Improving efficacy of diabetes management using treatment algorithms in a mainly Hispanic population

The current diabetes education experience: Findings of a cross-sectional survey of adults with type 2 diabetes

OBJECTIVE

To survey persons with type 2 diabetes (PWD) on their experiences with diabetes education to better understand what it means when a PWD says they have "had diabetes education."

METHODS

We conducted a cross-sectional descriptive study among a convenience sample of adult PWD receiving primary care and/or diabetes self-management education and support in a mid-Atlantic regional US healthcare system. Descriptive, bivariate, and regression analyses were used to describe and explore the diabetes education experience.

RESULTS

Participants (n = 498) were majority female, African American, and non-Hispanic. Half reported having "had diabetes education." Of those, 44% had only one session. Education was most often provided in clinical settings by a dietitian (68%) or doctor (51%), in one-on-one (70%) sessions. While most participants reported receiving core diabetes knowledge, fewer reported education on topics that are not related to their daily routine, such as what to do about diabetes medications when sick.

CONCLUSION

The self-reported diabetes education experience varies in content, modality, setting, and education provider. Education receipt is low, and for those who receive education, the amount is low.

PRACTICAL IMPLICATIONS

The diabetes education experience may fall short of the comprehensive US National Standards-recommended process. Innovative strategies are needed to address these gaps.

Leveraging Registered Dietitian Nutritionists and Registered Nurses in Medication Management to Reduce Therapeutic Inertia

Objective

To conduct a systematic review of studies that used registered dietitian nutritionists (RDNs) or registered nurses (RNs) to deliver pharmacological therapy using protocols for diabetes, dyslipidemia, or hypertension.

Research Design and Methods

A database search of PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and the Cumulative Index to Nursing and Allied Health Literature was conducted of literature published from 1 January 2000 to 31 December 2019.

Results

Twenty studies met the inclusion criteria, representing randomized controlled trials (12), retrospective (1) and prospective cohort design studies (6), and time series (1). In all, the studies include 7,280 participants with a median study duration of 12 months (range 6-25 months). Fifteen studies were led by RNs alone, two by RDNs, and three by a combination of RDNs and RNs. All demonstrated improvements in A1C, blood pressure, or lipids. Thirteen studies provided a lifestyle behavior change component in addition to medication protocols.

Conclusion

This systematic review provides evidence that RDN- and RN-led medication management using physician-approved protocols or treatment algorithms can lead to clinically significant improvements in diabetes, dyslipidemia, and hypertension management and is as good or better than usual care.

THE SYNERGY TO ENABLE GLYCEMIC CONTROL FOLLOWING EMERGENCY DEPARTMENT DISCHARGE PROGRAM FOR ADULTS WITH TYPE 2 DIABETES: STEP-DIABETES

OBJECTIVE

To evaluate a diabetes (DM) care delivery model among hyperglycemic adults with type 2 DM being discharged from the emergency department (ED) to home. The primary hypothesis was that a focused education and medication management intervention would lead to a greater short-term improvement in glycemic control compared to controls.

METHODS

A 4-week, randomized controlled trial provided antihyperglycemic medications management using an evidence-based algorithm plus survival skills diabetes self-management education (DSME) for ED patients with blood glucose (BG) levels ≥200 mg/dL. The intervention was delivered by endocrinologist-supervised certified diabetes educators. Controls received usual ED care.

RESULTS

Among 101 participants (96% Black, 54% female, 62.3% Medicaid and/or Medicare insurance), 77% completed the week 4 visit. Glycated hemoglobin A1C (A1C) went from 11.8 ± 2.4 to 10.5 ± 1.9% (P<.001) and 11.5 ± 2.0 to 11.1 ± 2.1% in the intervention and control groups, respectively (P = .012). At 4 weeks, the difference in A1C reduction between groups was 0.9% (P = .01). Mean BG decreased for both groups (P<.001), with a higher percentage of intervention patients (65%) reaching a BG <180 mg/dL compared to 29% of controls (P = .002). Hypoglycemia rates did not differ by group, and no severe hypoglycemia was reported. Medication adherence (Modified Morisky Score(©)) improved from low to medium (P<.001) among intervention patients and did not improve among controls.

