Amy Douglas - Home
Methods to Improve Glucose Control
in Newly Diagnosed Diabetic Type II Patients
Amy Douglas
Auburn University/Auburn University Montgomery
Abstract
Type II diabetes is a disorder characterized by elevated blood glucose levels and impairment of pancreas and liver cells that over time can destroy blood vessels and nerves throughout the body. Self-management of the disease plays a significant role in the patient outcomes and quality of life. New innovative technology methods are being used to teach patients self-management of the disease. The PICO question asks “how well does interactive computer technology compared to written educational materials with lifestyle modifications such as diet, exercise, and medication management improve glucose control?” Diabetes will be explained and the best level of evidence for diabetes education and management of the disease will be explored through a review of literature and critical appraisal of evidence from prior studies, reviews, and trials. Recommendations will guide the intervention to examine the feasibility of using smart phone technology on Type II diabetes self-care and self-management of the disease in a clinical population. Both short term and long terms goals and the small test of change will be addressed in addition to the overall project plan.
Methods to Improve Glucose Control
in Newly Diagnosed Diabetic Type II Patients
Diabetes is a disorder in which blood levels of glucose are abnormally high because the body doesn’t release or use insulin adequately. Approximately 21 million Americans are currently diagnosed with diabetes. According to the Center for Disease Control and Prevention (CDC) there are 3 types of Diabetes: Type I, Type II, and Gestational, with Type II diabetes accounting for 90% to 95% of all diagnosed diabetes. With Type 2 Diabetes, the body either resists the effects of insulin, a hormone that regulates the movement of sugar into the cells, or doesn’t produce enough insulin to maintain a normal glucose level. The incidence of diabetes is increasing at an alarming rate and is currently the sixth leading cause of death in the United States. Type II diabetes is one of the leading causes of kidney failure, non-traumatic lower limb amputations, blindness, heart disease, and strokes (CDC, 2011). Research shows that keeping blood glucose levels as close to normal as possible can delay many of the complications associated with the disease (Evans, 2010).
According to the American Diabetes Association, Type II diabetes is more common is African Americans, Latinos, North Americans, Asian Americans, Native Hawaiians, Pacific Islanders, and older adults. The disease if often associated with obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, and physical inactivity (ADA, 2011). Type II diabetes is often referred to as adult-onset diabetes because it is most commonly diagnosed in adults; however, the disease is increasingly affecting children as childhood obesity increases. Some of the common symptoms of Type II diabetes are increased thirst and frequent urination, increased hunger, weight loss, fatigue, blurred vision, slow-healing sores or frequent infections, and areas of darkened skin (ADA, 2011).
Many people with Type II diabetes can have better control of their glucose levels by following a healthy meal plan and exercise program, losing excess weight, and taking oral medications or insulin. Medications required for patients with Type II diabetes will often change during the course of the disease (ADA, 2011). Patient education is a critical component in management of Type II diabetes. A person diagnosed with Type II diabetes should understand what the disease is, how it affects their body, and how to modify their lifestyle to minimize the effects of the disease. Management of the disease is an interactive, collaborative, ongoing process that the patient and the educator must be tailored for each individual patient. The process involves assessing the individual’s specific educational needs, identifying the individual’s specific diabetes self-management goals, implementing educational and behavioral interventions directed toward helping the individual achieve self-management goals, and evaluating the individual’s attainment of goals (Rivers & Rowell, 2007).
Health care providers should consistently implement evidence-based practice to provide patients with the highest quality of care in order to improve patient health outcomes. The focus of this project is to empower patients to make necessary lifestyle changes to improve glucose control by providing educational information on self-management of Type II Diabetes.
PICO Question
The PICO question, “In newly diagnosed adult patients with type II Diabetes, how well does interactive computer technology compared to written educational materials with lifestyle modifications such as diet, exercise, and medication management improve glucose control?”, was developed to find the best evidence related to the topic. The “P” represents the specific population which is adult diabetic patients who have recently been diagnosed with Type II diabetes and are working with healthcare providers with the common goal of diabetes management. The “I”, or intervention, is interactive computer technology to educate the patient about interventions to implement in the management of their diabetes. This type of education, interactive technologies, such as internet, CD-ROM, or DVDs has become increasingly accessible. Current technology allows for more active involvement by users who can plug information into a computer, telephone, or portable device and receive individually tailored audio or visual feedback. The “C” portion of the PICO question is related to comparison. The comparison is between written educational materials such as handouts that are in easy to understand language with simple illustrations on diabetic education. The “O” in the PICO question represents the outcome. The expected outcome is that lifestyle modifications improve glucose control. The desired outcome measurement is compliance with lifestyle modifications such as diet, exercise, and medication management will improve glucose control. A time frame was not applicable in this case. Each patient has different learning needs and some will require more education than others to reach the desired outcome. Management of Diabetes Type II depends on a complete lifestyle change and requires extensive teaching.
Framework
Evidence based practice gives practitioners and patients access to the most current, valid, and best information to treat and hopefully manage a specific health issue or concern. There are many frameworks which are available to organize EBP processes and approaches. The ACE Star Model was chosen for this project because it allows the use of both old and new concepts in the plan of improving care. The ACE Star Model consists of five stages: Knowledge Research, Evidence Summary, Translation of Evidence into Practice Recommendations, Practice Integration, and Outcome Evaluation (Melnyk & Fineout-Overholt, 2011). In the first stage, new knowledge is discovered through traditional research methods. It allows one to gain a better understanding of the literature review and research that has taken place in the area of education of diabetes and interventions which have been used in the management of the disease. Next, this information is summarized and can be used to help discover the cause and effect relationship. Literature from systematic reviews, clinical practice guidelines, randomized controlled trials, and other pertinent studies are summarized and recommendations are summarized. The third stage involves clinical practice guidelines that can be used to link the best recommendations and the supporting evidence. Reliable and valid recommendations are produced after summaries and clinical expertise is translated. The fourth stage involves changing individual and organizational practices by implementing new teaching techniques for the management of diabetes. The practice recommendations, strategies, and actions are translated into practice. The final stage shows the impact of EBP on patient health outcome. It is in this stage that the patient, healthcare provider and system outcomes are evaluated. The ACE Star model allows the patient and practitioner to organize both old and new concepts of improving care. The ACE Star Model will allow patients to receive current quality improvement processes to manage their diabetes through education of the disease and specific self-management strategies.
Review of Literature
A literature review provides information and evidence related to the topic and allows the researcher to obtain the most current information available. The literature reviewed for this topic is a systematic review, a clinical practice guideline, and randomized controlled trials. All literature was peer reviewed and was chosen from numerous articles available in a large selection of databases. Cochrane, CINAHL, ERIC, MEDLINE, and Academic Search Premier are some of the databases that provided many informative articles on Type II diabetes and management of the disease through lifestyle interventions such as diet and exercise, consistent monitoring of blood glucose levels and a clear understanding of the disease.
