Rebecca Wong

Effects of Telephone-Based Peer Support in Patients With Type 2 Diabetes Mellitus Receiving Integrated Care: A Randomized Clinical Trial

IMPORTANCE In type 2 diabetes mellitus (T2DM), team management using protocols with regular feedback improves clinical outcomes, although suboptimal self-management and psychological distress remain significant challenges. OBJECTIVE To investigate if frequent contacts through a telephone-based peer support program (Peer Support, Empowerment, and Remote Communication Linked by Information Technology [PEARL]) would improve cardiometabolic risk and health outcomes by enhancing psychological well-being and self-care in patients receiving integrated care implemented through a web-based multicomponent quality improvement program (JADE [Joint Asia Diabetes Evaluation]). DESIGN, SETTING, AND PARTICIPANTS Between 2009 and 2010, 628 of 2766 Hong Kong Chinese patients with T2DM from 3 publicly funded hospital-based diabetes centers were randomized to the JADE + PEARL (n = 312) or JADE (n = 316) groups, with comprehensive assessment at 0 and 12 months. INTERVENTIONS Thirty-three motivated patients with well-controlled T2DM received 32 hours of training (four 8-hour workshops) to become peer supporters, with 10 patients assigned to each. Peer supporters called their peers at least 12 times, guided by a checklist. MAIN OUTCOMES AND MEASURES Changes in hemoglobin A(1c) (HbA(1c)) level (primary), proportions of patients with attained treatment targets (HbA(1c) <7%; blood pressure <130/80 mm Hg; low-density lipoprotein cholesterol <2.6 mmol/L [to convert to milligrams per deciliter, divide by 0.0256]) (secondary), and other health outcomes at month 12. RESULTS Both groups had similar baseline characteristics (mean [SD] age, 54.7 [9.3] years; 57% men; disease duration, 9.4 [7.7] years; HbA(1c) level, 8.2% [1.6%]; systolic blood pressure, 136 [19] mm Hg; low-density lipoprotein cholesterol level, 2.89 [0.82] mmol/L; 17.4% cardiovascular-renal complications; and 34.9% insulin treated). After a mean (SD) follow-up period of 414 (55) days, 5 patients had died, 144 had at least 1 hospitalization, and 586 had repeated comprehensive assessments. On intention-to-treat analysis, both groups had similar reductions in HbA(1c) (JADE + PEARL, 0.30% [95% CI, 0.12%-0.47%], vs JADE, 0.29% [95% CI, 0.12%-0.47%] [P = .97]) and improvements in treatment targets and psychological-behavioral measures. In the JADE + PEARL group, 90% of patients maintained contacts with their peer supporters, with a median of 20 calls per patient. Most of the discussion items were related to self-management. CONCLUSIONS AND RELEVANCE In patients with T2DM receiving integrated care, peer support did not improve cardiometabolic risks or psychological well-being. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00950716.

Diabetes-Related Distress and Physical and Psychological Health in Chinese Type 2 Diabetic Patients

OBJECTIVE To validate a Chinese version of the Diabetes Distress Scale (CDDS). RESEARCH DESIGN AND METHODS The CDDS was derived using forward-backward translation and administered in 189 Chinese type 2 diabetic patients with evaluation of its psychometric properties. RESULTS On the basis of principal-component analysis, three factors of the 15-item version of the CDDS (CDDS-15) accounted for 63% of the variance. The correlation coefficient between the original 17-item and 15-item scales was 0.99. The Cronbach α for internal consistency was 0.90, and the test-retest reliability coefficient was 0.74. The CDDS-15 score was significantly associated with glycemic control, obesity, depressive symptoms, and quality of life. CONCLUSIONS The CDDS-15 is a valid and reliable instrument to assess diabetes-related distress.

Accuracy, precision and user-acceptability of self blood glucose monitoring machines

The performance of six self-monitoring blood glucose (SMBG) machines (Accutrend, Reflolux S, Companion 2, Glucometer GX, Glucometer IV and One Touch II) were examined using venous blood samples from 88 patients. Whole blood glucose (BG) values were measured by four machines from each brand. Machine-generated whole blood glucose (BG) values were corrected before comparison with laboratory plasma glucose values, measured by a glucose oxidase method. Based on error grid analysis, most of the corrected machine-generated BG values were clinically acceptable. Accutrend, Glucometer IV and Companion 2 showed the greatest consistency between machines of the same brand. Over 80% of corrected BG values generated by Glucometer IV fell within +/-10% of the reference values. One Touch II yielded the most reproducible results with a mean CV of 2.7% and was considered the most user friendly machine. More studies are required to examine the performance of these machines in the hands of patients.

