Diabetes: Case Study

References
American Diabetes Association, (2010). Standards of Medical Care in Diabetes-2010. Diabetes Care 33 p. S11-S61. DOI: 10.2337/dc10-s011
Burke, S. D., Sherr, D., & Lipman, R. D. (2014). Partnering with diabetes educators to improve patient outcomes. Diabetes, Metabolic Syndrome & Obesity: Targets & Therapy, 745.
Centers for Disease Control and Prevention. (2011). Diabetes successes and opportunities for population-based prevention and control: At a glance 2011. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/AAG/ddt.htm
Cowie, C. C., Rust, K. F., Ford, E. S., Byrd-Holt, D. D., Li, C., Williams, D. E., Gregg, E. W., Bainbridge, K. E., Sayday, S. H. & Geiss, L. S. (2009). Full accounting of diabetes and pre-diabetes
in the U.S. population in 1988-1994 and 2005-2006. Diabetes Care, 32(2), 287-294. Doi: 10.2337/dc08-1296
Engvall, J. C., Padula, C., Krajewski, A., Rourke, J., Gomes McCillivray, C., Desroches, S., & Anger Jr., W. (2014). Empowering the Development of a Nurse-Driven Protocol. MEDSURG Nursing, 23(3), 149-154.
Free, C., Phillips, G., Galli, L., Watson, L., Felix, L., Edwards, P., & .Haines, A. (2013). The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review. Plos Medicine, 10(1), 1-45. Doi:10.1371/journal.pmed.1001362
Ikram, U. Z., Kunst, A. E., Lamkaddem, M. M., & Stronks, K. K. (2014). The disease burden across different ethnic groups in Amsterdam, the Netherlands, 2011-2030. European Journal of Public Health, 24(4), 600-605. Doi:10.1093/eurpub/ckt136
Melynk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Modic, M., Vanderbilt, A., Siedlecki, S. L., Sauvey, R., Kaser, N., & Yager, C. (2014). Diabetes management unawareness: what do bedside nurses know?. Applied Nursing Research, 27(3), 157-161. Doi:10.1016/j.apnr.2013.12.003
Polisena, J. J., Tran, K. K., Cimon, K. K., Hutton, B. B., McGill, S. S., & Palmer, K. 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
Sackett, D., Rosenburg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidenced based Stetson, B., Schlundt, D., Peyrot, M., Ciechanowski, P., Austin, M. M., Young-Hyman, D., & ... Sherr, D. (2011). Monitoring in diabetes self-management: Issues and recommendations for improvement. Population Health Management, 14(4), 189-197. Doi:10.1089/pop.2010.0030
Texas Department of State Health Services, Texas Diabetes Program/Council. (2008). The burden of diabetes in Texas. Retrieved from http://www.dshs.6state.tx.us/diabetes/tdcdata.shtm
Texas Department of State Health Services, Texas Diabetes Council (2011). Texas Diabetes Fact Sheet. Retrieved from: http://www.dshs.state.tx.us/diabetes/tdcdata.shtm
United States Bureau of the Census, (2010). State and County Quick Facts: Garland (city), Texas. Retrieved from: http://quickfacts.census.gov/qfd/states/48/4829000.html
Wu, L. L., Forbes, A. A., Griffiths, P. P., Milligan, P. P., & While, A. A. (2010). Telephone follow-up to improve glycaemic control in patients with Type 2 diabetes: systematic review and meta-analysis of controlled trials. Diabetic Medicine, 27(11), 1217-1225. Doi:10.1111/j.1464-5491.2010.03113.x
Zolfaghari, M., Mousavifar, S., Pedram, S., & Haghani, H. (2012). The impact of nurse short message services and telephone follow-ups on diabetic adherence: which one is more effective? Journal of Clinical Nursing, 21(13/14), 1922-1931. Doi:10.1111/j.1365-2702.2011.03951.x

Jaye Krubally
Evidence Table-Matrix
NUR 702 Evidence as the Basis for Practice Change Assignment