Technology-based
A randomized controlled trial was conducted by Dyson, Beatty, & Matthews (2010) to develop a video-based lifestyle education program for newly diagnosed Type II diabetic patients to evaluate changes in knowledge, biomedical indices, and quality of life. The subjects in the study received medical care from their primary care physician, including education about lifestyle management of diabetes. People with chronic diseases, such as diabetes, are open to innovative methods of health education such as picture charts, video techniques, computer packages, text messaging, and emails. Diabetes knowledge was measured by a questionnaire that can be adapted to match particular areas of knowledge. The results showed that a short video intervention concerning lifestyle modifications in the treatment of diabetes management improved diabetes knowledge. Secondary measures included HbAlc, body weight, total cholesterol, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol levels, triglyceride concentrations, quality of life, dietary intake, and physical activity. After 6 months, the intervention group showed increased knowledge compared to the control groups. The intervention group showed improvements in HbAlc, total cholesterol, low-density lipoprotein cholesterol, and increased physical activity. These findings suggest that a short video intervention increased diabetes knowledge and may comprise an effective way of directing patients to positive self-care strategies in the management of their diabetes.
Mobile Health Technologies
A systematic review was completed to assess the effect of mobile phone intervention on glycemic control in diabetes self-management (Liang, Wang, Yang, Cao, Chen, Mo, Huang, Wang, & Gu, 2011). The mobile phone intervention included support for self-monitoring blood glucose levels, medication management, improvements in self-care regarding diet and exercise, monitoring side-effects of treatment, delivering test results, and reminding patients of appointments. The pooled results from the included trials provided strong evidence that mobile phone intervention led to statistically significant improvement in blood glucose levels and self-management in diabetes care, especially for Type II diabetic patients. There was a significantly greater reduction in HbA1c in diabetes patients when comparing the mobile phone intervention group with the control group. Many patients diagnosed with diabetes have difficulty following recommendations for self-management of the disease. Patient outcomes largely depend on the patient’s adherence to changes in diet and exercise. A person with diabetes needs to understand the severity of their disease and simple ways they can minimize the effects of the disease. The current trend in providing health education to patients is through the use of interactive technology. Advance practice nurses must use the best evidence based information in the implementation of techniques in the management of diabetes.
Additionally, Polisena, Tran, Cimon, McGill and Palmer (2009) conducted a systematic review and meta-analysis to assess the potential benefits of home telehealth through the use of home telemonitoring and telephone support. An electronic literature search was conducted to identify studies on diabetic patients who had participated in home telehealth in the management of their diabetes. Using telehealth, individuals were able to communicate live through audio and video conferencing while in their home with a health care provider at a distant location. Twenty six studies, involving 5069 patients, were selected. Twenty-one studies evaluated home telemonitoring and 5 randomized controlled trials assessed telephone support. Home telemonitoring was found to have a positive effect on glycemic control for diabetic patients. The results also showed that home telehealth also had a positive impact on reducing the number of patients hospitalized, the number of hospitalizations, and the bed days of care.
Cell Technology
Another randomized control trial was conducted by Fradi, Liberti, Suval, Northrup, Ali, and Katz (2008) with 15 clients to examine the feasibility of utilizing technology such as internet and cellphones to assist with diabetes self-care in a clinic population as well as its impact on clinical outcomes. Fifteen intervention patients attended a 1 day training workshop and were taught how to use an informative feedback system (NICHE) that uses wireless remote technology to provide tailored feedback and reminders to patients and providers via messages on cellular phones. Interventions and educational information provided included weight, blood pressure, general and specific diet, physical exercise, glucose testing, foot care, and medication management. After a 3 month period, a mean improvement in HbAlc levels was apparent in the intervention group, compared with a mean deterioration in the control. Self-efficacy scores improved significantly in the intervention group compared with no improvement in the control. The results indicated the intervention had a positive impact on clinical outcome and self-efficacy.
Nurse Led
In order to assess the effectiveness of nurse’s education by cellular phone in maintaining glucose levels in Type II diabetic patients, a randomized control trial was conducted by Kim (2007). The interventions, including continuous diabetic education, reinforcement of diet, exercise and medication adjustments, and self-monitoring of glucose levels, was applied for a period 12 weeks. Of the 60 subjects enrolled in the program, 51 subjects participated, for the entire period including 25 intervention participants and 26 in the control group. The intervention participants would send their self-monitored blood glucose levels and drug information into the program’s website once a week. The researcher would view the information and send recommendations back to each patient by a short message service of cellular phone and wire Internet weekly. After the 12 week follow-up examination, HbA1c levels were significantly decreased in the Internet-based system group.
Prior to the 2007 randomized control trial, Kim (2006) and an associate of hers conducted a similar randomized control trial over a 6 month period. In this Level II trial, 25 type II diabetic patients were assigned to an intervention group and 26 to a control group. The trial was conducted to test the effectiveness of a nurse short message diabetic education service in patients with Type II diabetes. Participants were asked to input their blood glucose level, diet and exercise regime into the program’s website daily. Recommendations were sent to the participants on a weekly basis. The 6 months of intervention included continuous education and reinforcement of diet, exercise, medication adjustment and self-monitoring of blood glucose levels. The results showed that there was a significant decrease in HbA1c levels in patients in the intervention group.
Nurse Led
Another randomized control trial was completed by Sacco, Malone, Morrison, Friedman and Wells (2009) to evaluate the effects of brief, regular and proactive telephone intervention on diabetes adherence, glycemic control, and diabetes-related medical symptoms. The 62 participants were equally divided into 31 in the intervention group and 31 in the control group. Twenty-one of the intervention group completed the trial for a 6 month period. The intervention group received one 15 to 20 minute call per week for the first 3 months and one bi-weekly phone call for the remaining 3 months. The coaching information included diabetes self-care, blood glucose testing, medication management, diet/nutrition, physical activity, foot care, stress management, and when relevant, eye exams, dental care, and flu and pneumonia vaccinations. Goal setting and goal attainment were discussed in each phone call. The results showed increased exercise and feet inspection, improved diet, reduced diabetes medical symptoms, and lowered depressive symptoms. The intervention group’s HbA1c levels were significantly lower after the telephone intervention.
Additionally, a quasi-experimental, two-group, pre-test and post-test design was used to evaluate the effectiveness of nurse’s short message diabetic education via cell phones and telephones in patients with Type II diabetes for 3 months. Zolfaghari and others (2012) conducted the study by randomly assigning patients to 2 groups. Eighty patients began the study with 77 completing the study. The two groups were divided as follows: 39 were placed in the telephone follow-up group and 38 in the short message service (SMS) group. Patients in the SMS group received weekly messages related to diet, exercise, medication management, and self-monitoring of blood glucose levels for a period of 12 weeks. The telephone group received 16 phone calls within the 3 month period. The nurse provided counseling to patients on nature of diabetes, risk factors, importance of maintaining blood glucose levels, and reinforcement of diet, exercise, and medication management during each 20 minute phone call. The results showed that both interventions had significant mean changes in glycosylated hemoglobin levels.
Self-tracking
Another randomized control trial by Zyskind, Jones, Pomerantz and Barker (2009) looked at computer based health information resources and their impact on control of diabetes. The 108 participants were divided into the intervention group of 58 and the control group of 50. The intervention group received computer based diabetes education from the Medline- website. There are four diabetes related tutorials on the website that provided information concerning general information about diabetes meal planning/diet and foot and eye care. The outcome of improved health was assessed by evaluating the clinical information routinely collected at patient visits and entered into an internal diabetes registry. At the conclusion of the12 month study period, the research team assessed any differences in the clinical indicators for diabetes control. The results showed a slight decrease in the HbA1c levels.
