Simplified integration of optimal self-management behaviors is associated with improved HbA1c in patients with type 1 diabetes

PURPOSE

Living with type 1 diabetes requires burdensome and complex daily diabetes self-management behaviors. This study aimed to determine the association between integrated behavior performance and HbA1c, while identifying the behavior with the most significant impact on HbA1c.

METHODS

A simple and feasible questionnaire was used to collect diabetes self-management behavior in patients with type 1 diabetes (n = 904). We assessed six dimensions of behavior performance: continuous glucose monitor (CGM) usage, frequent glucose testing, insulin pump usage, carbohydrate counting application, adjustment of insulin doses, and usage of apps for diabetes management. We evaluated the association between these behaviors and HbA1c.

RESULTS

In total, 21.3% of patients performed none of the allotted behavior, while 28.5% of patients had a total behavior score of 3 or more. 63.6% of patients with a behavior score ≥ 3 achieved HbA1c goal, contrasting with only 30.4% of patients with a behavior score of 0-1. There was a mean 0.54% ± 0.05% decrease in HbA1c for each 1-unit increase in total behavior score after adjustment for age, family education and diabetes duration. Each behavior was independently correlated with a lower HbA1c level, with CGM having the most significant effect on HbA1c levels.

CONCLUSIONS

Six optimal self-management behaviors, especially CGM usage, were associated with improved glycemic control, emphasizing the feasibility of implementing a simplified version of DSMES in the routine clinical care.

REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03610984.

Group-based trajectory analysis identifies varying diabetes-related cost trajectories among type 2 diabetes patients in Texas: an empirical study using commercial insurance

BACKGROUND

The trend of Type 2 diabetes-related costs over 4 years could be classified into different groups. Patient demographics, clinical factors (e.g., A1C, short- and long-term complications), and rurality could be associated with different trends of cost. Study objectives are to: (1) understand the trajectories of cost in different groups; (2) investigate the relationship between cost and key factors in each cost trajectory group; and (3) assess significant factors associated with different cost trajectories.

METHODS

Commercial claims data in Texas from 2016 to 2019 were provided by a large commercial insurer and were analyzed using group-based trajectory analysis, longitudinal analysis of cost, and logistic regression analyses of different trends of cost.

RESULTS

Five groups of distinct trends of Type 2 diabetes-related cost were identified. Close to 20% of patients had an increasing cost trend over the 4 years. High A1C values, diabetes complications, and other comorbidities were significantly associated with higher Type 2 diabetes costs and higher chances of increasing trend over time. Rurality was significantly associated with higher chances of increasing trend over time.

CONCLUSIONS

Group-based trajectory analysis revealed distinct patient groups with increased cost and stable cost at low, medium, and high levels in the 4-year period. The significant associations found between the trend of cost and A1C, complications, and rurality have important policy and program implications for potentially improving health outcomes and constraining healthcare costs.

Association between personality traits and glycemic control after inpatient diabetes education

Aims

The longitudinal effect of personality traits on glycemic control is unclear. This prospective observational study explored the relationship between personality traits and glycemic control in patients with uncontrolled diabetes after inpatient diabetes education.

Methods

Patients with diabetes mellitus (HbA1c ≥ 7.5%, measured by high-performance liquid chromatography) who received inpatient diabetes education were scored on the Big Five personality traits: neuroticism, extraversion, openness, agreeableness, and conscientiousness. Multiple linear analysis was used to determine whether any personality traits were independently associated with HbA1c on admission and HbA1c change from admission to 1, 3, and 6 months after discharge.

Results

One hundred seventeen participants (mean age 60.4 ± 14.5 years; 59.0% male) were enrolled. HbA1c values on admission and 1, 3, and 6 months after discharge were 10.2 ± 2.1%, 8.3 ± 1.4%, 7.6 ± 1.4%, and 7.7 ± 1.5%, respectively. Multiple linear analysis showed that no personality traits were associated with HbA1c on admission. Neuroticism was negatively associated with the HbA1c change from admission to 3 months (β = -0.192, P = 0.025) and 6 months after discharge (β = -0.164, P = 0.043).

