You may delay, but time will not. Beta cells lost are never found again: a case for timely initiation of basal insulin in type 2 diabetes.

Since its first use just over a century ago, insulin treatment has evolved dramatically, such that the molecules are physiologic in nature, and treatment can now closely resemble the natural hormone response over 24 hours. Newer, longer-acting basal insulin analogs have provided insulin therapies with improved characteristics and, therefore, ease of use, and can readily be incorporated as part of routine treatment for type 2 diabetes (T2D), but evidence suggests that insulin remains underused in people with T2D. We review the barriers to initiation of basal insulin and the education needed to address these barriers, and we provide practical pointers, supported by evidence, for primary care physicians and advanced practice providers to facilitate timely initiation of basal insulin in the people with T2D who will benefit from such treatment.

Type 2 diabetes is a complex disease. It causes increased amounts of sugar in the blood, which can cause damage to the body. Medications are given to people with type 2 diabetes to keep their blood sugar at normal levels. Unfortunately, type 2 diabetes worsens over time, so regular adjustments to medications are needed to keep blood sugar levels controlled.Basal insulin, which is a type of insulin that works over the entire day, is a key treatment for type 2 diabetes. It works best if it is started as soon as other medications (tablets or non-insulin injections) are not working to control blood sugar levels. Unfortunately, delays in starting basal insulin are common. Some healthcare professionals and people with type 2 diabetes believe insulin is difficult to use. False information on insulin is common; for example, some people with diabetes believe that their symptoms are caused by insulin treatment rather than high blood sugar.This review summarizes key information to encourage effective conversations between healthcare professionals and people with type 2 diabetes about starting basal insulin. Proactive, positive, early discussion of the benefits of basal insulin can help to: 1) address concerns, 2) set appropriate, individual treatment targets, and 3) provide practical information and training to help with injecting insulin. This will give people living with type 2 diabetes the knowledge and confidence to take an active part in managing their diabetes and overcome any barriers to using basal insulin.

Ensuring Advanced Practice Nursing Students Meet the 2023 Drug Enforcement Agency Requirements.

BACKGROUND: All advanced practice nursing students in the doctor of nursing practice program at Johns Hopkins School of Nursing are required to complete 3 core courses (pathophysiology, pharmacology, and physical assessment). As of June 2023, the Drug Enforcement Agency (DEA) required all prescribers of controlled medications to attest to at least 8 hours of substance use training. PURPOSE: To quantify the amount of time advanced practice nursing students learn substance use-related content and engage in teaching/learning activities across the 3 courses as a basis for meeting the DEA requirement. METHODS: Lead course faculty teaching identified content related to substance use disorders, including reading assignments and skill-building activities, and the minimum amount of time that students spend in those teaching/learning experiences. RESULTS: Advanced practice nursing students complete a total of 14 hours of substance use-related content in the 3 core courses. CONCLUSIONS: This article describes substance use-related content and strategies that can be integrated in advanced practice nursing programs for students to meet the new DEA requirement.

Mobilizing nurses to address the opioid misuse epidemic.

BACKGROUND: The opioid epidemic is a major health challenge in the United States. PURPOSE: Members from the American Academy of Nursing joined to write a consensus paper about nurses' role in the opioid epidemic. METHODS: The panel reviewed the history of the opioid epidemic and policies to care for patients with opioid use disorder (OUD) and how registered nurses (RNs) and advanced practice nurses (APRNs) could increase care for people with OUD. DISCUSSION: Recommendations are presented to advance policies that empower RNs and APRNs to abate the opioid epidemic. CONCLUSION: Recommendations include (a) advance legislation that supports RNs and APRNs full scope of practice and expands professional role in pain management and addiction prevention; (b) evaluate effective policies that promote RN and APRN care; support federal elimination of X-waiver with state law alignment; (c) sustain the use of nurses in telemedicine; (d) support nursing research on nurse involvement in all aspects of OUD.

Experiences and Perceptions of Telehealth Visits in Diabetes Care During and After the COVID-19 Pandemic Among Adults With Type 2 Diabetes and Their Providers: Qualitative Study.

