title: Problem solving and diabetes self-care Comparison of Community Health WorkerLed Diabetes Medication Decision-Making Support for Low-Income Latino and African American Adults With Diabetes Using E-Health Tools Versus Print Materials Cluster-Randomized Trial of a Mobile Phone Personalized Behavioral Intervention for Blood Glucose Control Implementation and evaluation of a low-literacy diabetes education computer multimedia application. Comprehensive Diabetes Management Program for Poorly Controlled Hispanic Type 2 Patients at a Community Health Center Outcomes from a Multiple Risk Factor Diabetes Self-Management Trial for Latinas: ¡Viva Bien! Online Diabetes Self-Management Program Interactive Health Communication Applications for people with chronic disease. Usability in the real world: assessing medical information technologies in patients' homes TeleHealth Improves Diabetes Self-Management in an Underserved Community The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials A review of the United Kingdom Prospective Diabetes Study (UKPDS) and a discussion of the implications for patient care. Inpatient Diabetes Education Is Associated With Less Frequent Hospital Readmission Among Patients With Poor Glycemic Control Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure A patient-centric, provider-assisted diabetes telehealth self-management intervention for urban minorities. Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study An Internet-Based Diabetes Management Platform Improves Team Care and Outcomes in an Urban Latino Population Impact of computer-generated personalized goals on HbA(1c). Evaluation of a Remote Monitoring System for Diabetes Control.
abstract: An important objective of diabetes care is to provide patients with self-regulation skills . For patients to assume responsibility for their own regimens , they need to have good problem-solving skills to cope with ongoing personal , social , and environmental barriers to adherence . Therefore , a Diabetes Problem Solving Interview for adults was developed and evaluated with 126 non-insulin-dependent out patients . Interviewers elicited problem-solving strategies patients would use to cope with a variety of situations potentially interfering with dietary , exercise , and glucose testing adherence . Interviews were tape recorded and coded by trained raters to produce scores on both overall problem-solving skill ratings and frequency of use of different types of strategies . Results revealed only minor influences of patient characteristics on problem-solving measures . Prospect i ve analyses revealed that problem-solving measures were significant and independent predictors of levels of dietary and exercise self-care at a 6-month follow-up Adults with type 2 diabetes mellitus often struggle with their antihyperglycemic medication regimens . To improve medication management , providers must ensure that their patients underst and potential benefits , harms , and burdens of available options and elicit patients ' preferences and barriers to taking medications . Patients who are actively involved in treatment decision making tend to be more satisfied with their health care , be more adherent to treatment , and have improved clinical outcomes ( 13 ) . Such discussion s , however , can be too time-consuming for clinic visits . For inner-city low-income African American and Latino adults , low health literacy and limited English proficiency are often additional barriers ( 4 ) that reduce the exchange of information and decrease patient participation during primary care visits ( 58 ) . This contributes to less optimal treatment decisions and lower patient satisfaction , leading to poor medication adherence and outcomes ( 3 , 911 ) . There is therefore an urgent need for cost-effective approaches to enable low-re source health systems to help these high-risk population s gain information and decision support so that they can more actively participate in and improve satisfaction with their treatment decision making . Since 2000 , the REACH ( Racial and Ethnic Approaches to Community Health 2010 ) Detroit Partnership , a coalition of community , health system , and academic partners , has used community-based participatory research principles to guide development , implementation , and evaluation of interventions to meet this need among African American and Latino adults with diabetes in Detroit , Michigan . These interventions have built on evidence that community health workers ( CHWs ) are effective in improving diabetes outcomes , particularly among racial and ethnic minority communities ( 12 ) . CHW interventions train community members to work as bridges between their ethnic , cultural , or geographic communities and health care providers ( 13 ) . Two cohorts of participants in our previous CHW-led diabetes self-management support interventions  improved hemoglobin A1c ( HbA1c ) levels and diabetes distress compared with usual care ( 14 , 15 ) . An important next step in increasing