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Hui-Chun HsuPhD, RN, CDEChief, Department of Diabetes ManagementLee’s Endocrinology ClinicPingtung, Taiwan

Disclosure to ParticipantsConflict of Interest (COI) and Financial Relationship Disclosures:

Presenter: Hui-Chun Hsu, PhD, RD, CDE – No COI/Financial Relationship to disclose

Development of A Simplified Self-Reported “Diabetic-Behavior Scoreboard” as a Promising

Assessment Tool to Key Diabetic Behavior

Hsu H-C1, An L-W2, Lee Y-J, Wang R-H3

1Department of Internal Medicine, Lee’s Endocrinology Clinic, Pingtung, 90000 Taiwan2Department of Medical Education, Beijing Ruijing Diabetes Hospital, Beijing 100078, China3Department of Nursing, School of Nursing, Kaohsiung Medical University, Kaohsiung, 80317, Taiwan

Diabetes Self- Management Education & Support, (DSME/S )

DSME/S is a complex and ongoing process Provide patients the knowledge and skill training Identifying the barriers Facilitate the problem-solving and coping skills It is effective at enhancing self-care

behaviors and improving glycemic control.62016/6/10

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Assessment of DSME/S related behavior & risk factors

• The initial step for education, training & support.

• Provide subjective evidence to identify the problem/diagnosis and key etiology that could be modified by intervention procedure.

Diabetic BehaviorHypoglycemia awareness & management skillHealthy eating Taking medication Being active Self -monitoring of blood glucose (SMBG) Psychological stress problemQuality of life

Aim-(I)1. To construct a self-reported

diabetes-related behavior dashboard for daily clinical

practice

Diabetes Information & Management System

Diabetes Self-Management Behavior Assessment

Client History Medication History Physical & Laboratory Exam.

Hypoglycemia AssessmentOption

Behavior Evaluation Risk Factor & Complication Assessment

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Assessment of Diabetes Self Management Behavior

• 1st priority- Hypoglycemia awareness and skill of management

• Simple, accurate, quantifiable scale with reasonable reproducibility and precision

Hypoglycemia Assessment

Hyperglycemia AssessmentOption Option

Sick day management Skill

Scoring

Health Eating

Being Active

Taking Medicine

SMBG

Scoring

PAID-Chinese SF

Hsu HC, et al. J Nurs Res. 2013 Sep;21(3):212-8.

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Hsu HC, et al. J Nurs Res. 2013 Sep;21(3):212-8. Hsu HC, et al. J Nurs Res. 2013 Sep;21(3):212-8.

ScoringWHO 5 well-being index-Chinese WHO 5 well-being index Chinese

WHO 5 well-being index ChineseOptionPSQI

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OptionPSQI

Risk Factor & Complication Assessment

Hypoglycemia AssessmentOption

Behavior Evaluation Risk Factor & Complication Assessment

AssessmentDiagnosis/Problem

Intervention Re-Evaluation

Diabetes Self-Management Behavior Assessment Dashboard

• Validity test:• Two professors of nursing, four endocrinologists, four

certified diabetic educators, three Nutritionists and two diabetic patients were invited to assess the content validity.

Results:• Content validity index (CVI) :0.866~1.0• The process of inter-rater reliability assessment to :

0.816-0.965• The test-retest reliability of intra-class correlation

coefficient : 0.752

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Operating Time• 80% (n=8) of CDEs agreed “Diabetic-

Behavior Scoreboard” is easy to assess diabetes behaviors.

• The mean of operating time was12.8 ±6.9 minutes per patients with type 2 diabetes

Aim- (II)Clinical Application

• Patients: From August 2012 to August 2013 at, a total of 3,404 patients with type 2 diabetes mellitus were enrolled into in a specialized diabetic polyclinic.

Subjects• The exclusive criteria were age of ≤18 years or >80

years, being pregnant, having cognitive disabilities (dementia, mental retardation), or having a history of cerebrovascular disease.

• Patients were followed-up in the program for at least for 2 years were included in this clinical observational study.

Subjects• a comprehensive diabetic care program under the

ADA diabetic practice guidelines covered by the National Health Insurance system

• In this comprehensive diabetic care program, patients were requested to return to the clinic every 3 months.

Variable Baseline (N=3,404) 12-Month follow-up (N=3,404)

Difference betweenbaseline and follow-up

Range Mean (SD) Range Mean (SD) tWaist (cm) 52.8-140.0 90.2(10.4) 55.0-144.0 90.5(10.3) 2.7 (p=0.006)Waist-to-hip ratio 0.7-1.3 0.9(0.1) 0.7-1.2 0.9(0.1) 2.3 (p=0.023)Body mass index (kg/m2) 11.0-66.6 26.7(4.3) 12.8-66.6 26.6(4.3) -4.2 (p<.0001)SBP (mmHg) 70-205 135(18) 74-208 134(19) -2.8 (p=0.005)DBP (mmHg) 41-147 77(13) 36-159 76.2(12.3) -4.7 (p<.0001)Fasting sugar (mg/dl) 56-600 146.7(51.7) 50.0-519.0 146.7(47.8) -0.0 (p=0.994)HBA1C (%) 4.1-16.5 7.6(1.4) 4.1-16.3 7.5(1.4) -5.0 (p<.0001)T-cholesterol (mg/dl) 107.0-469.0 187.0(34.7) 70.0-504.0 178.0(33.1) -13.7 (p<.0001)Triglyceride (mg/dl) 30.0-3855.0 128.6(117.2) 30.0-2692.0 128.2(113.4) -0.2 (p=0.850)HDL-cholesterol (mg/dl) 15.0-153.0 54.5(14.4) 13.0-130.0 54.6(15.0) 0.5 (p=0.607)LDL-cholesterol (mg/dl) 15.0-293.0 100.7(27.8) 10.0-371.0 90.9(25.7) -18.3 (p<.0001)Creatinine (mg/dl) 0.5-9.9 1.0(0.5) 0.5-11.6 1.0(0.6) 7.4 (p<.0001)eGFR 4.0-160.0 80.0(23.6) 3.7-164.9 78.8(24.5) -5.1 (p<.0001)

Table 1. Clinical and biochemical characteristics and diabetes behavior scores of participants Variable

Baseline 12-Month follow-upDifference betweenbaseline and follow-

upRange Mean (SD) Range Mean (SD) t

DBS per dimensionDiet 0-7 5.3(2.3) 0-7 5.6(2.0) 7.2 (p<.0001)Exercise 0-7 5.0(2.8) 0-7 5.3(2.7) 3.7 (p=0.0002)Medication 0-7 6.4(1.5) 0-7 6.4(1.6) 0.1 (p=0.927)Monitoring 0-7 3.1(3.2) 0-7 2.9(3.2) -2.9 (p=0.004)

PAID 0-40 4.3(6.0) 0-39 3.0(4.9) -11 (p<.0001)WHO 5 well-being index 0-25 17.8(3.8) 0-25 18.0(3.5) 2.0 (p=0.047)Total behavior score 0-28 19.9(5.9) 0-28 20.3(5.7) 2.7 (p=0.007)

Table 1. Clinical and biochemical characteristics and diabetes behavior scores of participants

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Table 2. Correlations between baseline diabetes behavior scoreboard dimensions and health indicatorsA. Correlations between baseline diabetes behavior scoreboard dimensions and health indicatorsVariable HbA1c BMI Waist LDL-C Triglycerides MBP eGFRAge -0.095 -0.158 -0.009 -0.083 -0.123 -0.010 -0.436Sex -0.032 0.058 -0.156 -0.009 -0.069 -0.010 -0.072DM duration 0.071 -0.049 0.008 -0.035 -0.026 0.001 -0.257Education level -0.000 -0.036 -0.030 -0.010 0.057 -0.013 0.214Diet-b -0.230 -0.096 -0.124 -0.075 -0.122 -0.025 -0.056Exercise-b -0.124 -0.105 -0.095 -0.049 -0.133 -0.021 -0.073Medication-b -0.129 -0.052 -0.032 -0.074 -0.092 -0.013 -0.033Monitoring-b -0.061 -0.045 -0.062 -0.022 -0.058 -0.002 -0.052Total score of PAID-b 0.175 0.039 -0.016 0.055 0.046 0.044 0.086Total score of WHO 5 well-being index-b

-0.078 -0.025 -0.003 -0.010 -0.002 -0.004 -0.075Total diabetic behavior score-b

-0.210 -0.123 -0.136 -0.085 -0.164 -0.026 -0.098

Table 2. Correlations between 12-month follow-up of diabetes behavior scoreboard dimensions and health indicatorsB. Correlations between 12-month follow-up of diabetes behavior scoreboard dimensions and health indicatorsVariable HbA1c BMI Waist LDL-C Triglycerides MBP eGFRAge -0.077 -0.176 -0.038 -0.112 -0.142 0.000 -0.424Sex -0.011 0.048 -0.173 -0.001 -0.064 -0.031 -0.018DM duration 0.105 -0.053 0.004 0.009 -0.040 -0.024 -0.254Education level -0.031 -0.025 -0.019 0.048 0.066 -0.017 0.216Diet-a -0.340 -0.104 -0.150 -0.044 -0.096 -0.053 -0.054Exercise-a -0.187 -0.136 -0.108 -0.038 -0.160 -0.035 -0.061Medication-a -0.175 -0.052 -0.046 -0.089 -0.071 0.005 -0.035Monitoring-a -0.161 -0.067 -0.075 -0.046 -0.061 -0.008 -0.071Total score of PAID-a 0.159 0.048 -0.005 0.039 0.037 0.042 0.029Total score of WHO 5 well-being index-a

