Background

• Computerized patient diabetes self management education (DMSE) assessment tools have shown promise in office-based diabetes education research

• May help the diabetes educator in busy clinical settings capture key patient self management data in a systematic, brief, and user-friendly manner

• Frees diabetes educator to spend more time developing rapport with the patient and more structured, in-depth diabetes education and skills training

• Offers the potential benefit of wide translation to national diabetes education network• 15,000 certified diabetes educators and 15,000 diabetes educators in US• Accessible to any educator with a web browser http://www.dscpsurvey.com/

Research gap

• These computerized assessment tools are in an early stage of development• Little research on feasibility and acceptability• Benefits for diabetes outcomes (e.g., hemoglobin A1c levels) are unclear

Current study

•The Diabetes Self Care Profile (DSCP) is a web-based, computerized DSME assessment tool that has been developed by our group

• $15,000 to develop • Applied within a larger clinical trial evaluating novel patient centered counseling approaches to diabetes education

• We evaluated the efficacy of the DSCP) to reduce HbA1c in a population of poorly controlled (HbA1c>8%) patients with type 2 diabetes. •This tool:

• Briefly assesses diet, exercise, medication, and physical activity behaviors that impact blood glucose control • Identifies one behavior selected by the patient for discussion and associated barriers to self management• Documents psychosocial problems that can impede optimal self management

• Depression, diabetes distress, hypoglycemia, low social support, binge eating, alcohol abuse• Attitudes and barriers to commencing insulin therapy if on oral agents• Provides visual feedback on HbA1c control (red, yellow, or green “thermometer”)

MethodsMethods

ResultsResults

Garry Welch, PhD1 Sofija Zagarins, PhD1 Rebecca Feinberg Shayne, MPH1 Jane Garb, MS2

IntroductionIntroduction1Department of Behavioral Medicine Research and 2Department of Academic Affairs,

Baystate Medical Center, Springfield MA

DiscussionDiscussion• Effective in terms of HbA1c change when used by Certified Diabetes Educator over a mean of 3.5 intervention sessions

• Change in three of the psychosocial measures (SCI, PAID, DTSQ) explained 40% of the variation in HbA1c change• The observed 1% drop in HbA1c correlates to a 37% reduction in micro-vascular complications based on the findings from the United Kingdom Prospective Diabetes Study

• Provides a tailored patient summary of key issues and barriers to optimal diabetes self management in a time-efficient (10 minute), easy-to-use format• Potentially scaleable patient self management assessment tool• Web based tool can be updated or modified easily over time• Available to any clinician if a web browser is available.• Can be incorporated into EMR or other clinical information system for nurse, educator, case manager based education and pt. tracking• Future research should explore wider testing and use of DSCP

Study Design and Population

• Type 2 diabetics with diagnosis >6 months were recruited from the Springfield, MA area

• Prospective study with two research assessments (R1 baseline and R2 at 6 months) and four diabetes education sessions with a certified diabetes educator (CDE1 – CDE4)

• DSCP assessment conducted at first of 4 education sessions

Research Assessments

• Hemoglobin A1c tested at Baystate Reference Laboratory

• Behavioral and psychosocial information collected using published questionnaires having satisfactory reliability and construct validity

• Self-care inventory (SCI) – Measures diabetes self-care behaviors

• Problem Areas in Diabetes (PAID) – Measures diabetes-related emotional distress

• Center for Epidemiologic Studies Depression scale (CES-D) – Measures major depression

• Diabetes Treatment Satisfaction Questionnaire (DTSQ-change version)

• Patient perceptions of importance and self efficacy attitudes regarding diabetes self-care behaviors (medication, glucose self-monitoring, diet, exercise)

A Brief Intervention Using a Web-based Patient Self Management A Brief Intervention Using a Web-based Patient Self Management Assessment Tool Improves Blood Glucose Control (HbA1c)Assessment Tool Improves Blood Glucose Control (HbA1c)

R1+

HbA1c

R2+

HbA1c

CDE1 +

DSCP

CDE4

2 weeks 4 weeks 6 weeks 3 months 1 week

CDE3 CDE2

5

6

7

8

9

10

11

R1 R2

He

mo

glo

bin

A1

c

Figure 2. Change in HbA1c from R1 to R2

Table 1. Selected characteristics of study participants Mean ± SD Range Age at R1 visit (years) 57.2 ± 10.9 32.0 – 77.0 Duration of diabetes (years) 7.0 ± 6.5 0.5 – 32.0 Body mass index at R1 (kg/m2) 34.4 ± 6.6 21.3 – 48.1 Female 63.8% - White race 81.0% - Hispanic 12.0% - Education beyond high school 57.4% - Used insulin at R1 22.4% - Used oral agents at R1 84.5% -

Table 2. Computer Assessment at CDE 1 Mean completion time 10 min. Minimum 3 min. Maximum 23 min. Diabetes self-care topic selected Meal plan 76.3% Exercise 8.5% Medication 6.8% Check blood sugar 8.5% Life Challenges Depression 42.4% Emotional distress 42.4% Binge eating 25.4% Alcohol 1.7% Hypoglycemia 33.9% Low social support 49.2% Attitudes about starting insulin Would be OK with starting insulin 0.0% Upset, but would start insulin 69.0% Would not start 31.0% Barriers to starting insulin Would want to try other treatment options first

92.9%

Would mean diabetes was getting worse

78.6%

Reluctant to give myself shots in public

45.2%

Scared about needle pain 42.9% Worried about gaining weight 35.7%

Table 4. Determinants of Hemoglobin A1c change from R1 to R2

Variables in model1 β ± SE p-value Partial

R-Square Model

R-Square2

Change in SCI score -0.05 ± 0.02 <0.01 0.23 0.23 Change in PAID score 0.03 ± 0.01 <0.01 0.12 0.35 Change in DTSQ score -0.06 ± 0.03 0.08 0.05 0.40 1 Determined using stepwise linear regression; selection criteria of p=0.10 for both inclusion and retention 2 Cumulative R-square for each variable added to the model

Figure 1. Change in SCI and PAID score from R1 to R2

Table 3. Change in covariates from R1 to R2

Covariate Mean

Difference ± SD p-value

BMI -0.8 ± 1.7 <0.01 HbA1c -1.0 ± 1.3 <0.01 SCI score 10.8 ± 11.1 <0.01 PAID score -10.6 ± 15.8 <0.01 CES-D score -1.1 ± 8.3 0.39 DTSQ score 9.8 ± 6.0 <0.01 Importance 4.3 ± 19.1 0.16 Confidence 0.8 ± 18.7 0.80