Population Health Research and PICOT Statement.

Based on the PICOT you developed for NUR-550, summarize the change initiative you will be proposing. How does this support the population of focus, your setting, and role? Justify how the problem you selected to investigate is amenable to a research-based intervention using the PICOT format. I live in El Paso Texas, Diabetes is high in the elderly population. I uploaded the PICOT paper Any questions please let me know.Population Health Research and PICOT Statement.

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The proposed change initiative in this project is continuous glucose monitoring (CGM). The initiative is meant to facilitate the management of type 1 diabetes mellitus (T1DM) among the elderly as an alternative to the traditional self-monitoring of blood glucose (SMBG) levels(Charleer et al., 2018). The expected outcomes of the change initiative include reduced hospital readmissions or long-term admissions, improve glycemic control and decrease hypoglycemic events.Population Health Research and PICOT Statement.

The proposed change initiative supports the health of the elderly population. This is because, it seeks to manage their type 1 diabetes mellitus which is increasingly prevalent in geriatrics. Continuous monitoring of their glucose level will help track their health status and prevent them from getting to the extremes that result in hospitalization. Moreover, it reduces the risk of complications such as heart failure, stroke, eye diseases, kidney diseases and poor circulation of blood to the limbs(Wan et al., 2018). On the other hand, the hospital setting is not overwhelmed by increased patient population resulting from readmissions and long-hospital stays as well as increased demand for patient needs. The role of the nurse is supported by patient engagement in their treatment plans, reduced workload and burnout.Population Health Research and PICOT Statement.

The selected problem in this paper is type 1 diabetes mellitus which is increasingly becoming a healthcare burden. It isamenable to a research-based intervention using the PICOT in that it has a well-defined target audience, elderly patients who need urgent intervention. Moreover, the population makes up a majority of the people who make a big part of the El Paso Texas population and considering the health burden the problem imposes on the healthcare system; the problem can be easily acted upon using the approach presented in the PICOT, that is, continuous glucose monitoring.Population Health Research and PICOT Statement.

Population Health Research and PICOT Statement

PICOT Question

In elderly patients with type 1 diabetes mellitus (T1DM), how does continuous glucose monitoring (CGM), when compared to the traditional self-monitoring of blood glucose (SMBG) levels decrease hypoglycemic events, improve glycemic control, and reduce hospital readmissions or admissions in the long-term.

Demographic Description of Health Population

Diabetes is one of the leading causes of death in the United States. The National Diabetes Statistics Report revealed that there are 88 million adults with prediabetes and 34.2 million with diagnosed diabetes. Out of the diagnosed cases, 26.8% were older patients aged over 65 years, followed by those between 45 and 64 years (Center for Disease Control and Prevention, 2020). However, in Texas, the condition is more prevalent in patients between 45 and 64 years, followed by patients over 76 y/o. The prevalence of the disease in the state is higher than the national average. Rusk, Wichita, Waller, and Nueces Counties have higher prevalence rates than the State and national average. About 2.3 million Texans were diagnosed with diabetes, 11.2% of whom were adults. The condition is disproportionately concentrated in East Texas, in older patients and ethnic minorities in the region (Texas Demographic Center, 2018).Population Health Research and PICOT Statement.

The condition is also nationally prevalent among American Indians/Alaska Natives and people of Hispanic origin in the country. About 1.4 million of the diagnosed adults have type 1 diabetes (T1D), while type 2 diabetes (T2D) accounts for 95% of all the diagnosed cases. The education level and socioeconomic status of patients significantly influence the prevalence of the condition. According to the Center for Disease Control, 13.3% of those diagnosed with diabetes have less than high school education, 9.7% with at least a high school education, and 7.5% with tertiary education (Center for Disease Control and Prevention, 2020). Complications associated with the condition include chronic kidney disease, stroke, heart diseases, lower-limb amputations, and adult-onset blindness. Population Health Research and PICOT Statement.

Explain How Nursing Science, Health Determinants, Epidemiologic, Genomic, and Genetic Data Impact Population Health Management for the Selected Population

Health determinants typically fall into multiple broad categories: Social factors, health services, biology and genetics, individual behavior, and policymaking. Policies at federal, state, and local levels impact population and personal health for diabetic patients. Social health determinants typically reflect the physical conditions and social factors of an individual’s environment, and they affect a broad range of functioning, quality-of-life, and health outcomes. Examples of social health determinants that impact adult diabetic patients in Texas include the accessibility to resources that meet daily needs such as healthy foods, living wages, job, and educational opportunities, social attitudes, and norms towards the diabetes management, social support and interactions, socioeconomic conditions, for instance, poverty, and transport options. Physical health determinants include the built environment, e.g., transportation, exposure to toxic substances, and neighborhoods, housing, and homes.Population Health Research and PICOT Statement.

