Self-Management in this presentation refers to those activities people undertake in an effort to promote health, prevent disease, limit illness, and restore well being. Several investigators contend that self-management be made a major component of many patient health-care strategy (Glasgow, et al., 2001; Wagner, et al., 2001). Currently, nearly 125 million Americans suffer from chronic debilitating illnesses (Anderson, 2000). These national figures clearly underscore the need to develop a multidimensional approach in regards to disease management. Accordingly, measures that incorporate the patient’s perspective in managing his or her health should be explored. Diabetes mellitus is among those conditions suspected to be highly influenced by self-management activities (Sprangers, et. al., 2000). If benefits do indeed exist, they need to be fully evidenced. The investigation presented here sought to examine the role self management plays in the health outcomes of individuals living with diabetes.

1. A CORRELATION STUDY TO DETERMINE
THE EFFECT OF DIABETES SELFMANAGEMENT ON
DIABETES OUTCOMES
Kurt Naugles, M.D., M.P.H.
Tennessee State University
College of Health Sciences
Department of Public Health

2. Presentation Outline
Part I – Diabetes Mellitus Overview
1.
2.
3.
4.
What is Diabetes Mellitus
Why is Diabetes Mellitus a Public Health Concern
Public Health Medicine’s Response
Diabetes Self-Management Education
Part II – Capstone Internship
1.
2.
Capstone Internship Site
Capstone Internship Goals and Objectives
Part III – Capstone Project
1.
2.
3.
4.
Capstone Project Rationale
Capstone Project Goals and Objectives
Capstone Project Design, Methods, Analysis, and Results
Discussion
Part IV – Conclusion
1.
2.
3.
4.
5.
Study Limitations
Recommendations
Lessons Learned
Acknowledgements
References

3. Diabetes Mellitus
Diabetes Mellitus (DM)
 A collection of disease processes
 All characterized by hyperglycemia (glucose >126 mg/dl)
 Defects in insulin secretion and/or action
 Symptoms: Polyuria, Polydipsia, Weight Loss
 Two major types: Type-1 & Type-2

4. Diabetes Type-1
Type-1
 Juvenile Diabetes
 5-10% of DM cases
 Autoimmune disease of the pancreas
 Progressive loss of insulin production
 Complications -> Acute

Diabetic coma

Keto-acidosis
 Treatment

Requires life-long insulin replacement

5. Diabetes Type-2
Type-2
 Adult Onset Diabetes
 90-95% of DM cases
 Insulin deficiency or resistance
 Complications-> Chronic

Effects:
Heart, Kidneys, Nerves, Eyes, & Blood
Vessels
 Treatment

Mild – Diet and Exercise

Moderate – Diet, Exercise, & Oral Drugs

Severe – Diet, Exercise, Drugs, & Insulin

6. Public Health Concern?
Epidemiology
 Incidence and Prevalence
 Morbidity and Mortality
 Cost

7. Diabetes Incidence & Prevalence
Incidence & Prevalence (U.S.)
 26 million Americans ( 8.3% )
 3 million new cases (2009-11) – Epidemic?
 79 million -> Pre-diabetic
 Rise in teenage and adolescent cases
 Increased association with Obesity
 Disparity in Racial/Ethnic Incidence Rates

Native Americans->Blacks->Hispanics->Asians ->Whites

8. Diabetes Prevalence in the U.S.
Incidence & Prevalence (U.S.)
 Higher Incidence rates
reported in the Southern,
South-Western, and MidWestern States
 Tennessee ranks among the
top 5 States with record
high incidence rates

9. Diabetes Morbidity & Mortality
Morbidity & Mortality (U.S.)
 7th leading cause of death
 A leading cause of kidney
disease, heart disease, &
stroke
 70% of diabetics suffer from
neuropathy
 60% of limb amputations due
to diabetes

10. Costs Associated with Diabetes
Cost (U.S.)
 Second biggest driver of
Health-care cost
 $174 billion in direct and
indirect cost
 Diabetics spend on average
$6,000 annually to treat
their condition

11. Public Health Medicine’s Response to
Diabetes
Healthy People 2020
“Reduce the disease and economic burden of
diabetes mellitus (DM) and improve the quality of
life for all persons who have, or are at risk
for, DM.”

