Type 1 Diabetes—A Clinical Perspective Essay

Section C: Solution Description Write a paper of 500-750 words for your proposed evidence-based practice project solution. Address the following criteria: 1. Proposed Solution: (a) Describe the proposed solution (or intervention) for the problem and the way(s) in which it is consistent with current evidence. Heavily reference and provide substantial evidence for your solution or intervention. (b) Consider if the intervention may be unrealistic in your setting, if it may be too costly, or if there is a lack of appropriate training available to deliver the intervention. If the intervention is unrealistic, you may need to go back and make changes to your problem statement before continuing. 2. Organization Culture: Explain the way(s) in which the proposed solution is consistent with the organization or community culture and resources. 3. Expected Outcomes: Explain the expected outcomes of the project. The outcomes should flow from the problem statement. 4. Method to Achieve Outcomes: Develop an outline of how the outcomes will be achieved. List any specific barriers that will need to be assessed and eliminated. Make sure to mention any assumptions or limitations that may need to be addressed. 5. Outcome Impact: Describe the impact the outcomes will have on one or all of the following indicators: quality care improvement, patient-centered quality care, efficiency of processes, environmental changes, or professional expertise. You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content. Type 1 Diabetes—A Clinical Perspective Essay. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Please, Please look at he paper uploaded to continue with Section C. This is a continuous proposal. I also live in El Paso, Texas I work for a managed care organization in case you need that information

Evidence-Based Practice Proposal

Type 1 Diabetes (T1D) is a chronic disease that limits pancreas from producing enough insulin (Kahanovitz, Sluss & Russell, 2017). Insulin is an essential hormone in the body. It is required to allow sugar or glucose to enter body cells to produce energy. Although T1D is commonly diagnosed in childhood, its incidence has been rising in the elderly population. The condition predisposes them to hypoglycemia, which is associated with seizures, loss of consciousness, and altered mental status. An effective way to manage T1D in the elderly is the application of continuous glucose monitoring (CGM). According to Health Quality Ontario (2018), CGM is more effective than self-monitoring of blood glucose in T1D management. In light of this, the paper describes CGM as the proposed solution, explains how CGM is consistent with the organization’s culture and expounds the expected outcomes. The paper also provides insights on methods used to achieve the outcomes and describes the impact of the outcomes.

Proposed Solution

Several factors, including certain viruses, age, environmental factors, and genetics contribute to T1D. The condition may lead to neuropathy, heart attack, stroke, atherosclerosis, nephropathy, high blood pressure, blindness, skin and mouth infections, and damage to the foot. To manage type 1 diabetes and prevent the mentioned complications, the Managed Care organization should use continuous glucose monitoring strategy on the elderly patients.

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Continuous glucose monitoring tracks blood glucose levels or blood sugar all day (Heinemann & Stuhr, 2018). An individual can see their glucose levels anytime when using a continuous glucose monitoring device. In healthcare organizations, CGM devices can be used to review how a patient’s glucose changes over a specified period; for instance, over a few days or hours to note the trends. As healthcare providers have glances of a patient’s glucose levels in real-time, they can make more informed decisions, such as administering drugs, conducting physical therapy, or balancing the patient’s food (Sørgård, Iversen & Mårtensson, 2019). Type 1 Diabetes—A Clinical Perspective Essay. Elderly patients with T1D are unable to reach or maintain the recommended A1C targets. However, evidence shows that real-time CGM devices potentially help users enhance diabetes control as it reduces hypoglycemic and hyperglycemic exposures (Wood, O’Neal, Furler & Ekinci, 2018). The proposed solution is realistic in the Managed Care organization since staff members are willing to participate and adopt evidence-based practices. Additionally, the organization is knowledgeable and equipped with EBP skills.

