S Daneeka Armont-Woods, MSN, APRN, NP-C S Adult Nurse Practitioner S - - PowerPoint PPT Presentation
The Feasibility of Implementing a Diabetes Distress Toolkit to Improve Outcomes in Adults with Uncontrolled Type 2 Diabetes: A DNP Project Daneeka Armont-Woods, MSN, APRN, NP-C DNP Candidate Southeastern Louisiana University Laurie Kinchen,
The Feasibility of Implementing a Diabetes Distress Toolkit to Improve Outcomes in Adults with Uncontrolled Type 2 Diabetes: A DNP Project
Daneeka Armont-Woods, MSN, APRN, NP-C DNP Candidate Southeastern Louisiana University Laurie Kinchen, DNP, APRN, PNP, DNP Project Committee Chair Christine Hadeed, DNP, APRN, ACNP, Second Faculty Committee Member Karen Rice, DNS, APRN, ACNS-BC, ANP, Facility Mentor
S Adult Nurse Practitioner S Graduated with BSN in 2002 from Dillard University of
New Orleans, LA
S Graduated with MSN in 2009 from Southeastern Louisiana
University of Hammond, LA
S Has worked as a Nurse Practitioner in the Diabetes
Specialty Clinic of Ochsner Medical Center of New Orleans since February 2010
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Over 29 million people in the United States have diabetes
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Diabetes is the seventh leading cause of death in the United States
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Medical expenditures for those with diabetes are significantly higher than those without diabetes
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Direct (medications/treatments, hospitalizations) and indirect costs (disability, premature death, lost of income) of diabetes=$245 billion
<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
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Diabetes Distress (DD) are those emotional concerns, worries, fears, and anxieties that frequently accompany a chronic disease such as diabetes (Fisher, Hessler, Masharani, & Strycker, 2014, p. 740).
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DD is associated with poor diabetes control and self-management (Fisher et al., 2014, p. 740).
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DD impacts as many as 40% of people diagnosed with diabetes and can increase
Davies, Lindsay, & Dempster, 2015, p. 279).
S Increases in DD are associated with feelings of
fear, anger, and resentment, which can lead to worsening diabetes control (Philips, 2014, p. 615).
S Interventions to reduce DD can lead to
improvements in diabetes care.
S Reduced DD is anticipated to improve diabetes
S Evaluate the feasibility of measuring DD and piloting a
toolkit anticipated to improve DD and diabetes-related
Trusting, caring relationship
Expression
Allowance for spiritual forces Teaching- learning Assisting with basic human needs Sensitivity to self & others Instilling faith and hope Humanistic/ altruistic value system Supportive/p rotective environment Creative problem solving
Jean Watson’s Theory of Human Caring
S Cumulative Index to Nursing and Allied Health Literature
(CINAHL), Medline, and Pubmed searched.
S Keywords: T2DM, diabetes distress, glycemic control, support S 225 articles initial yield S Excluded articles: Type 1 diabetes, depression, group support
without diabetes.
S 24 articles included
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Intervention trials should target individuals with high A1C and DD levels (Berry et al., 2015).
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There is a significant association between distress and A1C (Fisher, Glasgow, & Strycker, 2010).
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DD is responsive to interventions (Fisher, Hessler, Glasgow, Arean, Masharani, Naranjo, & Strycker, 2013).
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Decreases in regimen distress are associated with improvements in A1C and self- management (Hessler, Fisher, Glasgow, Strycker, Dickinson, Arean, & Masharani, 2014).
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More attention should be given to non-clinical factors when addressing diabetes related distress (Karlsen & Bru, 2014).
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Changes in DD are associated with changes in glycemic control for patients with uncontrolled T2DM (Zagarins, Allen, Garb, & Welch, 2012).
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Adherence to diabetes treatment is linked to DD more than depression (Zhang, Xu, Wu, Xue, Xu, Li, Gao, & Liu, 2013).
