National standards for diabetes self-management education

A retrospective cohort study of a community-based primary care program's effects on pharmacotherapy quality in low-income Peruvians with type 2 diabetes and hypertension

Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

A Risk Stratification Approach to Allocating Diabetes Education and Support Services

The objective of this study was to describe a predictive modeling approach to risk stratify people with type 2 diabetes for diabetes self-management education and support (DSMES) services. With data from a large health system, a predictive model including age, glycated hemoglobin (HbA1c), and insulin use among other factors, was developed to assess risk of future high HbA1c. The model was retrospectively applied to a cohort of people who received DSMES over a 2-year period to assess the impact of DSMES on glycemia by risk strata. Of 6934 eligible people, 4014 (58%) were in the composite low-risk group and 2604 (38%) were in the composite high-risk group. Mean HbA1c change after DSMES was -0.38% in the low-risk group and -0.84% in the high-risk group. This analysis demonstrates the potential application of predictive modeling as one approach to target DSMES resources to people who will benefit most.

Self-Management Nursing Intervention for Controlling Glucose among Diabetes: A Systematic Review and Meta-Analysis

As the diabetic population increases, self-management of diabetes, a chronic disease, is important. Given that self-management nursing interventions using various techniques have been developed, an analysis of their importance is crucial. This study aimed to identify the overall effects of self-management nursing interventions on primary (HbA1c) and secondary (self-care, self-efficacy, fasting blood sugar level blood pressure, lipid, body mass index, waist circumference, distress, anxiety, depression, and quality of life) outcomes in diabetes. Systematic review and meta-analysis were used. The meta-analysis involved the synthesis of effect size; tests of homogeneity and heterogeneity; trim and fill plot; Egger’s regression test; and Begg’s test for assessing publication bias. The overall effect on HbA1c was −0.55, suggesting a moderate effect size, with HbA1c decreasing significantly after nursing interventions. Among the nursing interventions, the overall effect on HbA1c of nurse management programs, home visiting, and customized programs was −0.25, −0.61, and −0.65, respectively, a small or medium effect size, and was statistically significant. Healthcare professionals may encourage people with diabetes to engage in self-management of their glucose levels, such as patient-centered customized intervention. Interventions that reflect the individual’s characteristics and circumstances are effective in enabling self-management.

Investigation of a Mobile Health Texting Tool for Embedding Patient-Reported Data Into Diabetes Management (i-Matter): Development and Usability Study

Background

Patient-reported outcomes (PROs) are increasingly being used in the management of type 2 diabetes (T2D) to integrate data from patients’ perspective into clinical care. To date, the majority of PRO tools have lacked patient and provider involvement in their development, thus failing to meet the unique needs of end users, and lack the technical infrastructure to be integrated into the clinic workflow.

Objective

This study aims to apply a systematic, user-centered design approach to develop i-Matter (investigating a mobile health [mHealth] texting tool for embedding patient-reported data into diabetes management), a theory-driven, mobile PRO system for patients with T2D and their primary care providers.

Methods

i-Matter combines text messaging with dynamic data visualizations that can be integrated into electronic health records (EHRs) and personalized patient reports. To build i-Matter, we conducted semistructured group and individual interviews with patients with T2D and providers, a design thinking workshop to refine initial ideas and design the prototype, and user testing sessions of prototypes using a rapid-cycle design (ie, design-test-modify-retest).

Results

Using an iterative user-centered process resulted in the identification of 6 PRO messages that were relevant to patients and providers: medication adherence, dietary behaviors, physical activity, sleep quality, quality of life, and healthy living goals. In user testing, patients recommended improvements to the wording and timing of the PRO text messages to increase clarity and response rates. Patients also recommended including motivational text messages to help sustain engagement with the program. The personalized report was regarded as a key tool for diabetes self-management by patients and providers because it aided in the identification of longitudinal patterns in the PRO data, which increased patient awareness of their need to adopt healthier behaviors. Patients recommended adding individualized tips to the journal on how they can improve their behaviors. Providers preferred having a separate tab built into the EHR that included the personalized report and highlighted key trends in patients’ PRO data over the past 3 months.

Conclusions

PRO tools that capture patients’ well-being and the behavioral aspects of T2D management are important to patients and providers. A clinical trial will test the efficacy of i-Matter in 282 patients with uncontrolled T2D.

Trial Registration

ClinicalTrials.gov NCT03652389; https://clinicaltrials.gov/ct2/show/NCT03652389

Glycemic control in adolescents with type 1 diabetes: Are computerized simulations effective learning tools?

OBJECTIVE

Type 1 diabetes mellitus (T1DM) in adolescent patients is often characterized by poor glycemic control. This study aimed at exploring the contribution of learning with computerized simulations to support: (a) mechanistic understanding of the biochemical processes related to diabetes; (b) diabetes self-management knowledge; and (c) glycemic control. We hypothesized that learning with such simulations might support adolescents in gaining a better understanding of the biochemical processes related to glucose regulation, and consequently improve their glycemic control.

