Evaluation of an Interprofessional Continuing Professional Development Course on Comprehensive Diabetes Care: A Mixed-Methods Approach

RATIONALE: Since there are only 33 endocrinologists within the Department of Defence and over 150 000 beneficiaries with diabetes, most patients with diabetes will be treated by primary care providers (PCPs). Comprehensive diabetes care visits are extensive and the clinical practice guidelines (CPGs) routinely change; thus, providing current evidence-based care is difficult. Most professional development courses aim to update PCPs on CPGs but are often inadequate as they focus on only the PCPs (not the interdisciplinary team) without a plan to implement changes into practice. OBJECTIVE: To evaluate the biannual (twice yearly), 3-day, interprofessional Diabetes Champion Course (DCC) developed by the US Air Force Diabetes Center of Excellence on comprehensive diabetes care. METHODS: A mixed-methods approach was used to evaluate three iterations of the DCC course (Sept 2014-Sept 2015). Quantitatively, pre-course and post-course surveys were used to obtain impact on knowledge, skills, and intention to change clinical practice. Qualitatively, semi-structured phone interviews were conducted with participants to obtain benefits to their clinic related to attending the DCC and barriers to implementation of the CPG process improvement project. RESULTS: Twelve of 19 responding clinics (63%) reported implementing all or part of their original CPG project developed at the DCC, and 17 of 19 clinics (89%) reported improvements associated with attending the DCC. Post-course surveys, from on location participants, revealed significant improvements in knowledge (P \u3c 0.01). Likewise, foot exam skills and ability to demonstrate glucose meters to patients improved. Even with high pre-course confidence, 97% of providers reported acquiring new knowledge about prescribing and titrating insulin. CONCLUSION: The DCC is innovative as it employs a team-based, interprofessional, didactic, and interactive approach that is effective in improving knowledge, skills, and intention to change clinical practice, which should translate to better care for patients with diabetes

Who\u27s Distressed? A Comparison of Diabetes-Related Distress by Type of Diabetes and Medication

OBJECTIVE: We hypothesized that diabetes-related distress would vary by type of diabetes and medication regimen [Type 1 diabetes (T1DM), Type 2 diabetes with insulin use (T2DM-i), Type 2 diabetes without insulin use (T2DM)]. Thus, the aim of this study was to identify groups with elevated diabetes-related distress. METHODS: We administered the 17-item Diabetes-related Distress Scale (DDS-17) to 585 patients. We collected demographics, medications, and lab results from patient records. RESULTS: Patients were categorized by type of diabetes and medication: T1DM (n = 149); T2DM-i (n = 333); and T2DM (n = 103). ANOVA revealed significant differences in sample characteristics. ANCOVA were conducted on all four DDS-17 domains [Emotional Burden (EB); Physician-related Distress (PD); Regimen-related Distress (RD); and Interpersonal Distress (ID)]; covariates included in the models were sex, age, duration of diabetes, BMI, and HbA1c. EB was significantly lower in T1DM than T2DM-i, p \u3c 0.05. In addition, RD was significantly lower in T1DM than either T2DM-i, p \u3c 0.05 and T2DM, p \u3c 0.05. CONCLUSIONS: EB and RD are higher for those with type 2 diabetes. Thus, interventions to reduce EB and RD need to be considered for patients with type 2 diabetes. IMPLICATIONS: DDS-17 is useful in identifying diabetes-related distress in patients with diabetes. Efforts need to be made to reduce EB and RD

Is It Distress, Depression, or Both? Exploring Differences in the Diabetes Distress Scale and the Patient Health Questionnaire in a Diabetes Specialty Clinic

IN BRIEF Patients (n = 314) completed the Patient Health Questionnaire and the Diabetes Distress Scale as part of standard care. Although most patients (70.4%) had no symptoms of depression or diabetes-related distress, 23.9% scored high on the distress questionnaire in at least one of its four domains. Regular screening for distress related to the demands of living with diabetes is crucial in identifying and preventing poor health outcomes associated with diabetes-related distress