Author Publication Year Publication Impact Factor Level of Evidence Berry, Lockhart, Davies, Lindsay, & Dempster 2015 Postgraduate Medical Journal 1.448 VI Dale, Williams, & Bowyer 2012 Diabetic Medicine 3.241 I Fisher et al. 2007 Diabetes Care 7.851 IV Fisher, Glasgow, & Strycker 2010 Diabetes Care 7.141 II Fisher, Hessler, Polonsky, & Mullan 2012 Diabetes Care 7.735 IV Fisher et al. 2013 Diabetes Care 8.570 II Fisher, Hessler, Masharani, & Strycker 2014 Diabetic Medicine 3.115 II Fonda, McMahon, Gomes, Hickson, & Conlin 2009 JDST N/A II Hessler et al. 2014 Diabetes Care 8.420 II Jansen et al. 2014 Diabetes Care 8.420 II Karlsen & Bru 2014 IJNS 2.901 IV Liu et al. 2014 JDI 1.825 II Partiprajak, Hanucharurnkul, Piaseu, Brooten, & Nityasuddhi 2011 PRIJN N/A II Phillips, A. 2014 Practice Nursing N/A VI Pick, A. 2009 Practice Nursing N/A IV Polonsky et al. 2005 Diabetes Care 7.844 VI
Author Publication Year Publication Impact Factor Level of Evidence Sarwat et al. 2010 Diabetic Medicine 3.036 II Smaldone et al. 2006 Diabetes Care 7.912 VI Tovote et al. 2014 Diabetes Care 8.420 II Vries et al. 2014 BMC Endocrine Disorders 1.710 II Wagner, Tennen, Feinn, & Osborn 2015 JOI 1.482 (2014) IV Yu et al. 2014 BMC Medical Informatics Decision Making 1.830 IV Zagarins, Allen, Garb, & Welch 2012 JBM 2.216 II Zhang et al. 2013 NDT 2.154 VI
4% 50% 25% 21%
Articles
Level I Level II Level IV Level VI
S Is it feasible to measure DD and implement a DD toolkit in
patients with T2DM being treated in an APRN-led diabetes specialty clinic?
S What are the reports of patients with uncontrolled T2DM and
moderate to high DD in those that used the interventions in the toolkit versus those that did not use the interventions?
S What are the diabetic outcomes in those with T2DM with
moderate to high DD that used the toolkit compared to those that did not use the toolkit?
S What are the barriers and facilitators in those patients with T2DM
and moderate to high DD that used the DD toolkit?
S Quality improvement design S Quality improvement projects in healthcare entail efforts
that seek to improve services for the future (Moran, Burson, & Conrad, 2014).
S Screen patients presenting to the advanced practice
registered nurse (APRN)-led diabetes specialty clinic for DD.
S 17-item DD survey (DDS-17) completed in the waiting room
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DDS-17: Developed by Dr. Polonsky and Dr. Fisher
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Emotional burden
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Physician/provider related distress
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Regimen Distress
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Interpersonal Distress
S All patients completing the DDS-17 received a copy of the
DD toolkit
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Uncontrolled T2DM (A1C ≥ 7%), and at least moderate DD via a score of 3
and all interventions were explained in detail.
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A1C.
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Exclusion: Type 1 Diabetes, depression, A1C <7%, altered mental status.
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Clinic visit evaluation completed
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Telephone survey 4-6 weeks after initial visit.
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Telephone visit evaluation completed
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Return visit in 3-4 months
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17-item DD survey and review A1C .
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All information entered into an Excel spreadsheet for data analysis
S Primary endpoint: the feasibility of measuring DD and
implementing the toolkit.
S Secondary outcomes
S A1C S DD levels
Assessed for eligibility (N=175) T2DM A1C 7% or greater Able to complete DDS-17 Age 18 and older Score of 3 or more in overall DD or subscales Excluded (N=162) Not meeting inclusion criteria (n=12) Type 1 Diabetes (n=5) Depression (n=6) A1C <7% (n=1) Refused to Complete DDS-17 (n=1) No time to complete DDS-17 (n=31) Not identified with any component of DD (n=118) Consented participants (N=13) Completed pre DDS-17 Received DD toolkit Lost to follow up (N=2) Did not complete post DDS-17 Analyzed (N=11)
Sample sized based
360 with a 95% confidence level, 5% error resulted in 189. Survey response rate=81.71%
Variable Any Diabetes Distress [M(SD)] Range Age 59.64(11.79) 35-80 Years of Diabetes 19.45(11.73) 7-50 Variable Pre (n=11) Post (n=11) Percent change A1C % [M(SD)] 10.01(0.97) 8.73(0.81) 12.79 ↓ Total DD [n(%)] 7(64) 0(0) 100 ↓ Emotional burden subscale 9(82) 1(9) 88.89 ↓ Physician distress subscale 1(9) 0(0) 100 ↓ Regimen distress subscale 10(91) 0(0) 100 ↓ Interpersonal distress subscale 5(45) 2(18.18) 60 ↓
1 2 3 4 5 6 7 Online Website Writing down readings Made a list of support people Attended support group Journaled Feelings
Use of Toolkit Interventions
Use of Toolkit Interventions
Sex Age Online website Writing down glucose readings Made a list
supportive people Attended support group Kept a journal of feelings Percent change in A1C F 63 Yes No No No No 12.5 ↓ F 54 No Yes No No No 0.96 ↓ M 64 No Yes No Yes No 18.18 ↓ F 35 No No No No Yes 36.15 ↓ F 61 No Yes No No No 13.42 ↑ M 50 Yes No Yes Yes Yes 25.62 ↓ F 68 No Yes No No No 16.67 ↓ F 70 No Yes No No Yes 1.25 ↓ M 80 No Yes No No No 2.33 ↓
Toolkit Use and Percent Change in A1C
Toolkit Use n=11 Pre A1c (M[SD]) Post A1c (M[SD]) % Change Did not use any component 2 10.75 (0.64) 9.3 (2.26) 13.08↓ Used > 1 components (all users) 9 9.38 (0.88) 8.15 (0.25) 13.11↓ Used 1 component 6 8.75 (0.88) 7.97 (1.77) 8.91↓ Used > 2 components 3 10.00 (2.05) 8.33 (0.59) 16.70↓
Descriptive statistics for participants’ self-reported use of the toolkit (n=11)
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Is it feasible to measure DD and implement a DD toolkit in patients with T2DM being treated in an APRN-led diabetes specialty clinic?