The review of the literature shows that education plays a key role in the development of self-management skills that lead to improved health care outcomes. Lifestyle modifications such as diet, exercise, foot care, and medication self-management must be implemented to promote positive outcomes with diabetes management. New innovative techniques provide tailored interventions that can be successful in the improvement of self-management behavior. Increasing patient self-efficacy is critical for our healthcare system to achieve goals in the management of the disease through the use of innovative tools that will teach patients the changes they must make in order to improve their health and quality of life.
Appraisal of the Evidence
The article by Liang and others (2011) is a systematic review that provides Level I evidence related to population of newly diagnosed Type II diabetic patients over the age of 18. The article examined the effect of mobile phone intervention on glycemic control in diabetes self-management. The review detected potential publication bias, assessed the quality of included trials, and used statistical methods to calculate missing values. There could be confounding and selection bias such as patients enrolled in the intervention study may be more likely to have positive results because they are motivated because of the new technology. The results showed significant reduction in HbAlc levels.
Likewise, a Level I systematic review and meta-analysis conducted by Polisena and others (2009) offers evidence that telehealth in the form of telemonitoring and telephone support has a positive impact on the number of health services such as hospitalization and days of care as well as glycemic control. Because of the diverse patient populations clinical heterogeneity was present in the review.
Furthermore, a randomized controlled trial by Dyson, Beatty & Matthews (2010) provided Level II information that explores the assessment of lifestyle video education for people who are newly diagnosed with Type II diabetes. The intervention also included an assessment of glycemic control, body weight, and cardiovascular risk factors. The sample size included forty-two newly diagnosed Type II diabetic patients, over age 18. All subjects received usual medical care from their primary care physician, including diabetes management information from a practice nurse. In addition, subjects in the video intervention group received three lifestyle videos and were asked to watch them in their own time. The results show that the video intervention group showed significantly increased knowledge of diabetes compared to the control group and significant reductions in HbAlc levels.
Another study, a randomized control trial by Faridi and others (2008), offers Level II evidence by evaluating the impact of mobile telephone technology on Type II diabetic patient’s self-management. With a sample size of thirty, fifteen patients were randomized to the control group and fifteen to the intervention group. There were improvements noted in HbAlc levels, self-efficacy levels, and clinical outcomes. The sample size was small which might have yielded significant results. Only about 25% of the intervention subjects utilized the intervention technology for 75% of the study. Low adherence was due to a lack of user-friendly interface and inexperience with the technology tools.
Additionally, Kim’s (2007) a Level II randomized control trial, evaluated the impact of a nurse’s short educational message on blood glucose level reduction in patients with Type II diabetes. With a beginning sample size of 60, 51 participants completed the program, 25 in the intervention group and 26 in the control group. The results showed a significant decrease in the HbA1c levels in the intervention group. Although this trial demonstrated the positive results of the nursing educational messages for diabetic patient’s glucose levels, the long term effectiveness is not determined since the trial was for a 12 week period.
In addition, a randomized control Level II trial was conducted by Kim (2006) and an associate with very similar data collection, but was for a period of 6 months. Fifty-one participants were chosen, 25 in the intervention group and 26 in the control group. The nurse’s educational short message was sent to the patients in the intervention group on a weekly basis for a period of 6 months with recommendations determined from information the patient supplied on a daily basis on the program’s website. The results showed a significant decrease in HbA1c levels in the patients in the intervention group. Patients benefited from an individualized approach in which each message was individually tailored. The limitation of this study is that some participants did not input the diet, exercise and adverse data into the website. Five members of the intervention group did not complete the study.
Another Level II randomized control trial completed by Sacco, Malone, Morrison, Friedman and Wells (2009) was developed to evaluate the effects of brief, regular and proactive telephone intervention on diabetes adherence, glycemic control, and diabetes-related medical symptoms. The results yielded increased in exercise and feet inspection, improvements in diet and medical symptoms and a decrease in HbA1c levels. Long term effects were undetermined since the trial only lasted a period of 6 months. Because effects were observed on face-valid self-report methods, positive results could have reflected a response bias.
Likewise Zolfaghari and others (2012) conducted a Level II quasi-experimental, two-group, pre-test and post-test design to evaluate the effectiveness of nurse’s short message diabetic education via cell phones and telephones in patients with Type II diabetes for 3 months. The study randomly assigned patients to 2 groups beginning with 80 patients with 77 completing the study. Patients in the SMS group received weekly messages related to diet, exercise, medication management, and self-monitoring of blood glucose levels for a period of 12 weeks. The telephone group received 16 phone calls within the 3 month period with the same type information. After a period of 3 months, there was significant improvement in HbA1c levels in both groups. There may have been bias in the study based on the self-report of the adherence questionnaire. There is also a question regarding maintenance in the long term results since this was only a short term study.
Additionally a randomized control trial by Zyskind, Jones, Pomerantz and Barker (2009) looked at computer based health information resources and their impact on control of diabetes. The tutorials offered information to increase patient’s general knowledge of diabetes, diet, and foot and eye care. The outcome was assessed by evaluating the clinical information routinely collected at patient’s visits. The results showed a slight decrease in HbAlc levels in the intervention group. Many of the participants were Spanish speaking patients who had limited exposure to computers which may have affected the efficiency of the intervention although there were interpreters present to assist patients.
Review of the evidence in these articles reveals that the use of interactive computer technology, telehealth interventions, and consistent mobile phone messages from health care providers with lifestyle modifications such as diet, exercise, and medication management can be significant factors in improving glucose control. Appraisal of the evidence shows that the importance of Type II diabetic patients being properly educated on diabetes management is very significant in improving HbA1c levels, quality of life, and patient outcomes on a short term and long term basis.
Recommendations
After a review of the literature, the following recommendations have been developed and are listed below with their grade equivalent.
1. Educational diabetes material should be tailored on an individual basis to meet the patient’s needs and must motivate the patient to take an active role in the management of diabetes. (Grade A). (Liang, et al., 2011).
2. Home care is an instrumental part of diabetes management, and home telehealth is an extension of health-care delivery in a patient’s home environment. Home telehealth shows to be clinically effective. (Grade A). (Polisena, 2009).
3. The health care provider can offer innovative technological teaching tools that can aid in the self-management of diabetes. (Grade B). (Dyson, Beatty, & Matthews, 2010).
4. Technological monitoring of dietary and physical activity modifications, weight reduction, and self-monitoring of blood glucose should be a part of the diabetic patient’s daily regime. (Grade B).
(Faridi, et al. 2008).
5. Use of technology in coaching interventions by a health care team can be used to improve diet, exercise, foot care, depressive symptoms, and diabetes medical symptoms in patients. (Grade B). (Sacco, 2009).
6. SMS intervention and telephone follow-up equally improved HbA1c level and adherence to diabetic medication taking, exercising, and taking diet. Patients with diabetes need more frequent contacts with nurses and health providers for managing the disease. (Grade B). (Zolfaghari, 2012).
7. Computer based patient education can be used to positively impact both clinical and behavioral outcomes. (Grade B). (Zyskind, 2009).