CONCLUSIONS

This study provides evidence that a focused diabetes care delivery intervention can be initiated in the ED among adults with type 2 diabetes and hyperglycemia and safely and effectively completed in the ambulatory setting. Improvement in short-term glycemic outcomes and medication adherence were observed.

Strategies to reduce diabetes disparities: an update

Racial and ethnic minorities in the US have a higher prevalence, as well as suffer from more complications, lower quality care, and poorer outcomes for diabetes than their counterparts. Given the US health care system is in the midst of drastic transformation, with the passage of health care reform, and efforts in payment reform, and value-based purchasing, there is now support to provide more intensive, team-based care for those conditions that are complex, costly, and highly prevalent. Addressing and improving diabetes disparities, given they are prevalent and costly, will be an important area of focus in the years to come. The latest research demonstrates that community-based efforts, multifactorial approaches, and the deployment of health information technology can be successful in addressing diabetes disparities, and require support, attention, resources, and continued evaluation. Ultimately, these efforts should improve the quality of care for all persons with diabetes, especially those who are most vulnerable.

Comprehensive diabetes management program for poorly controlled Hispanic type 2 patients at a community health center

Technology and improved care coordination models can help diabetes educators and providers meet national care standards and provide culturally sensitive diabetes education that may improve diabetes outcomes. The purpose of the study was to evaluate the clinical usefulness of a nurse-led diabetes care program (Comprehensive Diabetes Management Program, CDMP) for poorly controlled Hispanic type 2 diabetes (T2DM) patients in an urban community health center setting. Patients were randomized to the intervention condition (IC; n = 21) or an attention control condition (AC; n = 18). IC and AC conditions were compared on rates of adherence to national clinical practice guidelines (blood glucose, blood pressure, foot exam, eye exam), and levels of diabetes distress, depression, and treatment satisfaction. IC patients had a significant improvement in A1C from baseline to 12-month follow-up compared with AC (-1.6% ± 1.4% versus -0.6% ± 1.1%; P = .01). The proportion of IC patients meeting clinical goals at follow-up tended to be higher than AC for A1c (IC = 45%; AC = 28%), systolic blood pressure (IC = 55%; AC = 28%), eye screening (IC = 91%; AC = 78%), and foot screening, (IC = 86%; AC = 72%). Diabetes distress and treatment satisfaction also showed greater improvement for IC than AC (P = .05 and P = .06, respectively), with no differences for depression. The CDMP intervention was more effective than an attention control condition in helping patients meet evidence-based guidelines for diabetes care.

Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis

We conducted a meta-analysis of studies reporting diabetes case management interventions to examine the impact of case management on blood glucose control (HbA1c). Databases used for the search included Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. A composite estimate of effect size was calculated using a random effects model and subgroup analyses were conducted. Twenty-nine salient studies involving 9397 patients had sufficient data for analysis. Mean patient age was 63.2 years, 49% were male, and ethnicity/race was 54% White. Type 2 diabetes was the focus in 91% of studies. Results showed a large overall effect size favoring case management intervention over controls or baseline values on HbA1c (ES=0.86, 95%CI: 0.52-1.19, Z=5.0, p<0.001). This corresponds to a mean HbA1c reduction of 0.89 (95%CI: 0.63-1.15). Subgroup analyses showed clinical setting, team composition, and baseline HbA1c were important predictors of effect size, but not diabetes self-management education which was poorly described or absent in most diabetes case management interventions examined. Nurse-led case management provides an effective clinical strategy for poorly controlled diabetes based on a meta-analysis of clinical trials focusing on blood glucose control.

The economic consequences of diabetes and cardiovascular disease in the United States

Diabetes-related care and complications constitute a significant proportion of the United States' (US) health care expenditure. Of these complications, cardiovascular disease (CVD) is a major component. Higher morbidity and mortality rates translate to higher costs of care in patients with diabetes compared to those who do not have the disease. Minorities bear a disproportionate burden of diabetes and CVD. We review this disparity and examine potential etiologies for it in Hispanics and African-Americans, the two largest minority groups in the US. We examine strategies in these populations that may improve outcomes in diabetes and CVD, potentially decreasing health care costs.