the potential effect of CHWs and other lay health care workers is to develop and test effective tools they can use to better present evidence -based information to patients and to help patients make better self-management decisions ( 16 ) . Little is known about the effectiveness of different approaches for nontraditional care providers , such as CHWs , to deliver health information to ethnic minority and low-literacy population s ( 17 ) . By definition , CHWs and other lay workers do not have medical expertise and thus rely on effectively sharing printed educational and support material s with patients as part of their coaching and counseling efforts . Decision aids can increase satisfaction with treatment decisions and result in treatments that better reflect patients ' preferences ( 18 , 19 ) . There is also evidence that tailored health messages are more effective than generic group messages ( 20 , 21 ) , including for patients with diabetes ( 22 , 23 ) . Tailoring individualizes information and behavior change strategies to reach each person based on characteristics unique to that person derived from an individual assessment and related to the outcome of interest ( 24 ) . Software programs that are being developed to automatically embed tailored content into portable e-health Web applications show promise in improving health behaviors and outcomes ( 25 , 26 ) . To date , however , most e-health applications have been design ed for use by patients with relatively high literacy and the skills to navigate them ( 27 ) . Do more sophisticated , tailored , interactive e-health tools increase the effectiveness of CHW outreach with underserved patients compared with reliance on printed educational material s alone ? We addressed this question by developing and evaluating a personally tailored , interactive diabetes medication decision aid ( iDecide [ in English ] or iDecido [ in Spanish ] ) design ed for CHWs to deliver on tablet computers with 3 G wireless access to African American and Latino adults with diabetes and low health literacy . We then evaluated the effectiveness of iDecide in improving key diabetes outcomes compared with CHW delivery of the same evidence -based information , without tailoring , through print consumer booklets developed by the Agency for Healthcare Research and Quality ( AHRQ ) . Methods Setting This study was developed and implemented by using community-based participatory research principles ( 28 ) in partnership with the REACH Detroit Partnership and the Community Health and Social Services Center ( CHASS ) , a federally qualified health center in Southwest Detroit serving more than 13000 patients with 47099 visits in 2012 ( 29 ) . The University of Michigan and CHASS institutional review boards approved the study . Content of AHRQ Consumer Guides The AHRQ guides ( Pills for Type 2 Diabetes and Premixed Insulin for Type 2 Diabetes ) ( 30 , 31 ) provide information on diabetes and summarize the effectiveness of currently available medication classes  ( oral and insulin ) on HbA1c . They also provide information on administration methods , costs , medication adverse effects , risks for diabetes complications , suggested questions to discuss with health care providers , and prompts to make notes of any questions for the doctor . The booklets include pictures of patients and tables and graphs summarizing information . Content of iDecide The development process and content of the iDecide program have been described in detail elsewhere ( 32 ) . Briefly , we used community-based participatory research and user-centered design ( 33 , 34 ) principles to iteratively develop and refine the iDecide tool . iDecide is available in English and Spanish , can be delivered via tablet computers , and enables navigation by the CHW and participant to selectively explore issues most important to the participant . The iDecide program is organized into 4 main sections and includes the same content as the AHRQ consumer guides . However , its information is presented in a more graphical style suited to patients with low literacy . Table 1 summarizes key differences between the presentation of information in iDecide and the printed material s. The first section illustrates , through animations , how diabetes affects the way glucose is processed in the body and how different medication classes , foods , and physical activity affect blood glucose . The second section includes pictographs showing participants ' own risk for diabetes complications ( tailored according to their baseline HbA1c ) and enabling participants to explore how their risk for different complications changes with their HbA1c levels . In the third section , participants review their current diabetes medications and barriers to taking the medications they had reported on the baseline survey . This section includes an interactive issue card approach to help elicit patient preferences and priorities about different medication characteristics ( for example , cost , adverse effects , effects