Katherine Pereira

Feasibility and Preliminary Effects of a Virtual Environment for Adults With Type 2 Diabetes: Pilot Study

Background Innovative interventions that empower patients in diabetes self-management (DSM) are needed to provide accessible, sustainable, cost-effective patient education and support that surpass current noninteractive interventions. Skills acquired in digital virtual environments (VEs) affect behaviors in the physical world. Some VEs are programmed as real-time three-dimensional representations of various settings via the Internet. For this research, a theoretically grounded VE that facilitates DSM was developed and pilot tested. It offered weekly synchronous DSM education classes, group meetings, and social networking in a community in which participants practiced real world skills such as grocery shopping, exercising, and dining out, allowing for interactive knowledge application. The VE was available 24/7 on the Internet, minimizing access barriers. Objective The objective of this study was to evaluate the feasibility and efficacy of participation in a VE for DSM education and support. Methods This study utilized a single group, pre-mid-post measure design. At 0, 3, and 6 months, we assessed participants’ perceived VE usability and usefulness, self-efficacy, diabetes self-management behaviors, perceived social support, and diabetes knowledge using validated survey measures; and we recorded metabolic indicators (HbA1c, BP, BMI). Process data were continuously collected in the VE (log-ins, voice recordings, locations visited, objects interacted with, and movement). Data analysis included descriptive statistics, t tests to evaluate changes in mediators and outcomes over time, and depiction of utilization and movement data. Results We enrolled 20 participants (13/20, 65% white, 7/20, 35% black), with an age range of 39-72 years (mean age, 54 years) and diabetes duration from 3 months to 25 years. At baseline, 95% (18/19) and 79% (15/19) of participants rated usefulness and ease of use as high on validated surveys with no significant changes at 3 or 6 months. Participants logged into the site a mean of 2.5 hours/week over the course of 6 months. High DSM class attendance was reflected by the largest percentage of time spent in the classroom (48.6%). Self-efficacy, social support, and foot care showed significant improvement (P<.05). There were improvement trends in clinical outcomes that were clinically meaningful but did not reach statistical significance given the small sample size. Conclusions Because relatively little is known about usability, acceptability, and efficacy of health interventions in VEs, this study constitutes an important, innovative first step in exploring the potential of VEs for facilitating DSM. The preliminary data suggest that VEs provide a feasible and useful platform for patients and educators that affects self-management and related mediators. Flexible access to both synchronous and asynchronous diabetes education, skill building activities, and support from a home computer remove barriers to attending clinic-based meetings. This program has potential for improving DSM in an easily disseminated alternative model.

Tailored Case Management for Diabetes and Hypertension (TEACH-DM) in a community population: study design and baseline sample characteristics.

BACKGROUND Despite recognition of the benefits associated with well-controlled diabetes and hypertension, control remains suboptimal. Effective interventions for these conditions have been studied within academic settings, but interventions targeting both conditions have rarely been tested in community settings. We describe the design and baseline results of a trial evaluating a behavioral intervention among community patients with poorly-controlled diabetes and comorbid hypertension. METHODS Tailored Case Management for Diabetes and Hypertension (TEACH-DM) is a 24-month randomized, controlled trial evaluating a telephone-delivered behavioral intervention for diabetes and hypertension versus attention control. The study recruited from nine community practices. The nurse-administered intervention targets 3 areas: 1) cultivation of healthful behaviors for diabetes and hypertension control; 2) provision of fundamentals to support attainment of healthful behaviors; and 3) identification and correction of patient-specific barriers to adopting healthful behaviors. Hemoglobin A1c and blood pressure measured at 6, 12, and 24 months are co-primary outcomes. Secondary outcomes include self-efficacy, self-reported medication adherence, exercise, and cost-effectiveness. RESULTS Of 377 randomized patients, 193 were allocated to the intervention and 184 to attention control. The cohort is balanced in terms of gender, race, education level, and income. The cohorts mean baseline hemoglobin A1c and blood pressure are above goal, and mean baseline body mass index falls in the obese range. Baseline self-reported non-adherence is high for diabetes and hypertension medications. Trial results are pending. CONCLUSIONS If effective, the TEACH-DM interventions telephone-based delivery strategy and nurse administration make it well-suited for rapid implementation and broad dissemination in community settings.

Assessing electronic health record phenotypes against gold-standard diagnostic criteria for diabetes mellitus.

Objective: We assessed the sensitivity and specificity of 8 electronic health record (EHR)-based phenotypes for diabetes mellitus against gold-standard American Diabetes Association (ADA) diagnostic criteria via chart review by clinical experts. Materials and Methods: We identified EHR-based diabetes phenotype definitions that were developed for various purposes by a variety of users, including academic medical centers, Medicare, the New York City Health Department, and pharmacy benefit managers. We applied these definitions to a sample of 173 503 patients with records in the Duke Health System Enterprise Data Warehouse and at least 1 visit over a 5-year period (2007–2011). Of these patients, 22 679 (13%) met the criteria of 1 or more of the selected diabetes phenotype definitions. A statistically balanced sample of these patients was selected for chart review by clinical experts to determine the presence or absence of type 2 diabetes in the sample. Results: The sensitivity (62–94%) and specificity (95–99%) of EHR-based type 2 diabetes phenotypes (compared with the gold standard ADA criteria via chart review) varied depending on the component criteria and timing of observations and measurements. Discussion and Conclusions: Researchers using EHR-based phenotype definitions should clearly specify the characteristics that comprise the definition, variations of ADA criteria, and how different phenotype definitions and components impact the patient populations retrieved and the intended application. Careful attention to phenotype definitions is critical if the promise of leveraging EHR data to improve individual and population health is to be fulfilled.