Organizational Culture

The organization’s culture acknowledges the adoption of evidence-based practices that help improve the quality of life. Staff members are willing and have the knowledge required in implementing the proposed solution. In the case of healthcare workers displaying resistance, the Managed Care organization has a change champions program that educates about the significance of EBP changes. Additionally, CGM project is consistent with the organization’s resources in that leadership and management provides necessary finances and resources such as electronic devices, computers, and the internet in support of the EBP.

Expected Outcomes

Based on research, the use of continuous glucose monitoring in the organization will address the problem of older adults with type 1 diabetes. CGM will lower hypoglycemia a crucial aspect in T1D management. Thus, minimizing complications associated with hypoglycemia. Also, since the elderly do not recognize signs and symptoms of low or high blood glucose level, CGM will assist providers in determining the appropriate time for medication or balanced diets, hence increasing patient satisfaction.

Methods to Achieve Outcomes

Outcomes will be achieved by interprofessional collaboration in the treatment and management of elderly patients with T1D. The interprofessional collaboration will reduce workload or burn-outs when checking real-time data from CGM devices. CGM data will inform healthcare providers about the patient’s glucose trends and levels and the rate of change. Alarms will constitute the second method, through which healthcare providers will be alerted to administer subcutaneous insulin infusion or insulin injection therapies.

Outcome Impact

The outcomes of implementing continuous glucose monitoring will impact quality care improvement. Healthcare providers will provide care that abides by the six domains of quality that comprise timeliness, safety, efficiency, effectiveness, patient-centeredness, and equitability.Through CGM alerts, providers will provide medication on time and generate informed decisionson the effective and patient-centred approach in managing patients’ conditions.
References

Health Quality Ontario. (2018). Continuous monitoring of glucose for type 1 diabetes: a health technology assessment. Ontario health technology assessment series, 18(2), 1.

Heinemann, L., & Stuhr, A. (2018). Self-measurement of Blood Glucose and Continuous Glucose Monitoring – Is There Only One Future?. European Endocrinology, 14(2), 24. doi: 10.17925/ee.2018.14.2.24

Kahanovitz, L., Sluss, P., & Russell, S. (2017). Type 1 Diabetes—A Clinical Perspective. Point Of Care: The Journal Of Near-Patient Testing & Technology, 16(1), 37-40. doi: 10.1097/poc.0000000000000125

Sørgård, B., Iversen, M., & Mårtensson, J. (2019). Continuous glucose monitoring in adults with type 1 diabetes: A balance between benefits and barriers: A critical incident study. Journal Of Clinical Nursing, 28(17-18), 3318-3329. doi: 10.1111/jocn.14911

Wood, A., O’Neal, D., Furler, J., & Ekinci, E. (2018). Continuous glucose monitoring: a review of the evidence, opportunities for future use and ongoing challenges. Internal Medicine Journal, 48(5), 499-508. doi: 10.1111/imj.13770 . Type 1 Diabetes—A Clinical Perspective Essay.

Although patients with T1DM know the advantages of having optimal blood glucose control, most patients have suboptimal blood glucose control. Poor control increases micro and macrovascular risks, which subsequently increases healthcare costs and reduces the QoL (Wan et al., 2018). A major barrier to ensuring intensive blood glucose management is increased hypoglycemic risk, which negatively impacts the patient’s QoL and management of diabetes.
CGM emerged as a more precise and accurate method to achieve glycemic control with improved decision-making in the management of diabetes. Compared with SMBG, CGM decreases HbA1C without increasing hypoglycemia with the highest HbA1c levels at baseline. Current evidence suggests that good glycemic control decreases and prevents complications in individuals with T1DM (Polonsky et al., 2017). Presently, the most common CGM systems are either connected to insulin pumps or are standalone systems that interrupt the administration of insulin to 2 hours when the concentration of glucose goes below a given threshold.
This paper reviews literature to find evidence that supports CGM as the most effective intervention compared to SMBG to improve blood glucose control, prevent hypoglycemic events, and reduce admissions among patients with T1DM. It describes the methods used by the author to search for literature, and an analysis of the methods and findings of each article. It also compares the limitations, differences, and similarities of literature and discusses the implications for future research.