Summary
Type II Diabetes is an epidemic that is affecting populations worldwide. Increasing patient self-efficacy is critical for the goals of the management of diabetes. Diabetic education, in whatever form is best for the patient, must be taught on a consistent basis so that the patient has a clear understanding of the material. Nurse practitioners have an important role in ensuring that patients are educated on what diabetes is, how it affects their body, and the significance of interventions to improve quality of life and to ensure positive health care outcomes. Medication adherence, self-monitoring, exercise, diet control, and regular health screenings must be an important part of the diabetic patient’s lifestyle to avoid other serious health complications. Healthcare providers must develop an interactive teaching tool, based on the best evidence that will motivate patients to adhere to the lifestyle changes necessary to the management of diabetes.
Evidence-Based Practice Project Proposal Part II
Clinical Setting Assessment
The clinical setting chosen for this Evidence Based Practice project is the Baptist Health Center for Diabetes located in Montgomery, Alabama. The educational team consists of four educators which includes two registered nurses and two registered dieticians. This educational team provides services for patients with Type I Diabetes, Type II Diabetes, and Gestational Diabetes. The patients spend an entire day in a classroom setting at the clinic from 9:00 a.m. until 5:00 p.m. During this time the patients spend the first half of the day with a registered nurse and the second part of the day with a dietician. The registered nurses teach diabetes disease process and treatment plans and the dieticians teach incorporating nutritional management into their lifestyle.
The primary patient population at this center has Type II Diabetes. Of the 857 patients serviced in this center in 2012, 748 were diagnosed with Type II Diabetes. There were 2 Type II patients who are aged 0 - 18 years old and 748 patients who are over the age of 19. There were 10 patients diagnosed with Type I Diabetes. One of the Type I patients was under the age of 18 years old and 9 were aged 19 and older. The center provided services to 92 women diagnosed with Gestational Diabetes. There were 5 patients diagnosed with Impaired Glucose Tolerance. The patient caseload included 462 Caucasians, 382 African Americans, 6 Asians, and 7 who were Hispanic, Indian, or another race. There was 311 males and 546 females enrolled in the Diabetes management program at this facility. The center provides services to 30 to 50 patients on a weekly basis.
The current practice patterns include providing information to patients related to incorporating nutritional management into lifestyle, importance of physical activity, medication management, monitoring blood glucose and interpreting results, prevention, detection, and treatment of acute and chronic complications, strategies to promote health through changes in behavior, appropriate screenings, and care during pregnancy, if applicable. Patients are also informed of support groups to help them with any psychosocial issues related to the disease. Each patient participates in 30 minutes of individual instruction on learning to use a glucometer and giving insulin injections. The dietician teaches carbohydrate counting and meal planning with the patients. Instruction materials used include a Diabetes education book, exchange list for meal planning, facts on fruits, vegetables, and fast food, sample menus, food model demonstration, alcohol handout, and a book about healthy eating. Patients are also provided with a list of websites concerning Diabetes in their teaching book. Each patient is scheduled a follow-up appointment in 2 weeks. They are instructed to keep a blood sugar log during this time and to set goals for themselves. The patients receive a follow up call in 6 months to determine if their goals have been met. This clinic did use video technology in prior years, but once the material was outdated they did not order updated ones. The contact person prefers written teaching tools and face to face instruction, but agrees that technology teaching material would be beneficial during the follow-up phase for younger age groups. The booklet that the clinic provides to each patient has a list of websites that would be beneficial in providing diabetic education. Online teaching tools and website use would not be cost prohibitive. The project could include a PowerPoint presentation that could run on a continuous basis on the television in the waiting room at the clinic to provide diabetic educational information and lists of websites to use in the management of the disease.
According to the registered nurse interviewed, over half of the patients do not come for the initial follow up and won’t answer calls at the end of the 6 month period. The clinic sends letters and tries to contact patients twice after the 6 month period. The clinic’s goal is to make follow-up contact with 75% of their patient population. There is a concern because over half of the patients do not follow up after their initial educational program is completed. The clinic is not reaching their goal in making follow-up contact with 75% of their population so there is certainly a need for implementation of a program that will encourage participation. The clinic is also not able to determine if their diabetic teaching tools have helped in the management of diabetes due to patients not be compliant in returning for a follow-up visit.
Payment from insurance companies is a barrier in this health care setting. According to the registered nurse, insurance will only pay for the initial visit and one follow up visit. She believes this is one reason half of the patients do not return for their follow up visits. The costs of the additional visits to the clinic and additional lab work would have to be paid for by the patient or either the clinic would have to agree to for the services to be provided pro bono. Another potential barrier may be computer illiteracy or lack of access to a computer or telephone. The clinic is open to new ideas, but their budget does not currently allow purchasing of new teaching technology. New video teaching tools would be an unexpected expense for the clinic. The clinic is willing to provide patient information to allow contact to be made to see if there are any interested participants. The employees at the clinic would be strong facilitators of the project because they appear to be eager to develop ways to improve the health of their patients and to find ways to encourage patients to be compliant.
Participants in the project employed by the same parent company as the clinic would not be required to sign a letter of agreement. Baptist does have an Institutional Review Board who would monitor and review my evidence-based project. Any purchasing of new teaching tools would have to be approved by upper management. A letter to the patients explaining who is guiding the project, what the project concerns, and desired achievements would allow the participants to have a better understanding and perhaps be more willing to participate.
Implementation Plan
After the appraisal of the evidence in the self-management of diabetes, a cost effective intervention was chosen to implement in order to promote diabetes adherence, glycemic control, increased exercise, and improved diet and quality of life. Patient non-compliance is very common at the diabetes organization, Baptist Health Diabetic Clinic. During the clinical assessment employees at the clinic agreed that patients would benefit from interactive technologies and interventions. The clinic’s goal is for 75% of their patients to come for a follow-up evaluation, but often this goal is not reached. Type II diabetes affects millions of Americans and the numbers are expected to continue to increase. The patients who will be participating in the project will be newly diagnosed patients, within the last 12 – 18 months. The project leader is hopeful that by early interventions, the patients will gain knowledge of diabetes and will learn self-management of their disease can be an attainable goal.
The implementation of the project will begin by discussing the project in detail with the employees at the facility. A letter for patients will be developed explaining in detail the purpose of the evidence-based project and what will be done to evaluate the outcome. After the patient agrees to participate in the intervention project and the target population is chosen, the project leader will teach patients at their initial visit about the interactive technology that has been selected. Patients will be able to choose their means of keeping a daily log of their blood glucose levels, either through a website listed in the clinic brochure, application on their Smart phone, or a daily manual log. Baseline weight and blood glucose levels will be documented at this time.
After a period of 6 weeks, the project leader will contact each patient by phone and will review their collected data. Recommendations and modifications to medicine, diet, and exercise will be discussed if positive health changes are not noted. The project manager will contact the patients in intervals of 3 months, 6 months and 12 months to monitor progress. The project manager will maintain the information on an Excel spreadsheet to document the data gathered.
Patient compliance can be a very detrimental barrier to the success of the project. The project manager must make sure that patients have a clear understanding of the disease and that there are self-management tools that must be developed and used that will help improve their quality of life. The project manager is hopeful that the individualized phone contact with patients will encourage their participation and will encourage them to follow the recommendations from the nurses, dieticians and the project manager. Some people may have limited access to computers or smart phones. One of the most important factors that will influence successful implementation is for the patients to see positive results from their changes in behavior which will encourage them to continue to make progress.