Conclusions

Neuroticism was associated with good long-term glycemic control after inpatient diabetes education.

Overcoming the struggle of living with type 2 diabetes - diabetes specialist nurses' and patients' perspectives on digital interventions

BACKGROUND

Diabetes self-management education and support (DSMES) is a cornerstone in the treatment of type 2 diabetes mellitus (T2DM). It is unclear whether delivering DSMES as a digital health intervention (DHI) might meet the needs experienced by patients with T2DM and diabetes specialist nurses (DSN) of the primary health care system in Sweden.

METHODS

Fourteen patients with T2DM and four DSN participated in three separate focus groups: two groups comprised patients and one group comprised DSN. The patients discussed the questions: "What needs did you experience after your T2DM diagnosis?" and "How might these needs be met with a DHI?" The DSN discussed the questions: "What needs do you experience when treating a patient with newly diagnosed T2DM?" and "How might these needs be met with a DHI?". Furthermore, data were collected in the form of field notes from group discussions at a meeting including 18 DSNs working with T2DM in PHCCs. The discussions from focus groups were transcribed verbatim and analyzed together with the field notes from the meeting using inductive content analysis.

RESULTS

The analysis yielded the overall theme: "Overcoming the struggle of living with T2DM", which was summarized in two categories: "learning and being prepared" and "giving and receiving support". Important findings were that, for success, a DHI for DSMES must be integrated into routine care, provide structured, high-quality information, suggest tasks to stimulate behavioral changes, and provide feedback from the DSN to the patient.

CONCLUSION

This study highlighted several important aspects, from the perspectives of both the patient with T2DM and the DSN, which should be taken into consideration for the successful development and use of a DHI for DSMES.

Feasibility of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention

BACKGROUND

Diabetes self-management education and support is the cornerstone of diabetes care, yet <10% of adults with diabetes manage their condition successfully. Feasible interventions are needed urgently.

OBJECTIVE

Our aim was to assess the feasibility of a cooking intervention with food provision and diabetes self-management education and support.

DESIGN

This was a waitlist-controlled, randomized trial.

PARTICIPANTS/SETTING

Thirteen adults with type 1 or type 2 diabetes who participated in Cooking Matters for Diabetes (CMFD) participated in 2 focus groups.

INTERVENTION

CMFD was adapted from Cooking Matters and the American Diabetes Association's diabetes self-management education and support intervention into a 6-week program with weekly lesson-aligned food provisions.

MAIN OUTCOME MEASURES

Feasibility was evaluated quantitatively and qualitatively along the following 5 dimensions: demand, acceptability, implementation, practicality, and limited efficacy.

STATISTICAL ANALYSIS

Two coders extracted focus group themes with 100% agreement after iterative analysis, resulting in consensus. Administrative data were analyzed via descriptive statistics.

RESULTS

Mean (SD) age of focus group participants was 57 (14) years; 85% identified as female; 39% identified as White; 46% identified as Black; and income ranged from <$5,000 per year (15%) to $100,000 or more per year (15%). Mean (SD) baseline hemoglobin A1c was 8.6% (1.2%). Mean attendance in CMFD was 5 of 6 classes (83%) among all participants. Demand was high based on attendance and reported intervention utilization and was highest among food insecure participants, who were more likely to report using the food provisions and recipes. Acceptability was also high; focus groups revealed the quality of instructors and interaction with peers as key intervention strengths. Participant ideas for implementation refinement included simplifying recipes, lengthening class sessions, and offering more food provision choices. Perceived effects of the intervention included lower hemoglobin A1c and body weight and improvements to health-related quality of life.

CONCLUSIONS

The CMFD intervention was feasible according to the measured principles of demand, acceptability, implementation, practicality, and limited efficacy.