Evaluation of a diabetes specialist-guided primary care diabetes treatment program

PURPOSE

An initial pilot program demonstrated promising results in improvements in glycosylated hemoglobin (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP) and prompted us to test these findings in a controlled trial. The purpose of the Diabetes-focused, Algorithm-directed care, Midlevel practitioner-administered, Electronically coached, Treatment (DAMET-2) program clinical trial was to investigate the benefits of a novel program for disseminating guidance in the treatment of diabetes from a central specialist clinic to primary care centers with access to midlevel provider services.

DATA SOURCES

DAMET-2 included standardized treatment algorithms and education disseminated through computer-assisted and traditional methods associated with distance medicine. Two primary care practices were selected and subjects with diagnosed type 2 diabetes > or =6 months, > or =18 years of age with one or more cardiovascular risk factors (identified by chart review) were eligible for inclusion. Midlevel practitioners for subjects in the experimental group (N = 34) received training in American Diabetes Association treatment algorithms, had telephone consultations at 2- to 4-week intervals and bimonthly visits with diabetes specialists, and received treatment guidance within 24 h from remote diabetes specialists. Weekly diabetes clinics were made available to subjects in the experimental group. After 12 months, the last available subject data were extracted from the subjects' charts and compared to 12-month chart data from a control group (N = 101) that did not receive additional study services.

CONCLUSIONS

Mean HbA(1c) values decreased from baseline by 0.46% in the active treatment group versus 0.06% in the control group; however, reductions in HbA(1c) did not achieve statistical significance potentially because of the small sample size of the experimental group. Mean SBP values were significantly reduced in both groups; however, LDL-C was only significantly reduced in the control group, where more aggressive use of statins may have had an effect.

IMPLICATIONS FOR PRACTICE

Despite the inconsistencies in risk factor reduction from the pilot program, the DAMET-2 program provided insights regarding the importance of electronic records and provider notifications, patient adherence, prioritization of provider resources by risk factor level among patients, and access to self-management education.

The impact of an assisted diabetes care programme on a private practice

AIMS

Specially trained nurses who follow detailed protocols and algorithms under the supervision of a diabetologist can markedly improve diabetes outcomes in community health centres. We aimed to study the impact of a nurse-assisted diabetes care (NADC) model on diabetes and clinic's financial outcomes in a private practice setting.

METHODS

Nurse-assisted diabetes care was provided to the diabetic patients referring to a Monday private diabetes clinic in Shiraz. 107 patients who had received such care were hierarchically matched with 107 diabetic patients receiving usual endocrinologist care in the same clinic during the rest of the week. At the end of 6 months of follow-up, outcomes [glycosylated haemoglobin (HbA1c), serum triglycerides, low-density lipoprotein (LDL) cholesterol, duration of patient's visit and net clinic's income] for patients under NADC were compared with those of usual care patients and also with those derived from the 6 months before receiving NADC.

RESULTS

Under NADC, HbA1c levels had a more significant fall (p < 0.03), significantly smaller proportions of patients had triglyceride levels of > 1.69 mmol/l (150 mg/dl) and LDL cholesterol of > 2.58 mmol/l (100 mg/dl) (both p < 0.05), the time for one patient's visit decreased by an average of 9.3 min (p = 0.000) while the clinic's net income increased by 21.25%.

CONCLUSION

Nurse-assisted diabetes care, while improving diabetes outcomes significantly, spares time for the physician and allows more patients to be seen per clinic hours. The excess income from extra visits much outweighs the expenditures including the nurses' wages. NADC is profitable for private diabetes clinics or offices.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

[Evaluation of a protocol to monitor cardiovascular risk factors in diabetic patients attended in primary care]

OBJECTIVE

To evaluate a primary care protocol for intensive monitoring of cardiovascular risk (CVR) factors in type-2 diabetes patients versus usual care.

DESIGN

Randomised trial with clusters.

SETTING

Primary care clinics.