When Military Fitness Standards No Longer Apply: The High Prevalence of Metabolic Syndrome in Recent Air Force Retirees

BACKGROUND: Metabolic syndrome (MetS) is strongly associated with cardiovascular disease. With MetS prevalence rates increasing in the U.S. population, prevention efforts have largely focused on diet and exercise interventions. Before retirement, military service members have met fitness requirements for at least 20 years, and have lower MetS rates compared to age-matched U.S. population controls (23.4% vs. 39.0%), which suggests a protective effect of the lifestyle associated with military service. However, MetS rates in military retirees have not been previously reported, so it is unknown whether this protective effect extends beyond military service. The purpose of this study was to examine the prevalence of MetS and individual diagnostic criteria in a population of recent U.S. Air Force (USAF) retirees. METHODS: We obtained institutional review board approval for all participating sites at Wilford Hall Ambulatory Surgical Center. From December 2011 to May 2013, USAF retirees within 8 years of their date of retirement were recruited at five USAF bases. Consenting subjects underwent examination and laboratory studies to assess the five diagnostic criteria measures for MetS. We used binary logistic regression to examine the relationship between various factors and the presence of MetS. RESULTS: The study population (n = 381) was primarily male (81.9%), enlisted (71.1%) and had a mean age of 48.2 years. When applying the American Heart Association MetS diagnostic criteria to this population, the MetS prevalence was 37.2%. When using alternative diagnostic criteria found in other published studies that did not include the use of cholesterol medications, the MetS prevalence was 33.6%. Per American Heart Association criteria, the prevalence of each of the MetS diagnostic criteria was as follows: central obesity, 39.8%; elevated fasting glucose, 32.4%; high blood pressure, 56.8%; low-high-density lipoproteins cholesterol, 33.3%; and elevated triglycerides, 42.7%. MetS was more common among males (odds ratio [OR] = 4.05; confidence interval [CI] = 1.94, 8.48) and enlisted (OR = 2.23; CI = 1.24, 4.01). It was also strongly associated with a history of participating in the Air Force Weight Management Program (OR = 2.82; CI = 1.41, 5.63) and increased weight since retirement (OR = 4.00; CI = 1.84, 8.70). However, the study did not find an association between the presence of MetS and time since retirement or self-reported diet and exercise changes since retirement. CONCLUSIONS: The MetS prevalence among recent USAF retirees represents a shift from age-matched active duty rates toward higher rates described in the overall U.S. POPULATION: This finding suggests the protective health effects of fitness standards may be reduced shortly after retirement. This is true despite activities such as screening before and during military service and exposure to USAF health promotion efforts and fitness standards throughout a period of active duty service lasting at least 20 years. In general, military members should be counseled that on retirement, efforts to maintain a healthy weight have continued benefit and should not be forgotten. The risk of MetS after retirement is particularly increased for those identified as being overweight during their active duty careers. Interventions that prevent and reduce unhealthy weight gain may be an appropriate investment of resources and should be studied further

Evaluation of the Group Lifestyle Balance Program in a Military Setting: An Investment Worth Expanding

Introduction: The Diabetes Prevention Program (DPP) demonstrated that lifestyle intervention programs were effective in preventing or delaying the onset of diabetes. The Group Lifestyle Balance (GLB) program translated the DPP curriculum into a 12-wk group intervention for those at risk for diabetes. This retrospective evaluation examined clinical outcomes for patients in the Diabetes Center of Excellence GLB program located at Wilford Hall Ambulatory Surgical Center from 2009 to 2013. Objectives included determining rates of retention, demographic characteristics of program completers, and changes in metabolic surrogates of disease prevalence. Study Design: Adults with prediabetes or metabolic syndrome (MetS) were referred to the GLB program. Updated participant metabolic data were collected at regular intervals during their participation. Results: During the 5-yr study, 704 patients attended the initial class. Overall, 52% of all participants completed the program with the greatest decline in participation occurring by the fourth week (30%). Baseline prevalence of conditions of interest for those who completed the program was prediabetes (93.2%), obesity (56.1%), and MetS (31.5%). GLB completers were older and retired (p \u3c 0.05). A significant number of active duty military members (44.9%, p \u3c 0.01, n = 53) dropped out of the program before the fourth week. Furthermore, those who completed the program saw a 2.0% reduction in prediabetes prevalence (p \u3c 0.001), obesity decreased by 8.7% (p \u3c 0.001), and MetS decreased by 6.8% (p \u3c 0.01). Significant differences were found for central obesity, triglycerides, and fasting blood sugar (p \u3c 0.001). Conclusions: The GLB program is a valuable DPP and was effective at improving clinical outcomes and reducing the incidence of prediabetes, obesity, and MetS for participants who completed the program. Every effort should be made to support and encourage GLB participants to complete the program