METHODS

A prospective case-control study was conducted in 12- to 18-year-old adolescents with T1DM (n = 85) who were routinely treated at an outpatient diabetes clinic. While the control group (n = 45) received the routine face-to-face follow-up, the intervention group (n = 40) learned in addition with computerized simulations that were embedded in pedagogically supportive activities. Participants in both groups completed a set of questionnaires regarding sociodemographic characteristics, diabetes mechanistic reasoning and diabetes self-management. Clinical data and serum glycated hemoglobin (HbA1c) levels were gathered from medical records. All the data was collected at recruitment and 3 months later.

RESULTS

Analysis revealed improvement HbA1c levels in the intervention group (8.7% ± 1.7%) vs the controls (9.6% ± 1.6%) after 3 months (P < .05). Regression analysis showed that levels of diabetes mechanistic understanding and diabetes self-management knowledge, in addition to sociodemographic parameters, accounted for 31% of the HbA1c variance (P < .001).

CONCLUSION

These results suggest that learning with computerized simulations about biochemical processes can improve adolescents' adherence to medical recommendations and result in improved glycemic control. Implementing scientific learning into the hospital educational setting is discussed.

Application of salutogenic concept in social work with diabetic patients

In the context of salutogenesis, coping with diabetes is perceived as a dynamic process of changes in all aspects of biopsychosocial model of health/disease. Understanding of salutoprotective factors allows for estimation of client's extent of vulnerability and ability to cope with the disease. The objective of the study is to assess selected salutoprotective factors in diabetic clients (SOC-type hardiness, well-being-subjective feelings and states scale [SUPOS], perceived social support scale [PSSS]). Low values of SOC, PSSS, and SUPOS suggest an increased need in psychosocial care. The possibility to strengthen an individual's hardiness and to influence perceived social support adverts to the irreplaceable role of social workers at counseling and educational levels as well as that of a form of social support.

Young patients with type 1 diabetes poorly controlled and poorly compliant with self-monitoring of blood glucose: can technology help? Results of the i-NewTrend randomized clinical trial

AIMS

To compare iBGStar™ + DMApp (experimental meter + telemedicine system) (iBGStar) with a traditional glucose meter (Control) in type 1 diabetes adolescents/young adults.

METHODS

i-NewTrend was a multicenter, open-label, randomized trial involving subjects aged 14-24 years, on basal-bolus insulin, HbA1c ≥ 8.0%, and poorly compliant with SMBG (i.e., <30% of the recommended frequency). Primary end points were change in HbA1c and achievement of compliance with SMBG (≥30% of the recommended frequency) after 6 months. Quality of life was also evaluated. A post-trial observational phase was conducted, where both groups used the experimental device.

RESULTS

Of 182 randomized patients (51.1% male; age 17.7 ± 3.0 years; diabetes duration 8.8 ± 4.7 years; HbA1c levels 10.0% ± 1.4), 92 were allocated to iBGStar and 90 to Control; 6.5% in iBGStar and 8.9% in Control dropped-out. After 6 months, HbA1c changes (±SE) were -0.44% ± 0.13 in iBGStar and -0.32% ± 0.13 in Control (p = 0.51). In the post-trial phase, HbA1c changes from 6 months (±SE) were -0.07% ± 0.14 in iBGStar and -0.31% ± 0.14 in Control (p = 0.24). Compliance end point was reached by 53.6% in iBGStar and 55.0% in Control (p = 0.86). Mean daily SMBG measurements increased from 1.1 to 2.3 in both groups without worsening quality of life. Compliant subjects showed a greater reduction in HbA1c levels (-0.60% ± 0.23 in iBGStar; -0.41% ± 0.21 in Control; p = 0.31). Within iBGStar group, telemedicine users (38.0%) reduced HbA1c by -0.58 ± 0.18.

CONCLUSIONS

iBGStar was not superior to the traditional meter. Irrespective of the strategy, increasing from 1 to 2 SMBG tests/day was associated with HbA1c reduction in both groups, without pharmacologic interventions. Identifying new technologies effective and acceptable to patients is an option to improve adherence to diabetes care.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov (registration number NCT02073188).

Peer Support Training Improved the Glycemic Control, Insulin Management, and Diabetic Behaviors of Patients with Type 2 Diabetes in Rural Communities of Central China: A Randomized Controlled Trial

Background

The efficacy of peer support in Chinese diabetes patients is still uncertain. The purpose of this study was to observe the effects of a peer support program on the outcomes of patients with type 2 diabetes who received community-based insulin therapy in rural communities of central China.

Material/Methods

Two hundred and eight eligible patients with type 2 diabetes were randomly assigned into the traditional training group (control group, n=111) and peer support intervention group (peer group, n=97) between June 2013 and January 2014 in 2 rural communities of Jingzhou area, China. Both groups received 3-month traditional training, followed by another 4-month traditional training or peer support training, respectively. At baseline and 7 months after treatment, the blood glycemic level was evaluated by biochemical detection. Capacities of self-management and knowledge related to insulin usage were assessed by questionnaire survey.

Results

Ninety-seven and ninety patients completed this study in the control group and peer group, respectively. There was no significant difference in age, gender, diabetes duration, insulin usage time, and complications between the 2 groups at baseline (P>0.05). Compared with the control group, peer group patients achieved a more significant decrease in blood glycosylated hemoglobin levels (P<0.05), increase in knowledge related to insulin usage, and increase of diabetes self-management ability (P<0.05).

