Lasting effects of a 2-year diabetes self-management support intervention: outcomes at 1-year follow-up.

INTRODUCTION: Diabetes-related health improvements achieved from self-management education interventions are not sustained long-term. We examined the health effects at 1 year follow-up of a 2-year, empowerment-based, diabetes self-management support intervention designed for African Americans. METHODS: We collected data from 52 African American adults with type 2 diabetes who completed the 3-year study. The intervention consisted of weekly groups led by 2 health care professionals and emphasized experiential learning, emotional coping, problem solving, goal setting, and action planning; group discussion was guided by participant-identified self-management priorities and concerns. Measurements were taken at baseline, 24 months (postintervention), and 36 months (1 year follow-up) to assess glycemic control; weight; body mass index; serum cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol levels; systolic and diastolic blood pressure; self-care behaviors; diabetes-specific quality of life; and diabetes empowerment. RESULTS: Following the 2-year diabetes self-management support intervention, we found significant improvements for following a healthy diet (P = .03), spacing carbohydrates evenly across the day (P = .005), using insulin as recommended (P = .047), and achieving diabetes-specific quality of life (P = .02). At 1-year follow-up, not only did participants sustain the behavioral improvements made in the 2-year diabetes self-management support intervention, but they also demonstrated additional improvements in glycemic control (P < .001) and in serum cholesterol (P < .001) and low-density lipoprotein cholesterol levels (P = .001). CONCLUSION: Participation in an empowerment-based diabetes self-management support intervention may have a positive and enduring effect on self-care behaviors and on metabolic and cardiovascular health.

Sustaining short-term improvements over the long-term: results from a 2-year diabetes self-management support (DSMS) intervention.

AIM: This study examined the long-term impact of a 24-month, empowerment-based diabetes self-management support (DSMS) intervention on sustaining health-gains achieved from previous diabetes self-management education (DSME). METHODS: Prior to the intervention, all participants received 6 months of mailed DSME consisting of weekly educational newsletters coupled with clinical feedback. The intervention consisted of 88 weekly group-based sessions that participants were encouraged to attend as frequently as they needed. Sessions were guided by participants' self-management questions and also emphasized experiential learning, coping, goal-setting, and problem-solving. Baseline, 6-month, and 30-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. RESULTS: This report is based on 60 African-American adults with type 2 diabetes (n=89 recruited at baseline) who completed the study. Post 6-month DSME, participants demonstrated significant improvements for diastolic BP (p<0.05), serum cholesterol (p<0.001), healthy diet (p<0.01), blood glucose monitoring (p<0.05) and foot exams (p<0.01). Post 24-month intervention, participants sustained the improvements achieved from the 6-month DSME and reported additional improvements for healthy diet (p<0.05), carbohydrate spacing (p<0.01), insulin use (p<0.05), and quality of life (p<0.05). CONCLUSIONS: Findings suggest that an empowerment-based DSMS model can sustain or improve diabetes-related health gains achieved from previous short-term DSME.

Experience may not be the best teacher: patient logs do not correlate with clerkship performance.

BACKGROUND: With the recent emphasis on core competencies, medical schools and residency programs have attempted to monitor and regulate trainees' patient encounters. The educational validity of this practice is unknown. Our objective was to determine whether patient encounter logs correlate with educational outcomes. METHODS: We reviewed patient logs of all 212 neurology clerkship students from the 2005-2006 academic year and determined the number of patients each student saw in five diagnostic categories (seizure, headache, stroke, acute mental status change, and dementia). We compared these numbers with the students' written examination scores (total and category-specific) and clinical evaluation scores using Pearson product-moment correlations. RESULTS: The more patients in a given diagnostic category that students saw, the lower the students' examination subscores in that disease category (r = -0.066, p = 0.03). The total number of patients each student saw did not correlate with the student's total examination score (r = -0.021, p = 0.77) or the student's overall clinical performance rating (r = 0.089, p = 0.23). CONCLUSIONS: Higher numbers of logged patients did not correlate with better clerkship performance, whether the outcome measures were written tests or faculty ratings, and whether the analysis involved total or disease-specific patient counts. Thus, patient census may not be a meaningful index of educational experience or outcome. Considerable time, money, and effort are required to maintain accurate logs of trainees' encounters with patients; based on the current study, this may be an inefficient use of resources.

