Laurie Ruggiero

Assessing the Value of the Diabetes Educator

Purpose The purpose of this study was to evaluate the effectiveness of diabetes self-management education or training provided by diabetes educators in reducing complications and improving quality of life. Methods Commercial and Medicare payer-derived claims data were used to assess the relationship between DSME/T and cost. Unlike the prior study that examined diabetes education provided by all professionals, the current study focused on the value of interventions performed as part of formal accredited/recognized diabetes education programs provided by diabetes educators only. Specifically, the current study focused on diabetes education delivered in diabetes self-management training programs based on 2 codes (G0108 and G0109). Results Results of the study provide insights into the differences in trends between participants and nonparticipants in DSMT. People with diabetes who had DSMT encounters provided by diabetes educators in accredited/recognized programs are likely to show lower cost patterns when compared with a control group of people with diabetes without DSMT encounters. People with diabetes who have multiple episodes of DSMT are more likely to receive care in accordance with recommended guidelines and to comply with diabetes-related prescription regimens, resulting in lower costs and utilization trends. Conclusions and Policy Implications The collaboration between diabetes educators and patients continues to demonstrate positive clinical quality outcomes and cost savings. This analysis shows that repeated DSMT encounters over time result in a dose-response effect on positive outcomes.

Community-Based Translation of the Diabetes Prevention Program’s Lifestyle Intervention in an Underserved Latino Population

Purpose The objective was to take prevention from the clinic to the community by including a high-risk group and working with the community to tailor, enhance, deliver, and evaluate a community-based version of the Diabetes Prevention Program’s (DPP) clinic-based lifestyle intervention. Methods This was a nonrandomized prospective study using a single-group design. Study eligibility included a screening glucose value in the normal to prediabetes range with no current diagnosis of diabetes, overweight, not pregnant nor planning to become pregnant during study period, aged 18 to 65, Latino, living in the study target communities, and no reported medical restrictions related to the program goals. A total of 69 individuals participated. The Healthy Living Program (HLP) was based on the DPP’s 1-year intensive lifestyle program, was tailored and enhanced for a Latino community, and was delivered by community health workers. Anthropometric and paper and pencil measures were administered to examine program outcome at 6 months and 12 months. Results In general, results indicate statistically significant improvements in anthropometrics and many behavioral outcomes, particularly at 6 months. Participants demonstrated forward movement through the stages of change during the program. Conclusions Results support the effectiveness of the intervention and show that delivery of the translated version of the DPP’s lifestyle intervention in the community by community residents holds promise as one strategy to reach people at increased risk of developing diabetes. Use of this translation model, including collaboration with community health workers, offers diabetes educators an opportunity to extend their reach into underserved communities.

Supporting diabetes self-care in underserved populations: a randomized pilot study using medical assistant coaches.

Purpose The purpose of this study was to evaluate the impact of an innovative intervention that utilized a certified medical assistant with specific diabetes training to work with a multidisciplinary diabetes care team to help provide basic diabetes education and self-care support in low-income minority populations with type 2 diabetes. Methods Enrolled participants were randomized to either the medical assistant coaching (MAC) group (N = 25) or the treatment as usual (TAU) group (N = 25). Deidentified data was obtained on a matched no contact control (NCC) group (N = 50). Results Analysis of covariance (ANCOVA) comparisons revealed no significant differences between the 3 groups on A1C, but a trend was observed. A1Cs decreased across time for the MAC group, while increasing for the TAU and NCC groups. ANCOVA comparisons also indicated that the MAC group experienced significantly greater increases in perceived empowerment and a larger, although non-significant, reduction in perceived diabetes related problems than the TAU group. Conclusions This randomized controlled pilot study suggests that the inclusion of a medical assistant self-care coach as part of the diabetes care team holds promise in improving outcomes and should be further examined in a large-scale study.

Translation of the diabetes prevention program's lifestyle intervention: Role of community health workers

Approximately 8.3% of the US population has diabetes and estimates indicate that 79 million adults have prediabetes and 33.8% are obese, increasing their risk of diabetes. The national Diabetes Prevention Program (DPP) and subsequent translation studies have demonstrated the efficacy of the DPP lifestyle intervention (DPPLI) on lowering weight and reducing risk of type 2 diabetes over 10xa0years. Innovative strategies are needed to translate the DPPLI to reach people at risk of diabetes. Community health workers represent a group of individuals poised to play a role in supporting the translation of the DPPLI, especially in underserved populations. This article aims to 1) describe community health workers in general; 2) describe their role and impact on diabetes care in general; and 3) provide a detailed overview of studies involving community health workers in the translation of the DPPLI.