Conclusions

Peer support intervention effectively improves outcomes of patients with type 2 diabetes in rural communities of central China.

National standards for asthma self-management education

BACKGROUND

Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that "if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease." Without a standardized curriculum, reimbursement from payers is beyond reach.

OBJECTIVE

Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement.

METHODS

The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document.

RESULTS

This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014.

CONCLUSION

This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.

Individual and Group Education in Diabetes and Outcomes

Objetivo: El propósito del presente estudio fue examinar los efectos de las dos técnicas de educación diabética que se estaban implementando en un entorno real sobre los resultados de la atención (los niveles de conocimiento, el manejo del auto - cuidado, A1c , BMI ). Métodos: La investigación se llevó a cabo como un estudio correlacional y descriptivo. El muestreo fue compuesto por 391 personas. Los datos se seleccionaron mediante formularios de evaluación diabética, formularios de evaluación de los conocimientos diabéticos, la Escala de Agencia de Autocuidado y formularios de evaluación de A1c y BMI. Resultados: Los resultados indicaron que la modalidad de la técnica educativa fue capaz de afectar a los niveles de conocimiento en un 77 %, a la agencia de autocuidado en un 76 % , a los niveles de A1c en un 78% y al índice de masa corporal en un 75 %. Conclusion: Se ve que una combinación de educación diabética individual y grupal es un mejor método para asegurar la autogestión eficaz de un individuo.

Outcomes from a diabetes self-management intervention for Native Hawaiians and Pacific People: Partners in Care

BACKGROUND

Culturally adapted interventions are needed to reduce diabetes-related morbidity and mortality among Native Hawaiian and Pacific People.

PURPOSE

The purpose of this study is to pilot test the effectiveness of a culturally adapted diabetes self-management intervention.

METHODS

Participants were randomly assigned in an unbalanced design to the Partners in Care intervention (n = 48) or wait list control group (n = 34). Assessments of hemoglobin A1c, understanding of diabetes self-management, performance of self-care activities, and diabetes-related distress were measured at baseline and 3 months (post intervention). Analysis of covariance was used to test between-group differences. The community steering committee and focus group data informed the cultural adaptation of the intervention.

RESULTS

There were significant baseline adjusted differences at 3 months between the Partners in Care and wait list control group in intent-to-treat (p < 0.001) and complete case analyses (p < 0.0001) for A1c, understanding (p < 0.0001), and performing diabetes self-management (p < 0.0001).

CONCLUSIONS

A culturally adapted diabetes self-management intervention of short duration was an effective approach to improving glycemic control among Native Hawaiian and Pacific Islanders.

Linking internet-based diabetes self-management to primary care: lessons learned and implications for research translation and practice implementation

There has been little discussion of or research on the key translational issue of how to integrate patient self-management programs across multiple primary care clinics within an HMO. The purpose of this study was to summarize our experiences and lessons learned in trying to integrate information from a web-based diabetes self-management program into primary care and the electronic health record (EHR). We describe plans, implementation, adaptations made, and data on patient and physician reactions to the My Path diabetes self-management program provided to 331 adult primary care patients. Mixed methods results revealed that, despite the availability of a state-of-the-art EHR, the intervention was not well integrated into primary care. Information from health-promotion and disease management programs, even within the same organization and with advanced EHR systems, is challenging to integrate into busy primary care.

Impact of an education program on patient anxiety, depression, glycemic control, and adherence to self-care and medication in Type 2 diabetes

Background:

Diabetes mellitus (DM) requires continuous medical care, patients’ self-management, education, and adherence to prescribed medication to reduce the risk of long-term complications. The aim of this study was to assess the benefits of an education program on diabetes, patient self-management, adherence to medication, anxiety, depression and glycemic control in type 2 diabetics in Saudi Arabia.

Materials and Methods:

This was a prospective study, conducted among 104 diabetic patients at a major tertiary hospital in Riyadh, Saudi Arabia, between May 2011 and October 2012. Education materials given to diabetic patients included pamphlets/handouts written in Arabic, the national language. Special videotapes about DM were made and distributed to all participants. In addition, specific educational programs through the diabetes educators and one-on-one counseling sessions with the doctor were also arranged. Patients were interviewed using a structured interview schedule both during the baseline, and after 6 months of the program. The interview schedule included, socio-demographics, clinical characteristics, diabetes self-management, adherence to medication, anxiety, and depression. Glycemic control was considered poor, if hemoglobin A1c (HbA1c) was ≥ 7%.

Results:

The mean age of the study population was 57.3 ± 14.4 years. Seventy one were males (68.3%) and 33 (31.7%) were females. After six months of the diabetes education program, there were significant improvements in patients’ dietary plan (P = 0.0001), physical exercise (P = 0.0001), self-monitoring of blood glucose (SMBG) (P = 0.0001), HbA1c (P = 0.04), adherence to medication (P = 0.007), and depression (P = 0.03).

Conclusions:

Implementation of education programs on diabetes among type 2 diabetic patients is associated with better outcomes such as their dietary plan, physical exercise, SMBG, adherence to medication, HbA1c and depression.

