Community Program Improves Quality of Life and Self-Management in Older Adults with Diabetes Mellitus and Comorbidity

Maureen Markle-Reid, Jenny Ploeg, Kimberly D Fraser, Kathryn A Fisher, Amy Bartholomew, Lauren E Griffith, John Miklavcic, Amiram Gafni, Lehana Thabane, Ross Upshur, Maureen Markle-Reid, Jenny Ploeg, Kimberly D Fraser, Kathryn A Fisher, Amy Bartholomew, Lauren E Griffith, John Miklavcic, Amiram Gafni, Lehana Thabane, Ross Upshur

Abstract

Objectives: To compare the effect of a 6-month community-based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities.

Design: Multisite, single-blind, parallel, pragmatic, randomized controlled trial.

Setting: Four communities in Ontario, Canada.

Participants: Community-dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159).

Intervention: Client-driven, customized self-management program with up to 3 in-home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation.

Measurements: Quality-of-life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES-D-10), Summary of Diabetes Self-Care Activities (SDSCA), Self-Efficacy for Managing Chronic Disease, and healthcare costs.

Results: Morbidity burden was high (average of eight comorbidities). Intention-to-treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI) = 0.28-5.09, P = .03), SDSCA (mean difference = 3.79, 95% CI = 1.02-6.56, P = .01), and CES-D-10 (mean difference = -1.45, 95% CI = -0.13 to -2.76, P = .03). No group differences were seen in PCS score, anxiety, self-efficacy, or total healthcare costs.

Conclusion: Participation in a 6-month community-based intervention improved quality of life and self-management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs.

Keywords: community-based program; comorbidity; older adults; self-management; type 2 diabetes mellitus.

© 2017 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Mean difference in older adults’ quality of life as measured according to physical functioning (Medical Outcomes Study 12‐item Short‐Form Survey (SF‐12) Physical Component Summary (PCS)) and mental functioning (SF‐12 Mental Component Summary (MCS)) scores from baseline to 6 months for 5 subgroups (age, sex, number of chronic conditions, self‐efficacy, diabetes duration).

