Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes

Efficacy of StepAdd, a Personalized mHealth Intervention Based on Social Cognitive Theory to Increase Physical Activity Among Patients With Type 2 Diabetes Mellitus: Protocol for a Randomized Controlled Trial

BACKGROUND

Increasing physical activity improves glycemic control in patients with type 2 diabetes (T2D). Mobile health (mHealth) interventions have been proven to increase exercise, but engagement often fades with time. As the use of health behavior theory in mHealth design can increase effectiveness, we developed StepAdd, an mHealth intervention based on the constructs of social cognitive theory (SCT). StepAdd improves exercise behavior self-efficacy and self-regulation through the use of goal-setting, barrier-identifying, and barrier-coping strategies, as well as automatic feedback functions. A single-arm pilot study of StepAdd among 33 patients with T2D showed a large increase in step count (mean change of 4714, SD 3638 daily steps or +86.7%), along with strong improvements in BMI (mean change of -0.3 kg/m2) and hemoglobin A1c level (mean change of -0.79 percentage points).

OBJECTIVE

In this study, we aim to investigate the efficacy and safety of StepAdd, an mHealth exercise support system for patients with T2D, via a large, long, and controlled follow-up to the pilot study.

METHODS

This is a randomized, open-label, multicenter study targeting 160 patients with T2D from 5 institutions in Japan with a 24-week intervention. The intervention group will record daily step counts, body weight, and blood pressure using the SCT-based mobile app, StepAdd, and receive feedback about these measurements. In addition, they will set weekly step count goals, identify personal barriers to walking, and define strategies to overcome these barriers. The control group will record daily step counts, body weight, and blood pressure using a non-SCT-based placebo app. Both groups will receive monthly consultations with a physician who will advise patients regarding lifestyle modifications and use of the app. The 24-week intervention period will be followed by a 12-week observational period to investigate the sustainability of the intervention's effects. The primary outcome is between-group difference in the change in hemoglobin A1c values at 24 weeks. The secondary outcomes include other health measures, measurements of steps, measurements of other behavior changes, and assessments of app use. The trial began in January 2023 and is intended to be completed in December 2025.

RESULTS

As of September 5, 2023, we had recruited 44 patients. We expect the trial to be completed by October 8, 2025, with the follow-up observation period being completed by December 31, 2025.

CONCLUSIONS

This trial will provide important evidence about the efficacy of an SCT-based mHealth intervention in improving physical activities and glycemic control in patients with T2D. If this study proves the intervention to be effective and safe, it could be a key step toward the integration of mHealth as part of the standard treatment received by patients with T2D in Japan.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (JRCT) jRCT2032220603; https://rctportal.niph.go.jp/en/detail?trial_id=jRCT2032220603.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53514.

The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review

A majority of individuals with limited English proficiency (LEP) in the U.S. are foreign-born, creating a complex intersection of language, socio-economic, and policy barriers to healthcare access and achieving good outcomes. Mapping the research literature is key to addressing how LEP intersects with healthcare. This scoping review followed PRISMA-ScR guidelines and included PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Study selection included quantitative studies since 2000 with outcomes specified for adults with LEP residing in the U.S. related to healthcare service access or defined health outcomes, including healthcare costs. A total of 137 articles met the inclusion criteria. Major outcomes included ambulatory care, hospitalization, screening, specific conditions, and general health. Overall, the literature identified differential access to and utilization of healthcare across multiple modalities with poorer outcomes among LEP populations compared with English-proficient populations. Current research includes inconsistent definitions for LEP populations, primarily cross-sectional studies, small sample sizes, and homogeneous language and regional samples. Current regulations and practices are insufficient to address the barriers that LEP individuals face to healthcare access and outcomes. Changes to EMRs and other data collection to consistently include LEP status and more methodologically rigorous studies are needed to address healthcare disparities for LEP individuals.

Validation and optimization of the French Generic Adherence for Chronic Diseases Profile (GACID-P) using classical test and item response theory

BACKGROUND

The Generic Adherence for Chronic Diseases Profile is a French generic scale (GACID-P) developed to measure adherence in several disease areas such as cardiology, rheumatology, diabetes, cancer and infectiology.

METHOD

We aimed to study the measurement invariance of the Generic Adherence for Chronic Diseases Profile by an item response model, optimize the new instrument version from item response model and qualitative content analyses results, and validate the instrument. The metric properties of the optimized version were studied according to classical test theory and item response model analysis.

RESULTS

A sample of 397 patients consulting at two French hospitals (in diabetes, cardiology, rheumatology, cancerology and infectiology) and in four private practices was recruited; 314 (79%) patients also completed the questionnaire 15 days later. Factor analyses revealed four dimensions: "Forgetting to take medication", "Intention to comply with treatment", "Limitation of risk-related consumer habits" and "Healthy lifestyle". The item response model and content analyses optimized these four dimensions, regrouping 32 items in four dimensions of 25 items, including one item conditioned on tobacco use. The psychometric properties and scale calibration were satisfactory. One score per dimension was calculated as the sum of the items for the dimensions "Forgetting to take medication" and "Intention to comply with treatment" and as a weighted score according to the item response model analysis for the two other dimensions because of differential item functioning found for two items.

CONCLUSION

Four adherence profile scores were obtained. The instrument validity was documented by a theoretical approach and content analysis. The Generic Adherence for Chronic Diseases Profile is now available for research targeting adherence in a broad perspective.

Assessment of Glucose Monitoring Adherence in Medicare Beneficiaries with Insulin-Treated Diabetes

Background: We investigated the potential associations between race/ethnicity and adherence to prescribed glucose monitoring in a sample of Medicare beneficiaries with diabetes and how adherence to the method used impacted diabetes-related inpatient hospitalizations and associated costs among beneficiaries with intensive insulin-treated diabetes. Methods: This 12-month retrospective analysis utilized Centers for Medicare & Medicaid Services data to identify Medicare beneficiaries who used intensive insulin therapy from January through December 2018 and classified them into four groups: (1) persons using real-time continuous glucose monitoring (rtCGM), (2) persons using any method of blood glucose monitoring (BGM) who followed prescribed use patterns (adherent), (3) persons who were prescribed BGM but were nonadherent in its use, and (4) no record of any form of BGM. Analyses compared these groups and the role that comorbidities (Charlson Comorbidity Index [CCI]), and race/ethnicity played on group assignment, diabetes-related inpatient hospitalizations, and costs. Results: Among the 1,329,061 persons assessed, 38.14% had no record of glucose monitoring and 35.42% were BGM nonadherent. Similarly, among the 629,514 beneficiaries with a CCI risk score of ≥2, 466,646 (74.13%) were either nonadherent to BGM or had no monitoring record. The percentage of White (3.65%) rtCGM adherent beneficiaries was significantly larger than Black (1.58%) and Hispanic (1.28%) beneficiaries, both P < 0.0001. Hospitalizations and costs were higher for Black and Hispanic beneficiaries versus Whites within the risk score ≥ 2 group regardless of glucose monitoring method. Conclusions: Race is associated with increased hospitalizations and costs associated with diabetes care and absence of any form of BGM was associated with higher rates of comorbidities. Persons of color were less likely to use rtCGM despite Medicare coverage. New initiatives that promote diabetes self-management education and support services are needed to improve utilization of glucose monitoring within the Medicare diabetes population.