Comparison of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a randomized controlled trial

Mindful eating may be an effective intervention for increasing awareness of hunger and satiety cues, improving eating regulation and dietary patterns, reducing symptoms of depression and anxiety, and promoting weight loss. Diabetes self-management education (DSME), which addresses knowledge, self-efficacy, and outcome expectations for improving food choices, also may be an effective intervention for diabetes self-care. Yet few studies have compared the impact of mindful eating to a DSME-based treatment approach on patient outcomes. Adults 35 to 65 years old with type 2 diabetes for ≥1 year not requiring insulin therapy were recruited from the community and randomly assigned to treatment group. The impact of a group-based 3-month mindful eating intervention (MB-EAT-D; n = 27) to a group-based 3-month DSME "Smart Choices" (SC) intervention (n = 25) postintervention and at 3-month follow-up was evaluated. Repeated-measures ANOVA with contrast analysis compared change in outcomes across time. There was no significant difference between groups in weight change. Significant improvement in depressive symptoms, outcome expectations, nutrition and eating-related self-efficacy, and cognitive control and disinhibition of control regarding eating behaviors occurred for both groups (all p < .0125) at 3-month follow-up. The SC group had greater increase in nutrition knowledge and self-efficacy than the MB-EAT-D group (all p < .05) at 3-month follow-up. MB-EAT-D had significant increase in mindfulness, whereas the SC group had significant increase in fruit and vegetable consumption at study end (all p < .0125). Both SC and MB-EAT-D were effective treatments for diabetes self-management. The availability of mindful eating and DSME-based approaches offers patients greater choices in meeting their self-care needs.

From intervention to innovation: applying a formal implementation strategy in community primary care

Objective. To describe a comprehensive strategy for implementing an effective diabetes self-management support intervention incorporating goal-setting and followup support in community health clinics (CHCs) serving vulnerable patients. Methods. The Replicating Effective Programs (REP) framework was applied to develop an intervention strategy. In order to create a strategy consistent with the REP framework, four CHCs engaged in an iterative process involving key-informant interviews with clinic staff, ongoing involvement of clinic staff facilitating translational efforts, feedback from national experts, and an instructional designer. Results. Moving through the REP process resulted in an implementation strategy that aims to facilitate commitment, communication, and change at the clinic level, as well as means of providing interactive, time-limited education about patient behavior change and support to health care providers. Conclusion. The REP offered a useful framework for providing guidance toward the development of a strategy to implement a diabetes self-management intervention in CHCs serving medically underserved and underrepresented patient populations.

Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals

BACKGROUND

Diabetes education can improve the quality of care of people with diabetes, but many organizations are not equipped to manage its implementation. Involving people with diabetes in the education process can overcome the problem. Thus, we compared clinical, metabolic and psychological outcomes in people with type 2 diabetes 1 year after attending a structured diabetes education programme implemented by professional educators versus the same programme implemented by trained peers with diabetes that also provided ongoing peer support.

METHODS

People with type 2 diabetes (25-75 years) were randomly assigned to attend a 4-week structured diabetes education course delivered by professional educators (control) or previously trained peers (peer). Peers also received continuing psychological support, including examples on how to apply diabetes knowledge in daily life via weekly peer cellular phone calls and bimonthly face-to-face interviews in small groups (ten patients), using a structured questionnaire related to the patient's clinical, metabolic and psychological progress. Identical outcome data from both groups were used for follow-up.

RESULTS

Both groups had a comparable positive effect on clinical, metabolic and psychological indicators immediately following the programme. Over the following year, peer-educated subjects had lower A(1C) and systolic blood pressure and showed higher adherence to physical activity and better control of hypoglycaemic episodes.

CONCLUSION

The non-inferiority of the peer outcomes and the mentioned improvements in this group suggest that volunteer trained peer educators and ongoing support can be successful. This approach provides an effective alternative method of education, especially in areas with limited availability of professionals and economic resources.

Telehealth--an effective delivery method for diabetes self-management education?

Diabetes is a chronic disease that is often comorbid with cardiovascular disease, hypertension, kidney disease, and neuropathy. Its management is complex, requiring ongoing clinical management, lifestyle changes, and self-care. This article examines recent literature on telehealth and emerging technological tools for supporting self-management of diabetes and identifies best practices. The authors conducted a PubMed search (January 2008-2012) that was supplemented by review of meeting materials and a scan of the Internet to identify emerging technologies. Fifty-eight papers were reviewed; 12 were selected for greater analysis. This review supports earlier findings that the delivery of diabetes self-management and training (DSME/T) via telehealth is useful, appropriate, and acceptable to patients and providers. Best practices are emerging; not all technology is appropriate for all populations--interactive technology needs to be appropriate to the patient's age, abilities, and sensitivities. Telehealth is scalable and sustainable provided that it adds value, does not add to the provider's workload, and is fairly reimbursed. However, there are multiple barriers (patient, provider, health system) to remotely provided DSME/T. DSME/T delivered via telehealth offers effective, efficient, and affordable ways to reach and support underserved minorities and other people with diabetes and related comorbidities. The new generation of smartphones, apps, and other technologies increase access, and the newest interventions are designed to meet patient needs, do not increase workloads, are highly appropriate, enhance self-management, and are desired by patients.

