Assessment of short and long-term outcomes of diabetes patient education using the health education impact questionnaire (HeiQ)

Modern Management of Cardiometabolic Continuum: From Overweight/Obesity to Prediabetes/Type 2 Diabetes Mellitus. Recommendations from the Eastern and Southern Europe Diabetes and Obesity Expert Group

The increasing global incidence of obesity and type 2 diabetes mellitus (T2D) underscores the urgency of addressing these interconnected health challenges. Obesity enhances genetic and environmental influences on T2D, being not only a primary risk factor but also exacerbating its severity. The complex mechanisms linking obesity and T2D involve adiposity-driven changes in β-cell function, adipose tissue functioning, and multi-organ insulin resistance (IR). Early detection and tailored treatment of T2D and obesity are crucial to mitigate future complications. Moreover, personalized and early intensified therapy considering the presence of comorbidities can delay disease progression and diminish the risk of cardiorenal complications. Employing combination therapies and embracing a disease-modifying strategy are paramount. Clinical trials provide evidence confirming the efficacy and safety of glucagon-like peptide 1 receptor agonists (GLP-1 RAs). Their use is associated with substantial and durable body weight reduction, exceeding 15%, and improved glucose control which further translate into T2D prevention, possible disease remission, and improvement of cardiometabolic risk factors and associated complications. Therefore, on the basis of clinical experience and current evidence, the Eastern and Southern Europe Diabetes and Obesity Expert Group recommends a personalized, polymodal approach (comprising GLP-1 RAs) tailored to individual patient's disease phenotype to optimize diabetes and obesity therapy. We also expect that the increasing availability of dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) agonists will significantly contribute to the modern management of the cardiometabolic continuum.

Current Landscape and Future Directions of Patient Education in Adults with Interstitial Lung Disease

Background

Understandable, comprehensive, and accessible educational materials for patients with interstitial lung disease (ILD) are lacking. Patients consistently ask for improved access to evidence-based information about ILD. Nonetheless, few research studies focus directly on developing and evaluating interventions to improve patient knowledge.

Objective

We describe the current landscape of patient education in ILD, identify gaps in current approaches to information delivery, and provide frameworks to address these challenges through novel educational tools.

Methods

A literature review was conducted in collaboration with a medical librarian (M.R.D.) in April 2022 using Ovid MEDLINE (1946-), Embase (1947-), Cochrane Central (1993-), and CINAHL (1961-). Search terms included "interstitial lung disease," "pulmonary fibrosis," "patient education," and "information seeking behavior" (see the data supplement for full search terms). Reference lists from selected articles were used to identify additional studies.

Results

Currently, patient education is commonly combined with exercise regimens in pulmonary rehabilitation programs in which benefits of the educational component alone are unclear. Few studies investigate improving knowledge access and acquisition for patients with ILD and their caregivers regarding self-management, oxygen use, and palliative care plans. Online distribution of health information through social media runs the risk of being unregulated and outdated, although it is an avenue of increasing accessibility.

Conclusion

By expanding access to novel ILD-specific education programs and accounting for social determinants of health that impact healthcare access, patient education has the potential to become more attainable, improving patient-centered outcomes. Further research into optimal development, delivery, and efficacy testing of patient education modalities in ILD is warranted.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

A NEw MOdel of individualized and patient-centered follow-up for women with gynecological cancer (the NEMO study)-protocol and rationale of a randomized clinical trial

BACKGROUND

Follow-up programs for gynecological cancer patients are currently under revision. There is limited evidence that traditional follow-up and clinical examinations improve survival in an early-stage gynecological setting. Further, traditional follow-up programs fail to accommodate the patient's need for psychosocial and sexual supportive care and to actively involve patients and their relatives in the follow-up process. Individualized programs may replace traditional routine follow-up with fixed intervals and length. Focusing on alarm-symptoms and self-reporting may ensure detection of recurrence while allowing a continuous attention to the patient's well-being and return to daily life. In this study, a nurse-led, individualized, and need-based intervention with a specific focus on patient empowerment is tested against a standard physician-led model primarily focusing on the detection of recurrence.