References

    1. Diabetes Fact Sheet . World Health Organization Media Centre [on‐line]. Available at Accessed March 3, 2017.
    1. World Health Organization . Definition, Diagnosis and Classification of Diabetes Mellitus and Its Complications: Report of a WHO Consultation. Part 1, Diagnosis and Classification of Diabetes Mellitus. World Health Organization Department of Noncommunicable Disease Surveillance, 1999. [on‐line]. Available at Accessed March 3, 2017.
    1. Kirkman M, Briscoe VJ, Clark N et al. Diabetes in older adults: A consensus report. J Am Geriatr Soc 2012;60:2342–2356.
    1. Sinnige J, Braspenning J, Schellevis F et al. The prevalence of disease clusters in older adults with multiple chronic diseases: A systematic literature review. PLoS ONE 2013;8:e79641.
    1. Willi C, Bodenmann P, Ghali WA et al. Active smoking and the risk of type 2 diabetes: A systematic review and meta‐analysis. JAMA 2007;298:2654–2664.
    1. Fisher K, Griffith L, Gruneir A et al. Comorbidity and its relationship with health service use and cost in community‐living older adults with diabetes: A population‐based study in Ontario, Canada. Diabetes Res Clin Pract 2016;122:113–123.
    1. Usitupa M, Tuomilehto J, Puska P. Are we really active in the prevention of obesity and type 2 diabetes at the community level? Nutr Metab Cardiovasc Dis 2011;21:380–389.
    1. Knowler WC, Barrett‐Connor E, Fowler SE et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New Engl J Med 2002;346:393–403.
    1. Tuomilehto J, Schwarz P, Lindström J. Long‐term benefits from lifestyle interventions for type 2 diabetes prevention. Diabetes Care 2011;34(Suppl 2):S210–S214.
    1. Yoon U, Kwok LL, Magkidis A. Efficacy of lifestyle interventions in reducing diabetes incidence in patients with impaired glucose tolerance: A systematic review of randomized controlled trials. Metabolism 2013;62:303–314.
    1. Diabetes Prevention Program Research Group , Knowler WC, Fowler SE et al. 10‐year follow‐up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:1677–1686.
    1. Busetto L, Luijkx KG, Elissen AM et al. Intervention types and outcomes of integrated care for diabetes mellitus type 2: A systematic review. J Eval Clin Pract 2016;22:299–310.
    1. Smith SM, Wallace E, O'Dowd T et al. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2016;3:CD006560.
    1. Whittemore R. A systematic review of translational reseasrch on the Diabetes Prevention Program. Transl Behav Med 2011;1:480–491.
    1. Katula JA, Vitolins MZ, Morgan TM et al. The Healthy Living Partnerships to Prevent Diabetes Study: 2‐year outcomes of a randomized controlled trial. Am J Prev Med 2013;44(4 Suppl 4):S324–S332.
    1. Cruz‐Jentoft AJ, Carpena‐Ruiz M, Montero‐Errasquin B et al. Exclusion of older adults from ongoing clinical trials about type 2 diabetes mellitus. J Am Geriatr Soc 2013;61:734–738.
    1. IDF Diabetes Atlas, 6th Ed International Diabetes Federation [on‐line]. Available at Accessed March 3, 2017.
    1. Sakharova OV, Inzucchi S. Treatment of diabetes in the elderly. Addressing its complexities in this high‐risk group. Postgrad Med 2005;118:19–26, 29.
    1. Markle‐Reid M, Ploeg J, Fraser KD et al. The ACHRU‐CPP versus usual care for older adults with type 2 diabetes and multiple chronic conditions and their family caregivers: Study protocol for a pragmatic randomized controlled trial. Trials 2017;18:1–16.
    1. Loudon K, Treweek S, Sullivan F et al. The PRECIS‐2 tool: Designing trials that are fit for purpose. BMJ 2015;350:h2147.
    1. Markle‐Reid M, Ploeg J, Fisher K et al. The Aging, Community and Health Research Unit‐Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: A feasibility study. Pilot Feasibility Stud 2016;2:24.
    1. Lavis JN, ed. Ontario's Health System: Key Insights for Engaged Citizens, Professionals and Policymakers. Hamilton: McMaster Health Forum, 2016. [on‐line]. Available at Accessed March 3, 2017.
    1. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23:433–441.
    1. Cochran J, Conn VS. Meta‐analysis of quality of life outcomes following diabetes self‐management training. Diabetes Educ 2008;34:815–823.
    1. Heinrich E, Schaper NC, de Vries NK. Self‐management interventions for type 2 diabetes: A systematic review. European Diabetes Nursing 2010;7:71–76.
    1. Cezaretto A, Ferreira SR, Sharma S et al. Impact of lifestyle interventions on depressive symptoms in individuals at‐risk of, or with, type 2 diabetes mellitus: A systematic review and meta‐analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2016;26:649–662.
    1. Ware J, Kosinski M, Keller SD. A 12 item short form health survey: Construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220–233.
    1. Irwin M, Artin KH, Oxman MD. Screening for depression in the older adult: Criterion validity of the 10‐item Center for Epidemiological Studies Depression Scale (CES‐D). Arch Intern Med 1999;159:1701–1704.
    1. Löwe B, Decker O, Müller S et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD‐7) in the general population. Med Care 2008;46:266–274.
    1. Lorig KR, Sobel DS, Ritter PL et al. Effect of self‐management program on patients with chronic disease. Eff Clin Pract 2001;4:256–262.