Patient and provider perceptions of diabetes: measuring and evaluating differences.

OBJECTIVE: This study measures diabetes care perceptions of patients and their providers, and examines perceptions differences of patient-provider pairs. METHODS: Patient and provider perceptions were assessed using the Diabetes Semantic Differential Scales (DSDS) which ask respondents to rate diabetes care concepts using contrasting adjective pairs. The DSDS was scored by two methods: using means and using factor analysis. Persons with diabetes 40-years-old or older were recruited. Using a "snowball" sampling strategy, potential provider participants were identified by their patients; 71 providers agreed. These providers represented 51% of the patient participants and created 138 patient-provider pairs. RESULTS: For the mean scores, there were significant differences between patients and providers for 5 of the 18 semantic differentials (28%). Similarly, the factor scores indicated significant differences for 14 of 54 factors (26%). The effect sizes indicated practical differences. CONCLUSION: Significant differences exist between patient and provider perceptions. Generally, patients have the more positive diabetes perceptions. PRACTICE IMPLICATIONS: During patient and provider discussions, participants can perceive diabetes concepts differently. The DSDS can determine perception differences. While it is best to use factor analyses to score the DSDS, mean scores are more easily calculated and indicate the broad conceptual areas where patient and provider differ.

Pharmacist recognition of and adherence to medication-use policies and safety practices.

PURPOSE: Pharmacist recognition of and adherence to medication-use policies and safety practices were assessed. METHODS: Simulation testing was used to assess the performance of pharmacists in hypothetical scenarios simulating real-life situations. Fifty test case medication orders were developed, some requiring specific intervention and some requiring no special action. Orders were classified into four categories: those posing safety concerns n ( = 16), those with formulary and product standardization issues (n = 4), those with pharmacy and therapeutics (P&T) committee restrictions (n = 4), and those requiring no special action (n = 26). Potential barriers to compliance were identified by the project team and the orders categorized accordingly. The orders were processed by 25 pharmacists using a simulation testing procedure. Data were analyzed by pharmacists' demographics, order category, and perceived barriers to compliance. RESULTS: Pharmacists were correctly able to recognize 77.3% of test orders: 67.3% with safety concerns, 98.9% with formulary issues, and 98.5% with restrictions. Appropriate action was taken with 74.2% of test orders: 64.5% of safety orders, 96.6% of formulary orders, and 92.4% of restriction orders. There was no correlation between pharmacists' performance and demographic characteristics. The two barriers to correct response identified most often were ambiguous responsibility and low perceived level of importance. CONCLUSION: Pharmacists generally recognized and took appropriate action with simulated medication orders that contained problems related to formulary or P&T committee restrictions. They were less able to recognize and act appropriately on orders with safety-related problems. Ambiguous responsibility and low perceived importance were the most significant factors contributing to noncompliance with P&T committee policies and guidelines.

Evaluating a problem-based empowerment program for African Americans with diabetes: results of a randomized controlled trial.

OBJECTIVE: The objective of this study was to evaluate the impact of a problem-based empowerment patient education program specifically tailored for urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: The study used a randomized controlled trial (RCT) pretest/post-test design with repeated measures. Patients were randomly assigned to either a six-week intervention group or a six-week wait-listed control group. After completing the six sessions, patients were invited to participate in one of two follow-up conditions; attend a monthly support group or receive a monthly phone call from a nurse. Assessment measures included HbA1C, lipids, blood pressure, weight, self-management behavior and psychosocial adaptation. RESULTS: Both control and intervention patients showed a broad array of small-to-modest positive changes during the six-week RCT. These gains were maintained or improved upon during the one-year follow-up period. For patients in the two follow-up conditions, a positive correlation was seen between the number of follow-up contacts and their one-year HbA1C values. CONCLUSIONS: We believe that results of this study can be attributed to volunteer bias, study effects (ie, providing study data on several occasions to patients and their physicians during the one-year study period), and impact of the interventions. However, the study design does not allow us to examine the relative impact of these three factors on the patient improvements seen over the one-year study period.

