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Running head: DIABETES MANAGEMENT

Diabetes Management Through Information Technology

Kailey Hamrick

Auburn University/ Auburn University Montgomery

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Abstract

Diabetes is a disease characterized by high glucose levels in the blood due to

defects in the body's ability to produce and/or use insulin. There are two types of

diabetes, Type 1, and Type 2. Type 1 diabetes is when the body does not produce

insulin. Type 2 diabetes mellitus (T2DM) is a disease that causes problems with insulin

production or utilization, which causes sugar levels in the blood to elevate which can lead

to permanent damage of the blood vessels and associated complications, such as heart

disease and stroke. T2DM comprises 90% of people with diabetes around the world. To

better manage their T2DM, patients must understand what it is and how and what

interventions are significant to controlling it. This paper seeks to answer the question of

in patients diagnosed with diabetes mellitus, does using information technology to deliver

education and management strategies compared to only face-to-face interactions, improve

patient glucose control, lifestyle choices, and knowledge? To begin an evidence-based

practice approach to answering this question, multiple articles will be analyzed and

recommendations will be drawn. Next, an implementation plan will be created and

potential facilitators and barriers to this plan, as well as expected short term and long-

term outcomes will be discussed in detail. A small test of change will then be executed

of which results will be evaluated and an evidence-based conclusion drawn.

Keywords: Diabetes mellitus, Information Technology (IT), evidence-based,

GlucoseBuddy

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Diabetes Management Through Information Technology

Evidence-based practice (EBP) is described by Melnyk and Fineout-Overholt

(2011) as a “problem-solving approach to clinical practice that integrates a systematic

search for as well as critical appraisal and synthesis of the most relevant and best research

to answer a burning clinical question, one’s own clinical expertise […], and patient

preferences and values (p. 4).” EBP allows for evidence to be translated into the best

clinical practice in order to obtain the best patient outcomes.

Introduction

Diabetes is a disease characterized by high glucose levels in the blood due to

defects in the body's ability to produce and/or use insulin. There are two types of

diabetes, Type 1, and Type 2. Type 1 diabetes is when the body does not produce

insulin. Type 2 diabetes mellitus (T2DM) is a disease that causes problems with insulin

production or utilization, which causes sugar levels in the blood to elevate which can lead

to permanent damage of the blood vessels and associated complications, such as heart

disease and stroke. T2DM comprises 90% of people with diabetes around the world.

Diabetes is a serious health problem that affects many people today. Diabetes lasts

throughout a patients’ life and can affect any age or race. It affects patients’ families,

wealth, lifestyle habits, potential comorbidities, and in turn life expectancy. Karakurt and

Kaşıkçı (2012) write the following:

In the next 25 years, it is predicted that diabetes will be one of the major fatal and

mutilating diseases in the world. According to the experts, the number of patients

with diabetes will be more than 300 million by the year 2025. […] Diabetes

incidence is expected to increase by 165% in the next 50 years. […] It is

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estimated that there are 17 million people in the USA alone with diabetes. (p.

170).

These statistics show the importance of diabetes education and management.

Many people affected by diabetes do not know or understand the disease, its’

management, and its’ potential for severely debilitating and fatal comorbidities. For

patients to better manage their diabetes, patients must understand what it is and how and

what interventions are significant to controlling it. Successful treatment of diabetes is

directly associated with education of both patients and their families. Patient education is

one of the most vital responsibilities of nurses. Evidence-based practice should be used to

find the best ways to accomplish meaningful education that encompasses the needs and

goals of people with diabetes. The goal should be to empower patients with a better

understanding of their disease so they can take a more active role in self-management

(Tang et al., 2012).

PICO formatted questions are used in EBP in order to yield the most relevant and

best information (Melnyk & Fineout-Overholt, 2011). The PICO question used in this

paper is as follows; in patients diagnosed with diabetes mellitus (DM), does using

information technology to deliver education and management strategies compared to only

face-to-face interactions, improve patient glucose control, lifestyle choices, and

knowledge? The Population focus is patients who are over the age of 18 who have been

diagnosed with DM, and have not had diabetes education with the assistance of IT before.

The Intervention is providing necessary education, including but not limited to diet

changes, lifestyle modifications, medication guidelines, and signs of hypo and

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hyperglycemia, with the assistance of IT, such as Glucose Buddy. The Comparison

intervention is only educating patients on the information stated above via face-to-face

interactions, or the standard currently used. The Outcome desired is more consistent

control of blood glucose levels observed on the trend tracker, which would be between 70

and 160, and a decrease in hemoglobin A1C level, preferably to a level less than 7. A

decrease in weight to bring the patients BMI closer to normal values, between 18.5-24.9,

and an increase in exercise is also desired outcomes because these factors are directly

related to blood glucose levels. Along with these knowledge/behavior outcomes, an

increase in the patients’ overall confidence in their diabetes management abilities is

anticipated.

Framework

The EBP model that will be used is the Rosswrum and Larrabee Model.

According to Thurston and King (2004), Rosswurm and Larrabees’ model is intended to

guide nurses through an evidence-based change process by following six steps: (1) assess

the need for change in practice, (2) link the problem with interventions and outcomes

using standardized classifications and language, (3) synthesize best evidence, (4) design

change(s) in practice, (5) implement and evaluate the change, and (6) integrate and

maintain the practice change. Facchiano, Snyder, and Núñez (2011), break these steps

down further: step 1 must include stakeholders, collect internal data about current

practice, compare internal data with external data, and identify the problem. For this

project the stakeholders are the not only the patients and doctors, but everyone involved

in healthcare as a whole, and the problem identified is poorly managed diabetes. Step 2

must use standardized classification systems and language, identify potential

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interventions and activities, and select outcomes indicators. Once these are established,

step 3 can begin. Step 3 involves searching research literature related to major variables,

critiquing and weighing the evidence, synthesizing the best evidence, and assessing the

feasibility, benefits, and risks. Preforming extensive literature reviews on systematic

reviews, clinical practice guidelines, randomized controlled trials, and other pertinent

studies on diabetes education and management will do this. In step 4, one defines the

proposed change for diabetes education and management, identifies needed resources,

plans the implementation process, and defines the expected outcomes of the evidence-

based practice project. Step 5 consists of implementing the diabetes project, evaluating

the process and outcome, and deciding to adapt, adopt, or reject the practice change. The

final step, step 6, is comprised of communicating the recommended change in diabetes

management and education to stakeholders, presenting a staff in service on change in

standards of practice, and monitoring the process and outcomes. This model will help

because it lays out the steps needed to critically think about potential evidence-based

changes in diabetes management by “utilizing change theory and a combination of

quantitative and qualitative data along with clinical expertise (Facchiano, Snyder, &