METHODS

The study is designed as a clinical, randomized trial conducted in one of four national onco-gynecological centers in Denmark. Patients with early-stage cervical or endometrial cancer are eligible for inclusion. The intervention group undergoes individualized, nurse-led follow-up supporting patient empowerment including repeated use of electronic patient-reported outcome measures (ePROMs) before each contact as a dialogue support tool. The follow-up contacts are mainly conducted by telephone. All project nurses attended a special training program before project start and are all well-educated and dedicated onco-gynecological nurses. The control group receives standard, physician-led, follow-up without use of ePROMs or specific focus on empowerment. The effect of the intervention is evaluated by questionnaires completed by patients at baseline (3 months after surgery) and 12, 18, and 36 months after surgery. Outcomes include empowerment using the Skill and technique subscale of the HEI-Q questionnaire as the primary outcome while fear of cancer recurrence and health-related quality of life as well as the remaining subscales of the HEI-Q represent secondary outcomes. Data is collected by use of the REDCap technology, which also provides a customized visual support function for the dialogue tool.

DISCUSSION

This study will provide new information about follow-up in early-stage gynecological cancer settings and thereby contribute to improvement of future follow-up programs. Importantly, the study will provide knowledge about the impact of specific focus on patient empowerment in follow-up programs and, further, how to facilitate empowerment among patients.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov: ID no. NCT03838861. Registered on 6 February 2019. Protocol version 2, issue date 21 November 2022.

Effectiveness of the "Living with Cancer" peer self-management support program for persons with advanced cancer and their relatives: study protocol of a non-randomized stepped wedge study

BACKGROUND

Persons with advanced cancer and their relatives experience physical, emotional, and psychosocial consequences of the illness. Most of the time, they must deal with these themselves. While peer self-management support programs may be helpful, there is little evidence on their value for this population. We present the research protocol of our SMART study that will evaluate the effectiveness of the "Living with Cancer" peer self-management support program, aimed at improving self-management behaviors, self-efficacy, and health-related quality of life of persons with advanced cancer and their relatives.

METHODS

We will conduct a non-randomized stepped wedge study in the Netherlands. We will include 130 persons with advanced cancer and 32 relatives. Participants can choose to either start the program within 4 weeks after inclusion or after eight to 10 weeks. The "Living with Cancer" is a peer self-management support program, based on the Chronic Disease Self-Management Program. It consists of six 1,5 hours video-conferencing group meetings with eight to 12 participants, preceded by two or three preparatory audio clips with supportive text per session. The program has the following core components: the learning of self-management skills (action-planning, problem-solving, effective communication, and decision-making), discussing relevant themes (e.g. dealing with pain and fatigue, living with uncertainty, and future planning), and sharing experiences, knowledge, and best practices. The primary outcome for both persons with advanced cancer and relatives is self-management behavior assessed by the subscale "constructive attitudes and approaches" of the Health Education Impact Questionnaire. Secondary outcomes are other self-management behaviors, self-efficacy, health-related quality of life, symptoms, depression and anxiety, and loneliness. Participants complete an online questionnaire at baseline, and after eight and 16 weeks. After each session, they complete a logbook about their experiences. Group meetings will be video recorded.

DISCUSSION

SMART aims to evaluate an innovative program building on an evidence-based self-management program. New features are its use for persons with advanced cancer, the inclusion of relatives, and the video-conferencing format for this population. The use of both quantitative and qualitative analyses will provide valuable insight into the effectiveness and value of this program.

TRIAL REGISTRATION

This study was registered in the Dutch Trial Register on October 2021, identifier NL9806 .

Positive impact of a co-designed digital resource for women with early menopause

OBJECTIVE

To evaluate a co-designed early menopause digital resource, including audio/video clips, question prompt list, and information links.

METHODS

Pre/post-test study. Women with early menopause, defined as menopause before age 45 years, were recruited from the community. Following online informed consent, participants were emailed links to the digital resource and online surveys to complete before (baseline) and, immediately and 1 month after viewing the resource. Main outcome measures: Health-related empowerment (Health Education Impact Questionnaire), illness perception (Brief Illness Perception Questionnaire), menopause symptoms (Greene Climacteric Scale), risk perception, and knowledge change.

