Omar Fernandes

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 ≥ …

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),

Using Simulation Technology to Teach Diabetes Care Management Skills to Resident Physicians

85.47 (Method 2), and

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

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.

CC1-01: A Simulated Diabetes Learning Intervention Improves Provider Knowledge and Confidence in Managing Diabetes

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 …

PS1-47: Primary Care Residents Highly Rate Simulated Diabetes Training

Background: Simulation is widely used to teach medical procedures. Our goal was to develop and implement an innovative virtual model to teach resident physicians the cognitive skills of type 1 and type 2 diabetes management. Methods: A diabetes educational activity was developed consisting of (a) a curriculum using 18 explicit virtual cases, (b) a web-based interactive interface, (c) a simulation model to calculate physiologic outcomes of resident actions, and (d) a library of programmed feedback to critique and guide resident actions between virtual encounters. Primary care residents in 10 U.S. residency programs received the educational activity. Satisfaction and changes in knowledge and confidence in managing diabetes were analyzed with mixed quantitative and qualitative methods. Results: Pre- and post-education surveys were completed by 92/142 (65%) of residents. Likert scale (five-point) responses were favorably higher than neutral for general satisfaction (94%), recommending to colleagues (91%), training adequacy (91%), and navigation ease (92%). Finding time to complete cases was difficult for 50% of residents. Mean ratings of knowledge (on a five-point scale) posteducational activity improved by +0.5 (p < .01) for use of all available drug classes, +0.9 (p < .01) for how to start and adjust insulin, +0.8 (p < .01) for interpreting blood glucose values, +0.8 (p < .01) for individualizing treatment goals, and +0.7 (p < .01) for confidence in managing diabetes patients. Conclusions: A virtual diabetes educational activity to teach cognitive skills to manage diabetes to primary care residents was successfully developed, implemented, and well liked. It significantly improved self-assessed knowledge and confidence in diabetes management.

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

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.

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

Background/Aims Provider performance on diabetes measures is variable, and is at least partially due to differences in provider knowledge and confidence in managing patients with diabetes and multiple co-morbidities. Objective To evaluate whether a simulated learning program can improve provider knowledge and self-confidence in diabetes management. Methods 19 primary care residency programs and 341 consented residents were randomized to (a) intervention (177 residents) or (b) control (164 residents) conditions. Intervention subjects were assigned 18 learning cases using SimCare Diabetes, a web-based immersive simulation program that challenges providers to achieve blood sugar, blood pressure, and lipid goals in 6 months of simulated time, as well as to address other issues such as severe obesity and insulin resistance, hypoglycemia, depression, obstructive sleep apnea, and non-adherence. Between simulated encounters with a patient, providers receive personalized feedback on progress to goals and treatment actions taken or omitted. 92 intervention and 128 control subjects completed a post-intervention follow-up online survey with 10 multiple choice knowledge and 5 self-confidence assessment questions using a 5-point Likert scale (1=not at all confident, 5=very confident). Mean (95% CI) knowledge test and self- confidence measures, adjusting for residency program clustering, were compared by group. Results On knowledge testing, 46% of the intervention group answered more than half the answers correctly compared to 16% of the control group. The mean knowledge score (95% CI) was 5.31 (4.87–5.75) for intervention and 4.1 (3.69–4.50) for control subjects (p<.001). Self-confidence measures were higher for intervention compared to control subjects for: use of all available drug classes to manage diabetes (3.64 vs. 3.09, p<.001), insulin use (4.12 vs. 3.36, p<.001), interpretation of blood sugars (4.21 vs. 3.58, p< .001), setting individualized treatment goals (4.06 vs. 3.42, p< .001), and overall confidence in managing diabetes (3.97 vs. 3.28, p< .001). Discussion An immersive online simulated diabetes learning program was effective at improving knowledge and self-confidence for diabetes management in primary care residents. Support and partnerships to maintain and spread the technology are desirable.