Evaluation of a Community-wide Diabetes Prevention Program

This thesis is an evaluation of the effectiveness of a community-wide diabetes prevention program conducted in three Divisions of General Practice in Sydney, Australia. The aims were to assess whether translation of diabetes prevention programs was feasible in real-life settings and whether results achieved were comparable with those of randomised trials on which this intervention was based. Its primary goals were to assess whether the lifestyle intervention could increase participation in moderate-to-vigorous physical activity to 210 minutes per week, reduce total fat and saturated fat consumption to 30% and 10% of total daily energy intake, increase fibre consumption to 15 g/1,000 kcal/day, and lead to 5% weight loss over one year. The background section covers the physiopathology of type 2 diabetes, its risk factors, and the available population screening tools to identify people at risk. The growing morbidity and mortality burden, the economic implications of this public health problem, and the importance and feasibility of preventing or delaying the onset by intervening in the precursor stages are then summarised. Evidence for preventability is examined through a literature review of lifestyle interventions in research settings comprising highly structured and closely monitored physical activity and dietary programs under controlled conditions. Examples of the effectiveness of translation of randomised controlled trials (RCTs) into less stringent programs in community settings such as workplaces, churches, indigenous communities and whole-of-country initiatives are presented. A systematic review and meta-analysis of effectiveness of the lifestyle approaches in routine clinical practice supplements the evidence for application of prevention principles in real-life settings. The main chapters of the thesis centre on process and impact evaluation of the semi-structured Sydney-based intervention, which recruited 1,250 participants from the mainstream Australian 29 public using general practitioner services in the study area, who were followed for 12 months. The intervention’s goals aligned with those of the Finnish Diabetes Prevention Program but with less stringent entry criteria and less intensive intervention components delivered by purpose-trained lifestyle officers. The Program included an initial individual assessment and coaching session, three subsequent group sessions in the following three months, then three follow-up coaching calls at three, six and nine months. A final assessment at one year, using the same objective and self-reported measures as in the initial assessment, captured changes in body weight, physical activity and dietary habits. The process evaluation showed that it is feasible and effective to use targeted screening to identify and recruit high-risk individuals into a free-of-charge program in the general practice setting, however a quarter of participants were lost to follow-up by one year. While minor variations in aspects of the Program were required to meet local need, Program fidelity in delivering components, and self-reported adherence to diet and physical activity was high. Using a before-after study design, the impact evaluation measured 1-year changes in key Program parameters in relation to baseline. These comprised: measured weight, waist circumference, BMI, and glycaemia measurements; and self-reported dietary intake and structured physical activity, using a 3-day food record and the Physical Activity Scale for the Elderly (PASE) questionnaire, respectively. The main findings at 12 months for the 586 completers as at December 2010 were: a mean weight loss of 2.1 kg; waist circumference reduction of 2.5 cm; no significant change in glycaemia; 3% reduction of fat and saturated fat intake; 16% increase in fibre intake; and mean increase in moderate-to-vigorous physical activity of 13.7 minutes/week. All these changes were smaller than those achieved by the RCTs in research settings, most likely due to the lower intensity and monitoring of the Sydney intervention. Weight loss and waist circumference reductions were similar for participants in 30 group session and those who received telephone-only coaching. Diabetes incidence was 1% at the end of the first year. An economic appraisal of the Program implementation completes the evaluation. A cost of A$400 per kg lost among people achieving the weight goal was estimated on Program completion, but the cost was double for the overall group that included non weight losers. The cost of achieving the physical activity goal and the dietary goals was not feasible or sustainable with resources available in routine clinical settings. The costs per outcome were similar for participants not attending group sessions, who received only telephone coaching. Hence it is worth exploring this less labour-intensive modality if a general practice based Program were to be delivered as routine preventive care. In sum, the evaluation of this community-wide diabetes prevention program showed that translation of diabetes prevention programs into routine practice, while feasible at less intensive levels than in RCTs, has a somewhat lower effect on diabetes risk reduction and it can still be a financial burden in clinical settings. However, given the potential for population-wide benefit, the effectiveness of alternative delivery modes, number and duration of program components and more targeted patient sub-groups should be investigated.The Sydney Diabetes Prevention Program was funded by New South Wales Health as part of the Australian Better Health Initiative. Financial contribution and other in-kind support were provided by the Sydney South West Area Health Service and the Australian Diabetes Council -NSW