RESULTS

One hundred fifty women participated. Compared to baseline, at 1-month health-related empowerment, 'health directed behavior' scores increased (mean change: +0.13; 95% CI: 0.01-0.24; and P = 0.03), 'emotional distress' decreased (mean change: -0.15; 95% CI: -0.25 to -0.05; and P = 0.003) and physical and emotional menopause symptom scores decreased (P = 0.001 and P  = 0.02, respectively). Illness perception scores increased at both immediate and 1-month follow-up versus baseline for 'personal control' (P < 0.001 and P  = 0.02) and 'coherence' (P = 0.003 and P  < 0.001). After viewing the digital resource, more women perceived that hormone therapy decreases heart disease risk, reduces hot flashes, and prevents fractures versus baseline (all P  < 0.05). More women correctly answered questions regarding early menopause prevalence (60% vs 35%), cause (46% vs 33%), risk (76% vs 55%), effect of phytoestrogens (60% vs 27%), and osteoporosis prevention (64% vs 44%) at immediate or 1-month follow-up versus baseline (all P  < 0.05).

CONCLUSIONS

A co-designed early menopause digital resource may improve women's health-related empowerment, illness perception, menopause symptoms, risk perception, and knowledge.

Nurse-led self-management support after organ transplantation-protocol of a multicentre, stepped-wedge randomized controlled trial

BACKGROUND

Recipients of an organ transplantation face a number of challenges and often need to change their health behaviour. Good self-management skills are essential for optimal clinical outcomes. However, few interventions are available to support post-transplant self-management. To fill this gap, we developed a self-management support intervention offered by nurse practitioners. The primary aim of the study is to implement and test the effectiveness of the ZENN intervention in promoting self-management skills among heart, kidney liver and lung transplant recipients in comparison to standard care. The secondary aim is to assess the self-management support skills of nurse practitioners who will deliver the intervention.

METHODS

This multi-centre stepped-wedge randomized controlled trial will take place from September 2020 until May 2023. All departments will commence with inclusion of patients in the control period. Each department will be randomly assigned to a start date (step in the wedge) to commence the experimental period. Patients in the control period will receive standard care and will be asked to complete questionnaires at baseline (T0), 6 months (T1) and 12 months (T2), to assess self-management, self-regulation, quality of life and adherence. During the experimental period, patients will receive standard care plus the ZENN intervention and receive the same set of questionnaires as participants in the control period. Nurse practitioners will complete a baseline and follow-up questionnaire to assess differences in self-management support skills. Video recordings of outpatient clinic consultations during the control and experimental periods will determine the differences in nurses' needs-thwarting and needs-supporting skills between the control and experimental period.

DISCUSSION

The ZENN intervention could be a useful approach to support patients' self-management skills after organ transplantation and thus promote clinical outcomes as well as avoid adverse events.

TRIAL REGISTRATION

Dutch Trial Register NL8469 . Registered on March 19, 2020.

Evaluating Effectiveness of Outpatient Monitoring in Type 2 Diabetes: The One-Year Experience in an Italian Group of Primary Care

Nowadays, chronic disease management is the primary challenge of the healthcare system. From 2015, in the Veneto region (Italy), patients with a diagnosis of type 2 diabetes mellitus (T2DM) have been included in the diagnostic-therapeutic pathway (PDTA) program, and their clinical condition has been continuously monitored. The aim of this retrospective study is to determine the effectiveness of PDTA intervention, alone or in combination with a specialized one, in subjects with diagnosis of T2DM. Clinical and behavioral characteristics were collected at baseline and after 1 year of follow-up. Two subgroups were considered: subjects enrolled in PDTA only and subjects enrolled in both the PDTA program and in the care plan proposed by the specialized medical center (CAD group). Longitudinal analysis showed a relevant positive effect of time on diastolic blood pressure, while CAD enrollment appears to be related to higher levels of glycated hemoglobin. When included together in the same model, interaction between time and CAD covariates results in completely nonsignificant effects. As long-term management of chronic disorders, such as T2DM, is often difficult due to disease characteristics and problems in healthcare organization, monitoring programs, such as PDTA, and specialized care programs, such as CAD, do not show a clinically relevant effect in the first year of follow-up. Therefore, they should be analyzed over a longer period. However, they should also carefully consider the need for adequate tools for data collection and sharing, in addition to the context of application, patient expectations and the need for a long-term educational program.

Improving Diabetes Self-management by Providing Continuous Positive Airway Pressure Treatment to Patients With Obstructive Sleep Apnea and Type 2 Diabetes: Qualitative Exploratory Interview Study

Background

There is a high prevalence of unexplained and unexplored obstructive sleep apnea (OSA) among patients with type 2 diabetes. The daytime symptoms of OSA include severe fatigue, cognitive problems, a decreased quality of life, and the reduced motivation to perform self-care. These symptoms impair the management of both diabetes and daily life. OSA may therefore have negative implications for diabetes self-management. Continuous positive airway pressure (CPAP) therapy is used to treat OSA. This treatment improves sleep quality, insulin resistance, and glycemic control. Although the benefits of using CPAP as a treatment for OSA are clear, the noncompliance rate is high, and the evidence for the perceived effect that CPAP treatment has on patients with type 2 diabetes and OSA is poor.

Objective

The purpose of this study was to analyze the impacts that comorbid diabetes and OSA have on the daily lives of older adults and to investigate the perceived effect that CPAP treatment for OSA has on patients’ diabetes self-management.

Methods

A qualitative follow-up study that involved in-depth, semistructured dyad interviews with couples before and after CPAP treatment (N=22) was conducted. Patients were recruited from the Hilleroed Hospital in Denmark and were all diagnosed with type 2 diabetes, aged >18 years, and had an apnea-hypopnea index of ≥15. All interviews were coded and analyzed via thematic analysis.

Results

The results showed that patients and their partners did not consider OSA to be a serious disorder, as they believed that OSA symptoms were similar to those of the process of aging. Patients experienced poor nocturnal sleep, took frequent daytime naps, exhibited reduced cognitive function, and had low levels of physical activity and a high-calorie diet. These factors negatively influenced their diabetes self-management. Despite the immediate benefit of CPAP treatment, most patients (11/12, 92%) faced technical challenges when using the CPAP device. Only the patients with severe OSA symptoms that affected their daily lives overcame the challenges of using the CPAP device and thereby improved their diabetes self-management. Patients with less severe symptoms rated CPAP-related challenges as more burdensome than their symptoms.

Conclusions

If used correctly, CPAP has the potential to significantly improve OSA, resulting in better sleep quality; improved physical activity; improved diet; and, in the end, better diabetes self-management. However, there are many barriers to undergoing CPAP treatment, and only few patients manage to overcome these barriers and comply with correct treatment.

Role of network cloud platform-based and progressive health education in postoperative rehabilitation of patients with tibial fracture

OBJECTIVE

To explore the short-term and long-term effect of rehabilitation in patients with tibial fracture based on network cloud platform and progressive health education.

METHODS

A total of 100 patients with tibial fracture treated in our hospital from December 2018 to February 2020 were selected as the research subjects. According to their admission order, they were divided into a control group (n=50) and experimental group (n=50). The control group was given routine health education and nursing, while the experimental group was given progressive health education and nursing based on a network cloud platform. The fracture healing time, complication rate, knee joint function, hospitalization stay, ability of daily living, and self-efficacy of the two groups were analyzed.

RESULTS

(1) The fracture healing time and hospitalization stay of the experimental group were (72.03 ± 5.33) d and (13.15 ± 2.05) d, which were significantly lower than those of the control group [(90.89 ± 5.88) d and (18.56 ± 2.87) d] (T=16.80, 10.85, P < 0.001). (2) After nursing, the Lysholm score of the experimental group (43.13 ± 5.62) was significantly higher than that of the control group (31.77 ± 5.51) (T=10.21, P < 0.001). (3) The incidence of complications in the experimental group was significantly lower in comparison with that of the control group. (4) After nursing, the ADL score of the experimental group was significantly higher than that of the control group (T=7.85, P < 0.001). (5) After nursing, as compared with the control group, the GSEs score of the experimental group was significantly higher (T=5.22, P < 0.001).