Methods
The author conducted an initial search for evidence-based literature in Cochrane, PubMed, and Medline databases. The author used the following keywords; T1DM, CGM, SMBG, and glycemic control. For a more refined search outcome, the author used ‘or’ and ‘and’ Boolean search operators. The general search yielded 12 articles. To obtain the most recent and best articles, the author used the following exclusion and inclusion criteria:
Inclusion Criteria
The author selected articles published within the last five years in English. These studies included both qualitative and quantitative articles with experimental and non-experimental designs. The search focused on articles whose study sample had type 1 DM and used CGM as a primary intervention and SBGM as a comparison with the following outcome measures; decreased hospital admissions and readmissions, reduced hypoglycemic events, and improved glycemic control. The author also considered articles with other significant outcome measures, such as improved QoL or cost-effectiveness.
Exclusion Criteria
The author excluded articles that were not published in English and were beyond the last five years. Besides, articles whose population sample focused on patients with type 2 DM or other types of diabetes, did not use CGM and SBGM as the primary and comparison interventions respectively were excluded. The final search yielded five articles.
Literature Synthesis
Part A
The article by Charleer et al. (2018) is a quantitative study with a multicenter prospective, observational cohort design whose purpose was to examine how CGM impacts glycemic control, absenteeism, hospital admission, and QoL. The study included 515 adult participants with type 1 DM who were on CGM (intervention). The researchers analyzed data from all patients initiated in a CGM reimbursement program. Charleer et al. (2018) found that 81 %( 417) participants used CGM for 12 months. At the start of the program, the baseline HbA1Cwas 7.7 (9.8mmol/mol) and reduced to 7.4. Type 1 Diabetes—A Clinical Perspective Essay.
There was a potential reduction in the HbA1C levels of participants who began CGM due to poor blood glucose control at 4, 8, and 12 months in comparison to those who began CGM due to pregnancy or hypoglycemia. Besides, 16% of the participants were admitted for severe ketoacidosis or hypoglycemia in comparison to 4% (P < 0.0005) after the intervention (Charleer et al., 2018). Besides, days of admission reduced (P < 0.0005) (54 to 18 per 100 patient-years) Within the same period, there was a significant improvement in the QoL and a decrease in absenteeism and hypoglycemic fear (Charleer et al., 2018).
Beers et al. (2016) conducted RCTs in two medical clinics to determine how CGM impacts T1DM patient’s hypoglycemia awareness. The study included 52 patients between 18-75 years, diagnosed with T1DM. The researchers randomly assigned participants to an intervention group, CGM (16 weeks) group including a 12-week washout and 16 weeks SMBG or to a comparison group, SMBG (16 weeks) group with 12 weeks washout and 16 weeks CGM (Beers et al., 2016). The intervention group (CGM-SMBG) had 26 participants, while the comparison group (SMBG-CGM) had 26 participants. These researchers noted a decrease in hypoglycemic time and hyperglycemia (p<0·0001, and 5·0%, 3·1–6·9; p<0·0001) respectively. Besides, there was a decrease hypoglycemic events in the CGM than the comparison phase (SBMG) (p=0·033).
Wan et al. (2018) conducted a DIAMOND RCTs to evaluate how cost-effective CGM was in patients with T1DM. They randomized 158 patients with HbA1C exceeding 7.5% and T1DM to either CGM (intervention) or a control group. Participants filled surveys after six months, and complications were simulated using a modified TID policy model. The primary outcomes were costs per QALY (quality-adjusted life-year). Wan et al. (2018) noted that the QALYs in the intervention and control groups were similar (0.462 vs. 0.455, P = 0.61).
The study by Polonsky et al. (2017) is a quantitative article with an RCT design whose purpose was to establish whether CGM improves QoL. The researchers conducted a prospective RCT to assess CGM vs. SMBG among 158 adult participants with poorly controlled T1DM. The participants completed a QoL measure before the study and a CGM satisfaction survey after the study. QoL changes were analyzed using linear regression. The researchers further assessed relationships between outcomes of QoL changes and CGM satisfaction. Polonsky et al. (2017) found a significant increase in confidence and a marked reduction in distress (P=0.01) in the intervention group than the comparison group. However, there was no difference in fear of hypoglycemia and well-being. Satisfaction with CGM had no association glycemic changes but was linked to decreases in hypoglycemic fear (P=0.002) and diabetic distress and (P < 0.001) and increased hypoglycemic confidence and well-being (P=0.01).
The article by Olafsdottir et al. (2018) is a quantitative study with an RCT design that examined how CGM impacts hypoglycemic confidence, daytime, and nocturnal hypoglycemia, and glycemic variability in patients with T1DM. The researchers performed evaluations from GOLD RCTs with 161 participants over 69 weeks, where a comparison was made between CGM and SMBG in participants with T1DM. The researchers conducted evaluations using the hypoglycemia confidence questionnaire and masked CGM. Olafsdottir et al. (2018) found a 48 % (P<0.001) decrease in nocturnal hypoglycemia (<70mg/dL glucose levels), 65% decrease in glycemic levels (<54mg/dL) (P < 0.001). Daytime hypoglycemia also decreased by 40% (P < 0.001) compared with 54% (P < 0.001) (Olafsdottir et al., 2018). Besides, CGM increased hypoglycemia confidence (P=0.016). When using CGM, the participants reported a lot of confidence (P = 0.0033) in identifying and responding to hypoglycemia. Type 1 Diabetes—A Clinical Perspective Essay.
Part B
A major similarity among all the studies is that the researchers focused on adult patients with type 1 DM as the population sample with CGM as the intervention and SMBG as the comparison. However, in the study by Wan et al. (2018), apart from having a diagnosis of T1DM, the participants also had an HbA1C >7.5%. Polonsky et al. (2017) included adult patients aged >25 years with an HbA1C 7.5–10.0%. Beers et al. (2016) included patients 18-75 years managed with either SMBG or CGM, while Olafsdottir et al. (2018) included patients aged 18 years with T1DM and HbA1C >7.5%.
A limitation of the study by Charleer et al. (2018) was that other factors such as education, training, and frequent contact with healthcare providers at the initiation of CGM contributed to the outcome benefits. Besides, since it was observational, the study did not have a prospective comparison group. Beers et al. (2016) used CGM devices whose accuracy differed, yet when interpreting CGM derived data, researchers should take accuracy to account. Besides, the CGM devices that the researchers used could be outdated as the CGM devices entered the market when the study was ongoing.
Wan et al. (2018) used patient-reported descriptions of NSHEs (nonsevere hypoglycemic events), which differ with the international description of 54mg/Dl achievable by a CGM device for 20 successive minutes. Besides, there were possible inaccuracies in the number of days worked with a productivity of 50%, missed days of work, and hours devoted to the self-management of diabetes care daily (Wan et al., 2018). Although these limitations had minor implications on the statistical significance, they had no clinical significance. The statistical implications, however, cannot limit the applicability of the outcomes general population settings. Besides, since all studies only incorporated adult patients diagnosed with T1DM, researchers cannot apply the findings to other patient groups, especially patients with T2DM.
Areas of Further Study
The findings of this literature review reveal that CGM is a common, precise, and more accurate method to achieve glycemic control with improved decision-making in the management of diabetes compared to SMBG. CGM reduces hospital admissions and readmissions, decreases hypoglycemic events, and improves blood glucose control in T1DM. Further studies should examine whether similar outcomes can be observed in other patient groups such as those aged 17 years and younger with T1DM or patients with T2DM.
Conclusion
The findings from the literature review recommend using CGM as an effective intervention to reduce hospital admissions and readmissions, decrease hypoglycemic events, and improve blood glucose control in T1DM. A major similarity of the studies is that the population samples were adult patients diagnosed with T1DM, and CGM was the primary intervention with SMBG as the comparison method. Further studies should examine whether similar outcomes can be observed in other patient groups such as those aged 17 years and younger with T1DM or patients with T2DM. Type 1 Diabetes—A Clinical Perspective Essay.