Development and validation of the self-management profile for type 2 diabetes (SMP-T2D)

BACKGROUND

This study evaluated the measurement properties of a newly developed instrument - the Self-Management Profile for Type 2 Diabetes (SMP-T2D).

METHODS

The 18-item SMP-T2D assesses 12 constructs: level and perceived ease of performance in five self-care domains (blood glucose monitoring, medication-taking, healthy eating, being physically active, and coping), and two global constructs (ease of weight management, confidence with ability to manage diabetes). Validation analyses were based on two studies involving 240 patients with T2D, Study 1 (Clinicaltrials.gov #NCT00637273) with SMP-T2D administration supplemented by SMP-T2D retest one week later, and Study 2 (Clinical trials.gov #NCT00877890) with SMP-T2D administration supplemented by 24-week SMP-T2D follow-up after medication change. Validation included clinical indicators and measures of patient reported quality of life, psychological well-being and treatment outcomes.

RESULTS

All multi-item SMP-T2D measures showed acceptable internal consistency (alphas = 0.71 to 0.87); ten measures had test-retest reliability >0.75. Correlations among SMP-T2D measures and between SMP-T2D measures and validation measures, which were as hypothesized, provided evidence of convergent and discriminant validity. Scores for six SMP-T2D measures improved significantly during Study 2. Multiple regression analysis showed independent associations between change in SMP-T2D measures and change in trial outcomes from baseline to end-of-study.

CONCLUSIONS

Two studies provide preliminary evidence regarding the reliability, validity and responsiveness of the SMP-T2D. Further research on the utility of the instrument is needed.

Group diabetes education administered through telemedicine: tools used and lessons learned

OBJECTIVE

To describe the use of telemedicine for teaching group diabetes education classes to individuals with diabetes mellitus in a rural medically underserved area.

SUBJECTS AND METHODS

Adults with diabetes from a rural area served by Oswego Hospital in upstate New York were asked to participate in this study. Volunteers received diabetes education through real-time teleconferencing (n=27) by joining age- and sex-matched patients from the Joslin Diabetes Center, Syracuse, NY, in our "Living with Diabetes Class" (n=39). The two 3-h sessions offered comprehensive diabetes education by a diabetes nurse educator, dietitian, and exercise physiologist. These sessions were followed in 3 months by a 3-h follow-up class. Each group receiving tele-education consisted of two or three patients with diabetes.

RESULTS

The hemoglobin A1c test (a blood test that estimates the overall average glucose levels over the past 3 months) improved in the face-to-face and the telemedicine groups. There was no significant change in weight between groups. Each group had significant improvements in scores on the Problem Areas In Diabetes survey, which is a measure of emotional functioning in diabetes. Diabetes treatment satisfaction as measured in the Diabetes Treatment Satisfaction Questionnaire improved in the face-to-face group but not in the telemedicine group. Although the face-to-face group had significantly higher scores in the Diabetes Treatment Satisfaction Questionnaire, the telemedicine group was highly satisfied with the services provided.

CONCLUSIONS

Telemedicine offers an effective alternative approach for providing group diabetes education to individuals with poor access to diabetes education programs.

Prospective associations between intervention components and website engagement in a publicly available physical activity website: the case of 10,000 Steps Australia

Background

Effectiveness of and engagement with website-delivered physical activity interventions is moderate at best. Increased exposure to Internet interventions is reported to increase their effectiveness; however, there is a lack of knowledge about which specific intervention elements are able to maintain website engagement.

Objective

To prospectively study the associations of website engagement and exposure to intervention components for a publicly available physical activity website (10,000 Steps Australia).

Methods

Between June and July 2006 a total of 348 members of 10,000 Steps completed a Web-based survey to collect demographic characteristics. Website engagement was subsequently assessed over a 2-year period and included engagement data on website components; individual challenges, team challenges, and virtual walking buddies; and indicators of website engagement (average steps logged, days logging steps, and active users).

Results

On average participants logged steps on 169 (SD 228.25) days. Over a 2-year period this equated to an average of 1.6 logons per week. Binary logistic regression showed that individuals who participated in individual challenges were more likely to achieve an average of 10,000 steps per day (odds ratio [OR] = 2.80, 95% confidence interval [CI] 1.45–5.40), log steps on a higher than average number of days (OR = 6.81, 95% CI 2.87–13.31), and remain an active user (OR = 4.36, 95% CI 2.17–8.71). Additionally, those using virtual walking buddies (OR = 5.83, 95% CI 1.27–26.80) and of older age logged steps on a higher than average number of days. No significant associations were found for team challenges.

Conclusions

Overall engagement with the 10,000 Steps website was high, and the results demonstrate the relative effectiveness of interactive components to enhance website engagement. However, only exposure to the interactive individual challenge feature was positively associated with all website engagement indicators. More research is needed to examine the influence of intervention components on website engagement, as well as the relationship between website engagement and physical activity change.

A nursing educational intervention helped by One Touch UltraSmart improves monitoring and glycated haemoglobin levels in type I diabetic children

OBJECTIVES

To improve the monitoring and control of glycated haemoglobin in insulin-dependent children. This article describes an educational intervention for this purpose where One Touch UltraSmart Software was used to manage diabetes. The results showed that this intervention helped to reduce the levels of blood glucose and glycated haemoglobin to less than 7%.

