Project Partners: 計劃夥伴： Funded by: 捐助機構： 1 A Community Model for Care of Older...

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Project Partners:計劃夥伴：

Funded by:捐助機構：

A Community Model for Care of Older Persons with Diabetes Mellitus:

a Randomised Controlled TrialDr Elsie Hui, FRCP

Senior Medical Officer, Shatin Hospital

A CADENZA Initiated Research

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Diabetes among older people in Hong Kong:how big is the problem?

1 in 5 persons aged 65 to 84 have diabetes

Among adults diagnosed with diabetes, half are elderly

By 2036, the number of older diabetics is expected to be 300,000

(McGhee et al, 2009)

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Burden of diabetes

On patientsComplications

Disability & handicap

Poor quality of life

Pre-mature death and increase in mortality

Increase in health care cost

On societyMore dependent persons

Increase in utilization of healthcare services

Increased demand for personal care

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Barriers encountered by older people with diabetes

Special needs of older diabeticsCo-morbidities (e.g. hypertension, heart diseases, stroke)

Co-existing geriatric syndromes (e.g. cognitive impairment, depressive symptoms, falls, urinary incontinence)

Poor (health) literacy

Over-emphasis on hospital- and clinic-based services and medication therapy

Lack of support in the community

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Behaviour in managing diabetes (older HK men)

8.4

85.3

27.5

57.7 61.2

14.0

79.0

13.4

51.2 55.4

84.191.5

0102030405060708090

100

Taking insulin Taking diabetic

pills

Taking over the

counter

medication

Controlling weight

or losing weight

Increasing

physical activity or

exercise

Eating fewer high

sugar content,

high fat content or

high cholesterol

foodsBehaviour

Perc

enta

ge (%

)

Aged 15-64 Aged 65+

(Department of Health, HKSAR & Department of Community Medicine, HKU, 2005)

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Behaviour of managing diabetes (older HK women)

(Department of Health, HKSAR & Department of Community Medicine, HKU, 2005)

10.4

66.4

13.6

69.2 73.5

18.3

82.1

19.1

43.3 45.2

76.888.3

0102030405060708090

100

Taking insulin Taking diabeticpills

Taking over thecounter

medication

Controllingweight or losing

weight

Increasingphysical activity

or exercise

Eating fewer highsugar content,

high fat content orhigh cholesterol

foodsBehaviour

Per

cent

age

(%)

Aged 15-64 Aged 65+

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Behaviour in managing diabetes among older HK persons

Therapeutic management

Majority (80%) taking oral hypoglycemics~ 20% older women taking ‘over the counter’ drugs

Lifestyle modifications

Older men are more capable than older women

Older diabetics much worse than younger patients, especially women

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Patient education for older diabetics

Address common geriatric syndromes and co-morbid conditions

Besides glycemic control, focus onmanaging symptoms (e.g. hypoglycemia, vision, neuropathic pain)maintaining functional independenceimproving quality of life

lifestyle restrictionsdepression

Take into account learning habits of older peoplesimple instructionsintensive training on practical skillsreinforcement and maintenance

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Pilot study: single arm, pre-, post-test design8-week intervention

Significant changes were observed in the following outcomes

Diabetes Knowledge Test

Mean post-prandial blood glucose (12 8 mmmol/l)

Nutritional statusdietary intake (carbohydrates, protein, fat)

Body Mass Index (25.4 24.9)

weight reduction in 36% of subjects

QOLDiabetes QOL questionnaire (all domains)

SF-36 (6 out of 8 domains)

Chan WM, Woo J, Hui E, et al. A Community model for care of elderly people with diabetes via telemedicine. Appl Nurs Res 2005;18:77-81.

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CADENZA Initiated Research

“CADENZA: A Jockey Club Initiative for Seniors” initiated a research study on a community-based, chronic disease management programme for older persons with diabetes

The Cadenza Research Team collaborated with Dr. E Hui of Shatin Hospital to develop the intervention and evaluate outcomes

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A Community Model for Care of Older Persons with

Diabetes Mellitus:

a randomised controlled trial

E Hui & Cadenza Research Team

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Features of programme

Community-basedcommunity social centres & day care centres for the elderly in Shatin

Small groups6-10 participants

8 sessions, 2 hours each, once a week

3 core componentsEducation

Exercise

Peer support

Added relevant topicsblood pressure management

Self-management concepts

Conducted by non-professional personnel

1 or 2 research assistants

leaders’ training

following a standardized “Leader’s

Manual”

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Components of programme (1)

Educational talksVisual aids

Games

Group discussion

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Behavioral modification

strategies

Action plan

Goal setting

Problem solving

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Group exerciseAerobic & resistance

Home exercise prescribed

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Research design

Randomized controlled trial

Since January 2008 & still on-going

Comparing the changes in physical and quality of life outcomes in programme participants (intervention group) with those did not join the programme (control group) at 8 weeks

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Participants

Aged 50 or above

Confirmed diagnosis of diabetes

Receiving medical treatmentsoral medications

insulin injection

Living in the community

Satisfactory cognitive function (MMSE ≥ 19)