The physical examination of patients with abdominal pain: the long-term effect of adding standardized patients and small-group feedback to a lecture presentation.

BACKGROUND: One of the most effective methods for teaching physical diagnosis may be standardized patient instructors. PURPOSE: To determine if a lecture plus standardized patient instructors with small-group sessions is more effective than a lecture alone for teaching the evaluation of patients with abdominal pain. METHODS: Control (class of 2001) and intervention (class of 2002) groups both attended a lecture on the abdominal examination. The intervention group then underwent an exercise with standardized patient instructors and a review session with surgical faculty. An evaluation 18 months later used standardized patient instructors to complete evaluations assessing history-taking and physical examination skills. RESULTS: The intervention group performed significantly better than the control group on both the history and the physical examination subscales. CONCLUSION: It is possible to have an important, measurable, and lasting effect on physical examination skills by adding standardized patient instructors and small-group discussion to a lecture presentation.

Informal diabetes education: impact on self-management and blood glucose control.

PURPOSE: The purpose of this study was to determine if participation in screening clinics to detect and treat diabetes-related eye disease also led to informal patient learning that had an impact on self-management behavior and blood glucose control. METHODS: To evaluate the evidence for patient learning over time, the data of patients who returned as advised for 2 subsequent annual diabetes disease screenings were analyzed. Evaluation measures included medication use, self-management behavior, and hemoglobin A1c (A1C). RESULTS: During the 2-year study period, the use of insulin increased by 37% at the first exam, 43% at the second exam, and 42% at the third exam (P = .02). No significant changes were found in the use of oral medication. Glucose self-monitoring also increased by 61% at the first exam, 71% at the second exam, and 76% at the third exam (P < .01). Mean A1C values for returning participants declined by 9.2% at the first exam, 8.9% at the second exam, and 8.6% at the third exam (P = .03). CONCLUSIONS: The screening clinics had an educational impact associated with behavior change (improved self-management and glucose control) even though the clinics were not intended to produce such change. Therefore, caregivers should consider that patient learning can and should be part of every diabetes care encounter.

Personalized follow-up increases return rate at urban eye disease screening clinics for African Americans with diabetes: results of a randomized trial.

OBJECTIVE: To evaluate the effectiveness of using personalized follow-up, as compared to reminder letters, in increasing return rates at urban eye disease screening clinics for African Americans with diabetes, and to identify factors predictive of the patient's likelihood of returning for annual follow-up exams. RESEARCH DESIGN AND METHODS: All patients attending free community-based retinopathy screening clinics who were advised to return in one year for another diabetes eye evaluation (DEE) were randomized to standard or personalized follow-up interventions. Patients in the standard follow-up group received reminder letters a month before it was time to return for their next annual DEE. Patients in the intensive personalized intervention also received the letters, but those patients who did not call for an appointment within 10 days received a phone call from project staff, encouraging them to return for a DEE. RESULTS: One hundred thirty-two African Americans with diabetes were randomized to one of the 2 treatments. The return rate for the intensive, personalized follow-up group was 66%, significantly (P=.001) higher than the 35% return rate for the standard follow-up group. CONCLUSION: This study demonstrated the efficacy of personal contact by telephone in improving return rates for annual DEEs in this population of patients. This finding is consistent with one of the key design principles of the project, which was to establish credible personal relationships with community leaders and patients as a means to maximize the utilization of the eye screening clinics.

Conducting community-based, culturally specific, eye disease screening clinics for urban African Americans with diabetes.