BACKGROUND: Since the COVID-19 pandemic, telehealth has been widely adopted in outpatient settings in the United States. Although telehealth visits are publicly accepted in different settings, little is known about the situation after the wide adoption of telehealth from the perspectives of adults with type 2 diabetes mellitus (T2D) and their providers. OBJECTIVE: This study aims to identify barriers and facilitators of maintaining continuity of care using telehealth for patients with T2D in a diabetes specialty clinic. METHODS: As the second phase of a multimethod study to understand missed appointments among adults with T2D, we conducted semistructured, individual, in-depth phone or Zoom interviews with 23 adults with T2D (14/23, 61% women; mean age 55.1, SD 14.4, range 35-77 years) and 10 providers from diabetes clinics in a tertiary academic medical center in Maryland. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis by the research team. RESULTS: Adults with T2D and their providers generally reported positive experiences with telehealth visits for diabetes care with some technical challenges resulting in the need for in-person visits. We identified the following 3 themes: (1) "perceived benefits of telehealth visits," such as convenience, time and financial efficiencies, and independence from caregivers, benefits shared by both patients and providers; (2) "perceived technological challenges of telehealth visits," such as disparities in digital health literacy, frustration caused by unstable internet connection, and difficulty sharing glucose data, challenges shared by both patients and providers; and (3) "impact of telehealth visits on the quality of diabetes care," including lack of diabetes quality measures and needs and preferences for in-person visits, shared mainly from providers' perspectives with some patient input. CONCLUSIONS: Telehealth is generally received positively in diabetes care with some persistent challenges that might compromise the quality of diabetes care. Telehealth technology and glucose data platforms must incorporate user experience and user-centered design to optimize telehealth use in diabetes care. Clinical practices need to consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care and to optimize diabetes outcomes. Policy flexibilities should also be considered to broaden access to diabetes care for all patients with T2D.

A Targeted Discharge Planning for High-Risk Readmissions: Focus on Patients and Caregivers.

PURPOSE OF STUDY: Racial and ethnic minorities with socioeconomic disadvantages are vulnerable to 30-day hospital readmissions. A 16-week quality improvement (QI) project aimed to decrease readmissions of the vulnerable patient populations through tailored discharge planning. The project evaluated the effectiveness of using a 25-item checklist to increase patients' and caregivers' health knowledge, skills, and willingness for self-care and decrease readmissions. PRIMARY PRACTICE SETTING: The project took place in an inner-city teaching hospital in the Mid-Atlantic region. METHODOLOGY AND PARTICIPANTS: A casual comparative design compared readmissions of the before-intervention group (May 1-July 31, 2021) and the after-intervention group (August 1-October 31, 2021). A pre- and postintervention design evaluated the effectiveness of a 25-item checklist by analyzing the differences of Patient Activation Measure (PAM) pre- and postintervention survey scores and levels in the after-intervention group. Participants were General Medicine Unit patients 18 years or older who had Medicare Fee-for-Service, resided in 10 zip codes near the hospital, and were discharged home. RESULTS: Of 30 patients who received the intervention, one patient was readmitted compared with 11 readmissions from 58 patients who did not receive the intervention. The readmission rate was decreased from 19% to 4% during the 16-week project: 11 (19%) versus 1 (4%), p = .038. After receiving the intervention, patients' PAM scores were increased by 8.55, t(22) = 2.67, p < .014. Three patients had a lower postintervention survey level, whereas 12 patients obtained a higher postintervention survey level (p = .01). The increase in scores and levels supported that the intervention effectively improved patients' self-management knowledge, skill, and willingness for self-care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The QI project showed that the hospital could partner with patients at high risk for readmission and their caregivers. Accurate evaluation of patients' health knowledge, skills, and willingness for self-care was essential for sufficient discharge planning. Tailored use of the checklist improved patients' self-activation and functionally facilitated patients' and caregivers' care needs and capabilities. The checklist was statistically and clinically effective in decreasing 30-day hospital readmissions of vulnerable patient populations.

Predictors of Follow-Up Appointment No-Shows Before and During COVID Among Adults with Type 2 Diabetes.

