OBJECTIVES:To evaluate whether outcomes from diabetes self-management education for patients with suboptimal control were sustained.STUDY DESIGN:A randomized controlled trial of 623 adults with type 2 diabetes and glycated hemoglobin (A1C) > 7% assigned to receive conventional individual education (IE), group education (GE) using US Diabetes Conversation Maps, or usual care (UC) with no education.METHODS:A1C tests, Problem Areas in Diabetes (PAID), Diabetes Self-Efficacy (DES), Recommended Food Score (RFS), physical activity, and medication use were quantified at baseline and 1 year of follow-up through electronic health records and quarterly mailed surveys. Short-term (mean 6.8 months) and long-term (12.8 months) outcomes were evaluated using linear mixed models. In addition, follow-up trajectories were plotted in a random effects generalized additive model with smooth splines.RESULTS:Compared with UC, IE resulted in long-term improved DES and PAID scores (DES, +.11, P = .03 and PAID, -2.94, P = .04), but not significantly improved long-term RFS or physical activity change. The A1C trajectory declined more steeply in IE than GE and UC for the first 150 days post randomization. However, by 250 days, there was no treatment group A1C difference. The model fit likelihood ratio test for A1C intervention trends was significant for 3 distinct non-linear trajectories (P = .02).CONCLUSIONS:Conventional IE (but not GE) resulted in significant and sustained improvements in self-efficacy and reduced diabetes distress compared with UC, but short-term improvements in A1C, nutrition, and physical activity were not sustained. Patients may need ongoing reinforcement to achieve lasting behavioral change and glucose control.

Background/Aims For patients with type 2 diabetes of long duration, we evaluated whether improved short-term outcomes obtained through diabetes education were sustained. Methods 623 adults with glycosylated hemoglobin (A1c) greater or equal to 7% were randomized to individual education (IE), group education (GE) using Conversation Maps, or usual care (UC). A1c, Problem Areas in Diabetes (PAID), Diabetes Self-Efficacy (DES), Recommended Food Score (RFS), Physical Activity (PA), and medication intensification (an increase in number of medication classes or insulin start) were evaluated at baseline and at approximately 6 month intervals for the following year using linear mixed models. Results Compared to UC, IE resulted in sustained improved DES and PAID scores in the long-term (DES, +0.11, p=.03 and PAID, −2.94, p=.04), but not significant RFS or PA long-term change. IE resulted in a short-term A1c reduction of .25% (p=.03) and odds ratio (OR) of 1.83 (1.05–3.17) for achieving an A1c < 7% compared with UC, but significant effects were not observed after 6 additional follow-up months. No differences were observed between GE and UC for short-term and long-term DES, PAID, RFS, PA, or A1c. In patients with pharmacy claims data (n=488), odds ratios of medication intensification comparing IE to UC were short-term 0.83(0.44–1.57) and long-term 0.79(0.43–1.47); comparing or GE to UC were short-term 1.22(0.66–2.26) and long-term 0.92(0.50–1.68). Discussion In patients with suboptimal glycemic control, improved measures of self-efficacy and lower diabetes distress observed with IE in the short-term were sustained long-term. However, short-term improvements in glucose control, nutrition, and physical activity were not sustained. Educational interventions did not result in higher medication intensification rates. Results are consistent with most behavior change theories, and suggest greater attention to maintenance and relapse, possibly from continued ongoing support from educators, may be needed to sustain improvements in healthy behaviors and glucose control.

