The Feasibility of Implementing a Diabetes Distress Toolkit to Improve Outcomes in Adults with Uncontrolled Type 2 Diabetes: A DNP Project Daneeka Armont-Woods, MSN, APRN, NP-C DNP Candidate Southeastern Louisiana University Laurie Kinchen, DNP, APRN, PNP, DNP Project Committee Chair Christine Hadeed, DNP, APRN, ACNP, Second Faculty Committee Member Karen Rice, DNS, APRN, ACNS-BC, ANP, Facility Mentor S
Daneeka Armont-Woods, MSN, APRN, NP-C S Adult Nurse Practitioner S Graduated with BSN in 2002 from Dillard University of New Orleans, LA S Graduated with MSN in 2009 from Southeastern Louisiana University of Hammond, LA S Has worked as a Nurse Practitioner in the Diabetes Specialty Clinic of Ochsner Medical Center of New Orleans since February 2010
INTRODUCTION: BACKGROUND Over 29 million people in the United States have diabetes S Diabetes is the seventh leading cause of death in the United States S Medical expenditures for those with diabetes are significantly higher than those S without diabetes Direct (medications/treatments, hospitalizations) and indirect costs (disability, S premature death, lost of income) of diabetes=$245 billion
Age-Adjusted Prevalence of Diagnosed Diabetes Among US Adults 2004 Missing data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
Age-Adjusted Prevalence of Diagnosed Diabetes Among US Adults 2014 Missing data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data
INTRODUCTION Diabetes Distress (DD) are those emotional concerns, worries, fears, and anxieties S that frequently accompany a chronic disease such as diabetes (Fisher, Hessler, Masharani, & Strycker, 2014, p. 740). DD is associated with poor diabetes control and self-management (Fisher et al., S 2014, p. 740). DD impacts as many as 40% of people diagnosed with diabetes and can increase S over time, especially in those with Type 2 Diabetes (T2DM) (Berry, Lockhart, Davies, Lindsay, & Dempster, 2015, p. 279).
INTRODUCTION S Increases in DD are associated with feelings of fear, anger, and resentment, which can lead to worsening diabetes control (Philips, 2014, p. 615). S Interventions to reduce DD can lead to improvements in diabetes care. S Reduced DD is anticipated to improve diabetes outcomes
PURPOSE S Evaluate the feasibility of measuring DD and piloting a toolkit anticipated to improve DD and diabetes-related outcomes.
THEORETICAL FRAMEWORK Trusting, caring relationship Creative Expression problem of feelings Jean Watson ’ s solving Theory of Human Supportive/p Allowance Caring Patients rotective for spiritual environment forces & Family Members Humanistic/ Teaching- altruistic learning value system Instilling Assisting faith and with basic hope human needs Sensitivity to self & others
LITERATURE REVIEW S Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and Pubmed searched. S Keywords: T2DM, diabetes distress, glycemic control, support S 225 articles initial yield S Excluded articles: Type 1 diabetes, depression, group support without diabetes. S 24 articles included
LITERATURE REVIEW: LEVELS OF EVIDENCE
LITERATURE REVIEW: SUMMARY OF FINDINGS Intervention trials should target individuals with high A1C and DD levels (Berry et al., S 2015). There is a significant association between distress and A1C (Fisher, Glasgow, & S Strycker, 2010). DD is responsive to interventions (Fisher, Hessler, Glasgow, Arean, Masharani, S Naranjo, & Strycker, 2013). Decreases in regimen distress are associated with improvements in A1C and self- S management (Hessler, Fisher, Glasgow, Strycker, Dickinson, Arean, & Masharani, 2014). More attention should be given to non-clinical factors when addressing diabetes related S distress (Karlsen & Bru, 2014). Changes in DD are associated with changes in glycemic control for patients with S uncontrolled T2DM (Zagarins, Allen, Garb, & Welch, 2012). Adherence to diabetes treatment is linked to DD more than depression (Zhang, Xu, Wu, S Xue, Xu, Li, Gao, & Liu, 2013).