Núñez, 2011, p. 421).” In the past studies of outcomes related to diabetes self-

management education have shown mixed results. This illustrates that more evidence-

based practice is needed to evaluate the effect of educational strategies on more long-

term outcomes and the Rosswurm and Larrabees’ model can guide this.

Review of Literature

With the prevalence of diabetes and other chronic illnesses increasing it is

imperative to use EBP to create new opportunities for improvement in healthcare delivery

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for these patients; upon literature review, it was found that advances in Information

Technology (IT) are creating these opportunities. The literature reviewed for this project

was found by searching multiple databases and multiple keywords. The databases

searched were Academic Search Premier, CINAHL, PubMed, and Medline, and the

keywords searched were diabetes, diabetes management, diabetes education, diabetes

treatment, diabetes training, diabetes teaching, technology, and technology education.

The result achieved from this search yielded multiple articles imperative to this EBP

project, and will be discussed in detail below.

The AACE Diabetes Mellitus Clinical Practice Guidelines Task Force

(AACEDMCPGTF) provides clinicians with guidelines to care for patients with DM.

The guidelines demonstrate the effectiveness of lifestyle interventions in preventing the

progression of DM and state that rechecking patients’ understanding of basic self-care

concepts should be done routinely (AACEDMCPGTF, 2007). Information technology

can be used to recheck patients’ understanding of diabetes at regular intervals and can

help educate patients about lifestyle interventions, such as weight loss, and monitor such

interventions via online logs.

In their systemic review of 86 articles, H. Cooper, J. Cooper, and Milton (2009)

appraised 5 that found that Information and Communication Technology (ICT)-based

education has beneficial effects on knowledge and psychosocial wellbeing as well as

improvements in self-care behaviors. The review found that ICT allowed patients to

translate what they learned and that there was an increase in adherence of self-care as

evident by the numbers of transmitted blood glucose tests (with a decrease in frequency

of hyperglycemia and a maintenance of A1C levels of < 8%) (Cooper et al., 2009). The

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article showed that a key issue is facilitating discussion in a way that enables patients to

talk about personal or sensitive information. ITC supports such discussion by providing a

forum for disclosure of personal or embarrassing questions that patients may feel unable

to ask in face-to-face sessions.

Adaji, Schattner, and Jones (2008) conducted a systematic review that also

highlighted how IT can improve patient self-management in diabetes and enhance the

way in which diabetes care is delivered. They reviewed 444 studies and following

appraisal included 29 trials that involved IT being used to provide clinicians with access

to data about individual patients, such as blood glucose and blood pressure readings that

were uploaded from the patients. The IT could also send reminders and alerts to patients

regarding their specific information. These web-based programs were also used to

provide diabetes education, physical activity programs tailored to the patient’s specific

needs, and access to online coaches and peer support groups. Their review supported that

with the use of IT, there was a significant improvement in HbA1c and lipids levels, and

the numbers of foot and eye check ups (Adaji et al., 2008).

Polisena et al. (2009) executed a systemic review and meta analysis on 26 home

telehealth studies and found that home telemonitoring (HTM) for patients with diabetes,

compared to usual care (UC), had a positive effect on glycemic control and that HTM

helped to reduce the number of patients hospitalized and bed days of care. In their

reviews, HTM was defined as remote care delivery or monitoring between the patients in

their place of residence and the health-care provider at a distant location. The HTM

could be IT that enabled individuals to communicate live through audio conferencing and

videoconferencing, or IT that involved storing data, which was forwarded to a healthcare

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professionals via the Internet. The review showed that fewer patients were hospitalized

following the one-year post-enrolment period compared with the baseline (21.3% vs.

42.2%), and that the HbA1c levels in the HTM group were significantly lower than those

of patients in the UC group (Polisena et al., 2009).

A randomized control trial (RCT) of 104 diabetic patients done by McMahon et

al. (2005), assessed web-based care management for glucose and blood pressure control

in patients with poorly controlled diabetes. The trial consisted of randomly dividing the

participants into those who continued with their usual care or those who received web-

based care management. The web-based group received a laptop, glucose and blood

pressure monitoring devices, and access to a website that provided educational modules,

accepted uploads from monitoring devices, and had a messaging system for patients to

communicate with the care manager. The outcomes found were that web-based care

management might be useful in the care of patients with poorly controlled diabetes as

evident by the improvements in A1C (McMahon et al., 2005).

A RCT of 379 patients done by Tang et al. (2012) evaluated an online disease

management system supporting patients with uncontrolled type 2 diabetes. The trial

consisted of randomly dividing the participants into those who continued with their usual

care or those who received web-based care management. The intervention group was

given a wirelessly uploading home glucometer that took readings with graphical

feedback, access to online comprehensive patient-specific diabetes summary status

reports on their nutrition and exercise logs, and insulin records, access to online

messaging with the patient's health team, and personalized text and video educational

‘nuggets’ dispensed electronically by the care team. The outcomes found were that

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nurse-led, multidisciplinary health teams could manage a population of diabetic patients

primarily using online management and communication tools (Tang et al., 2012).