Evidence
Level of Evidence (I to VII)
Finding
Conclusion
Use of Evidence in EBP Project Plan
Culica, D., Walton, J. & Prezio, E. (2007). CoDE: Community Diabetes Education for uninsured Mexican Americans. Baylor University Medical Center Proceedings, 20(2), 111-117.
II
They conducted a study in a low-income clinic in downtown Dallas to determine if a low cost educational diabetes program would decrease cost and end organ damage, for a group of patients who have limited access to traditional diabetes education due to lack of insurance and who are non-English speaking. The study included 162 patients that had either Type 1 or Type 2 diabetes, who are or are not taking medications, and who had no known complications of diabetes. A series of follow-up meetings with the patient were scheduled over a 12-month period. The meetings consisted of a total of 7 hours of one on one education focused on diet and exercise, self-monitoring, and short and long-term complications. Goals were established with patient participation, glycosylated hemoglobin (HbA1c) was tested quarterly, blood pressure, height and weight were taken at each visit; and urine microalbumin was screened yearly to assess progress and evidence of end organ damage. Patients were encouraged to take an active role in the food choices they were making, including education on how to read labels. They were assisted with personal dietary plans including number of carbohydrates, calories, fats and proteins. They were also helped in goal setting, choosing one goal for each visit such as to maintain medication regimen, start a walking program, following the simple meal program, perform twice a day home glucose monitoring, to stop smoking, or to limit alcohol intake. The patients who completed the program over twelve months had significant changes at 12 months in their HgbA1c measurements. The patients who had missed at least one of their appointments, did not have significant improvement at 6 months, but did by the 12 month mark. Those who did not miss an appointment had significant improvements at both the 6 and 12 month measurements
Educational diabetes program would decrease cost and end organ damage
Low cost Community Diabetes Education (CoDE) programs are shown to be as effective as other programs with higher cost, and that diabetic education program help decrease cost and end organ damage.
(Community base programs can help decrease ER visits for hyperglycemic patients) problem identification and patient education; Significance
Modic, M., Vanderbilt, A., Siedlecki, S. L., Sauvey, R., Kaser, N., & Yager, C. (2014). Diabetes management unawareness: what do bedside nurses know? Applied Nursing Research, 27(3),157-161. V
The authors conducted a descriptive, correlation study of 2250 registered nurses working in a health care center.The researchers developed a tool (pr and post test of a 20 question assessment) that measured nurses ' comfort, familiarity, and knowledge of diabetes management principles of the hospitalized patient, by using The Diabetes Management Knowledge Assessment Tool” (DMKAT). At the end of the study they found no differences in level of knowledge as demonstrated on the DMKAT based on education level (F = 1.564; p =0.181) or years of experience (F =1.549; p = 0.158).They also found no correlation between neither comfort (r = 0.002; p = 0.912) nor familiarity (r = − 0.013; p =0.556) and diabetes management knowledge; but they did find a correlation between comfort and familiarity (r = 0.706; p < 0.001).The researchers used a paired t-test to examine the differences in diabetes management knowledge before and after the Diabetes Management Educational Program. They found a significant (t = 90.59; p < 0.001) increase in scores from pretest (x = 11) to posttest (x = 20).

They concluded that nurses did not feel comfortable because they were not adequately prepared to provide survival skills to the patients. The nurses lack knowledge to education the diabetic patients.

Significance
Ikram, U. Z., Kunst, A. E., Lamkaddem, M. M., & Stronks, K. K. (2014). The disease burden across different ethnic groups in Amsterdam, the Netherlands, 2011-2030. European Journal of Public Health, 24(4), 600-605. Doi:10.1093/eurpub/ckt136

IV
The aim of the study was to assess the disease burden as measured by the disability-adjusted life years (DALYs) for six ethnic groups in Amsterdam for 2011 and 2030. The DALYs were calculated by combining three components: disease, sex, age-specific, disease-specific relative risks (RRs) by ethnicity; and sex-/age-specific population sizes by ethnicity in Amsterdam for 2011 and 2030. Disease-specific DALYs were derived from the National Institute of Public Health. The RRs were obtained through a systematic review of studies published in 1997-2008. The population figures were gathered from the Statistics Netherlands and municipality of Amsterdam. Their findings suggest that cardiovascular disease and anxiety and depressive disorders dominate disease burden in all ethnic groups in 2011 and 2030. However, in most of the non-Western ethnic minorities diabetes mellitus is the strongest contributor to disease burden