LEVELS OF EVIDENCE Author Publication Year Publication Impact Factor Level of Evidence Berry, Lockhart, Davies, 2015 Postgraduate Medical Journal 1.448 VI Lindsay, & Dempster Dale, Williams, & Bowyer 2012 Diabetic Medicine 3.241 I Fisher et al. 2007 Diabetes Care 7.851 IV Fisher, Glasgow, & Strycker 2010 Diabetes Care 7.141 II Fisher, Hessler, Polonsky, & 2012 Diabetes Care 7.735 IV Mullan Fisher et al. 2013 Diabetes Care 8.570 II Fisher, Hessler, Masharani, & 2014 Diabetic Medicine 3.115 II Strycker Fonda, McMahon, Gomes, 2009 JDST N/A II Hickson, & Conlin Hessler et al. 2014 Diabetes Care 8.420 II Jansen et al. 2014 Diabetes Care 8.420 II Karlsen & Bru 2014 IJNS 2.901 IV Liu et al. 2014 JDI 1.825 II Partiprajak, Hanucharurnkul, 2011 PRIJN N/A II Piaseu, Brooten, & Nityasuddhi Phillips, A. 2014 Practice Nursing N/A VI Pick, A. 2009 Practice Nursing N/A IV Polonsky et al. 2005 Diabetes Care 7.844 VI
LEVELS OF EVIDENCE Author Publication Year Publication Impact Factor Level of Evidence Sarwat et al. 2010 Diabetic Medicine 3.036 II Smaldone et al. 2006 Diabetes Care 7.912 VI Tovote et al. 2014 Diabetes Care 8.420 II Vries et al. 2014 BMC Endocrine Disorders 1.710 II Wagner, Tennen, Feinn, & 2015 JOI 1.482 (2014) IV Osborn BMC Medical Informatics Yu et al. 2014 1.830 IV Decision Making Zagarins, Allen, Garb, & Welch 2012 JBM 2.216 II Zhang et al. 2013 NDT 2.154 VI
LEVELS OF EVIDENCE Articles Level I Level II Level IV Level VI 4% 21% 50% 25%
CLINICAL QUESTIONS S Is it feasible to measure DD and implement a DD toolkit in patients with T2DM being treated in an APRN-led diabetes specialty clinic? S What are the reports of patients with uncontrolled T2DM and moderate to high DD in those that used the interventions in the toolkit versus those that did not use the interventions? S What are the diabetic outcomes in those with T2DM with moderate to high DD that used the toolkit compared to those that did not use the toolkit? S What are the barriers and facilitators in those patients with T2DM and moderate to high DD that used the DD toolkit?
METHODOLOGY: DESIGN S Quality improvement design S Quality improvement projects in healthcare entail efforts that seek to improve services for the future (Moran, Burson, & Conrad, 2014).
METHODOLOGY: INTERVENTION S Screen patients presenting to the advanced practice registered nurse (APRN)-led diabetes specialty clinic for DD. S 17-item DD survey (DDS-17) completed in the waiting room or the exam room with the APRN. DDS-17: Developed by Dr. Polonsky and Dr. Fisher S Emotional burden S Physician/provider related distress S Regimen Distress S Interpersonal Distress S S All patients completing the DDS-17 received a copy of the DD toolkit
METHODOLOGY: INTERVENTION Uncontrolled T2DM (A1C ≥ 7%), and at least moderate DD via a score of 3 S or more in overall DD or any of the subscales were invited to be consented and all interventions were explained in detail. A1C. S Exclusion: Type 1 Diabetes, depression, A1C <7%, altered mental status. S Clinic visit evaluation completed S Telephone survey 4-6 weeks after initial visit. S Telephone visit evaluation completed S Return visit in 3-4 months S 17-item DD survey and review A1C . S All information entered into an Excel spreadsheet for data analysis S
METHODOLOGY: OUTCOME MEASURES S Primary endpoint: the feasibility of measuring DD and implementing the toolkit. S Secondary outcomes S A1C S DD levels
METHODOLOGY: DATA COLLECTION TOOLS
DDS-17
DDS-17 SCORING SHEET
A1C
CLINIC AND TELEPHONE VISIT EVALUATIONS
TELEPHONE SURVEY
DIABETES DISTRESS TOOLKIT
Assessed for eligibility (N=175) T2DM A1C 7% or greater Able to complete DDS-17 Age 18 and older Sample sized based Score of 3 or more in overall DD or subscales on a population of S 360 with a 95% Excluded (N=162) Not meeting inclusion criteria (n=12) confidence level, A Type 1 Diabetes (n=5) 5% error resulted Depression (n=6) in 189. A1C <7% (n=1) Refused to Complete DDS-17 (n=1) M No time to complete DDS-17 (n=31) Not identified with any component of DD (n=118 ) P L Consented participants (N=13 ) Completed pre DDS-17 Received DD toolkit E Survey response rate=81.71% Lost to follow up (N=2 ) Did not complete post DDS-17 Analyzed (N=11 )
RESULTS Variable Any Diabetes Distress Range [M(SD)] Age 59.64(11.79) 35-80 Years of Diabetes 19.45(11.73) 7-50 Variable Pre (n=11) Post (n=11) Percent change A1C % [M(SD)] 10.01(0.97) 8.73(0.81) 12.79 ↓ Total DD [n(%)] 7(64) 0(0) 100 ↓ 88.89 ↓ Emotional burden 9(82) 1(9) subscale Physician distress 1(9) 0(0) 100 ↓ subscale Regimen distress 10(91) 0(0) 100 ↓ subscale 60 ↓ Interpersonal distress 5(45) 2(18.18) subscale
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