Utilization of Personalized Machine-Learning to Screen for Dysglycemia from Ambulatory ECG, toward Noninvasive Blood Glucose Monitoring

Blood glucose (BG) monitoring is important for critically ill patients, as poor sugar control has been associated with increased mortality in hospitalized patients. However, constant BG monitoring can be resource-intensive and pose a healthcare burden in clinical practice. In this study, we aimed to develop a personalized machine-learning model to predict dysglycemia from electrocardiogram (ECG) data. We used the Medical Information Mart for Intensive Care III database as our source of data and obtained more than 20 ECG records from each included patient during a single hospital admission. We focused on lead II recordings, along with corresponding blood sugar data. We processed the data and used ECG features from each heartbeat as inputs to develop a one-class support vector machine algorithm to predict dysglycemia. The model was able to predict dysglycemia using a single heartbeat with an AUC of 0.92 ± 0.09, a sensitivity of 0.92 ± 0.10, and specificity of 0.84 ± 0.04. After applying 10 s majority voting, the AUC of the model's dysglycemia prediction increased to 0.97 ± 0.06. This study showed that a personalized machine-learning algorithm can accurately detect dysglycemia from a single-lead ECG.

A WHO key informant language survey of people with lived experiences of diabetes: Media misconceptions, values-based messaging, stigma, framings and communications considerations

AIMS

This study aimed to learn from people with lived experiences of diabetes to raise the quality of diabetes communications.

METHODS

An online key informant survey for people (18+) with a direct and/or adjacent (caregiver, friend, family-member etc.,) lived experience of diabetes. Through thematic analysis, we gathered insights on perceptions of media reporting on diabetes and communicating with accuracy, impact and without stigma. Descriptive analysis also investigated effective values for WHO to communicate diabetes with key audiences of policy-makers, funding partners and the general public.

RESULTS

918 respondents in 58 WHO Member States were analysed. Participants identified five key themes requiring more appropriate consideration in the media: accurately defining diabetes types, over-emphasis on sugar and lifestyle, negative impacts of diabetes stigma, burden of costs (financial, personal and interpersonal) and mental health. Irrespective of audience, key values-based messages identified as important for WHO to convey included: 'urgency', 'preventing suffering', 'improving wellbeing' and 'meaningful engagement' of people with lived experience.

CONCLUSION

Learning from people with lived experience of diabetes identifies key diabetes communication considerations. Continued meaningful engagement of this group, including in WHO's work and the multistakeholder diffusion of this methodology to local contexts, could improve public discourse on diabetes and related policies.

The role of social networks in diabetes self‐care: A cross‐sectional study

Background

Patient involvement with diabetes self‐care is critical to reducing complications, morbidity, and mortality. Social media, as one of the most important forms of digital health, has always been available for diabetes self‐care, although the role of these media in supporting patient self‐care is unclear.

Aims

The aim of this study was to investigate the role of social networks in diabetes self‐care. In this study, the most important social networks used to receive self‐care services, diabetes self‐care behaviors, diabetes self‐care educations and benefits of using various services provided through social networks were identified.

Methods

The present study is a cross‐sectional study that was conducted through an electronic researcher‐made questionnaire in 2021. Two hundred and eighteen patients were selected to participate in the study from centers of diabetes of Fasa city, south of Iran. Sampling was performed by convenience sampling and in accordance with inclusion and exclusion criteria. Data were analyzed by descriptive statistics and analytical tests.

Results

In the data analysis section on Diabetes self‐care behaviors, there was no significant relationship between gender (p = 0.292), age (p = 0.49), type of diabetes (p = 0.909) and duration of diabetes (p = 0.076) with the use of self‐care services provided through social networks. There was a significant relationship between education level and the use of self‐care services provided through social networks (p = 0.01). “Recognizing diabetes and its complications,” “observing personal hygiene,” and “the impact of physical activity on diabetes control” were the most important educations. “Increasing patient knowledge and understanding about diabetes and its complications,” “reducing the consumption of high‐calorie foods and sugars,” and “observing personal and public health” were the most important social network's benefits, respectively.

Conclusions

Various self‐care educations and services provided through social networks can increase the in‐depth knowledge of diabetic patients about self‐care techniques and their effective role in controlling and managing diabetes and performing more self‐care processes.

Optimizing the use of technology to support people with diabetes: research recommendations from Diabetes UK's 2019 diabetes and technology workshop

AIMS

To identify key gaps in the research evidence base that could help improve how technology supports people with diabetes, and provide recommendations to researchers and research funders on how best to address them.

METHODS

A research workshop was conducted, bringing together research experts in diabetes, research experts in technology, people living with diabetes and healthcare professionals.

RESULTS

The following key areas within this field were identified, and research recommendations for each were developed: Matching the pace of research with that of technology development Time in range as a measure Health inequalities and high-risk groups How to train people to use technology most effectively Impact of technology usage on mental health CONCLUSIONS: This position statement outlines recommendations through which research could improve how technology is employed to care for and support people living with diabetes, and calls on the research community and funders to address them in future research programmes and strategies.

Literature Review of Type 2 Diabetes Management and Health Literacy

OBJECTIVE

The purpose of this literature review was to identify educational approaches addressing low health literacy for people with type 2 diabetes. Low health literacy can lead to poor management of diabetes, low engagement with health care providers, increased hospitalization rates, and higher health care costs. These challenges can be even more profound among minority populations and non-English speakers in the United States.

METHODS

A literature search and standard data extraction were performed using PubMed, Medline, and EMBASE databases. A total of 1,914 articles were identified, of which 1,858 were excluded based on the inclusion criteria, and 46 were excluded because of a lack of relevance to both diabetes management and health literacy. The remaining 10 articles were reviewed in detail.

RESULTS

Patients, including ethnic minorities and non-English speakers, who are engaged in diabetes education and health literacy improvement initiatives and ongoing follow-up showed significant improvement in A1C, medication adherence, medication knowledge, and treatment satisfaction. Clinicians considering implementing new interventions to address diabetes care for patients with low health literacy can use culturally tailored approaches, consider ways to create materials for different learning styles and in different languages, engage community health workers and pharmacists to help with patient education, use patient-centered medication labels, and engage instructors who share cultural and linguistic similarities with patients to provide educational sessions.

CONCLUSION

This literature review identified a variety of interventions that had a positive impact on provider-patient communication, medication adherence, and glycemic control by promoting diabetes self-management through educational efforts to address low health literacy.

Factors influencing self-care behavior of socio-economically disadvantaged diabetic patients: A systematic review

Diabetes mellitus and its complications carry broad financial misfortune to the diabetic patients and their family, to the well-being frameworks, and to the public economies through direct clinical expenses and decreased work efficiency. The present study systematically reviewed the possible factors that are influencing self-care behavior of disadvantaged diabetic patients that contribute heavily to the management of this chronic illness. Structured searches were conducted on PubMed, ScienceDirect, and manual searches on Google Scholar for articles published between the years 2000 and 2020. The review was limited to a particular time frame due to the change in WHO criteria for diagnosis and classification of abnormal glucose tolerance. Initially, 96858 articles were identified, and following the screening and full-text reading, 10 studies that met the inclusion criteria were chosen for systematic review. Seven studies had reported the factors influencing self-care behavior among disadvantaged diabetic population. Three studies had reported the importance of intervention strategies and its impact on self-care behavior among them. Findings show that self-care management of socio-economically disadvantaged people entails dimensions including diabetes knowledge, lack of physical activities, social support, lack of access to services, life disruptions, denial of illness, societal attitudes, responsibilities, and treatment costs. It was additionally discovered that diabetes self-management support mediations are successful in drawing in lower economy patients, tending to contending life needs and hindrances to self-care, and encouraging behavior change. Taken together, future methodologically efficacious studies that establish health promoting behaviors and explorations of the factors influencing self-care behaviors of disadvantaged diabetic patients are needed.

Episodic Real-Time CGM Use in Adults with Type 2 Diabetes: Results of a Pilot Randomized Controlled Trial

INTRODUCTION

Resistance to initiating insulin therapy is common for people with type 2 diabetes (T2D) using multiple oral agents, resulting in sustained poor glycemic control. We explored a non-pharmacologic option and examined whether adults with T2D and elevated hemoglobin A1c (HbA1c) who were using multiple, non-insulin antihyperglycemics could obtain glycemic benefit from limited, episodic use of real-time continuous glucose monitoring (rtCGM).

