despite barriers such as device cost and occasional system limitations. These interventions highlight the potential of advanced technologies to enhance diabetes care, particularly for aging populations. Previous RCTs show that education, structured management programs, effective insulin therapies, and advanced digital treatments improve patient experience, though well-designed studies focusing on patient experience as a primary outcome are lacking. Developing patient experience assessment scales for aging diabetes patients and adapting healthcare systems to maximize patient experience amid digitalization trends are essential, warranting further research.

Evidence supporting an association between hypoglycemic events and depression

OBJECTIVES

This retrospective study investigated the association between hypoglycemic events (HEs) and depression events (DEs) in patients with diabetes mellitus (type 1 and type 2).

METHODS

Analyzed data were from health care claims for individuals with employer-sponsored primary or Medicare supplemental insurance from the Thomson Reuters Market Scan database during the years 2008 and 2009. A baseline period (January 2008 to December 2008) was used to identify eligible patients and collect baseline clinical and demographic characteristics. Eligible patients were aged ≥18 years with diabetes (ICD-9-CM codes: 250.00, 250.01, 250.02, 250.03) who had not experienced any HEs or DEs and were not on antidepressant therapy during the baseline period. We studied the relationships between the DEs and HEs before and after adjusting for the covariates.

RESULTS

Of the 923,024 patients meeting the inclusion criteria, 22,735 (2.46%) patients had HEs (ICD-9-CM coded: 251.0, 251.1, 251.2, 250.8) and 6164 (0.67%) patients had DEs (ICD-9-CM: 311) during the evaluation period. Patients reporting HEs had 78% higher odds of experiencing depression than patients without HEs before adjusting for the covariates. Similarly, after adjusting for the covariates, data indicated that patients with HEs had higher odds of experiencing depression (OR = 1.726; 95% CI = 1.52-1.96). Similar analyses in different age categories showed that the OR monotonically increases with age regardless of whether the other covariates are included in the model.

CONCLUSIONS

ICD-9-CM-coded HEs were independently associated with an increased risk of DEs in patients with diabetes, and this incidence increased with the patients' age.

KEY LIMITATIONS

A key limitation to this study is that only those HEs that resulted in health care provider contact and subsequent claims coding indicative of hypoglycemia were included. It is likely that many cases of mild hypoglycemia, particularly those not severe enough to warrant medical attention, were not captured in this study.

Programmatic influences on outcomes of an evidence-based fall prevention program for older adults: a translational assessment

Investigating the implementation and dissemination of evidence-based health-promotion programs to reach large numbers of diverse older adults is needed. The purpose of this study is to examine relationships between class size and session attendance and assess differences in intervention outcomes based on these community-based fall prevention program characteristics. Pre-post data were analyzed from 2,056 falls prevention program participants. PROC MIXED for repeated measures and ordinary least squares regressions were employed. Approximately 32% of participants enrolled in recommended class sizes (eight to 12 participants) and 76.4% of enrolled seniors attended more than five of eight sessions. Enrolling in smaller class sizes was associated with higher class attendance (X (2) = 43.43, p < 0.001). Recommended class sizes and those with 13-20 participants reported significant improvements in falls efficacy and physical activity. Perfect attendance was associated with improvements in falls efficacy (t = 2.52, p < 0.05) and activity limitation (t = -2.66, p < 0.01). Findings can inform fall prevention program developers and lay leader deliverers about ideal class sizes relative to maximum intervention benefits and cost efficiency.

Controlled trial of nursing interventions to improve health outcomes of older African American women with type 2 diabetes

BACKGROUND

Type 2 diabetes affects one in five African American women older than 60 years. These women face distinct challenges in managing diabetes self-care. Therefore, tailored self-care interventions for this population need to be developed and tested.

OBJECTIVES

The effectiveness of a tailored, four-visit, in-home symptom-focused diabetes intervention with and without booster telephone calls was compared with an attentional control focused on skills training for weight management and diet.

