Jodi Lavin-Tompkins

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.

Educator Experience with the U.S. Diabetes Conversation Map® Education Program in the Journey for Control of Diabetes: The IDEA Study

It is widely accepted that educating patients about ways to better understand and self-manage type 2 diabetes is a cornerstone for managing the disease.1 However, there is still much debate over the educational approach that is most effective in delivering such crucial health information in a way that leads to measurable changes in patient behavior and improved clinical outcomes.2 In an effort to help resolve this debate, the Journey for Control of Diabetes: The IDEA Study, a multisite randomized trial, is underway, conducted by researchers at Health-Partners Research Foundation (HP) in Minneapolis, Minn., and LCF Research (LCF), in Albuquerque, N.M. The study aims to evaluate the effectiveness of two methods of education: 1 ) a traditional individual educational approach and 2 ) a more novel group-based, interactive learning experience called IDEA (Interactive Dialogue to Educate and Activate) using the U.S. Diabetes Conversation Map education program (created by Healthy Interactions in collaboration with the American Diabetes Association [ADA] and sponsored by Merck & Co.). This form of group education, using the Conversation Map education tools as a vehicle to facilitate interaction between educators and patients, shows promise to change patient attitudes toward diabetes, improve self-efficacy, and lead to better clinical outcomes. The purpose of this article is to describe the IDEA Study educator experience with implementing the Conversation Map education approach to inform and assist others in integrating this learning tool in their care settings. The IDEA Study enrolled 623 participants with a history of suboptimally controlled type 2 diabetes through HP and LCF from June 2008 to May 2009, with the purpose of evaluating the effectiveness of an interactive, group-based diabetes educational experience using the Conversation Map tools. Individuals interested in the study were eligible to participate if they had an A1C value within the past 6 months of ≥ …

Factors Influencing Patient Completion of Diabetes Self-Management Education

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 …

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

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.

Use of Continuous Glucose Monitoring as an Educational Tool in the Primary Care Setting

The prevalence of diabetes has increased dramatically world-wide in the past 30 years because of an increase in life expectancy, urbanization, changing population demographics, and increasing rates of obesity and physical inactivity.1–3 The disease is considered a world-wide epidemic and major chronic health problem.3,4 According to the International Diabetes Federation, the United States has 23.7 million people with diabetes (27.7% of whom are undetected), and undiagnosed cases are responsible for an additional

2017 National Standards for Diabetes Self-Management Education and Support

18 billion in annual health care costs. Diabetes is recognized as a silent disease, and in 70% of patients with type 2 diabetes, cardiovascular problems and coronary disease are the main cause of death.5,6 Improvements in blood pressure, lipids, and blood glucose management reduce the risk of diabetes-related micro- and macrovascular disease,7–9 with a potential legacy effect as demonstrated with the U.K. Prospective Diabetes Study, which showed a reduced incidence of myocardial infarction in the intensively treated group after 10 years of follow-up.10 Long-term complications are preventable with a multi-interventional strategy addressing blood glucose, blood pressure, and lipid management.11 Nevertheless, many patients experience difficulty achieving recommended care goals using the current approach. Multiple options for diabetes treatment are available for patients, including diet and exercise regimens and 11 different drug classes. Several strategies are required for better management of diabetes, including factors pertinent to patients, care providers, and the health care system, all of which affect the quality of diabetes care. Diabetes educators can support these care strategies by performing services such as counseling, medication management, monitoring of disease control and progression through self-monitoring of blood glucose (SMBG) results, and screening for microvascular complications, all of which can influence the delivery of health care to patients with diabetes.12 To evaluate the risk of …

PS2-01: Factors Influencing Completion in the IDEA Diabetes Education Study

This article was copublished in Diabetes Care 2017;40:1409–1419 and The Diabetes Educator 2017;43:449–464 and is reprinted with permission. The previous version of this article, also copublished in Diabetes Care and The Diabetes Educator, can be found at Diabetes Care 2012;35:2393–2401 (https://doi.org/10.2337/dc12-1707).

C-C2-03: Journey for Control of Diabetes: The Interactive Dialogue to Educate and Activate (IDEA) Study – Short-term Results of a Randomized Controlled Trial

Background/Aims Participant non-adherence to study protocols can adversely affect clinical trials by reducing statistical power. Similarly non-adherence is an important issue in clinical practice. Ceasing to participate is one form of non-adherence. Subject characteristics appear to influence adherence. We evaluated relationships between subject characteristics and completion of educational sessions in IDEA, a clinical trial testing 2 modes of diabetes education in patients with sub-optimal diabetes control. Methods IDEA eligibility criteria included Type 2 diabetes, A1c =7%, and no recent diabetes education. Subjects (n=623) were randomly allocated to one of 3 diabetes education treatment arms; individual education, group education, or a comparison group with no active intervention. Individual education consisted of three 1-hour sessions, following an AADE program. Group education was delivered in four 2-hour group sessions that emphasized patient interaction. Subjects were considered adherent if they completed all assigned sessions. At the end of the study, tracking data indicated completion rates of 72.0% (175/243) in the group education intervention and 86.1% (211/245) in the individual treatment intervention. We sought to identify demographic, psychosocial and clinical characteristics that might explain non-completion. We hypothesized that, within each arm, baseline health status (SF-12 mental composite and physical composite scores), depression (PHQ9), personality type (TIPI Big 5; extraversion, agreeability, emotional stability, conscientiousness, and openness), and Hb A1c level were associated with completion. Results In the group education arm, subjects scoring higher on the emotional stability scale were more likely to complete (p<0.05). Generally, demographic factors were more strongly associated with completion of group education than were psychosocial or clinical factors: women and older subjects were more likely to complete than men and younger subjects (gender, p=0.008; age, p=<0.0005). Within the individual education arm, completion was predicted by higher physical health score (SF12-PCS; p=0.005), higher mental health scales (SF12-MCS, p=0.008), lower depression score (PHQ9, p=0.002), and lower Hb A1c (p<0.05). However, neither gender nor age was associated with completion. Conclusions Factors related to study completion appear to differ between the 2 diabetes educational interventions. These results may be relevant to diabetes educational programs considering strategies to improve “no show” and lack of completion rates.