The current diabetes education experience: Findings of a cross-sectional survey of adults with type 2 diabetes

OBJECTIVE

To survey persons with type 2 diabetes (PWD) on their experiences with diabetes education to better understand what it means when a PWD says they have "had diabetes education."

METHODS

We conducted a cross-sectional descriptive study among a convenience sample of adult PWD receiving primary care and/or diabetes self-management education and support in a mid-Atlantic regional US healthcare system. Descriptive, bivariate, and regression analyses were used to describe and explore the diabetes education experience.

RESULTS

Participants (n = 498) were majority female, African American, and non-Hispanic. Half reported having "had diabetes education." Of those, 44% had only one session. Education was most often provided in clinical settings by a dietitian (68%) or doctor (51%), in one-on-one (70%) sessions. While most participants reported receiving core diabetes knowledge, fewer reported education on topics that are not related to their daily routine, such as what to do about diabetes medications when sick.

CONCLUSION

The self-reported diabetes education experience varies in content, modality, setting, and education provider. Education receipt is low, and for those who receive education, the amount is low.

PRACTICAL IMPLICATIONS

The diabetes education experience may fall short of the comprehensive US National Standards-recommended process. Innovative strategies are needed to address these gaps.

The AH-HA! Project: Transforming Group Diabetes Self-Management Education Through the Addition of Flash Glucose Monitoring

Background: The majority of individuals referred to diabetes self-management education and support (DSMES) programs do not access this resource. Of those who do, attrition is high, with anecdotal reports pointing to the didactic and impersonal nature of these programs contributing to low utilization and completion rates. In an effort to develop a more engaging form of DSMES for adults with type 2 diabetes (T2D), we constructed a nondidactic "discovery learning"-based DSMES program centered on real-time flash glucose monitoring (FGM). Methods: In this single-arm pilot study, 35 adults with T2D duration 1-5 years, ages 21-75 years, not using insulin and HbA1c ≥8.0% were introduced to FGM and participated in five weekly group sessions. DSMES content was personalized, emerging from the concerns and questions arising from participants' FGM discoveries. The primary outcome was glycemic change as assessed by blinded FGM at baseline and month 3. Secondary outcomes included psychosocial and behavioral measures. Results: There was a significant gain in percentage time in range (% TIR) 70-180 mg/dL from baseline (55%) to month 3 (74%), and a parallel drop-in percentage time above range (TAR) >180 mg/dL from 44% to 25% (Ps = 0.01). Overall well-being rose significantly (P = 0.04), whereas diabetes distress showed a nonsignificant drop. Participants reported improvements in healthy eating (P < 0.001) and physical activity, although the latter did not reach statistical significance. Conclusions: These findings support a new approach to DSMES, a method that integrates FGM with a highly interactive and engaging patient-driven "discovery learning" approach to education.

Outcomes of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention

BACKGROUND

Diabetes self-management education and support is the cornerstone of diabetes care, yet only 1 in 2 adults with diabetes attain hemoglobin A1c (HbA1c) targets. Food insecurity makes diabetes management and HbA1c control more difficult.

OBJECTIVE

Our aim was to test whether a cooking intervention with food provision and diabetes self-management education and support improves HbA1c and diabetes management.

DESIGN

This was a waitlist-controlled, randomized trial.

PARTICIPANTS/SETTING

Participants were 48 adults with type 1 or type 2 diabetes.

INTERVENTION

Cooking Matters for Diabetes was adapted from Cooking Matters and the American Diabetes Association diabetes self-management education and support intervention into a 6-week program with weekly food provision (4 servings).

MAIN OUTCOME MEASURES

Surveys (ie, Summary of Diabetes Self-Care Activities; Medical Outcomes Study Short Form Health Survey, version 1; Diet History Questionnaire III; 10-item US Adult Food Security Survey Module; and Stanford Diabetes Self-Efficacy Scale) were administered and HbA1c was measured at baseline, post intervention, and 3-month follow-up.

STATISTICAL ANALYSIS

Mixed-effects linear regression models controlling for sex and study wave were used.