Are We Missing an Opportunity? Prediabetes in the U.S. Military

INTRODUCTION: The prevalence of prediabetes is estimated to be one-third of Americans with approximately 80% of these individuals unaware of the diagnosis. In the active duty military population, the prevalence of prediabetes is largely unexplored. The purpose of this study was to investigate the prevalence of prediabetes in military service members by quantifying those meeting prediabetes screening criteria, those actually being screened, and those being appropriately diagnosed. MATERIALS AND METHODS: Data were analyzed from calendar years 2014 to 2018 for active duty service members 18 years of age or older. Vitals records were collected to obtain body mass index values. Composite Health Care System laboratory data were queried for hemoglobin A1c (HbA1c) results as well as fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) results. The percentage of active duty service members meeting criteria for prediabetes screening was determined by totaling members age 45 and older with members age 18- to 44-year old with a body mass index ≥25.0 kg/m2, then dividing by the total number of members for each respective military branch. The percentage of active duty service members actually screened for prediabetes was determined based on members meeting prediabetes screening criteria who in fact had FPG, OGTT, or HbA1c labs. The total number of labs meeting prediabetes criteria was determined based on those aforementioned labs with results in the prediabetes range (FPG between 100 and 125 mg/dL, OGTT between 140 and 199 mg/dL, or HbA1c range of 5.7%-6.4%). The total number of service members with appropriate prediabetes International Classification of Disease (ICD) code was determined by identifying members with ICD-9 and ICD-10 codes 790.21, 790.22, and R73.01-R73.03 in their medical record. RESULTS: From 2014 to 2018, 53.9% of 332,502, 56% of 543,081, and 47.3% of 531,313 active duty service members in the Air Force, Army and Navy, respectively, met criteria for prediabetes screening. The rates of actually screening for prediabetes were similar across the Air Force (4.8%), Army (6.7%), and Navy (5.5%). The percentage with labs meeting prediabetes criteria ranged from 17.9% to 28.4% in the Air Force, 24.2% to 30.3% in the Army, and 24.2% to 30.9% in the Navy. The rate of ICD coding for prediabetes increased from 2014 to 2018 across all branches (29.8%-65.3% for the Air Force, 24.6%-46.8% for the Army, and 40.0%-45.5% for the Navy). CONCLUSION: Screening for prediabetes in the active duty military population is grossly inadequate, and even of those screened, diagnosing those meeting prediabetes criteria is similarly inadequate. Although this scenario is not unique to the Military Health System, but reflective of a larger national problem, efforts should be made within the Military Health System to increase the screening for this common disorder. Identifying service members with prediabetes enables opportunities for targeted interventions to delay or prevent the progression to diabetes mellitus

Heterometallic cobalt(ii) calix[6 and 8]arenes: synthesis, structure and electrochemical activity

