A Retrospective Study on the Patient Benefits of Utilizing Conversation Maps™ For Group DSME

Heather F. DeBellis, Pharm.D., CDE and Joycelyn A. Cornthwaite, M.S., R.D., L.D., CDE

South University School of Pharmacy and Tuttle Army Health Clinic Savannah, Georgia

OBJECTIVES

To identify and maintain Healthy Interaction's Diabetes Conversation Maps

as a part of a core curriculum; functioning to reinforce diabetes self-

management education (DSME) concepts and goals. To demonstrate and

quantify the efficacy of these maps as an innovative part of diabetes care

and education, through objective analysis of pre-education and post-

education laboratory results.

INTRODUCTION

Currently a registered dietitian and clinical pharmacist are providing

monthly diabetes education classes and follow-up conversation map

sessions at a primary care clinic on Hunter Army Airfield in Savannah,

Georgia. The follow-up conversation map experiences are primarily

utilized as an interactive reinforcement encounter to gauge the patient's

understanding of information presented during the initial diabetes

education class and to emphasize key concepts that are essential to diabetes

self-care such as monitoring blood sugar, healthy eating, and medication

compliance.

The first diabetes education class offered at Tuttle Army Health Clinic was

in July 2008, and the first conversation map experience was offered in

August 2008. On average, attendance for each conversation map included

about 5 patients. The results presented currently review outcomes collected

through December 2010. These outcomes measure the percentage of

patients experiencing a total change in glycosylated hemoglobin A1c

(HgA1c), total cholesterol, triglycerides, low-density lipoprotein (LDL),

and high-density lipoprotein (HDL) after attending at least one

conversation map session in addition to the initial diabetes education

session.

The Tuttle Army Health Clinic utilizes four of the five conversation maps

provided by Healthy Interactions in collaboration with the American

Diabetes Association (ADA). Once the patient has attended the initial

diabetes education session consisting of meal patterning and survival skill

information, they are invited to attend the subsequent conversation maps.

The On the Road to Managing Your Diabetes conversation map begins our

series with a summation of diabetes and self-management basics. The

Monitoring Your Blood Glucose conversation map follows and directly

focuses on blood glucose values and target goals. Next, the Diabetes and

Healthy Eating conversation map revisits dietary considerations and

patients are able to reassess their current dietary practices and goals. The

mapping series concludes with the Continuing Your Journey conversation

map, which reveals the importance of continued self-care and management

for optimal health outcomes and for the minimization of long-term

complications intrinsic to the natural course of diabetes. The Caring for

Gestational Diabetes conversation map is currently not a part of the

sequence due to the patient population.

METHODS

LIMITATIONS

Limitations to the generalization of these results

across populations include the size and

characteristics of those in the cohort, attrition, and

medication effects. The size of the cohort was

effected by attrition. Many patients attending the

initial class were unable to attend the mapping

sessions due to conflicting schedules. Attendees to

the conversation maps were unable to attend all maps

in the series, also due in large part to scheduling

conflicts. Incomplete data due to non-adherence of

scheduled lab orders further reduced the cohort.

Lastly, we are unable to conclude that attendance to

the conversation mapping sessions alone resulted in

the improvements described above. Patients who

returned to the mapping sessions may have been

those with an increased likelihood for optimal self-

guided care; compliance with medications as

prescribed, exercise regularly and good nutrition.

Many patients had one-on-one follow-ups with the

clinical pharmacist and/or the registered dietician in

addition to attendance of the conversation maps.

Therefore, the direct effect of the maps is difficult to

infer. In the future our resulting laboratory data will

include results of the Healthy Interactions patient

survey which may indicate indirect effects of

conversation maps by gauging an increase in self-

efficacy and resultant improvement in outcomes.

OUTCOMES We report a change in the group average for the lipid values of total

cholesterol, triglycerides, and HDL cholesterol. Total cholesterol improved

by 1.23% to a group average of 16.86% below (or a decrease of

approximately 34 mg/dL) desired 200mg/dL. Triglycerides were reduced

by 17.6% to an average 126mg/dL (16% below goal). HDL cholesterol

improved to an average of 3.2% above desired goal. The group average

LDL cholesterol remains below desired goal of 100 mg/dL, despite a shift

from 6% below to 4.6% below goal. No statistical significance was seen

when comparing pre-education versus post-education lipid value averages

for lipid values (p=0.81 for total cholesterol, p=0.19 for triglycerides,

p=0.87 for HDL, and p=0.81 for LDL cholesterol).

According to current ADA guidelines, HgA1c, a key indicator of recent

blood glucose control, should register less than 7% for optimal health

outcomes and risk reduction in patients with diabetes. We report a

statistically significant change when comparing average values of HgA1c

in the group pre-education versus post-education (p=0.003). HgA1c pre-

education was twenty-three percent above desired goal of less than 7%.

The group average HgA1c was reduced to 6.9% post-education, achieving

desired goal.

IMPLICATIONS

Medical complications such as diabetic retinopathy,

kidney disease, neuropathy, cardiovascular disease,

vascular disease, and amputations are among the

most common causes of morbidity and mortality due

to diabetes; costing the United States $174 billion in

2007. The onset of many of these complications may

be delayed or avoided with consistency and

compliance to medical nutrition therapy and medical

care. The Healthy Interaction Conversation Maps

provide a method by which to increase patient's

knowledge, understanding and subsequent self-guided

diabetes care. These retrospective results provide a

promising indication that integrating conversation

maps into an existing curriculum can be seamless and

a measurably effective educational tool; helping both

patients and providers achieve positive outcomes.

Pre and post laboratory results were collected for each patient who

attended at least one conversation map experience after first attending the

initial diabetes education class. Glycosylated hemoglobin A1c, total

cholesterol, triglycerides, LDL, and HDL were collected for each patient

whose data was available in the clinic’s electronic medical record, Armed

Forces Health Longitudinal Technology Application (AHLTA). The pre

laboratory results were drawn prior to the patient attending the initial

diabetes education class and the post laboratory results were drawn 3 to 6

months after the patient attended their first conversation map encounter.

The two sample z-Test was used.

COURSE SCHEDULE

MAPPING EXPERIENCE

U.S.A. MEDDAC

Fort Stewart – Hunter AAF