Resources to be used will include the diabetic pamphlets that are currently in use at the diabetic clinic, personal cells phones or regular telephones, web sites, computers, and applications for Smart phones. There will be no additional costs to the patients for the interactive technology which will be used for diabetes teaching tools because free applications for Smart phones and free on-line websites will be searched and used.
Outcome/Evaluation Plan
The long term expected outcomes for the project after a period of 12 months are compliance especially with follow-up, glucose control, adherence to daily monitoring of blood glucose levels, medication management, regular exercise, daily feet inspection, and improved quality of life. After a period of 3 months, the short term expected outcomes for the project are improved HbA1c and blood glucose levels, increased exercise regime, improvements in diet, weight loss, increased knowledge of diabetes and diabetic medications, and improvements in self-monitoring of blood glucose. The short term expected outcomes for HbA1c levels are less than 7 and blood glucose levels between 70 and 110. Physical exercise should increase to at least 3 times per week for a period of 45 minutes to an hour each day of exercise. Self-monitoring of blood glucose is expected to improve to before each meal and at bedtime on a daily basis.
Population data perceived as important to collect for the project is age, diagnosis, ethnicity, educational ability, demographic characteristics, health-related characteristics such as smoking and alcohol consumption, willingness to participate and participants’ access to technology devices such as telephone and computer with internet services. Participants should be individuals who have been diagnosed with Type II diabetes within the last 12 months to 18 months and who are patients at the facility where the project will be implemented. The age of patients should be between the ages of 19 years and 65 years old. It is preferred that the patients will be English speaking as the project manager does not speak another language fluently. It is also important that the participants are able to read and understand material on a 6th grade level and above and have access to a telephone and computer with internet service. Diabetic knowledge, diabetic care behavior, and glycemic control are also important pieces of data information that will be important to obtain.
The medical staff at the facility will also encourage patient participation. The project manager will compose a letter to be given to each patient at their initial visit to the clinic explaining the Evidence Based Project in detail and asking for their participation. The method of data collection will begin with an interview where the project will be discussed in detail with the potential participants. The patients’ health history from the Center for Diabetes Health History will be reviewed. The information will be obtained from the form the patient completed when they began treatment at the facility after their initial diagnosis.
Additionally, evaluations will be completed on all participants by obtaining health information at the initial screening to get a baseline for weight, exercise and medication regimes, and HbA1c and blood glucose levels. A diabetes knowledge test will be given to each participate to get a baseline of their knowledge and management of the disease. The Michigan Diabetes Research and Training Center (MDRTC) knowledge test will be used to gather this information. The test has been supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health for use in obtaining a general diabetes knowledge measurement. The test includes 23 items which takes about 15 minutes to complete. The test’s readability was measured to be on a 6th grade level by the Flesch-Kincaid grade level (Fitzgerald, et. al.). This same test will be completed at a 6 month interval and also at the end of the project as a post test to determine knowledge gained.
The outcomes will be tracked by measurements collected from the patients who have agreed to participate in the program. Each patient will turn in a log book of daily blood sugar checks before meals and at bedtime and labs will be drawn to determine the HbA1c levels at 3 months, 6 months, and 12 months. Patients will be monitored through follow-up phone calls after the first 6 weeks by the project manager. Follow up phone calls will be made by the project manager at 3 months, 6 months, and 12 months after the patient’s log books and lab results have been reviewed by the project manager to review their goals and progress. Patients will complete the diabetes knowledge post-test to test their knowledge and management of the disease at 6 months. The information will be turned in to the project leader and will be repeated after 12 months. The information will be added to an excel spreadsheet to track and analyze the data.
Evidence-Based Practice Project Proposal Part III
Small Test of Change
Components of Implementation
The small test of change was implemented at Baptist Health Center for Diabetes and Nutrition Education in Montgomery, Alabama. The project leader met with the staff at the diabetic center to schedule the days the leader would come to the center to meet with potential participants. During the initial meetings with possible participants, a handout was created which explained in detail the purpose of the project and what the participants’ involvement would include. The project leader explained the purpose of the project, data that would be collected, possible health benefits for the participants, and that the project was completely voluntary. The project leader explained that all data collected would be accessible only by the project leader and that the participants could drop out of the project at any time. The project leader informed the participants that they could have consistent telephone and email contact with the leader with any questions at any time during the project implementation. Participants were made aware that the project leader would call them once a week to gather data and to respond to any concerns or questions they may have. All 6 of the potential participants agreed to participate in the project. After consents were signed, the smart phone application, “Diabetes in Check”, was downloaded on each participant’s smart phone and the use of the application was explained in detail to each participant. Participants were assured that they could to choose to stop participation in the project at any time without any repercussions.
Budget
There were no expenses incurred for the participants in the project. The smart phone application that was chosen is a free application for any smart phone subscriber. The project leader printed handouts for potential participants. Ink and paper was used through Baptist Medical Center South and the leader did not have to pay any amount to use the equipment at the hospital.
Sample
Those who agreed to participate in this project were 6 adult patients of Baptist Health Center for Diabetes and Nutrition Education who were diagnosed with Type II Diabetes within the last 6 months and who had access to a smart phone or tablet. The mean age of the participants was 53.7 years with a range of 43 to 64 years of age and included 50% (3) males and 50% (3) females. The group included 17% (1) Caucasian and 83% African American. The majority of the participants’ level of education included high school graduates (66.7%). 16.7% were college graduates, and 16.7% went beyond college such as a master’s or doctorate degree. The most common access to the internet was via smart phone (100%). The most common treatment (66.7%) in the patients was diet alone. 33.3% of the participants managed their blood glucose with oral medications only. None of the participants were currently taking insulin. The average HbA1c level was 8.567 with a range of 6.5 to 12.9.
Tools and Instruments
Participants were selected based on the inclusion criteria of being 19 years of age or older, being diagnosed with Type II Diabetes within the last 6 months, and having access to a Smart phone or tablet. Once the patient met inclusion criteria, consents were signed, baseline information was collected, and the pre-implementation knowledge test was completed by the participant. The knowledge test was comprised of 23 questions based on basic diabetes knowledge. The project leader chose to administer the Michigan Diabetes Research and Training Center’s Brief Diabetes Knowledge Test as the pre-test and post-test. Baseline information obtained included age, gender, ethnicity, weight, highest level of education completed, medication regimes, blood glucose levels, and HbA1c levels. At the initial visit, the Smart phone application, “Diabetes In Check” was installed on each participant’s Smart phone and they were taught in detail how to use the application. This program was chosen because it is a cost effective application that can be accessed on any Smart phone or tablet and is easy to use. This free application offers digital coaching by a certified diabetes educator. It allows one to track blood glucose levels, medications, diet, and exercise. It also provides constructive feedback, reminders, and tips on diabetes management.
The participants then left the clinic and started their IT education and diabetes management. Participants kept a daily log of their blood glucose levels using the smart phone application for the next five weeks and received weekly phone calls from the project leader who offered encouragement and answered any questions. Finally, after the 6 weeks, the participants were again called and the post-implementation data was collected. This included blood glucose levels and body weight. The diabetes knowledge post-test was also completed at this time and emailed to the project leader. This data was then input into an Excel spreadsheet and the SPSS software for analysis.