Accessing to health services can affect the health of diabetic patients. Limited access or lack of access to health services greatly impacts the health status of diabetic patients. Adult diabetic patients in Texas encounter various barriers to healthcare access; these barriers include language barriers, particularly among the Hispanic community, lack of insurance coverage, high diabetes care costs, and limited access to specialized care.  The individual behavior of diabetic patients also impacts their health outcomes. For instance, a diabetic patient who does not smoke is physically active, takes his/her medication, as per the physician’s instructions, and observes a healthy diet has minimal risk for rehospitalization or hospital admissions. Various genetic and biological factors impact specific populaces more than the others. Type 1 diabetes is an autoimmune condition characterized by the destruction of pancreatic β cells that produce insulin. Population Health Research and PICOT Statement.The genetic background of the patient is an essential component in the destruction of beta cells. Diabetes Type 1 is linked to the HLA class II genes, which account for 30-50% of the gene-associated risk factors. Environmental factors may trigger the immune-mediated destruction of the β cells. Although patients with T1D may lack a family history of the condition, the presence of HLA genotype and insulin gene polymorphism increases susceptibility to the condition. The probability of developing T1D with no family history is 0.4%, relation with affected mother is 1% to 4%, relation with affected father is 3% to 8%, and a relationship with both parents affected is 30%.Population Health Research and PICOT Statement.

Nursing science impacts the management of diabetes in the populace by influencing the development of practical conceptualizations and theories for improving how clinicians/healthcare providers and patients administer diabetes care and manage the condition. Nursing science typically merges the worlds of human, applied, and natural science holistically into a multidimensional lens that explores new and improved ways to deliver healthcare services to diabetes patients. Furthermore, it emphasizes the importance of patient-centered care, and it contributes to the discovery and research of innovative approaches that aim to improve the health outcomes of diabetic patients. Nurses understand their patients best, and, according to AUTHOR, the communication and trust between nurses and their patients promote better patient experiences, diagnoses, and treatment.Population Health Research and PICOT Statement.

In a world of the ever-increasing technological diagnoses and empirically/practically infinite/interminable data points, nursing science maintains a crucial human aspect in the balance of diabetes care. For instance, telenursing puts cutting-edge technology in nurses’ hands, allowing them to monitor patients with chronic diseases, e.g., diabetes and to offer critical care to patients located in remote regions. Telenursing removes/eliminates the burden of transportation and distance, thereby increasing care beyond hospital admissions, providing healthcare access to patients with mobility issues, and even minimizing response times. Moreover, telenursing decreases costs by structuring therapy sessions, allowing self-test, and sorting patients as per urgency prior to them showing up at the care facility. Epidemiological data promotes the identification of the distribution of the disease, i.e., diabetes, the factors that underlie its cause and source, and methods/approaches for its control. Genetic and genomic data, on the other hand, facilitate researchers’ capacity to predict who might develop the disease (i.e., diabetes), the personalization of treatment, and the likelihood of identifying the genetic correlation between phenotype and genotype.Population Health Research and PICOT Statement.

Potential solution and PICOT statement

The Use of Continuous Glucose Monitoring

Measuring glycated hemoglobin has been a gold standard for the management of diabetes. However, these methods do not reflect the intra and interday glycemic levels, which increase the risk of microvascular and macrovascular complications. Intermittently-viewed CGM and continuous glucose monitoring can be used to address such complications. Patients can opt to use continuous glucose monitors or self-monitoring testing strips to measure and monitor the concentration of blood sugar glucose.Population Health Research and PICOT Statement.

Although SMBG has been proven to be helpful or correlates with the efficient management of diabetes in non-insulin treated and insulin-treated diabetes, it has notable drawbacks. First, according to Danne, Nimri, Battelino, Bergenstal, Close, and Garg (2017), the aforementioned approach requires a fingerstick to get a blood sample. Furthermore, SMBG only offers a single “point-in-time” measurement that provides no indication of the rate or direction of the change in glucose levels; therefore, utilizing SMBG data solely may trigger inappropriate treatment decisions (for instance administering correction insulin in cases where there is a decrease in glucose levels). Secondly, securing glucose data using SMBG depends on the self-monitoring decision of the patient. Thirdly, SMBG typically fails to detect asymptomatic and nocturnal hypoglycemia.Population Health Research and PICOT Statement.