METHODS

A randomized, pilot trial enrolled patients with T2D who were using two or more non-insulin therapies and had HbA1c values of 7.8-10.5%. Following a baseline, 10-day, blinded CGM session, participants were randomized 2:1, rtCGM or self-monitoring of blood glucose (SMBG). Medication changes were not made during the 12-week study unless required for safety; benefits would result from lifestyle changes. The rtCGM group used unblinded rtCGM for three sessions at weeks 0, 4, and 8, and the control group managed diabetes with SMBG and wore blinded rtCGM at week 8. Glycemic endpoints were assessed.

RESULTS

Seventy participants were enrolled from eight North American sites and data were available from 68 (n = 45 rtCGM; n = 23 SMBG). Median (IQR) baseline HbA1c was 8.4 (0.8)% and 8.3 (1.2)% and median (IQR) change in HbA1c at week 12 was - 0.5 (1.3)% and - 0.2 (1.1)% for the rtCGM and SMBG groups, respectively (between-group difference p = 0.74). More than one-third (34.1%) of the rtCGM group vs 17.4% of the SMBG group reached the HbA1c goal of less than 7.5% at week 12 (between-group difference p = 0.12). Compared to run-in, mean (SD) time in range (TIR 70-180 mg/dL) at week 8 increased for the rtCGM group (56.3 [24.5]% vs 63.1 [25.5]%) while it decreased for the SMBG group (68.4 [21.5]% vs 55.1 [30.3]%). HbA1c reductions were not sustained at month 9.

CONCLUSION

In this pilot study, limited episodic rtCGM use in people failing multiple non-insulin therapies resulted in modest, short-term glycemic benefits.

Impact of Cognitive Impairment on Adherence to Treatment and Self-Care in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Elderly patients with diabetes have a significantly increased prevalence of mild cognitive impairment compared with people of similar age without diabetes. Tasks related to diabetes self-management involve multiple cognitive skills and processes, such as memory, attention, planning, and calculating. Impaired cognitive function can threaten the patient's ability to perform self-monitoring. The objectives of the study were: to assess cognitive deficits and the level of self-care in elderly patients with diabetes, to identify correlations between cognitive deficits and self-care, and to determine which variables influence self-care behaviors and cognitive deficits.

METHODS

The study involved 169 patients with type 2 DM. Standardized tools were used: Mini-mental State Examination (MMSE) to assess cognitive function and the Self-Care of Diabetes Inventory (SCODI) to assess the level of self-care. Socioclinical data were taken from the hospital records.

RESULTS

56.8% of patients had cognitive impairment (MMSE≤26). In the comparative analysis, patients with cognitive impairment had significantly lower results in all domains of the SCODI: self-care maintenance (72.9 vs 75), self-care monitoring (53.1 vs 56.3), self-care management (71.9 vs 84.4), self-care confidence (79.5 vs 86.4). Correlation analysis showed that the MMSE score correlates significantly and positively (p˂0.05; r˃0) with all SCODI subscales, and the higher the MMSE score the higher the level of self-care (A: r=0.252, B: r=0.244, C: r=0.019, D: r=0.28).

CONCLUSION

In this elderly type 2 diabetes population, and using only one test to verify the cognitive function, self-care management was worse in terms of self-care management (blood glucose control). Cognitive function components are independent determinants of self-care in patients with type 2 diabetes. Recall is an independent predictor of self-care maintenance, and writing a predictor of self-care monitoring.

Profile of diabetes patients' chronic illness care in India and its role in their adherence

BACKGROUND AND AIMS

Negligence of illness care in terms of non-adherence may give rise to serious health outcomes in patients with type 2 diabetes mellitus. Considering the importance of both chronic illness care and adherence, the primary purpose of the study is to explore the profile of diabetic patients' chronic illness care and examine its role in their clinical adherence. In addition to this, we have also investigated the major confounding variables in understanding the chronic illness care of diabetic patients.

METHODS

We have conducted this study using a simple retrospective design with one group involving the patients primarily diagnosed with type 2 diabetes (N = 200) in India.

RESULTS

The cluster analysis (k-Means) has yielded three clusters on the basis of five domains of chronic illness care-patient activation, delivery system design, goal setting, problem solving, and follow-up/coordination. The findings further reveal that the profile of chronic illness care plays a significant role in deciding the clinical adherence of patients with type 2 diabetes. The three clusters of diabetes patients, however, are confounded by health risk behaviour.

CONCLUSIONS

These initial findings are suggestive of an association between chronic illness care, clinical adherence, and health risk behaviour of patients with type 2 diabetes. More research on this topic, however, needs to be undertaken involving other important dimensions of health care system like patient-provider relationship and quality of life during hospitalisation. The implications and shortcomings are discussed.

Variability in preventive care practices among US adults with diabetes mellitus

INTRODUCTION

Patients with diabetes are advised to follow standard medical care including daily blood glucose and foot checks, eye examinations with pupil dilation, and cholesterol checks to prevent diabetes-related complications. It is unclear how these practices currently vary across different US population subgroups. The objective of this study was to assess variation in overall and individual diabetes care practices and identify specific factors associated with differences in these practices in a representative sample of US diabetic adults.

RESEARCH DESIGN AND METHODS

Cross-sectional data were from the 2017 Behavioral Risk Factor Surveillance System. Survey logistic regression was used to account for the complex sampling design.

RESULTS

Among 30 780 eligible participants, 8957 (equivalent to 28% of the target population) followed all four diabetes care practices. Insulin-dependent participants had higher adjusted odds (adjusted OR=2.95; 95% CI 2.62 to 3.31) of following all four diabetic care practices compared with those who did not. Cost-related variables (having healthcare coverage and/or a personal doctor) were positively associated with diabetes care practices, with the strongest association observed for adherence to more costly practices (annual eye examination and cholesterol check) versus less costly ones (daily blood glucose check, daily foot check).

CONCLUSIONS

Our findings suggest the need for diabetes care practice-specific and population subgroup-specific public health interventions to encourage early adherence to diabetic care practices and reduce complications.

Global burden of noncommunicable diseases attributable to high fasting plasma glucose

BACKGROUND

Hyperglycemia is a major public health concern. An understanding of the latest trends of the global burden of noncommunicable diseases (NCDs) by high fasting plasma glucose (HFPG) is critical for determining research priorities and planning health policy.

METHODS

This is a comparative burden-of-disease study. We obtained global, regional, and national data on deaths and disability-adjusted life years (DALYs) of NCDs attributable to HFPG from the Global Burden of Disease Study 2017, performed a secondary analysis of deaths and DALYs by time, age, gender, location, and specific causes, and analyzed their associations.

RESULTS

In 2017, 6.39 million deaths and 166.36 million DALYs from NCDs were attributable to HFPG, accounting for 15.6% and 10.7% of all deaths and DALYs, respectively. The burden's rate decreased with time, increased with age and was significantly higher in males. A negative association was found between the sociodemographic index (SDI) and disease burden, and a positive association was found between SDI and male superiority by gender difference and gender ratio.

CONCLUSIONS

The burden of NCDs attributable to HFPG has increased significantly since 1990 and varied widely across regions. Greater efforts are needed to prevent and control hyperglycemia, especially in less developed countries and among males.

An examination of the socio-demographic correlates of patient adherence to self-management behaviors and the mediating roles of health attitudes and self-efficacy among patients with coexisting type 2 diabetes and hypertension

BACKGROUND

Patients with coexisting type 2 diabetes and hypertension generally exhibit poor adherence to self-management, which adversely affects their disease control. Therefore, identification of the factors related to patient adherence is warranted. In this study, we aimed to examine (i) the socio-demographic correlates of patient adherence to a set of self-management behaviors relevant to type 2 diabetes and hypertension, namely, medication therapy, diet therapy, exercise, tobacco and alcohol avoidance, stress reduction, and self-monitoring/self-care, and (ii) whether health attitudes and self-efficacy in performing self-management mediated the associations between socio-demographic characteristics and adherence.