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

© 2018, The Author(s). Abstract: To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients. Methods: Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy. Results: 2493 patients, with median age 78–80 years (DK–Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7–8.6 vs. 5.8 95% CI 5.6–5.9) and Danish mean 7.1 (95% CI 6.6–7.5 vs. 5.5 95% CI 5.4–5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL’s accuracy was only modest for in-hospital death prediction in either setting. Conclusions: The modified CriSTAL tool (with CFS instead of Fried’s frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician’s confidence in initiating earlier end-of-life discussions

The Sydney Diabetes Prevention Program: A community-based translational study

Background. Type 2 diabetes is a major public health problem in Australia with prevalence increasing in parallel with increasing obesity. Prevention is an essential component of strategies to reduce the diabetes burden. There is strong and consistent evidence from randomised controlled trials that type 2 diabetes can be prevented or delayed through lifestyle modification which improves diet, increases physical activity and achieves weight loss in at risk people. The current challenge is to translate this evidence into routine community settings, determine feasible and effective ways of delivering the intervention and providing on-going support to sustain successful behavioural changes. Methods/Design. The Sydney Diabetes Prevention Program (SDPP) is a translational study which will be conducted in 1,550 participants aged 50-65 years (including 100 indigenous people aged 18 years and older) at high risk of future development of diabetes. Participants will be identified through a screening and recruitment program delivered through primary care and will be offered a community-based lifestyle modification intervention. The intervention comprises an initial individual session and three group sessions based on behaviour change principles and focuses on five goals: 5% weight loss, 210 min/week physical activity (aerobic and strength training exercise), limit dietary fat and saturated fat to less than 30% and 10% of energy intake respectively, and at least 15 g/1000 kcal dietary fibre. This is followed by 3-monthly contact with participants to review progress and offer ongoing lifestyle advice for 12 months. The effectiveness and costs of the program on diabetes-related risk factors will be evaluated. Main outcomes include changes in weight, physical activity, and dietary changes (fat, saturated fat and fibre intake). Secondary outcomes include changes in waist circumference, fasting plasma glucose, blood pressure, lipids, quality of life, psychological well being, medication use and health service utilization. Discussion. This translational study will ascertain the reach, feasibility, effectiveness and cost-effectiveness of a lifestyle modification program delivered in a community setting through primary health care. If demonstrated to be effective, it will result in recommendations for policy change and practical methods for a wider community program for preventing or delaying the onset of type 2 diabetes in high risk people. © 2010 Colagiuri et al; licensee BioMed Central Ltd

What impact does nursing care left undone have on patient outcomes? Review of the literature

AIMS AND OBJECTIVES: Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes. BACKGROUND: A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear. DESIGN: Systematic review. METHODS: We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses' aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review. RESULTS: Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged. CONCLUSIONS: The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self-reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required. RELEVANCE TO CLINICAL PRACTICE: Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses' reports of missed care and consider routine monitoring as a quality and safety indicator

Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis

<p>Abstract</p> <p>Background</p> <p>Many lifestyle interventions for patients with prediabetes or type 2 diabetes mellitus (T2DM) have been investigated in randomised clinical trial settings. However, the translation of these programmes into primary care seems challenging and the prevalence of T2DM is increasing. Therefore, there is an urgent need for lifestyle programmes, developed and shown to be effective in real-world primary care. We evaluated a lifestyle programme, commissioned by the Dutch government, for patients with prediabetes or type 2 diabetes in primary care.</p> <p>Methods</p> <p>We performed a retrospective comparative medical records analysis using propensity score matching. Patients with prediabetes or T2DM were selected from ten primary healthcare centres. Patients who received the lifestyle intervention (n = 186) were compared with a matched group of patients who received usual care (n = 2632). Data were extracted from the electronic primary care records. Propensity score matching was used to control for confounding by indication. Outcome measures were exercise level, BMI, HbA1c, fasting glucose, systolic and diastolic blood pressure, total cholesterol, HDL and LDL cholesterol and triglycerides and the follow-up period was one year.</p> <p>Results</p> <p>There was no significant difference at follow-up in any outcome measure between either group. The reduction at one year follow-up of HbA1c and fasting glucose was positive in the intervention group compared with controls, although not statistically significant (-0.12%, <it>P </it>= 0.07 and -0.17 mmol/l, <it>P </it>= 0.08 respectively).</p> <p>Conclusions</p> <p>The effects of the lifestyle programme in real-world primary care for patients with prediabetes or T2DM were small and not statistically significant. The attention of governments for lifestyle interventions is important, but from the available literature and the results of this study, it must be concluded that improving lifestyle in real-world primary care is still challenging.</p

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities. Aims The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice. Methods We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff. Findings Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely. Future Research Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc

Factors that influence nurses' assessment of patient acuity and response to acute deterioration.

