Toward Reliable Symptom Coding in Electronic Health Records for Symptom Assessment and Research: Identification and Categorization of International Classification of Diseases, Ninth Revision, Clinical Modification Symptom Codes.

To date, symptom documentation has mostly relied on clinical notes in electronic health records or patient-reported outcomes using disease-specific symptom inventories. To provide a common and precise language for symptom recording, assessment, and research, a comprehensive list of symptom codes is needed. The International Classification of Diseases, Ninth Revision or its clinical modification ( International Classification of Diseases, Ninth Revision, Clinical Modification ) has a range of codes designated for symptoms, but it does not contain codes for all possible symptoms, and not all codes in that range are symptom related. This study aimed to identify and categorize the first list of International Classification of Diseases, Ninth Revision, Clinical Modification symptom codes for a general population and demonstrate their use to characterize symptoms of patients with type 2 diabetes mellitus in the Cerner database. A list of potential symptom codes was automatically extracted from the Unified Medical Language System Metathesaurus. Two clinical experts in symptom science and diabetes manually reviewed this list to identify and categorize codes as symptoms. A total of 1888 International Classification of Diseases, Ninth Revision, Clinical Modification symptom codes were identified and categorized into 65 categories. The symptom characterization using the newly obtained symptom codes and categories was found to be more reasonable than that using the previous symptom codes and categories on the same Cerner diabetes cohort.

Reducing health-related stigma in adults living with chronic non-communicable diseases: A systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review was to synthesize the components of interventions that are aimed at reducing stigma among adults living with chronic non-communicable diseases (NCDs). A secondary objective was to assess the effectiveness of interventions in reducing health-related stigma. METHODS: A search was conducted on OVID MEDLINE, OVID APA PsycINFO, EBSCO CINAHL Complete, Web of Science, and Cochrane Central in July 2023 for articles that report the development and/or testing of health-related stigma-reduction interventions among adults with NCDs. The quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklists. Intervention components were narratively synthesized. The DerSimonian-Laird random effect model was used to pool standardized mean differences across studies. RESULTS: Nineteen articles were included in the review. Interventions addressed individual level (intrapersonal and interpersonal) and structural level stigmas. Components of intrapersonal interventions included cognitive exercises, stress reduction, promoting self-efficacy, developing communication skills, and listening to other patients' stories. Contact-based interventions were used in many interpersonal interventions. Structural interventions included mass media campaigns and training for healthcare professionals. Pooled intervention effects indicated a significant reduction in stigma levels post-intervention for both persons with NCD (Hedge's g = -1.13; 95% CI: 1.66, -0.60, I2 = 85%, N = 6 studies) and those without (Hedge's g = -2.45, 95% -4.84, -0.06; I2 = 97%, N = 2 studies). CONCLUSION: Interventions to address NCD stigma, although multifaceted, are often not multilevel. Future studies are needed to design and test multilevel NCD stigma-reduction interventions.

Impact of Negative or Stigmatizing Messages on Diabetes Outcomes: An Integrative Review.

PURPOSE: The purpose was to determine if negative or stigmatizing language and messaging have an impact on diabetes distress, outcomes, or care behaviors in people with diabetes. Since 2012, when the first language position statement was published, the way health care professionals talk to people with diabetes has been an ongoing topic of discussion. However, there have been no recent literature reviews evaluating the impact of problem language on outcomes among people with type 1 and type 2 diabetes. METHODS: An integrative review was conducted using 4 electronic databases: CINAHL, Embase, Web of Science, and Medline (Ovid). Studies reporting on diabetes, language, stigma, diabetes distress, glycemic outcomes, and self-care behaviors were included. RESULTS: The review included 9 studies, all of which were of high quality. The impact of negative or stigmatizing language on self-care behaviors was the most commonly addressed outcome. Whereas some studies revealed no change, others reported a decrease in self-care behaviors by people with diabetes who had negative perceptions of provider messages. Actual or perceived use of negative or stigmatizing language is linked to higher A1C. Four studies reported an association between messages and diabetes distress. CONCLUSIONS: Negative/stigmatizing language has both an immediate and long-term effect on people with diabetes. The inconsistent approaches to studying language in diabetes makes it challenging to compare outcomes and identify themes. Future research is needed to identify effective interventions to change the messages in diabetes.