on weight , and dosing schedules ) ( 22 , 35 ) . The fourth section prompts participants to set goals and develop specific action plans to address identified barriers or other concerns and identify specific questions and concerns to discuss with their doctor about their medications or making lifestyle changes . Personal information from the baseline assessment is interwoven throughout the program ( high-depth tailoring within sentences ) . Motivational interviewingbased , tailored discussion prompts encourage autonomy-supportive CHWpatient interactions at key points with open-ended questions and values exploration to help participants discover their motivation , overcome barriers to change , and develop an action plan ( 36 ) . Table 1 . Comparison of Content and Mode of Delivery Between the iDecide Study Group and the Printed Material s Group Recruitment and R and omization From September 2011 to August 2012 , potentially eligible participants were identified from a computer-generated list of CHASS patients with physician-diagnosed type 2 diabetes . Inclusion criteria required a HbA1c value greater than 7.5 % in the previous 6 months or expressed concerns about current diabetes medications during the screening assessment . Exclusion criteria were age younger than 21 years , terminal health conditions , self-reported alcohol or drug abuse , and conditions ( such as blindness and dementia ) that would impede meaningful participation . Pregnant women and individuals who reported that they could not be contacted by telephone were also excluded . Introductory letters were sent in timed batches . Research staff then telephoned patients and screened them for eligibility . Interested eligible patients met with research staff , who facilitated completion of written informed consent , administered baseline surveys in English or Spanish , and measured HbA1c and blood pressure . Participants received a stipend of $ 20 after each assessment . Within 1 to 14 days , participants were scheduled for a visit with a CHW ( at home , the clinic , or another agreed-upon place ) . At the beginning of the CHW visits , participants were registered into the iDecide program and r and omly assigned by the computer program , through use of a r and om-sequence algorithm , into 1 of 2 study groups . There were no differences between the steps to participate in either study group . Patients , research staff , and CHWs were blinded to r and omization results through completion of all baseline measures up to the start of the intervention . Data assessors remained blinded to group assignment throughout the study . CHW Intervention for Both Study Groups All participants received an initial one-on-one , face-to-face session with a CHW and a copy of the printed material s to take home . The iDecide sessions lasted approximately 2 hours , and the sessions using printed material s lasted OBJECTIVE To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with st and ard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS A cluster-r and omized clinical trial , the Mobile Diabetes Intervention Study , r and omly assigned 26 primary care practice s to one of three stepped treatment groups or a control group ( usual care ) . A total of 163 patients were enrolled and included in analysis . The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period . Secondary outcomes were changes in patient-reported diabetes symptoms , diabetes distress , depression , and other clinical ( blood pressure ) and laboratory ( lipid ) values . Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support . Patients received automated , real-time educational and behavioral messaging in response to individually analyzed blood glucose values , diabetes medications , and lifestyle behaviors communicated by mobile phone . Providers received quarterly reports summarizing patient ’s glycemic control , diabetes medication management , lifestyle behaviors , and evidence -based treatment options . RESULTS The mean declines in glycated hemoglobin were 1.9 % in the maximal treatment group and 0.7 % in the usual care group , a difference of 1.2 % ( P = 0.001 ) over 12 months . Appreciable differences were not observed between groups for patient-reported diabetes distress , depression , diabetes symptoms , or blood pressure and lipid levels ( all P > 0.05 ) . CONCLUSIONS The combination of behavioral mobile coaching with blood glucose data , lifestyle behaviors , and patient self-management data individually analyzed and presented with evidence -based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year OBJECTIVE To evaluate a clinic-based multimedia intervention for diabetes education targeting individuals with low health literacy levels in a diverse population . RESEARCH DESIGN AND METHODS Five public clinics in Chicago , Illinois , participated in the study with computer kiosks installed in waiting room areas . Two hundred forty-four subjects with diabetes were r and omized to receive either supplemental computer multimedia use ( intervention ) or st and ard of care only ( control ) . The intervention includes audio/video sequences to communicate information , provide psychological support , and promote diabetes self-management skills without extensive text or complex navigation .  