BACKGROUND

Various research studies have been performed on the effective control of glycated haemoglobin values in diabetic children by means of technological devices. However, none of this research has evaluated the impact of an educational intervention in conjunction with the use of monitoring instruments such as One Touch UltraSmart.

DESIGN

We present an 18-month longitudinal, analytical and observational study of 37 type 1 diabetic patients, 9-16 years of age. For each patient, initial and final values of glycated haemoglobin and the number of blood glucose controls were recorded.

METHODOLOGY

For the purposes of our study seven educational workshops, attended by diabetic children and their parents, were conducted. In addition, participants were asked to complete a brief questionnaire so that information could be gathered regarding the eating and exercise habits of the patients.

RESULTS

This educational intervention using One Touch UltraSmart led to a statistically significant average reduction of glycated haemoglobin.

CONCLUSIONS

Our research showed that the use of One Touch UltraSmart in the context of an educational intervention raised the awareness of the diabetic children and thus helped them to effectively control their disease and to fully understand the necessity of having good dietary and exercise habits.

RELEVANCE TO CLINICAL PRACTICE

It can be concluded that the educational intervention led to a significant improvement in the dietary habits of these patients and also helped them to exercise regularly, all of which has a positive impact on their health.

The National Diabetes Education Program

A guide to this one-stop, easy-to-use resource for nurses and patients.

The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to determine the effect of nurse-led diabetes self-management education (DSME) on blood glucose control and cardiovascular risk factors.

METHODS

The electronic databases PubMed and ISIS Knowledge were searched for relevant randomized controlled studies published between 1999 and 2009. Effect size was calculated for change in A1C, blood pressure, and lipid levels using both fixed- and random-effects models. Subgroup analyses were performed on patient age, gender, diabetes type, baseline A1C, length of follow-up, and study setting.

RESULTS

A total of 34 randomized controlled trials with a combined cohort size of 5993 patients was identified. Mean patient age was 52.8 years, 47% were male, and mean A1C at baseline was 8.5%. Mean change in A1C was a reduction by -0.70% for nurse-led DSME versus -0.21% with usual care (UC). This corresponded to an effect size of 0.506, using a random-effects model for nurse-led DSME versus UC. Effect size was significantly associated with patient age older than 65 years and with duration of follow-up. Nurse-led DSME was also associated with improvements in cardiovascular risk factors, particularly among male patients, among those with good glycemic control, and in studies conducted in the United States.

CONCLUSIONS

Nurse-led DSME is associated with improved glycemic control, demonstrating that programs are most effective among seniors and with follow-up periods of 1 to 6 months. Future programs tailored to the needs of patients younger than 65 years may improve the impact of DSME on blood glucose.

Diabetes knowledge, medication adherence and glycemic control among patients with type 2 diabetes

BACKGROUND

Most of interventions that have attempted to improve medication adherence in type 2 diabetes have been educational; on the assumption that knowledge regarding diabetes might affect patients' adherence to their treatment regimen.

OBJECTIVES

The purpose of the study was to investigate any association of knowledge and medication adherence with glycemic control in patients with type 2 diabetes mellitus. Setting The study was conducted at the Diabetes Outpatients Clinic, Hospital Pulau Penang.

METHODS

A cross-sectional study was conducted with a convenience sample of 540 adult patients with type 2 diabetes attending the clinic. A questionnaire including previously validated Michigan Diabetes Knowledge Test and Morisky Medication Adherence Scale was used and the patients' medical records were reviewed for haemoglobin A1C (HbA1C) levels and other disease-related information. A total of 35 (6.48%) patients were excluded after data collection due to lack of HbA1C results.

RESULTS

Five hundred and five patients were included in the final analysis, with a mean age of 58.15 years (SD = 9.16), 50.7% males and median HbA1C of 7.6 (IQR was 6.7-8.9). The median total knowledge score was 7.0 (IQR was 5.0-10.0) while the median adherence score was 6.5 (IQR was 4.75-7.75). Significant correlations were found between the three variables (HbA1C, knowledge and adherence). A significantly higher score for knowledge and adherence (P < 0.05) was found in those patients with lower HbA1C. Higher diabetes knowledge, higher medication adherence and using mono-therapy were significant predictors of good glycemic control in the multivariate analysis.

CONCLUSION

Patients' knowledge about diabetes is associated with better medication adherence and better glycemic control. In addition to other factors affecting medication adherence and glycemic control, healthcare providers should pay attention to knowledge about diabetes that the patients carry towards medication adherence.

Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

BACKGROUND

Self-management support is seen as a cornerstone of good diabetes care and many countries are currently engaged in initiatives to integrate self-management support in primary care. Concerning the organisation of these programs, evidence is growing that engagement of health care professionals, in particular of GPs, is critical for successful application. This paper reports on a study exploring why a substantial number of GPs was (initially) reluctant to refer patients to a self-management education program in Belgium.

METHODS

Qualitative analysis of semi-structured face-to-face interviews with a purposive sample of 20 GPs who were not regular users of the service. The Greenhalgh diffusion of innovation framework was used as background and organising framework.