They concluded that the total disease burden would increase more strongly in non-Western ethnic minorities than ethnic Dutch would. In ethnic minorities, diabetes also plays an important role in their disease burden. Suggesting that researchers should focus on estimating disease burden by ethnicity so that health priorities can be set in the fields of policy, health care and research.

Significance; clinical problem
Hollis, M., Glaister, K., & Lapsley, J. (2014). Do practice nurses have the knowledge to provide diabetes self-management education?.Contemporary Nurse: A Journal For The Australian Nursing Profession,46(2), 234-241. Doi:10.5172/conu.2014.46.2.234

A cross-sectional study to determine the diabetes knowledge levels of practice nurses in Australia. A convenience sample of (N = 52) The nurses they surveyed have different background knowledge; 89.6% registered nurses, and one postgraduate qualification in diabetes, and 76% had short courses in diabetes. A 14-item knowledge survey was done. Found that: Pathophysiology related knowledge was (M = 88%) knowledge concerning blood glucose monitoring (87%). Less strong was dietary knowledge (79.5%), although one particular question relating to sources of carbohydrate contributed to the lower score. The weakest knowledge area was medication management with mean score of only 54%.
These findings suggest that nurses lack the knowledge to educate diabetic patients.

Burke, S. D., Sherr, D., & Lipman, R. D. (2014). Partnering with diabetes educators to improve patient outcomes. Diabetes, Metabolic Syndrome & Obesity: Targets & Therapy, 745.

VII
The article is addressing the importance in collaborating with diabetic educators to promote self-management behaviors in patients. The authors discuss the findings on a diabetic education program that was conducted in 2012 by The Diabetes Education Accreditation Program (DEAP), which is one of the two national accreditation bodies for diabetes education in the US. The DEAP in their study reports that the programs were effective. The programs demonstrated a reduction in HbA1C from 8.39±0.03 7.16±0.67 for individuals who completed the Diabetes Self-management Education (DSME) program. Suggesting that 1.23% reduction (P=0.0000) in A1C is both statistically significant and clinically meaningful.

They concluded that patients who are given the knowledge to self- manage their disease have better outcomes. Incorporating knowledgeable diabetes educators into practice settings will improve clinical and quality of life outcomes for diabetic patients.
Improving nurses knowledge
Engvall, J. C., Padula, C., Krajewski, A., Rourke, J., Gomes McCillivray, C., Desroches, S., & Anger Jr., W. (2014). Empowering the Development of a Nurse-Driven Protocol. MEDSURG Nursing, 23(3), 149-154.

IV
Conducted a study to assess the level of knowledge nurses had related to DM. An e-mail invitation to the study was sent to 625 direct-care nurses. Nurses who chose to participate were instructed to complete the pre-test, which involved comple­tion of the DKBT and the DSRT.
One hundred fifteen nurses (18% return rate) completed the pre-test. They found that only 10 percent of nurses correctly identified the proper way to treat an adult having a hypoglycemic episode. This supports the idea that nurses need to be further educated on DM

Suggest that a nurse-driven hyperglycemic protocol would not only help patients better manage their disease, but also better educate nurses on how to deal with DM patients and be a go-to source of information for both patients and other health professionals alike.
Improving nurses knowledge
Zolfaghari, M., Mousavifar, S., Pedram,S.,& Haghani, H. (2012). The impact of nurse short message services and telephone follow-ups on diabetic adherence: which one is more effective? Journal of Clinical Nursing, 21(13/14), 1922-1931. Doi:10.1111/j.1365-2702.2011.03951.x

