Ann Hanson

Comparative effectiveness of patient education methods for type 2 diabetes: a randomized controlled trial.

BACKGROUND Group education for patients with suboptimally controlled diabetes has not been rigorously studied. METHODS A total of 623 adults from Minnesota and New Mexico with type 2 diabetes and glycosylated hemoglobin (HbA(1c)) concentrations of 7% or higher were randomized to (1) group education (using the US Diabetes Conversation Map program), (2) individual education, or (3) usual care (UC; ie, no assigned education). Both education methods covered content as needed to meet national standards for diabetes self-management education and were delivered through accredited programs from 2008 to 2009. General linear mixed-model methods assessed patient-level changes between treatment groups in mean HbA(1c) levels from baseline to follow-up at 6.8 months. Secondary outcomes included mean change in general health status (Medical Outcomes Study 12-Item Short Form Health Survey [SF-12]), Problem Areas in Diabetes (PAID), Diabetes Self-Efficacy (DES-SF), Recommended Food Score (RFS), and Physical Activity (PA, min/wk). RESULTS Mean HbA(1c) concentration decreased in all groups but significantly more with individual (-0.51%) than group education (-0.27%) (P = .01) and UC (-0.24%) (P = .01). The proportion of subjects with follow-up HbA(1c) concentration lower than 7% was greater for individual education (21.2%) than for group (13.9%) and UC (12.8%) (P = .03). Compared with UC, individual education (but not group) improved SF-12 physical component score (+1.88) (P = .04), PA (+42.95 min/wk) (P = .03), and RFS (+0.63) (P = .05). Compared with group education, individual education reduced PAID (-3.62) (P = .02) and increased self-efficacy (+0.1) (P = .04). CONCLUSIONS Individual education for patients with established suboptimally controlled diabetes resulted in better glucose control outcomes than did group education using Conversation Maps. There was also a trend toward better psychosocial and behavioral outcomes with individual education. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00652509.

Does Diabetes Double the Risk of Depression

PURPOSE In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits. METHODS We matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients. RESULTS With matching for age and sex alone, patients with prevalent diabetes having few primary care visits were significantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confidence interval [CI], 1.19–1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77–1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07–1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80–1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients. CONCLUSIONS Patients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

A comparative analysis of recruitment methods used in a randomized trial of diabetes education interventions.

Recruitment methods heavily impact budget and outcomes in clinical trials. We conducted a post-hoc examination of the efficiency and cost of three different recruitment methods used in Journey for Control of Diabetes: the IDEA Study, a randomized controlled trial evaluating outcomes of group and individual diabetes education in New Mexico and Minnesota. Electronic databases were used to identify health plan members with diabetes and then one of the following three methods was used to recruit study participants: 1. Minnesota Method 1--Mail only (first half of recruitment period). Mailed invitations with return-response forms. 2. Minnesota Method 2--Mail and selective phone calls (second half of recruitment period). Mailed invitations with return-response forms and subsequent phone calls to nonresponders. 3. New Mexico Method 3--Mail and non-selective phone calls (full recruitment period): Mailed invitations with subsequent phone calls to all. The combined methods succeeded in meeting the recruitment goal of 623 subjects. There were 147 subjects recruited using Minnesotas Method 1, 190 using Minnesotas Method 2, and 286 using New Mexicos Method 3. Efficiency rates (percentage of invited patients who enrolled) were 4.2% for Method 1, 8.4% for Method 2, and 7.9% for Method 3. Calculated costs per enrolled subject were

Factors Influencing Patient Completion of Diabetes Self-Management Education

71.58 (Method 1),

CA6-05: Improved Glycemic Control from Diabetes Self-management Education is Not Sustained

85.47 (Method 2), and

A qualitative study of processes used to implement evidence-based care in a primary care practice

92.09 (Method 3). A mail-only method to assess study interest was relatively inexpensive but not efficient enough to sustain recruitment targets. Phone call follow-up after mailed invitations added to recruitment efficiency. Use of return-response forms with selective phone follow-up to non-responders was cost effective.