Goals for the project were a decrease in patient weight, a decrease in blood glucose average, and an increase in patient knowledge scores. Once the data was obtained and reviewed and the post test was completed, it was determined that the results did meet project goals. Paired samples statistics were computed for variables of initial blood glucose to 6-week follow-up blood glucose, initial body weight to 6-week follow-up body weight, and initial knowledge test score to 6-week follow-up knowledge test score. After 6 weeks, there was a drop from the initial mean body weight of 238.83 to the follow-up body weight mean of 230.5. The result was significant with a t score of 4.8 with a p-value of 0.005. There was also a decrease in the mean blood glucose levels from the initial mean of 299.33 to the follow-up blood glucose mean of 113.67. The t-score was 2.4 with a p-value of 0.062, which demonstrates a statistically significant change in blood glucose levels after 6 weeks of intervention. There was also an increase from the initial mean knowledge test score of 57.83 to the follow-up knowledge test score mean of 79.17. This also shows a significant result with a t-score of -7.8 and a p-value of 0.001. These results are illustrated in Figure 1 and Figure 2.
Figure 1. Results with Significant Change.
|Variable | T Score | P Value |
| Weight | 4.8 | 0.005 |
| Blood Glucose | 2.4 | 0.062 |
| Test Score | -7.8 | 0.001 |
Figure 2. Results with Significant Change.
Timeline
The timeline for the small test of change was six weeks. The project began on February 5, 2014 when the project leader met with potential participants. Information about the project in the form of a handout from the project leader was developed for the potential participants. Only 2 patients were recruited on the date the project began. Ms. Green, office manager at the clinic, informed the leader that patient caseload had been very low lately due to insurance changes and the leader agreed to come back the following week to interview more patients. Four additional patients agreed to participate the following week. Participants began using the smart phone application the day they agreed to participate. The project leader began making weekly phone calls to participants to monitor their progress and to be available to answer any questions they had. During week 2 the project leader developed a code book and began input of pre-implementation information from demographic sheet such as age, gender, highest level of education, ethnicity, baseline medication regimes, weight, HbA1c levels, blood glucose levels, and scores from diabetes knowledge pre-test. Participants recorded a daily log of their blood glucose levels. Participants were called by the project leader on a weekly basis. At the end of week 6, the data was collected and entered on a spreadsheet. The data was then analyzed using the statistical software program, SPSS. The leader developed a poster based on the information obtained to present to the clinic, faculty, staff, and classmates. No adaptations were needed during the small test of change.
Application to Overall Project
The results from the small test of change (STOC) showed exciting and encouraging results related to the EBP project. The results indicate that the smart phone application, “Diabetes in Check”, has potential to be a positive alternative to improving diabetic knowledge and self-care tips to patients. The assessment tool offered diabetes educational material that appeared to improve patient’s knowledge of self-care tools, a better understanding of the disease, and steps that can be followed to lead to improvements in HbAlc levels. The knowledge post-test showed improvements in diabetes knowledge at the end of 6 weeks for all 6 participants. If patients would adhere to use of the smart phone application in their daily diabetic self-care on a long term basis, self-management of the disease is expected to continue. It is hopeful that the significant improvements in weight, blood glucose levels, and diabetic knowledge documented in the STOC will encourage patients to continue using the smart phone application which is easily accessed and is cost effective. The use of a take-home PowerPoint presentation for patients that would emphasize the importance of follow-up would be beneficial to encourage adherence to self-care and self-management of diabetes. Long term assessments and expansion of this project should be implemented to determine long term effects of the intervention on HbAlc levels. The smart phone application should be implemented into practice at the diabetes clinic for smart phone subscribers. This small test of change does not require a large amount of preparedness for staff members. The application is cost effective and easy to understand and use and showed promising results in only 6 weeks. The project leader believes that continued implementation would be beneficial for diabetic patients.
Conclusion
Health care providers are responsible for providing the best quality of care available for patients. Diabetes is a disease that affects millions of people and is increasing at an alarming rate. It is currently listed as the sixth leading cause of death in the United States and often leads to many other health problems such as amputations, blindness, kidney disease, strokes, and other life altering health issues. As an advanced practical nurse there will likely be opportunities to care for patients with diabetes and to find better interventions that will warrant positive results that cost less. This EPB project has afforded the project leader with the knowledge of the importance of having a clear understanding of the EPB process and the significance of a small test of change. The project leader gained significant knowledge related to what can be accomplished through an EBP project in finding new innovative tools to improve health care for all patients. Positive results in the STOC showed the significance of completing the project and it is hopeful that the participants will continue to improve their self-care and self-management of the disease. Participation in the EBP project has assured the project leader that the intervention and STOC was successful and the project leader looks forward to implementing further projects in the future as a health care provider in the clinical setting.
References
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Dyson, P., Beatty, S., & Matthews, D. (2010). An assessment of lifestyle video education for people newly diagnosed with type 2 diabetes. Journal of Human Nutrition and Dietetics, 23(4), 353-359. doi: 10.1111/j.1365-277X.2010.01
Evans, M. (2010). Evidence-based practice protocol to improve glucose control in individuals with type 2 diabetes mellitus. MEDSURG Nursing, 19(6), 317-322. Retrieved July 20, 2013 from
Faridi, Z., Liberti, L., Shuval, K., Ali, A., & Katz, D. (2008). Evaluating the impact of mobile telephone technology on type 2 diabetic patients’ self-management: The niche pilot study. Journal of Evaluation in Clinical Practice, 14(3), 465-469. doi: 10.1111/j.13652753.2007.00881.x
Fitzgerald, J., Funnell, M., Hess, G., Barr, P., Anderson, R., Hiss, R. & Davis, W. (1998). The
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Liang, X., Wang, Q., Yang, X., Cao, J., Chen, J., Mo, X., Huang, J., Wang, L., & Gu, D. (2011). Effect of mobile phone intervention for diabetes on glycemic control: A meta-analysis. Diabetic Medicine, 28(4), 455-463. doi: 10.1111/j.1464-5491.2010.03180.x
Melnyk, B. M. & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare (2nd ed.). China: Lippincott Williams & Wilkins
Polisena, J., Tran, K., Cimon, K., Hutton, B., McGill, B. & Palmer, K. (2009). Home telehealth
for diabetes management: A systematic review and meta-analysis. Diabetes, Obesity &
Metabolism, 11(10), 913-930. doi: 10.1111/j.1463-1326.2009.01057.x
Qaseem, A., Humphrey, L., Sweet, D., Starkey, M., & Shekelle, P. (2012). Oral pharmacologic treatment of type 2 diabetes mellitus: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 156(3), 218-226. Retrieved from the CINAHL database on July 15, 2013.