HbA(1c ) ( A1C ) , BMI , blood pressure , diabetes knowledge , self-efficacy , self-reported medical care , and perceived susceptibility of complications were evaluated at baseline and 1 year . Computer usage patterns and implementation barriers were also examined . RESULTS Complete 1-year data were available for 183 subjects ( 75 % ) . Overall , there were no significant differences in change in A1C , weight , blood pressure , knowledge , self-efficacy , or self-reported medical care between intervention and control groups . However , there was an increase in perceived susceptibility to diabetes complications in the intervention group . This effect was greatest among subjects with lower health literacy . Within the intervention group , time spent on the computer was greater for subjects with higher health literacy . CONCLUSIONS Access to multimedia lessons result ed in an increase in perceived susceptibility to diabetes complications , particularly in subjects with lower health literacy . Despite measures to improve informational access for individuals with lower health literacy , there was relatively less use of the computer among these participants Technology and improved care coordination models can help diabetes educators and providers meet national care st and ards and provide culturally sensitive diabetes education that may improve diabetes outcomes . The purpose of the study was to evaluate the clinical usefulness of a nurse-led diabetes care program ( Comprehensive Diabetes Management Program , CDMP ) for poorly controlled Hispanic type 2 diabetes ( T2DM ) patients in an urban community health center setting . Patients were r and omized to the intervention condition ( IC ; n = 21 ) or an attention control condition ( AC ; n = 18 ) . IC and AC conditions were compared on rates of adherence to national clinical practice guidelines ( blood glucose , blood pressure , foot exam , eye exam ) , and levels of diabetes distress , depression , and treatment satisfaction . IC patients had a significant improvement in A1C from baseline to 12-month follow-up compared with AC ( −1.6 % ± 1.4 % versus −0.6 % ± 1.1 % ; P = .01 ) . The proportion of IC patients meeting clinical goals at follow-up tended to be higher than AC for A1c ( IC = 45 % ; AC = 28 % ) , systolic blood pressure ( IC = 55 % ; AC = 28 % ) , eye screening ( IC = 91 % ; AC = 78 % ) , and foot screening , ( IC = 86 % ; AC = 72 % ) . Diabetes distress and treatment satisfaction also showed greater improvement for IC than AC ( P = .05 and P = .06 , respectively ) , with no differences for depression . The CDMP intervention was more effective than an attention control condition in helping patients meet evidence -based guidelines for diabetes care Background Culturally appropriate interventions are needed to assist Latinas in making multiple healthful lifestyle changes . Purpose The purpose of this study was to test a cultural adaptation of a successful multiple health behavior change program , ¡ Viva Bien ! Methods R and om assignment of 280 Latinas with type 2 diabetes to usual care only or to usual care + ¡ Viva Bien !  , which included group meetings for building skills to promote the Mediterranean diet , physical activity , stress management , supportive re sources , and smoking cessation . Results ¡ Viva Bien ! participants compared to usual care significantly improved psychosocial and behavioral outcomes ( fat intake , stress management practice , physical activity , and social – environmental support ) at 6 months , and some improvements were maintained at 12 months . Biological improvements included hemoglobin A1c and heart disease risk factors . Conclusions The ¡ Viva Bien ! multiple lifestyle behavior program was effective in improving psychosocial , behavioral , and biological/ quality of life outcomes related to heart health for Latinas with type 2 diabetes ( Clinical Trials.gov no : NCT00233259 ) OBJECTIVE We hypothesized that people with type 2 diabetes in an online diabetes self-management program  , compared with usual-care control subjects , would 1 ) demonstrate reduced A1C at 6 and 18 months , 2 ) have fewer symptoms , 3 ) demonstrate increased exercise , and 4 ) have improved self-efficacy and patient activation . In addition , participants r and omized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement . RESEARCH DESIGN AND METHODS A total of 761 participants were r and omized to 1 ) the program  , 2 ) the program with e-mail reinforcement , or 3 ) were usual-care control subjects ( no treatment ) . This sample included 110 American Indians/Alaska Natives ( AI/ANs ) . Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups . RESULTS At 6 months , A1C , patient activation , and self-efficacy were improved for program participants compared with usual care control subjects ( P < 0.05 ) . There were no changes in other health or behavioral indicators . The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects . The subgroup with initial A1C > 7 % demonstrated stronger improvement in A1C ( P = 0.01 ) . At 18 months , self-efficacy and patient activation were improved for program participants . A1C was not measured . Reinforcement showed no improvement . CONCLUSIONS An online diabetes self-management program is acceptable for people with type 2 diabetes . Although the results were mixed they suggest 1 ) that the program may have beneficial effects in reducing A1C , 2 ) AI/AN population s can be engaged in and benefit from online interventions , and 3 ) our follow-up reinforcement appeared to have no value BACKGROUND : Interactive Health Communication Applications ( IHCAs ) are computer-based , usually web-based health information packages for patients that combine information with at least one of social support , decision support , or behaviour change support . These are innovations in health care and their effects on health are uncertain . OBJECTIVES : To assess the effects of IHCAs for people with chronic disease . SEARCH STRATEGY : We design ed a four-part search strategy . First , we search ed electronic bibliographic data bases for published work ; second , we search ed the grey literature and third , we search ed for ongoing and recently completed clinical trials in the appropriate data bases . Finally , research ers of included studies were contacted , and reference lists from relevant primary and review articles were followed up . As IHCAs require relatively new technology , the search commenced at 1990 where possible . SELECTION CRITERIA : R and omised controlled trials ( RCTs ) of Interactive Health Communication Applications for adults and children with chronic disease . DATA COLLECTION AND ANALYSIS : One review er screened abstract s. Two review ers screened all c and i date studies to determine eligibility , apply quality criteria , and extract data from included studies . Authors of included RCTs were contacted for missing data . Results of RCTs were pooled using a r and om effects model and st and ardised mean differences ( SMDs ) were calculated to provide net effect sizes . MAIN RESULTS : We screened 24,757 unique citations and retrieved 958 papers for further assessment , yielding 28 RCTs involving 4042 participants . One of these had an inadequate method of concealment of allocation , and sensitivity analyses were performed to determine the effects of including or excluding these data in the meta-analyses . Results in the abstract are from the meta-analyses excluding data from this study .IHCAs were found to have a positive effect on knowledge ( SMD 0.49 ; 95 % confidence interval ( CI ) 0.14 to 0.84 ) and on social support ( SMD 0.47 ; 95 % CI 0.28 to 0.66 ) . IHCAs were found to have no effect on self-efficacy ( SMD 0.15 ; 95 % CI -0.13 to 0.43 ) or behavioural outcomes ( SMD -0.09 ; 95 % CI -0.49 to 0.32 ) . IHCAs had a negative effect on clinical outcomes ( SMD -0.32 ; 95 % CI -0.63 to -0.02 ) . REVIEW ERS ' CONCLUSIONS : The number and range of IHCAs is increasing rapidly ; however there is a shortage of high quality evaluative data . Consumers who wish to increase their knowledge or social support amongst people with a similar problem may find an IHCA helpful . However , consumers whose primary aim is to achieve optimal clinical outcomes should not use an IHCA at present . Further research is needed to determine the reason for this negative effect on clinical outcomes , whether an optimal IHCA can achieve behaviour change and improved health outcomes , and if so , what are the essential features of such an IHCA , and the extent to which they differ according to patient group or condition OBJECTIVE This paper presents an approach to  usability evaluation of computer-based health care systems design ed for patient use in their homes . Although such devices are becoming more prevalent , there is very little known about their usability . DESIGN The theoretical foundations for the methods are discussed . The approach incorporates a cognitive walkthrough usability evaluation and new methods for usability testing that can be conducted in patient 's homes . The method was applied to the IDEATel intervention , a multi-institution r and omized controlled trial of the feasibility , acceptability , and clinical utility of a home-based telemedicine  system for diabetic Medicare population . The usability study was design ed to assess barriers to optimal use of the system . The focus was both on dimensions of the interface and on dimensions of patient skills and competency . The usability field research involved testing 25 patients in their homes using the system . The analysis included a range of video-analytic methods of varying levels of granularity . RESULTS The usability evaluation revealed aspects of the interface that were sub-optimal