Longitudinal motivational predictors of dietary self-care and diabetes control in adults with newly diagnosed type 2 diabetes mellitus

OBJECTIVEnThis prospective study examined relationships between constructs from social-cognitive theory (Bandura, 1986) and self-determination theory (Deci & Ryan, 1985; Deci & Ryan, 1991) and the diabetes outcomes of dietary self-care and diabetes control.nnnMETHODnLongitudinal data were collected from 237 people newly diagnosed with Type 2 diabetes who filled in questionnaires on dietary self-care, and motivational factors derived from social-cognitive theory and self-determination theory. Blood samples were taken to assess diabetes control (HbA1c). Repeated measurements were taken every 3-4 months for a total of five time points over 18 months. Predictor measures included autonomy support, autonomous and controlled motivation, amotivation, dietary self-efficacy, positive and negative outcome expectancies for dietary self-care and self-evaluation. Age, sex, BMI, and diabetes knowledge were included as control measures.nnnRESULTSnUsing Generalized Estimating Equations (GEE) analyses two models were tested: a standard model reflecting longitudinal associations between absolute values of predicted and outcome variables; and a change model examining motivational predictors of changes over time in diabetes outcomes of dietary self-care and diabetes control (HbA1c). Dietary self-care was longitudinally associated with self-efficacy, self-evaluation (the strongest predictor) autonomy support and autonomous motivation, but not with controlled motivation or outcome expectancies. Changes in dietary self-care were predicted by changes in self-efficacy, self-evaluation, and controlled motivation but not by changes in autonomous motivation or autonomy support. Negative outcome expectancies regarding diet were longitudinally associated with HbA1c, and changes in negative outcome expectancies predicted changes in HbA1c. However, there were indications that dietary self-care predicted changes in HbA1c.nnnCONCLUSIONSnThe results indicate that autonomy support, self-efficacy and, in particular, self-evaluation are key targets for interventions to improve dietary self-care.

A Pharmacist and Health Promoter Team to Improve Medication Adherence Among Latinos with Diabetes

BACKGROUND There is a need to improve blood glucose levels of underserved Latino patients with uncontrolled diabetes. OBJECTIVE To determine the feasibility of a pharmacist and health promoter team designed to address the barriers to medication adherence and adjustment and improve self-care among Latinos with type 2 diabetes. METHODS Clinical staff at the University of Illinois at Chicago Medical Center referred Latino patients with uncontrolled diabetes (hemoglobin A1c [A1C] ≥8.0%) to the study. A research assistant assessed patients on diabetes and medical history, medication list, medication adherence and related habits, health literacy, diabetes knowledge and numeracy, beliefs in benefits of diabetes therapy, depression, social support, and access to care. A bilingual, bicultural health promoter reviewed these assessments and worked with patients through home and clinic visits and telephone calls. The health promoter communicated with a pharmacist to receive assistance in medication management (reconciliation and adjustment). Participants received case management for 6 months. RESULTS Nine patients were successfully recruited. The mean age was 58 years and mean duration of diabetes was 21 years. Successful collaboration between pharmacists and the health promoter required frequent communication and intense effort to address complex patient barriers. Health promoter contact time, in person, per participant ranged from 0 minutes to 640 minutes, and telephone call time ranged from 27 minutes to 111 minutes during the study period. Eight participants had medication adjustments during the study period, with a maximum of 7 adjustments per participant. Mean hemoglobin A1C declined from an average of 9.6% to 9.0%. Two patients are presented as case studies to describe how the pharmacist-health promoter team functioned. Information was obtained from health promoter records, survey results, and chart reviews. CONCLUSIONS The pharmacist and health promoter team management of uncontrolled diabetes among Latinos appears to be a feasible approach to improving medication management.

Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

Abstract Objective: To assess differences in psychological outcomes as well as risk and protective factors for these outcomes among several USA ethnic groups and identify correlates of these psychological outcomes among adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Research design and methods: The core USA DAWN2 sample was supplemented by independent samples of specific ethnic minority groups, yielding a total of 447 White non-Hispanics, 241 African Americans, 194 Hispanics, and 173 Chinese Americans (nu2009=u20091055). Multivariate analysis examined ethnic differences in psychological outcomes and risk/protective factors (disease, demographic and socioeconomic factors, health status and healthcare access/utilization, subjective burden of diabetes and social support/burden). Separate analyses were performed on each group to determine whether risk/protective factors differed across ethnic groups. Main outcome measures: Psychological outcomes include well-being, quality of life, impact of diabetes on life domains, diabetes distress, and diabetes empowerment. Clinical trial registration: NCT01507116. Results: Ethnic minorities tended to have better psychological outcomes than White non-Hispanics, although their diabetes distress was higher. Levels of most risk and protective factors differed significantly across ethnic groups; adjustment for these factors reduced ethnic group differences in psychological outcomes. Health status and modifiable diabetes-specific risk/protective factors (healthcare access/utilization, subjective diabetes burden, social support/burden) had strong associations with psychological outcomes, especially diabetes distress and empowerment. Numerous interactions between ethnicity and other correlates of psychological outcomes suggest that ethnic groups are differentially sensitive to various risk/protective factors. Potential limitations are the sample sizes and representativeness. Conclusions: Ethnic groups differ in their psychological outcomes. The risk/protective factors for psychological outcomes differ across ethnic groups and different ethnic groups are more/less sensitive to their influence. These findings can aid the development of strategies to overcome the most prominent and influential psychosocial barriers to optimal diabetes care within each ethnic group.