    1. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self‐care activities measure: Results from 7 studies and a revised scale. Diabetes Care 2000;23:943–950.
    1. Browne G, Gafni A, Roberts J. Approach to the Measurement of Resource Use and Costs (Working Paper S06–01). Hamilton, Ontario, Canada: McMaster University, System‐Linked Research Unit on Health and Social Service Utilization, 2006.
    1. Markle‐Reid M, Gafni A, Ploeg J et al. Health and Social Service Utilization Costing Manual: Ontario. Hamilton, Ontario, Canada: McMaster University, School of Nursing, Aging, Community and Health Research Unit, 2016.
    1. Browne G, Roberts J, Gafni A et al. Economic evaluations of community‐based care: Lessons from twelve studies in Ontario. J Eval Clin Pract 1999;5:367–385.
    1. Browne G, Roberts J, Gafni A et al. The costs and effects of addressing the needs of vulnerable populations: Results of 10 years of research. Can J Nurs Res 2001;33:65–76.
    1. Drummond M, Weatherly H, Ferguson B. Economic evaluation of health interventions. BMJ 2008;337:a1204.
    1. Maruish ME, ed. User's Manual for the SF‐12v2 Health Survey, 3rd Ed Lincoln, RI: QualityMetric Inc, 2012.
    1. Spinal Cord Injury Research Institute . Center for Epidemiological Studies Depression Scale (CES‐D and CES‐D‐10). SCIRE professional [on‐line]. Available at Accessed March 3, 2017.
    1. Oregon Research Institute . Summary of Diabetes Self‐Care Activities (SDSCA): FAQs. Oregon Research Institute [on‐line]. Available at Accessed March 3, 2017.
    1. Thabane L, Mbuagbaw L, Zhang S et al. A tutorial on sensitivity analyses in clinical trials: The what, why, when and how. BMC Med Res Methodol 2013;13:92.
    1. He Y. Missing data analysis using multiple imputation: Getting to the heart of the matter. Circ Cardiovasc Qual Outcomes 2010;3:98–105.
    1. Pocock SJ, McMurray JJ, Collier TJ. Statistical controversies in reporting of clinical trials. J Am Coll Cardiol 2015;66:2648–2662.
    1. Galdas P, Fell J, Bower P et al. The effectiveness of self‐management support interventions for men with long‐term conditions: A systematic review and meta analysis. BMJ Open 2015;5:e006620.
    1. Ontario Ministry of Health and Long Term Care . Health Data Branch Web Portal [on‐line]. Available at Accessed April 6, 2017.
    1. Mihaylova B, Briggs A, O'Hagan A et al. Review of statistical methods for analysing healthcare resources and costs. Health Econ 2011;20:897–916.
    1. McCrum‐Gardner E. Which is the correct statistical test to use? Br J Oral Maxillofac Surg 2008;46:38–41.
    1. Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada . Tri‐Council Policy Statement: Ethical Conduct for Research Involving Humans [on‐line]. Available at Accessed November 15, 2016.
    1. Andresen EM, Malmgren JA, Carter WB et al. Screening for depression in well older adults: Evaluation of a short‐form of the CES‐D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med 1994;10:77–84.
    1. Kroenke K, Spitzer RL, Williams JB et al. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317–325.
    1. Kolappa K, Henderson DC, Kishore SP. No physical health without mental health: Lessons unlearned? Bull World Health Organ 2013;91:3–3A.
    1. Bayliss EA, Bonds DE, Boyd CM et al. Understanding the context of health for persons with multiple chronic conditions: Moving from what is the matter to what matters. Ann Fam Med 2014;12:260–269.
    1. Graves H, Garrett C, Amiel SA et al. Psychological skills training to support diabetes self‐management: Qualitative assessment of nurses’ experiences. Prim Care Diabetes 2016;10:376–382.
    1. Peyrot M, Rubin RR, Lauritzen T et al. Psychosocial problems and barriers to improved diabetes management: Results of the Cross‐National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabet Med 2005;22:1379–1385.
    1. Lloyd CE, Gill P, Stone M. Psychological care in a national health service: Challenges for people with diabetes. Curr Diab Rep 2013;13:894–899.
    1. Gabbay RA, Añel‐Tiangco RM, Dellasega C et al. Diabetes nurse case management and motivational interviewing for change (DYNAMIC): Results of a 2‐year randomized controlled pragmatic trial. J Diabetes 2013;5:349–357.
    1. Chen SM, Creedy D, Lin HS et al. Effects of motivational interviewing intervention on self‐management, psychological and glycemic outcomes in type 2 diabetes: A randomized controlled trial. Int J Nurs Stud 2012;49:637–644.
    1. Lloyd CE, Hermanns N, Nouwen A et al. The epidemiology of depression and diabetes In: Katon W, Maj M, Sartorius N, eds. Depression and Diabetes. Chichester: JohnWiley & Sons Ltd, 2010.
    1. Ontario Ministry of Health and Long Term Care . Patients First: A Proposal to Strengthen Patient‐Centred Health Care in Ontario: Discussion Paper. Ottawa, Ontario, Canada: Ontario Ministry of Health and Long‐Term Care, 2015. [on‐line]. Available at Accessed March 3, 2017.
    1. Wyatt KD, Stuart LM, Brito JP et al. Out of context: Clinical practice guidelines and patients with multiple chronic conditions: A systematic review. Med Care 2014;52(Suppl 3):S92–S100.
    1. Moore GF, Audery S, Barker M et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ 2015;350:h1258.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren