Evaluation of an Advanced Practice Nurse–Managed Diabetes Clinic for Veterans

Article Outline

• Abstract
• Introduction and Scope of the Problem
  • Literature Review
    • Knowledge
    • Self-care
    • Empowerment
    • Social Support
    • Theoretical Framework
  • Research Questions
• Methods
  • Research Site
  • Design
  • Procedures
  • Data Analysis
• Results
  • Sample Characteristics
  • Transportation
• Discussion
  • Limitations
• Conclusions
  • Implications for Clinical Practice
• Acknowledgment
• References
• Copyright

Abstract 

The purpose of this descriptive pilot study was to evaluate physiological and behavioral outcomes among veterans with type 2 diabetes attending an advanced practice nurse-managed diabetes clinic. Participants completed baseline and follow-up interviews approximately 6 weeks apart, and physiological data were obtained from medical records after each interview. Physiological outcomes did not change significantly from baseline to follow-up; however, some behavioral outcomes improved significantly. Although further research is warranted, this study provided insight into the beliefs of patients with type 2 diabetes, which may inform the treatment and education of such patients in primary care.

Keywords:  advanced practice nurse , clinic , diabetes , veterans

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Introduction and Scope of the Problem 

Diabetes is a metabolic disease that affects people of all ages and ethnicities at any stage of their lives. Currently, 23.6 million Americans are affected with diabetes.¹, ² The prevalence of diabetes is highest between the ages of 65 and 74 years, regardless of gender and race/ethnicity. African Americans (AA) have a higher incidence of diabetes than Caucasians and Asian Americans across all age groups.³ Diabetes is more prevalent in men than women, as men account for 12 million individuals with diabetes in the 20-year-old or older age group.¹, ² Although there is currently no cure for diabetes, it is possible for persons living with diabetes to maintain a normal blood sugar through lifestyle changes and collaboration among patients, families, and clinicians.

AAs have the highest incidence of diabetes compared to Caucasians, Hispanics, and Asian Americans.¹ Diabetes ranks as the fourth leading cause of death among AAs, whereas it is the seventh leading cause of death among Caucasians.⁴ Overall, compared to Caucasians, AAs are not only more likely to die from diabetes but are also more likely to develop complications and disabilities related to the disease.⁵ These disparities may explain why there is such a high number of diabetes-related complications and hospitalizations among AAs. This is especially true in the veteran population.⁶

There are 24.9 million U.S. veterans, and of those veterans, 23.2 million are men and 2.4 million are AA.⁷ Veterans with diabetes account for 15% of the total number of veterans receiving care in the Department of Veterans Affairs medical facilities. Due to the complex nature of diabetes, $2.5 billion are spent annually for the treatment and care of this veteran population.⁶

Management of diabetes is complex, and patients carry the primary responsibility for self-management.⁸ Although the development of type 2 diabetes has a genetic association, lifestyle components, such as obesity, smoking, and a sedentary lifestyle, may be synergistic. Due to an increase in the prevalence of these lifestyle factors combined with the growing number of older Americans, type 2 diabetes has the potential to reach epidemic proportions.², ³ As such, the purpose of this descriptive pilot study was to assess the feasibility of evaluating physiological and behavioral outcomes among veterans with type 2 diabetes attending an advanced practice nurse (APN)-managed diabetes clinic. Secondary aims were to evaluate specific physiological outcomes, such as hemoglobin A1c (HgbA1c) level, blood pressure, body mass index (BMI), and lipid profiles, and specific behavior outcomes, such as knowledge, self-care, and empowerment, at two time points during clinic attendance.