METHODS

We performed a secondary analysis of data collected in a randomized controlled trial. The sample comprised 148 patients with coexisting type 2 diabetes mellitus and hypertension. Data were collected by a questionnaire and analyzed using logistic regression.

RESULTS

Female patients were found to be less likely to exercise regularly (odds ratio [OR] = 0.49, P = 0.03) and more likely to avoid tobacco and alcohol (OR = 9.87, P < 0.001) than male patients. Older patients were found to be more likely to adhere to diet therapy (OR = 2.21, P = 0.01) and self-monitoring/self-care (OR = 2.17, P = 0.02). Patients living with family or others (e.g., caregivers) were found to be more likely to exercise regularly (OR = 3.44, P = 0.02) and less likely to avoid tobacco and alcohol (OR = 0.10, P = 0.04) than those living alone. Patients with better perceived health status were found to be more likely to adhere to medication therapy (OR = 2.02, P = 0.03). Patients with longer diabetes duration (OR = 2.33, P = 0.01) were found to be more likely to adhere to self-monitoring/self-care. Self-efficacy was found to mediate the association between older age and better adherence to diet therapy, while no significant mediating effects were found for health attitudes.

CONCLUSIONS

Adherence to self-management was found to be associated with socio-demographic characteristics (sex, age, living status, perceived health status, and diabetes duration). Self-efficacy was an important mediator in some of these associations, suggesting that patient adherence may be improved by increasing patients' self-management efficacy, such as by patient empowerment, collaborative care, or enhanced patient-physician interactions.

The evolution of a healthcare interpreting service mapped against the bilingual health communication model: a historical qualitative case study

Background

Twenty-five years ago, the need for health care interpreting in Switzerland increased due to the sharp influx of asylum seekers from war zones and countries of political unrest. Due to complex health needs, there was a need to move away from using volunteers as interpreters towards qualified interpreter services.

Methods

A historical qualitative case study design was used to describe the evolution of the language assistance programmes at Geneva University Hospitals, between 1992 and 2017. The aim was to map the evolution of the interpreter services against the Bilingual Health Communication Model with the constructs—Communicative Goals, Individual Agency, System Norms and Quality and Equality of Care—while identifying key factors to optimise interpreter service and patient care.

Results and discussion

Five phases were identified during the 25 years of service evolution studied: (1) Service initiation—the interpreter services were first used in a small service that cared for refugees and asylum seekers. (2) Growth and formalisation—due to the arrival of high numbers of Albanian-speaking asylum seekers, Albanian-speaking interpreters were provided to all departments of the Geneva University Hospitals. This helped roll out the use of interpreters among doctors and nurses. (3) Ensuring quality—the care for all patients, whether foreign-language speaking or not, became an issue and led to research into the quality of patient-provider communication. (4) Institutionalisation—this phase dealt with challenges including the lack of interpreter financing regulation and the clarification of interpreter roles. (5) Equity—healthcare interpreter services were put in an overall framework of equity standards. The Bilingual Health Communication Model was applied and showed that some items were not implemented: clear shifts (i) towards a culturally sensitive focus, (ii) towards community interpreting, (iii) towards triadic communication, (iv) towards spelling out the right to have an interpreter and (v) towards the involvement of insurance companies. Finally, the inclusion of healthcare interpreting as an essential ingredient in healthcare provision, including chronic disease management, is incomplete or missing.

Conclusions

Healthcare interpreting at Geneva University Hospitals has evolved from a ‘muddling-through’ approach towards an institutional approach by addressing quality of care, by focussing on the mental health of asylum seekers, training of both interpreters and users of interpreters and institutional policy based on equity.

Effect of socioeconomic deprivation on outcomes of diabetes complications in patients with type 2 diabetes mellitus: a nationwide population-based cohort study of South Korea

INTRODUCTION

This study aimed to examine the effect of socioeconomic deprivation on the outcomes of diabetes complications in patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

We conducted a cohort study using claims data and 2005 national census data. We included of 7510 patients newly diagnosed with T2DM from 2004 to 2012 and aged 40 years or above. We excluded participants who had onset of diabetes complications and hospitalization within 1 year after initial onset T2DM, aged less than 40 years and with missing covariates. We used the regional socioeconomic deprivation index and classified study participants into five categories according to the quintile distribution. We calculated the adjusted HR and 95% CI for hospitalization related to diabetes complications and all-cause mortality by applying Cox proportional hazards model and the adjusted subdistribution hazards model.

RESULTS

The percentages of participants in the first quintile (least deprived) to fifth quintile (most deprived) were 27.0%, 27.9%, 19.5%, 14.8%, and 10.8% for socioeconomic deprivation; 25.4%, 28.8%, 32.4%, 34.6%, and 37.6% for hospitalization due to diabetes complications; 1.3%, 2.1%, 2.5%, 2.9%, and 3.6% for deaths from diabetes complications; and 5.7%, 7.2%, 9.7%, 9.7%, and 13.1% for deaths from all causes, respectively. Participants with higher socioeconomic deprivation had a higher HR for hospitalization and mortality from all-cause and diabetes complications. These associations were the strongest among men and participants in their 40s in hospitalization related to diabetes complications, 50s in diabetes complications-specific mortality and 50s and 60s in all-cause mortality.

CONCLUSIONS

Patients with T2DM with high socioeconomic deprivation had higher hospital admission and mortality rates for diabetes complications than those with low deprivation. We cannot fully explain the effect of socioeconomic deprivation on diabetes outcomes. Therefore, further studies are needed in order to find underlying mechanisms for these associations.

Health literacy, health outcomes, and the caregiver role in traumatic brain injury

Purpose/Objective: The purpose of this study is to estimate the occurrence of low health literacy among caregivers of people with traumatic brain injury (TBI), and to evaluate associations of health literacy with caregiver health-related quality of life (HRQOL) and perceptions of the caregiving role. Research Method/Design: The TBI-CareQOL measurement system assesses important self-reported outcomes for caregivers of civilians or service members/veterans (SMVs) with TBI. The validation phase included the Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT) measure. Multivariable regression evaluated the impact of low health literacy on generic and TBI-specific HRQOL and appraisals of the caregiving role, adjusted for caregiver gender, race/ethnicity and education, and the functional status of the TBI care recipient. Results: Among 131 caregivers, 28 (21%) had low health literacy. Compared with the high health literacy group, the group with low health literacy had fewer women, more racial/ethnic minorities, and lower education (all p < .05). The low health literacy group reported more subjective caregiving burden, less satisfaction with their relationship with the TBI recipient, less caregiving mastery, and poorer physical health (all p < .05). There were no differences between health literacy groups in caregiving ideology, caregiver-specific HRQOL or general mental health. Conclusions/Implications: A better understanding of the links between health literacy and caregiver HRQOL and the caregiving role can help identify strategies to meet the needs of this underserved population. Tailored interventions for caregivers with low health literacy could improve outcomes for both the caregiver and the care recipient. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Diabetes Mellitus and Stroke - A cross Sectional Study of 2.5 Million Adults in the United States

Objectives: The main purpose of this work is to study diabetes mellitus and stroke in the United States during the years 2007-2017 and to find not only statistically significant predictors for diabetes, but also a possible association between diabetes and stroke. Methods: Chi-square test and One-way analysis of variance (ANOVA) were the statistical methods used to derive the results of this work in order to check the statistical significance of diabetes mellitus in relation to patients' socioeconomic factors. In addition, a multivariate logistic regression analysis was used to obtain odds ratio and find statistically significant prognostic factors for both diabetes and stroke. Results: According to multiple logistic regression analysis, the risk for diabetes mellitus is four times higher in widowed men and two times higher in unemployed male subjects who had previously worked. In addition, marital status and employment have been shown to be prognostic risks for stroke. Conclusion: The results describe for the first time the importance of deprivation (of work and partner) as a primary prognostic risk factor for diabetes. Moreover, the same factor was proved to be the primary prognostic risk factor for both stroke and diabetes, which implies a nexus between diabetes mellitus and stroke.