CONCLUSION

Implementation of network cloud platform-based and progressive health education for patients with tibial fracture after operation has a positive effect on improving the short-term and long-term rehabilitation effect.

Self-management and adherence to recommended follow-up after gynaecological cancer: results from the international InCHARGE study

OBJECTIVE

To assess the relationship between self-management skills and adherence to follow-up guidelines among gynecological cancer survivors in the Netherlands, Norway, and Denmark, and to assess the relationship between adherence to follow-up programs and use of additional healthcare services.

METHODS

For this international, multicenter, cross-sectional study, we recruited gynecological cancer survivors 1-5 years after completion of treatment. Information on follow-up visits, use of healthcare resources, self-management (measured by the Health Education Impact Questionnaire), clinical characteristics, and demographics were obtained by validated questionnaires. Participants were categorized as adherent if they attended the number of follow-up visits recommended by national guidelines, non-adherent if they had fewer visits than recommended, or over-users if they had more visits than recommended.

RESULTS

Of 4455 invited survivors, 2428 (55%) returned the questionnaires, and 911 survivors were included in the analyses. Survivors with high self-management most frequently adhered to recommended follow-up. Non-adherent survivors showed lower self-management in the health-directed activity domain (OR 1.54, 95% CI 1.03 to 2.32) than adherent survivors. No other associations between self-management and follow-up adherence were revealed. Non-adherent survivors tended to have endometrial cancer, surgical treatment only, be older, and be Danish residents. Over-users reported more follow-up visits and also used additional healthcare services more frequently than adherent survivors.

CONCLUSION

Low self-management appears to reduce the likelihood of adherence to national guidelines for gynecological cancer follow-up. Focusing on patient education for survivors at risk of low self-management to ensure adherence to recommended follow-up may improve personalization of follow-up.

Co-designing an Early Menopause Digital Resource: Model for Interdisciplinary Knowledge Translation

Early menopause/premature ovarian insufficiency is associated with negative health impacts, unmet information needs, delayed diagnosis, and variation in management. Co-designed digital resources for women with early menopause/premature ovarian insufficiency and health practitioners were developed to address information needs and support management. A five-phase mixed methods multidisciplinary research, co-design and translation process comprised: (1) survey/interviews with women and health practitioners to explore early menopause/premature ovarian insufficiency needs, experiences, and management; (2) appraisal of clinical guidelines to develop management algorithms; (3) digital resource development (https://healthtalkaustralia.org/early-menopause-experiences-and-perspectives-of-women-and-health-professionals/; (4) evaluation; and (5) dissemination/implementation. The digital resources included audio/video clips of women with early menopause/premature ovarian insufficiency and health practitioners providing early menopause/premature ovarian insufficiency care, a question prompt list, health practitioner algorithms, information links, and a list of services for women, achieving high satisfaction ratings from women and health practitioners. Engaging our stakeholder partners, multimodal dissemination has included community and conference presentations, social media, lay and professional publications, and webinars. This project provides a model for successful interdisciplinary co-design research translation to improve women's health.

A Smartphone App to Restore Optimal Weight (SPAROW) in Women With Recent Gestational Diabetes Mellitus: Randomized Controlled Trial

Background

Women with a history of gestational diabetes mellitus (GDM) are at an increased risk of developing type 2 diabetes mellitus (T2DM). Lifestyle interventions aimed at postpartum weight loss to reduce T2DM risk have been reported, but poor compliance remains a barrier. Smartphone-based interventions may improve compliance, but data on its use in women with recent GDM are limited.

Objective

This trial aimed to investigate the efficacy of a smartphone app in restoring optimal weight following delivery in women with GDM, in the setting of a population with high rates of GDM and type 2 diabetes.