Literature Review 

Knowledge about one's disease positively affects outcomes by increasing motivation to change behavior, which will ultimately lead to improvement in physiological measures of that disease. Specific to diabetes, an increase in knowledge has been shown to result in a decrease in HgbA1c level and BMI and improved lipid profiles.⁹, ¹⁰ Increase in knowledge was also found to result in a decrease in both systolic and diastolic blood pressures in hypertensive patients, which would be a favorable outcome in those with diabetes.¹¹ In addition, patients receiving a knowledge intervention demonstrated greater empowerment and improved self-care abilities than those who did not receive knowledge intervention.⁹

Self-care is another component of disease management necessary for positive outcomes. Patients with diabetes who participate in self-care have lower HgbA1c levels than those lacking in self-care abilities.¹², ¹³ Participation in a self-care training program was also associated with considerably more knowledge about one's disease.¹⁴ Similarly, there was a correlation between increased self-care and greater empowerment among those with diabetes.¹³

Patient empowerment refers to a process of behavior change that enables patients to become more knowledgeable and to take control of their bodies, disease, and treatment,¹⁵ thereby leading to positive health outcomes. It is hypothesized in this pilot study that patients who feel empowered will seek out knowledge and thus be better able to care for themselves and manage their disease. Lower HgbA1c levels were seen in studies of patients with diabetes who had higher levels of empowerment.¹⁶, ¹⁷, ¹⁸ Higher levels of empowerment were also associated with a decrease in BMI in overweight patients with diabetes.¹⁷

Social support is also an important factor in patient outcomes and can be vital to successful management of one's disease. For example, those patients with a social support system showed increased adherence to self-care activities¹⁹, ²⁰ and had lower HgbA1c levels.¹⁹ In addition, positive social support correlated significantly with increased self-care behaviors, healthy eating habits, and greater physical activity in AAs.²⁰

Testing of a theoretical model was beyond the scope of this study. However, we did use a well-known behavior change model, the Precede-Proceed Model (PPM), to guide our selection of variables as a platform for future experimental designs. Knowledge, self-care, and empowerment, which can be considered predisposing factors, motivate people with diabetes and other chronic diseases to take action in an effort to improve outcomes related to their disease. Enabling factors, such as social support, are resources that assist people in achieving behavior change and positive outcomes.²¹ Outcomes of interest for people with diabetes in this pilot study included decreased HgbA1c level, blood pressure, and BMI; improved lipid profile; and increased knowledge, self-care, and empowerment.

The PPM provides a structure for identifying individual determinants of health that are important to a specific population, and developing and implementing community-centered programs to meet their needs. The precede phases (phases 1-5) of the PPM involve factors that affect behavior and guide the development of the health-related program. The proceed phases (phases 6-9) guide the implementation and evaluation of the program designed in the precede phases.²² Of the nine phases in the PPM, phase 4, which includes predisposing, enabling, and reinforcing factors related to individual behavior, was utilized. A modified version of phase 4 from the PPM guided this pilot study. Reinforcing factors were not considered, given the short time frame.

Research Questions 

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Methods 

Research Site 

This pilot study was conducted at a Midwestern Veteran's Affairs (VA) medical center. Of the 41,748 patients at the medical center, approximately 94% are male and 65% are AA. One of the newer primary care clinics is the APN-managed diabetes clinic, which began in January 2008 and was the research site for this study. The diabetes management clinic was created to address management of patients with HgbA1c levels of 9% or higher. Medical record review identified approximately 700 patients who were eligible for follow-up in the clinic.

The initial clinic visit consisted of obtaining a history, performing a physical examination, assessing educational needs, and laboratory testing. Specifically, the APNs interviewed the patients about their current knowledge regarding their disease process, medications, and self-care practices, followed by diabetes education tailored to the individual needs of the patient, adjusting medications as needed and forming a plan of care. Each follow-up visit consisted of taking a focused history and physical examination and laboratory testing. In addition, issues discussed at the initial visit were evaluated to further identify educational needs and determine whether the plan of care needed to be revised.

Design 

This descriptive feasibility study was approved by the institutional review boards at two major Midwestern medical centers. This study is the result of work supported with the resources and the facilities at the VA medical center. Participants were recruited and data were collected between September and December 2008.