Patient competence in chronic illness: A concept derivation.

AIMS AND OBJECTIVES: This paper aims to inform nursing and other healthcare disciplines by clearly defining patient competence and the skills required to improve self-care behaviours. BACKGROUND: Competence has been defined in education and leadership. However, competence in persons with chronic disease has not been expanded upon since one publication in 1983. Patient competence needs to be developed and defined so that healthcare disciplines can understand the attributes necessary for a patient to be deemed competent to promote self-care behaviours. DESIGN: A concept derivation. METHODS: Walker and Avant's approach to concept derivation was used to identify a base concept (competence) that is well-defined in another field, define the concepts associated with the parent field, and transpose that definition to a new field to formulate a redefined concept. PsycINFO, Scopus, Web of Science and Medline were searched, and 21 articles were included. RESULTS: Patient competence is defined as the ability of a person with a chronic illness to reach skill mastery, achieve knowledge, maintain a positive attitude and develop trust in themselves and in healthcare providers that will facilitate active engagement to improve self-care behaviours. CONCLUSIONS: Defining patient competence is important in assisting nurses and other healthcare providers in understanding the attributes needed to deem a patient competent, especially those living with chronic illnesses requiring lifelong self-care behaviours. More research is needed to aid in the designing of a precise instrument for measuring this phenomenon. RELEVANCE TO CLINICAL PRACTICE: Concept derivation of patient competence provides a framework for nurses and other members of the healthcare profession to understand the attributes needed to determine patient competence.

Impact of Gaming (Gamification) on Diabetes Self-Care Behaviors and Glycemic Outcomes Among Adults With Type 2 Diabetes.

PURPOSE: The purpose of this systematic review was to determine if the use of gaming (gamification) among persons with type 2 diabetes improves diabetes self-management behaviors and diabetes outcomes. METHODS: A systematic review was conducted using electronic databases including MEDLINE, Embase, Web of Science, and CINAHL. Studies reporting on the impact of gaming on at least 1 of the Association of Diabetes Care and Education Specialists self-care behaviors (ADCES7) were included. RESULTS: The review included 9 studies, 8 of which were of strong/high quality. Five of the self-care behaviors were addressed in at least 1 of the included studies. However, taking medications and problem solving were not reported in any of the studies. Physical activity and self-efficacy or quality of life (healthy coping) were the most frequently reported ADCES7 behaviors. Six of the studies used A1C as an outcome measure, with a reduction reported in all the studies except 1. CONCLUSION: Type 2 diabetes affects a person holistically, necessitating a range of self-care behaviors to effectively manage the chronic condition. Novel gaming interventions may improve coping mechanisms, lifestyle behaviors, medication engagement, and monitoring of risks and problems, all of which are essential in facilitating optimal diabetes self-management.

Effect of COVID-19 on Type 2 Diabetes Self-Care Behaviors: A Rapid Review.

OBJECTIVE: The aim of this review was to describe how the coronavirus disease 2019 (COVID-19) lockdown affected the self-care behaviors of people living with type 2 diabetes. Methods: A systematic rapid review was conducted using four electronic databases. Studies reporting on the lockdown's impact on at least one of the self-care behaviors that were published from January 2020 through October 2021 were included. Findings were synthesized narratively, using the Association of Diabetes Care & Education Specialists ADCES7 Self-Care Behaviors as a framework. The methodological level of evidence and quality ratings of the articles were assessed using the Joanna Briggs Institute Appraisal Checklist. Results: Fifteen articles were included. Most studies reported on at least five of the self-care behaviors. There were reported increases in diabetes-related stress, as well as in increases in dietary intake and changes in the timing of meals. Physical activity was reported to decrease. Overall, taking medications and glycemic self-monitoring of blood glucose (SMBG) were unaffected by the lockdown. Of the studies reporting glycemic outcomes, the lockdown appeared to have little negative effect. None of the articles assessed all the self-care behaviors. The self-care behavior of SMBG was the least assessed. Most articles had a medium level of evidence and a medium to high quality rating (scores >60%). Conclusion: The findings from this review found the COVID-19 lockdown had a variable impact on diabetes self-care behaviors. Because the potential for future COVID-19 surges and/or other virulent transmissible diseases remains a concern, health care providers should continue to address the importance of self-care behaviors to mitigate the risk of poor health outcomes in people with diabetes.