Medical assistant coaching to support diabetes self-care among low-income racial/ethnic minority populations: randomized controlled trial.

Innovative, culturally tailored strategies are needed to extend diabetes education and support efforts in lower-resourced primary care practices serving racial/ethnic minority groups. A randomized controlled trial (RCT) examined the effect of a diabetes self-care coaching intervention delivered by medical assistants and the joint effect of intervention and ethnicity over time. The randomized repeated-measures design included 270 low-income African American and Hispanic/Latino patients with type 2 diabetes. The 1-year clinic- and telephone-based medical assistant coaching intervention was culturally tailored and guided by theoretical frameworks. A1C was obtained, and a self-care measure was completed at baseline, 6 months, and 12 months. Data were analyzed using mixed-effects models with and without adjustment for covariates. There was a significant overall improvement in mean self-care scores across time, but no intervention effect. Results revealed differences in self-care patterns across racial/ethnic subgroups. No differences were found for A1C levels across time or group.

Spiritual and Religious Beliefs and Practices and Social Support’s Relationship to Diabetes Self-Care Activities in African Americans

Purpose The purpose of this study is to investigate the relationship among spiritual and religious beliefs and practices, social support, and diabetes self-care activities in African Americans with type 2 diabetes, hypothesizing that there would be a positive association. Method This cohort study used a cross-sectional design that focused on baseline data from a larger randomized control trial. Diabetes self-care activities (Summary of Diabetes Self-Care Activities) and sociodemographic characteristics were assessed, in addition to spiritual and religious beliefs and practices and social support based on the Systems of Belief Inventory subscales I (beliefs and practices) and II (social support). Results There were 132 participants: most were women, middle-aged, obese, single, high school educated, and not employed. Based on Pearson correlation matrices, there were significant relationships between spiritual and religious beliefs and practices and general diet. Additional significant relationships were found for social support with general diet, specific diet, and foot care. Based on multiple linear regression, social support was a significant predictor for general diet, specific diet, and foot care. Sex was a significant predictor for specific diet, and income was a significant predictor for blood glucose testing. Conclusions The findings of this study highlight the importance of spiritual and religious beliefs and practices and social support in diabetes self-care activities. Future research should focus on determining how providers integrate patients’ beliefs and practices and social support into clinical practice and include those in behavior change interventions.

Diabetes Island: Preliminary Impact of a Virtual World Self-Care Educational Intervention for African Americans With Type 2 Diabetes

Background Diabetes is a serious worldwide public health challenge. The burden of diabetes, including prevalence and risk of complications, is greater for minorities, particularly African Americans. Internet-based immersive virtual worlds offer a unique opportunity to reach large and diverse populations with diabetes for self-management education and support. Objective The objective of the study was to examine the acceptability, usage, and preliminary outcome of a virtual world intervention, Diabetes Island, in low-income African Americans with type 2 diabetes. The main hypotheses were that the intervention would: (1) be perceived as acceptable and useful; and (2) improve diabetes self-care (eg, behaviors and barriers) and self-care related outcomes, including glycemic control (A1C), body mass index (BMI), and psychosocial factors (ie, empowerment and distress) over six months. Methods The evaluation of the intervention impact used a single-group repeated measures design, including three assessment time points: (1) baseline, (2) 3 month (mid intervention), and (3) 6 month (immediate post intervention). Participants were recruited from a university primary care clinic. A total of 41 participants enrolled in the 6 month intervention study. The intervention components included: (1) a study website for communication, feedback, and tracking; and (2) access to an immersive virtual world (Diabetes Island) through Second Life, where a variety of diabetes self-care education activities and resources were available. Outcome measures included A1C, BMI, self-care behaviors, barriers to adherence, eating habits, empowerment, and distress. In addition, acceptability and usage were examined. A series of mixed-effects analyses, with time as a single repeated measures factor, were performed to examine preliminary outcomes. Results The intervention study sample (N=41) characteristics were: (1) mean age of 55 years, (2) 71% (29/41) female, (3) 100% (41/41) African American, and (4) 76% (31/41) reported annual incomes below US