PARTICIPANTS

Sixty family physicians.

INTERVENTIONS

Participants were randomised between following a protocol of intensive monitoring of CVR factors and maintaining their habitual practice with DM2 patients. Follow-up lasted 12 months. Data on HbA1C, CVR factors and CVR were collected at the start of the study and at 12 months.

RESULTS

In all, 188 patients (94 intervention group and 94 control group) were included. At baseline measurement, CVR in control group (CG) was 36.3% (95% CI, 33.9%-38.6%); and in intervention group (IG), 35.9% (95% CI, 33.5%-38.4%), with no significant differences between groups. At one year, CVR in CG was 33.1% (95% CI, 30%-36.1%) and in IG 30.5% (95% CI, 27.8%-33.2%). The CVR difference between baseline and 1-year measurements was 2.9% (95% CI, 0.2%-5.7%) in CG and 5.4% (95% CI, 2.8%-7.1%) in IG.

CONCLUSIONS

Although improvement of CVR is greater in the IG, the difference between the two groups is not significant. The characteristics of the doctors chosen may have meant that the patients of the two groups received similar treatment.

A nurse-managed diabetes care programme

AIMS

To compare diabetes outcomes in patients under endocrinologist-directed diabetes care with those in patients in a nurse-managed diabetes care (NMDC) programme.

METHODS

NMDC was provided to the diabetic patients referring to a Wednesday diabetes clinic in Shiraz. A total of 159 patients who had received such care were hierarchically matched with 159 diabetic patients receiving usual endocrinologist care in the same clinic during the rest of the week. Outcomes in patients who completed 1 year under NMDC were compared with those of usual endocrinologist care patients and also with those derived from the year before receiving NMDC.

RESULTS

For patients in NMDC programme, the process measures recommended by the American Diabetes Association (ADA) were carried out more frequently than for the appropriate control patients. Under NMDC, HbA(1c) levels fell 3.2% in the 117 patients who were followed for at least 6 months, when compared with a 2.5% fall under usual endocrinologist care (p < 0.001). During the year before the study, in 73 patients mean HbA(1c) levels decreased by 2.6%. At the end of a year under the NMDC programme, the values fell further by 0.65% (p < 0.001). Also, the proportions of patients with TG levels > 150 mg% and LDL levels > 100 mg% decreased from 31% and 36% to 16% and 20%, respectively (p < 0.04 and p < 0.05, respectively).

CONCLUSION

NMDC programme improves diabetes outcomes more significantly than endocrinologist-directed care.

Effect of a nurse-directed diabetes disease management program on urgent care/emergency room visits and hospitalizations in a minority population

OBJECTIVE

To evaluate whether nurse-directed diabetes care reduced preventable diabetes-related urgent care/emergency room visits and hospitalizations in a minority population.

RESEARCH DESIGN AND METHODS

Diabetic patients who receive care in a county public health clinic were randomly selected for a Diabetes Managed Care Program (DMCP) in which a specially trained nurse followed detailed treatment algorithms to provide diabetes care for 1 year. Preventable diabetes-related urgent care/emergency room visits and hospitalizations for these patients incurred during the intervention year and the year before enrollment were compared. Preventable diabetes-related causes were defined as metabolic (diabetic ketoacidosis, hyperglycemia, or hypoglycemia) or infection (cellulitis, foot ulcer, osteomyelitis, fungal infection, or urinary tract infection).

RESULTS

Use of the urgent care/emergency room and hospitalizations during the intervention year and the year prior were available for 331 patients who completed the DMCP intervention. There were 95 [corrected] total urgent care/emergency room visits and hospitalizations in the year before entering the DMCP and 52 [corrected] during the DMCP year, a 45[corrected]% reduction. Preventable diabetes-related episodes were far fewer. During the prior year, 14 patients made 15 urgent care/emergency room visits and 5 patients incurred 6 hospitalizations. During the DMCP year, four different patients made five emergency room/urgent care visits and one other patient was hospitalized. Preventable diabetes-related use was significantly (P < 0.001) lower during the intervention year compared with the prior year. Total charges for urgent care/emergency room visits and hospitalizations only (not other charges related to diabetes care) during the year before entering the DMCP were $129,176 compared with $24,630 during the DMCP year.