Background: The coronavirus disease 2019 (COVID-19) pandemic has rapidly transformed health care delivery into telehealth visits. Attending regular medical appointments are critical to prevent or delay diabetes-related complications. Although telehealth visits have addressed some barriers to in-person visits, appointment no-shows are still noted in the telehealth setting. It is not completely clear how the predictors of appointment no-shows differ between in-person and telehealth visits in diabetes care. Objective: This retrospective study examined if predictors of appointment no-shows differ (1) between pre-COVID (January 1, 2019-March 22, 2020) and COVID (March 23, 2020-December 31, 2020) periods and (2) by health care delivery modes (in-person or telehealth visits) during COVID among adults with type 2 diabetes mellitus (T2DM). Methods: We used electronic health records between January 1, 2019 and December 31, 2020 across four diabetes clinics in a tertiary academic hospital in Baltimore, Maryland. Appointments marked as completed or no-show by established adults with T2DM were included in the analyses. Results: Among 7,276 appointments made by 2,235 patients, overall appointment no-show was 14.99%. Being older and White were protective against appointment no-shows in both unadjusted and adjusted models during both time periods. The interaction terms of COVID periods (i.e., pre-COVID vs. COVID) were significant for when glycated hemoglobin drawn before this visit and for missing body mass index. Telehealth visits during COVID decreased more half of the odds of appointment no-shows. Conclusions: In the context of diabetes care, the implementation of telehealth reduced appointment no-shows. Future studies are needed to address social determinants of health, including access to internet access, to further reduce health disparities among adults with T2DM.

The impact of the COVID-19 pandemic on the future of telehealth in primary care.

This policy paper reviews the history, use and significance of telehealth in primary care. The emergence of telehealth as a primary strategy to continue to deliver value based, timely primary care during COVID-19 is discussed with recommendations for future applications, payment and preparation of providers to continue to provide quality care of clients in the future using telehealth.

Factors associated with missed appointments by adults with type 2 diabetes mellitus: a systematic review.

Keeping regular medical appointments is a key indicator of patient engagement in diabetes care. Nevertheless, a significant proportion of adults with type 2 diabetes mellitus (T2DM) miss their regular medical appointments. In order to prevent and delay diabetes-related complications, it is essential to understand the factors associated with missed appointments among adults with T2DM. We synthesized evidence concerning factors associated with missed appointments among adults with T2DM. Using five electronic databases, including PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Web of Science, a systematic literature search was done to identify studies that describe factors related to missed appointments by adults with T2DM. A total of 18 articles met the inclusion criteria. The majority of studies included in this review were cohort studies using medical records. While more than half of the studies were of high quality, the operational definitions of missed appointments varied greatly across studies. Factors associated with missed appointments were categorized as patient characteristics, healthcare system and provider factors and interpersonal factors with inconsistent findings. Patient characteristics was the most commonly addressed category, followed by health system and provider factors. Only three studies addressed interpersonal factors, two of which were qualitative. An increasing number of people live with one or more chronic conditions which require more careful attention to patient-centered care and support. Future research is warranted to address interpersonal factors from patient perspectives to better understand the underlying causes of missed appointments among adults with T2DM.

A 10-year evaluation of projects in a doctor of nursing practice programme.

AIMS AND OBJECTIVES: The role of professional doctorates is receiving increased attention internationally. As part of building the rigour and scholarship of these programmes, we assessed projects undertaken as part of a doctor of nursing practice (DNP) programme at Johns Hopkins University. Recommendations for programme development in professional doctorates are provided. BACKGROUND: Past research has described the methodologic limitations and dissemination of DNP projects. However, few studies have provided recommendations for strengthening these projects and alternative strategies for achieving scale in larger student cohorts. DESIGN: A descriptive study reported in accordance with STROBE guidelines. METHODS: From 2009-2018, 191 final DNP project reports were obtained from the DNP programme administrator. Essential project characteristics from the papers were extracted, including use of theoretical framework, design, setting, sample and dissemination through publication. To determine whether the results of the projects had been published, the title and student's name were searched in Google Scholar and Google. RESULTS: Of the 191 projects, 83% focused on adults and 61% were conducted in the hospital setting. Sample sizes ranged from 7 to 24,702. Eighty per cent of the projects employed a pretest/post-test design, including both single and independent groups. The projects spanned six overarching themes, including process improvement, clinician development, patient safety, patient outcome improvement, access to care and workplace environment. Twenty-one per cent of the project findings were published in scholarly journals. CONCLUSIONS: Conducting a critical review of DNP projects has been useful in refining a strategy shifting from incremental to transformative changes in advanced practice. RELEVANCE TO CLINICAL PRACTICE: Programme evaluation is critical in order to sufficiently prepare nurses in advanced nursing practice to influence healthcare outcomes at the individual or population level.

Health literacy enhanced intervention for inner-city African Americans with uncontrolled diabetes: a pilot study.