Heterometallic cobalt p-tert-butylcalix[6 and 8]arenes have been generated from the in situ reaction of lithium reagents (n-BuLi or t-BuOLi) or NaH with the parent calix[n]arene and subsequent reaction with CoBr2. The reverse route, involving the addition of in situ generated Li[Co(Ot-Bu)3] to p-tert-butylcalix[6 and 8]arene, has also been investigated. X-ray crystallography reveals the formation of complicated products incorporating differing numbers of cobalt and lithium or sodium centers, often with positional disorder, as well as, in some cases, the retention of halide. The electrochemical analysis revealed several oxidation events related to the subsequent oxidation of Co(ii) centers and the reduction of the metal cation at negative potentials. Moreover, the electrochemical activity of the phenol moieties of the parent calix[n]arenes resulted in dimerized products or quinone derivatives, leading to insoluble oligomeric products that deposit and passivate the electrode. Preliminary screening for electrochemical proton reduction revealed good activity for a number of these systems. Results suggest that [Co6Na(NCMe)6(μ-O)(p-tert-butylcalix[6]areneH)2Br]·7MeCN (6·7MeCN) is a promising molecular catalyst for electrochemical proton reduction, with a mass transport coefficient, catalytic charge transfer resistance and current magnitude at the catalytic turnover region that are comparable to those of the reference electrocatalyst (Co(ii)Cl2)

The Choice Should Be Yours: Diabetes-Related Distress by Insulin Delivery Method for People with Type 1 Diabetes

Background: American Diabetes Association (ADA) recommends psychosocial assessment for people with diabetes, including diabetes-related distress. Elevated diabetes-related distress is associated with poor self-management, lower medication adherence, and poorer quality of life. Insulin delivery methods are multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Because people with type 1 diabetes mellitus (T1DM) require comprehensive insulin therapy to manage blood glucose, we explored the association of insulin delivery methods and diabetes distress in this group. Methods: The U.S. Air Force Diabetes Center of Excellence (DCOE), a specialty clinic for adults who are Military Health System beneficiaries, administers the validated 17-item Diabetes-related Distress Scale (DDS-17) as part of standard care. Patient data were analyzed from June 2015 to August 2016 using SPSS version 22. Patients were free to choose the method of insulin delivery with minimal or no additional cost. Results: There were 203 patients with T1DM who completed the DDS-17 as part of standard care during the time period. Patients were categorized as CSII (57.6%) or MDI (42.4%). Women were significantly more likely to choose MDI over CSII than men (P = 0.003). DDS-17 scores were low in both groups, and there were no significant differences in DDS-17 by insulin delivery method. Furthermore, no significant differences were found in hemoglobin A1c (HbA1c) between CSII (7.9% or 63 mmol/mol) and MDI (8.1% or 65 mmol/mol) users (P = 0.22) and no significant differences in body mass index (BMI) between patients using CSII (M = 28.33 kg/m2) and MDI (28.49 kg/m2) users (P = 0.15). Conclusions: Our study demonstrated that if patients are relatively free to choose the insulin delivery method (minimal or no financial constraints), there were no differences in diabetes distress scores, HbA1c, or BMI between CSII and MDI. Therefore, people with T1DM may benefit from choosing the method of insulin delivery that will enable them to achieve individual goals and manage diabetes-related distress

Getting New Test Results to Patients

New diagnostic results are constantly arriving to outpatient practices. It is imperative to effectively communicate these results and their implications to patients. METHODS: We surveyed 100 patients and our clinic personnel to assess opinions regarding methods of communication in common scenarios. RESULTS: Response rate was 79% from patients and 75% from clinic personnel. Most patients thought letters were an appropriate way to receive normal test results (83%). They also felt medical-technician calls were appropriate for normal results (88%), medication dose changes (75%), or need for additional studies (71%). Respondents considered nurse calls acceptable in most scenarios except for new diagnoses of cancer or need for surgery; the consensus was that physicians should directly communicate to patients in these situations. CONCLUSIONS: Providers should take the time to discuss results with patients that lead to significant interventions, but employ support staff to disseminate information about normal results, medication dose changes, and need for additional diagnostic testing

Leadership Training in Graduate Medical Education: Time for a Requirement?

INTRODUCTION: The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution. MATERIALS AND METHODS: Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort. RESULTS: The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency. CONCLUSIONS: This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level