-0.088 -0.015 -0.005 -0.010 -0.052 0.019 0.013Total diabetic behavior score-a

-0.336 -0.158 -0.158 -0.069 -0.164 -0.049 -0.107

Table 3. Linear regression analysis of variables associated with baseline HbA1c levels in subjects studied

Baseline HbA1c levelsSimple Multiple

Variable β coefficient p value β coefficient p valueAge -0.095 <.0001 - -Sex 0.032 0.065 - -Diabetes duration 0.071 <.0001 0.091 <.0001Education level 0.000 0.998 - -BMI-b 0.086 <.0001 0.046 0.016Mean BP-b 0.077 <.0001 0.062 0.001Triglyceride-b 0.135 <.0001 0.074 <.0001LDL-cholesterol-b 0.142 <.0001 0.110 <.0001eGFR-b 0.000 0.997 - -Diet-b -0.230 <.0001 -0.131 <.0001Exercise-b -0.124 <.0001 - -Medication-b -0.129 <.0001 -0.055 0.008Monitoring-b -0.061 0.001 - -Total score of PAID-b 0.175 <.0001 0.125 <.0001Total score of WHO 5 well-being index-b

-0.078 <.0001 - -Total behavior score-b -0.210 <.0001 -0.083 0.001

Baseline

Table 3. Linear regression analysis of variables associated with 12-month follow-up HbA1c levels in subjects studied

12-month follow-up HbA1c levelsSimple Multiple

Variable β coefficient p value β coefficient p valueAge -0.076 <.0001 - -Sex 0.011 0.534 - -Diabetes duration 0.105 <.0001 0.128 <.0001Education level -0.031 0.069 -0.050 0.007BMI-a 0.138 <.0001 0.065 0.001Mean BP-a 0.073 <.0001 0.043 0.021Triglyceride-a 0.156 <.0001 0.119 <.0001LDL-cholesterol-a 0.143 <.0001 0.108 <.0001eGFR-a -0.042 0.015 - -Diet-a -0.340 <.0001 -0.195 <.0001Exercise-a -0.187 <.0001 - -Medication-a -0.175 <.0001 -0.047 0.019Monitoring-a -0.161 <.0001 - -Total score of PAID-a 0.159 <.0001 0.091 <.0001Total score of WHO 5 well-being index-a

-0.088 <.0001 - -Total behavior score-a -0.336 <.0001 -0.158 <.0001

12-month follow up

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Diabetic-Behavior health eating , taking medication,

exercise, blood glucose self-monitoring, psychologic behavior

H3

H 4

H 2

H 1

Demographiccharacter

Age, Sex, Diabetic duration, Education level

Diabetes mellitus controlBMI, B;ood pressure, HaA1C, LDL-Cholesterol,

eGFR

Figure 1. Theoretical model of diabetic behavior and diabetes mellitus control.

Demographiccharacter

DiabeticBehavior

DM control

AgeSex

Education

Duration(Diabetes)

0.940.160.46

0.26

HbA1cBMI

MBP

TGLDL

0.450.33

0.170.350.19

-0.05

PAID Monitoring Medication Exercise DietWHO

0.420.410.200.19-0.43

0.35

-0.66***0.46***

Figure 2. Final model of diabetic behavior and diabetes mellitus control (baseline report). ***p < 0.001

Demographiccharacter

DiabeticBehavior

DM control

AgeSex

Education

Duration(Diabetes)

0.900.180.46

0.28

HbA1cBMI

MBP

TGLDL

0.590.31

0.180.320.16

0.09*

PAID Monitoring Medication Exercise DietWHO

0.520.450.230.31

-0.340.24

-0.87***0.41***

Figure 3. Final model of diabetic behavior and diabetes mellitus control (12-month follow-up report). *p<0.05, ***p < 0.001

Table 4. Linear regression analysis of 12-month diabetes behavior scoreboard associated with difference in baseline and 12-month HbA1C levels in subjects studiedSimple Multiple

Variable β coefficient p value β coefficient p valueAge 0.025 0.141 - -Sex -0.025 0.150 - -Diabetes duration 0.034 0.045 0.080 <.0001Education level -0.034 0.046 - -Baseline HbA1c -0.490 <.0001 -0.490 <.0001Diet-d -0.125 <.0001 - -Exercise-d -0.048 0.020 -0.062 0.009Medication-d -0.093 <.0001 - -Monitoring-d -0.079 <.0001 - -Total score of PAID-d 0.113 <.0001 0.058 0.004Total score of WHO 5 well-being index-d

-0.107 <.0001 -0.060 0.002Total behavior score-d -0.141 <.0001 -0.187 <.0001

Summary1. High Validity with 0.866~1.0.2. Convenient, easy performed, time saving.3. Self reported diabetes related behavior

correlated with glycemic control status.

Conclusion• Diabetes Behavior Scoreboard

– a precise, convenient computer-based system to evaluate and follow the changes of diabetes related behavior in patients with T2DM

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Thank you

Diabetes life, Health life, Joyous life, Living more amazing