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Procedure

Recruitment in community elderly centres, day care centres, out-patient clinics in health centres and public hospitals

Randomization

Complete baseline assessment

Intervention group Control group

Community-based Diabetes Management Programme

Complete follow-up assessment

Baseline

8 weeks

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Outcome measurements (1)

Physical measuresBody mass index (BMI)Waist-hip ratio (WHR)Random glucoseHbA1cSystolic and diastolic blood pressure

Process measureDiabetes knowledge scale1

Quality of life measuresChinese Diabetes quality of life Score2

Medical Outcomes Study SF-36 (Hong Kong)3

1Beeney LJ, Dunn SM, Welch G. 1994; Measurement of diabetes knowledge: The development of the DKN scales. In C. Bradley (Ed.), Handbook of psychology and diabetes. London: Harwood Academic Publishers, pp 159-189.2Cheng AY, Tsui EY, Hanley AJ, Zinman B. Developing a quality of life measure for Chinese patients with diabetes. Diabetes Res Clin Pract 1999;46:259-267.3Lam LK, Gandek B, Ren X, Chan MS. Tests of scaling assumptions and contruct validity of the Chinese (HK) version of the SF-36 health survey. J Clin Epidemiol 1998;51:1139-1147.

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Focus Group Interviews

14 subjects randomly selected from intervention group

Group discussion led by a facilitator

Open-ended questions

4 themes identifiedi) Comments on existing health care services for diabetics

ii) Experiences of participation in the new service model (intervention)

iii) Motivation to join the programme

iv) Suggestions for improvement of the new service model

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Interim findings

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Participants

Recruited participants (n=208)

Intervention group (n=107) Control group (n=101)

Community-based Diabetes Management Programme

n=83 (77.6%)

n=80 (79.2%)

Baseline

Completed 8-week programme and follow-up

Drop-out: n=15 (14.0%)

Pending assessment: n=9 (8.4%)

Drop-out: n=13 (12.9%)

Pending assessment: n=8 (7.9%)

Until September 2009

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Characteristics of participants

Demographics Intervention group (n=92) Control group (n=88) P-value

Age (years) 71.84 (7.98) 72.05 (7.88) 0.860

% Female 65.2 % 75.0% 0.152

Education level 0.010

Illiterate or no formal education 21.7% 37.5%

Primary 39.1% 42.0%

Secondary or above 39.1% 20.5%

Years of having DM 12.74 (9.28) 12.17 (9.24) 0.680

% DM-related admission in last year 12.9% 10.5% 0.610

Total number of medications 5.60 (2.99) 5.51 (2.75) 0.840

% Oral hypoglycemic agent 93.5% 90.9% 0.715

% Insulin Injection 21.7% 25.0% 0.605

Total number of comorbid diseases 3.96 (2.32) 3.55 (1.89) 0.194

% Hypertension 73.9% 71.6% 0.726

% Hyperlipidemia 26.1% 36.4% 0.137

% Heart disease 14.1% 17.0% 0.590

% Stroke 17.4% 15.9% 0.790

Exercise time per week (minutes) 299.13 (254.95) 323.13 (258.58) 0.532

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Outcomes of intervention group at baseline and 8 weeks – physical and process measures (n=83)

Baseline mean (SD) 8 weeks mean (SD) P-value

Physical outcome measures

BMI (kg/m2) 24.86 (3.58) 24.84 (3.76) 0.891

Waist hip ratio 0.97 (0.07) 0.97 (0.07) 0.907

Random glucose (mmol/L) 10.63 (4.59) 10.14 (4.61) 0.317

HbA1c (%) 7.45 (1.52) 7.23 (1.46) 0.022

Systolic BP (mmHg) 137.49 (14.94) 130.99 (16.16) 0.001

Diastolic BP (mmHg) 76.58 (10.71) 73.00 (11.48) 0.003

Process outcomes measure

Diabetes knowledge score (0-14) 10.64 (2.43) 11.87 (2.15) <0.0005

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Outcomes of intervention group at baseline and 8 weeks – quality of life measures (n=83)

Quality of life measures Baseline mean (SD) 8 weeks mean (SD) P-value

DMQOL (1-5)

Satisfaction 2.53 (0.43) 2.41 (0.44) 0.026

Impact 1.84 (0.52) 1.77 (0.47) 0.031

Worry 1.85 (0.68) 1.73 (0.60) 0.012

SF-36 (0-100)

Physical functioning 70.06 (22.93) 72.83 (22.89) 0.082

Role-physical 63.86 (40.62) 63.55 (39.49) 0.993

Bodily pain 65.41 (29.18) 65.65 (27.37) 0.750

General health 43.02 (24.86) 44.43 (24.01) 0.873

Vitality 58.13 (25.77) 61.08 (22.85) 0.470

Social functioning 83.13 (27.01) 85.09 (25.78) 0.442

Role-emotional 63.45 (40.53) 67.07 (40.15) 0.425

Mental health 71.08 (24.61) 75.71 (19.49) 0.046

SF-36 Physical component 60.59 (22.38) 61.62 (22.33) 0.641

SF-36 Mental component 68.95 (23.79) 72.24 (22.32) 0.128

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Comparing outcome changes between intervention and control groups at 8 weeks – physical and process measures