Methods

In this unblinded randomized controlled trial, 200 women with GDM were randomized to receive the intervention or standard care following delivery. The intervention enabled logging of weight, meals, and activity, with web-based interaction with a team comprising dieticians, a physiotherapist, and an occupational therapist. The primary outcome was an achievement of optimal weight (defined as the restoration of first trimester weight if first trimester BMI≤23 kg/m² or weight loss of at least 5% from first trimester weight if first trimester BMI>23 kg/m²) at 4 months post partum. Secondary outcome measures included absolute weight loss, serum metabolic markers, self-reported nutritional intake, health education, and quality of life via questionnaires and user engagement in the intervention group.

Results

In total, 40% (38/96) of women in the intervention group achieved optimal weight at 4 months post delivery compared with 32% (28/93) in the control group (P=.27). Compared with the control group, women in the intervention group reported significantly reduced caloric intake at 4 months after delivery (P<.001) and higher health-directed behavior scores (P=.045). The intervention group also reported increased emotional distress scores (P=.01). At 4 months, participant engagement with the intervention was maintained at 60.8% (SD 33.9%).

Conclusions

Although a statistically significant increase in women achieving healthy weight was not observed, this app remains promising, as women in the intervention group reported improved health behaviors and lower caloric intake. Importantly, the high retention rates suggest that a larger study with a longer follow-up period might confirm the effectiveness of this app for weight management.

Trial Registration

ClinicalTrials.gov NCT03324737; https://clinicaltrials.gov/ct2/show/NCT03324737

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-7691-3

Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review

The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.

Sociodemographic disparities in the management of type 2 diabetes in the United States

Objective: To examine the potential sociodemographic disparities in type 2 diabetes (T2D) management and care among US adult individuals, after controlling for clinical and behavioral factors.Methods: This was a retrospective cohort study of individuals with T2D (N = 4552) from a linked database of the National Health and Wellness Survey and a large US ambulatory electronic health record (EHR) database. This study period was between 1 January 2015 and 31 December 2018 and individuals were followed up for at least 6 months through EHR after the completion of the survey. The sociodemographic characteristics included gender, race, ethnicity, marital status, education, employment status, household income, insurance status, and geographic region. The independent variables included testing and control of HbA1c, blood pressure (BP), and low-density lipoprotein-cholesterol (LDL-C); hypoglycemia, emergency room (ER) visits, and all-cause hospitalization. Multivariable analyses were conducted using generalized linear models.Results: The percentage of uncontrolled HbA1c was 38.6%. With clinical and behavioral characteristics adjusted, individuals living in the Northeast region had 30% higher odds of having HbA1c testing than those who lived in the South. Blacks and Asians were less likely to have HbA1c control than Whites. Uninsured individuals had a lower likelihood of receiving HbA1c, BP, or LDL-C testing compared with commercial insurers. Individuals with low income were more likely to have higher ER visits and hospitalizations.Conclusion: Potential sociodemographic disparities exist in T2D management and care in the US, indicating the needs for improvement in healthcare access, educational and behavioral programs, as well as disease and treatment management in these subgroups.

Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review

Diabetes mellitus is a chronic disease characterized by high social, economic and health burden, mostly due to the high incidence and morbidity of diabetes complications. Numerous studies have shown that optimizing metabolic control may reduce the risk of micro and macrovascular complications related to the disease, and the algorithms suggest that an appropriate and timely step of care intensification should be proposed after 3 months from the failure to achieve metabolic goals. Nonetheless, many population studies show that glycemic control in diabetic patients is often inadequate. The phenomenon of clinical inertia in diabetology, defined as the failure to start a therapy or its intensification/de-intensification when appropriate, has been studied for almost 20 years, and it is not limited to diabetes care, but also affects other specialties. In the present manuscript, we have documented the issue of inertia in its complexity, assessing its dimensions, its epidemiological weight, and its burden over the effectiveness of care. Our main goal is the identification of the causes of clinical inertia in diabetology, and the quantification of its social and health-related consequences through the adoption of appropriate indicators, in an effort to advance possible solutions and proposals to fight and possibly overcome clinical inertia, thus improving health outcomes and quality of care.

Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study

PURPOSE OF REVIEW

In recent years, the recommendation for and use of patient-reported outcome measures (PROMs) in routine diabetes care has significantly increased. We review recent evidence and highlight key opportunities and challenges related to the active clinical use of PROMs to support person-centered diabetes care and focus areas for future research in the area.