Smith et al. (2004) hypothesized that MyCareTeam (MCT), a web-based diabetes

management system, would provide frequent interactions between patients and providers

and thus result in improved glycemic control. They came to this hypothesis by

preforming a nonrandomized prospective feasibility study of 16 patients with poorly

controlled diabetes mellitus. Patients were asked to transfer their blood glucose data

electronically, maintain exercise logs, and communicate with their provider via MCT.

The provider gave interventions to optimize blood glucose control and education on

diabetes, nutrition, and exercise information via MCT. Findings showed a significant

reduction of over 2.22% points in hemoglobin A1C was seen for the total patient

population, as well as an improvement in systolic blood pressure, diastolic blood

pressure, total cholesterol, HDL, LDL, and triglycerides (Smith et al., 2004).

Turner, Larsen, Tarassenko, Neil, and Farmer (2009) reviewed experiences of 23

diabetic patients and the clinicians from 9 general practices who used IT monitoring.

Like the previously mentioned studies, this informal review involved patients

participation in a cohort study who received a mobile phone with a preloaded software

application that provided real-time data transmission and feedback through transmission

of blood glucose test results and real-time feedback of trends, an electronic patient diary

to record insulin doses, blood pressure results, and weight, and a blood glucose meter

linked to the phone via a BluetoothTM cradle. Unlike the other studies, this study

showed aspects of the IT valued from the clinicians standpoint: the ability to access up-

to-date information about patients’ blood glucose readings and insulin doses; the

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potential to support patients in making their own adjustments to insulin regimens; and the

opportunity for patients with diabetes to enhance their personal control over the

management of their diabetes (J. Turner et al., 2009). This study correlated with the

previous studies in that there was a decrease in HbA1c seen after IT interventions. Six

weeks post-implementation, the participants HbA1C decreased by an average of 0.52%

and patients reported feeling more ‘in control’ and confident in their ability to self-

manage insulin titration (J. Turner et al., 2009).

Sevean, Dampier, Spadoni, Strickland, and Pilatzke, (2009) explored 10 patients’

and 4 family members’ experiences with video telehealth consultations as a method of

health care delivery in their qualitative study, and found that telehealth was valued for

three key reasons; it lessened the burden (cost of travel, accommodations, lost wages, lost

time and physical limitations), it increased supports (access to familiar home

environment, nurses and other care providers), and it allowed for tailoring specific e-

health systems to enhance patient and family needs. This study showed that video

telehealth is effective for delivering nursing and other health services to patients who

may not be able to physically go to healthcare facilities and therefore can impact

positively on the quality of health care for these patients (Sevean et al., 2009). This, as

well as the previously mentioned articles, demonstrates how IT has a positive effect on

DM management, as evident by multiple positive outcomes, and is therefore essential to

future healthcare delivery models.

The review of the literature shows that patients’ understanding of their disease

and the treatments for it is paramount to having improved health care outcomes. Patients

must not only make lifestyle modifications and keep logs to track their progress, but must

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understand why they are doing so in order to truly achieve desired outcomes. Information

technology provides 24/7 access to education materials, support chat rooms, and

glucose/diet/exercise logs, and can help improve diabetes self-management behaviors in

those who utilize it.

Critical Appraisal of Evidence

There are seven levels for rating the hierarchy of evidence, the strongest being a

level I, and the weakest being a level VII. The AACE Diabetes Mellitus Clinical Practice

Guidelines Task Force is ranked level I. The objectives are clearly defined and results

considered extremely valid as multiple endocrinologists produced them, each of which

are experts and practitioners in diabetes, has published in the field of diabetes, and is

active in one or more of the main medical societies on diabetes care. The guidelines

speaks directly about the population of this project, stating T2DM is the most common

form of DM, making up more than 90% of DM cases.

Adaji, et al. (2008), Cooper et al. (2009), and Polisena et al. (2009) are all level I

articles because they are all systematic reviews and/or meta-analysis’s. Each of these

reviews are very consistent with each other; each population is patients with T2DM, each

intervention is a form of IT, each comparison is usual care, and each denotes outcomes of

reduced HbA1C levels. They are further appraised as follows:

Adaji et al. (2008) reviewed 25 articles and identified web-based programs as the

latest application of IT for chronic disease management. The findings are limited

by a few factors, one being that the scope was limited and did not, for example,

look at telemedical services. Also, there is considerable variability in the methods

used in the studies which have been identified and the majority of the studies were

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implemented in the USA which could limit the generalization of the findings.

However this article is significant because it highlights how IT can improve

patient self-management in diabetes.

Cooper et al. (2009) reviewed 5 articles. The findings in this review are limited by

a few factors; the small number of viable studies, the heterogeneity of

interventions, short-term follow-up and diverse focal points. The reviews validity

is shown by way of the findings corresponding with those from other less targeted

reviews of ICT-based patient education, reinforcing the potential of ICT to

provide an impact on and a link between education and treatment concordance.

Polisena et al. (2009) reviewed 26 articles and only included articles whose

quality rated A-C on a scale from A (high quality and high degree of confidence

in study findings) to E (poor quality and unacceptable uncertainty for study

findings), these included RCTs and prospective cohort. A possible weakness this

review has is that some studies included did not report whether the patients

involved had type 1 or type 2 diabetes. Validity however, is shown by the fact that

the findings of this systemic review are generally consistent with several systemic

reviews on HTM or telecare for diabetes management. The significance lies in the

finding that home telehealth is clinically effective as evident by the positive

impact on the use of numerous health services and glycemic control.

McMahon et al. (2005) is a level II article as it is a randomized control trial

(RCT). The majority of participants were men in which >50% had college degrees. This

may reflect bias towards women and people who do not have higher education, however

the study states previous studies with a more balanced ratio of men and women show

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similar outcomes (McMahon et al., 2005). Again this article focused on the population of

DM patients, used the intervention of IT, and had the outcome of decreased HbA1C.