RESULTS

Several barriers, linked to different components of the Greenhalgh model, emerged from the interview data. One of the most striking ones was the limited readiness for innovation among GPs. Feelings of fear of further fragmentation of diabetes care and frustration and insecurity regarding their own role in diabetes care prevented them from engaging in the innovation process. GPs needed time to be reassured that the program respects their role and has an added value to usual care. Once GPs considered referring patients, it was not clear enough which of their patients would benefit from the program. Some GPs expressed the need for training in motivational skills, so that they could better motivate their patients to participate. A practical but often mentioned barrier was the distance to the centre where the program was delivered. Further, uncertainty about continuity interfered with the uptake of the offer.

CONCLUSIONS

The study results contribute to a better understanding of the reasons why GPs hesitate to refer patients to a self-management education program. First of all, the role of GPs and other health care providers in diabetes care needs to be clarified before introducing new functions. Feelings of security and a basic trust of providers in the health system are a prerequisite for participation in care innovation. Moreover, some important lessons regarding the implementation of an education program in primary care have been learned from the study.

Assessing the need for diabetes self-management education in the Oklahoma city vietnamese community

INTRODUCTION

To assess the diabetes self-management educational (DSME) needs of the Vietnamese diabetic population in the Oklahoma City metropolitan area.

METHODS

Participants in this explorative study included 50 Vietnamese adults with type 1 or type 2 diabetes recruited from the offices of four primary care physicians in the Oklahoma City metropolitan area. Participants completed a culturally sensitive survey focused on their diabetes history, knowledge and need of DSME, and health beliefs. Responses were evaluated using means and frequency analysis.

RESULTS

The mean age of participants was 62.7±9.1 years. Over 80% of participants were most comfortable speaking and reading Vietnamese, and 62% had never received a high school diploma. Less than 50% of participants reported ever receiving education regarding diabetic complications, nutrition, desirable glycated hemoglobin values, diabetic medications, daily self-care, risk of smoking, or cardiovascular risk associated with diabetes. More than 80% of participants requested more education in all areas of DSME except smoking risk in diabetes, with all participants requesting delivery of this education in Vietnamese.

CONCLUSION

DSME is needed and desired in the Vietnamese community of the Oklahoma City metropolitan area. Education should be provided in the Vietnamese language with most targeted to lower literacy levels. Vietnamese diabetes educators should facilitate increased access to DSME knowledge and skills in efforts to improve glycemic control and overall health status for this community.

Results of a successful telephonic intervention to improve diabetes control in urban adults: a randomized trial

OBJECTIVE

To compare the effectiveness of a telephonic and a print intervention over 1 year to improve diabetes control in low-income urban adults.

RESEARCH DESIGN AND METHODS

A randomized trial in Spanish and English comparing a telephonic intervention implemented by health educators with a print intervention. Participants (N = 526) had an A1C ≥7.5% and were prescribed one or more oral agents. All were members of a union/employer jointly sponsored health benefit plan. Health coverage included medications. Primary outcomes were A1C and pharmacy claims data; secondary outcomes included self-report of two medication adherence measures and other self-care behaviors.

RESULTS

Participants were 62% black and 23% Hispanic; 77% were foreign born, and 42% had annual family incomes <$30 thousand. Baseline median A1C was 8.6% (interquartile range 8.0-10.0). Insulin was also prescribed for 24% of participants. The telephone group had mean ± SE decline in A1C of 0.23 ± 0.11% over 1 year compared with a rise of 0.13 ± 0.13% for the print group (P = 0.04). After adjusting for baseline A1C, sex, age, and insulin use, the difference in A1C was 0.40% (95% CI 0.10-0.70, P = 0.009). Change in medication adherence measured by claims data, but not by self-report measures, was significantly associated with change in A1C (P = 0.01). Improvement in medication adherence was associated (P = 0.005) with the telephonic intervention, but only among those not taking insulin. No diabetes self-care activities were significantly correlated with the change in A1C.

CONCLUSIONS

A 1-year tailored telephonic intervention implemented by health educators was successful in significantly, albeit modestly, improving diabetes control compared with a print intervention in a low-income, insured, minority population.

The development of a pilot training program for peer leaders in diabetes: process and content

PURPOSE

The goal of this study is to describe the process of developing a program that trains peers to facilitate an empowerment-based diabetes self-management support intervention.

METHODS

To guide and advise the development process, the authors formed a peer leader training action committee. The committee was an interdisciplinary group (principal investigator, nurse-certified diabetes educators, dietitian-certified diabetes educators, nutritionist, physician, and 3 community members) that met every 3 months over a 1-year period for continuous quality improvement meetings. During meetings, the committee reviewed and supervised the curriculum development, provided feedback, and informed modifications and improvements.

RESULTS

The resulting peer leader training program is a 46-hour program with 2 training sessions conducted per week over a 12-week period. The competency-based training program is based on the theory of experiential learning, and it consists of 3 major components--namely, building a diabetes-related knowledge base, developing skills (communication, facilitation, and behavior change), and applying skills in experiential settings. All components are integrated within each training session using a range of instructional methods, including group brainstorming, group sharing, role-play, peer leader simulations, and group facilitation simulations.

CONCLUSION

Through the process described above, the authors developed a training program that equips peer leaders with the knowledge and skills to facilitate empowerment-based diabetes self-management support interventions. Future directions include conducting and evaluating the peer training program.