and impeded the performance of certain tasks . It also found a range of patient-related factors such as numeracy and psychomotor skills that constituted barriers to productive use . CONCLUSIONS A multifaceted usability approach provided important insight regarding use of technology by an elderly chronic-care patient population and more generally , for underst and ing how home health initiatives can more effectively use such technology OBJECTIVE To conduct a 1-year r and omized clinical trial to evaluate a remote comprehensive diabetes self-management education ( DSME ) intervention , Diabetes TeleCare , administered by a dietitian and nurse/certified diabetes educator ( CDE ) in the setting of a federally qualified health center ( FQHC ) in rural South Carolina . RESEARCH DESIGN AND METHODS Participants were recruited from three member health centers of an FQHC and were r and omized to either Diabetes TeleCare , a 12-month , 13-session curriculum delivered using telehealth strategies , or usual care .  RESULTS Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin ( GHb ) in the Diabetes TeleCare group from baseline to 6 and 12 months ( 9.4 ± 0.3 , 8.3 ± 0.3 , and 8.2 ± 0.4 , respectively ) compared with usual care ( 8.8 ± 0.3 , 8.6 ± 0.3 , and 8.6 ± 0.3 , respectively ) . LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care . Although not part of the original study design , GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group ( 9.2 ± 0.4 , 7.4 ± 0.5 , and 7.6 ± 0.5 , respectively ) compared with usual care ( 8.7 ± 0.4 , 8.1 ± 0.4 , and 8.1 ± 0.5 , respectively ) in a post hoc analysis of a subset of the r and omized sample who completed a 24-month follow-up visit . CONCLUSIONS Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Introduction Diabetes Mellitus is a chronic illness that increases the risk of microvascular complication and results in blindness , kidney failure , and lower extremity amputations , and macrovascular complication of coronary artery disease and stroke . In the State of Hawaii , an estimated eight to ten percent of the population have diabetes mellitus , i.e. about 80,000 to 100,000 individuals , primarily adults with type 2 diabetes . Alarmingly , native Hawaiian adults over 30 years of age have been identified with a diabetes prevalence rate of 20 % . Several studies clearly document the increasing rate of diabe tes among native Hawaiians over the past 30 years . Based on recent data , it is estimated that about 20,000 adult native Hawaiians ( 1820 % prevalence rate ) have diabetes mellitus ) It would appear that interventions to prevent diabetes and diabetic complications receive the highest priority in the effort to improve the health status of the people of Hawaii , especially native Hawaiians . Two major intervention trials have clearly demonstrated that intensive glycemic control prevents and delays the development of microvascular complication in patients with type 1 diabetes : the Diabetes Control and Complications Trial ( DCCT ) and the Stockholm Diabetes Intervention Study ( SDIS ) . 23 Results from a r and omized prospect i ve 6-year study in Japan show that intensive insulin treat ment of type 2 diabetic patients reduces microvascular complica tion . 4Many studies have demonstrated the association of hypergly cemia with macrovascular complications of ischemic heart disease and stroke and increased cardiovascular disease risk factors , e.g. , dyslipidemia , hypertension , and obesity . The 12-year cardiovascu lar mortality of men screened in the Multiple Risk Factor Interven tion Trial ( MRFIT ) showed that diabetic patients consistently had higher cardiovascular mortality than non-diabetic men matched for one or more of the major risk factors for CVD . 5 The data from OBJECTIVE To explore the relationship between inpatient diabetes education ( IDE ) and hospital readmissions in patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS Patients with a discharge diagnosis of diabetes ( ICD-9 code 250.x ) and HbA1c > 9 % who were hospitalized between 2008 and 2010 were retrospectively identified . All-cause first readmissions were determined within 30 days and 180 days after discharge . IDE was conducted by a certified diabetes educator or trainee . Relationships between IDE and hospital readmission were analyzed with stepwise backward logistic regression models . RESULTS In all , 2,265 patients were included in the 30-day analysis and 2,069 patients were included in the 180-day analysis . Patients who received IDE had a lower frequency of readmission within 30 days than did those who did not ( 11 vs. 16 % ; P = 0.0001 ) . This relationship persisted after adjustment for sociodemographic and illness-related factors ( odds ratio 0.66 [ 95 % CI 0.51–0.85 ] ; P = 0.001 ) . Medicaid insurance and longer stay were also independent predictors in this model . IDE was also associated with reduced readmissions within 180 days , although the relationship was attenuated . In the final 180-day model , no IDE , African