Direct observation of glucose fingerprint using in vivo Raman spectroscopy

Noninvasive blood glucose monitoring has been a long-standing dream in diabetes management. The use of Raman spectroscopy, with its molecular specificity, has been investigated in this regard over the past decade. Previous studies reported on glucose sensing based on indirect evidence such as statistical correlation to the reference glucose concentration. However, these claims fail to demonstrate glucose Raman peaks, which has raised questions regarding the effectiveness of Raman spectroscopy for glucose sensing. Here, we demonstrate the first direct observation of glucose Raman peaks from in vivo skin. The signal intensities varied proportional to the reference glucose concentrations in three live swine glucose clamping experiments. Tracking spectral intensity based on linearity enabled accurate prospective prediction in within-subject and intersubject models. Our direct demonstration of glucose signal may quiet the long debate about whether glucose Raman spectra can be measured in vivo in transcutaneous glucose sensing.

Development and Evaluation of a Blood Glucose Monitoring YouTube Video for Marshallese Patients Using a Community-Based Participatory Research Approach

The purpose of this study was to (a) describe the development of a culturally appropriate glucose monitoring video using a community-based participatory research approach and (b) assess the cultural appropriateness and effectiveness of the video. The topic of the video-using a glucometer and the importance of performing blood glucose checks-was chosen by Marshallese community stakeholders. The video was produced in Marshallese with English subtitles and disseminated through YouTube. Participants were recruited from August 16, 2016 to September 12, 2016 in a diabetes clinic that serves Marshallese patients in northwest Arkansas. Fifty participants completed a survey at pre- and postintervention, with questions capturing demographic information and questions on glucose monitoring self-efficacy using an adapted version of the Stanford Patient Education Research Center's Diabetes Self-Efficacy Scale. Twenty of those participants who completed the survey also completed semistructured interviews that assessed cultural appropriateness and effectiveness of the video. Participants reported significant increases in self-efficacy related to glucometer use and the importance of performing blood glucose checks (p < .001) and a 1.45% reduction in A1C between preintervention and 12 weeks postintervention (p = .006). Qualitative results indicated the video was both culturally appropriate and effective. The findings of this study were consistent with evidence in the literature, which shows health education videos can be effective at improving health behaviors. Using a community-based participatory research approach to prioritize video topics, and including members of the community in the creation and dissemination of the videos, could aid in ensuring the videos are effective and culturally appropriate.

The Challenges of Iran's Type 2 Diabetes Prevention and Control Program

Background:

Incidence and prevalence of type 2 diabetes are one of the major challenges of Iran health system. Despite policies on diabetes prevention and control, Iran is faced with many problems in prevention and control of this disease at the executive level. This study seeks to identify the problems of Type 2 diabetes prevention and control program in Iran.

Methods:

In this qualitative study, 17 participants were interviewed purposefully. The semi-structured interview guide was designed based on literature review and four initial in-depth interviews. Framework analysis method was used for the analysis of qualitative data.

Results:

Six themes and 29 subthemes explaining the problems of type 2 diabetes prevention and control program were identified: Referral system, human resources, infrastructure, cultural problems, access, and intersectoral coordination issues.

Conclusions:

Despite the well-developed policy of type 2 diabetes prevention and control, the implementation is faced with some problems which endangers the effectiveness of the plan. Any attempt to improve the successful implementation of the type 2 diabetes prevention and control program requires effective measures, deep understanding of the problems and solving them.

Patient-Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda

Although patient-provider language concordance has the potential to reduce health disparities for people with limited English proficiency, no previous work has synthesized this literature. Our systematic review sought to describe the characteristics of studies examining relationships between language concordance and health outcomes, summarize the nature of observed associations, and propose an evidence map and research agenda. A comprehensive search of published articles identified 38 quantitative studies for inclusion. Most studies were cross-sectional, conducted in primary care, concentrated in Western states, and focused on Spanish speakers and physician providers. Results were split between supporting a positive association versus no association of language concordance with patient behaviors, provider behaviors, interpersonal processes of care, and clinical outcomes. Several methodological limitations were identified. Based on these results, we developed an evidence map, identified knowledge gaps, and proposed a research agenda. There is a particular need for quasi-experimental longitudinal studies with well-characterized samples.

Improving Diabetes Control Through Remote Glucose Monitoring in a Diabetes Self-Management Program for Employees of a Health System

IN BRIEF This study investigates the combination of diabetes education, telehealth, a wireless enabled meter, and medication algorithms to improve care for a targeted population of employees with type 1 or type 2 diabetes. After more than 2 years of follow-up, mean A1C was reduced by 1.8%, and a reduction was observed in cost of care, along with an increase in visits with the managing physician provider. Thus, this study showed improved diabetes control using new technologies to provide remote monitoring and telehealth augmenting the outreach and education provided in a diabetes self-management program.

Patient-provider communication quality for persons with disabilities: A cross-sectional analysis of the Health Information National Trends Survey

BACKGROUND

It is unclear how perceived patient-provider communication quality (PPPCQ) varies according to disability status. Lack of adequate patient-provider communication may prevent providers from considering healthcare issues that are relevant and important to persons with disabilities (PWD), potentially contributing to poorer health outcomes.

OBJECTIVE/HYPOTHESIS

To examine PPPCQ by disability status using current U.S. Department of Health and Human Services standards for surveillance of functional disabilities.

METHODS

This cross-sectional study used nationally-representative data from the 2012-2013 Health Information National Trends Survey (HINTS). Participants were categorized as having any disability (hearing, vision, mobility, cognitive, self-care, and/or independent living limitations). PPPCQ was assessed using seven HINTS questions about communication with healthcare professionals. Linear regression was used to estimate mean differences in composite PPPCQ scores, and logistic regression was used to estimate odds ratios (OR) for a provider "always or usually" performing PPPCQ.

RESULTS

The study population comprised 5301 participants, representing 180,442,731 U.S. adults. Overall, 22.1% (weighted) reported any disability. Adjusted mean PPPCQ scores were significantly lower for PWD (72.8, 95% CI: 68.2-77.4) than persons without disability (78.3, 95% CI: 76.5-80.2), p = 0.021. More specifically, PWD were significantly less likely to be given attention needed to address feelings and emotions (OR = 0.6, 95% CI: 0.4, 0.9, p = 0.017), to have next steps understood (OR = 0.4, 95% CI: 0.2, 0.8, p = 0.019), and to receive a clear explanation (OR = 0.3, 95% CI: 0.1, 0.8, p = 0.018).

CONCLUSIONS

PWD are less likely to report key elements of effective patient-provider communication. Implementing patient-centered care may improve patient-provider communication for this vulnerable population.