BACKGROUND: Disparities in diagnosis and control of type 2 diabetes mellitus are most evident in African Americans (AAs) with lower socioeconomic status. Health literacy is an important predictor of adequate self-management and control of diabetes. The purpose of this pilot study was to test the feasibility and preliminary efficacy of a health literacy-enhanced diabetes intervention, PLAN 4 Success (Prevention through Lifestyle intervention And Numeracy)-Diabetes, in inner-city, low-income AAs with uncontrolled type 2 diabetes. METHODS: Nineteen of 30 participants who completed the baseline survey received the study intervention which consisted of 4-week health literacy training and disease knowledge education followed by two home visits and monthly phone counseling for over 24 weeks. RESULTS: A retention rate of 58% was achieved at 24 weeks. All participants who completed the follow-up assessment at 24 weeks reported high satisfaction with the intervention. Participation in the PLAN 4 Success-Diabetes was associated with improved glucose control and psychological outcomes at 12 weeks but the positive trend was attenuated at 24 weeks. CONCLUSIONS: The current intervention protocols were in general feasible and highly acceptable. The results support health literacy training as a promising component of interventions to promote glucose control among inner-city AAs. Some changes are suggested to optimize the protocols, before conducting a randomized controlled trial. Future interventions should consider addressing social determinants of health such as transportation as part of designing an intervention targeting low-income AAs with uncontrolled type 2 diabetes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03925948. Registered on 24 April 2019-retrospectively registered.

Views of regulatory authorities on standards to assure quality in online nursing education.

BACKGROUND: With the rapid growth in online education programs in nursing, quality of education through this modality is becoming of greater importance. PURPOSE: This paper aims to explore current recommendations and standards for quality in online nursing education offered by nursing regulatory, accrediting, and licensing organizations. METHOD: Individual interviews were conducted with the leaders from four accrediting, licensing and certifying organizations in nursing about their perspectives on quality standards for online education. FINDINGS: The following themes emerged from the qualitative interviews: Theme 1- Standards are not specific to online education; Theme 2-This is not up to us - Professional organizations can offer recommendations but not responsible for regulations; and Theme 3- Each institution has responsibility to provide support and evaluate the quality of online education. DISCUSSION: Schools of nursing should continue to incorporate current standards for quality in online education as the methods of delivery continue to evolve in this highly technologically-oriented world.

eHealth Literacy in People Living with HIV: Systematic Review.

BACKGROUND: In the era of eHealth, eHealth literacy is emerging as a key concept to promote self-management of chronic conditions such as HIV. However, there is a paucity of research focused on eHealth literacy for people living with HIV (PLWH) as a means of improving their adherence to HIV care and health outcome. OBJECTIVE: The objective of this study was to critically appraise the types, scope, and nature of studies addressing eHealth literacy as a study variable in PLWH. METHODS: This systematic review used comprehensive database searches, such as PubMed, EMBASE, CINAHL, Web of Science, and Cochrane, to identify quantitative studies targeting PLWH published in English before May 2017 with eHealth literacy as a study variable. RESULTS: We identified 56 unique records, and 7 papers met the eligibility criteria. The types of study designs varied (descriptive, n=3; quasi-experimental, n=3; and experimental, n=1) and often involved community-based settings (n=5), with sample sizes ranging from 18 to 895. In regards to instruments used, 3 studies measured eHealth literacy with validated instruments such as the eHealth Literacy Scale (eHEALS); 2 studies used full or short versions of Test of Functional Health Literacy in Adults, whereas the remaining 2 studies used study-developed questions. The majority of studies included in the review reported high eHealth literacy among the samples. The associations between eHealth literacy and health outcomes in PLWH were not consistent. In the areas of HIV transmission risk, retention in care, treatment adherence, and virological suppression, the role of eHealth literacy is still not fully understood. Furthermore, the implications for future research are discussed. CONCLUSIONS: Understanding the role of eHealth literacy is an essential step to encourage PLWH to be actively engaged in their health care. Avenues to pursue in the role of eHealth literacy and PLWH should consider the development and use of standardized eHealth literacy definitions and measures.

Evaluation of a Worksite Diabetes Education Program at a Large Urban Medical Center.

Evidence suggests that diabetes education can be delivered at the worksite to better support employees' diabetes self-management and improve productivity and health care costs. This study was conducted to address the feasibility of a diabetes worksite education program for employees at a large urban academic health care institution. The diabetes education program was delivered in the diabetes center at the institution, a resource that was previously underutilized by employees. Through collaboration with groups in the institution, 20 employees of diverse ethnicity participated in the worksite diabetes education program with positive outcomes: improved glycemic control measured (HbA1c), attainment of self-management goals, and satisfaction with the program. Work absences trended downward, but numbers of hospitalizations and emergency department visits were unchanged in the 3 months following education. Recommendations include replication of the study with more employee participation and program evaluation over a longer period of time to continue assessment of employees' educational needs.