Clinical outcomes of immune checkpoint inhibitor diabetes mellitus at a comprehensive cancer center.

Introduction: Immune checkpoint inhibitor-associated diabetes mellitus (ICI-DM) is a rare adverse event. In this study, we characterize clinical outcomes of patients with ICI-DM and evaluate survival impact of this complication on melanoma patients. Research design & methods: We conducted a retrospective review of 76 patients diagnosed with ICI-DM from April 2014 to December 2020. Results: 68% of patients presented in diabetic ketoacidosis, 16% had readmissions for hyperglycemia, and hypoglycemia occurred in 70% of patients after diagnosis. Development of ICI-DM did not impact overall survival or progression-free survival in melanoma patients. Conclusion: Development of ICI-DM is associated with long-term insulin dependence and pancreatic atrophy; the use of diabetes technology in this patient population can help improve glycemic control.

Cancer treatment with immune checkpoint inhibitors can cause irreversible side effects. In this study, we describe the clinical presentations of 76 patients who developed immune checkpoint inhibitor diabetes mellitus, a rare complication of checkpoint inhibitor therapy that requires lifelong treatment with insulin therapy. Most patients presented with a life-threatening hyperglycemic emergency and had experienced weight loss and hyperglycemia several weeks prior to diagnosis. After diagnosis, these patients are at risk for high and low blood sugars, but the use of glucose monitoring devices and insulin pumps can help improve blood sugar control. In our study, the development of this complication did not affect survival for melanoma patients. We need to improve awareness of this rare complication to ensure timely treatment for patients.

Characterization of Symptoms and Symptom Clusters for Type 2 Diabetes Using a Large Nationwide Electronic Health Record Database.

OBJECTIVE: A variety of symptoms may be associated with type 2 diabetes and its complications. Symptoms in chronic diseases may be described in terms of prevalence, severity, and trajectory and often co-occur in groups, known as symptom clusters, which may be representative of a common etiology. The purpose of this study was to characterize type 2 diabetes-related symptoms using a large nationwide electronic health record (EHR) database. Methods: We acquired the Cerner Health Facts, a nationwide EHR database. The type 2 diabetes cohort (n = 1,136,301 patients) was identified using a rule-based phenotype method. A multistep procedure was then used to identify type 2 diabetes-related symptoms based on International Classification of Diseases, 9th and 10th revisions, diagnosis codes. Type 2 diabetes-related symptoms and co-occurring symptom clusters, including their temporal patterns, were characterized based the longitudinal EHR data. Results: Patients had a mean age of 61.4 years, 51.2% were female, and 70.0% were White. Among 1,136,301 patients, there were 8,008,276 occurrences of 59 symptoms. The most frequently reported symptoms included pain, heartburn, shortness of breath, fatigue, and swelling, which occurred in 21-60% of the patients. We also observed over-represented type 2 diabetes symptoms, including difficulty speaking, feeling confused, trouble remembering, weakness, and drowsiness/sleepiness. Some of these are rare and difficult to detect by traditional patient-reported outcomes studies. Conclusion: To the best of our knowledge, this is the first study to use a nationwide EHR database to characterize type 2 diabetes-related symptoms and their temporal patterns. Fifty-nine symptoms, including both over-represented and rare diabetes-related symptoms, were identified.

Economic impact and health care utilization outcomes of diabetes self-management education and support interventions for persons with diabetes: a systematic review protocol.