Preparing for the ICD-10-CM Transition: Automated Methods for Translating ICD Codes in Clinical Phenotype Definitions.

Background: The national mandate for health systems to transition from ICD-9-CM to ICD-10-CM in October 2015 has an impact on research activities. Clinical phenotypes defined by ICD-9-CM codes need to be converted to ICD-10-CM, which has nearly four times more codes and a very different structure than ICD-9-CM. Methods: We used the Centers for Medicare & Medicaid Services (CMS) General Equivalent Maps (GEMs) to translate, using four different methods, condition-specific ICD-9-CM code sets used for pragmatic trials (n=32) into ICD-10-CM. We calculated the recall, precision, and F score of each method. We also used the ICD-9-CM and ICD-10-CM value sets defined for electronic quality measure as an additional evaluation of the mapping methods. Results: The forward-backward mapping (FBM) method had higher precision, recall and F-score metrics than simple forward mapping (SFM). The more aggressive secondary (SM) and tertiary mapping (TM) methods resulted in higher recall but lower precision. For clinical phenotype definition, FBM was the best (F=0.67), but was close to SM (F=0.62) and TM (F=0.60), judging on the F-scores alone. The overall difference between the four methods was statistically significant (one-way ANOVA, F=5.749, p=0.001). However, pairwise comparisons between FBM, SM, and TM did not reach statistical significance. A similar trend was found for the quality measure value sets. Discussion: The optimal method for using the GEMs depends on the relative importance of recall versus precision for a given use case. It appears that for clinically distinct and homogenous conditions, the recall of FBM is sufficient. The performance of all mapping methods was lower for heterogeneous conditions. Since code sets used for phenotype definition and quality measurement can be very similar, there is a possibility of cross-fertilization between the two activities. Conclusion: Different mapping approaches yield different collections of ICD-10-CM codes. All methods require some level of human validation.

Practical Approaches to Diagnosing, Treating and Preventing Hypoglycemia in Diabetes

Hypoglycemia in individuals with diabetes can increase the risk of morbidity and all-cause mortality in this patient group, particularly in the context of cardiovascular impairment, and can significantly decrease the quality of life. Hypoglycemia can present one of the most difficult aspects of diabetes management from both a patient and healthcare provider perspective. Strategies used to reduce the risk of hypoglycemia include individualizing glucose targets, selecting the appropriate medication, modifying diet and lifestyle and applying diabetes technology. Using a patient-centered care approach, the provider should work in partnership with the patient and family to prevent hypoglycemia through evidence-based management of the disease and appropriate education.

A Peer-led Diabetes Education Program in a Homeless Community to Improve Diabetes Knowledge and Empowerment

ABSTRACT Peer-led diabetes education has been shown to be as effective, or more effective, than traditional education in improving glycemic control and diabetes self-care measures. A 4-week peer-led diabetes education program was conducted in a homeless community in Grand Rapids, Michigan to increase diabetes knowledge and empowerment. Knowledge scores increased significantly during sessions covering signs, symptoms, and complications of diabetes and diabetes medications (ps <.05). Empowerment scores after attending the 4-week program were significantly increased when compared to scores prior to the first session (p = .027). Field notes and postimplementation focus group support increased empowerment and knowledge among participants.

Diabetes Self-management Training in a Virtual Environment

Diabetes self-management training (DSMT) improves diabetes health outcomes. However, low numbers of patients receive DSMT. Using virtual environments (VEs) for DSMT is an innovative approach to removing barriers for patients. The purpose of this paper is to describe the experience of health professionals and diabetes educators establishing and teaching DSMT in a VE, Diabetes LIVE© (Learning in Virtual Environments), and the implications for future use of VEs in DSMT. It was found that providing DSMT in a VE preserves real-time interaction between patients and educators. To facilitate ongoing patient learning and engagement, the DSMT curriculum was expanded beyond the core content as “Above and Beyond” topics. Using a VE for DSMT presents challenges and opportunities. Challenges include overcoming technological barriers and improving comfort levels to orient educators and patients to the functionality of the VE. Opportunities include overcoming barriers to reaching patients, particularly given the diabetes epidemic and relatively small number of diabetes educators. Using a VE also affords a simulated community for experiential learning. VEs may become powerful tools for diabetes and other health educators to reach patients. Ongoing education and support are vital to successful self-management of chronic disease.

Caring for women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting reproductive-age women. PCOS causes hyperandrogenism and anovulation and increases the risk of multiple health conditions including infertility, diabetes mellitus, and cardiovascular disease. This article outlines current recommendations for diagnostic testing, treatment options, and holistic care of the woman with PCOS.

Secondary amenorrhea: Diagnostic approach and treatment considerations

Disruptions in the menstrual cycle are a common complaint in primary care and womens health. Irregular or absent menstrual periods should trigger an evaluation to identify the root cause. This article discusses secondary amenorrhea and provides a systematic approach to its diagnostic evaluation, with referral considerations.

Integrating mental health concepts in the care of adults with chronic illnesses: A curricular enhancement

BACKGROUND In the United States, inadequate attention has been given to the mental health needs of chronically ill adults, and the attempts to integrate mental health in primary care have fallen short. METHOD This article describes the beginning efforts of the faculty at Duke University School of Nursing to integrate mental health concepts into its adult-gerontological nurse practitioner and family nurse practitioner curricula. RESULTS Competency and course content mapping activities revealed opportunities for mental health enhancement. Five mental health concepts were identified for module development: spectrum of emotions, validation skills, self-management, resilience, and diversity. Mental health modules will be integrated in the nurse practitioner Physical Assessment and Diagnostic Reasoning course, as well as in various clinical courses. CONCLUSION Challenges and lessons learned, including efforts to foster active interprofessional learning among medical, physician assistant, and nurse practitioner students, are described.