The Sweet Spot: Improving Metabolic Outcomes of Type 2 Diabetics (2) ABSTRACTPurpose Diabetes is a complex chronic condition that imposes a substantial burden on society, both locally and worldwide.  Many patients with type 2 diabetes receive suboptimal treatment in the primary care setting; therefore we sought to improve metabolic outcomes by implementing a protocol based on the American Diabetes Association standards of medical care.Methods Inthisquality improvement initiative we implemented a comprehensive protocol in the form of a checklist and based on the American Diabetes Association standards of medical care on all diabetic patients, as well as implement individualized diabetes self-management education at a local underserved primary care practice.  Data was collected in a retrospective chart review pre project implementation and post project implementation.  Data will be analyzed using the IBM SPSS platformResults A collaborative approach in care of the adult type 2 diabetic patient that includes a comprehensive medical evaluation, glycemic control through self-monitoring and A1C levels, pharmacological interventions as appropriate and diabetes self-management education and support optimize diabetes management.  Detailed final results will be provided at project implementation completion.Conclusions This study provides preliminary evidence that diabetes self-management education and the implementation of clinical practice guidelines can improve metabolic outcomes for type 2 diabetics by increasing patient self-efficacy and increasing provider knowledge in evidence-based practices.Keywords Type 2 Diabetes, Diabetes Self-Management Education, Clinical practice guidelines, primary careAbbreviations ADA-American Diabetes Association   A1C-Glycosolated hemoglobin   BMI-Body Mass Index   BP-Blood pressure DSME-Diabetes Self-Management Training         INTRODUCTIONType 2 diabetes is a fast-growing global epidemic.  The disease affects 25 million Americans, with the annual economic cost exceeding $327 billion.1,2   Of this population, 90% receive treatment in the primary care setting, all the while enduring poor glycemic control.3  The rise in obesity, sedentary lifestyle, high caloric diets, and an ageing population, has contributed to the number of patients with type 2 diabetes, catapulting the projected prevalence rate to 1 in 3 people having the disease by 2050.4,5  Increased disease burden is experienced as a result of suboptimal glycemic control.  Complications associated with poor glycemic control include microvascular issues such as retinopathy, neuropathy and nephropathy, as well as higher risk macrovascular complications, such as coronary artery disease, peripheral artery disease, and stroke.6    Diabetes significantly impacts the racial and ethnic minorities, as well as the socioeconomically disadvantaged populations.7    Research has discovered a geographically recognizable area known as the ‘Diabetes Belt,’ which is located in the southern United States and characterized by a diabetes prevalence of 11% or greater among the adult population.8 Georgia holds the unfortunate distinction of being one of the states included in this region.  In Georgia, 11.6% of adults have been diagnosed with diabetes, a prevalence 20% higher than the national average, causing a death rate 8% higher than the national average and costing the state approximately $5.1 billion in 2013 alone.9  Despite these staggering statistics, studies have demonstrated many complications can be prevented or delayed through effective disease management. Methodical management and support in the treatment of diabetes is crucial considering suboptimal disease management can result in increased morbidity and mortality.  Evidence shows that the integration of comprehensive best practices including pharmacologic and nonpharmalogical modifications such as lifestyle changes, medical nutrition therapy, and telemonitoring improve hemoglobin A1C.  With every percentage point decrease in A1C level there is a 25% reduction in diabetes-associated deaths, 35% reduction in the risk of microvascular complications, and 18% reduction in combined fatal and non-fatal myocardial infarctions.4,10,11   Despite the recommendation for comprehensive best practices in the management of diabetes, there are limited studies on the utilization of a multi-faceted approach that includes the pairing of the implementation of a protocol/checklist based on the American Diabetes Association (ADA) standards of medical care, as well as diabetes self-management education.  We therefore implemented a quality improvement project at a local underserved primary care office to determine the efficacy of this multi-faceted approach.METHODSStudy Design and Setting The project was a 12-week comprehensive quality improvement effort, based on the ADA standards of medical care and granted a statement of Institutional Review Board exemption.  The predominant purpose of the project was to improve metabolic outcomes, patient self-efficacy, and quality of life for type 2 diabetic patients.  The quality improvement project was conducted at a local primary care practice located in an underserved area in Riverdale, GA.  The population of the local county in 2015 was 273, 955; diverse, less educated, lower income earning, and with a poverty rate of 24%, higher than the state of Georgia.12Sample Inclusion criteria for participation was a diagnosis of type 2 diabetes, A1C > 7.5%, ages 18 to 64 years, English speaking and no cognitive deficits.  Excluded from the study were patients with a diagnosis of pre-diabetes or type 1 diabetes, pregnancy, non-English speaking, and positive cognitive and mental dysfunction.  Patients were recruited through a convenience sample over a period of approximately 5 weeks, via poster announcement, flyer distribution, one on one meetings, phone calls and office staff recommendation. Intervention Description A comprehensive protocol in the form of a checklist and based on the ADA standards of medical care was initiated on all diabetic patients at the practice.  