A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes.

Basal-prandial insulin therapy is a physiologic approach to insulin delivery that utilizes multiple daily injections to cover both basal (ie, overnight fasting and between-meal) and prandial (ie, glucose excursions above basal at mealtime) insulin needs. While basal-prandial therapy with multiple daily injections is an important therapeutic option for patients with type 2 diabetes, there is a common perception that this therapy is difficult to initiate in the primary care setting. To address this issue, a panel of clinical experts convened to develop practical recommendations on how to initiate basal-prandial therapy in patients with type 2 diabetes, focusing on patient selection, simple dosing and titration, and monitoring. Patients with type 2 diabetes who are appropriate candidates for basal-prandial insulin therapy include those who: 1) are unable to achieve glycemic control on oral antidiabetic drugs, 2) are unable to achieve glycemic control on split-mixed/premixed insulin regimens, 3) are newly diagnosed but unlikely to respond to oral antidiabetic drugs alone (ie, the patient has severe hyperglycemia or a markedly elevated glycosylated hemoglobin A1C level for which oral antidiabetic drug therapy alone is unlikely to achieve goals), and 4) prefer this therapy due to socioeconomic or other individual considerations. Basal-prandial insulin can be initiated in a simple stepwise manner, starting first with the addition of basal insulin to the existing oral antidiabetic drug regimen, followed by the introduction of 1 prandial insulin injection to the basal insulin plus oral antidiabetic drug regimen (after basal insulin has been optimized). Subsequently, other injections of prandial insulin may be added when needed. Based on home glucose monitoring data, patients may be converted from split-mixed or premixed insulin regimens to basal-prandial regimens with similar ease. Basal-prandial therapy using newer insulin formulations, such as long- and rapid-acting insulin analogs, can be relatively simple to use in patients with type 2 diabetes and is an appropriate methodology for application by primary care clinicians.

Overcoming psychological barriers to insulin use in type 2 diabetes.

Type 2 diabetes mellitus (DM) is characterized by a gradual decrease in insulin sensitivity in peripheral tissues and the liver (insulin resistance), followed by a gradual decline in beta-cell function and insulin secretion. Given this decline, many patients with type 2 DM will require insulin therapy to achieve the glycemic target recommended by the American Diabetes Association of glycosylated hemoglobin (A1C) <7%. The combination of insulin plus oral antidiabetic drugs (OADs) has been shown to improve A1C values in patients who were not adequately controlled with OADs alone. Despite its established benefits, however, insulin therapy continues to be underused. The reluctance to initiate insulin therapy is often related to both provider and patient misperceptions about insulin's efficacy and side effects, as well as the perceived complexity of the treatment regimen. In addition, insulin therapy may be viewed as a "last resort" treatment option for severe disease or as "punishment" for patients' failure to manage their disease. However, patients should be made aware from the time of diagnosis that diabetes is a progressive disease and that it is likely that insulin therapy will be required at some point during the course of the disease. The subject of insulin therapy, therefore, should be approached positively and should be presented as an effective and flexible way to achieve glycemic goals for any patient at any time during therapy.

Early intervention to achieve optimal outcomes in type 2 diabetes: a case presentation.

Type 2 diabetes mellitus (DM) is a progressive disease characterized by insulin resistance and impaired insulin secretion. To compensate for these metabolic dysfunctions, pancreatic beta-cells begin to overproduce insulin; however, it is this compensatory mechanism that eventually results in beta-cell exhaustion, impaired insulin secretion, and relative insulin deficiency. The metabolic abnormalities associated with diabetes also contribute to vascular dysfunction and an increased risk of coronary heart disease. Among patients with type 2 DM, cardiovascular disease, particularly macrovascular disease, is the primary cause of mortality, accounting for 55% of deaths. Management of the disease, therefore, must address all of the contributing factors, including a sedentary lifestyle and diet that contribute to overweight/obesity, and comorbidities such as hypertension and dyslipidemia. In this paper, we present a case study based on actual clinical experience to illustrate an evidence-based rationale for early and aggressive intervention for patients with type 2 DM, including lifestyle modification, oral antidiabetic agents, and insulin.