S
What are the reports of patients with uncontrolled T2DM and moderate to high DD in those that used the interventions in the toolkit versus those that did not use the interventions?
and distress in each subscale
Online website helpful in choosing foods and aiding in diabetes self-care Glucose monitoring increased self- accountability; support group helpful Common themes in those not using any interventions were lack of time, no desire, no transportation, or no computer/Internet access.
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What are the diabetic outcomes in T2DM with moderate to high DD that used the toolkit compared to those that did not use the toolkit?
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What are the barriers and facilitators in those patients with T2DM and moderate to high DD that used the DD toolkit? No use: 13.08% decrease 1 component: 8.91% decrease 2 or more components: 16.70% decrease Computer/Internet access Transportation Self-motivation Lack of financial burden
S Conducted in one setting S Some interventions required access to a computer and/or
transportation
S Recall bias in telephone surveys S Low participation S Established relationship with APRN S Consenting process during clinic appointment S Changes in diabetes medications/doses
S These findings of improved DD and A1C levels from this
project reinforce the need to change the current practice in the clinical setting and screen patients for DD.
S APRN education on DD and implementing a screening tool
with interventions can be helpful in improving patient care.
S Guidelines on diabetes care could eventually change to
reflect the need to screen for DD as a part of routine diabetes care.
S Low cost and minimal use of additional resources. S Screening for DD supported in the literature. S Suggestions for improvement
S Expand screening for DD to all APRN patients in the diabetes
specialty clinic
S Provide patients with information on DD before using the
screening tool.
S Provide those without internet access or transportation with
additional resources could be beneficial
S Avoid consenting during the clinic visit time
S Explore ways to combat possible social desirability S Avoid changing diabetes regimen during the intervention S If regimen changed, keep track of which participants
regimen was changed
S Diabetes Specialty Clinic department presentation: March
7, 2017
S Podium presentation at Sigma Theta Tau Research Day:
April 21, 2017
S Podium and poster presentation at OHS Research Night:
May 16, 2017
S OHS RN residency program: June 14, 2017 S Speaker at Endocrinology and Diabetes Summit: September
2017
S DD is related to uncontrolled diabetes and poor outcomes S It is feasible to screen for DD in the clinical setting and
implement interventions
S Interventions aimed at improving DD and diabetes should
extend into the personal environment of patients as well as family members
S Diabetes is a chronic problem that requires the use of
evidence based practices and quality improvement initiatives
S Screening for DD and implementing interventions to target
DD can help to improve diabetes outcomes
American Diabetes Association. (2015). Statistics about diabetes. National Diabetes Statistics Report. Retrieved from http://www.diabetes.org/diabetes- basics/statistics/ Berry, E., Lockhart, S., Davies, M., Lindsay, J.R., & Dempster, M. (2015). Diabetes distress: Understanding the hidden struggles of living with diabetes and exploring intervention strategies. Postgraduate Medical Journal, 91, 278-283. Centers for Disease Control and Prevention. (2014). Estimates of Diabetes and its burden in the Untied
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Jansen, H.J., Vervoort, G.M.M., de Haan, A.F.J., Netten, P.M., de Grauw, W .J., Tack, C.J. (2014). Diabetes- related distress, insulin dose, and age contribute to insulin-associated weight gain in patients with type 2 diabetes: Results of a prospective study. Diabetes Care, 37, 2710-2717. Karlsen, B. & Bru, E. (2014). The relationship between diabetes-related distress and clinical variables and perceived support among adults with type 2 diabetes: A prospective study. International Journal of Nursing Studies, 51, 438-447. Liu, Y., Han, Y., Shi, J., Li, R., Li, S., Jin, N., Gu, Y., & Guo, H. (2014). Effect of peer education on self- management and psychological status in type 2 diabetes patients with emotional disorders. Journal
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