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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
2
Project Partners:計劃夥伴:
Funded by:捐助機構:
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)
3
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
4
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
5
Project Partners:計劃夥伴:
Funded by:捐助機構:
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)
6
Project Partners:計劃夥伴:
Funded by:捐助機構:
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+
7
Project Partners:計劃夥伴:
Funded by:捐助機構:
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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Project Partners:計劃夥伴:
Funded by:捐助機構:
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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Project Partners:計劃夥伴:
Funded by:捐助機構:
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.
10
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
11
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 trial
E Hui & Cadenza Research Team
12
Project Partners:計劃夥伴:
Funded by:捐助機構:
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”
13
Project Partners:計劃夥伴:
Funded by:捐助機構:
Components of programme (1)
Educational talksVisual aids
Games
Group discussion
14
Project Partners:計劃夥伴:
Funded by:捐助機構:
Components of programme (2)
Behavioral modification
strategies
Action plan
Goal setting
Problem solving
15
Project Partners:計劃夥伴:
Funded by:捐助機構:
Components of programme (3)
Group exerciseAerobic & resistance
Home exercise prescribed
16
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
17
Project Partners:計劃夥伴:
Funded by:捐助機構:
Participants
Aged 50 or above
Confirmed diagnosis of diabetes
Receiving medical treatmentsoral medications
insulin injection
Living in the community
Satisfactory cognitive function (MMSE ≥ 19)
18
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
19
Project Partners:計劃夥伴:
Funded by:捐助機構:
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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Project Partners:計劃夥伴:
Funded by:捐助機構:
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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Project Partners:計劃夥伴:
Funded by:捐助機構:
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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Project Partners:計劃夥伴:
Funded by:捐助機構:
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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Project Partners:計劃夥伴:
Funded by:捐助機構:
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
25
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
26
Project Partners:計劃夥伴:
Funded by:捐助機構:
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)
8 weeks adjusted mean changes
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
27
Project Partners:計劃夥伴:
Funded by:捐助機構:
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)
8 weeks adjusted mean changes
Baseline mean (SD)
8 weeks adjusted mean changes
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
28
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
30
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
31
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
32
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
34
Project Partners:計劃夥伴:
Funded by:捐助機構:
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
35
Project Partners:計劃夥伴:
Funded by:捐助機構:
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’