12. Public Health Medicine’s Response to
Diabetes
Diabetes Self-Management
 Definition – those activities people undertake in an effort to promote health, prevent
disease, limit illness, and restore well being

Rigorous medication compliance

Regular clinical visits

Routine HbA1C testing

Multi-daily blood-glucose self checks

Proper insulin administration

Improved dieting and exercise

Scrupulous foot care

Systematic disease monitoring
 Requires

Hard work and Perseverance

Education and Training

13. Diabetes Self-Management Education
Diabetes Self-Management Education
(DSME)

14. Diabetes Self-Management Education
 DSME was designed by a Diabetes Task Force to establish
National Standards for DM self-care
 Provides the knowledge and training to perform diabetes self-
care tasks.
 Primary Objective:

Manage “Glycemic Status”

Improve Diabetes Outcome
 Recognized by the ADA as an essential part of diabetes care.

15. Diabetes Self-Management Education
Theoretically Framework
 Health Belief Model
->Perceived susceptibility, severity, barriers, and benefits
 Social Support Model
->Emotional, Instrumental, Informational, and Appraisal Support
 Social Cognitive Theory - acquisition of knowledge through
observation
-> Self-Efficacy – the belief in one’s ability to execute a course of action

16. Diabetes Self-Management Education
There is no one “best” education program or approach;
however, DSME programs are guided by a set of core
principles.

Patient-Centered

Objective-Oriented

Age-Specific

Lifestyle and Behavior Based

Culturally-Sensitive

Group-Assisted

17. Diabetes Self-Management Education
Why is DSME a good strategy?
 How can you effectively self-manage a complex disease
without education and training?
 Each $1 spent on outpatient diabetes education saves $2 to
$3 dollars in hospitalization costs (APhA Foundation 2003
Statistics - JAPhA)
 Patients who never received self-management education
were 4 times more likely to develop a chronic complication
(Nicolucci Study)

18. Impact of Diabetes Education

19. Diabetes Self-Management
Question:
“Will the relationship (correlation)between
Diabetes Self-Management and Diabetes
Outcomes seen in the literature be
evidenced in other patient populations?”

20. Watts Primary Care
INTERNSHIP/CAPSTONE PROJECT SITE

21. Watts Primary Care
Internship Site
Watts Primary Care (WPC)
 Private Medical Practice
 2001 Charlotte Ave.
 Internal, Family, and Preventive Medicine
 Physicians (2)


Dr. Eli Watts - Internal Medicine Certified; Endocrinology Specialist
Dr. Kenneth Williams – Family Medicine Certified; Geriatric Specialist
 Medical Receptionist (1)
 Medical Clerk (1)
 Medical Assistants (3)
 Affiliations (3)
 Baptist Hospital, Centennial Medical Center, and Skyline Medical Center

22. Watts Primary Care
WPC Mission Statement:
“Our primary mission is to provide excellent health care to the residents of
the Greater Nashville community. We believe health first begins by
empowering patients with the knowledge, skills, and support needed to live
healthy lifestyles. For this, we are committed to providing quality services
for the timely assessment of both acute and chronic illnesses with the
primary goal of early prevention and effective treatment. Above all, we take
pride in considering the whole patient in determining health needs.”

23. Watts Primary Care Internship
Internship Goals
 Gain the knowledge, skills and attitude necessary to assess
any patient with a general medical illness;
 Demonstrate the ability to develop a specific management
plan;
 Provide this information to the both the healthcare team
and the patient.

24. Capstone Project

25. Capstone Project Rationale
Why WPC for Capstone Project?
 Primary Care Facility
 Emphasis on Disease Prevention and Management
 Specializes in Endocrinology and Geriatrics
 Maintains Electronic Medical Records
 Employs a Certified Diabetes Educator
 Offers DSME Services
 Great Supporting Staff
 Wonderful Patients

26. Project Goals & Objectives
 Goal: To conduct a correlation study to determine the effect of
diabetes self-management on clinical outcomes for diabetic patients
served by Watts Primary Care.