Tang et al. (2012) is also a level II article because it is also a RCT. This study

had a large sample size of 379 patients even after its’ strict inclusion criteria, suggesting a

good sample of participants. It did however limit to English speaking patients and those

who have had diabetes for over a year. This is bias towards different ethnic groups and

leaves out other patients who could benefit and add to the article. The article shows that

using this technology decreases HgbA1C and LDL cholesterol levels, as well as leads to

patients recording their home glucose readings more frequently, talking with their

providers more, and having significantly lower treatment-distress scores and better

overall knowledge about diabetes and glucose testing. Patients who used the technology

also had greater overall treatment satisfaction and willingness to recommend the

technology to others (Tang et al., 2012).

Smith et al. (2004) is a level III article because it is a nonrandomized prospective

feasibility study. This feasibility study had a small population size and did not include a

control group, however, it did show significant trends in A1C reductions in patients who

used the intervention, IT, reflecting an outcome consistent with the previous articles.

J. Turner et al. (2009) is a level IV article because it is an informal review of a

cohort study. Twenty-three patients with uncontrolled T2DM from nine general practices

were used, creating diversity in population. However, only patients who commenced an

insulin regimen in the past 12 months were included, which would bias towards patients

who had been using insulin longer who still may need education. This study showed the

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outcomes of decreased HbA1C levels as well as increased levels of overall confidence in

the participants’ diabetes management abilities.

Sevean et al. (2009) is a level V article because it is a qualitative study. The

articles’ sample size was 10 patients and four family members in nine communities. The

small and geographically focused nature makes transferability of the findings difficult,

however, this article showed how IT could benefit those who may not seek treatment due

to their lack of access to care by allowing practitioners to monitor and educate these

patients via the Internet. Refer to Appendix 1 for a more detailed analysis of the

evidence.

Recommendations

After a thorough review of the literature, the following recommendations have

been established and are listed with their grade equivalent.

1. Routinely rechecking patients’ understanding of basic self-care concepts and

evaluating the effectiveness of the patients’ lifestyle interventions in preventing

the progression of T2DM. (Grade A). (AACEDMCPGTF, 2007).

2. Self-care at home is an immense component of diabetes management, and

telehealth has shown to be clinically effective as a home care tool. (Grade A).

(Polisena et al., 2009).

3. Using IT for forums where patients can discuss personal information they may

feel is embarrassing to ask in face-to-face sessions, which allows for patients to

better comprehend their T2DM and in turn be more likely to adhere to correct

self-care management. (Grade A). (Adaji, et al., 2008; Cooper et al., 2009).

4. Use IT to record/store logs of patients' blood glucose, insulin, diet, and exercise,

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so they can be shared with the patients’ practitioner who can then evaluate and

manage their patients DM. It is recommended that IT should be used because it

allows access to educational modules, coaches, and peer support groups that

facilitate the comprehension process and in turn increase each patients

confidence. (Grade A). (Adaji, et al., 2008; J. Turner et al., 2009; McMahon et al.,

2005; Polisena et al., 2009; Smith et al., 2004;).

5. Empowering patients with a better understanding of their disease processes and

encouraging them to take a more active role in self-management leads to better

control of their disease and can be done through technology. (Grade A). (Tang et

al., 2012).

6. Using video telehealth consultations as a method of health care delivery. (Grade

D). (Sevean et al., 2009).

Clinical Setting Assessment

The Baptist Health Center for Diabetes and Nutrition Education has been

recognized for excellence by the American Diabetes Associates since 1995. At this

organization there are two registered dieticians and two registered nurses, three out of the

four of these employees are certified diabetes educators. The center is next to Baptist East

Hospital and has multiple rooms set up for different lesson plans.

The primary patient population at this center is adults over the age of 20, referred

to the diabetes center by their primary care physician. In 2012, 857 patients were seen at

this center. 748 were diagnosed with Type II Diabetes. The patient demographics for

2012 consisted of 462 Caucasians, 382 African Americans, 7 who were Hispanic, Indian,

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or another race, and 6 Asians. 546 of the patients were females and 311 were males. The

approximate volume of patients seen per week at the center is around 25.

Education sessions at the center are done on Mondays, Wednesdays, and

Thursdays. Currently the patients are taught one-on-one and in small groups about

diabetes management; blood glucose testing, medication, diet and exercise. The center

utilizes food models, handouts, and food and exercise diaries. They provide new

diabetics with 30 minutes of one-on-one teaching followed by six hours of group

teaching, three with the registered nurse and three with the dietician, and then another 30-

minute one-on-one session for review and questions. The patients are encouraged to

follow up and are called by the center six months after their visit. An educator at the

center said there is a lot of lost patient follow-ups and continuing of monitoring and

educating after that initial visit. She stated that almost none of their patients return or call

for follow up appointments, and that therefore they do not have data showing the

effectiveness of their education. The educator suggests that these patients do not follow

up because insurance only covers a short amount of hours for education and any further

meetings at the center would be an out-of-pocket expense.

The primary educator at the center was informed of the evidence-based project

(EBP) and PICO question of in patients diagnosed with diabetes mellitus, does using

information technology to deliver education and management strategies compared to only

face-to-face interactions, improve patient glucose control, lifestyle choices, and

knowledge? The educator seemed very reluctant to consider change in terms of new

models of education or follow-up modalities. She voiced multiple times that she feels

nothing is better than the face-to-face interaction for educating patients. She did however

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state that she saw how technology could help improve follow-ups with patients and

increase the patients’ educational participation after the initial teaching. She said she is

willing to try anything that could help increase education and improve outcomes for her

patients. The educator also stated she saw the importance of technology in the future and

how online programs and smart phone apps could offer a place for questions to be

answered 24/7 and could provide better follow up and tracking than what currently takes

place at the center.

“One of the most significant barriers to diabetes self-management is the burden of

tracking and collating all of the important elements to manage the disease (Tang et al.,

2012, p. 3).” The lack of log keeping, communication, and follow up by patients as seen

at the center is evidence of a need for change in diabetes education and management.

