Kurt Naugles, M.D., M.P.H.

Tennessee State UniversityCollege of Health Sciences

Department of Public Health

A CORRELATION STUDY TO DETERMINE THE EFFECT OF

DIABETES SELF-MANAGEMENT ON DIABETES OUTCOMES

Presentation Outline

Part I – Diabetes Mellitus Overview1. What is Diabetes Mellitus2. Why is Diabetes Mellitus a Public Health Concern3. Public Health Medicine’s Response4. Diabetes Self-Management Education

Part II – Capstone Internship5. Capstone Internship Site6. Capstone Internship Goals and Objectives

Part III – Capstone Project7. Capstone Project Rationale8. Capstone Project Goals and Objectives9. Capstone Project Design, Methods, Analysis, and Results10. Discussion

Part IV – Conclusion11. Study Limitations12. Recommendations13. Lessons Learned14. Acknowledgements15. References

Diabetes Mellitus

Diabetes Mellitus (DM) A collection of disease processes

All characterized by hyperglycemia (glucose >126 mg/dl)

Defects in insulin secretion and/or action

Symptoms: Polyuria, Polydipsia, Weight Loss

Two major types: Type-1 & Type-2

Diabetes Type-1

Type-1 Juvenile Diabetes

5-10% of DM cases

Autoimmune disease of the pancreas

Progressive loss of insulin production

Complications -> Acute Diabetic coma

Keto-acidosis

Treatment Requires life-long insulin replacement

Diabetes Type-2

Type-2 Adult Onset Diabetes

90-95% of DM cases

Insulin deficiency or resistance

Complications-> Chronic Effects: Heart, Kidneys, Nerves,

Eyes, & Blood Vessels

Treatment Mild – Diet and Exercise

Moderate – Diet, Exercise, & Oral

Drugs

Severe – Diet, Exercise, Drugs, &

Insulin

Public Health Concern?

Epidemiology Incidence and Prevalence Morbidity and Mortality Cost

Diabetes Incidence & Prevalence

Incidence & Prevalence (U.S.) 26 million Americans ( 8.3% )

3 million new cases (2009-11) – Epidemic?

79 million -> Pre-diabetic

Rise in teenage and adolescent cases

Increased association with Obesity

Disparity in Racial/Ethnic Incidence Rates Native Americans->Blacks->Hispanics->Asians ->Whites

Diabetes Prevalence in the U.S.

Higher Incidence rates

reported in the Southern,

South-Western, and Mid-

Western States

Tennessee ranks among

the top 5 States with

record high incidence

rates

Incidence & Prevalence (U.S.)

Diabetes Morbidity & Mortality

7th leading cause of death

A leading cause of kidney

disease, heart disease, &

stroke

70% of diabetics suffer

from neuropathy

60% of limb amputations

due to diabetes

Morbidity & Mortality (U.S.)

Costs Associated with Diabetes

Cost (U.S.) Second biggest driver of

Health-care cost

$174 billion in direct and

indirect cost

Diabetics spend on

average $6,000 annually

to treat their condition

Public Health Medicine’s Response to Diabetes

Healthy People 2020

“Reduce the disease and economic burden

of diabetes mellitus (DM) and improve the

quality of life for all persons who have, or

are at risk for, DM.”

Public Health Medicine’s Response to Diabetes

Diabetes Self-Management Definition – those activities people undertake in an effort to promote

health, prevent disease, limit illness, and restore well being Rigorous medication compliance

Regular clinical visits

Routine HbA1C testing

Multi-daily blood-glucose self checks

Proper insulin administration

Improved dieting and exercise

Scrupulous foot care

Systematic disease monitoring

Requires Hard work and Perseverance

Education and Training

Diabetes Self-Management Education

Diabetes Self-Management Education(DSME)

DSME was designed by a Diabetes Task Force to establish National Standards for DM self-care

Provides the knowledge and training to perform diabetes self-care tasks.

Primary Objective: Manage “Glycemic Status”

Improve Diabetes Outcome

Recognized by the ADA as an essential part of diabetes care.

Diabetes Self-Management Education

Theoretically Framework

Health Belief Model->Perceived susceptibility, severity, barriers, and benefits

Social Support Model->Emotional, Instrumental, Informational, and Appraisal

Support

Social Cognitive Theory - acquisition of knowledge through observation -> Self-Efficacy – the belief in one’s ability to execute a

course of action

Diabetes Self-Management Education

Diabetes Self-Management Education

There is no one “best” education program or approach; however, DSME programs are guided by a set of core principles.

Patient-Centered

Objective-Oriented

Age-Specific

Lifestyle and Behavior Based

Culturally-Sensitive

Group-Assisted

Why is DSME a good strategy?How can you effectively self-manage a complex

disease without education and training?