The administration of DSMA Surveys with WPC patients.
The administration of a Demographic & Physiologic Surveys with WPC patients.
The assessment of diabetes clinical outcomes among WPC patients.
 Study Questions:


Is there a significant correlation between diabetes self care (DSMA) and diabetes
outcome (HbA1C levels) in an adult population group currently receiving medical
care?
Are any co-variables (demographic characteristics: age, race, gender, education,
income; or physiologic characteristics: BMI, duration of diabetes, treatment-type, and
diabetic complications) related to diabetes outcome?
 Hypotheses:


There will be a statistically significant correlation between self-care and DM outcome.
There will be a particular set of subject characteristics related to DM outcome.

27. Diabetes Outcomes & Self-Management:
Operational Definitions
 Diabetes Outcome is defined as a clinical interpretation of
one’s glycemic status, including one’s risk for diabetic
complications (Goldstein et al., 2004).

Measured by the Hemoglobin A1C test (<6.5% is Ideal)
 Diabetes Self-Management is defined as the performance of
a variety of DM self-care activities and skill sets (Toobert &
Glasgow, 2000).

Measured by the Diabetes Self-Management Activities (DSMA) survey

28. Diabetes SelfManagement Activities
(DSMA) Survey:
The DSMA is a 12-item
questionnaire frequently
used to assess the degree of
diabetes self-management
in the seven days preceding
the questionnaire.
Five Sections: dietary
habits, exercise routine,
self-monitoring of blood
glucose (SMBG), foot-care
practice, and medication
compliance.
Combined Scores: 0 to 77
Glasgow reported internal
consistency and reliability
through inter-item
reliability testing.

29. Demographic Survey
(DS): In-house
questionnaire
Demographic
characteristics:

Gender, age, income,
education,
employment status,
marital status,
medical coverage, and
past diabetes self
management
education.
Physiologic
characteristics:

BMI, patient and
family DM history,
treatment regimen,
DM complications,
and smoking habits.

30. Capstone Project Study Design
 Descriptive correlation (observational) study
 Independent variables


DSMA: Self-Management
Demographic and physiological characteristics
 Dependent variable

HbA1C: DM Outcome

31. Project Study Population & Inclusion
Criteria
 WPC adult patients (>18 years old)
 Type 1 or Type 2 DM
 Volunteers only: n=148
 Preclusions


Pregnant women
Patients with a mental illness, on steroid or chemo-therapy, diagnosed
with alcoholism, or post-operative.

32. Project Methods
 Administration of a Research Packet

Consent Form and (2) Questionnaires
 After obtaining written and verbal consent, subjects
completed the two surveys.


DSMA
DS
 HbA1C values were recorded on DS

33. Project Data Analysis
Data Analysis: SPSS
 Descriptive analysis ->statistical report

Demographic and physiological attributes
 Nominal variables


Frequencies
Percentages
 Continuous variables



Minimum and maximum values
Means
Standard Deviations (SD)

34. Project Data Analysis
Data Analysis: SPSS
Mixed-Effect Model
 Correlation
 Two methods

The unadjusted univariate method assessed the correlation between the
independent variables (DSMA, demographic characteristics, and
physiological characteristics) and the dependent variable (HbA1C) with
random effect.

The adjusted univariate method assessed the correlation between the
independent variable (DSMA) and the dependent variable (HbA1C) with
covariates that turned statistically significant in the unadjusted univariate
method with random effect.
 Random effect was assigned to choice of primary care provider.

35. Project Results:
Demographic
characteristics:

Gender, age, income,
education,
employment status,
marital status,
medical coverage,
and past diabetes self
management
education.

36. Project Results:
Physiologic
characteristics:

Patient and family
DM history,
treatment regimen,
DM complications,
and smoking habits.