References
Charleer, S., Mathieu, C., Nobels, F., De Block, C., Radermecker, R. P., Hermans, M. P., & Fieuws, S. (2018). Effect of continuous glucose monitoring on glycemic control, acute admissions, and quality of life: a real-world study. The Journal of Clinical Endocrinology & Metabolism, 103(3), 1224-1232.
Olafsdottir, A. F., Polonsky, W., Bolinder, J., Hirsch, I. B., Dahlqvist, S., Wedel, H., & Heise, T. (2018). A randomized clinical trial of the effect of continuous glucose monitoring on nocturnal hypoglycemia, daytime hypoglycemia, glycemic variability, and hypoglycemia confidence in persons with type 1 diabetes treated with multiple daily insulin injections (GOLD-3). Diabetes technology & therapeutics, 20(4), 274-284.
Polonsky, W. H., Hessler, D., Ruedy, K. J., & Beck, R. W. (2017). The impact of continuous glucose monitoring on markers of quality of life in adults with type 1 diabetes: further findings from the DIAMOND randomized clinical trial. Diabetes Care, 40(6), 736-741.
van Beers, C. A., DeVries, J. H., Kleijer, S. J., Smits, M. M., Geelhoed-Duijvestijn, P. H., Kramer, M. H., … & Serné, E. H. (2016). Continuous glucose monitoring for patients with type 1 diabetes and impaired awareness of hypoglycemia (IN CONTROL): a randomized, open-label, crossover trial. The Lancet Diabetes & endocrinology, 4(11), 893-902.
Wan, W., Skandari, M. R., Minc, A., Nathan, A. G., Winn, A., Zarei, P., & Huang, E. S. (2018). Cost-effectiveness of continuous glucose monitoring for adults with type 1 diabetes compared with self-monitoring of blood glucose: the DIAMOND randomized trial. Diabetes Care, 41(6), 1227-1234.

