Use and Impact of Type 2 Diabetes Prevention Interventions

INTRODUCTION

RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes.

METHODS

The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program.

RESULTS

Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p<0.001) or had bariatric surgery (-0.318%; p<0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p<0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients.

CONCLUSIONS

Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

Prevalence of Social Determinants of Health Among Health System Employees

Introduction/Objectives:

Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. However, little is known about social determinants of health among health system employees. We sought to examine the prevalence of social determinants among employees of The MetroHealth System, a large safety-net health system in Cleveland, Ohio.

Methods:

We invited participants in an employee wellness program to answer the same screening questions that patients answer about 9 social determinants of health, including food insecurity, financial strain, transportation difficulty, inability to pay for housing or utilities, intimate partner violence, social isolation, infrequent physical activity, daily stress, and lack of internet access. We then determined the percentage of employees who met pre-defined criteria for being at risk for each social determinant. We also examined how these percentages varied across employee job categories.

Results:

Of 4191 full-time employees, 1932 (46%) completed the survey. The percentage of employees at risk for each social determinant were: food insecurity (11%), financial strain (12%), transportation difficulty (4%), inability to pay for housing or utilities (10%), intimate partner violence (4%), social isolation (48%), infrequent physical activity (10%), daily stress (58%), and lack of internet access (3%). Being at risk for specific social determinants was more common among support staff compared to staff physicians and nurses. For example, the survey participants included 436 administrative support staff, a job category that includes secretaries and patient service representatives. Among this group, 20% reported food insecurity, 20% financial strain, and 17% inability to pay for housing or utilities.

Conclusions:

Social determinants of health are common among health system employees, especially among workers in lower paid job categories. Health systems should routinely screen employees for social determinants and adjust salaries, benefits, and assistance programs to address their social needs.

Characteristics of Patients Engaging in Quitline Counseling After an Electronic Referral

INTRODUCTION

Proactive, electronic referral of primary care patients to quitlines has great potential to provide evidence-based tobacco-cessation assistance to tobacco users. However, the quitline contact rates and engagement of individuals beyond 1 counseling call are poor. This study examines the characteristics of electronically referred patients who engage with the quitline.

METHODS

This cross-sectional study included 2,407 primary care patients who reported using tobacco and accepted an electronic referral to the quitline. Outcomes included contact, enrollment, and receipt of ≥2 counseling sessions from the quitline. All measures were assessed from the electronic health record. The association of patient characteristics and outcomes was evaluated using logistic regression modeling with generalized estimating equation methods. Data were collected in 2016‒2018 and were analyzed in 2020.

RESULTS

Among 2,407 referred patients, 794 (33.0%) were contacted; of those, 571 enrolled (71.9%); and of those, 240 (42.0%) engaged in ≥2 quitline counseling sessions. In multivariable analyses, older adults (aged 50-64 and ≥65 years) were significantly more likely to be contacted (OR=2.32, 95% CI=1.6, 3.4) and to receive ≥2 counseling sessions (OR=2.34, 95% CI=1.2, 4.7) than those aged 18-34 years. Those with both Medicare and Medicaid insurance coverage were more likely than those with Medicaid only to be contacted (OR=1.71, 95% CI=1.4, 2.2), to enroll (OR=1.84, 95% CI=1.2, 2.9), and to receive ≥2 counseling sessions (OR=1.83, 95% CI=1.2, 2.9).

CONCLUSIONS

The current quitline phone-based approach is less likely to engage younger adults and those with Medicaid coverage; however, there is a need to improve quitline engagement across all patients. Identification and testing of alternative engagement approaches are needed.

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support

Introduction

This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach.

Methods

A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts.

Results

Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2–33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7).

Conclusions

Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased.

Implications

Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach.

Trial Registration

clinicaltrials.gov #NCT02764385, registration date 06/05/2016.

A 60-Week Prospective RCT of a Self-Management Intervention for Individuals With Serious Mental Illness and Diabetes Mellitus

OBJECTIVES

A 60-week randomized controlled trial assessed the effects of targeted training in illness management (TTIM) versus treatment as usual among 200 individuals with serious mental illness and diabetes mellitus.

METHODS

The study used the Clinical Global Impression (CGI), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Brief Psychiatric Rating Scale (BPRS) to assess psychiatric symptoms; the Global Assessment of Functioning (GAF) and the Sheehan Disability Scale (SDS) to assess functioning; the 36-Item Short-Form Health Survey (SF-36) to assess general health, and serum glycosylated hemoglobin (HbA1c) to assess diabetes control.

RESULTS

Participants' mean±SD age was 52.7±9.5 years, and 54% were African American. They were diagnosed as having depression (48%), schizophrenia (25%), and bipolar disorder (28%). At baseline, depression severity was substantial but psychosis severity was modest. At 60 weeks, there was greater improvement among TTIM participants versus treatment-as-usual recipients on the CGI (p<.001), the MADRS (p=.016), and the GAF (p=.003). Diabetes knowledge was significantly improved among TTIM participants but not in the treatment-as-usual group. In post hoc analyses among participants whose HbA1c levels at baseline met recommendations set by the American Diabetes Association for persons with high comorbidity (53%), TTIM participants had minimal change in HbA1c over the 60-week follow-up, whereas HbA1c levels worsened in the treatment-as-usual group.

CONCLUSIONS

TTIM was associated with improved psychiatric symptoms, functioning, and diabetes knowledge compared with treatment as usual. Among participants with better diabetes control at baseline, TTIM participants had better diabetes control at 60 weeks compared with recipients of treatment as usual.