RESULTS

Mean (SD) age of participants was 57 (12) years; 65% identified as female, 52% identified as White, 40% identified as Black, and 19 (40%) were food insecure at baseline. Intervention participants improved Summary of Diabetes Self-Care Activities general diet score (0 to 7 scale) immediately post intervention (+1.51; P = .015) and 3 months post intervention (+1.23; P = .05), and improved Medical Outcomes Study Short Form Health Survey, version 1, mental component score (+6.7 points; P = .025) compared with controls. Healthy Eating Index 2015 total vegetable component score improved at 3 months (+0.917; P = .023) compared with controls. At baseline, food insecure participants had lower self-efficacy (5.6 vs 6.9 Stanford Diabetes Self-Efficacy Scale; P = .002) and higher HbA1c (+0.77; P = .025), and demonstrated greater improvements in both post intervention (+1.2 vs +0.4 Stanford Diabetes Self-Efficacy Scale score; P = .002, and -0.12 vs +0.39 HbA1c; P = .25) compared with food secure participants.

CONCLUSIONS

Cooking Matters for Diabetes may be an effective method of improving diet-related self-care and health-related quality of life, especially among food insecure patients, and should be tested in larger randomized controlled trials.

Lessons learned from the pilot family model of diabetes self-management intervention in the Republic of the Marshall Islands

Background

The Republic of the Marshall Islands (RMI) has a high rate of type 2 diabetes mellitus (T2DM). To address the high rate of T2DM, we tested a culturally adapted family model of diabetes self-management education and support (F-DSMES). We report the results of the 12-month post-intervention data collection and describe the lessons learned from the delivery of the F-DSMES intervention.

Methods

Recruitment took place in four churches in Majuro and included 10 h of content delivered over 8-10 weeks. Forty-one participants with T2DM were included. The primary study outcome was glycemic control measured by a change in HbA1c. We also conducted participant interviews to document the participant-reported barriers encountered during the F-DSMES intervention.

Results

Participants did not show improvements in their biometric markers; however, participants did show improvement on multiple measures of diabetes knowledge and family support. We identified five areas to improve future interventions: 1) issues with recruitment, retention, and attendance; 2) needing help accessing information and additional healthcare provider counseling; 3) struggles with adhering to diet recommendations; 4) difficulty getting exercise, and 5) improving lessons within the intervention.

Conclusion

Although the biomarker data did not show improvement, valuable information was gained to improve the development of larger-scale trials. The results provide evidence of the need for these trials and the desire of participants to continue pursuing this effort. Others doing similar work in other low-to-middle income countries will need to take into consideration the potential barriers and facilitators within participants' social and physical environments.

Lower education and immigrant background are associated with lower participation in a diabetes education program - Insights from adult patients in the Outcomes & Multi-morbidity In Type 2 diabetes cohort (OMIT)

OBJECTIVES

Diabetes educational programmes should be offered to patients with type 2 diabetes mellitus (T2DM). We assessed the proportion of diabetes educational program participation among adults with T2DM, and its associations with place of residence in Norway, education, and immigrant background.

METHODS

We identified 28,128 diagnosed with T2DM (2008-2019) in the Outcomes & Multi-morbidity In Type 2 diabetes cohort. To examine associations between sociodemographic factors and participation in diabetes start courses (yes/no), we computed adjusted risk ratios (95% CI) using log-binomial regression.

RESULTS

Overall, 18% participated on the diabetes start course, but partaking differed by Norwegian counties (range:12-34%). Individuals with an immigrant background were 29% less likely to participate (RR 0.71, CI 0.65-0.79). Similarly, those with a lower educational level were 23% less likely to participate (RR 0.77, CI 0.72-0.83) than those with the highest education. The association between education and start course participation was not significant in the subgroup of immigrant individuals (RR 0.88 CI 0.70-1.12).

CONCLUSIONS

We found that diabetes start course participation was overall low, especially in individuals with low education and immigrant background.