Procedures 

Study eligibility criterion was attendance at the diabetes management clinic. Initial contact was made with the potential participants following their clinic appointment. Interviewers explained the purpose of the study and obtained written informed consent. Participants then completed an initial contact form, followed by the baseline questionnaire consisting of demographic questions and subscales for knowledge, self-care, and empowerment. The questionnaire was administered in person, and questions were read aloud to each participant. Baseline physiological data were obtained from the medical record.

The follow-up interview occurred 6 weeks later and consisted of administration of the same three subscales and collection of current physiological data from the medical record. The follow-up interview was conducted in the same manner, and also occurred after the participants' clinic appointment. At the end of the meeting with the interviewer, participants were given a gift card in the amount of $5 for full participation in the study. If participants were unable to return to the clinic for the follow-up interview, the interview was conducted via telephone, and the gift card was sent by mail.

In this pilot study, measures included the Brief Diabetes Knowledge Test and the Diabetes Empowerment Scale'short Form from the Michigan Diabetes Research and Training Center²³ and the Self-Care Inventory—Revised Version.²⁴ The reliability and validity of these measures have been demonstrated in previous research.²³, ²⁵, ²⁶

Data Analysis 

Data were analyzed using Statistical Package for the Social Sciences software version 16.0.

Bivariate analyses were run between predisposing factors and outcomes and between enabling factors and outcomes. Changes in predisposing and enabling factors from baseline to follow-up were assessed using a paired t test. Research questions 2 and 3 were answered by comparing baseline interview responses, HbgA1c levels, blood pressure, BMI, and lipid profiles with follow-up results. In addition, chi-square analysis was used for nominal level data to assess changes in blood pressure from pre- to posttesting.

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Results 

Results from this pilot study are presented in Table 2, Table 3. To answer research question number 1, only 19 participants enrolled in the study. Even with the high response rate of 95% (only one potential participant refused due to lack of time), feasibility of surveying patients in this clinic setting was low. There were no missing data for the baseline interviews or the physiological measures. Five of the 19 participants were lost to follow-up interviews due to a lack of attendance at clinic appointments or the inability to reach them via telephone. In addition, certain laboratory tests were not performed within the time frame for this study, leading to some missing physiological data at follow-up.

Table 2. Physiological Variables

*Chi-square (p value).

Abbreviations: sd = standard deviation; BP = blood pressure.

Table 3. Behavior Variables

Abbreviations: sd = standard deviation.

Sample Characteristics 

A total of 19 participants were recruited for this pilot study, all of whom completed the baseline interview. Of the 19 participants, 14 completed the follow-up interview. Sample characteristics are described in Table 1. The mean age of the participants was 59 (6 standard deviation [SD] 5 8 years). All but one of the participants were male, and 78.9% of participants were AA. The majority (58%) reported attending some college or having a college degree, and 31.6% of participants reported having graduated from high school. Most (68.5%) reported an annual income of between $15,001 and $75,000. Of note, 15.8% of participants did not know their income or preferred not to answer this question. Just over half the sample (52.6%) reported driving their own car to their clinic appointment on the day of the baseline interview (Table 1).

Table 1. Sample Characteristics

Abbreviations: sd = standard deviation; GED = high school equivalency test.

Due to the exploratory nature of this pilot study, results were considered statistically significant at a p value of <0.1. In terms of research question 2, participation in an APN-managed diabetes clinic resulted in increases in HgbA1c level, BMI, total cholesterol, low-density lipoprotein (LDL), and triglycerides, and a decrease in high-density lipoprotein HDL. The number of participants with hypertension remained approximately the same from baseline to follow-up. However, none of these results was statistically significant at p <0.1 (Table 2).