CONCLUSIONS

When compared with usual care, nurse-directed diabetes care resulted in significantly fewer urgent care/emergency room visits and hospitalizations for preventable diabetes-related causes. Policy makers seeking to improve diabetes care and conserve resources should seriously consider adopting this approach.

Ethnic differences in control of cardiovascular risk factors in patients with type 2 diabetes attending an Inner London diabetes clinic

BACKGROUND

South Asians have higher risk of diabetic complications compared with white Europeans. The aim of this study was to compare management of cardiovascular risk factors between Bangladeshis and white Europeans.

METHODS

A retrospective survey of all diabetic patients attending an Inner London hospital diabetic clinic over one year was undertaken. Data were obtained from the hospital diabetes database: presence of macrovascular (myocardial infarction, angina, stroke, transient ischaemic attack, cardiac intervention) and microvascular disease (neuropathy, retinopathy, and nephropathy), glycated haemoglobin, blood pressure, lipids, smoking, and body mass index (BMI) were all determined.

RESULTS

A total of 1162 white European and 912 Bangladeshi patients with full data available were included in the analyses. The groups were equivalent in age, sex, duration of diabetes. Compared with white Europeans, Bangladeshis had more macrovascular disease (19.5% v 11.9% p<0.01), sight threatening retinopathy (7.2% v 3.8%, p<0.01), and nephropathy (15.3% v 9.1%, p<0.01). In addition, Bangladeshis had significantly more male smokers (28.1% v 22.1%, p<0.01), poorer glycaemic control (mean HbA1c 8.6% v 8.1%, p = 0.039), greater proportion with uncontrolled hypercholesterolaemia (total cholesterol >5.0 mmol/l, 31.6% v 26% p = 0.05), and poorer control of blood pressure (proportion with BP >140/80 mm Hg, 43.2% v 32.1%, p<0.01).

CONCLUSIONS

South Asians with type 2 diabetes have poorer glycaemic, blood pressure, and lipid control than white Europeans. The reasons for this are probably multifactorial.

A systematic review of interventions to improve diabetes care in socially disadvantaged populations

OBJECTIVE

To identify and synthesize evidence about the effectiveness of patient, provider, and health system interventions to improve diabetes care among socially disadvantaged populations.

RESEARCH DESIGN AND METHODS

Studies that were included targeted interventions toward socially disadvantaged adults with type 1 or type 2 diabetes; were conducted in industrialized countries; were measured outcomes of self-management, provider management, or clinical outcomes; and were randomized controlled trials, controlled trials, or before-and-after studies with a contemporaneous control group. Seven databases were searched for articles published in any language between January 1986 and December 2004. Twenty-six intervention features were identified and analyzed in terms of their association with successful or unsuccessful interventions.

RESULTS

Eleven of 17 studies that met inclusion criteria had positive results. Features that appeared to have the most consistent positive effects included cultural tailoring of the intervention, community educators or lay people leading the intervention, one-on-one interventions with individualized assessment and reassessment, incorporating treatment algorithms, focusing on behavior-related tasks, providing feedback, and high-intensity interventions (>10 contact times) delivered over a long duration (>or=6 months). Interventions that were consistently associated with the largest negative outcomes included those that used mainly didactic teaching or that focused only on diabetes knowledge.

CONCLUSIONS

This systematic review provides evidence for the effectiveness of interventions to improve diabetes care among socially disadvantaged populations and identifies key intervention features that may predict success. These types of interventions would require additional resources for needs assessment, leader training, community and family outreach, and follow-up.

Health care organizations' use of race/ethnicity data to address quality disparities

Health care organizations-health plans, hospitals, community health centers, clinics, and group practices-can play an important role in the elimination of racial/ethnic disparities in health care. There are now a number of examples of organizations that have been successful in reducing or eliminating disparities, and a number of published examples of how quality improvement initiatives can improve care for members of targeted minority groups, thereby contributing to the elimination of disparities.