PRACTICE IMPLICATIONS

More efforts are needed to promote diabetes start courses in patients with T2DM.

Effectiveness-implementation trial comparing a family model of diabetes self-management education and support with a standard model

BACKGROUND

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.

METHODS

We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.

CONCLUSION

Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.

REGISTRATION

The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

SEE-diabetes, a patient-centered diabetes self-management education and support for older adults: Findings and information needs from providers' perspectives

BACKGROUND AND AIMS

Diabetes self-management education and support (DSMES) can improve clinical and health outcomes of people with diabetes. However, DSMES has been underutilized because of many barriers. We aimed to develop a patient-centered educational aid, SEE-Diabetes (Support-Engage-Empower-Diabetes), that facilitates shared decision-making about DSMES between patient and provider during the follow-up visit. We investigated the information needs to inform the design of the SEE-Diabetes from the providers' perspective.

METHODS

We conducted an online survey (N = 42) and three focus groups (N = 13) involving providers who have experience managing diabetes in older patients. Survey collected demographics and assessed knowledge of DSMES. During the subsequent focus groups, participants evaluated the Assessment and Plan section of three clinic notes of older people with diabetes. We also demonstrated the potential workflow of DSMES documentation using SEE-Diabetes during clinical practice.

RESULTS

The survey showed 60% of providers were familiar with DSMES. Focus group findings showed clinic notes should convey concise information at an appropriate reading level, numbered problems, and less medical jargon to improve the readability of clinic notes. Application of SMART (Specific, Measurable, Attainable, Relevant, Time-bound) goals was suggested to deliver effective diabetes self-care information.

CONCLUSIONS

Providers should consider adopting validated DSMES guidelines along with goal-setting strategies to provide patient-centered care. The research team will integrate the provider recommendations when we develop SEE-Diabetes.

SEE-Diabetes, a patient-centered diabetes self-management education and support for older adults: Findings and information needs from patients' perspectives

AIMS

This study identified the information needs of people with diabetes aged 65 and older through surveys and focus groups to inform the development of a patient-centered educational decision aid for diabetes care, SEE-Diabetes (Support-Engage-Empower-Diabetes).

METHODS

We conducted survey (N = 37) and three focus groups (N = 9). The survey collected demographics, diabetes duration, insulin usage, and clinic notes accessibility through a patient portal. In focus groups, participants evaluated the Assessment and Plan section of three selected deidentified clinic notes to assess readability and helpfulness for diabetes care.

RESULTS

The mean age of participants was 66 (24-82, SD = 12), and 22 were female (60%). The mean diabetes duration was 20.9 years (1-63, SD=15). Most participants (80%) read their clinical notes via patient portal. In the focus groups, the readability of clinic notes was noted as a primary concern because of medical abbreviations and poor formatting. Participants found the helpfulness of clinic notes was negatively impacted by vague or insufficient self-care information.

CONCLUSIONS

We found the high use of patient portal for reading clinic notes, which offers a use case opportunity for the proposed SEE-Diabetes educational aid. Feedback about the readability and helpfulness of clinic notes will be considered during the design process.

Patient engagement and presence in a virtual world world diabetes self-management education intervention for minority women

OBJECTIVE

We aim to explore how users' experience of presence in a virtual world (VW) learning environment enhanced patient engagement in DSME/S programs conducted in an online VW platform with minority women with type 2 diabetes.

METHODS

We conducted an embedded, mixed methods study, using a convergent study design to analyze qualitative field notes and interview data and quantitative survey data gathered from the Women in Control 2.0 (WIC2) clinical trial participants. The WIC2 clinical trial compared a diabetes group visit program delivered using an online VW platform versus an in-person approach.