Each $1 spent on outpatient diabetes education saves $2 to $3 dollars in hospitalization costs (APhA Foundation 2003 Statistics - JAPhA)

Patients who never received self-management education were 4 times more likely to develop a chronic complication (Nicolucci Study)

Diabetes Self-Management Education

Impact of Diabetes Education

Question:

“Will the relationship (correlation)between Diabetes Self-

Management and Diabetes Outcomes seen in the literature be evidenced in

other patient populations?”

Diabetes Self-Management

INTERNSHIP/CAPSTONE PROJECT SITE

Watts Primary Care

Internship SiteWatts Primary Care (WPC)Private Medical Practice2001 Charlotte Ave. Internal, Family, and Preventive MedicinePhysicians (2)

Dr. Eli Watts - Internal Medicine Certified; Endocrinology Specialist Dr. Kenneth Williams – Family Medicine Certified; Geriatric Specialist

Medical Receptionist (1)Medical Clerk (1)Medical Assistants (3)Affiliations (3)

Baptist Hospital, Centennial Medical Center, and Skyline Medical Center

Watts Primary Care

WPC Mission Statement:

“Our primary mission is to provide excellent health care to the residents of the Greater Nashville community. We believe health first begins by empowering patients with the knowledge, skills, and support needed to live healthy lifestyles. For this, we are committed to providing quality services for the timely assessment of both acute and chronic illnesses with the primary goal of early prevention and effective treatment. Above all, we take pride in considering the whole patient in determining health needs.”

Watts Primary Care

Internship Goals

Gain the knowledge, skills and attitude necessary to assess any patient with a general medical illness;

Demonstrate the ability to develop a specific management plan;

Provide this information to the both the healthcare team and the patient.

Watts Primary Care Internship

Capstone Project

Why WPC for Capstone Project?

Primary Care FacilityEmphasis on Disease Prevention and ManagementSpecializes in Endocrinology and GeriatricsMaintains Electronic Medical RecordsEmploys a Certified Diabetes EducatorOffers DSME ServicesGreat Supporting StaffWonderful Patients

Capstone Project Rationale

Goal: To conduct a correlation study to determine the effect of diabetes self-management on clinical outcomes for diabetic patients served by Watts Primary Care. The administration of DSMA Surveys with WPC patients. The administration of a Demographic & Physiologic Surveys with WPC patients. The assessment of diabetes clinical outcomes among WPC patients.

Study Questions: Is there a significant correlation between diabetes self care (DSMA) and diabetes

outcome (HbA1C levels) in an adult population group currently receiving medical care?

Are any co-variables (demographic characteristics: age, race, gender, education, income; or physiologic characteristics: BMI, duration of diabetes, treatment-type, and diabetic complications) related to diabetes outcome?

  Hypotheses:

There will be a statistically significant correlation between self-care and DM outcome.

There will be a particular set of subject characteristics related to DM outcome.

Project Goals & Objectives

Diabetes Outcome is defined as a clinical interpretation of one’s glycemic status, including one’s risk for diabetic complications (Goldstein et al., 2004). Measured by the Hemoglobin A1C test (<6.5% is Ideal)

Diabetes Self-Management is defined as the performance of a variety of DM self-care activities and skill sets (Toobert & Glasgow, 2000). Measured by the Diabetes Self-Management Activities (DSMA)

survey

Diabetes Outcomes & Self-Management: Operational Definitions

Diabetes Self- Management Activities (DSMA) Survey:

The DSMA is a 12-item questionnaire frequently used to assess the degree of diabetes self-management in the seven days preceding the questionnaire.

Five Sections: dietary habits, exercise routine, self-monitoring of blood glucose (SMBG), foot-care practice, and medication compliance.

Combined Scores: 0 to 77

Glasgow reported internal consistency and reliability through inter-item reliability testing.

Demographic Survey (DS): In-house questionnaire

Demographic characteristics:

Gender, age, income, education, employment status, marital status, medical coverage, and past diabetes self management education.

Physiologic characteristics:

BMI, patient and family DM history, treatment regimen, DM complications, and smoking habits.

Descriptive correlation (observational) study

Independent variables DSMA: Self-Management Demographic and physiological characteristics

Dependent variable HbA1C: DM Outcome

Capstone Project Study Design

WPC adult patients (>18 years old)Type 1 or Type 2 DMVolunteers only: n=148Preclusions

Pregnant women Patients with a mental illness, on steroid or chemo-therapy,

diagnosed with alcoholism, or post-operative.