Standards of care for diabetes: what's new?

Each year, the American Diabetes Association (ADA) publishes standards of medical care for people with diabetes. The ADA updates these standards based on the latest evidence so that healthcare professional scan incorporate this evidence into their care. The standards also summarize and rate the levels of evidence on which the recommendations are based. This article describes new recommendations in the 2010 Standards of Medical Care in Diabetes (the 2010 Standards).

Advancing quality diabetes education through evidence and innovation

Patients with type 2 diabetes crowd emergency rooms; fill medical, surgical, and cardiac beds; and now appear in maternal health and pediatric units. Education is critical in hospital care of diabetes; however, what level of knowledge exists among acute care nurses? A systematic approach was used to examine levels of nursing knowledge about diabetes. An innovative and cost-effective structure was created to improve the quality of patient care through supporting diabetes education.

Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

The diagnosis of a chronic disease such as diabetes generally evokes strong emotions and often brings with it the need to make changes in lifestyle behaviours, such as diet, exercise, medication management and monitoring clinical and metabolic parameters. The diagnosis thus affects not only the person diagnosed but also the family members. Chronic illnesses are largely self-managed with approximately 99% of the care becoming the responsibility of patients and their families or others involved in the daily management of their illnesses. While the responsibility for outcomes, such as metabolic control and chronic complications, are shared with the health care team, the daily decisions and behaviours adopted by patients clearly have a strong influence on their future health and well-being. While diabetes self-management education is essential, it is generally not sufficient for patients to sustain behaviours and cope with a lifetime of diabetes. Peers have been proposed as one method for assisting patients to deal with the behavioural and affective components of diabetes and to provide ongoing self-management support. This paper first describes effective behavioural strategies in diabetes, based on multiple studies and/or meta-analyses, and then provides examples of their use by peers or in peer-based programmes in diabetes. A comprehensive search using the MEDLINE and Cinahl databases was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay health workers and community health workers. Studies that clearly identified behavioural strategies used by peers were included.

Know your diabetes risk project: Student pharmacists educating adults about diabetes risk in a community pharmacy setting

OBJECTIVES

To determine the feasibility of educating adults about their risk of prediabetes/diabetes in a community pharmacy, to determine the common risk factors for prediabetes/diabetes in adults visiting a community pharmacy, and to assess any association between risk factors and age.

DESIGN

Cross sectional.

SETTING

Oklahoma community pharmacies between April 1 and December 31, 2008.

PARTICIPANTS

1,852 patients aged 18 to 80 years.

INTERVENTION

Student pharmacists invited adults to complete a survey to assess their risk for diabetes/prediabetes. Students reviewed participants' risk and educated them on lifestyle changes to lower diabetes risk.

MAIN OUTCOME MEASURES

Patient risk factors, pharmacy identifier, and pharmacy type (independent, chain, or clinic pharmacy) and location (rural, suburban, or city).

RESULTS

Diabetes risk assessment and education of 1,852 adults was performed by 110 student pharmacists in 52 community pharmacies located in 27 cities across 13 (of 77) Oklahoma counties. Obesity/overweight was the most common risk factor (57%), with positive family history, hypertension, elevated cholesterol, member of high-risk ethnic group, and sedentary lifestyle being reported by at least 20% of participants. The number of risk factors increased with age, with a significant increase occurring in participants older than 40 years of age.

CONCLUSION

This project demonstrated that it is feasible to perform diabetes risk assessment and to provide education on lowering that risk through community pharmacies.

Examining Patient Risk Factors, Comorbid Conditions, Participation, and Physician Referrals to a Rural Diabetes Self-management Education Program

Purpose

The purpose of this study was to examine patients’ diabetes risk factors, comorbid conditions, and patient participation in and primary care practitioner (PCP) referrals to a rural diabetes self-management education (DSME) program.

Methods

A total of 295 patients in a rural community were identified by their PCP as having type 2 diabetes (T2D). Using patient information that was collected and entered into a diabetes data management system, patients’ risk factors, comorbid conditions, and patient participation in and PCP referral patterns to a DSME program were examined.

Results

Of the 295 patients with T2D, 162 (65%) reported that they had never received any DSME services. Despite educator efforts to improve patient participation and PCP awareness of local DSME services, 123 (76%) of the 162 patients never received a subsequent referral for DSME. Those patients who did receive a referral had a higher number of risk factors and comorbid conditions than those who did not receive a referral. Eighty-three percent of the patients who received a PCP referral attended the DSME program.

Conclusions

The findings reaffirm concerns that DSME patient participation and PCP referral practices are poor. Advocacy efforts should force policies and procedures that will make DSME a mandatory service and universally accessible. Unless referral practices are attended to, it is doubtful that the United States will reach the Healthy People 2010 objective for diabetes education.

Comparing the processes: accreditation and recognition

Diabetes education programs are developed to serve the diabetes community by offering quality education that meets a set of standards and is then eligible for third-party insurance reimbursement. Three organizations are authorized by the U.S. Centers for Medicare and Medicaid Services to determine whether diabetes education programs meet required standards. Each of the three relies on the 2007 edition of the National Standards for Diabetes Self-Management Education. This article summarizes similarities among and unique qualities of each of the organization's approaches to assuring quality.