RESULT

We enrolled 158 VW participants, of which 144 completed baseline data, 124 completed the post-intervention follow up survey, and 30 participated in key informant and focus group interviews. Overall, participants reported a sense of social (63.7%, mean 3.7/5.0), physical (63.1%, mean 3.6/5.0), and self (49.0%, mean 3.3/5.0) presence while engaged in VW group DSME/S. Three themes emerged from mixed methods analysis including, 1) Participants' identification with their avatars enhances a sense of self presence in a VW, 2) physical presence enables visualization and imaginative play modalities of social learning, and 3) social presence cultivates meaningful social support and psychological safety.

CONCLUSION

Our research empirically supports the premise that participants' experience of three domains of presence (self, physical and social) in a VW environment enhances participant engagement in DSME/S programs.

PRACTICE IMPLICATIONS

Further research is warranted to study optimal approaches to implementation and dissemination of this novel approach to patient education and engagement.

The design of an evaluation framework for diabetes self-management education and support programs delivered nationally

BACKGROUND

The aim of this work was to develop a National Evaluation Framework to facilitate the standardization of delivery, quality, reporting, and evaluation of diabetes education and support programs delivered throughout Australia through the National Diabetes Services Scheme (NDSS). The NDSS is funded by the Australian Government, and provides access to diabetes information, education, support, and subsidized product across diverse settings in each state and territory of Australia through seven independent service-providers. This article reports the approach undertaken to develop the Framework.

METHODS

A participatory approach was undertaken, focused on adopting nationally consistent outcomes and indicators, nominating objectives and measurement tools, specifying evaluation processes, and developing quality standards. Existing programs were classified based on related, overarching indicators enabling the adoption of a tiered system of evaluation.

RESULTS

Two outcomes (i.e., improved clinical, reduced cost) and four indicators (i.e., improved knowledge and understanding, self-management, self-determination, psychosocial adjustment) were adopted from the Eigenmann and Colagiuri national consensus position statement for diabetes education. This allowed for the identification of objectives (i.e., improved empowerment, reduced distress, autonomy supportive program delivery, consumer satisfaction) and related measurement instruments. Programs were categorized as comprehensive, topic-specific, or basic education, with comprehensive programs allocated to receive the highest-level of evaluation. Eight quality standards were developed, with existing programs tested against those standards. Based on the results of testing, two comprehensive (OzDAFNE for people with type 1 diabetes, DESMOND for people with type 2 diabetes), and eight topic-specific (CarbSmart, ShopSmart, MonitorSmart, FootSmart, MedSmart, Living with Insulin, Insulin Pump Workshop, Ready Set Go - Let's Move) structured diabetes self-management education and support programs were nominated for national delivery.

CONCLUSIONS

The National Evaluation Framework has facilitated consistency of program quality, delivery, and evaluation of programs delivered by multiple service providers across diverse contexts. The Framework could be applied by other service providers who facilitate multiple diabetes education and support programs and could be adapted for use in other chronic disease populations where education and support are indicated.

A Risk Stratification Approach to Allocating Diabetes Education and Support Services

The objective of this study was to describe a predictive modeling approach to risk stratify people with type 2 diabetes for diabetes self-management education and support (DSMES) services. With data from a large health system, a predictive model including age, glycated hemoglobin (HbA1c), and insulin use among other factors, was developed to assess risk of future high HbA1c. The model was retrospectively applied to a cohort of people who received DSMES over a 2-year period to assess the impact of DSMES on glycemia by risk strata. Of 6934 eligible people, 4014 (58%) were in the composite low-risk group and 2604 (38%) were in the composite high-risk group. Mean HbA1c change after DSMES was -0.38% in the low-risk group and -0.84% in the high-risk group. This analysis demonstrates the potential application of predictive modeling as one approach to target DSMES resources to people who will benefit most.

Digital interventions self-management education for type 1 and 2 diabetes: A systematic review and meta-analysis

OBJECTIVE

To describe and assess digital health-led diabetes self-management education and support (DSMES) effectiveness in improving glycosylated hemoglobin, diabetes knowledge, and health-related quality of life (HrQoL) of Type 1 and 2 Diabetes in the past 10 years.

DESIGN

Systematic Review and Meta-Analysis. The protocol was registered on PROSPERO registration number CRD42019139884.