An evaluation of a web-based diabetes education program designed to enhance self-management among patients living with diabetes

Diabetes is a global public health problem. Maintaining optimal glycemic control is critical for minimizing associated long-term complications and achieving better quality of life. Effective diabetes self-management education is one key component to enhance diabetes clients’ self-management capabilities. The research team established a “Caring for Yourself—Managing Your Diabetes” Web site, which contained 35 video clips about diabetes management. The aim of this study was to evaluate user satisfaction with the Web-based diabetes self-management education program. A convenience sample of 100 diabetes clients (mean age, 61.5 [SD, 10.7] years) was invited to view one of the video clips via a laptop computer. A modified version of the Computer-Aided Learning Evaluation Questionnaire and the End-User Computing Satisfaction Questionnaire was used to evaluate participants’ satisfaction with the program. The results indicate that participants were satisfied with the format, content, and accuracy of the Web-based diabetes education program. Some participants suggested adding different types of exercises that are specific to the needs of client groups and more explanation of diabetes medications. The results of this study support the use of computer-assisted learning as a promising method for delivering diabetes self-management education, which is satisfactory to diabetes clients.

The Clinical Utility of SUDOSCAN in Chronic Kidney Disease in Chinese Patients with Type 2 Diabetes

There are gaps between recommendations on regular screening for diabetic kidney disease (DKD) and clinical practice especially in busy and low resource settings. SUDOSCAN (Impeto Medical, Paris, France) is a non-invasive technology for assessing sudomotor function using reverse iontophoresis and chronoamperometry which detects abnormal sweat gland function. Vasculopathy and neuropathy share common risk factors and we hypothesized that SUDOSCAN may be used to detect chronic kidney disease (CKD). Between 2012 and 2013, SUDOSCAN was performed in a consecutive cohort of 2833 Hong Kong Chinese adults with type 2 diabetes. Chronic kidney disease was defined as estimated glomerular filtration rate <60 ml/min/1.73m2. In this cross-sectional cohort (mean age 58.6±9.5 years, 55.7% male, median disease duration 8 [interquartile range 3–14] years), 5.8% had CKD. At a cut-off SUDOSCAN-DKD score of 53, the test had sensitivity of 76.7%, specificity of 63.4% and positive likelihood ratio of 2.1 to detect CKD. The area under receiver operating characteristic curve for CKD was 0.75 (95% confidence interval 0.72–0.79). Patients without CKD but low score had worse risk factors and complications than those with high score. We conclude that SUDOSCAN may be used to detect patients at risk of impaired renal function as part of a screening program in Chinese population, especially in outreach or low resource settings.

Gender, diabetes education, and psychosocial factors are associated with persistent poor glycemic control in patients with type 2 diabetes in the Joint Asia Diabetes Evaluation (JADE) program.

Factors associated with persistent poor glycemic control were explored in patients with type 2 diabetes under the Joint Asia Diabetes Evaluation (JADE) program.

Effects of Providing Peer Support on Diabetes Management in People With Type 2 Diabetes

PURPOSE We examined the effects of participating in a “train-the-trainer” program and being a peer supporter on metabolic and cognitive/psychological/behavioral parameters in Chinese patients with type 2 diabetes. METHODS In response to our invitation, 79 patients with fair glycemic control (HbA1c <8%) agreed to participate in a “train-the-trainer” program to become peer supporters. Of the 59 who completed the program successfully, 33 agreed to be peer supporters (“agreed trainees”) and were each assigned to support 10 patients for 1 year, with a voluntary extension period of 3 additional years, while 26 trainees declined to be supporters (“refused trainees”). A group of 60 patients with fair glycemic control who did not attend the training program and were under usual care were selected as a comparison group. The primary outcome was the change in average HbA1c levels for the 3 groups from baseline to 6 months. RESULTS At 6 months, HbA1c was unchanged in the trainees (at baseline, 7.1 ± 0.3%; at 6 months, 7.1 ± 1.1%) but increased in the comparison group (at baseline, 7.1 ± 0.5%; at 6 months, 7.3 ± 1.1%. P = .02 for between-group comparison). Self-reported self-care activities including diet adherence and foot care improved in the trainees but not the comparison group. After 4 years, HbA1c remained stable among the agreed trainees (at baseline, 7.0 ± 0.2%; at 4 years: 7.2 ± 0.6%), compared with increases in the refused trainees (at baseline, 7.1 ± 0.4%; at 4 years, 7.8 ± 0.8%) and comparison group (at baseline, 7.1 ± 0.5%; at 4 years, 8.1 ± 0.6%. P = .001 for between-group comparison). CONCLUSIONS Patients with diabetes who engaged in providing ongoing peer support to other patients with diabetes improved their self-care while maintaining glycemic control over 4 years.