Background/Aims ‘Journey for Control of Diabetes: The IDEA Study’ is an ongoing randomized trial evaluating the efficacy of group diabetes education (GE) using US Diabetes Conversation MapsTM and conventional individual diabetes education (IE) among adults with sub-optimally controlled Type 2 diabetes (A1c>=7%). The study is being conducted at 2 sites, Minneapolis, MN, and Albuquerque, NM. Because the 2 sites are regions with diverse demographic characteristics, the goal of this paper was to identify differences in the main outcome (A1c) between sites. Methods In addition to A1c>=7, study inclusion criteria were patients who were diagnosed with diabetes, and were diabetes education-naive within the last one to two years. Consenting patients were randomly assigned to receive either: GE, IE or usual care (UC) as recommended by the primary care provider. All education was provided through each care system’s ADA-recognized education program. Follow-up A1c levels were obtained from electronic laboratory data. Differences in A1c levels were evaluated using Generalized Linear Models (SAS 9.2). Results There were 623 patients enrolled: 337 from MN and 286 from NM. Sample demographics were: mean age of 60.0 (MN) and 64.0 (NM); percent female, 44.8 (151/337) for MN and 54.9 (157/286) for NM; race/ethnicity, 81.1% (276/337) white, 8.1% (27/337) black, 3.6% (12/337) Hispanic, and 7.2% (24/337) other for MN, and NM 45.6% (130/286) white, 2.5% (7/286) black, 43.9% (126/286) Hispanic, and 8.1% (23/286) other. Mean baseline A1c was 8.1% for MN and 8.3% for NM. There was a significant difference in percentages of patients having an A1c in the post-randomization follow-up period (approximately 6 months), 89.0% (300/337) for MN and 67.5% (193/286) for NM. Of those with an A1c test, NM patients had a significantly greater A1c reduction with GE (−0.947 for NM vs. −0.136 for MN), IE (−1.093 for NM vs. −0.497 for MN), and UC (−0.700 for NM vs. −0.253 for MN), (p<.0001). Conclusions Although it appears that IE and GE were more effective for NM patients compared to MN, the large number of NM patients without A1c values in the follow-up period makes any conclusions tentative. The long-term data analysis is pending and should provide a more definitive conclusion.

BACKGROUND Group education for patients with suboptimally controlled diabetes has not been rigorously studied. METHODS A total of 623 adults from Minnesota and New Mexico with type 2 diabetes and glycosylated hemoglobin (HbA(1c)) concentrations of 7% or higher were randomized to (1) group education (using the US Diabetes Conversation Map program), (2) individual education, or (3) usual care (UC; ie, no assigned education). Both education methods covered content as needed to meet national standards for diabetes self-management education and were delivered through accredited programs from 2008 to 2009. General linear mixed-model methods assessed patient-level changes between treatment groups in mean HbA(1c) levels from baseline to follow-up at 6.8 months. Secondary outcomes included mean change in general health status (Medical Outcomes Study 12-Item Short Form Health Survey [SF-12]), Problem Areas in Diabetes (PAID), Diabetes Self-Efficacy (DES-SF), Recommended Food Score (RFS), and Physical Activity (PA, min/wk). RESULTS Mean HbA(1c) concentration decreased in all groups but significantly more with individual (-0.51%) than group education (-0.27%) (P = .01) and UC (-0.24%) (P = .01). The proportion of subjects with follow-up HbA(1c) concentration lower than 7% was greater for individual education (21.2%) than for group (13.9%) and UC (12.8%) (P = .03). Compared with UC, individual education (but not group) improved SF-12 physical component score (+1.88) (P = .04), PA (+42.95 min/wk) (P = .03), and RFS (+0.63) (P = .05). Compared with group education, individual education reduced PAID (-3.62) (P = .02) and increased self-efficacy (+0.1) (P = .04). CONCLUSIONS Individual education for patients with established suboptimally controlled diabetes resulted in better glucose control outcomes than did group education using Conversation Maps. There was also a trend toward better psychosocial and behavioral outcomes with individual education. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00652509.

JoAnn Sperl-Hillen, MD1, Sarah Beaton, PhD2, Omar Fernandes, MPH1, Jodi Lavin-Tompkins, RN, CNP1, Ann Von Worley, RN, BSHS2, Emily Parker, PhD, MPH1, Ann Hanson, BS1, Patricia Glasrud, MS, RDABQ1, Herbert Davis, PhD2, Kenneth Adams, PhD1, William Parsons, MS2 and Vic Spain, PhD, DVM3 1HealthPartners 2LCF Research 3Merck and Co., Inc

Kenneth Adams, PhD1, Sarah Beaton, PhD2, Emily Parker, MPH, PhD1, Jodi Lavin-Tompkins, RN, CNP1, JoAnn Sperl-Hillen, MD1, Ann Hanson, BS1, Herbert Davis, PhD2, Omar Fernandes, MPH1, Ann Von Worley, RN, BSHS2, Patricia Glasrud, MS, RDABQ1, William Parsons, MS2 and Vic Spain, PhD, DVM3 1HealthPartners 2LCF Research 3Merck and Co, Inc