Intermittently-viewed CGM, according to Danne et al. (2017), usually provides the current glucose value as well as retrospective glucose information for a particular period upon “scanning.” Two surveys using iCGM have shown statistically significant improvements in hypoglycemia, user satisfaction, glycemic variability, and time-in-range (Danne et al., 2017). RT-CGM (a CGM medical device) in unblinded mode offers real-time graphical and numerical data regarding a patient’s current glucose trends, glucose level, and the rate/direction of change of glucose. CGM devices with programmable alarms/alerts that warn users about the current or/and impending low or high glucose provide additional safety benefits.Population Health Research and PICOT Statement. Several studies have demonstrated that the utilization of RT-CGM improves the quality-of-life and glycemic control in both adults and children with T1D with either multiple daily insulin injection therapies or subcutaneous insulin infusion (Welsh, 2018). The use of rtCGM, according to Danne et al. (2017), aids in improving HbA1c, decreasing the period spent in hyperglycemia and hypoglycemia, and decreasing moderate-to-severe hypoglycemia. RT-CGM’s benefits are typically observed in patients who utilize these devices frequently. The cost-efficacy of rtCGM over SMBG has also been reported using a large populace-based model (Danne et al., 2017). Furthermore, in a lifetime evaluation/analysis, the use of RT-CGM was shown to reduce overall complications related to diabetes.Population Health Research and PICOT Statement.

A real-world survey conducted by Charleer, Mathieu, Nobels, Block, Radermecker, and Hermans (2018) which aimed to evaluate the effect of RT-CGM in actual-world settings on QOL, work absenteeism, hospital admissions, and glycemic control revealed that sensor-augmented pump therapy in T1D patients aid in improving HbA1c, QOL, and hypoglycemia and in reducing hospital admissions due to acute diabetes complications and work absenteeism. Sensor-augmented pump therapy has also been ascertained to be cost-effective for the treatment of T1D (Danne et al., 2017). A review by Rodbard (2017) also demonstrates the importance of CGM in improving glycemic outcomes. According to Rodbard (2017), CGM has been shown to be clinically valuable, decreasing risks for hyperglycemia and hypoglycemia, improving patients’ QOL for a broad range of patient populaces and clinical indications, and providing glycemic variability. Rodbad (2017) further argues that the use of CGM can aid in reducing mean glucose and HbA1c. In a systematic review, Janapala, Jayaraj, Fathima, Kashif, Usman, and Dasari (2019) conclude that the utilization of CGM in T2D is beneficial because it significantly decreases HbA1c compared to the traditional SMBG method. Danne et al. (2017) recommend the use of CGM in conjunction with HbA1c during the assessment of glycemic status and therapy adjustment for T1D patients and T2D patients treated with intensive insulin therapy who aren’t attaining glucose targets, particularly if the patient experiences problematic hypoglycemia.Population Health Research and PICOT Statement.

Two experimental studies demonstrated that CGM could reduce the risk of hypoglycemia by 33% to 50%. Apart from the recent improvements in the accuracy of the calibration of the CGMs, the tools are FDA approved for non-adjuvant use. A recent crossover randomized study demonstrated that CGM is useful for T1D management in special health populations, including pregnant women, hypoglycemic elderly with poor glycemic control, and hospitalized patients (Rodbard, 2017).Population Health Research and PICOT Statement.

How the solution incorporates health policies and goals that support health care equity

The management of diagnosed diabetes is estimated to cost $327 billion annually (Janapala et al., 2019). Cost is a major influencing factor, not just inequitable healthcare but in diabetic management. Most insurance plans, including Medicare, only cover a portion of the total cost of healthcare, forcing patients to copay in total healthcare costs. The healthcare system in the United States is marked by significant inequalities across economic, gender, and racial lines. There are approximately 29 million uninsured Americans (Glantz, Duncan, Ahmed, Fan, Reed, &Kalirai, 2019). A recent study showed that the cost of diabetics for Hispanics and older patients in the US is significantly higher than in other health populations.Population Health Research and PICOT Statement. Medicare Part B covers CMG monitors, test strips, lancet devices, and glucose control solutions for all diabetic patients regardless of whether they use insulin or not. Patients on insulin receive a maximum of 300 test strips and lancets after every three months, while those not on insulin receive a maximum of 100 test strips, lancets, and other testing supplies recommended by a healthcare professional (American Diabetes Association, n.d.). The use of Continuous Glucose Monitoring incorporates the concepts of health equity because they are not only cost-effective but also user friendly for any health population regardless of their education level, the socioeconomic and ethnic background of the patient (Janapala et al., 2019).Population Health Research and PICOT Statement.