In terms of research question 3, which addresses predisposing factors, mean scores for knowledge, knowledge of insulin, and self-care significantly increased from baseline to follow-up at p <0.1. There was a slight increase in empowerment among participants, with a mean score of 32.58 at baseline and 33.14 at follow-up. However, this increase was not statistically significant (Table 3).

Transportation 

In this study, type of transportation was used to assess the social support networks of participants, which is an enabling factor in the PPM. The majority of participants (52.6%) arrived at their clinic appointments at baseline by driving their own car. Public transportation was used by 36.9% of participants, and 10.5% of participants received a ride to their clinic appointments with a friend or family member. At follow-up, 10 participants were either lost to follow-up or had their interview conducted via telephone. Because of this, transportation could be assessed only for 9 participants at follow-up, the majority (67%) of whom drove their own cars to the appointment.

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Discussion 

Overall, the impact of an APN-managed diabetes clinic on physiological and behavior outcomes among veterans with type 2 diabetes is unclear. Feasibility of enrolling participants in a pre- and poststudy design was low, with only 19 participants enrolled over a period of 6 weeks, 5 of whom were lost to follow-up. Additional recruitment and retention strategies will need to be followed in subsequent study designs. However, we were able to show the feasibility of using a framework such as the PPM to guide the evaluation of patient outcomes. For secondary aims, HgbA1c level, BMI, total cholesterol, LDL, and triglycerides increased over 6 weeks, while HDL decreased, and hypertension stayed relatively consistent, which were unexpected outcomes (although not statistically significant).

There are several possible reasons why lipid profiles did not improve. Cholesterol-lowering medications have various effects on the lipid profile, and many patients with type 2 diabetes require multiple medications.²⁷ Participants may not have been taking their cholesterol-lowering medications as prescribed, or they may not have been on the appropriate medications to meet their cholesterol goals.

In addition, it is impossible to know whether participants fasted prior to having their lipid profiles drawn, which could also affect the results. Lifestyle factors that may be common to the veteran population, such as smoking and a sedentary lifestyle, can also contribute to poor lipid profiles, as well as increased HgbA1c level, blood pressure, and BMI. Although lifestyle modifications are important in improving diabetes outcomes, 6 weeks may not be enough time to see significant changes in physiological data. Other reasons for the lack of significant changes could also be related to the small sample size, missing physiological data at follow-up, and participants' nonadherence to APN recommendations.

In terms of behavior outcomes, or predisposing factors that may provide patients with a rationale for changing behavior,²¹ there were significant increases in both general knowledge about diabetes and about insulin. These were expected findings, although surprising given the small sample size in this study. This increase is most likely due to the education provided by the APNs at the clinic visits. There was also a significant increase in self-care abilities among participants. Education and support provided by the APNs may have contributed to improved self-care behaviors in this population. This is supported by previous research that found that educational interventions were associated with greater self-care abilities.⁹ However, empowerment among participants increased only slightly during the study period and was not statistically significant. A possible reason for this was that the Diabetes Empowerment Scale—Short Form, which includes only eight questions to assess empowerment, was used in this study to reduce respondent burden. The original form of this scale uses 28 questions and divides the responses into categories related to patient self-efficacy, which may provide a more sensitive assessment of empowerment.

In this study, social support (an enabling factor) was assessed by asking participants, “What mode of transportation did you use to get to your clinic appointment today?” Although social support may encompass broader domains, we used transportation as an indicator of social support because it has been shown to influence patients' adherence to medical regimens. Patients may not seek necessary medical care if they lack available and affordable transportation.²⁸ In addition, persons with diabetes needed the most assistance with transportation in a social support context.²⁹ Social support was defined in this study by having a family member or friend who would drive participants to their clinic appointments. However, the majority of participants did not receive a ride to their clinic appointment from a friend or family member. This could indicate that either the majority of participants did not have a strong social support network or that they simply did not need assistance with transportation. Based on these results, the relationship between transportation and social support remains unclear, and other factors should be examined in order to assess social support.