Primary Care Resident Training for Obesity, Nutrition, and Physical Activity Counseling: A Mixed-Methods Study

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency programs are preparing physicians to counsel about obesity, nutrition, and physical activity (ONPA) and to examine program members' perspectives regarding the place of ONPA counseling in the curriculum, and its relevance in primary care training. Using mixed methods, we collected and analyzed data on 25 family medicine, internal medicine, and obstetrics/gynecology residency programs across Ohio. Programs averaged 2.8 hours of ONPA-related didactics per year. Ten programs (42%) taught techniques for health behavior counseling. Having any ONPA-related didactics was associated with greater counseling knowledge (p = .01) among residents but poorer attitudes (p < .001) and poorer perceived professional norms (p = .004) toward ONPA counseling. Findings from interview data highlighted similar perceived barriers to ONPA counseling across all three specialties but variation in perception of responsibility to provide ONPA counseling. While widespread expectations that primary care physicians counsel their overweight and obese patients prevail, few residency programs provide training to support such counseling.

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling

BACKGROUND

Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity.

OBJECTIVE

To assess the degree to which residents training in adult primary care programs are prepared to provide obesity, nutrition, and physical activity (ONPA) counseling.

METHODS

Senior residents (postgraduate year [PGY]-3 and PGY-4) from 25 Ohio family medicine, internal medicine, and obstetrics and gynecology programs were surveyed regarding their knowledge about obesity risks and effective counseling, as well as their attitudes, self-efficacy, and perceived professional norms toward ONPA counseling. We examined summary scores, and used regression analyses to assess associations with resident demographics and training program characteristics.

RESULTS

A total of 219 residents participated (62% response rate). Mean ONPA counseling knowledge score was 50.8 (± 15.6) on a 0 to 100 scale. Specialty was associated with counseling self-efficacy (P < .001) and perceived norms (P = .002). Residents who reported having engaged in an elective rotation emphasizing ONPA counseling had significantly higher self-efficacy and more positive attitudes and professional norms scores.

CONCLUSIONS

Our findings suggest that primary care residents' knowledge of ONPA assessment and management strategies has room for improvement. Attitudes, self-efficacy, and perceived norms also are low and vary by training program characteristics. A deeper understanding of curricula associated with improved performance in these domains could inform interventions to enhance residents' ONPA counseling skills and prevent chronic disease.

If we build it, we will come: a model for community-led change to transform neighborhood conditions to support healthy eating and active living

Neighborhoods affect health. In 3 adjoining inner-city Cleveland, Ohio, neighborhoods, residents have an average life expectancy 15 years less than that of a nearby suburb. To address this disparity, a local health funder created the 2010 to 2013 Francis H. Beam Community Health Fellowship to develop a strategic community engagement process to establish a Healthy Eating & Active Living (HEAL) culture and lifestyle in the neighborhoods. The fellow developed and advanced a model, engaging the community in establishing HEAL options and culture. Residents used the model to identify a shared vision for HEAL and collaborated with community partners to create and sustain innovative HEAL opportunities. This community-led, collaborative model produced high engagement levels (15% of targeted 12 000 residents) and tangible improvements in the neighborhood's physical, resource, and social environments.

Best practices: Optimizing care for people with serious mental illness and comorbid diabetes

Diabetes and obesity among patients with serious mental illness are common. Use of second-generation antipsychotics compounds risk, and widely prevalent unhealthy behaviors further contribute to negative outcomes. This column describes Targeted Training in Illness Management, a group-based psychosocial treatment that blends psychoeducation, problem identification, goal setting, and behavioral modeling and reinforcement. The intervention has been adapted to the primary care setting and is targeted at individuals with serious mental illness and diabetes. A key feature of the intervention is the use of peer educators with serious mental illness and diabetes to teach and model self-management. Promising results from a 16-week trial are reported.

PACE+ Nutrition and Exercise Counseling for Obese Patients Based on Stage of Change at an Urban Primary Care Clinic

Background: Obesity screening and behavioral counseling for adults is recommended but rarely feasible to reduce the risk of developing cancer and many chronic diseases. We intiated obesity screening at an urban clinic and offered obese patients tailored counseling using PACE+, a validated tool designed for the primary care setting.

Aim: To evaluate obesity screening rates, readiness to change, preferences for change and change in BMI in patients counseled with PACE+.

Methods: Electronic medical record (EMR) review of patient data from May 2006 to March 2008. Analyses comparing stage of change to patient characteristics was conducted using the Cochran-Armitage Trend Test. Bivariate comparisons of the continuous items were analyzed using the Chi-square.

Results: Of 5,390 patients in the clinic practice, 2532 (47%) were obese, 2269 (42%) were normal or overweight, and 589 (11%) were not screened. PACE+ educators counseled 843 obese patients (33%) May 2006-March 2008. Mean age 50, mean BMI 39, 79% female and 98% African American. 31% of PACE+ participants had hypertension, diabetes mellitus and hyperlipidemia. Stage of change for exercise was most often contemplation (38%) and preparation (40%). The preferred activity was walking (62%). Most cited reasons to change behavior were to lower blood pressure, improve health, reduce weight, and increase energy. Most reported activity barriers were pain (20%), weather (13%), and time (10%). Most patients rated their stage of change for reducing calories as preparation (62%). Anticipated nutrition adherence barriers were “will-power,” cost, and time. Participants rated their self-confidence for activity and dietary changes highly. A trend to weight stabilization and weight loss was observed with follow-up.

Conclusion: Obesity screening and a structured low-intensity behavioral counseling by educators was feasible and reached 33% of obese patients in the practice. PACE+ evaluation in the EMR provides retrievable and measurable information about patient stage of change, preferences and perceived adherence barriers. This data can direct efforts to link community and personal resources to optimize behavioral and weight outcomes. Pain cited as an activity barrier by 20% needs further study.