Janet W. Helduser

Factors Associated With Successful Completion of the Chronic Disease Self-Management Program by Adults With Type 2 Diabetes

This study examines factors associated with completion (attendance ≥4 of 6 sessions) of the Chronic Disease Self-Management Program (CDSMP) by adults with type 2 diabetes. Patients with glycated hemoglobin ≥ 7.5 within 6 months were enrolled and completed self-report measures on demographics, health status, and self-care (n = 146). Significant differences in completion status were found for several self-care factors including healthful eating plan, spacing carbohydrates, frequent exercise, and general health. Completion was not influenced by race/ethnicity or socioeconomics. Results suggest better attention to exercise and nutrition at the start of CDSMP may be associated with completion, regardless of demographic subgroup.

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: A survival analysis model

OBJECTIVE This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization. METHODS Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization. RESULTS Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm. CONCLUSION CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM. PRACTICE IMPLICATIONS Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.

Perceived Utility of the RE-AIM Framework for Health Promotion/Disease Prevention Initiatives for Older Adults: A Case Study from the U.S. Evidence-Based Disease Prevention Initiative

Dissemination and implementation (D&I) frameworks are increasingly being promoted in public health research. However, less is known about their uptake in the field, especially for diverse sets of programs. Limited questionnaires exist to assess the ways that frameworks can be utilized in program planning and evaluation. We present a case study from the United States that describes the implementation of the RE-AIM framework by state aging services providers and public health partners and a questionnaire that can be used to assess the utility of such frameworks in practice. An online questionnaire was developed to capture community perspectives about the utility of the RE-AIM framework. Distributed to project leads in 27 funded states in an evidence-based disease prevention initiative for older adults, 40 key stakeholders responded representing a 100% state-participation rate among the 27 funded states. Findings suggest that there is perceived utility in using the RE-AIM framework when evaluating grand-scale initiatives for older adults. The RE-AIM framework was seen as useful for planning, implementation, and evaluation with relevance for evaluators, providers, community leaders, and policy makers. Yet, the uptake was not universal, and some respondents reported difficulties in use, especially adopting the framework as a whole. This questionnaire can serve as the basis to assess ways the RE-AIM framework can be utilized by practitioners in state-wide D&I efforts. Maximal benefit can be derived from examining the assessment of RE-AIM-related knowledge and confidence as part of a continual quality assurance process. We recommend such an assessment be performed before the implementation of new funding initiatives and throughout their course to assess RE-AIM uptake and to identify areas for technical assistance.

Perceptions About Community Applications of RE-AIM in the Promotion of Evidence-Based Programs for Older Adults

Despite the growing literature about the RE-AIM framework as a planning, implementation, and evaluation tool, little is known about practitioners’ adoption of the framework, confidence to utilize framework elements, or perceptions of its usefulness. To assess how RE-AIM was implemented by state aging service providers and public health partners, data were collected using an Internet-delivered, cross-sectional survey from 40 stakeholders in 27 funded states in an evidence-based disease prevention initiative for older adults. Most participants agreed the framework was useful for planning, implementation, and evaluation and relevant for evaluators, providers, community leaders, and policy makers. Yet nearly half felt monitoring RE-AIM requirements requires special expertise, and one third felt the different RE-AIM elements were difficult to measure. Findings indicate the RE-AIM’s appropriateness and utility for planning and evaluating the dissemination of evidence-based programs to older adults; however, additional trainings, resources, and technical assistance are warranted to enhance uptake in community-wide intervention efforts.

Provision of Counseling on Diabetes Self-Management: Are There Any Age Disparities?

OBJECTIVE To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas. METHODS EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes. RESULTS There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37-0.98). The mean HbA1c for patients aged ≥75 and 65-74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<0.001). CONCLUSION While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults. PRACTICE IMPLICATIONS Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.

The role of health literacy and communication habits on previous colorectal cancer screening among low-income and uninsured patients

Objective To determine the association between health literacy, communication habits and colorectal cancer (CRC) screening among low-income patients. Methods Survey responses of patients who received financial assistance for colonoscopy between 2011 and 2014 at a family medicine residency clinic were analyzed using multivariate logistic regression (n = 456). There were two dependent variables: (1) previous CRC screening and (2) CRC screening adherence. Our independent variables of interest were health literacy and communication habits. Results Over two-thirds (67.13%) of respondents had not been previously screened for CRC. Multivariate analysis showed a decreased likelihood of previous CRC screening among those who had marginal (OR = 0.52; 95% CI = 0.29–0.92) or inadequate health literacy (OR = 0.49; 95% CI = 0.27–0.87) compared to those with adequate health literacy. Controlling for health literacy, the significant association between educational attainment and previous CRC screening was eliminated. Thus, health literacy mediated the relationship between educational attainment and previous CRC screening. There was no significant association between communication habits and previous CRC screening. There was no significant association between screening guideline adherence, and health literacy or communication. Conclusion Limited health literacy is a potential barrier to CRC screening. Suboptimal CRC screening rates reported among those with lower educational attainment may be mediated by limited health literacy.

