Multisite Quality Improvement Program Within the Project ECHO Diabetes Remote Network

BACKGROUND

The telementoring Project ECHO (Extension for Community Healthcare Outcomes) model has been shown to improve disease management in diabetes in many underserved communities. The authors aim to evaluate if ECHO could also be an effective tool for quality improvement (QI) of diabetes care in these communities.

METHODS

Thirteen clinics in underserved communities in California and Florida participating in Project ECHO Diabetes were recruited for a 12-month QI program. The program provided weekly tele-education sessions, including a didactic presentation and case-based discussion. In addition, clinics chose their own set of quality measures to improve and met remotely to discuss their efforts, successes, and setbacks every quarter with mentorship from QI experts.

RESULTS

Of the 31 QI initiatives attempted by different clinics, all had either made improvements (25 initiatives, 80.6%) or were in the process of making improvements (6 initiatives, 19.4%) in structural, process, and outcome measures. Examples of these measures include whether clinics have protocols to identify high-risk patients (structure), numbers of continuous glucose monitor prescriptions submitted by the clinics (process), and percentage of patients with diabetes whose most recent HbA1c are > 9% (outcome). For one measure, 40.0% of the clinics had achieved a higher percentage of cumulative HbA1c measurement in the third quarter of the year, compared to the fourth quarter in the previous year. The cost of QI implementation varied widely due to different number of personnel involved across sites.

CONCLUSION

A QI program delivered via Project ECHO Diabetes can facilitate quality improvements in underserved communities.

The Promising Success of Project Extension for Community Healthcare Outcomes (ECHO) Diabetes: Case Series

BACKGROUND

In the United States, there are over 37 million people with diabetes but only 8000 endocrinologists. Therefore, many people with diabetes receive care exclusively from primary care providers (PCPs). To democratize knowledge regarding insulin-requiring diabetes through tele-education, Stanford University and the University of Florida developed Project Extension for Community Healthcare Outcomes (ECHO) Diabetes.

OBJECTIVE

ECHO Diabetes uses a Hub and Spoke model connecting specialists (the "Hub") with PCPs (the "Spokes"). One-hour, weekly sessions include Hub diabetes didactic presentations and Spoke deidentified case presentations. Lessons learned during these sessions target provider knowledge and confidence surrounding diabetes management and patient care.

METHODS

Spokes were asked to provide short descriptions of people with diabetes whose diabetes management improved directly or indirectly from their providers' participation or their involvement with a Diabetes Support Coach (DSC). We provide a case series to describe individuals and outcomes. Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry.

RESULTS

A case series of 11 people with diabetes was compiled from 10 PCPs and 1 DSC from California and Florida between 2021 and 2022. The principal impact of ECHO Diabetes is the education amplified from PCPs and DSCs to people with diabetes. In all cases, people with diabetes reported increased engagement and improved diabetes management. Several cases reflected increased access to diabetes technology, improvement in glycemic outcomes, and positive trends in mental health measures.

CONCLUSIONS

This case series elucidates the potential value of the ECHO Diabetes program to people with diabetes who receive their diabetes care from PCPs. Those matched with a DSC saw clinically significant improvements in hemoglobin A1c and mental health outcomes.

A retrospective multisite examination of depression screening practices, scores, and correlates in pediatric diabetes care

Psychosocial guidelines recommend routine screening of depressive symptoms in adolescents and young adults (AYA) with diabetes. Best practices for screening in routine care and patient characteristics associated with depressive symptoms require further investigation. The purpose of this study was to examine psychometric properties of the Patient Health Questionnaire (PHQ-2 and PHQ-9); document rates of depressive symptoms and related clinical actions; and evaluate associations with patient characteristics. The Patient Health Questionnaire (PHQ-2 or PHQ-9) was administered at five pediatric academic medical centers with 2,138 youth with type 1 diabetes. Screening was part of routine clinical care; retrospective data from electronic health records were collected for the first screening date as well as 12 months prior. The PHQ demonstrated good psychometric properties. Evaluation of item-level PHQ-9 data identified 5.0% of AYA with at least moderate depressive symptoms who would not have been flagged for further screening using the PHQ-2 only. On the PHQ-9, 10.0% of AYA with type 1 diabetes endorsed elevated depressive symptoms and 7.0% endorsed thoughts of self-harm. Patients with moderate or greater depressive symptoms had a 43.9% documented referral rate for mental health treatment. Higher BMI, older age, public insurance, shorter diabetes duration, higher HbA1C, and a diabetic ketoacidosis (DKA) event in the past year were associated with depressive symptoms. The PHQ-9 identified AYA with elevated depressive symptoms that would not have been identified using the PHQ-2. Depressive symptoms were associated with negative diabetes indicators. To improve referral rates, standardized methods for provision and documentation of referrals are needed.

