Browsing Doctor of Nursing Practice (DNP) Projects by Subject "Diabetes Mellitus, Type 2"
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Behavioral Factors Associated with Glycemic Control in Diabetic VeteransBackground: Veterans have a higher prevalence of Type 2 diabetes than the general population, and experience more problems with glycemic control, placing them at greater risk for complications. The primary purpose of this study was to examine two self-management behaviors in a sample of diabetic veterans, and to evaluate indicators of adherence to diabetes treatment regimes and glycemic control. Our hypothesis was that veterans who maintained logs and refilled medications on time would have better glycemic control than those who did not perform these specific behaviors. Methods: We examined a convenience sample of 261 adult Type 2 diabetic veterans seen in Vet Fitness Clinic at VAMHCS from 2006-2009. All subjects were treated with prescribed medications as part of their routine diabetes care. Based on related studies, we identified Self-Monitoring of Blood Glucose (SMBG) and medication refill procurement as behavioral predictors of Hemoglobin A1c outcomes. Results: Using a dependent samples t test, improvements in HbA1c from first to final contact in clinic were evaluated. As an expected clinical outcome related to treatment, statistically significant improvements were seen in HgA1c from baseline to discharge (t 16.5,p=.000), however, 60% of the veterans were able to reach goal values (baseline mean 9.10%, ±2.1 0, discharge mean 7.40%, SD ± 1.21). The strongest behavioral predictor of glycemic control was medication refill (1= 3.11, p=.002). Maintenance of 5MBG logs did not produce significant improvements in HbAlc< (t= 0.33, p=.74). Conclusions: Despite timely medication refills, 40% of the subjects did not attain optimal HgA1c, values. Actual adherence to medications cannot be established using refills as an indicator. While 5MBG logs have been associated with improvements in some studies, we did not find the same relationship here. We believe that other unmeasured self-management behaviors may be vitally important in optimizing glycemic control in veterans. For example, health literacy, which is known to be lower in veterans, warrants further examination, as veterans need working knowledge in order to self-manage all aspects of their disease.
Improving Medication Adherence Among Diabetes Patients Utilizing Mobile App and PamphletProblem and Purpose: The American Diabetes Association set the antidiabetic oral medication adherence rate to 80%. Medication nonadherence is strongly associated with poor glycemic control resulting in more healthcare services utilization. A family practice clinic noted that the majority of patients with diabetes are nonadherent to their medication. The purpose of this quality improvement (QI) project was to improve the medication adherence of patients with type 2 diabetes mellitus (T2DM) through the implementation of mobile health application reminder (MHAR) and diabetes adherence education pamphlet (DAEP). Methods: This project was implemented over thirteen weeks at a suburban primary care practice using the Mobilize, Assess, Plan, Implement, Track process framework. During an office visit, participants (N = 6) completed the likelihood of nonadherence (LON) online survey before the intervention and receive the DAEP. The participants used MHAR for four weeks and self-reported medication adherence rates. They also completed a post-LON survey via phone call by the project leader. Results: All the of participants (N=6) achieved low to medium LON post scores. There were no differences (z=0.577, p > 0.05) between pre- and post-intervention LON scores using the sign test as an alternative statistic. Only 67% (average) of patients seen received the DAEP at the last week of implementation. After four weeks of usage of the MHAR of each participant, 67% (n=4) reported adherent with an 80% or higher adherence rate, and 33% (n=2) nonadherent. The Pearson correlation coefficient for dichotomized compliance data predicted by post-intervention LON scores was found to be -0.31. This result indicated a weak negative correlation between adherence rate and post-LON. Conclusion: With the availability of MHAR, this tool must be leveraged to help patients adhere to their medication as prescribed. This project has demonstrated that when combined DAEP and MHAR have the potential to improve medication adherence among patients with T2DM. Providers can optimize the efficacy of these interventions to enhance verbal education during clinic visits.
Vitamin D Supplementation and Glycemic Control in Patients with Type 2 DiabetesPurpose: Treatment guidelines for the management of patients with type 2 diabetes (T2DM) and vitamin D deficiency do not exist. The primary purpose of this project was to describe repletion rates, prescribing patterns and monitoring patterns for patients with T2DM and vitamin D deficiency. This is a first step in the development of management guidelines. A secondary purpose was to examine glycemic control before and after correction of vitamin D hypovitaminosis. This was done in order to determine if future interventional studies examining the efficacy of treating vitamin D deficiency for patients with T2DM are warranted. Significance: In the United States 25.8 million (8.3%) individuals have diabetes; 90 to 95% have T2DM. The disease is responsible for increased morbidity and mortality as well as annual costs in the billions. Vitamin D deficiency in the United States is estimated to affect 70% of Caucasians and 95% of African Americans. A link between T2DM and vitamin D deficiency has been described. However, guidelines for vitamin D repletion of individuals with T2DM are not available, and the effect of vitamin D repletion on glycemic control has not been well studied. Methods: This project was a non-experimental retrospective audit of electronic medical records used in the outpatient diabetes department of a University Medical Center. Data were collected from the Epic documentation system. Descriptive statistics were used to describe care processes, and a paired samples Student t-test was used to examine A1C levels before and five to eight months after vitamin D repletion for subjects successfully repleted. Results: A total of 366 subjects qualified for inclusion in the study. Follow-up testing ranged from one to twelve tests per subject with a mean of 2.6 (SD = 1.5) and a range from 0 to 12 tests. Successful repletion rates per follow-up period ranged from 4.7 to 23.6%. Five to eight months after initiation of vitamin D, only 97 subjects (26.5%) were successfully repleted. Within this group results demonstrated a significant decrease from an initial to a follow-up mean A1C value (8.33 ± 0.69 vs 7.9 ± 1.3), indicating improved glycemic control (t = 3.58, p = .001). Conclusions: Treatment guidelines and standardization of care for patients with T2DM and vitamin D deficiency are needed. Further investigation is needed to investigate why the majority of patients were not successfully repleted. The findings of improved glycemic control for subjects with repletion also indicate a need for interventional studies with randomized controlled trials to investigate the effect of treating vitamin D deficiency on glycemic control.