III
Conducted a quasi-experimental on two-group, pretest and post-test design to evaluate the effectiveness of nurse 's follow-up via cellular phones and telephones.
The sample consisted of 77 patients with type 2 diabetes that randomly were assigned to two groups: telephone follow-up (n = 39) and short message service (n = 38). The researchers applied telephone interventions for three months, twice a week for the first month and every week for the second and third month. For three successive months, the short message service group that received messages about adherence to therapeutic regimen was examined, working with a nurse who provided them with a diabetes therapeutic regimen. The results showed that both interventions had significant mean changes in glycosylated hemoglobin. For the telephone group (p &lt; 0·001), a mean change of −0·93 and for the short message service group (p &lt; 0·001), a mean change of −1·01.
They concluded that patients had better results managing their disease, improved HbA1c levels, when following a tele-communications plan. Regardless of the type of follow-up care, patients Improved HbA1c levels and adherence to diabetes treatment
Follow up
Wu, L. L., Forbes, A. A., Griffiths, P. P., Milligan, P. P., & While, A. A. (2010). Telephone follow-up to improve glycaemic control in patients with Type 2 diabetes: systematic review and meta-analysis of controlled trials. Diabetic Medicine, 27(11), 1217-1225.
doi:10.1111/j.1464-5491.2010.03113.x

I
Wu et al., (2010) conducted a meta-analysis of 22 different studies concerning telephone follow up for patients with hyperglycemic issues. They examined the impact of telephone follow-up interventions on glycemic control in patients with Type 2 diabetes. The standardized effect of telephone follow-up was equivocal; with endpoint data showing weighted mean differences of -0.44 (95% CI -0.93 to 0.06) (Z = -1.72, P = 0.08) in favor of the telephone follow-up intervention. Subgroup analysis of more intensive interventions (interactive follow-up with health professional plus automated follow-up or non-interactive follow-up) showed (n = 1057) a significant benefit in favor of the treatment group, with a standardized mean difference of -0.84 (95% CI -1.67 to 0.0) (Z = 1.97, P = 0.05), indicating that more intensive (targeted) modes of follow-up may have better effects on glycemic control.
The included studies showed that overall telephone follow-up has a limited impact on glycaemic control for Type 2 diabetes.
However, there was a high level of heterogeneity in the
Interaction within the telephone follow-up interventionsTele phone could have a positive impact on glycaemic control for Type 2 diabetes

Follow up call
Free, C., Phillips, G., Galli, L., Watson, L., Felix, L., Edwards, P., & .Haines, A. (2013). The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review. Plos Medicine, 10(1), 1-45. doi:10.1371/journal.pmed.1001362

I
The study identified 75 total trials where mobile technology was implemented to assess if its use would positively affect patient outcomes and lifestyles. 59 trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviors. Nearly all trials were conducted in high-income countries. Trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (.400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72-0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47-1.32]).
Text messaging interventions increased adherence to ART and smoking cessation.
There is mix finding for asthma control, but there is increase adherence to OCT and TB meds, improve quality of life for heart failure and decrease HbA1C levels in daibetic
Patient follow up
Polisena, J. J., Tran, K. K., Cimon, K. K., Hutton, B. B., McGill, S. S., & Palmer, K. 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

I
Polisena et al. conducted a meta-analysis Twenty-six studies (n = 5069 patients) on home telehealth for diabetes. Twenty-one studies evaluated Home Tele Monitoring (HTM) and 5 randomized controlled trials assessed Telephone Support (TS). HTM had a positive effect on glycemic control [as measured by lower glycated hemoglobin level] compared with usual care (weighted mean difference =−0.21; 95% confidence interval −0.35 to −0.08), but the results varied for the TS. Study results indicated that home telehealth helps to reduce the number of patients hospitalized, and the number of hospitalized days.
The study found no differences between groups in patient satisfaction or health-related QoL, and both groups expressed high satisfaction with their overall diabetic care. Although patients in the
TS group reported greater self-efficacy. Home telehealty has positive impact on the use of numerous health services and glycaemic control.

Patient follow up

2/3/11 EAG; 7/27/11 DMW, 8/27/12 DMW