37. Project Results:
Nominal Variables:
BMI->Mean=32.42




Underweight <18.5
Normal 18.5–24.9
Overweight 25.0–29.9
Obesity >30.0
HbA1C->Mean=7.91



Normal 4% - 5.6%
Risk: 5.7% - 6.4%
Diabetes : >6.5%
(National Institutes of Health)

38. Project Results:
Diabetes SelfManagement Activities
(DSMA) Statistics:
1. Medication compliance – 6.81
2. General Dietary Habits – 4.88
3. Specific Diet Habits – 4.06
4. Foot Care – 3.86
5. Blood Sugar Testing – 3.12
6. Exercise Routine – 2.33

39. Project Results:
MEM Statistics:
Question 1:
“Is there a correlation
between self care (DSMA)
and DM control (HbA1C
levels) in an adult
population group currently
receiving medical care?”
Findings:
There was no statistically
significant correlation
between any of the DSMA
subscales and HbA1C
(p<0.05).

40. Project Results:
MEM Statistics:
Question 2:
“Are any co-variables
(demographic characteristics:
age, gender, marital status,
education, employment,
income, and health coverage;
or physiologic characteristics:
DM history, DM family history,
DM medication, DM therapy
type, DM education, DM
complications, smoking
history, and BMI) related to
DM control (HbA1C levels)?”
Findings:
Of the tested co-variables, age,
gender, DM complications, DM
history, DM therapy type, and
BMI demonstrated a
statistically significant
relationship with HbA1C levels
(p<0.05).

41. Project Results
 DSMA subscales did not demonstrate any statistically
significant correlation with HbA1C scores.

Does not support the hypothesis that diabetic patients who practice DM
self-care activities present with improved glycemic numbers compared
to patients who do not practice such measures.
 The co-variables, age, gender, DM therapy type, DM
history, DM complications, and BMI did demonstrated a
statistically significant relationship with HbA1C levels .

Supports the hypothesis that certain demographic/physiologic
characteristics do indeed influence diabetes outcome.
 Significance:

Reduction in HbA1C values by just 1% has proven to reduce diabetic
complications by as much as 25% (UKPDS, 1998).

42. Project Discussion
 Although not evidenced here, diabetes self-care activities based
on DSME standards still might play an important role in
glycemic control and reducing DM complications.
 One of the many diabetes-related aims of Healthy People 2020
(HP 2020) is to increase the proportion of individuals receiving
formal diabetes health education (USDHHS, 2012).
 The current national average is 56.8% of diabetic patients receive
diabetes health education and the HP 2020 target is 62.5 % by
the year 2020 (USDHHS, 2012).

43. Project Limitations
Limitations
 Observational (versus Experimental Study)

Pros – Observational Studies seem to be less affected by Threats to Internal Validity







Maturation
Repeated Testing
Instrumentality
Regression Towards Means
Attrition
Diffusion
Cons




Not Randomized - Volunteers
No Control Group
No Baseline
Self-Reported Surveys (Instrumentation)
 Self-efficacy – not measured
 Social Support – not measured

44. Recommendations
 Despite this study’s findings, providing patients access to
DSME services at WPC has the real potential of improving
health outcomes.
 Similar clinical models that incorporate DSME could serve
as a national model.
 WPC should continue offering DSME as part of their
current health care services.

45. Lessons Learned
 The impact of Social Determinants of Health can never
be overlooked: In this study Economic, Social, Service,
and Physical Environment could have played a major
underlining role; factors such as Self-Efficacy, Life
Course, and Food Deserts need to be considered.
 To that point, although a movement towards a
National Diabetes Education agenda seems promising,
in order to reach HP2020 goals additional studies that
investigate the role Social Determinants play in DSME
and DM outcomes need to be pursued.

46. Acknowledgements
 Dr. Eli Watts
 Dr. Kenneth Williams
 Watts Primary Care Staff
 TSU Department of Public Health
 Dr. Elizabeth Williams
 Dr. Mohamed Kanu

47. Questions

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