Patients with diabetes have a potentially life-long disease that can lead to serious and life-

threatening comorbidities. For this reason follow-ups are necessary to ensure the patients

understand the education taught and that they are capable of managing their diabetes. IT

can help monitor whether the patient understands and follows these education and

management skills by keeping a log of the patients’ blood glucose, diet, exercise, weight,

and more.

These online programs/applications also have support and question forums from

which patients can benefit 24/7. For example, J. Tran, R. Tran, & White (2012) share

that the app Glucose Buddy allows patients to record and monitor glucose, medications,

carbohydrate intake, and A1C and enables data to be easily synchronized online where it

can be shared with healthcare providers. The app also gives reminders to check blood

glucose and take medication at specific time intervals. There is also an online forum

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enabling users to share their experiences and have questions answered from others (p.

176). Patients are more likely to use these applications for monitoring because they do

not actually have to leave their homes, they can simply e-mail their results to their

educator or physician, and some of the applications are free to download and install.

Implementation Plan

With the population expanding and healthcare changing, there is an increased

demand on physicians’ to obtain first-rate patient outcomes while managing more

patients with less time. For this reason new methods for healthcare professionals to

partner in managing patients diabetes are needed (Tang et al., 2012). The center for

Diabetes/Nutrition Education is a good place to implement a new method of diabetes

management. Implementation of this project would require multiple steps. The first step

would include determining which web-based diabetes-learning program to implement at

the Center for Diabetes/Nutrition Education, whether it be computer or smart phone

based. Resources used for this include the Auburn University online library databases as

well as the Internet. Next, a flyer will be created that will be given to participants

explaining the online learning program, especially how to upload glucose readings,

record their diet and exercise logs, and use the interactive forums for questions/support.

Again, Auburn University’s’ online library databases will be used for resources on the

programs, as well as the websites/apps themselves, and the Internet will be used for flyer

examples. A print lab is also needed to form and print the high volume of flyers, which

will require financial resources. The subsequent step involves educating the center staff

about how to present the IT flyer to patients and how to instruct the patients to utilize the

website/application. Resources such as peer-reviewed articles on how other facilities

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implemented web-based learning will be used to educate the staff. The optimal form of

educating involves showing the patient first hand how to use the website/application.

Next, the patients will be selected based on inclusion criteria. The patient information is

available at the center to be used as a resource prior to the patient arrival so the decision

on whether the patient fits criteria or not is made before the patient walks through the

door. Once the patient meets inclusion criteria, baseline information/labs will be

obtained, staff will give them a flyer, provide a detailed explanation on the IT program,

and provide them with glucometers and computers/smart phones if the patients do not

already have such resources, or help them set up the program for those who do. This will

require staff to assist participants with becoming familiar with the IT program before they

leave the center. The participants will then leave and start their IT education and diabetes

management. Finally, data on patient outcomes with web based intervention will be

collected via mailed or over-the-phone questionnaires and laboratory data. Money for

stamps, envelopes, and printed questionnaires will be needed, as well as time from the

personnel to contact each patient and check follow up labs. All desired outcomes will be

measured and recorded using the statistics program at pre-implementation, six weeks

post-implementation, six months post-implementation, and a year post-implementation.

The methods for measuring these outcomes will be discussed further in the evaluation

section.

Potential Facilitators and Barriers

The center for Diabetes/Nutrition Education already has the name of web

resources printed on the back of their booklet, however I would seek to maximize this IT

resource by providing a more detailed flyer description of how the websites/applications

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can help/be used. The manager said she would pass out anything to her patients that may

help their diabetes management, and evidence-based flyer on IT programs for diabetes

management would fit this criterion. There are six employees at the center, therefore it

would be relatively easy to meet with all of the employees and educate them on the IT

program being implemented. Staff at the center talk with each patient individually and

can assess whether the patient meets criteria and if they should be given the flyer and

detailed explanation on the IT program. At this time the staff could obtain a baseline

glucose and HgbA1C from their records, weight, and BMI from patient. The biggest

facilitator to this project is that the educators having a strong passion for the wellness of

their patients, and therefore the willingness to try implementing the parts of the EBP

project capable.

Potential barriers to this EBP project are the small volume of patients, the older

age of the patients, the lack of access or lack of knowledge of computers or smart phones

of the patients, the budgetary requirements needed to provide patients with computers

and online access, or smart phones, and the cultural barriers of the center employees. The

educator stated most patients are older adults and that it was her feeling that most do not

use computer resources or smart phones for their diabetes education possibly due to lack

of access, which they do not supply, or lack of knowledge about maneuvering websites

and applications. There are many computer websites and smart phone apps that are free

or of low cost, however getting patients who do not have a computer/smart phone these

devices could be a huge financial requirement as well as a large requirement in time and

money from the human resources standpoint for the staff needed to train the patients on

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using the computers and websites. Exploring grants and insurance options could be an

option to possibly minimize this burden.

On the opposite barrier spectrum, is that of the culture of the centers’ employees.

Some of the educators at the center seem hesitant about the use of IT for diabetes

education and management, doubting its’ validity and fearing a change from the norm.

This barrier will attempt to be minimized by showing them the positive research found on

IT education and diabetes control. Another barrier involving center staff is that the

project director would not be at the site at all times to ensure the correct patients were

included or that the flyer was actually handed out and explained. To minimize faulty

patient selection and lack of handing out flyers, the criteria for selection will be stressed

with the staff at the center as well as the importance of handing out the flyer.

A barrier to the outcome measurement portion of this project is that center

employees will not be paid extra for calling participants and therefore may not desire to

do so, leaving it on the project leader. Patients may not return calls or e-mailed or mailed

questionnaires. The barrier of lack of patient response could be minimized by frequent

calls or e-mails to the participants explaining the importance of their response.