Multisite Examination of Depression Screening Scores and Correlates Among Adolescents and Young Adults With Type 2 Diabetes

OBJECTIVES

Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics.

METHODS

The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier.

RESULTS

Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms.

CONCLUSIONS

Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed.

Use of Ecological Momentary Assessment to Measure Self-Monitoring of Blood Glucose Adherence in Youth With Type 1 Diabetes

OBJECTIVE

Daily self-monitoring of blood glucose (SMBG) is essential for type 1 diabetes management yet is challenging during adolescence. Ecological momentary assessment (EMA) is the repeated sampling of behaviors and experiences in real time in the natural environment. The purpose of this study was to evaluate 1) the validity of self-reported SMBG values via text message-delivered EMA surveys compared with objective SMBG values via glucose meters and 2) in-the-moment motivators and barriers to performing SMBG in a pediatric type 1 diabetes population.

METHODS

Youth (n = 62, aged 11-21 years) with type 1 diabetes received three text messages daily for 10 days containing surveys inquiring about SMBG engagement. Objective SMBG values were downloaded from glucose meters.

RESULTS

On average, participants reported performing SMBG 4 times/day. Of the self-reported SMBG values, 39.6% were accurate. Inaccurate values included additions (i.e., self-reported value with no objective value), omissions (i.e., objective value with no self-reported value), and alterations (difference between self-report and objective SMBG values ≥10 mg/dL). Of the matched pairs of self-reported and objective SMBG values, 41.3% were altered. Bland-Altman plots determined that the mean difference between self-reported and objective glucose data were -5.43 mg/dL. Participants reported being motivated to check their blood glucose because it was important for their health, and reported barriers included wanting to ignore the task, forgetting, and not having devices.

CONCLUSION

Youth's self-reported SMBG values may not align with objective readings. The results of this study can facilitate future research to determine individual factors related to SMBG and accuracy of self-reporting.

Mother and Father Controlling Feeding Behaviors and Associations With Observed Mealtime Family Functioning

Objective

Mealtime family functioning is important in shaping health behaviors associated with overweight/obesity, particularly for preschool-aged children. Parental controlling feeding behaviors (i.e., restriction and pressure to eat), may impact mealtime family functioning and thus be targets of prevention and intervention efforts. The current study aimed to address literature gaps by examining both mother and father self-reports of controlling feeding behaviors, and the discrepancies between parents’ reports. Further, the study examined the associations among controlling feeding behaviors and objective mealtime family functioning in a community sample of preschool-aged children.

Methods

The sample included 27 children between 2 and 6 years of age and their immediate family members. Two mealtimes were videotaped for each family and coded for family functioning using the Mealtime Interaction Coding System, and self-reports of feeding practices were collected using the Child Feeding Questionnaire.

Results

Mother controlling feeding behaviors were not significantly related to any mealtime family functioning domain. Father controlling feeding behaviors were only significantly related to interpersonal involvement. However, discrepancies in the use of controlling feeding behaviors accounted for nearly one fourth of the variance in overall family functioning and affect management, with greater discrepancies being related to poorer family functioning.

Conclusions

Interventions may be designed to reduce parental discrepancies in the use of controlling feeding behaviors. Future research should consider longitudinal design, using larger, more representative samples, to better understand the impact of parental controlling feeding behaviors, particularly the impact of parental discrepancies in these areas, on mealtime family functioning and subsequent health outcomes.