Blood glucose meters and test strips: global market and challenges to access in low-resource settings

Blood glucose meters and test strips for self-monitoring of blood glucose (SMBG) are often inaccessible to, and infrequently used by, people with diabetes in countries with limited resources for health care. Supplies for measuring blood glucose can also be scarce in health facilities, despite being needed in a myriad of clinical settings at all levels of the health system. Numerous studies and international guidelines emphasise the value of SMBG in diabetes care, particularly in people with type 1 diabetes. In this Review, we assess global access to blood glucose meters and test strips, collating published information on cost, availability, system accuracy, competitive bidding, technological trends, and non-financial barriers. We also provide new information on global market share data and prices, taxes and tariffs, and product availability. Blood glucose meters and test strips should be viewed similarly to essential medicines, with issues of access prioritised by relevant international agencies. Efforts are needed to reduce tariffs and taxes and to create unified global system accuracy requirements and accountable post-marketing evaluations. Preferential pricing arrangements, pooled procurement, and best-purchasing practices could help to lower direct costs. SMBG supplies should also be included in national health insurance schemes. Enhanced diabetes education of health professionals and patients is crucial to ensure effective use of SMBG. Finally, as technology advances for people who can afford new interstitial fluid glucose monitoring systems, blood glucose meters and test strips must remain available and become more affordable in low-resource settings.

Comparison of self-care in non-cardiac diabetic patients

BACKGROUND

In general, the majority of diabetic patients suffering from a lack of capability in controlling different aspects of self-care have likely been prone to cardiovascular disease. To reduce the economic burden in societies and the rate of death on one hand, and improve life expectancy, on the other hand, it seems necessary to emphasize self-care training in diabetic patients. The purpose of this study was to determine comparison of self-care in cardiac and non-cardiac diabetic patients.

METHODS

This descriptive-analytic study was carried out with 136 diabetic participants selected using random sampling and divided into two groups of 68 non-cardiac diabetic patients. Data were collected using a demographic and diabetic patient's self-management questionnaire (DSMQ). For the analysis of the data, SPSS16 was employed to check the significance test at the level of P<0.05.

RESULTS

In this study, twenty-eight (41.2%) and forty (58.8%) of the participants in each group were male and female, respectively. Their ages spanned from (61.35±13.34) in non-cardiac diabetic group to (65.94±8.74) in cardiac diabetic participants. There were significant differences between two groups, specifically in patients with cardiac diabetic disease in different aspects, for instance, including glucose monitoring (F=4.977, P=0.027, η²=0.036), diet control (F=9.125, P=0.003, η²=0.064), physical activity (F=22.954, P=0.0001, η²=0.146) and health care awareness (F=31.366, P=0.0001, η²=0.19).

CONCLUSION

According to DSMQ questionnaire in the present study, glucose monitoring, diet control, physical activity, and health care awareness in diabetic patients with heart disease were significantly reported to have been better than the other group with no cardiac problem. Due to insufficient self-care in diabetic patients and some consequences such as poor health, heart disease as one of the complications of diabetes, hospital re-admission and heavy costs, the therapeutic team should be alerted to self-care training.

Health-Related Quality-of-Life and Diabetes Self-Care Activity in Elderly Patients with Diabetes in Korea

A critical goal in the management of elderly patients with diabetes is to improve their health-related quality of life (HRQOL). This study aimed to identify the factors affecting HRQOL in elderly Korean patients with diabetes. Participants were 365 elderly patients with diabetes who were treated in a general hospital in Korea. The data were analysed using independent t-tests, Pearson correlations, and stepwise multiple regression. The mean total HRQOL score was 74.77, and HRQOL showed positive correlations with activities of daily living (ADL), instrumental activities of daily living (IADL), and the Summary of Diabetes Self-care Activities (SDSA). There was a negative correlation between HRQOL and Short Geriatric Depression Scale (SGDS). Lower SGDS scores, higher SDSA scores, and being male were associated with higher HRQOL, with these variables explaining 57.5% of the variance in participants' HRQOL. Improvement in the HRQOL of elderly patients with diabetes requires the development of interventions for depression, and improvements in methods of diabetes self-care and gender-dependent managerial measures.

Cross-Validating a Structural Model of Factors Influencing Diabetes Self-Management in Chinese Americans with Type 2 Diabetes

Introduction: The purpose of this study was to cross-validate a structural model depicting the effects of individual and environmental factors on diabetes self-management in Chinese Americans with type 2 diabetes. Methodology: A cross-sectional survey was administered to a convenience sample of 209 Chinese Americans with type 2 diabetes in the Midwest of the United States. Structural equation modeling was used to cross-validate the model fit. Results: Provider–patient communication indirectly influenced self-management via belief in treatment. Knowledge indirectly influenced self-management via belief in treatment and self-efficacy. Social support indirectly influenced self-management via belief in treatment and knowledge. Discussion: This study demonstrated that the structural model, previously tested with Chinese diabetes patients in China, also fits Chinese Americans in the United States with few modifications. The cross-validated model provides a theoretical basis for developing culturally relevant diabetes self-management interventions for Chinese Americans, which may lead to health improvements in this ethnic population.

Reduced Diabetes Mellitus-related Comorbidities by Regular Self-monitoring of Blood Glucose: Economic and Quality of Life Implications

OBJECTIVES

The objective of the study was to understand the role of self-monitoring of blood glucose (SMBG) for better management of glycemic fluctuations, reducing the risk of complications, and the associated cost benefits for diabetes patients in India.

MATERIALS AND METHODS

An Excel-based Cost Impact Model was developed to analyze the impact of SMBG by calculating the savings over a 10-year time period. A literature review was undertaken to model the impact of SMBG on the risk of complications and cardiovascular morbidities. The model was developed based on inputs from previous studies.

RESULTS

In the base case, SMBG cohort was associated with a 10-year discounted cost of INR 718,340, resulting in an estimated saving of INR 120,173 compared to no SMBG cohort. Implementation of a once-daily SMBG protocol, for a decade, can reduce the complication-related costs. More frequent SMBG and tri-monthly hemoglobin A1c tests along with lifestyle changes can significantly reduce the financial burden on the patient over the lifespan.

CONCLUSION

Our study has shown that proactive management of diabetes with SMBG can improve treatment outcomes and reduce morbidity and mortality associated with this disease. Near-normal blood glucose levels can bring in cost savings in the form of reduced long-term complications and avoidance of repeated hospitalization for the management of such complications, along with an improved quality of life.

Effect of switching from conventional continuous subcutaneous insulin infusion to sensor augmented pump therapy on glycemic profile in Japanese patients with type 1 diabetes

AIMS

Evidence suggests that sensor augmented pump (SAP) therapy is superior to conventional continuous subcutaneous insulin infusion (CSII) for achieving glycemic control in patients with type 1 diabetes. However, the clinical benefit of SAP therapy in East Asians has not yet been demonstrated.

METHODS

The effect of switching from conventional CSII to SAP therapy on glycemic profile was examined in 18 Japanese patients with type 1 diabetes. The glycemic profile of the patients was determined by retrospective continuous glucose monitoring (CGM) within 1 month before the treatment switch, whereas that at 6 and 12 months after the switch was evaluated with the CGM function of the SAP device. Hemoglobin A1c levels were also measured before and after the switch to SAP therapy.

RESULTS

The duration of hypoglycemia was significantly decreased at both 6 and 12 months after the change in treatment (6.6 ± 4.5, 3.2 ± 4.1, and 3.0 ± 2.8 min/h for before and 6 and 12 months, respectively), as was the HbA1c level at 12 months (7.8 ± 1.0 and 7.4 ± 0.9%, respectively). The duration of hyperglycemia did not differ between before and after the treatment switch. The decline in HbA1c level at 12 months after the switch to SAP was negatively correlated with age.

CONCLUSION

Switching from conventional CSII to SAP therapy was associated with a decrease in both the duration of hypoglycemia and the level of HbA1c in Japanese patients with type 1 diabetes.

Factors Predicting Sodium Intake of Korean Americans with Type 2 Diabetes

The increasing prevalence of type 2 diabetes mellitus (T2DM) and its complications including cardiovascular disease and chronic kidney disease threaten Korean Americans (KAs). High dietary sodium intake contributes to both conditions. The purpose of the study was to assess dietary sodium consumption and to examine the predictors of sodium intake among KA with T2DM. A total 232 KA who had uncontrolled diabetes participated in this study. The majority of the sample (69%) consumed more sodium than current national guidelines. A high level of energy intake was the strongest predictor for sodium intake with gender and marital status also related. Our findings identified predictive factors to excessive sodium intake and these data support the need for culturally-tailored education about appropriate dietary sodium and energy intake are needed for patients about T2DM.

