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Diabetes Care Improvement by Point of Care Management Skills 

May 19, 2020
 
Editor: Steve Freed, R.PH., CDE

Author: Hira Gohar, Florida A&M University, College of Pharmacy, PharmD Candidate

Data focuses on veterans who have poorly controlled diabetes, and whether the intervention of  point of care, self-care management skills works as compared to using traditional means of education.  

In this two-phase behavioral randomized parallel clinical trial, researchers wanted to compare the effectiveness of self-reported patient activation and functional health literacy within a routine primary care practice versus those receiving enhanced usual care for diabetes management. This study was conducted on 284 Veterans who had poorly controlled diabetes with an average hemoglobin A1c that was greater than 8 percent.  

In phase one of this study, researchers focused on creating and initiating a diabetes goal-setting interference named “Empowering Patients in Chronic Care (EPIC).” EPIC was created to observe if veterans with poorly controlled diabetes had higher chances of self-reporting normal HgA1C levels and healthy blood glucose levels. Phase one of this trial was conducted by determining if one-on-one sessions with a designated Patient Aligned Care Team (PACT) member would be more beneficial as compared to its opposed comparative group. Patient Aligned Care Team members involve each veteran working side by side with healthcare professionals to plan for life extended health care for that specific patient. EPIC consisted of six 1-hour group sessions that focused heavily on patients’ health and values, ABCs of diabetes, setting goals and making action plans, communication with the health care provider, staying committed to their goals and reviewing and planning for their future. Once each group session ended, each Veteran was assigned to a specific PACT member who would work with the patient to create a collaborative goal that would help them achieve their goal in caring for their diabetes.  

In the comparative group, veterans with poorly controlled diabetes were undergoing a different interventional strategy called “EUC,” which stands for “Enhanced Usual Care.” Patients that were randomized to EUC to a PACT RN Care Manager for diabetes management also received a packet of educational materials regarding diabetes management that included a letter describing the available resources for diabetes management at their designated facility. The study had ended with a self-reported questionnaire and appropriate blood tests that were used to check their blood sugar levels at the beginning, post-intervention, and after six months of diabetes maintenance.  

Extensive research has suggested that one in four veterans who utilize the Veterans Affairs health care system have poorly controlled diabetes management skills. To maintain proper diabetes control in patients, self-management skills are deemed extraordinarily demanding and challenging to achieve due to a variety of reasons. Some of those reasons include time constraints at primary care appointments, narrow clinician training that goes along with behavioral changes, limited understanding of diabetes itself, and its proper management. As health care providers it is our job to create an overall understanding, especially for our veterans, to understand how to control their diabetes better effectively.   

There were two primary outcome measures; one included changes in percent glycosylated hemoglobin A1C levels during the intervention. The measurement of HgA1C was taken to assess average blood glucose levels throughout the study. Another primary outcome was the change in the quality of life; this was assessed using the Diabetes Distress Scale (DDS). The DDS was measured on a scale from 1 to 6. Higher scores showed an increased interval of diabetes distress.  

Analysis of primary outcome measures was as follows: 140 patients were assigned to the interventional “Empowering Patients in Chronic Care” group, and 140 patients were assigned to the “Enhanced Usual Care” group. In the interventional EPIC group, the differences in HbA1C at baseline, four months, and ten months were shown. At baseline, HgA1C levels did not change that much; at four months, levels decreased slightly as compared to the control group, and at ten months, HgA1C levels had a statistical difference in mean value – it being 0.11. This meant that the HgA1C in the EPIC group had shown significant reduction as compared to the control group. As for the other primary outcome – with the measurement of quality of life as seen with the Diabetes Distress Scale (DDS) – veterans in the EPIC interventional group had shown a lower level of diabetes distress at baseline, four months, and ten-month intervals. Data was also collected in determining all-cause mortality that showed nobody was affected in the EPIC interventional group versus in` the EUC control group, where four people were affected.  

This study concluded that veterans in the Empowering Patients in Chronic Care group had improved on their diabetes management skills as compared to the Enhanced Usual Care group. Diabetes affects nearly 25 percent of Veteran Affairs’ patient population. It is important to note that diabetes is also the leading cause of blindness, end-stage renal disease, and amputation for V.A. patients. This is hugely useful data that is needed for health care providers to use to better cater to veterans.  

Practice Pearls: 

  • Improvement of diabetes management skills is crucial towards achieving controlled blood glucose levels in veterans.  
  • Health care providers who interact/encounter veterans need to understand the dynamics of the Patient Aligned Health Care team and cohesively work together to provide better care for patients.  
  • Patients that have one-on-one interactions with their health care providers prove to show better improvement in achieving normal HgA1C levels.  

 

  1. Ladebue, Amy C, et al.The Experience of Patient Aligned Care Team (PACT) Members.Health Care Management Review, U.S. National Library of Medicine, 2016, https://www.ncbi.nlm.nih.gov/pubmed/25539056. 
  2. Office of Research & Development.Diabetes, https://www.research.va.gov/topics/diabetes.cfm.
  3. Point-of-Care Health Literacy and Activation Information to Improve Diabetes Care – Study Results.Point-of-Care Health Literacy and Activation Information to Improve Diabetes Care – Study Results – ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/results/NCT01876485?recrs=e&rslt=With&cond=diabetes&draw=4&rank=57.

 

Hira Gohar, Florida A&M University, College of Pharmacy, PharmD Candidate 

 

 

See more about point of care and other care management interventions.