Evidence-Based Practice Proposal

Section A: Organizational Culture and Readiness Assessment

The “organization Culture and Readiness for System-Wide Integration of Evidence-Based Practice” is the organizational culture survey tool that was utilized during the assessment. This tool has been shown to be effective in assessing and determining the organizational readiness to adopt evidence-based practice (EBP) (Yoo et al., 2019).

The survey findings show that the organization is ready to participate and adopt evidence-based practice. Nurses at the Managed Care organization are knowledgeable about EPB and are adequately equipped with EBP skills. The management and leadership in the organization are supportive of EBP and provide the necessary resources and finances to support EBP projects. The survey also identified that there are nurse scientists in the organization who generate evidence and actively search and locate research evidence. There are nurse practitioners who mentor nurses about EBP and support the implementation of EBP projects. There is the availability of computers, electronic devices, and the internet, where the staff can effectively search for evidence to support EBP.

However, the survey identified barriers to EBP, where some staff members were not ready to embrace changes and innovations due to time limitations and busy schedules. The staff members were generally resistant to changes. The resistance is attributable to heavy workload, and thus the staff may lack time to participate in EBP projects. This barrier can be addressed by using change champions to educate the staff members about the importance of EBP changes. Secondly, the organizational leadership should consider recruiting more staff members to reduce the workload among the staff. (Harper et al., 2017).

References

Harper M, Gallagher-Ford L, Warren J, Troseth M, Sinnott L &Thomas B. (2017). Evidence-Based Practice and US Healthcare Outcomes. Journal for Nurses in Professional Development. 33(4), 170-179.