The effects of health promotion model-based educational program on self-care behaviors in patients undergoing coronary artery bypass grafting in Iran

Background and aim

Post-operative self-care behaviors, have positive effects on increase in adaptability, and reduce cardiac surgery patients’ disability. The present study is carried out aimed at determining the effect of education based on a health promotion model on the patients’ self-care behaviors after coronary artery bypass surgery.

Methods

This is a semi-experimental study carried out in Mazandaran (Iran) in 2016. Two hundred and twenty patients who participated in the study were selected using a simple random sampling method from a population of postoperative patients, and divided into control and experimental groups (110 patients in each) using block (AABB) randomization. Self-designed self-care questionnaires based on a health promotion model were distributed among the patients once before and three months after intervention. The data were analyzed by SPSS-22, Chi-Square tests, Mann-Whitney and ANCOVA at the significance level of p<0.05.

Results

The average score of total self-care behaviors in cardiac surgery patients was not significant between the two groups before education (p=0.065), but after training, a significant difference was observed between the two groups (p<0.001). The analysis of ANOVA with repeated measure indicated that following the intervention, significant difference was observed between the two groups in terms of improvement of self-care behaviors after excluding the effect of pre-test and controlling demographic and health-related characteristics.

Conclusions

Developing and implementing a training program based on the health promotion model can enhance self-care behaviors and reduce the number of admissions in patients after cardiac surgery.

Patients’ Understanding of Anticoagulant Therapy in a Multiethnic Population

To investigate whether knowledge and perceptions of antithrombotic therapy differ between ethnic groups in the UK, we conducted a cross-sectional questionnaire survey of patients attending anticoagulation clinics in three Birmingham teaching hospitals. 180 consecutive patients were recruited—135 white European, 29 Indo-Asian, 16 Afro-Caribbean.

The average knowledge score was 5.5 out of 9, with no significant differences between the groups. Indo-Asians were significantly less likely than the other groups to know the name of the anticoagulant they were taking (warfarin) and Afro-Caribbeans to know the condition for which they were being anticoagulated. Few patients of any group were able to specify more than one side-effect of warfarin or the dose they were on. In logistic regression analysis the factors associated with a low score were age >gT 61 years, having been born outside the UK, and the perception of difficulty in comprehension. Nearly half the Indo-Asians felt unable to understand what was said to them in the clinic, and 62% expressed a preference for a doctor of the same ethnic group.

Although there were no significant between-group differences, this study points to gaps in the knowledge of patients from ethnic minorities and to deficiencies in the provision of information. In patient education, these groups should receive special attention.

Both the frequency of HbA1c testing and the frequency of self-monitoring of blood glucose predict metabolic control: A multicentre analysis of 15 199 adult type 1 diabetes patients from Germany and Austria

BACKGROUND

The objective of this study was to examine the association between metabolic control and frequency of haemoglobin A_1c (HbA_1c ) measurements and of self-monitoring of blood glucose, as well as the interaction of both.

METHODS

Data of 15 199 adult type 1 diabetes patients registered in a standardized electronic health record (DPV) were included. To model the association between metabolic control and frequency of HbA_1c testing or of self-monitoring of blood glucose, multiple hierarchic regression models with adjustment for confounders were fitted. Tukey-Kramer test was used to adjust P values for multiple comparisons. Vuong test was used to compare non-nested models.

RESULTS

The baseline variables of the study population were median age 19.9 [Q1; Q3: 18.4; 32.2] years and diabetes duration 10.4 [6.8; 15.7] years. Haemoglobin A_1c was 60.4 [51.5; 72.5] mmol/mol. Frequency of HbA_1c testing was 8.0 [5.0; 9.0] within 2 years, and daily self-monitoring of blood glucose frequency was 5.0 [4.0; 6.0]. After adjustment, a U-shaped association between metabolic control and frequency of HbA_1c testing was observed with lowest HbA_1c levels in the 3-monthly HbA_1c testing group. There was an inverse relationship between self-monitoring of blood glucose and HbA_1c with lower HbA_1c associated with highest frequency of testing (>6 daily measurements). Quarterly HbA_1c testing and frequent self-monitoring of blood glucose were associated with best metabolic control. The adjusted Vuong Z statistic suggests that metabolic control might be better explained by HbA_1c testing compared to self-monitoring of blood glucose (P < .0001).

CONCLUSION

This research reveals the importance of quarterly clinical HbA_1c monitoring together with frequent self-monitoring of blood glucose in diabetes management to reach and maintain target HbA_1c .

Lowering Cost Share May Improve Rates of Home Glucose Monitoring Among Patients with Diabetes Using Insulin

BACKGROUND

Not much is known about the extent to which lower cost share for blood glucose strips is associated with persistent filling.

OBJECTIVE

To evaluate the relationship between cost sharing for blood glucose testing strips and continued use of testing strips.

METHODS

This is a retrospective observational study using medical and pharmacy claims data integrated with laboratory hemoglobin A1c (A1c) values for patients using insulin and blood glucose testing strips. Diabetic patients using insulin who had at least 1 fill of blood glucose testing strips between 2010 and 2012 were included. Patients were divided into a low cost-share group (out-of-pocket cost percentage of total testing strip costs over a 1-year period from the initial fill < 20%; n = 3,575) and a high cost-share group (out-of-pocket cost percentage ≥ 20%; n = 3,580). We compared the likelihood of continued testing strip fills after the initial fill between the 2 groups by using modified Poisson regression models.

RESULTS

Patients with low cost share had higher rates of continued testing strip fills compared with those with high cost share (89% vs. 82%, P < 0.001). Lower cost share was associated with greater probability of continued fills (adjusted risk ratio [aRR] = 1.05, 95% CI = 1.03-1.07, P < 0.001). Other patient characteristics associated with continued fills included type 1 diabetes diagnosis, types of insulin regimens, and health insurance plan type. In a subset analysis of patients whose A1c values at baseline were above the target level (8%) set by the National Committee for Quality Assurance guidelines, we saw a slight increase in magnitude of relationship between cost share and continued fills (RR = 1.06, 95% CI = 1.03-1.10, P < 0.01).

CONCLUSIONS

There was a statistically significant association between cost share for testing strips and continued blood glucose self-monitoring. Among patients not achieving A1c control at baseline, there was an increase in the magnitude of relationship. Lowering cost share for testing strips can remove a barrier to persistence in diabetes self-management.

DISCLOSURES

Funding for this study was provided by Anthem, which had no role in the study design, data interpretation, or preparation or review of the manuscript. The decision to publish was strictly that of the authors. Xie, Agiro, and DeVries are employees of HealthCore, a wholly owned subsidiary of Anthem. Bowman is an employee of Anthem. Study concept and design were contributed by all the authors. Xie took the lead in data collection, along with Agiro, and data interpretation was performed by all the authors. The manuscript was written by Xie and Agiro, along with DeVries, and revised by Xie, Agiro, and Devries, along with Bowman.

Using an Expert Panel to Develop Social Support Program Sequencing for Young Adults With Type 1 Diabetes

BACKGROUND

Young adults living with type 1 diabetes (T1DM) often encounter poor health outcomes, such as uncontrolled blood glucose levels. Social support programs can be a helpful method to support T1DM self-management. Effectively planning and tailoring social support programs for young adults living with T1DM are crucial for improving these programs and associated outcomes.

OBJECTIVES

This study convened an expert panel primarily composed of young adults living with T1DM to generate ideas and key components for sequential inclusion in social support programs prioritizing them.