RECENT FINDINGS

Recent pragmatic studies support that integration of multi-dimensional PROMs for diabetes in clinical care as part of a care improvement strategy can be acceptable for and valued by people with diabetes (PWD) and healthcare professionals (HCPs) and may improve multiple aspects of quality of care, including screening, medical care monitoring and decision support, individualization of self-management support and goal-setting, and broader benefits related to active patient participation and person-centred diabetes care. We identify multiple intervention, individual, and care setting characteristics, which influence acceptability, feasibility, implementation, and effectiveness of PROMs in routine care. Recent clinical PROM studies highlight the value of mixed methods research and systematic involvement of PWD, clinicians, and other stakeholders in the design and implementation of questionnaires for patient input in routine diabetes care. We identified a new significant trend towards participatory development of multi-dimensional PROMs with the aim of IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes. While results from large-scale randomized controlled studies are still limited, a growing number of pragmatic implementation studies support that user-centric PROM interventions have the potential to facilitate significant improvements in care for PWD.

Addressing Clinical Inertia in Type 2 Diabetes Mellitus: A Review

The current epidemic of type 2 diabetes (T2D) represents a significant global and national health concern. Globally, the prevalence of diabetes has doubled between 1980 and 2014. In 2014 the World Health Organization estimated that there were 422 million adults living with diabetes worldwide. In the USA, the number of people diagnosed with T2D is estimated to increase to over 70 million by 2050, putting an immense strain on the US healthcare system. Achieving glycemic control is widely acknowledged as the key goal of treatment in T2D and is critical for reducing the onset and progression of diabetes-related complications such as cardiovascular diseases, neuropathies, retinopathies, and nephropathies. Despite the increase in the availability of antihyperglycemic medications and evidence-based treatment guidelines, the proportion of people with T2D who fail to achieve glycemic goals continues to rise. One major contributor is a delay in treatment intensification despite suboptimal glycemic control, referred to as clinical or therapeutic inertia. Clinical inertia prolongs the duration of patients' hyperglycemia which subsequently puts them at increased risk of diabetes-associated complications and reduced life expectancy. Clinical inertia results from a complex interaction between patient, healthcare providers, and healthcare system barriers that need to be addressed together, rather than as separate entities. In this article we provide an overview of clinical inertia in the clinical management of T2D and provide suggestions for overcoming aspects that may have a negative impact on patient care.Funding: Sanofi US, Inc.

The Other 45: Improving Patients' Chronic Disease Self-Management and Medical Students’ Communication Skills

Context

To improve chronic disease self-management among an underserved population and to improve the skills of second-year osteopathic medical students, an educational curriculum, The Other 45, was developed. In addition to a typical 15-minute office visit, this program allows second-year students to provide chronic disease education to patients for 45 minutes in an effort to improve patient disease self-management and associated health outcomes.

Objective

To determine whether patients who participate in The Other 45 report improvements in their ability to manage their chronic disease(s) and their health outcomes and whether second-year osteopathic medical students report changes in patient-centered care, clinical confidence, and medical/teaching knowledge.

Methods

Patients with a previously diagnosed chronic disease participated in 3 visits for The Other 45. Chronic disease self-management and health outcomes were measured using the Health Education Impact Questionnaire, which participants completed at each visit. Students received a formal presentation on teaching skills, and those who participated in The Other 45 completed a pre- and postclinic survey measuring 3 focused domains: patient-centered care, clinical confidence, and medical/teaching knowledge.

Results

A total of 47 patients and 69 students participated in the study. As measured by the Health Education Impact Questionnaire, patients’ skill and technique acquisition (P=.01), constructive attitudes and approaches (P=.01), and health services navigation (P=.03) showed significant improvement at the 3-week follow-up visit, and self-monitoring and insight showed significant improvement (P=.01) at the 3-month follow-up visit. Patients’ positive and active engagement in life (P=.04 and P=.03) and emotional well-being (P=.003 and P=.0007) significantly improved at the 3-week and 3-month follow-up, respectively. The students improved significantly in all 3 domains as a result of participating in the program: patient-centered care (P=.012), clinical confidence (P<.001), and medical/teaching knowledge (P=.002).