Expanding Access to Colorectal Cancer Screening: Benchmarking Quality Indicators in a Primary Care Colonoscopy Program

Background: An inadequate supply of physicians who perform colonoscopies contributes to suboptimal screening rates, especially among the underserved. This shortage could be reduced if primary care physicians perform colonoscopies. This purpose of this article is to report quality indicators from colonoscopy procedures performed by family medicine physicians as part of a colorectal cancer prevention program targeting uninsured, low-income individuals. Methods: A grant-funded colorectal cancer screening program was implemented to increase access to affordable colonoscopies for underinsured or uninsured residents of target counties while providing colonoscopy training to family medicine resident physicians. Colonoscopies were performed or supervised by 4 board-certified family physicians. Data were collected between 2011 and 2014. Results: A total of 1155 colonoscopies were performed on 1101 individuals over a 3-year period. Cecal intubation rate was 96.25%. Adenoma detection rates among men and women >50 years old were 38.15% and 25.96%, respectively. There was 1 perforation, which was referred to a hospital, and 1 instance of postprocedural bleeding, which spontaneously resolved. Conclusions: Primary care physicians performing colonoscopies met the recommended quality indicators set forth by the American Society for Gastrointestinal Endoscopy.

Physician Recommendation of Diabetes Clinical Protocols

Abstract The authors examined the responses of 63 primary care physicians to diabetes clinical protocols (DCPs) for the management of type II diabetes (T2DM). We measured physician demographics, current diabetes patient loads, and responses to DCPs (physician attitudes, physician familiarity, and physician recommendation of DCPs) using a 20-question electronic survey. Results of the survey indicate that primary care physicians may be unfamiliar with the benefits of diabetes clinical protocols for the self-management of T2DM. Given the importance of diabetes self-management education in controlling T2DM, those interested in implementing DCPs should address the beliefs and attitudes of primary care physicians.

Challenges Associated with Multi-institutional Multi-site Clinical Trial Collaborations: Lessons from a Diabetes Self-Management Interventions Study in Primary Care

Purpose: Project management for multi-institutional, multi-site clinical trials poses significant challenges. We describe the response to challenges encountered in a 5-year National Institutes of Health multi-institutional 7-site randomized controlled trial of type 2 diabetes (T2DM) self-management interventions study. Methods: The collaborating institutions consisted of a large 220,000-member integrated healthcare system and a university academic health science center partner. The clinical team comprised the principal investigator and research coordinators covering 6 of the 7 clinical sites, while the academic team comprised the co-principal investigator, coinvestigators, and other research and clinical coordination staff. Subjects recruited for the study had a glycosylated hemoglobin ≥ 7.5 within the last 6 months and received primary care at the participating clinics. Patients who met the inclusion criteria were consented at private orientation meetings, randomized into one of 4 study arms, and followed every 6 months over a 24-month period for data collection. Results: The encountered challenges concerned: 1) communication across the multiple clinic sites; 2) multiinstitutional coordinator training; 3) multiple record-keeping methods; 4) clinical access for academic personnel; 5) unanticipated clinical coordinator turnover; 6) subject recruitment and retention; and 7) multiple Institutional Review Boards (IRBs). Solutions included conducting full team weekly or bimonthly research meetings, coordinator crosstraining, adding study-specific templates with downloadable fields, developing a protocol for working with single point of contact in each clinic, securing commitment from the centralized clinical system to dedicate coordinator(s) to the project for the duration of the study period, setting explicit monthly recruitment goals for each clinic, and establishing a lead IRB up-front. Conclusion: Our challenges reflect the complexity of clinical trial collaborations across clinical and academic partners. Of critical importance to the success of clinical/academic collaborations is the commitment by all institutions for advance determination of communication strategies, IRB processes, records access and storage systems, and online training needs. Trial Registration Number/Site: NCT01221090, https://clinicaltrials.gov

The cost-effectiveness of training US primary care physicians to conduct colorectal cancer screening in family medicine residency programs.

BACKGROUND Demand for a wide array of colorectal cancer screening strategies continues to outpace supply. One strategy to reduce this deficit is to dramatically increase the number of primary care physicians who are trained and supportive of performing office-based colonoscopies or flexible sigmoidoscopies. This study evaluates the clinical and economic implications of training primary care physicians via family medicine residency programs to offer colorectal cancer screening services as an in-office procedure. METHODS Using previously established clinical and economic assumptions from existing literature and budget data from a local grant (2013), incremental cost-effectiveness ratios are calculated that incorporate the costs of a proposed national training program and subsequent improvements in patient compliance. Sensitivity analyses are also conducted. RESULTS Baseline assumptions suggest that the intervention would produce 2394 newly trained residents who could perform 71,820 additional colonoscopies or 119,700 additional flexible sigmoidoscopies after ten years. Despite high costs associated with the national training program, incremental cost-effectiveness ratios remain well below standard willingness-to-pay thresholds under base case assumptions. Interestingly, the status quo hierarchy of preferred screening strategies is disrupted by the proposed intervention. CONCLUSIONS A national overhaul of family medicine residency programs offering training for colorectal cancer screening yields satisfactory incremental cost-effectiveness ratios. However, the model places high expectations on primary care physicians to improve current compliance levels in the US.