Designing Online and Mobile Diabetes Education for Fathers of Children With Type 1 Diabetes: Mixed Methods Study

BACKGROUND

Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials.

OBJECTIVE

The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources.

METHODS

The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers' content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey.

RESULTS

Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again.

CONCLUSIONS

The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers' feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.

Transition Education for Young Adults With Type 1 Diabetes: Pilot Feasibility Study for a Group Telehealth Intervention

Background

Young adults with type 1 diabetes (T1D) experience a decline in glycemic outcomes and gaps in clinical care. A diabetes education and support program designed for young adults was delivered through group videoconference and mobile Web.

Objective

The objective of our study was to assess the feasibility, acceptability, and preliminary efficacy of the program as measured by attendance and webpage views, satisfaction, and pre- and postintervention psychosocial outcomes, respectively.

Methods

Young adults aged 18-25 years were recruited to attend five 30-minute group diabetes education videoconferences during an 8-week period. Videoconferences included an expert presentation followed by a moderated group discussion. Within 48 hours of each videoconference, participants were sent a link to more information on the study website. Feasibility was assessed using data on videoconference attendance and webpage views. Acceptability was assessed via a Satisfaction Survey completed at the conclusion of the study. Descriptive statistics were generated. Preliminary efficacy was assessed via a survey to measure changes in diabetes-specific self-efficacy and diabetes distress. Pre- and postintervention data were compared using paired samples t tests.

Results

In this study, 20 young adults (mean age 19.2 [SD 1.1] years) attended an average of 5.1 (SD 1.0) videoconferences equivalent to 153 (SD 30.6) minutes of diabetes education per participant during an 8-week period. Average participant satisfaction scores were 62.2 (SD 2.6) out of a possible 65 points. A total of 102 links sent via text message (short message service) or email resulted in 504 webpage views. There was no statistically significant difference between pre- and postintervention diabetes-specific self-efficacy or diabetes-related distress.

Conclusions

Delivery of diabetes education via group videoconference using mobile Web follow-up is feasible and acceptable to young adults with T1D. This model of care delivery has the potential to improve attendance, social support, and patient-reported satisfaction. Nevertheless, further research is required to establish the effect on long-term psychosocial and glycemic outcomes.

Telehealth interventions to reduce management complications in type 1 diabetes: A review

Type 1 diabetes is a chronic illness with a high burden of care. While effective interventions and recommendations for diabetes care exist, the intensive nature of diabetes management makes compliance difficult. This is especially true in children and adolescents as they have unique psychosocial and diabetes needs. Despite the development of effective in-person interventions targeting improving self-management and ameliorating psychosocial difficulties there are still a number of barriers to implementing these interventions, namely time, cost, and access. Telehealth interventions allow for the dissemination of these interventions to a broader audience. Self-management and psychosocial telehealth interventions are reviewed with a special emphasis on mobile phone and internet based technology use. While efficacy has been demonstrated in a number of telehealth interventions with improved cost effectiveness over in-person interventions, many challenges remain including high participant attrition and difficulties with receiving reimbursement for services rendered. These and other challenges are discussed with recommendations for researchers and telehealth providers provided.

Neuropsychological benefits of stationary bike exercise and a cybercycle exergame for older adults with diabetes: an exploratory analysis

OBJECTIVE

This quasi-experimental exploratory study investigated neuropsychological effects of exercise among older adults with diabetes mellitus (DM) compared with adults without diabetes (non-DM), and it examined the feasibility of using a stationary bike exergame as a form of exercise for older adults with and without diabetes. It is a secondary analysis that uses a small dataset from a larger randomized clinical trial (RCT) called the Cybercycle Study, which compared cognitive and physiological effects of traditional stationary cycling versus cybercycling.