Evaluation Plan

Population data important to collect for this EBP project includes gender, age,

ethnicity, and coinciding diagnoses. These are important because significant variances in

any of these can skew results, for example, a 76 year old female with arthritis may not be

able to lose weight or use a computer the way a 26 year old male with no comorbidities

can. This population data will be collected by the initial nurse/dietician via a

questionnaire prior to the EBP project being implemented, as well as an initial blood

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glucose, HgbA1C level, weight/BMI, amount of exercise per week, and the patients’

overall confidence in their diabetes management abilities and knowledge/behavior about

what foods to eat and which to avoid, signs and symptoms of hyper/hypoglycemia,

potential complications to look for, and how to properly use insulin, measured via a

visual analogue scale (VAS). This same data will be measured six weeks post-

implementation, six months post-implementation, and a year post-implementation by a

staff nurse. All of the data from this one pilot at the center will be transferred to the

statistical software program Statistical Package for the Social Sciences (SPSS) in order to

better track and visualize results.

Expected Outcomes

Expected short-term outcomes for six weeks post-implementation of this specific

EBP project include a decrease in blood glucose levels of patients to under 170 observed

on the trend tracker/glucose log, a HgbA1C less than 8, a decrease in BMI (for those

patients needing a reduction in BMI), and an increase in behavioral change, such as an

increase in knowledge/confidence on diabetes management, as evident on the VAS.

Long-term outcomes for one year post-implementation include better health outcomes

such as more consistent control of blood glucose levels, between 70 and 160, a decrease

in HgbA1C level, preferably to a level less than 7, a BMI preferably under 25, but

specific for each patient.

The process of measuring knowledge/behavior outcomes, as well as the patients

overall confidence in their diabetes management abilities, will be a VAS. Foley (2008)

writes that visual analogue scales are a form of graphic rating scale in which the rater

23


places a mark along a100 mm long line with no marks between the ends where one end

of the line represents 0 and the other end represents 100. Raters place a mark at a point

along the line to indicate their rating. The scale is scored using a ruler, measuring in

millimeters, the score being reflected by how many mms from 0 the rater has placed a

mark. Visual analogue scales have been compared with other kinds of scales to

determine whether two scales produce similar results and it was found that the VAS was

similar in both reproducibility and sensitivity (Foley, 2008). VAS has been used for

several years and has consistently produced evidence of reliability and validity. Foley

(2008) states that, “given the flexibility of this kind of scale, it has the potential to

enhance many areas of measurement in nursing education” (p. 210). This scale will be

particularly valuable in measuring the patients’ confidence in diabetes management

because as stated by Turner, Draaisma, Oosterveld, and ten Cate (2008), the VAS offers a

quick and simple measure of self-efficacy, which can be defined “as a persons’ belief in

his or her capability to organize and execute the course of action required to produce

particular outcomes”(p. 503). A strong sense of self-efficacy is believed to influence an

individuals’ behavior by influencing choices, thought patterns, and emotional reactions

and determining effort (N. Turner et al., 2008). The VAS is shorter than other

questionnaires, and therefore may improve compliance. Measurement of the more

specific outcomes, such as blood glucose levels, HgbA1C levels, and weight/BMI, will

be checked via logs, blood tests, and a calibrated physician scale, which along with

height, allows for interpretation of the patients’ BMI.

Implementation of the Small Test of Change

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A small test of change (STOC) pilot was executed at the Baptist Health Center for

Diabetes and Nutrition Education. It involved creating a pamphlet on the application

GlucoseBuddy, recruiting participants, educating participants on the app and installing

the app on their phones if available or instructing them how to download it on their

computer. Data was collected pre-pilot and four weeks after the participants used

GlucoseBuddy. Expenditures for this project included the cost of supplies such as paper

and ink used for the consent and flyers given to participants, as well as the gas and

mileage used driving to and from the center recruiting participants. No financial burdens

were presented to any participants or to the clinical setting employees or stakeholders.

The STOC pilot commenced January 14th, 2014. The first few weeks were spent

gathering and organizing all evidence-based articles and supplies for the project, gaining

approval for the project from Baptist and Auburns’ institutional review boards (IRB), and

creating a timeline for the project implementation. The project was put on hold for a few

days because Auburn’s IRB required additional information. After receiving IRB

approval, the Baptist Health Center for Diabetes and Nutrition Education staff were

educated about the project, including participant requirements, the IT program

GlucoseBuddy, and the flyer (Appendix 2) and consent forms to be given to the

participants. Dates for recruiting participants were then discussed and decided upon

based on whether the date had patients who could be potential participants. Participants

had to be adults over the age of 18 diagnosed with T2DM and referred to the diabetes

center by their primary care physician. These patients had to have a smart phone or

access to a computer in order to be able to use the IT and be involved in this pilot

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The project commenced at the center January 31st, 2014. The goal was to have

10 participants by February 14th, 2014, however this had to be pushed back to February

28th, 2014 because it was rather difficult obtaining willing and capable participants.

Multiple factors contributed to this including the center not having a high volume of new

diabetic patients and many of the prospective patients not showing up. Another issue was

that many of the patients were elderly and did not want to participate due to not having a

smartphone or not having much knowledge of computers. By February 28th however,

five participants were enrolled in the pilot. The participants were given a flyer on the

project as well as a detailed explanation on the GlucoseBuddy application. After giving

consent, baseline information was obtained from the participants. This information

included their age, gender, ethnicity, years since diagnosis of diabetes, diet, oral diabetic

medications, insulin type, weight, Body Mass Index (BMI), average blood glucose,

HgbA1C, participant’s current weekly exercise amount, and confidence score based on

the VAS questionnaire they filled out (Appendix 3). Next, the IT application was either

downloaded to the participants’ smartphone or they were sent home with instructions on

how to get it on their phone/computer later. The participants then went on to use the

application to help manage their diabetes.

Participants were called after initiation of the project to follow up on any

questions or concerns about the application/project they might have had. On March 28th,

2014, post-implementation data was collected from all five participants for analysis on

the projects’ efficacy. This data included their weight, exercise routine, blood sugar, and

confidence score based on the VAS questionnaire. The data was compiled into an excel

spreadsheet as well as SPSS software for appraisal.