The purpose of this study was to evaluate the need for, and efficacy of, community-based culturally specific eye disease screening clinics for urban African Americans with diabetes. The study employed a variety of culturally specific methods in the design and performance of 43 community-based eye disease screening clinics in southeastern Michigan. One thousand, thirty-seven subjects were recruited for the study. Of that number, 817 identified themselves as African Americans and are the focus of this report. Of the 817 African-American patients screened, 84 (10%) needed to be examined by an ophthalmologist immediately (< 30 days), and 180 (22%) needed to be examined soon (within 1 to 3 months), while 544 (67%) were advised to return for another exam a year later. The project demonstrated that it was possible to use culturally specific techniques to identify a significant number of urban African Americans with diabetes in need of eye screening and treatment. However, lack of health insurance proved to be the primary barrier to receiving needed treatment. Although the project was successful, it is not a solution to what is essentially a health systems problem, ie, inadequate access to appropriate diabetes care for a significant number of our population.

Decreasing rate of fatty involution at screening mammography.

RATIONALE AND OBJECTIVES: This study was performed to document the perceived decrease in fatty involution at screening mammography during the past decade and evaluate the influence of hormone replacement therapy (HRT). MATERIALS AND METHODS: In December 1996, the mammograms of 261 consecutive screening patients with a comparison study obtained 5 years earlier were evaluated, and their breasts were categorized according to Breast Imaging Reporting and Data System categories for breast density. The women, aged 50-59 years, included 119 who had been receiving HRT for 0.25-15 years (mean, 3 years). From the files, 261 age-matched screening mammograms from 1986 were obtained; these patients also had comparison mammograms from 1981. Analysis of variance was used to determine differences between the 1980s group, the 1990s group receiving HRT, and the 1990s group not receiving HRT. Scheffé tests were used for post hoc comparisons. Stepwise regression analysis was used to evaluate the relative influence of age, decade, score of the first mammogram, and HRT. RESULTS: Breast density for the 1991 mammograms did not differ significantly from that in 1981 (P < .05). Initial breast density was the best predictor of final breast density in both decades (P < .001), regardless of HRT status. The change in breast density (toward fatty) over the 5-year interval in the 1980s (mean, 0.48) was significantly greater than that in both 1990s groups (mean for HRT group, 0.11; no HRT, 0.30; P < .05). CONCLUSION: These results confirm that breast density at screening mammography in the 1990s did not decrease with age at the same rate as in the 1980s, even in patients not receiving HRT.

Does medical school performance predict radiology resident performance?

RATIONALE AND OBJECTIVES: The authors performed this study to examine the relationship, if any, of a large number of measures of medical school performance with radiology residency performance. MATERIALS AND METHODS: Applications of 77 radiology residents enrolled from 1991 to 2000 were reviewed. Medical school grades, dean's letter summary statements, letters of recommendation, selection to Alpha Omega Alpha (AOA), and National Board of Medical Examiners (NBME) and U.S. Medical Licensing Examination (USMLE) Step 1 scores were recorded. Student t tests, analysis of variance, and correlation coefficients were used to examine the relationship between these measures of medical school performance and subsequent performance during radiology residency as determined by rotation evaluations, retrospective faculty recall scores, and American College of Radiology (ACR) and American Board of Radiology (ABR) examination scores. Resident performance was also correlated with prestige of the medical school attended. RESULTS: Preclinical grades of Honors or A; clinical grades of Honors or A in medicine, surgery, and pediatrics; and high NBME/USMLE scores strongly predicted success on the ABR written clinical examination but did not predict rotation performance. Most other measures of medical school performance, including outstanding Dean's letters and letters of recommendation, AOA selection during the senior year, and high medical school prestige did not predict high examination scores or superior rotation performance during residency. CONCLUSION: Success on the ABR examination can be predicted by medical school success in preclinical courses, some clinical courses, and USMLE examination scores. Dean's letters, letters of recommendation, AOA selection during the senior year, and medical school prestige do not appear to predict future resident performance as reliably.