BACKGROUND: nurses play a crucial role in the early recognition and management of the deteriorating patient. They are responsible for the care they provide to their patients, part of which is the monitoring of vital signs (blood pressure, pulse, respiratory rate and temperature), which are fundamental in the surveillance of deterioration. The aim of this study was to discover what factors influence how nurses assess patient acuity and their response to acute deterioration. METHODS: a generic qualitative approach was used. Some 10 nurses working in an acute NHS trust were interviewed using a semi- structured approach, with equal representation from medical and surgical inpatient wards. RESULTS: the main themes identified were collegial relationships, intuition, and interpretation of the MEWS system (Modified Early Warning Score). Collegial relationships with the medical staff had some influence on the nurses' assessment, as they tended to accept the medical peers' assessment as absolute, rather than their own assessment. It was also highlighted that nurses relied on the numerical escalation of the MEWS system to identify the deteriorating patient, instead of their own clinical judgement of the situation. Interestingly, the nurses found no difficulty in escalating the patient's care to medical staff when the patient presented with a high MEWS score. The difficulty arose when the MEWS score was low-the participants found it challenging to authenticate their findings. CONCLUSION: this study has identified several confounding factors that influence the ways in which nurses assess patient acuity and their response to acute deterioration. The information provides a crucial step forward in identifying strategies to develop further training

Behavioural Lifestyle Intervention Study (BLIS) in patients with type 2 diabetes in the United Arab Emirates: A randomized controlled trial

BACKGROUND: Lifestyle modification is a cornerstone of the management of type 2 diabetes. However, in the United Arab Emirates, a country where type 2 diabetes is highly prevalent, non-compliance with a healthy lifestyle has been reported in many diabetic Emirati patients. The use of behavioural theories in lifestyle counselling is believed to facilitate behavioural changes, nevertheless, there are no published data regarding the use of structured behavioural lifestyle programmes tailored to suit Emirati culture. The primary objective of this study was to develop a behavioural lifestyle programme and to evaluate its effectiveness in improving glycaemic control in Emirati patients with type 2 diabetes. METHODS: The Behavioural Lifestyle Intervention Study (BLIS) was a translational randomized controlled trial in which patients (n = 35) were randomly assigned to the intervention or control group. Patients in the intervention group went through a six-month behavioural lifestyle programme composed of 8 sessions, whereas patients in the control group received standard care. Cognitive behavioural theory was the underpinning theory for the lifestyle intervention. HbA1c levels were the trial’s primary outcome measure, and the main dietary factor targeted for change was carbohydrate intake. They were measured at baseline, 3 months and 6 months and were assessed using one-way ANOVA at a significance level of P < 0.05. All of the patients were then followed up at 1 year on all outcome measures. RESULTS: At 6 months, the HbA1c levels of the patients (n = 18) in the intervention group were significantly reduced (−1.56 ± 1.81, P < 0.05), whereas no significant change was observed in the patients of the control group. Similarly, both carbohydrate intake from cereals and total carbohydrate intake (in grams) were reduced (p < 0.05) in the intervention group, by 32.92 ± 54.34 and 20.94 ± 56.73, respectively. At 1 year, the patients in the intervention group maintained a significant reduction in HbA1c levels (−1.12 ± 1.46, p < 0.05), whereas no change was observed in the control group. CONCLUSION: The behavioural lifestyle intervention programme was effective in improving glycaemic control and compliance with carbohydrate intake goals in Emirati patients with type 2 diabetes. Larger randomized controlled trials are needed to validate these results and to identify key behavioural strategies that will improve compliance to lifestyle modifications in real life. TRIAL REGISTRATION: Clinicaltrials.gov trial identifier NCT0238693