Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: a pragmatic randomized controlled trial

John J Miklavcic, Kimberly D Fraser, Jenny Ploeg, Maureen Markle-Reid, Kathryn Fisher, Amiram Gafni, Lauren E Griffith, Sandra Hirst, Cheryl A Sadowski, Lehana Thabane, Jean A C Triscott, Ross Upshur, John J Miklavcic, Kimberly D Fraser, Jenny Ploeg, Maureen Markle-Reid, Kathryn Fisher, Amiram Gafni, Lauren E Griffith, Sandra Hirst, Cheryl A Sadowski, Lehana Thabane, Jean A C Triscott, Ross Upshur

Abstract

Background: Type II diabetes mellitus (T2DM) affects upwards of 25% of Canadian older adults and is associated with high comorbidity and burden. Studies show that lifestyle factors and self-management are associated with improved health outcomes, but many studies lack rigour or exclude older adults, particularly those with multimorbidity. More evidence is needed on the effectiveness of community-based self-management programs in older adults with T2DM and multimorbidity. The study purpose is to evaluate the effect of a community-based intervention versus usual care on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with T2DM and 2 or more comorbidities.

Methods: Community-living older adults with T2DM and two or more chronic conditions were recruited from three Primary Care Networks (PCNs) in Alberta, Canada. Participants were randomly allocated to the intervention or control group in this pragmatic randomized controlled trial comparing the intervention to usual care. The intervention involved up to three in-home visits, a monthly group wellness program, monthly case conferencing, and care coordination. The primary outcome was physical functioning. Secondary outcomes included mental functioning, anxiety, depressive symptoms, self-efficacy, self-management, and the cost of healthcare service use. Intention-to-treat analysis was performed using ANCOVA modeling.

Results: Of 132 enrolled participants (70-Intervention, 62-Control), 42% were 75 years or older, 55% were female, and over 75% had at least six chronic conditions (in addition to T2DM). No significant group differences were seen for the baseline to six-month change in physical functioning (mean difference: -0.74; 95% CI: - 3.22, 1.74; p-value: 0.56), mental functioning (mean difference: 1.24; 95% CI: - 1.12, 3.60; p-value: 0.30), or other secondary outcomes..

Conclusion: No significant group differences were seen for the primary outcome, physical functioning (PCS). Program implementation, baseline differences between study arms and chronic disease management services that are part of usual care may have contributed to the modest study results. Fruitful areas for future research include capturing clinical outcome measures and exploring the impact of varying the type and intensity of key intervention components such as exercise and diet.

Trial registration: NCT02158741 Date of registration: June 9, 2014.

Keywords: Aging; Community-based program; Comorbidity; Older adults; Self-management; Type 2 diabetes mellitus.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study Flow Diagram
Fig. 2
Fig. 2
Group Differences in Outcomes (Multiple Imputation, n = 132, 5 imputations)
Fig. 3
Fig. 3
Interpreting 95% Confidence Intervals for PCS and MCS (“Inconclusive” Findings). Note: MID: minimally important difference

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