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Data Management

The variables, gender, and ethnicity were entered into an excel spreadsheet as 1-

male and 2-female, and 1- Caucasian, 2- Latino, 3- African American, and 4- other. The

participant’s age and years since diabetes diagnosis were entered as current age and

amount of time in years. The current diet variables were entered as: 1- regular, 2- low

carb (diabetic), 3- low fat, 4- low salt, and 5- other/combination. The current oral

diabetes medications used were labeled as: 1-Metformin, 2- Glipizide/DiaBeta, 3-

Avandia/Actos, 4- Januvia, 5- other/combination, and 6- none. The variables of use of

insulin types were labeled as: 1- Humalog/Novalog, 2- Humulin R/Novolin R, 3-

Humulin N/Novolin N, 4- Levemir/ Lantus, 5- other/combination, and 6- none. Weight

was entered in pounds, and current weekly exercise amount was entered as: 1- never, 2-

1-3 times week, 3- 3-5 times week, and 4- daily. The average initial glucose and HgA1c

levels were obtained based on the patients record and BMIs were obtained based on the

patients weight and height given. The VAS scores were entered as answered on the

participants’ questionnaire sheets.

Analysis Report

The data was entered into the statistical software program Statistical Package for

the Social Sciences (SPSS) and descriptive and inferential statistical analyses were

conducted. The groups’ data was analyzed for improvement using t-Tests. The variables

compared were their initial BMI, weight, blood glucose, exercise, and VAS score with

the post-implementation BMI, weight, blood glucose, exercise, and VAS score. The

level of significance was set at alpha = .01 due to the small sample size.

27


Description of sample. The group (n=5) was 60% male, 60% Caucasian, and

40% African American. The mean age of the participants was 56.8 (14.2 SD) years. Of

the participants, 20% reported eating a low carb diet, 40% a regular diet, and 40% a

combination or other diet. Initial exercise of the participants consisted of 80% never

exercising and 20% exercising 1-3 times a week. The mean for the initial VAS score was

64.4 (25.6 SD).

Tests for improvement. Paired samples statistics were computed for variables of

pre and post participation BMI, weight, blood glucose, exercise, and VAS score. After

implementation, the groups’ mean weight dropped from 233.6 (41.5 SD) to 229.2 (38.3

SD). The result was significant with a t score of 2.4 with a p-value of 0.07. The initial

mean BMI for the group was 33.6 (5.5 SD), and post-implementation the mean was 32.98

(5.1 SD). This showed significant improvement with a t score of 2.5 and a p-value of

0.07. The initial blood glucose readings for the group was 197 (54.3 SD), dropping to

119.2 (36.1 SD) post participation. This has a t score of 2.5 and a p-value of 0.07. These

results are illustrated in Figure 1.

WEIGHT BMI BLOOD GLUCOSE0

50

100

150

200

250

Results with Significant Change

PREPOST

Figure 1. Results with Significant Change. Weight: t= 2.4 p= .07, BMI: t= 2.5 p= .07, and blood glucose: t= 2.5 p= .07

28


The VAS questionnaire used to collect confidence data had a pre-implementation

mean of 64.4 (25. 6 SD), and a post- implementation mean of 86 (8 SD), showing

significance with a t score of -2.6 and a p-value of 0.06. Of the 10 questions on the

questionnaire, 5 were significantly improved and are illustrated in Figure 2.

How confident do you feel that you understand what diabetes is? t= -3.7 p=.02

How confident do you feel about recognizing signs of high and low blood sugar? t= -2.3 p= .09

How confident do you feel that you know what to do when your blood sugar level goes higher or lower than it should be? t= -3 p= .04

How confident do you feel about your knowledge on your diabetes medications? t= -2.9 p= .05

7.8

6.4

6.4

3.6

9.8

8.6

8.6

8.8

Specific Confidence Questions with Significant Change

Post Pre

Figure 2: Specific Confidence Questions with Significant Change

Application to Overall Project

This small test of change helped highlight issues that would need to be addressed

before implementing the larger project. First, more participants would need to be

included to get a better judge of efficacy. There was difficulty recruiting participants

because there was a low amount of newly diagnosed diabetics at the center on days the

project leader was present and most of the patients were elderly and not interested in or

unfamiliar with smartphones and computers. Perhaps another clinical setting would be

more conducive for the project in terms of having a higher number of younger to middle

aged adults who are more familiar with smartphones or computers and in turn would be

more willing to participate in a project with these devices. With more funding, the staff

29


where the pilot would be executed could be educated on how to conduct an evidence-

based pilot and how to maneuver the specific app GlucoseBuddy. This would allow the

staff to be able to recruit participants for the pilot, leading to the possibility of gaining

more participants than possible with just the project leader recruiting.

Some potential participants could not take part in the pilot because they did not

have a smartphone or access to a computer. It would greatly benefit the larger project to

be able to provide the participants with a form of one of these devices, either an iPhone or

iPad for example. Not only would providing devices allow for more participants, it

would also allow the project leader to track how often and how much the participants

used the GlucoseBuddy application.

More frequent check-ins with the participants would help trouble shoot questions

about the application as well as remind the participants to use the IT. These check-ins

could be done monthly via phone calls or more ideally clinic or home visits where the

device being used could be checked by the project leader. Also the implementation

would need to be set over a longer time frame, such as a year, in order to more adequately

evaluate the long-term effectiveness of the intervention. The STOC did show decreases

in blood glucose, however the time frame was to short to be able to monitor the more

precise judge of blood glucose control, HgbAlC.