C-B4-01: Educator Experience with Group Interactive Dialogue to Educate and Activate (IDEA) Using Conversation Maps

Background/Aims Group diabetes education for patients is cost-efficient and could be more effective than an individual approach. The objective is to determine whether outcomes of group education are comparable to individual education in the short-term. Methods We identified 9,971 patients from two healthcare systems, ABQ Health Partners in New Mexico and HealthPartners in Minnesota, through electronic health records (EHR) with type 2 diabetes (T2DM) diagnostic codes and sub-optimal blood sugar control (A1c > 7%). Invitations were mailed from June 2008 – May 2009 and 623 (6.2% participation) subjects were randomized to: Individual Education (IE), Group Education (GE), or Usual Care (UC)/no education. Education was delivered through the American Diabetes Association-recognized education programs of the participant’s care system. IE used a conventional approach with three 1-hr sessions, and GE used four 2-hr sessions using the U.S. Diabetes Conversation Map® education program. Psychosocial and behavioral measures were survey-assessed at baseline, 1, and 4 months after the last scheduled educational session. Clinical measures were obtained through the patient’s EHR in the 6 months preceding baseline & randomization and preceding the second follow-up survey. General and linear mixed modeling methods were used to assess patient changes from baseline to follow-up in A1c, General Health Status (SF-12), Problem Areas in Diabetes (PAID), Diabetes Empowerment Scale (DES), components of the Diabetes Care Profile (DCP), Readiness to Change (RTC), Recommended Food Score (RFS), and physical activity (PA) using the BRFSS. Results At follow-up, the mean A1c for IE decreased .61% (p<.001), .36% for GE (p=.003) and .34% for UC (p=.01). The A1c for IE decreased by .27% compared to UC (p=.02) and .25% compared to GE (p=.01). Compared to UC, mean PAID was reduced by IE (−.37, p=.02) and GE (−.30, p=.05) and SF12 physical health score, PA, and RFS were increased by IE 1.98 (p=.03), 41.17 minutes/ week (p=.05), and.62 (p=.06), respectively. DES, RTC, and DCP were not significantly changed by IE or GE. Conclusion At 4 months post-education completion, individual education for this patient population resulted in improved A1c’s compared to usual care and group education. Diabetes-specific distress (PAID score) was reduced with both methods of education.

Abstract PS1-16: A Study Design to Evaluate Group Dialogue Activities to Improve Diabetes Outcomes

Aims: In order to improve self- efficacy and clinical outcomes for people with diabetes, new approaches using more interactive methods of group education are being promoted. We report results of an educator evaluation of IDEA to assist others who may be interested in starting similar groups in their care settings. Methods: A qualitative analysis was conducted as part of an ongoing randomized trial comparing two different educational interventions (Group IDEA and Individual Education) to Usual Care. As part of the study, educators at HealthPartners clinics in Minneapolis, MN and ABQ Health Partners in Albuquerque, NM were trained on how to use Conversation Maps (CM). All educators completed a Likert scale questionnaire after each CM session with responses from 1–10 (10 being the best). An open- ended evaluation form was also used to solicit positive and negative opinions about the sessions. Analysis: The data consisted of 48 nurse and dietitian evaluations from two sites. The mean Likert scores of the educational experience were calculated and compared for each site and for each of the four CM topics (general information, monitoring, nutrition, and complications). All eight research team members also reviewed answers to the open-ended questions and group consensus was used to describe positive and negative themes. Results: Educator rated Likert scores of map sessions were excellent (mean scores for Maps 1, 2, 3, 4: Overall success 8.3, 7.6, 7.7, 8.8; Ease and comfort levels in facilitation 8.9, 8.9, 9.2, 9.5; Patient motivation to self-manage 7.7, 6.9, 8, 8.8). Scores did not differ significantly across sites or between maps. Positive comments on the maps outweighed the negatives. The challenges identified were: Disruptive (especially angry or negative) people; Distracting topics raised by patients and late arrivals; Variable reading levels among patients (too hard or too easy); and Not enough time to cover the content (especially nutrition). Conclusions: The IDEA method was perceived positively by educators due to its ability to promote patient interaction, sharing, and meaningful discussion. To be successful, however, educators need tips and practice on handling disruptive patients, distractions, variance in literacy, and covering intended nutritional content in a group context.