Yoo, J. Y., Kim, J. H., Kim, J. S., Kim, H. L., & Ki, J. S. (2019). Clinical nurses’ beliefs, knowledge, organizational readiness, and level of implementation of evidence-based practice: The first step to creating an evidence-based practice culture. PloS one, 14(12), e0226742. https://doi.org/10.1371/journal.pone.0226742

Section B: Proposal/Problem Statement and Literature Review

Proposal/Problem Statement

Diabetes is the leading cause of adult-onset blindness, chronic kidney disease, and the amputation of lower limbs. The condition is also associated with increased risk of stroke and heart disease, and evidence indicates that diabetes is the 7^th leading cause of death within the US (Yeoh et al., 2018). Moreover, diabetes is associated with high healthcare costs (about $327 billion annually), and financial burden is projected to increase exponentially with the increase of the aging population and increased life expectancy (Yeoh et al., 2018).

The geriatric population with type 1 diabetes (TID) keeps on rising, and predisposes older adults to hypoglycemia, especially when diabetes is long-lasting. Hypoglycemia is associated with aspects such as altered mental status, loss of consciousness, and seizures, which can be fatal (Yeoh et al., 2018). However, the problem of older adults with TID has not been adequately addressed. Lowering hypoglycemia is a vital component of the management of TID in the geriatric population because the majority of older adults have difficulties in identifying and recognizing symptoms and signs of hypoglycemia or cognitive impairment. Evidence shows that older adults using continuous glucose monitoring (CGM) devices can reduce the rate of hemoglobin A1c and thus reduce the rate of hypoglycemia and severe hypoglycemic incidents. Therefore, the proposed study aims to find out if the utilization of CGM can lower hypoglycemia in older adults with TID. The CGM device continuously measures the level of blood glucose and provides real-time values of the blood sugar levels, trends direction, and notifies the patients when the glucose level increases to high levels or drops too low levels (Yeoh et al., 2018). Type 1 Diabetes—A Clinical Perspective Essay.

Literature Review

According to Litchman & Allen (2017), people with TID are living longer, and thus there is a high number of older adults with the condition. The risk of fatal or severe hypoglycemia allied to taking insulin rises with age, and thus older adults are likely to experience incidents of fatal or severe hypoglycemia. This is supported by Janapala et al. (2019), who explains that the risk of hypoglycemia significantly increases among older adults because of decreased awareness to recognize warning signs of hypoglycemia, decreased counterregulatory response, as well as altered psychomotor performance. A study carried out by Azhar et al. (2020) demonstrated that type 1 diabetes in the geriatric population increases the risk of cerebrovascular and cardiovascular events, falls, hospitalization, seizures, and visits to the emergency department. It is challenging to diagnose hypoglycemic events in older adults who are mostly not aware of their hypoglycemia and can fail to be detected by the self-monitored blood glucose (SMBG) measurements.

Despite the high risk of hypoglycemia and other complications for older adults with T1D, few studies have tackled the use of technologies in the geriatric population. This can be attributed to the mistaken belief that the geriatric population lacks the knowhow to handle the advanced technologies. However, some studies have shown that CGM improves glycemic control and safety in older adults with T1D (Ruedy et al., 2017).

The benefits of CGM in people with T1D have been demonstrated in several studies, in comparison to the routine glucose testing. Therefore, CGM is now an essential tool for the management of T1D. However, Ruedy et al. (2017) explain that the use of CGM in T1D is limited, and the associate benefits of CGM have not been established. The management of diabetes in the geriatric population is also a challenge due to the polypharmacy and the multiple comorbidities in this population. Therefore, CGM equips individuals with diabetes with the ability to personalize diabetes management. Moreover, even though evidence shows that lowering HbA1c to <7% through comprehensive glycemic control reduces the risk of complications such as microvascular complications; this is associated with an elevated risk of hypoglycemia (Chehregosha et al., 2019). Since the continuous glucose monitoring devices are equipped with features like hypoglycemia alarms and trends, and also because the CGM devices are very accurate, CGMs can effectively lower the risk of severe hypoglycemic incidents among the older adults (Azhar et al., 2020). Type 1 Diabetes—A Clinical Perspective Essay.