Health-Related Quality of Life in Chinese Patients with Type 2 Diabetes: An Analysis of the Joint Asia Diabetes Evaluation (JADE) Program

Objective: Diabetes is associated with impaired health-related quality of life (HRQoL) which predicts adverse clinical outcome. To examine clinical factors associated with HRQoL in a cross-sectional cohort of 14,826 Hong Kong Chinese patients with type 2 diabetes receiving outpatient care. Methods: Adult patients with type 2 diabetes who underwent comprehensive assessment of risk factors and complications using the web-based Joint Asia Diabetes Evaluation (JADE) Program also completed the EuroQol-5D (EQ-5D) questionnaire and visual analogue scale (VAS) for evaluation of HRQoL. Multiple linear regression analysis was used to identify clinical correlates with EQ-5D index and the association was expressed using β-coefficient whereby β>0 indicates positive correlation and β<0 indicates negative correlation. Results: More patients reported problems with pain/discomfort (24.8%) and anxiety/depression (20.3%) than other dimensions of mobility (7.1%), self-care (2.2%) and usual activities (4.3%). Age (β=-0.001), female gender (β=- 0.049), obesity (β=-0.007), hypoglycemia at least once monthly (β=-0.04), presence of cardiovascular disease (β=- 0.034), nephropathy (β=-0.014) and sensory neuropathy (β=-0.063) were independently correlated with lower EQ-5D index, while hypertension (β=0.017) and use of insulin (β=0.017) were correlated with higher EQ-5D index (p<0.05). Conclusion: In Hong Kong Chinese patients with type 2 diabetes, somatic and psychological complaints were common. Apart from demographic characteristics, risk factors, complications and treatment all influenced HRQoL.

Depressive Symptoms, Co-Morbidities, and Glycemic Control in Hong Kong Chinese Elderly Patients With Type 2 Diabetes Mellitus

Background and objectives Undiagnosed depression is an important comorbidity in type 2 diabetes (T2D) which can be detected using the Geriatric Depression Scale (GDS-15) questionnaire. In this cross-sectional study, we examined the associations of depression using GDS score with control of cardiometabolic risk factors and health status in elderly patients with T2D. Setting and participants Between February and December 2013, patients aged ≥65 years who underwent structured comprehensive assessment as a quality improvement program at the Diabetes Center of a teaching hospital were invited to complete the GDS-15 questionnaire. Main outcome measures Depression was defined as a GDS score ≥7. Demographic data, prior history of co-morbidities, frequency of self-reported hypoglycemia, and attainment of treatment targets defined as HbA1c, <7%, blood pressure <130/80 mmHg, and LDL-C <2.6 mmol/L were documented. Results Among 325 participants (65% male, median [interquartile range] age: 69 [8] years), 42 (13%) had depression. Patients with depression had longer disease durations (mean ± SD: 15.1 ± 9.1 vs. 11.6 ± 8.1 years, P = 0.02), more frequent self-reported hypoglycemic events (17 vs. 6%, P = 0.03) and were less likely to attain all three treatment targets (0 vs. 16%, P = 0.004) than those without depression. On multivariable analysis, patients with depression had an odds ratio of 2.84 (95% confidence intervals: 1.35–6.00, P = 0.006) of reporting prior history of co-morbidities. Conclusion In elderly patients with T2D, depression was not uncommon especially in those with poor control of risk factors, hypoglycemia, and co-morbidities. Inclusion of GDS-15 questionnaire during structured assessment for complications and risk factors can identify these high-risk patients for more holistic management of their physical and mental health.

Regular mailing of personalized feedback reports improved glycemic control in diabetes – a randomized controlled trial

Background To examine the effects of mailing regular personalized follow-up(FU) reports on metabolic control and hospitalization in patients managed by the Joint Asia Diabetes Evaluation(JADE) Program. Methods: In 2013, 1200 Chinese patients with diabetes (95.8% type 2 diabetes, mean age:58.3 ± 12.6 years, disease duration:10.1 ± 8.2 years, HbA1c: 7.4 ± 1.4%, 35% insulin-treated) underwent comprehensive assessment(CA) with usual clinic FU visits. 600 patients were randomized to receive 2 FU reports(R+) by mail and 600 without(R-). The FU reports showed trends of HbA1c, blood pressure, low-density lipoprotein cholesterol and body weight with recommended targets and reminders on self-care triggered by attained targets. The primary outcome was change in HbA1c and frequency of hospitalization at month 12. Results Both groups had similar baseline HbA1c(R+:7.3 ± 1.45% versus R-:7.4 ± 1.31%, p = 0.362). After 575(519-646) [median (IQR)] days, HbA1c fell by -0.2% (95% CI [-0.27,-0.13], p < 0.001) in the whole cohort, with greater reduction in the R+ (-0.24[-0.35,-0.14]%) than the R- group (-0.15[-0.24, -0.06]%, p = 0.03). Linear regression confirmed independent effect of FU reports on reducing HbA1c (β coefficient: -0.23[-0.39,-0.07], p = 0.004). Fewer patients with chronic kidney disease (CKD) in the R+ group (42.3% versus 69.2%, p = 0.047) had hospitalizations with lower frequency (relative risk [95%CI], 0.50[0.28,0.91], p = 0.021) and shorter length of stay (0.49[0.23,0.94], p = 0.023) than the R- group, after adjustment for confounders including age, gender, diabetes duration, glycemic control, BMI, self-care behaviors, and complications with log-transformed follow up time as offset value. Conclusions Regular personalized feedback reports improved glycemic control in patients with diabetes and reduced hospitalization in those with CKD.