• Behavioral Factors Associated with Glycemic Control in Diabetic Veterans

      Mastella, Laura (2012)
      Background: 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.
    • Implementation of Screening Tool for Diabetic Patients Undergoing Interventional Procedure

      Mensah-Acquaye, Gloria; Michael, Kathleen (2019-05)
      Background: In healthcare today, a significant proportion of diabetic patients suffer from pain due to nerve radiculitis. One known treatment for chronic pain includes the use of steroid injections under fluoroscopic guidance. The use of steroids in diabetic patients comes with an increased risk of prolonged hyperglycemia after the procedure. Diabetic patients undergoing procedures with the use of steroids need to be properly screened to reduce their risk of prolonged hyperglycemia after the procedure. Local Problem: A large outpatient interventional pain department within a large health organization experienced an increased number of diabetic patients for steroid injections. Lacking a standardized treatment protocol, all diabetic patients received treatment in the department based on provider preference causing variations in practice. Due to this reason, the department recognize the need for a screening guideline for all diabetic patients undergoing procedure with the use of steroids. The purpose of this quality improvement project was to implement a standardized treatment protocol that included the screening of all diabetic patients prior to undergoing any interventional procedure with the use of steroids. Interventions: During the fall of 2018, a quality improvement project implemented a guidelinebased screening tool. The screening tool was used to screen all diagnosed diabetic patients to ensure they had a recent glycosylated hemoglobin (A1C) level of 9.0 or less within 90 days prior to the procedure and a random blood glucose of 250mg/dL or less on the day of the procedure. The incision criteria for screening included any patient scheduled for a procedure with an existing diagnosis of diabetes. After screening all diabetic, any patient with an A1C greater than 9.0 were reschedule to have their procedure after their blood sugar and A1C meet the guideline standard. They are also referred to the organization’s diabetes management program. An educational program was developed to train provider staff on the use of the screening tool. The screening tool questions were developed and incorporated in the electronic medical record to facilitate the practice change and maintain sustainability. A total of 10 providers in two interventional pain clinics (A and B locations) received education on the screening tool prior to implementation. During the eight-week project implementation timeline, the medical records of all scheduled diabetic patients for the interventional clinics were audited to ensure that they received screening with the tool prior to their steroid injection procedure. Results: Location A had a total of 55 patients who met the project inclusion criteria over the 8week period. Staff compliance with using the screening tool was 96% over the 8-week period. Location B had a total of 43 diabetic patients who met the project inclusion criteria. Staff compliance with using the screening tool prior to patient procedure was 88% over the 8-week period. Conclusions: The diabetic patient screening tool is beneficial for patients and providers. Decreasing prolonged hyperglycemic episodes in diabetic patients after the use of steroids will improve overall patient outcome for diabetic patients who undergo interventional procedure.