Intervention group (n=83) Control group (n=80)

Physical outcome measures

Baseline mean (SD)

8 weeks adjusted mean changes

Baseline mean (SD)


P-value

BMI (kg/m2) 24.86 (3.58) -0.02 24.58 (3.75) +0.12 0.413

Waist hip ratio 0.97 (0.07) +0.00 0.96 (0.08) +0.00 0.844

Random glucose (mmol/L) 10.63 (4.59) -0.17 9.35 (3.55) -0.26 0.884

HbA1c (%) 7.45 (1.52) -0.18 7.06 (1.18) -0.06 0.284

Systolic BP (mmHg) 137.49 (14.94)

-5.53 134.43 (16.15)

-4.52 0.673

Diastolic BP (mmHg) 76.58 (10.71) -3.11 76.14 (10.82) -1.63 0.402

Process outcomes measure

Diabetes knowledge score(0-14)

10.64 (2.43) +1.47 9.67 (2.82) -0.20 <0.0005

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Comparing outcome changes between intervention and control groups at 8 weeks – quality of life measures

Quality of life measures Intervention group (n=83) Control group (n=80)

DMQOL (1-5) Baseline mean (SD)


Baseline mean (SD)


P-value

Satisfaction 2.53 (0.43) -0.11 2.49 (0.45) +0.01 0.037

Impact 1.84 (0.52) -0.08 1.80 (0.55) -0.10 0.740

Worry 1.85 (0.68) -0.09 1.63 (0.71) -0.12 0.713

SF-36 (0-100)

Physical functioning 70.06 (22.93)

+3.18 68.58 (23.32)

+1.08 0.383

Role-physical 63.86 (40.62)

+4.17 58.81 (40.83)

+1.30 0.625

Bodily pain 65.41 (29.18)

+0.29 66.42 (28.78)

+0.45 0.969

General health 43.02 (24.86)

+1.05 46.55 (24.35)

+3.91 0.346

Vitality 58.13 (25.77)

+3.66 58.01 (23.22)

+0.52 0.293

Social functioning 83.13 (27.01)

+1.56 84.23 (24.53)

+1.82 0.944

Role-emotional 63.45 (40.53)

+6.78 62.50 (42.83)

-1.61 0.163

Mental health 71.08 (24.61)

+5.16 72.95 (21.10)

-1.36 0.006

SF-36 Physical component 60.59 (22.38)

+1.66 60.09 (22.18)

+2.22 0.840

SF-36 Mental component 68.95 (23.79)

+4.12 69.42 (22.89)

+0.02 0.151

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Some comments arising from Focus Group

Existing services for older people with diabetes were inadequate and could not address their needs

Participating in the current programme allowed participants to equip themselves with knowledge and skills, encouraged a positive attitude towards diabetes self-management, and provided emotional support

The programme should be run on a regular basis, targeting newly diagnosed patients, and provide more strategies in stress and psychological management

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Discussion

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Effectiveness of the programme

At the end of the Diabetes Management Programme, participants in the intervention group had improvements (pre- and post-test) in

HbA1c

Systolic and diastolic blood pressure

Diabetes-related knowledge

Diabetes quality of life higher satisfaction

lower impact

worry

Mental health

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Effectiveness of the programme

Comparing with those in the control group, participants in the intervention group had significant difference (improvements) in

Diabetes-related knowledge

Satisfaction in diabetes control

Mental health

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Limitations and Suggestions

Follow-up period of 8 weeks was too shortPhysical outcomes take longer to change

A small subset (n=37) was assessed at 6 months

BMI continued to decrease

Subjects’ diabetic control was fair HbA1c 7.45% (intervention), 7.06% (control)

Future study - target ‘high risk’ patients with poor control, complications and history of DM-related hospitalization

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Recommendations

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Incorporate into regular community services

Disseminate the concept of “Community Model for Care of Diabetes” (and other chronic diseases) to different organizations in both health and social sectors

Incorporate such programmes as routine services offered in community or day case centres serving older persons

Explore the possibility of training non-healthcare professionals or older volunteers to be the leaders of such programme (CDSMP lay-leader model)

To establish effective referral systems from hospitals and clinics to such community-based programmes

e.g., Risk Assessment & Management Programme for Diabetes

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Address special needs of older people with diabetes

There is a high prevalence of older diabetics with depression, cognitive impairment and co-morbidities

Programme design should meet the diversified needs of older people with multiple problems

Content of such programmes should be adapted to be more ‘elder-friendly’

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The EndThank you!

[email protected]

Project Partners: 計劃夥伴： Funded by: 捐助機構： 1 A Community Model for Care of Older...

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Transcript of Project Partners: 計劃夥伴： Funded by: 捐助機構： 1 A Community Model for Care of Older...