Limitations 

The two main limitations for this study were the small sample size and short study time period. The diabetes management clinic is relatively new, and patients were still actively being recruited for this clinic during the study period. As a result, the census for this clinic was lower than other clinics at the medical center. Interviewers were present on two of the 2.5 days per week that the clinic operated and noted that less than half of the scheduled patients showed up for their appointment on several days. Also contributing to the small sample size was the fact that many of the patients' records did not contain current contact information, which made it difficult for the APNs to recruit patients. The short time period for this study decreased recruitment numbers and affected availability of follow-up physiological data due to evidence-based practice guidelines for ordering laboratory studies. The short time period was necessary because this study was a graduate student project with time constraints.

The attrition rate for this study was 26%, which, given the small sample size, is considered a high drop-out rate. At follow-up, there was a fair amount of missing physiological data. Along with the evidence-based practice laboratory protocols mentioned above, the interviewers had no control over which laboratory studies were ordered or whether the APNs collected blood pressure and BMI measurements at the clinic visits. In addition to the missing physiological data, there were also five participants who were lost to follow-up interviews. All of these factors could have affected the overall significance of the results.

The sample recruited for this study was 94.7% male and 78.9% African-American, which is reflective of the overall population at the medical center. In addition, this study was conducted in a large urban area at only one research site, and all participants were veterans with type 2 diabetes. These characteristics make the sample very homogeneous. Due to the lack of gender and ethnic diversity in the sample, results are not generalizable to the general population.

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Conclusions 

Despite the limitations of this study and the lack of improvement among physiological variables, behavior variables did significantly improve. Based on the improvements that were seen in this study, it is reasonable to assume that given a longer period of time, patients would progress from improvements in behavior measures to improvements in physiological measures, which would in turn lead to more positive diabetes outcomes. In addition, the use of a control group would be helpful in comparing patients who attend diabetes clinics with patients who do not attend diabetes clinics.

Additional research is warranted to assess the impact of APN-managed diabetes clinics, which may well be a cost-effective way to reduce disparities and negative sequelae of diabetes. In terms of further research, more studies of this kind need to be conducted with larger samples and longer study periods. In addition, the use of a control group would be helpful in comparing patients who attend diabetes clinics with patients who do not attend clinics. It would also be beneficial to study diabetes clinics at multiple sites in various geographical areas with diverse patients in order to make this type of research more generalizable.

Implications for Clinical Practice 

The results of this study are important to clinical practice because of the growing number of patients with type 2 diabetes and diabetes-related complications. Although additional research is needed to determine the long-term effectiveness of APN-managed clinics in relation to diabetes outcomes, the improvement in behavior variables that was seen in this study is encouraging. There are challenges associated with recruitment and retention of participants in longitudinal research, but through research of this kind, APNs can gain insight into their role in promoting behavior change through patient education. A large part of the role of the APN is to provide quality patient education, and the results of this study show that even a small amount of education at each visit translates into increased knowledge and improved self-care abilities in patients with type 2 diabetes. It is important that APNs not be discouraged if patients do not show improvement in measures such as HgbA1c level, blood pressure, BMI, and lipid profiles in a short period of time, because behavior change must occur before improvement in physiological measures becomes evident. Given the significant increase in diabetes knowledge and self-care that was seen over a short period of time, it is recommended that APNs provide individualized education to their patients at each clinic visit. In addition, we recommend that clinicians follow current national guidelines for the management of patients with type 2 diabetes and stay up to date with current research in this area.

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Acknowledgment 

This work was supported by resources from and facilities at the Jesse Brown VA Medical Center, Chicago, IL. Ms. Carlucci and Ms. Arguello thank faculty advisor Dr. Kathryn Rugen, PhD, RN, associate chief nurse for education and research at the Jesse Brown VA Medical Center and clinical assistant professor at the University of Illinois at Chicago College of Nursing, for time and effort given in the facilitation of this research.

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