Project Study Population & Inclusion Criteria

Administration of a Research Packet Consent Form and (2) Questionnaires

After obtaining written and verbal consent, subjects completed the two surveys. DSMA DS

HbA1C values were recorded on DS

Project Methods

Data Analysis: SPSS

Descriptive analysis ->statistical report Demographic and physiological attributes

Nominal variables Frequencies Percentages

Continuous variables Minimum and maximum values Means Standard Deviations (SD)

Project Data Analysis

Data Analysis: SPSS

Mixed-Effect ModelCorrelationTwo methods

The unadjusted univariate method assessed the correlation between the independent variables (DSMA, demographic characteristics, and physiological characteristics) and the dependent variable (HbA1C) with random effect.

The adjusted univariate method assessed the correlation between the independent variable (DSMA) and the dependent variable (HbA1C) with covariates that turned statistically significant in the unadjusted univariate method with random effect.

Random effect was assigned to choice of primary care provider.

Project Data Analysis

Project Results:

Demographic characteristics:

Gender, age, income, education, employment status, marital status, medical coverage, and past diabetes self management education.

Project Results:

Physiologic characteristics:

Patient and family DM history, treatment regimen, DM complications, and smoking habits.

Project Results:

Nominal Variables:

BMI->Mean=32.42

Underweight <18.5 Normal 18.5–24.9 Overweight 25.0–

29.9 Obesity >30.0

HbA1C->Mean=7.91

Normal 4% - 5.6% Risk: 5.7% - 6.4% Diabetes : >6.5%

(National Institutes of Health)

Project Results:

Diabetes Self-Management Activities (DSMA) Statistics:

1. Medication compliance – 6.81

2. General Dietary Habits – 4.88

3. Specific Diet Habits – 4.06

4. Foot Care – 3.86

5. Blood Sugar Testing – 3.12

6. Exercise Routine – 2.33

Project Results:

MEM Statistics:

Question 1:

“Is there a correlation between self care (DSMA) and DM control (HbA1C levels) in an adult population group currently receiving medical care?”

Findings:

There was no statistically significant correlation between any of the DSMA subscales and HbA1C (p<0.05).

Project Results:MEM Statistics:

Question 2:

“Are any co-variables (demographic characteristics: age, gender, marital status, education, employment, income, and health coverage; or physiologic characteristics: DM history, DM family history, DM medication, DM therapy type, DM education, DM complications, smoking history, and BMI) related to DM control (HbA1C levels)?”

Findings:Of the tested co-variables, age, gender, DM complications, DM history, DM therapy type, and BMI demonstrated a statistically significant relationship with HbA1C levels (p<0.05).

DSMA subscales did not demonstrate any statistically significant correlation with HbA1C scores. Does not support the hypothesis that diabetic patients who practice

DM self-care activities present with improved glycemic numbers compared to patients who do not practice such measures.

The co-variables, age, gender, DM therapy type, DM history, DM complications, and BMI did demonstrated a statistically significant relationship with HbA1C levels . Supports the hypothesis that certain demographic/physiologic

characteristics do indeed influence diabetes outcome.

Significance: Reduction in HbA1C values by just 1% has proven to reduce diabetic

complications by as much as 25% (UKPDS, 1998).

Project Results

Although not evidenced here, diabetes self-care activities based on DSME standards still might play an important role in glycemic control and reducing DM complications.

One of the many diabetes-related aims of Healthy People 2020 (HP 2020) is to increase the proportion of individuals receiving formal diabetes health education (USDHHS, 2012).

The current national average is 56.8% of diabetic patients receive diabetes health education and the HP 2020 target is 62.5 % by the year 2020 (USDHHS, 2012).

Project Discussion

Limitations

Observational (versus Experimental Study) Pros – Observational Studies seem to be less affected by Threats to Internal

Validity Maturation Repeated Testing Instrumentality Regression Towards Means Attrition Diffusion

Cons Not Randomized - Volunteers No Control Group No Baseline Self-Reported Surveys (Instrumentation)

Self-efficacy – not measured Social Support – not measured

Project Limitations

Despite this study’s findings, providing patients access to DSME services at WPC has the real potential of improving health outcomes.

Similar clinical models that incorporate DSME could serve as a national model.

WPC should continue offering DSME as part of their current health care services.

Recommendations

Lessons Learned

The impact of Social Determinants of Health can never be overlooked: In this study Economic, Social, Service, and Physical Environment could have played a major underlining role; factors such as Self-Efficacy, Life Course, and Food Deserts need to be considered.

To that point, although a movement towards a National Diabetes Education agenda seems promising, in order to reach HP2020 goals additional studies that investigate the role Social Determinants play in DSME and DM outcomes need to be pursued.

Dr. Eli WattsDr. Kenneth WilliamsWatts Primary Care StaffTSU Department of Public HealthDr. Elizabeth WilliamsDr. Mohamed Kanu

Acknowledgements

Questions

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