METHODS

African American women (n = 180; >55 years old, Type 2 diabetes mellitus >1 year, HbA1c >7%) were randomly assigned to the intervention or attentional control condition. Half the intervention participants were assigned to also receive a telephone-delivered booster intervention. Participants were evaluated at baseline and 3, 6, and 9 months.

RESULTS

: Baseline HbA1 was 8.3 in the intervention group (n = 60), 8.29 in the intervention with booster group (n = 55), and 8.44 in the attentional control condition (n = 59). HbA1c declined significantly in the whole sample (0.57%) with no differences between study arms. Participants in the booster arm decreased HbA1c by 0.76%. Symptom distress, perceived quality of life, impact of diabetes, and self-care activities also improved significantly for the whole sample with no significant differences between study arms.

DISCUSSION

Parsimonious interventions of four in-person visits yielded clinically significant decreases in HbA1c. Although the weight and diet program was intended as an attentional control, the positive effects suggest it met a need in this population. Because the contents of both the intervention and the attentional control were effective despite different approaches, a revised symptom-focused intervention that incorporates weight and diet skills training may offer even better results.

Patient factors associated with attrition from a self-management education programme

OBJECTIVE

To examine utilization patterns of diabetes self-management training (DSME) and identify patient factors associated with attrition from these services at an ambulatory diabetes education centre (DEC).

METHODS

A retrospective medical chart review of first time visits (536) to the centre between 1 August 2000 and 31 July 2001 was conducted for patients with type 2 diabetes. Descriptive analyses were conducted to examine utilization patterns over a 1-year period. Multivariable logistic regression was used to identify patient factors associated with attrition from DSME and non-use of group education among new patients.

RESULTS

Almost 50% of new patients withdrew prematurely from recommended DSME services over the 1-year period, and only 24.8% attended group education. Patient variables such as being older than 65 years of age, primarily speaking English, or working full or part-time were associated with attrition from DSME and non-use of group education when compared with middle aged, non-English-speaking, and non-working patients.

CONCLUSIONS

High DSME attrition rates indicate that retention needs to become a focus of programme policy, planning and evaluation to improve programme effectiveness. DSME tailored to the cultural and linguistic characteristics of the community, and convenient and accessible to working and older patients will potentially increase retention in and accessibility to these services.

Predictors of participation and attendance in a new asthma patient self-management education program

BACKGROUND

Low participation limits the effectiveness of patient education interventions. In this study, the characteristics of patients who agreed to participate in a clinical trial of disease self-management education for asthma were compared to the characteristics of those who declined, and among the former group patients who actually attended were compared to those who did not.

METHODS

The education program, implemented at the Geneva University Hospitals between 1996 and 1998, consisted of three interactive sessions spread over 3 weeks. Only 131 of 253 eligible patients (52%) agreed to participate in the trial, and only 83 patients (63%) attended two to three educational sessions. All eligible patients filled out baseline questionnaires and were interviewed by a trained physiotherapist.

RESULTS

Lower confidence in the patient's own current treatment regimen and a more severe baseline asthma attack were independently associated with participation in the trial. Among those who agreed to participate in the study, a university education, longer asthma duration, older age, and a higher level of asthma management knowledge were associated with higher attendance. Quality-of-life scores were not associated with higher course attendance. Among all eligible participants, persons with lower knowledge of asthma management (which was assessed by what to do during an asthma attack and knowledge of the correct use of a peak expiratory flowmeter and inhalers) were less likely to enroll in the trial and to attend the educational training sessions.

CONCLUSIONS

Strategies need to be developed to motivate patients with lower disease self-management knowledge to participate in asthma education programs.

Characteristics of the adult learner

PURPOSE

This article provides an overview of adult learner characteristics, with an emphasis on those characteristics studied in diabetes patient education research.

METHODS

A selected review of the conceptual and research literature on general adult education and adult learning was conducted, with particular attention to diabetes patient education studies.