Rivers, D. & Rowell, K. (2007). Self-management education among African Americans with type 2 diabetes: A literature review. The Health Education Monograph Series, 24(2),
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Appendix
Evidence Review Grid
|Evidence Grid: |
|Article citation in APA format |Purpose of study/research questions |Research elements: |Major findings relevant to project |Critique of validity, bias and |
|(10 points) |(15 points) |- Design |(20 points) |significance for your project |
| | |- Sampling method | |(25 points) |
|Level of evidence | |- sample size | | |
| | |- Brief description of interventions | | |
| | |(if any) | | |
| | |- outcomes measured | | |
| | |(30 points) | | |
|Liang, X., Wang, Q., Yang, X., |The purpose of this study is to |-Design: Systematic Review and |The pooled results from the included trials |-Strengths: |
|Cao, J., Chen, J., Mo, X., |assess the effect of mobile phone |meta-analysis |provided strong evidence that mobile phone |Review detected potential publication |
|Huang, J., Wang, L., & Gu, D. |intervention on glycemic control in |-Sample method: Review of literature |intervention led to statistically significant|bias, assessed the quality of included |
|(2011). Effect of mobile phone |diabetes self-management. |was done including: |improvement in blood glucose control and |trials, and used statistical methods to |
|intervention for diabetes on | |Electronic databases including PubMed, |self-management in diabetes care, especially |calculate missing values. |
|glycemic control: A | |EMBASE, and Cochrane Library |for Type II diabetic patients. There was a |-Weaknesses: |
|meta-analysis. Diabetic | |Search terms: diabetes, diabetes |significantly greater reduction in HbA1c in |-Important confounding and selection |
|Medicine, 28(4), 455-463. | |mellitus, mobile phone, cellular phone,|diabetes patients when comparing the mobile |bias may remain in the original studies-|
|doi:10.1111/j.1464-5491.2010.031| |and text message |phone intervention group with the control |patients enrolled in a mobile phone |
|80.x | |Search was restricted to English |group. Subgroup analysis demonstrated that |intervention study may be more |
| | |language articles published between |mobile phone intervention had a statistically|motivated. |
|LOE: Level I | |January 1990 and February 2010. |greater effect for patients with Type II |-Smaller studies reported greater |
| | |-Sample size: The literature search |diabetes than patients with Type I diabetes. |reduction in HbA1c values than larger |
| | |identified 200 published original | |studies which possibly reflected |
| | |articles, 22 of which met inclusion | |publication bias. |
| | |criteria. 1657 patients were included | |-There is no gold standard of |
| | |for analysis. | |calculating the missing standard |
| | |-Description of interventions: 9 | |deviation, and therefore random errors |
| | |studies examined patients with Type I | |may exist. |
| | |diabetes, 10 studies examined patients | |-This intervention may not be suitable |
| | |with Type II diabetes, 2 studies | |for all patients with diabetes. Some |
| | |examined patients with either Type I or| |patients may have difficulty operating a|
| | |Type II, and 1 study did not specify | |cell phone on a regular basis or do not |
| | |the type of diabetes. Four studies were| |have a computer or Internet access. |
| | |done in tertiary hospitals and the | |-Significance for project: |
| | |others were done in a primary care | |This information is relevant to the aim |
| | |setting. | |of the interventions in the PICO |
| | |Mode of mobile phone intervention | |question. Educational diabetes material |
| | |varied among the 22 included trials. | |should be tailored on an individual |
| | |12 studies used both SMS and Internet | |basis to meet the patient’s needs and |
| | |to initiate the intervention and | |must motivate the patient to take an |
| | |provided support for self-monitoring | |active role in the management of |
| | |blood glucose, continuous education, | |diabetes. |
| | |reinforcement of diet, exercise, and | | |
| | |medication adjustment. | | |
| | |8 studies adopted a short message | | |
| | |service alone, or SMS or SMS combined | | |
| | |with other intervention strategies, | | |
| | |which included transmitting | | |
| | |self-monitored blood glucose to mobile | | |
| | |phone via a Bluetooth wireless link. | | |
| | |2 studies compared the effect of mobile| | |
| | |phone intervention with Internet based | | |
| | |care in the intervention group and | | |
| | |control group, respectively. | | |
| | |1 study combined mobile phone with | | |
| | |clinical visits that consisted of | | |
| | |clinical advice and structured | | |
| | |counselling from a diabetes specialist | | |
| | |nurse. | | |
| | |-Outcomes measured: The primary outcome| | |
| | |measure was HbA1c value from | | |
| | |pre-intervention to post-intervention, | | |
| | |comparing the intervention group with | | |
| | |the control group. | | |
|Polisena, J., Tran, K., Cimon, |The research objective was to |-Design: Systematic Review and |HTM had a positive effect on glycemic control|-Critique of validity: The quality of |
|K., Hutton, B., McGill, S., & |systematically review the literature |Meta-analysis |[as measured by lower glycated hemoglobin |the studies ranged from very high (6 |
|Palmer, K. (2009). Home |and perform meta-analyses to assess |-Sample method: An electronic |level] compared with UC (weighted mean |RCTs) to very low (2 observational |
|telehealth for diabetes |the potential benefits of home |literature search was conducted to |difference = -0.21; 95% |studies). |
|management: A systematic review |telehealth compared with usual care |identify studies on home telehealth and|confidence interval -0.35 to -0.08), but the|-Bias: A diverse patient population may |
|and meta-analysis. Diabetes, |(UC) for patients with diabetes. |patients with diabetes that were |results were mixed for TS. Study results |have affected the results because some |
|Obesity & Metabolism, 11(10), | |published between 1998 and 2008 using |indicated that home telehealth helps to |studies did not report the diabetes type|
|913-930. doi: | |Medline, Medline In-Process & Other |reduce the number of patients hospitalized, |and included patients with type 1 or |
|10.1111/j.1463-1326.2009.01057.x| |Non-Indexed |hospitalizations and bed days of care. Home |type 2 diabetes or both. |
|. | |Citations, BIOSIS Previews, EMBASE, |telehealth was similar or favorable to UC |-Weaknesses: The number of studies and |
|LOE: Level I | |CINAHL, and PsycINFO. Parallel searches|across studies for quality-of-life and |their sample sizes were low for a number|
| | |were run in PubMed, Cochrane Library |patient satisfaction outcomes. |of outcomes measured, and some studies |
| | |and Centre for Reviews and |In general, home telehealth had a positive |failed to report the measures of |
| | |Dissemination databases. |impact on the use of numerous health services|variation for several continuous |
| | |-Sample size: Twenty-six studies (n= |and glycemic control. More studies of higher |outcomes. More studies of higher quality|
| | |5069 patients) on home telehealth for |methodological quality are required to give |are required to give more precise |
| | |diabetes were selected. Twenty-one |more precise insights into the potential |insights. Patients with cognitive |
| | |studies evaluated home telemonitoring |clinical effectiveness of home telehealth |impairment, mental illness, a language |
| | |and 5 randomized controlled trials |interventions. |barrier, no telephone line, or computer |
| | |assessed telephone support. | |to transmit data or a life expectancy of|
| | |-Description of interventions: The | |less than 1 year were excluded from most|
| | |search concepts used were: home AND | |studies, so the generalizability of |
| | |telehealth. The full search strategy | |their findings may be limited. Studies |
| | |included controlled vocabulary | |should include more diverse patient |
| | |customized for each database plus | |poulations to increase the external |
| | |selected brand names and other keywords| |validity of their outcomes. It was also |
| | |to capture the concept of and | |unclear in several studies what clinical|
| | |techniques of home telehealth. The | |services were delivered by the home |
| | |concept of telehealth included keywords| |telehealth interventions. |