Outcomes from routine cognitive screening in a general neurology clinic

Achievement of high participation rates in research trials of diabetes self-management education (DMSE) is a major challenge. Subjects may initially agree to participate but then fail to attend the assigned educational sessions, or they may attend the sessions only sporadically. From a research perspective, if consented subjects are not exposed to the educational intervention, they do not benefit, which in turn reduces the ability to demonstrate a positive effect.1 DMSE programs are usually limited to only a small number of sessions, each covering a distinct topic or task, with a logical progression to the next session. Individuals who fail to attend even a single session are unlikely to achieve the full benefits. Furthermore, non-attendance raises questions about the generalizability of a DSME trials results to clinical populations.2,3 The issue of nonattendance extends beyond research studies to clinical diabetes education programs in health care systems. Knowledge of factors influencing DSME attendance is limited and often conflicting.4–6 Characteristics reported to be associated with missed clinic appointments in general include full-time work, younger age, non-white ethnicity, smoking, elevated blood pressure, and elevated initial A1C levels. Better understanding of factors influencing completion of DSME in research trials could also carry over into the clinical setting, enabling implementation of interventions that attain better adherence to DSME. This study evaluated subject characteristics associated with non-completion of group and individual DSME interventions, using data from an established clinical trial of diabetes education called Journey for Control of Diabetes: The IDEA (Interactive Dialogue to Educate and Activate). This trial afforded the opportunity to evaluate factors that affected attendance at scheduled group and individual DSME sessions in research study participants with type 2 diabetes of longstanding duration in suboptimal glycemic control. ### Study context The IDEA study was a behavioral intervention to evaluate diabetes outcomes …

D2-4: Failure on Cognitive Screening Predicts Increased Healthcare Utilization

Background/Aims For patients with type 2 diabetes of long duration, we evaluated whether improved short-term outcomes obtained through diabetes education were sustained. Methods 623 adults with glycosylated hemoglobin (A1c) greater or equal to 7% were randomized to individual education (IE), group education (GE) using Conversation Maps, or usual care (UC). A1c, Problem Areas in Diabetes (PAID), Diabetes Self-Efficacy (DES), Recommended Food Score (RFS), Physical Activity (PA), and medication intensification (an increase in number of medication classes or insulin start) were evaluated at baseline and at approximately 6 month intervals for the following year using linear mixed models. Results Compared to UC, IE resulted in sustained improved DES and PAID scores in the long-term (DES, +0.11, p=.03 and PAID, −2.94, p=.04), but not significant RFS or PA long-term change. IE resulted in a short-term A1c reduction of .25% (p=.03) and odds ratio (OR) of 1.83 (1.05–3.17) for achieving an A1c < 7% compared with UC, but significant effects were not observed after 6 additional follow-up months. No differences were observed between GE and UC for short-term and long-term DES, PAID, RFS, PA, or A1c. In patients with pharmacy claims data (n=488), odds ratios of medication intensification comparing IE to UC were short-term 0.83(0.44–1.57) and long-term 0.79(0.43–1.47); comparing or GE to UC were short-term 1.22(0.66–2.26) and long-term 0.92(0.50–1.68). Discussion In patients with suboptimal glycemic control, improved measures of self-efficacy and lower diabetes distress observed with IE in the short-term were sustained long-term. However, short-term improvements in glucose control, nutrition, and physical activity were not sustained. Educational interventions did not result in higher medication intensification rates. Results are consistent with most behavior change theories, and suggest greater attention to maintenance and relapse, possibly from continued ongoing support from educators, may be needed to sustain improvements in healthy behaviors and glucose control.

PS1-36: Season, Daylight, and A1C Levels

BACKGROUND Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients. OBJECTIVE To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients. METHODS We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice. RESULTS Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys. CONCLUSIONS Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.

PS2-06: Regional Variation in Response to Diabetes Education in the IDEA Study

MiDD was 9.90% in NCD, 16.89% in MCI, and 19.51% in ADD. The frequency of NIMH-dAD was 26.23%, 33.56%, and 40.24%, respectively. While the frequency of MaDD did not show any significant difference among cognitive subgroups, those of MiDD and NIMH-dAD, i.e., relatively milder depression syndromes, had significant group difference with gradual increase from NCD to ADD. Conclusions: The current findings obtained from a large number of cognitively diverse elderly individuals who visited a memory clinic indicated that mild depressive conditions are highly prevalent in general and more common in individuals with poorer cognitive condition, while the frequency of severe depressive disorder like MaDD is not related to cognitive status.