DATA SOURCES

PubMed, EMBASE, Cochrane library, Web of Science, and Scopus between January 2010 and August 2019. Study Selection and Appraisal: Randomized control trials of digital health-led DSMES for Type 1 (T1DM) or 2 (T2DM) diabetes compared to usual care were included. Outcomes were change in HbA1c, diabetes knowledge, and HrQoL. Cochrane Risk of Bias 2.0 tool was used to assess bias and GRADEpro for overall quality. The analysis involved narrative synthesis, subgroup and pooled meta-analyses.

RESULTS

From 4286 articles, 39 studies (6861 participants) were included. Mean age was 51.62 years, range (13-70). Meta-analysis revealed intervention effects on HbA1c for T2DM with difference in means (MD) from baseline -0.480% (-0.661, -0.299), I²75% (6 months), -0.457% (-0.761, -0.151), I² 81% (12 months), and for T1DM -0.41% (-1.022, 0.208) I² 83% (6 months), -0.03% (-0.210, 0.142) I² 0% (12 months). Few reported HrQoL with Hedges' g 0.183 (-0.039, 0.405), I² 0% (6 months), 0.153 (-0.060, 0.366), I² 0% (12 months) and diabetes knowledge with Hedges' g 1.003 (0.068, 1.938), I² 87% (3 months).

CONCLUSION

Digital health-led DSMES are effective in improving HbA1c and diabetes knowledge, notably for T2DM. Research shows non-significant changes in HrQoL. Intervention effect on HbA1c was more impressive if delivered through mobile apps or patient portals. Further research is needed on the impact of DSMES on these outcomes, especially for newly diagnosed diabetes patients.

Diabetes Management in Community Health Centers: a Review of Policies and Programs

PURPOSE OF REVIEW

Community health centers (CHCs) provide care to millions of vulnerable patients in the USA, including a disproportionate number with diabetes. Policies affecting diabetes management in CHCs therefore have broad implications for clinical practice and patient outcomes nationwide. We describe prior policies that have influenced diabetes management in CHCs, discuss current policies and programs, as well as present emerging innovations and future directions for diabetes care in this setting.

RECENT FINDINGS

Domains for current diabetes policies and programs in CHCs include coverage requirements, quality reporting and incentives, prescription discounts, healthy behavior incentives, and team-based care. Policies in these areas affect the management of diabetes at multiple levels, from organizations that support CHCs to individual health centers, and the providers and patients based there. Several domains of interrelated policies and programs impact CHC diabetes management at multiple levels. Stakeholders' understanding of these policies and programs may identify opportunities to improve diabetes care.

Overcoming barriers to self-management: The person-centred diabetes foot behavioural agreement

OBJECTIVE

Behavioural agreements have been proposed as a clinical strategy for improving concordance with diabetes foot self-management practices, both for individuals 'At-risk' of, and with active, diabetes foot disease. This narrative review sought to explore the potential supportive role of person-centred diabetes foot behavioural agreements in promoting protective foot self-management behaviours among 'At-risk' individuals.

CONCLUSIONS

Healthcare professionals (HCPs) involved in diabetes foot risk stratification and management dedicate considerable time, effort and resources to the prevention of diabetic foot ulcers (DFU) and lower extremity amputation (LEA) and are uniquely placed to deliver person-centred diabetes self-management education and support (DSMES) interventions. Written, verbal and non-verbal agreements are consistent with a wider global move toward DSMES approaches, respectful of people's preferences, and supporting them to undertake protective self-care behaviours.

PRACTICE IMPLICATIONS

It is theorised that clear communication of the roles of the person with diabetes, their family or carers and HCPs may improve concordance with self-management behaviours. Rather than a punitive measure or means of facilitating discharge of 'non-concordant' individuals, person-centred behavioural agreements should be framed positively, as a means of delineating, prescribing and supporting individual diabetes foot-care responsibilities. This is an area worthy of further research.