Conclusions

The Other 45 was effective in improving patients’ ability to manage their chronic disease(s), as well as improving second-year osteopathic medical students’ ability to educate a patient with chronic disease. Implementing this type of program has the potential to affect patients with chronic disease as well as medical students in a rural underserved setting.

Analysing mHealth usage logs in RCTs: Explaining participants' interactions with type 2 diabetes self-management tools

Background

The Introduction of mobile health (mHealth) devices to health intervention studies challenges us as researchers to adapt how we analyse the impact of these technologies. For interventions involving chronic illness self-management, we must consider changes in behaviour in addition to changes in health. Fortunately, these mHealth technologies can record participants’ interactions via usage-logs during research interventions.

Objective

The objective of this paper is to demonstrate the potential of analysing mHealth usage-logs by presenting an in-depth analysis as a preliminary study for using behavioural theories to contextualize the user-recorded results of mHealth intervention studies. We use the logs collected by persons with type 2 diabetes during a randomized controlled trial (RCT) as a use-case.

Methods

The Few Touch Application was tested in a year-long intervention, which allowed participants to register and review their blood glucose, diet and physical activity, goals, and access general disease information. Usage-logs, i.e. logged interactions with the mHealth devices, were collected from participants (n = 101) in the intervention groups. HbA1c was collected (baseline, 4- and 12-months). Usage logs were categorized into registrations or navigations.

Results

There were n = 29 non-mHealth users, n = 11 short-term users and n = 61 long-term users. Non-mHealth users increased (+0.33%) while Long-term users reduced their HbA1c (-0.86%), which was significantly different (P = .021). Long-term users significantly decreased their usage over the year (P < .001). K-means clustering revealed two clusters: one dominated by diet/exercise interactions (n = 16), and one dominated by BG interactions and navigations in general (n = 40). The only significant difference between these two clusters was that the first cluster spent more time on the goals functionalities than the second (P < .001).

Conclusion

By comparing participants based upon their usage-logs, we were able to discern differences in HbA1c as well as usage patterns. This approach demonstrates the potential of analysing usage-logs to better understand how participants engage during mHealth intervention studies.

The role of glycogen synthase kinase 3 beta in brain injury induced by myocardial ischemia/reperfusion injury in a rat model of diabetes mellitus

Myocardial ischemia/reperfusion injury can lead to severe brain injury. Glycogen synthase kinase 3 beta is known to be involved in myo-cardial ischemia/reperfusion injury and diabetes mellitus. However, the precise role of glycogen synthase kinase 3 beta in myocardial ischemia/reperfusion injury-induced brain injury is unclear. In this study, we observed the effects of glycogen synthase kinase 3 beta on brain injury induced by myocardial ischemia/reperfusion injury in diabetic rats. Rat models of diabetes mellitus were generated via intraperitoneal injection of streptozotocin. Models of myocardial ischemia/reperfusion injury were generated by occluding the anterior descending branch of the left coronary artery. Post-conditioning comprised three cycles of ischemia/reperfusion. Immunohistochemical staining and western blot assays demonstrated that after 48 hours of reperfusion, the structure of the brain was seriously damaged in the experimental rats compared with normal controls. Expression of Bax, interleukin-6, interleukin-8, terminal deoxynucleotidyl transferase dUTP nick end labeling, and cleaved caspase-3 in the brain was significantly increased, while expression of Bcl-2, interleukin-10, and phospho-glycogen synthase kinase 3 beta was decreased. Diabetes mellitus can aggravate inflammatory reactions and apoptosis. Ischemic post-conditioning with glycogen synthase kinase 3 beta inhibitor lithium chloride can effectively reverse these changes. Our results showed that myocardial ischemic post-conditioning attenuated myocardial ischemia/reperfusion injury-induced brain injury by activating glyco-gen synthase kinase 3 beta. According to these results, glycogen synthase kinase 3 beta appears to be an important factor in brain injury induced by myocardial ischemia/reperfusion injury.