References

Azhar, A., Gillani, S. W., Mohiuddin, G., & Majeed, R. A. (2020). A systematic review of the clinical implication of continuous glucose monitoring in diabetes management. Journal of Pharmacy and Bioallied Sciences, 12(2), 102.

Chehregosha, H., Khamseh, M. E., Malek, M., Hosseinpanah, F., & Ismail-Beigi, F. (2019). A View Beyond HbA1c: Role of Continuous Glucose Monitoring. Diabetes therapy: research, treatment, and education of diabetes and related disorders, 10(3), 853–863. https://doi.org/10.1007/s13300-019-0619-1

Janapala, R. N., Jayaraj, J. S., Fathima, N., Kashif, T., Usman, N., Dasari, A., Jahan, N., & Sachmechi, I. (2019). Continuous Glucose Monitoring Versus Self-monitoring of Blood Glucose in Type 2 Diabetes Mellitus: A Systematic Review with Meta-analysis. Cureus, 11(9), e5634. https://doi.org/10.7759/cureus.5634.

Litchman, M. L., & Allen, N. A. (2017). Real-time continuous glucose monitoring facilitates feelings of safety in older adults with type 1 diabetes: a qualitative study. Journal of diabetes science and technology, 11(5), 988-995.

Ruedy, K. J., Parkin, C. G., Riddlesworth, T. D., & Graham, C. (2017). Continuous glucose monitoring in older adults with type 1 and type 2 diabetes using multiple daily injections of insulin: results from the DIAMOND trial. Journal of Diabetes Science and Technology, 11(6), 1138-1146.

Yeoh, E., Lim, B. K., Fun, S., Tong, J., Yeoh, L. Y., Sum, C. F., … & Lim, S. C. (2018). Efficacy of self‐monitoring of blood glucose versus retrospective continuous glucose monitoring in improving glycaemic control in diabetic kidney disease patients. Nephrology, 23(3), 264-268.

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).

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.

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. For instance, increasing taxes on tobacco sales can improve the health of diabetic patients by reducing the number of individuals using tobacco. 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.

Access to and quality of health services can affect the health of diabetic patients. The limited access or lack of access to health services significantly 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. The genetic background of the patient is an essential component in the destruction of beta cells. Type 1 diabetes 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%. Type 1 Diabetes—A Clinical Perspective Essay.

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.

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.

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.

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.

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. 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.

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.

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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). Type 1 Diabetes—A Clinical Perspective Essay.

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. 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).

References

American Diabetes Association. (n.d.). Medicare. Retrieved from https://www.diabetes.org/resources/health-insurance/medicare.

Charleer, S., Mathieu, C., Nobels, F., Block, C., Radermecker, P. R., Hermans, P. M., &Gillard, P., (2018).  Journal of Clinical Endocrinology Metabolism, 103(3), 1224–1232. Doi: 10.1210/jc.2017-02498.

Center for Disease Control and Prevention. (2020). National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States Background. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.

Danne, T., Nimri, R., Battelino, T., Bergenstal, M. R., Close, L. K., DeVries, H. J., Garg, S., Heinemann, L., … Philip, M., (2017). International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care, 40, 1631–1640. https://doi.org/10.2337/dc17-1600.

Glantz, N. M., Duncan, I., Ahmed, T., Fan, L., Reed, B. L., Kalirai, S., & Kerr, D., (2019). Racial and Ethnic Disparities in the Burden and Cost of Diabetes for US Medicare Beneficiaries. Health Equity, 3(1), 211–218. https://doi.org/10.1089/heq.2019.0004

Janapala, R. N., Jayaraj, J. S., Fathima, N., Kashif, T., Usman, N., Dasari, A., … Sachmechi, I. (2019). Continuous Glucose Monitoring Versus Self-Monitoring of Blood Glucose in Type 2 Diabetes Mellitus: A Systematic Review with Meta-analysis. Cureus, 11(9). https://doi.org/10.7759/cureus.5634.