OBJECTIVE: The aim of this systematic review is to summarize and synthesize existing research on the economic impact of diabetes self-management education and support. INTRODUCTION: Diabetes self-management education and support is an essential component of diabetes care, yet it continues to be underutilized. A gap exists regarding the true measured economic impact of this intervention. INCLUSION CRITERIA: This review will consider studies that report the measured economic impact and health care utilization of diabetes self-management education and support for persons with diabetes or their caregivers. The inclusion criteria are as follows: quantitative studies providing measured data on the economic outcomes and health care utilization of diabetes self-management education and support interventions that include at least one of the Association for Diabetes Care and Education Specialists Seven Self-Care Behaviors. METHODS: The review will search the following databases: MEDLINE Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Daily and Versions; Embase; Scopus; CINAHL; ERIC, Cochrane Database of Systematic Reviews; and the Cochrane Register of Controlled Trials. Additionally, a search of gray literature will be performed using Google Scholar. Date limitations will be from January 2006 to May 2020. Two members of the research team will independently screen abstracts and full texts, and extract data. The screening process will be described using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Articles will be assessed for risk of bias using the JBI critical appraisal tools. Data will be narratively summarized. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (CRD42020166743).

Economic Impact and Health Care Utilization Outcomes of Diabetes Self-Management Education and Support Interventions for Persons With Diabetes: A Systematic Review and Recommendations for Future Research.

PURPOSE: Value-driven outcomes are important because health systems determine sustainability of diabetes self-management education and support (DSMES) programming. Health care utilization and clinical outcomes are critical factors when considering the impact of DSMES programs. OBJECTIVE: The aim of this systematic review was to describe studies that report on the economic and health care utilization outcomes of diabetes self-management programs. METHODS: A systematic literature review was performed in multiple databases. Studies reporting economic and health care utilization outcomes related to DSMES and including 1 or more of the ADCES7 Self-Care BehaviorsTM from January 2006 to May 2020 were included. Eligible articles needed to compare the intervention and comparison group and report on economic impact. The methodological quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist specific to each individual study design. RESULTS: A total of 22 of 14 556 articles published between 2007 and 2020 were included. Cost benefits varied, and there were considerable methodological heterogeneity among design, economic measures, population, perspective, intervention, and biophysical outcomes. CONCLUSION: DSMES interventions may positively impact economic outcomes and/or health care utilization, although not all studies showed consistent benefit. This review highlights an evidence gap, and future health economic evaluations are warranted.

Hyperglycemia and Cancer: A State-of-the-Science Review.

PROBLEM IDENTIFICATION: Hyperglycemia can increase the risk for adverse events and outcomes in patients undergoing treatment for cancer. The purposes of this state-of-the-science review were to explore the complexity of hyperglycemia in patients with cancer and to analyze physiologic mechanisms and outcomes in individuals with or at risk for cancer. LITERATURE SEARCH: PubMed® and the Cochrane Library databases were searched, and 95 articles were included. Findings were evaluated for their methods and analyses. Studies assessed as methodologically flawed were not included. DATA EVALUATION: The synthesis of the articles provided the evidence for describing normal and glycemic pathways. Hyperglycemia in patients with cancer was explored through chronic inflammatory mechanisms that lead to increased risks for adverse events and outcomes. SYNTHESIS: This article discusses normal glucose regulation and hyperglycemic pathways, hyperglycemia in patients with cancer, hyperglycemia and cancer-related inflammation, and outcomes (e.g., infections, mortality, symptoms). IMPLICATIONS FOR RESEARCH: Understanding the contributors to and consequences of hyperglycemia can guide the development of screening tools to predict which individuals are at the greatest risk for hyperglycemic episodes prior to starting cancer therapies. Research can lead to glycemic guidelines specific to patients with cancer for better outcomes.

Insulin Therapy: The Old, the New and the Novel-An Overview.

Since its development, insulin therapy has been a mainstay in the arsenal of every practitioner battling against diabetes. For patients with type 1 diabetes mellitus, insulin is essential for survival, and for those with type 2 diabetes mellitus, as the disease progresses, it may become a necessary addition to treatment. The goal of this article is to discuss insulin therapies that are currently available for use in the management of diabetes, from the old to the new and novel, and briefly discuss insulin use in special populations.

Controlling Malglycemia in Patients Undergoing Treatment for Cancer.