Clinical practice guidelines standardize work processes, promote safety, and improve communication thereby increasing quality of care and improve health outcomes.13 Front-line staff attended several educational trainings on the importance of consistent utilization of the diabetes checklist; the trainings were conducted during project development and prior to project implementation.  Once patient eligibility was determined and informed consent was gained, a follow-up appointment was set up to begin individualized diabetes self-management education (DSME).  Literature supports the use of DSME for increasing patient self-efficacy and improving overall health.14   During the initial visit, a retrospective chart audit was conducted to collect baseline data of the core measures: most recent A1C, body mass index (BMI), and blood pressure (BP).  During the initial visit and prior to initiating DSME training, the Diabetes Knowledge Test was administered to gauge participant’s knowledge of diabetes.  The Diabetes Knowledge Test score also collected as a core measure for the quality improvement project.  The Diabetes Knowledge Test is a 23 question test originally validated in 1998 to assess a patient’s diabetes and diabetes self-care knowledge; the test was later revised with reliability, validity and generalizability re-evaluated and supported.15  Once the pretest was completed, an intense self-care management training was conducted and included goal setting, healthy eating, active lifestyle, self-blood glucose monitoring, medication compliance, risk reduction effects, and healthy coping mechanisms.  To re-iterate the importance of the information discussed during the individualized education training session, patients were given pedometers, blood glucose logs, an ADA plan your portions plate portion guide placemat, and additional diabetes management information.  Weekly follow-up support was provided via telephone or in person meeting for the remainder of project implementation. The follow up appointments provided further opportunity to coach and support patients, as well as answer questions to ensure successful outcomes.  At the end of the 12-week project, the Diabetes Knowledge Test was re-administered to determine a change in self-management behaviors, and A1C, BMI and BP was reassessed and compared to pretest results. Data Analysis Pre and post project quantitative data analysis was performed using the IBM SPSS platform to examine the effects of DSME on A1C, BMI, BP and Diabetes Knowledge.  A1C measures hyperglycemia and determines a patient’s risk for developing chronic complications.  Research supports a relationship between obesity, insulin resistance and hypertension due to the shared chemical reactions of increased oxidative state, deficient glucose, lipid metabolism, elevated inflammatory mediators, hypercoagulability and endothelial cell damage.16,17  Baseline and outcome data was compared to evaluate overall project success with integrating the comprehensive ADA protocol to the treatment plan of diabeticsRESULTS A quality improvement project was implemented at a local, underserved primary care office in Riverdale, GA.  The project focused on the implementation of a comprehensive quality improvement protocol based on the ADA standards of medical care utilizing a collaborative approach with proactive providers and receptive patients; thereby improving glycemic control, decreasing morbidity and mortality, and optimizing self-care management by achieving target metabolic outcomes and improved self-care knowledge.  There were 15 participants recruited for the study, 3 men and 12 women.  Participant age ranges from 26-64.  Project aims include (a) 5% decrease in baseline A1C, (b) 5 to 7 mmHg decrease in systolic and diastolic BP, (c) 7% decrease in baseline BMI, and (d) 15% increase in Diabetes Knowledge test scores. Project aims will be evaluated by collecting and comparing pre and post-project A1C, BMI, BP and Diabetes Knowledge Test score ranges with means through a retrospective chart analysis. DISCUSSION The effects of type 2 diabetes on society cannot be ignored. Continued efforts to empower and educate patients are critical in disease management.  Lifestyle modification and the implementation of clinical practice guidelines can help prevent or delay diabetes complications.13,14  A detailed summary of the key findings will be discussed at project implementation completion.  The project has been successful thus far as evidenced by patient enthusiasm.  Two major project strengths include multi-component intervention implementation that allows maximum improvement and individualized education and support through face-to –face or telephone means to create a relaxed and convenient atmosphere.  Limitations to the project include small sample size, increased incompletion rates, and patients’ unwillingness to change behavior. Small sample size limited the project generalizability.  Increased incompletion rates were noticed due to the extended project length. Patient’s unwillingness to change behavior is often related to lack of motivation.  The implications of this study will hopefully confirm that an enhanced relationship between healthcare providers and patients improve processes of care and health outcomes; thereby directly influencing disease burden, rate of disease progression and co-morbidities which are essential  factors in improving outcomes and lowering overall health costs.  Future research can help develop additional innovative, technologically savvy ways to support patients during lifestyle change as we fight to implement evidence-based strategies in an effort to optimize diabetes care by improving metabolic outcomes. .References1. Beck J, Greenwood D, Blanton. 2017 national standard for diabetes self-management education and support. Diabetes Edu. 2017;43(5):449-464.2. Peterson M. Economic costs of diabetes in the U.S. in 2017. Diabetes Care. 2018;41(5): 917-928.3. Waddell J. 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