METHODS

In the RCT and the secondary analysis, older adults living in eight independent living retirement facilities in the state of New York were enrolled in the study and assigned to exercise five times per week for 45 min per session (two times per week was considered acceptable for retention in the study) by using a stationary bicycle over the course of 3 months. They were randomly assigned to use either a standard stationary bicycle or a "cybercycle" with a video screen that displayed virtual terrains, virtual tours, and racing games with virtual competitors. For this secondary analysis, participants in the RCT who had type 2 DM (n = 10) were compared with age-matched non-DM exercisers (n = 10). The relationship between exercise and executive function (i.e., Color Trials 2, Digit Span Backwards, and Stroop C tests) was examined for DM and non-DM patients.

RESULTS

Older adults with and without diabetes were able to use cybercycles successfully and complete the study, so the feasibility of this form of exercise for this population was supported. However, in contrast with the larger RCT, this small subset did not demonstrate statistically significant differences in executive function between the participants who used cybercycles and those who used stationary bikes with no games or virtual content on a video screen. Therefore, the study combined the two groups and called them "exercisers" and compared cognitive outcomes for DM versus non-DM patients. As predicted, exercisers with DM exhibited significant gains in executive function as measured by the Color Trails 2 test, controlling for age and education, while non-DM exercisers did not significantly gain in this measure [group × time interaction, F(1,16]) = 9.75; p = .007].

CONCLUSIONS

These preliminary results support the growing literature that finds that exercise may improve cognition among older adult with DM. Additional research is needed to clarify why certain aspects of executive function might be differentially affected. The current findings may encourage physicians to prescribe exercise for diabetes management and may help motivate DM patients' compliance for engaging in physical activity.

Exergaming and older adult cognition: a cluster randomized clinical trial

BACKGROUND

Dementia cases may reach 100 million by 2050. Interventions are sought to curb or prevent cognitive decline. Exercise yields cognitive benefits, but few older adults exercise. Virtual reality-enhanced exercise or "exergames" may elicit greater participation.

PURPOSE

To test the following hypotheses: (1) stationary cycling with virtual reality tours ("cybercycle") will enhance executive function and clinical status more than traditional exercise; (2) exercise effort will explain improvement; and (3) brain-derived neurotrophic growth factor (BDNF) will increase.

DESIGN

Multi-site cluster randomized clinical trial (RCT) of the impact of 3 months of cybercycling versus traditional exercise, on cognitive function in older adults. Data were collected in 2008-2010; analyses were conducted in 2010-2011.

SETTING/PARTICIPANTS

102 older adults from eight retirement communities enrolled; 79 were randomized and 63 completed.

INTERVENTIONS

A recumbent stationary ergometer was utilized; virtual reality tours and competitors were enabled on the cybercycle.

MAIN OUTCOME MEASURES

Executive function (Color Trails Difference, Stroop C, Digits Backward); clinical status (mild cognitive impairment; MCI); exercise effort/fitness; and plasma BDNF.

RESULTS

Intent-to-treat analyses, controlling for age, education, and cluster randomization, revealed a significant group X time interaction for composite executive function (p=0.002). Cybercycling yielded a medium effect over traditional exercise (d=0.50). Cybercyclists had a 23% relative risk reduction in clinical progression to MCI. Exercise effort and fitness were comparable, suggesting another underlying mechanism. A significant group X time interaction for BDNF (p=0.05) indicated enhanced neuroplasticity among cybercyclists.

CONCLUSIONS

Cybercycling older adults achieved better cognitive function than traditional exercisers, for the same effort, suggesting that simultaneous cognitive and physical exercise has greater potential for preventing cognitive decline.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov NCT01167400.

Cognitive health benefits of strengthening exercise for community-dwelling older adults

While aerobic exercise has been linked to improved performance on cognitive tasks of executive functioning among older adults, not all older adults can avail themselves of such exercise due to physical limitations. In this study, community-dwelling older adults were evaluated on tasks of executive functioning before and after a month-long strengthening, nonaerobic exercise program. A total of 16 participants who engaged in such exercise showed significantly improved scores on Digits Backward and Stroop C tasks when compared to 16 participants who were on an exercise waiting list. Positive benefits of strengthening exercise on cognition are supported. Additional research is needed to clarify the generalizability of these findings.