METHOD

Exploratory expert panel meetings consisting of four individuals living with T1DM were held where Nominal Group Technique and Ideawriting exercises were used to develop themes and discussion points.

RESULTS

Six themes emerged from the meetings representing areas of difficulty for young adults living with T1DM. Topics such as following self-care recommendations, nutrition, handling stress, coping with social situations, and navigating the health care system were identified as important issues facing young adults.

CONCLUSIONS

By incorporating this approach into new or existing support group improved program discussions for young adults can be achieved and pertinent issues addressed, thus leading to improved health care outcomes.

Socioeconomic inequalities in mortality, morbidity and diabetes management for adults with type 1 diabetes: A systematic review

Aims

To systematically review the evidence of socioeconomic inequalities for adults with type 1 diabetes in relation to mortality, morbidity and diabetes management.

Methods

We carried out a systematic search across six relevant databases and included all studies reporting associations between socioeconomic indicators and mortality, morbidity, or diabetes management for adults with type 1 diabetes. Data extraction and quality assessment was undertaken for all included studies. A narrative synthesis was conducted.

Results

A total of 33 studies were identified. Twelve cohort, 19 cross sectional and 2 case control studies met the inclusion criteria. Regardless of healthcare system, low socioeconomic status was associated with poorer outcomes. Following adjustments for other risk factors, socioeconomic status was a statistically significant independent predictor of mortality in 9/10 studies and morbidity in 8/10 studies for adults with type 1 diabetes. There appeared to be an association between low socioeconomic status and some aspects of diabetes management. Although only 3 of 16 studies made adjustments for confounders and other risk factors, poor diabetes management was associated with lower socioeconomic status in 3/3 of these studies.

Conclusions

Low socioeconomic status is associated with higher levels of mortality and morbidity for adults with type 1 diabetes even amongst those with access to a universal healthcare system. The association between low socioeconomic status and diabetes management requires further research given the paucity of evidence and the potential for diabetes management to mitigate the adverse effects of low socioeconomic status.

Access to Transportation and Health Care Visits for Medicaid Enrollees With Diabetes

PURPOSE

Diabetes is a chronic condition that requires frequent health care visits for its management. Individuals without nonemergency medical transportation often miss appointments and do not receive optimal care. This study aims to evaluate the association between Medicaid-provided nonemergency medical transportation and diabetes care visits.

METHODS

A retrospective analysis was conducted of demographic and claims data obtained from the Oklahoma Medicaid program. Participants consisted of Medicaid enrollees with diabetes who made at least 1 visit for diabetes care in a year. The sample was predominantly female and white, with an average age of 46.38 years. Two zero-truncated Poisson regression models were estimated to assess the independent effect of transportation use on number of diabetes care visits.

FINDINGS

Use of nonemergency medical transportation is a significant predictor of diabetes care visits. Zero-truncated Poisson regression coefficients showed a positive association between the use of transportation and number of visits (0.6563, P < .001). Age, gender, race/ethnicity, area of residence, and presence of additional chronic conditions had independent associations with number of visits. Older enrollees were likely to make more visits than younger enrollees with diabetes (0.02382); controlling for all other factors in the model, rural residents made more visits than urban; women made fewer visits than men (-0.09312; P < .001); and minorities made fewer visits than whites, with pronounced differences for Hispanics and Asians compared to whites.

CONCLUSIONS

Findings underscore the importance of ensuring transportation to Medicaid populations with diabetes, particularly in the rural areas where the prevalence of diabetes and complications are higher and the availability of medical resources lower than in the urban areas.

Clinical Pharmacist Team-Based Care in a Safety Net Medical Home: Facilitators and Barriers to Chronic Care Management

Collaborative care models incorporating pharmacists have been shown to improve quality of care for patients with hypertension and/or diabetes. Little is known about how to integrate such services outside of clinical trials. The authors implemented a 22-month observational study to evaluate pharmacy collaborative care for hypertension and diabetes in a safety net medical home that incorporated population risk stratification, clinical decision support, and medication dose adjustment protocols. Patients in the pharmacy group saw their primary care provider (PCP) more often and had higher baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) and A1c levels compared to patients who only received care from their PCPs. There were no significant differences in the proportion of patients achieving treatment goals (SBP <140, DBP <90; A1c < 8) or the magnitude of change in BP or A1c among patients who underwent collaborative care versus those who did not. Age, race, and number of PCP encounters were associated with BP and A1c trends. The median time to achieve disease control was longer in the pharmacy group. Although 70% of all patients with poorly controlled hypertension achieved treatment goals within 7 months, less than 50% of patients with poorly controlled diabetes achieved A1c < 8 within 15 months, suggesting that diabetes was harder to manage overall. Contextual factors that facilitated or hindered practice redesign included organizational culture, health information technology and related workflows, and pharmacy caseload optimization. Future studies should further examine implementation strategies that work best in specific settings to optimize the benefits of team-based care with clinical pharmacists.

Behavioral Analysis of Chinese Adult Patients with Type 1 Diabetes on Self-monitoring of Blood Glucose

BACKGROUND

The information-motivation-behavioral skills (IMB) model of health behavior is an effective tool to evaluate the behavior of diabetes self-management. The purpose of this study was to explore behavioral factors affecting the practice of self-monitoring of blood glucose (SMBG) within the frame of IMB model of health behavioral among adult patients with type 1 diabetes in a single diabetes clinic in China.

METHODS

A questionnaire with three subscales on SMBG information, motivation, and behavioral skills based on IMB model was developed. Validity and reliability of the measures were examined and guaranteed. Adult patients with type 1 diabetes visiting our diabetes clinic from January to March 2012 (n = 55) were consecutively interviewed. The self-completion questionnaires were administered and finished at face-to-face interviews among these patients. Both descriptive and correlational analyses were made.

RESULTS

Fifty-five patients finished the questionnaires, with the median duration of diabetes 4.5 years and the median of SMBG frequency 2.00. Specific SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants. Scores of SMBG motivation (r = 0.299, P= 0.026) and behavioral skills (r = 0.425, P= 0.001) were significantly correlated with SMBG frequency. The multiple correlation of SMBG information, SMBG motivation, and SMBG behavioral skills with SMBG frequency was R = 0.411 (R2 = 0.169, P= 0.023).

CONCLUSIONS

Adult patients with type 1 diabetes in our clinic had substantial SMBG information deficits, motivation obstacles, and skill limitations. This information provided potential-focused education targets for diabetes health-care providers.

Psychosocial factors in medication adherence and diabetes self-management: Implications for research and practice

Diabetes is a chronic illness that places a significant self-management burden on affected individuals and families. Given the importance of health behaviors-such as medication adherence, diet, physical activity, blood glucose self-monitoring-in achieving optimal glycemic control in diabetes, interventions designed and delivered by psychologists hold promise in assisting children, adolescents, and adults with diabetes in improving their health status and lowering their risk of serious complications. This article first provides an overview of diabetes self-management and associated challenges and burdens. Socioeconomic status factors that may influence diabetes management and outcomes are briefly highlighted. We then review the evidence base for select psychosocial factors that may be implicated in diabetes self-management. Modifiable targets of psychological intervention are presented across 3 overarching domains: (a) knowledge, beliefs, and related cognitive constructs; (b) emotional distress and well-being; and (c) behavioral skills and coping. Important methodological issues facing future research are discussed, along with opportunities for psychologists in improving the care and treatment outcomes of individuals and families living with diabetes. In conclusion, we advocate for continued research emphasis on improving psychosocial aspects of living with diabetes, with greater attention to the situational context in which the self-regulatory processes underlying self-management occur. Psychologists have important roles to play in reducing emotional distress, improving patient knowledge, and providing training in behavioral skills to promote successful self-management and to support patient-centered diabetes care. (PsycINFO Database Record