American race , Medicaid or Medicare insurance , longer stay , and lower HbA1c were independently associated with increased hospital readmission . Further analysis determined that higher HbA1c was associated with lower frequency of readmission only among patients who received a diabetes education consult . CONCLUSIONS Formal IDE was independently associated with a lower frequency of all-cause hospital readmission within 30 days ; this relationship was attenuated by 180 days . Prospect i ve studies are needed to confirm this association Purpose The purpose of this study was to determine the impact of diabetes self-management education ( DSME ) in improving processes and outcomes of diabetes care as measured by a five component diabetes bundle and HbA1c , in individuals with type 2 diabetes mellitus ( T2DM ) . Methods A retrospective analysis was performed for adult T2DM patients who received DSME training in 2011–2012 from an accredited American Diabetes Association center at Intermountain Healthcare ( IH ) and had an HbA1c measurement within the prior 3 months and 2–6 months after completing their first DSME visit . Control patients were selected from the same clinics as case- patients using r and om number generator to achieve a 1 to 4 ratio . Case and control patients were included if 1 ) pre-education HbA1c was between 6.0%–14.0 % ; 2 ) their main provider was a primary care physician ; 3 ) they met the national Healthcare Effectiveness Data and Information Set criteria for inclusion in the IH diabetes registry . The IH diabetes bundle includes retinal eye exam , nephropathy screening or prescription of angiotensin converting enzyme or angiotensin receptor blocker ; blood pressure < 140/90 mmHg , LDL < 100 mg/dL , HbA1c < 8.0 % . Results DSME patients had a significant difference in achievement of the five element IH diabetes bundle and in HbA1c % compared to those without DSME . After adjusting for possible confounders in a multivariate logistic regression model , DSME patients had a 1.5 fold difference in improvement in their diabetes bundle and almost a 3 fold decline in HbA1c compared to the control group . Conclusion St and ardized DSME taught within an IH American Diabetes Association center is strongly associated with a substantial improvement in patients meeting all five elements of a diabetes bundle and a decline in HbA1c beyond usual care . Given the low operating cost of the DSME program , these results strongly support the value adding benefit of this program in treating T2DM patients This article describes the design and implementation of an online diabetes self-management intervention for a sample of inner-city African Americans with diabetes . Study participants were r and omly assigned to the treatment ( 26 ) and control ( 21 ) conditions . The results indicate that treatment group participants were more likely to achieve positive outcomes in terms of lowered hemoglobin A1c and body mass index measurements than were control group members . These findings support the development of telehealth interventions to promote effective chronic disease management in medically underserved communities CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 OBJECTIVE To compare usual diabetes care ( UDC ) to a comprehensive diabetes care intervention condition ( IC ) involving an Internet-based “ diabetes dashboard ” management tool used by clinicians . RESEARCH DESIGN AND METHODS We used a parallel-group r and omized design . Diabetes nurses , diabetes dietitians , and providers used the diabetes dashboard as a clinical decision support system to deliver a five-visit , 6-month intervention to 199 poorly controlled ( HbA1c > 7.5 % [ 58 mmol/mol ] ) Latino type 2 diabetic ( T2D ) patients ( mean age 55 years , 60 % female ) at urban community health centers . We compared this intervention to an established , in-house UDC program ( n = 200 ) for its impact on blood glucose control and psychosocial outcomes . RESULTS Recruitment and retention rates were 79.0 and 88.5 % , respectively . Compared with UDC , more IC patients reached HbA1c targets of < 7 % ( 53 mmol/mol ; 15.8 vs. 7.0 % , respectively , P < 0.01 ) and < 8 % ( 64 mmol/mol ; 45.2 vs. 25.3 % , respectively , P < 0.001 ) . In multiple linear regression adjusting for baseline HbA1c , adjusted mean ± SE HbA1c at follow-up was significantly lower in the IC compared with the UDC group ( P < 0.001 ; IC 8.4 ± 0.10 % ; UDC 9.2 ± 0.10 % ) . The results showed lower diabetes distress at follow-up for IC patients ( 40.4 ± 2.1 ) as compared with UDC patients ( 48.3 ± 2.0 ) ( P < 0.01 ) , and also lower social distress ( 32.2 ± 1.3 vs. 27.2 ± 1.4 , P < 0.01 ) . There was a similar , statistically significant ( P < 0.01 ) improvement for both groups in the proportion of patients moving from depressed status at baseline to nondepressed at follow-up ( 41.8 vs. 40 % ; no significance between groups ) . CONCLUSIONS The diabetes dashboard intervention significantly improved diabetes-related outcomes among