Patients with or without preexisting diabetes undergoing treatment for cancer may be at risk for malglycemic events. Malglycemia, particularly hyperglycemia and diabetes in patients with cancer, may lead to adverse outcomes. Prevention, prompt recognition, and early intervention to regulate malglycemia can optimize the effects of cancer treatment, minimize the harmful consequences, and improve quality of life for patients with cancer. The development of evidence-based standards of care and protocols are needed to guide clinical practice when caring for patients with cancer.

Hyperglycemic-inducing neoadjuvant agents used in treatment of solid tumors: a review of the literature.

PURPOSE/OBJECTIVES: To review the literature regarding the development of hyperglycemia associated with neoadjuvant agents used in the treatment of solid tumor cancers. DATA SOURCES: Research articles were obtained from PubMed, CINAHL®, and Cochrane Reviews. The following search terms were used alone and in combination: diabetes, glycemic control, chemotherapy, androgen deprivation therapy, interferon-alpha, immunosuppressants, cancer, neoplasms, and hyperglycemia. DATA SYNTHESIS: Twenty-two studies were identified reporting the development of hyperglycemic events in patients who received a variety of chemotherapeutic agents. CONCLUSIONS: Findings suggest patients are at risk for the development of hyperglycemia from certain chemotherapeutic agents. Docetaxel, everolimus, and temsirolimus alone or in combination with other agents can promote hyperglycemia. Androgen-deprivation therapy commonly used in prostate cancer, increases the risk for the development of hyperglycemia and diabetes. IMPLICATIONS FOR NURSING: Oncology nurses play an important role in the identification and treatment of hyperglycemia in patients receiving chemotherapy. Future research is needed that focuses on the association between glycemic control and adverse outcomes in patients with a solid tumor cancer who are at risk for treatment-induced hyperglycemia.

Management of steroid-induced hyperglycemia in hospitalized patients with cancer: a review.

PROBLEM IDENTIFICATION: Glucocorticoids are prescribed for hospitalized patients with cancer for a variety of reasons, including cerebral edema, treatment and prevention of nausea, and as part of cancer treatment regimens. Glucocorticoids are known to cause hyperglycemia. The purpose of this study was to integrate the published research on the management and the effects of steroid-induced hyperglycemia in hospitalized adult patients with cancer with or without preexisting diabetes. LITERATURE SEARCH: MEDLINE®, PubMed, EMBASE, CINAHL®, and Scopus electronic databases were used to identify relevant articles. Bibliographies of included studies were reviewed for any pertinent studies that were not obtained through database search.Data Evaluation: 1,392 studies were identified. A total of 18 studies that met criteria were fully reviewed, 6 of which met all of the inclusion criteria. DATA ANALYSIS: Data were abstracted from the included studies using a systematic code sheet to document characteristics of the studies and findings on management of hyperglycemia. Characteristics of the studies and findings on management of hyperglycemia were organized into three tables: the patients did not have preexisting diabetes, the patients had preexisting diabetes, and patients with or without preexisting diabetes were both included in the study. Management and effects of management of hyperglycemia were then compared and synthesized.Presentation of Findings: Hyperglycemia occurs in hospitalized patients with cancer irrespective of whether patients have a prior history of diabetes. Hyperglycemia resulting from steroids is treated in a variety of ways, but the resulting glycemic control has not been consistently documented. However, this review suggests that scheduled insulin (basal-bolus) is effective in attainment of glucose targets. IMPLICATIONS FOR PRACTICE: Nurses should be aware of the effect that steroids have on glycemic control in patients and should be empowered to request or perform blood glucose monitoring when appropriate. Nurses can identify those patients receiving steroids and assess for signs and symptoms of hyperglycemia. They also can review routine laboratory results and assess for hyperglycemia in patients receiving steroids.

Safe and effective dosing of basal-bolus insulin in patients receiving high-dose steroids for hyper-cyclophosphamide, doxorubicin, vincristine, and dexamethasone chemotherapy.