RESULTS

Characteristics reviewed included learning styles, literacy level, age/aging, ethnicity or culture, gender, and knowledge. Studies of the learning style of group vs individual education indicated some positive benefits for group learning; questions remain about optimal size or periodicity. Studies evaluating the benefits of culturally specific interventions for diabetes management have yielded some information. Characteristics related to gender and age have been studied, but often in pilot or feasibility studies without the power to answer the study questions.

CONCLUSIONS

There continue to be many gaps in knowledge related to adult learner characteristics in diabetes education. Lessons from both general adult learning literature and patient education literature from other chronic diseases should be evaluated and incorporated. The complexities of these learner characteristics create challenges in designing studies. However, evidence to support the need for effective educational interventions is of great importance for implementing change in health care.

Diabetes patient education research: an integrative literature review

PURPOSE

The purpose of this study is to summarize the accumulated state of knowledge in the area of diabetes patient education research and highlight important issues that research has left unanswered.

METHODS

An integrative literature review was conducted on the topic of diabetes patient education between the years 1985 and 1998. Keywords used in the computerized search were diabetes mellitus, patient education, health education, research, and behavior change. The databases searched were MEDLINE, CINAHL, HealthSTAR, EMBASE, and CHID-HE. A total of 78 papers were reviewed.

RESULTS

Most studies lacked a theoretical framework and the majority of studies were conducted in an outpatient setting. HbA1c was the most frequently employed outcome measure, with little, if any, description of the interventions.

CONCLUSIONS

Much has been learned in terms of the effectiveness of diabetes education on improving knowledge. However, other topic areas and outcomes need further exploration.

The Diabetes Day Treatment experiment: a preliminary report on what we learned

PURPOSE

This paper presents data on the efficacy of a diabetes day treatment program to modify the healthcare behavior of elderly African Americans with diabetes.

METHODS

African American patients with Type 1 or Type 2 diabetes who were referred by their certified diabetes educator were eligible to participate in the day treatment program. The program was designed to serve eight patients for 4 hours 1 day a week over 9 months. Participants engaged in informal discussions, low-impact armchair exercises, and discussions of various diabetes issues. A flow sheet was initiated and maintained by the investigators to record information pertaining to each participant's blood pressure, blood sugar, and weight at each session. Attendance and reasons for not attending sessions were recorded. To obtain more in-depth information, the group leaders used a technique known as participant observation.

RESULTS

Having CDEs administer a blood sugar test, take blood pressure, and weigh each patient at each clinic visit promotes patient adherence to the diabetes treatment regimen. Memory loss was observed to be especially prevalent among the subjects.

CONCLUSIONS

The Diabetes Day Treatment Program may be used as a model for working with elderly persons with diabetes from different ethnic groups.

Development of a community-based diabetes and hypertension preventive program

The purpose of this project was to develop rapport with a Chinese Community Association and then establish preventive diabetic and hypertension programs with the Chinese in Chinatown, Hawaii. Subjects were recruited from this Chinese Community Association. Two hundred Chinese responded to the invitation. Among these, 75 individuals had either Type 2 diabetes, hypertension or both. Thirty-six males and 39 females ranging in age from 51 years old to 96 years old (Mean = 71.76, SD = 9.58) participated. Surveys and educational programs were carried out in Chinese. Results were described in terms of quantitative measures (family support and health outcomes) and qualitative experiences (case studies). Eighty percent of participants had decreased their diastolic blood pressure from above 95 mmHg to below 90 mmHg and systolic blood pressure from above 155 mmHg to below 140 mmHg. Ninety-five (n = 71) percent of participants had maintained their glucose level within the 90 mg/dL to 150 mg/dL range with a mean reduction of 57.86 mg/dL in one year. The hardest thing for families was the glucose self-monitoring. Case studies suggested that open-minded active listening and persistence formed the basis for developing a culturally sensitive community-based self management program for chronic diseases. Collaboration among the community, public health nurses, and diabetes nurse educators facilitated the process of community education and health promotion.