Conclusions

Diabetes Mellitus is a tangible and prevalent problem that left unmanaged can

lead to severe complications. Control of diabetes leads to a better quality of life for

patients and a decreased risk of developing comorbidities. Advanced practice nurses

have a tremendous responsibility towards their patients in relation to educating them on

30


how to control and manage their diabetes. With the prediction of diabetes incidence

rising drastically in the next 50 years, healthcare must attempt to get ahead of the

problem by finding programs with the best evidence-based reports of improvement for

managing the intricate disease of diabetes and preventing its’ complications. By

implementing an evidence-based project and choosing a research framework to guide

explorations, it is possible to ascertain the best evidence for managing diabetes. Clinical

practice is based off of this evidence, therefore, in advanced practice nursing it is

imperative to find the strongest evidence available and develop recommendations based

upon said recommendations. Advanced practice nurses must be able to provide patients

with the best tools available for increasing their understanding of diabetes and their

ability to manage it.

The small test of change did result in noteworthy changes in blood glucose,

weight, BMI, and confidence in diabetes management over the 4 weeks of

implementation. The significance of this report supports the incorporation and utilization

of Information Technology programs, such as GlucoseBuddy, in this setting to help

educate about and manage diabetes.

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association of clinical endocrinologists medical guidelines for clinical practice for

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Adaji, A., Schattner, P., & Jones, K. (2008). The use of information technology to

enhance diabetes management in primary care: A literature review. Informatics In

Primary Care, 16(3), 229-237.

Cooper, H., Cooper, J., & Milton, B. (2009). Technology-based approaches to patient

education for young people living with diabetes: A systematic literature review.

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Facchiano, L., Snyder, C., & Núñez, D. E. (2011). A literature review on breathing

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Larrabee's evidence-based practice model. Journal Of The American Academy Of

Nurse Practitioners, 23(8), 421-426. doi:10.1111/j.1745-7599.2011.00623.x

Foley, D. (2008). Development of a visual analogue scale to measure curriculum

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20080501-04

Karakurt, P., & Kaşıkçı, M. (2012). The effect of education given to patients with type 2

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170-179. doi:10.1111/j.1440-172X.2012.02013.x

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McMahon, G. T., Gomes, H. E., Hohne, S.H., Hu, T. M., Levine, B. A., & Conlin, P. R.

(2005). Web-based care management in patients with poorly controlled diabetes.

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http://www.mycareteam.com/documents/boston_va_randomized_clinical_trial.pd

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Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing &

healthcare (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Polisena, J. J., Tran, K. K., Cimon, K. K., Hutton, B. B., McGill, S. S., & Palmer, K. K.

(2009). Home telehealth for diabetes management: A systematic review and meta-

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1326.2009.01057.x

Sevean, P., Dampier, S., Spadoni, M., Strickland, S., & Pilatzke, S. (2009). Patients and

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Smith, K. E., Levine, B. A., Clement, S. C., Hu, M., Alaoui, A., & Mun, S. K. (2004).

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Hui, S. L., Hyde, S. M., Klieman, L. H., Mitchell, C. J., Perkins, A. J., Qureshi, L.

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Appendix 2

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Diabetes Control StudyBe part of an important diabetes research study

Are you older than 19 years of age?Do you want to be able to better understand and control your diabetes?Do you have access to a smartphone or computer?If you answered YES to these questions, you may be eligible to participate in research study on diabetes and information technology (IT).

The purpose of this research study is to determine if in patients with diabetes mellitus, using information technology to deliver education and management strategies compared to only face-to-face interactions, improves patient glucose control, lifestyle choices, and knowledge. Benefits include having access to a log that can be used to record and monitor blood sugar, medications, food intake, HgbA1C, weight, and exercise, as well as access to an online forum where you can share experiences and questions with others. The app also gives reminders to check blood glucose and take medication at specific time intervals. No medications will be given. It is theorized that using technology will help decrease your blood sugar levels, HgbA1C, and BMI (weight), and can help increase your knowledge and confidence on your diabetes management.

This study is being conducted by the Baptist Health Center for Diabetes and Nutrition Education.Please discuss with the center staff for more information or Kailey Hamrick, RN at [email protected].

Appendix 3

36

mailto:[email protected]


Diabetes Management Through Information Technology Initial Questionnaire

Personal Information:1. Name: Date:

2. Phone number:

3. Email:

4. Address:

5. What is your age:

6. What is your gender: Male Female

7. What is your ethnicity: Caucasian Latino African American Other

8. What type of diabetes do you have: Type 1 Type 2

9. How many years have you been diagnosed with diabetes:

10. What type of diet do you follow: Regular Low carb (diabetic) Low fat Low salt Other/ combo

11. What oral diabetes medications are you currently taking: Metformin Glipizide/ DiaBeta Avandia/ Actos Januvia Other/ combo None

12. What type of insulin are you currently on: Humalog/ Novalog Humulin R/Novolin R Humulin N/Novolin N Levemir/ Lantus Other/ combo None

13. How much do you weigh:

14. How tall are you:

15. Current average blood sugar:

16. Current HgbA1C:

37


17. How often do you exercise: Never 1-3 Xs week 3=5 Xs week Daily

Visual Analogue Scale Survey:

1. How confident do you feel that you understand what diabetes is?

Not at all CompletelyConfident 1 2 3 4 5 6 7 8 9 10 Confident

2. How confident do you feel about recognizing signs of high and low blood sugar?


3. How confident do you feel that you know what to do when your blood sugar level goes higher or lower than it should be?


4. How confident do you feel about checking your blood sugar?


5. How confident do you feel that you can choose the appropriate foods to eat when you are hungry and which to avoid (for example, snacks)?


6. How confident do you feel about your knowledge on your diabetes medications? Skip if not applicable.


7. How confident do you feel that you can judge when the changes in your illness mean you should visit the doctor?


8. How confident do you feel about understanding potential complications of diabetes?

Not at all Completely

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Confident 1 2 3 4 5 6 7 8 9 10 Confident

9. How confident do you feel that you can control your diabetes so that it does not interfere with the things you want to do?


10. How confident are you that information technology (smart phone or computer applications) will help you manage and learn about your diabetes?


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