Rodbard, D. (2017). Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes. Diabetes Technology & Therapeutics, 19(S3), S-25-S-37. https://doi.org/10.1089/dia.2017.0035.

Texas Demographic Center. (2018). Diabetes in Texas. Retrieved from https://demographics.texas.gov/Resources/publications/2018/2018_12_17_DiabetesProfile.pdf.

Welsh B. J., (2018). Role of Continuous Glucose Monitoring in Insulin-Requiring Patients with Diabetes. Diabetes Technology & Therapeutics, 20(S2), s2-45-s2-49. http://doi.org/10.1089/dia.2018.0100.

Typing Template for APA Papers: A Sample of Proper Formatting for the APA 6^th Edition

This is an electronic template for papers written in APA style (American Psychological Association, 2010). The purpose of the template is to help the student set the margins and spacing. Margins are set at 1 inch for top, bottom, left, and right. The type is left-justified only—that means the left margin is straight, but the right margin is ragged. Each paragraph is indented five spaces. It is best to use the tab key to indent. The line spacing is double throughout the paper, even on the reference page. One space is used after punctuation at the end of sentences. The font style used in this template is Times New Roman and the font size is 12.

First Heading

The heading above would be used if you want to have your paper divided into sections based on content. This is the first level of heading, and it is centered and bolded with each word of four letters or more capitalized. The heading should be a short descriptor of the section. Note that not all papers will have headings or subheadings in them. Type 1 Diabetes—A Clinical Perspective Essay.

First Subheading

The subheading above would be used if there are several sections within the topic labeled in a heading. The subheading is flush left and bolded, with each word of four letters or more capitalized.

Second Subheading

APA dictates that you should avoid having only one subsection heading and subsection within a section. In other words, use at least two subheadings under a main heading, or do not use any at all.

When you are ready to write, and after having read these instructions completely, you can delete these directions and start typing. The formatting should stay the same. However, one item that you will have to change is the page header, which is placed at the top of each page along with the page number. The words included in the page header should be reflective of the title of your paper, so that if the pages are intermixed with other papers they will be identifiable. When using Word 2003, double click on the words in the page header. This should enable you to edit the words. You should not have to edit the page numbers.

In addition to spacing, APA style includes a special way of citing resource articles. See the APA manual for specifics regarding in-text citations. The APA manual also discusses the desired tone of writing, grammar, punctuation, formatting for numbers, and a variety of other important topics. Although the APA style rules are used in this template, the purpose of the template is only to demonstrate spacing and the general parts of the paper. The student will need to refer to the APA manual for other format directions. GCU has prepared an APA Style Guide available in the Student Writing Center for additional help in correctly formatting according to APA style.

The reference list should appear at the end of a paper (see the next page). It provides the information necessary for a reader to locate and retrieve any source you cite in the body of the paper. Each source you cite in the paper must appear in your reference list; likewise, each entry in the reference list must be cited in your text. A sample reference page is included below; this page includes examples of how to format different reference types (e.g., books, journal articles, information from a website). The examples on the following page include examples taken directly from the APA manual. Type 1 Diabetes—A Clinical Perspective Essay.

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

Daresh, J. C. (2004). Beginning the assistant principalship: A practical guide for new school administrators. Thousand Oaks, CA: Corwin.

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients. Health Psychology, 24, 225-229. doi:10.1037/0278-6133.24.2.225

U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (2003). Managing asthma: A guide for schools (NIH Publication No. 02-2650). Retrieved from http://www.nhlbi.nih.gov/
health/prof/asthma/asth_sch.pdf .Type 1 Diabetes—A Clinical Perspective Essay.