Latinos with poorly controlled T2D compared with a similar diabetes team condition without access to the diabetes dashboard OBJECTIVE The public is increasingly aware of the importance of HbA(1c ) testing , yet the vast majority of patients with diabetes do not know their HbA(1c ) status or goal . We set forth to evaluate the impact of a system that provides uniquely formatted and personalized reports of diabetes status and goals on changes in HbA(1c ) levels . RESEARCH DESIGN AND METHODS A total of 150 patients with diabetes were r and omized to receive either st and ard care or intervention  inclusive of a computer-generated 11 " x 17 " color poster depicting an individual 's HbA(1c ) status and goals along with personalized steps to aid in goal achievement . All patients enrolled received diabetes education during the 3 months before enrollment .  HbA(1c )  was performed at baseline and 6 months . RESULTS At baseline , there were no significant differences between patient groups in terms of age , sex , education level , race , and HbA(1c ) or lipid levels . Among patients with baseline HbA(1c ) > or = 7.0 % , there was an 8.6 % ( 0.77 % absolute ) reduction in HbA(1c ) among control subjects compared with a 17.0 % ( 1.69 % absolute ) decline in the intervention group ( P = 0.032 ) . There were no differences between the control and intervention groups with respect to the frequency of patients experiencing any decline in HbA(1c ) ( 63 vs. 69 % , P = 0.87 ) ; among these patients experiencing a decline , the most substantial reductions were seen with the control group , which had a 13.3 % ( 1.15 % absolute ) decline compared with the intervention patients , who reduced their HbA(1c ) by 24.2 % ( 2.26 % absolute reduction ; P = 0.0048 ) . At study close , 77 % of the patients had their poster displayed on their refrigerator . CONCLUSIONS This unique and personalized computer-generated intervention result ed in HbA(1c ) lowering comparable to that of hypoglycemic agents PURPOSE The use of technology to implement cost-effective health care management on a large scale may be an alternative for diabetes management but needs to be evaluated in controlled trials . This study assessed the utility and cost-effectiveness of an automated Diabetes Remote Monitoring and Management System ( DRMS ) in glycemic control versus usual care . METHODS In this r and omized , controlled study , patients with uncontrolled diabetes on insulin were r and omized to use of the DRMS or usual care . Participants in both groups were followed up for 6 months and had 3 clinic visits at 0 , 3 , and 6 months . The DRMS used text messages or phone calls to remind patients to test their blood glucose and to report results via an automated system , with no human interaction unless a patient had severely high or low blood glucose . The DRMS made adjustments to insulin dose(s ) based on vali date d algorithms . Participants reported medication adherence through the Morisky Medication Adherence Scale-8 , and diabetes-specific quality of life through the diabetes Daily Quality of Life question naire . A cost-effectiveness analysis was conducted based on the estimated overall costs of DRMS and usual care . FINDINGS A total of 98 patients were enrolled ( 59 [ 60 % ] female ; mean age , 59 years ) ; 87 participants ( 89 % ) completed follow-up . HbA1c was similar between the DRMS and control groups at 3 months ( 7.60 % vs 8.10 % ) and at 6 months ( 8.10 % vs 7.90 % ) . Changes from baseline to 6 months were not statistically significant for self-reported medication adherence and diabetes-specific quality of life , with the exception of the Daily Quality of Life-Social/Vocational Concerns subscale score ( P = 0.04 ) . IMPLICATION S An automated system like the DRMS may improve glycemic control to the same degree as usual clinic care and may significantly improve the social/vocational aspects of quality of life . Cost-effectiveness analysis found DRMS to be cost-effective when compared to usual care and suggests DRMS has a good scale of economy for program scale up . Further research is needed to determine how to sustain the benefits seen with the automated system over longer periods
target: Discussion Findings suggest that medically underserved patients with diabetes achieve glycemic benefit following HIT DSME interventions , with dissipating but significant effects at 12 months .
  Telemedicine/telehealth interventions were the most successful HIT type because they incorporated interaction with educators similar to in-person DSME .
  Conclusion These results are similar to in-person DSME in medically underserved patients , showing that well- design ed HIT DSME has the potential to increase access and improve outcomes for this vulnerable group
background: Objective The purpose of this systematic review and meta- analysis was to examine the effect of health information technology ( HIT ) diabetes self-management education ( DSME ) interventions on glycemic control in medically underserved patients .