| | |for telemedicine, telecare, | |-Significance for project: This |
| | |telemonitoring, teleconferencing, and | |information is relevant to the aim of |
| | |e-health. Results with diabetes, | |the interventions in the PICO question. |
| | |non-insulin-dependent diabetes mellitus| |This review demonstrated that home |
| | |or insulin-dependent diabetes mellitus | |telehealth is generally clinically |
| | |mentioned in the title, abstract, or | |effective and shows great potential. |
| | |subject heading were flagged. | | |
| | |-Outcomes measured: glycemic control | | |
| | |using HgA1C and number of | | |
| | |hospitalizations | | |
|Dyson, P., Beatty, S., & |The purpose is to develop a |-Design: Randomized controlled trial |At 6 months, the intervention group showed |There was a lack of difference between |
|Matthews, D.R. (2010). An |video-based lifestyle education |-Sample method: Newly diagnosed type 2 |increased knowledge compared to controls. |the control and the intervention group |
|assessment of lifestyle video |programme for people newly diagnosed |diabetic subjects were recruited and |Although there were no significant |in terms of biomedical indices and |
|education for people newly |with type 2 diabetes and to evaluate |randomly allocated to either a video |differences in changes over 6 months between |quality of life. This could be due to |
|diagnosed with type 2 diabetes. |changes in knowledge, biomedical |education or control group |the two groups, the intervention group showed|the sample size being too small. Second,|
|Journal of Human Nutrition and |indices, and quality of life. |-Sample size: 42 |improvements in A1c, total cholesterol, |it is likely that both the control group|
|Dietetics, 23(4), 353-359. | |-Description of interventions: All |low-density lipoprotein cholesterol, and |and the intervention group received more|
|Doi:10.1111/j.1365-277X.2010.010| |subjects in the study received usual |increased physical activity measured by |intensive treatment than they otherwise |
|77.x | |medical care from their primary care |pedometer from baseline, with no significant |might have obtained before introduction |
| | |physician, including education about |changes in the control group. These findings |of QOFs, and this may have obscured any |
|LOE: Level II | |lifestyle management of type 2 |suggest that a short video intervention |differences between the groups. Third, |
| | |diabetes. Subjects that were randomized|increased diabetes knowledge amongst those |most studies have shown that any |
| | |to the video intervention received |newly diagnosed with type 2 diabetes and may |intervention at diagnosis of type 2 |
| | |three lifestyle videos and were told to|comprise an effective way of directing |diabetes appears to be effective and |
| | |watch them in their own time. The |education to such individuals. |that maybe 6 months is too soon for any |
| | |subjects in the control group received | |benefit of the education to show. |
| | |usual care, including education from a | |-Strengths: Strong design with moderate |
| | |practice nurse and were offered the | |sample size and innovative method. |
| | |videos at the end of the 6 month study | |-Significance for project: |
| | |period. | |This trial shows that diabetic |
| | |-Outcomes measured: The primary outcome| |education, in any form, is needed to |
| | |measure was the change in diabetes | |help patients reach their goals of |
| | |knowledge. This was measured by the | |managing their diabetes. The material in|
| | |ADKnowl questionnaire. General | |this article is relevant to the PICO |
| | |questions about diabetes were included | |question by exploring the effects of |
| | |together with specific questions about | |innovation technology in education of |
| | |diet, physical activity, and alcohol. | |diabetes. The health care provider can |
| | |Secondary measures included HbA1c, body| |offer innovative technological teaching |
| | |weight, total cholesterol, high-density| |tools that can aid in the |
| | |lipoprotein cholesterol and low-density| |self-management of diabetes. |
| | |lipoprotein cholesterol levels, | | |
| | |triglyceride concentrations, quality of| | |
| | |life, dietary intake, and physical | | |
| | |activity. All assessments were | | |
| | |undertaken at baseline and 6 months | | |
| | |after intervention. | | |
|Faridi, Z., Liberti, L., Shuval, |The primary purpose of |-Design: Randomized control trial |A mean improvement in HbA1c levels was |Small sample size; a larger sample size |
|K., Northrup, V., Ali, A., & Katz,|this study is to examine |-Sample method: Patients with a diagnosis of type |apparent in the intervention group, compared |might have yielded significant results. |
|D. (2008). Evaluating the impact |the feasibility of |2 diabetes at two Community Health Centers were |with a mean deterioration in the control. |Most subjects did not adhere to the |
|of mobile telephone technology on |utilizing technology such|randomized to intervention or control. |Self-efficacy scores improved significantly |intervention. Only about 25% of |
|type 2 diabetic patients’ |as Internet and |-Sample size: 30 |in the intervention group compared with no |intervention subjects utilized it for at|
|self-management: The niche pilot |cellphones to assist with|-Description of interventions: |improvement in the control. Participants |least 75% of the study duration. Low |
|study. Journal of Evaluation in |diabetes self-care in a |15 intervention patients attended a 1-day training|encountered numerous technological barriers |adherence was due to a lack of |
|Clinical Practice, 14(3), 465-469.|clinic population as well|workshop and were taught how to utilize NICHE |when attempting to adhere to the intervention|user-friendly interface and inexperience|
|Doi:10.1111/j.1365-2753.2007.00881|as its impact on clinical|technology for type 2 diabetes management. The |protocol. The results indicate the |with pedometers and mobile phone use. A |
|.x |outcomes. |technology is an interactive informational |intervention had a positive impact on some |longer duration of the intervention is |
| | |feedback system that uses wireless remote |clinical outcome and self-efficacy. |needed but only after the technology is |
|LOE: Level II | |technology to provide tailored feedback and | |upgraded, improved, and simplified. |
| | |reminders to patients and providers via messages | |-Strengths: Strong design with |
| | |on cellular phones. After the training, the | |innovative method. Study provided |
| | |intervention patients participated in a 3 month | |tailored information and interventions |
| | |intervention and were required to test their | |to promote self-care. |
| | |glucose once daily and wear their pedometers | |-Significance for project: |
| | |during the day. They were required to upload data | |The information obtained was relevant to|
| | |onto the NICHE server once a day. Control subjects| |the developed PICO question because half|
| | |continued with standard diabetes self-management | |of the participants used innovative |
| | |and tracked their step count using a pedometer. | |technology to increase their knowledge |
| | |-Outcomes measured: Feasibility was assessed as | |of diabetes. The intervention group |
| | |utilization of the system by community health | |received tailored daily messages via |
| | |center patients and consistent use of the system | |cell phone encouraging them to improve |
| | |by patients over the 3 month period. This was | |their diabetic self-management. Dietary |
| | |measured by mining the data collected by the NICHE| |and physical activity modifications, |
| | |server to obtain information. Post intervention | |weight reduction, and self-monitoring of|
| | |focus groups were held to illuminate barriers when| |blood glucose should be a part of the |
| | |utilizing the technology. Utility was assessed pre| |diabetic patient’s daily regime. |
| | |and post-intervention in clinical measures: HbA1c,| | |
| | |trend analysis of glucometer readings between | | |
| | |groups, and BMI. | | |
|Kim, H. (2007). Impact of |The purpose of this study|-Design: Randomized control trial |Patients with a baseline-glycosylated |-Weaknesses: Small sample size. |
|web-based nurse’s education on |was to evaluate whether |-Sample method: Participants were randomized by |hemoglobin or |-Significance for project: The |
| |hemoglobin at baseline |HbA1c > or =7.0% and a baseline HbA1c ................
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