BACKGROUND: Hyperglycemia occurs in cancer patients receiving high-dose steroids with cyclophosphamide, doxorubicin, vincristine, and dexamethasone (hyper-CVAD) protocol. The purpose of our study was to determine insulin requirements in patients with hyperglycemia on hyper-CVAD therapy using a systematic algorithm. SUBJECTS AND METHODS: We did a retrospective chart review of 23 leukemia inpatients with hyperglycemia (two glucose values >250 mg/dL) on hyper-CVAD chemotherapy managed by the Endocrine Diabetes Inpatient Team algorithm. We reviewed demographic and glycemic data, insulin dosages, and use of oral hypoglycemic agents. Using our algorithm, the dose of insulin for each patient was titrated daily and with each subsequent cycle of hyper-CVAD. RESULTS: Ninety-one percent of patients had known diabetes. The median body mass index was 32.5 (range, 21.6-40.9) kg/m², and median age was 61 (range, 40-80) years. The overall trend in glucose values across cycles showed a statistically significant decrease with each subsequent cycle of hyper-CVAD. Hyperglycemia accounted for 81% of glucose measurements in the first cycle and 60% of glucose values in the last cycle. Patients received 1-1.3 units/kg of insulin per cycle, and insulin requirements were similar across cycles. The distribution of basal versus bolus insulin for each cycle was 63-77% prandial and 23-37% basal. Nine of the 23 patients had at least one glucose value <70 mg/dL, which accounted for 1.3% of all recorded glucose values. None of the patients had severe hypoglycemia. CONCLUSIONS: Multiple-dose insulin therapy initiated at 1-1.2 units/kg/day, distributed as 25% basal and 75% prandial, reduced hyperglycemia in patients who were receiving high-dose dexamethasone as part of hyper-CVAD.

The impact of hyperglycemia on hematopoietic cell transplantation outcomes: an integrative review.

PROBLEM IDENTIFICATION: Many patients undergoing hematopoietic cell transplantation (HCT) for hematologic malignancies experience hyperglycemic events during treatment, leading to adverse outcomes. Understanding how hyperglycemia during the acute HCT treatment phase impacts outcomes is vital for preventing and mitigating adverse events. This integrative review evaluates the impact of hyperglycemia on adult patients undergoing HCT. LITERATURE SEARCH: PubMed, MEDLINE®, and CINAHL® electronic databases were used to identify relevant articles.Data Evaluation: The final sample for this integrative review included 12 empirical quantitative reports of clinical patient outcomes. Of the 12, 10 are retrospective, 1 is case-control, and 1 is prospective. DATA ANALYSIS: Content analysis was used to synthesize and summarize findings.Presentation of Findings: A review of published literature found associations between hyperglycemia and infection, time to engraftment, development of acute graft-versus-host disease, length of stay, and overall survival. Patient-related risk factors for hyperglycemia included older age, preexisting diabetes, and insulin resistance (i.e., prediabetes). Patients of normal weight experiencing hyperglycemia had worse outcomes than patients who were overweight or obese. Treatment-related risk factors for hyperglycemia include dose and duration of immunosuppressants, specifically corticosteroids, treatment with antihyperglycemic medications, and use of total parenteral nutrition. IMPLICATIONS FOR NURSING PRACTICE: HCT is one of the most complex treatments for hematologic disorders. The transplantation nurse, as part of an interdisciplinary team, plays an essential role in glycemic control during the acute phase of HCT. Understanding the effects of hyperglycemia, as well as factors that place the patient at risk for hyperglycemia, allows the nurse to make well-informed, proactive interventions aimed at glycemic control.

Management of hyperglycemia in the intensive care unit: when glucose reaches critical levels.

Hyperglycemia among hospitalized critically ill patients has been shown to be an independent predictor of poorer outcomes. Appropriate treatment of hyperglycemia among these patients has been associated with reduced mortality and morbidity. There are risk and benefits associated with management of hyperglycemia in the critically ill patient. The ultimate goal of treatment is to obtain glycemic control without causing undue hypoglycemia. This article discusses issues related to glycemic control among critically ill patients, glucose targets in this population, and best practices in the management of hyperglycemia in patients in the intensive care unit.