MNT: RDN in Medical Team (2015)
- Aged 18 years or older
- Type 2 diabetes
- A1C 7.5% or higher
- Seen within the past 12 months.
- Initial diagnosis of type 2 diabetes within the last 12 months
- Inability to speak or read English
- Lack of regular Internet access with e-mail capabilities
- Unwillingness to perform any self-monitoring at home
- Diagnosis of a terminal illness or entry into hospice care
- Pregnancy, planning a pregnancy or currently lactating
- Current enrollment in a care management program
- Family household member enrolled in EMPOWER-D study
- Resident of a long-term care facility
- Plans to discontinue primary care at the included sites during the study period
- Uninsured.
Recruitment
Participants were recruited from March 2008 through December 2009 through electronic health records at the Palo Alto Medical Foundation (PAMF) .
Design
Participants were randomly assigned to one of two study arms [intervention (INT) or usual care (UC)] and followed for 12 months.
Blinding Used
Data collectors were blinded to randomization status.
Intervention
- Participants randomized to the INT group had three in-person visits:
- A 90-minute group visit introducing the online tools
- A 90-minute one-to-one consultation visit with a nurse care manager to develop a shared care plan
- A 60-minute visit with a RD.
- A pharmacist reviewed all INT participants’ charts, made recommendations about medication management and was consulted by the care team as needed.
- The INT utilized an online system that included:
- Wireless glucometer upload system that transmits home glucometer readings to PAMF’s electronic health record
- Personalized diabetes summary status report
- Nutrition log
- Insulin record
- Exercise log
- Online messaging with the patient’s healthcare team, including nurse care managers (NCM) and RD
- Advice and medication changes from the NCM
- Patient-specific text and video educational content from NCMs.
- UC patients continued to receive standard-of-care treatment, including reminders about annual and preventive guideline-based laboratory tests and screening. UC participants received no EMPOWER-D treatment interventions.
Statistical Analysis
- The study design was powered to detect net A1C improvements of 0.5% or larger
- A sample size of 200 participants per arm was calculated to provide 91% power to detect an effect size of 0.36, assuming a 15% loss in follow-up
- Two-sample T-tests, X2 tests, ANOVA and Kruskal-Wallist test were used as appropriate
- Intent-to-treat analysis was conducted.
Timing of Measurements
Clinical measurements were collected at six and 12 months.
Dependent Variables
- Primary: Glucose control (A1C)
- Secondary:
- Blood pressure
- LDL
- Ten-year Framingham cardiovascular risk
- Satisfaction
- Psychosocial well-being.
Independent Variables
Intervention (INT) vs. Usual Care (UC).
Control Variables
- Baseline A1C
- Age
- Gender
- Race
- Ethnicity.
- Initial N: N=415 (249 male, 166 female)
- Attrition (final N): N=379 (91%) were included in final analysis (INT: N=186; UC: N=193)
- Age: Aged 26 to 85 years (INT: Mean=54.0±10.7 years; UC: Mean=53.5±10.2 years).
Ethnicity
- 59% white
- 21% Asian
- 9% Hispanic.
Other relevant demographics
Demographic characteristics, including education level, were comparable between groups.
Anthropometrics
Baseline clinical measures were comparable between groups.
Location
Mountain View, CA.
Key Findings
- At six months, participants in the INT group had significantly better diabetes control than those in the UC group (-1.32% INT vs. -0.66% UC; P<0.001)
- At 12 months, the difference in A1C was not significant between groups (-1.14% INT vs. -0.95% UC; P=0.133).
Other Findings
- The INT group had significantly better control of their LDL at 12 months compared with the UC group (-6.1mg per dL INT vs. 0.0mg per dL UC; P=0.001)
- There were no statistically significant differences between INT and UC groups at 12 months for blood pressure, weight or Framingham risk.
Government: | Agency for Healthcare Research and Quality | ||
University/Hospital: | Stanford University, Indiana University | ||
Not-for-profit |
|
||
In-Kind support reported by Industry: | Yes |
Quality Criteria Checklist: Primary Research
|
|||
Relevance Questions | |||
1. | Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) | Yes | |
2. | Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? | Yes | |
3. | Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? | Yes | |
4. | Is the intervention or procedure feasible? (NA for some epidemiological studies) | Yes | |
Validity Questions | |||
1. | Was the research question clearly stated? | Yes | |
1.1. | Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? | Yes | |
1.2. | Was (were) the outcome(s) [dependent variable(s)] clearly indicated? | Yes | |
1.3. | Were the target population and setting specified? | Yes | |
2. | Was the selection of study subjects/patients free from bias? | Yes | |
2.1. | Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? | Yes | |
2.2. | Were criteria applied equally to all study groups? | Yes | |
2.3. | Were health, demographics, and other characteristics of subjects described? | Yes | |
2.4. | Were the subjects/patients a representative sample of the relevant population? | Yes | |
3. | Were study groups comparable? | Yes | |
3.1. | Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) | Yes | |
3.2. | Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? | Yes | |
3.3. | Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) | Yes | |
3.4. | If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? | N/A | |
3.5. | If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) | N/A | |
3.6. | If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? | N/A | |
4. | Was method of handling withdrawals described? | Yes | |
4.1. | Were follow-up methods described and the same for all groups? | Yes | |
4.2. | Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) | Yes | |
4.3. | Were all enrolled subjects/patients (in the original sample) accounted for? | Yes | |
4.4. | Were reasons for withdrawals similar across groups? | Yes | |
4.5. | If diagnostic test, was decision to perform reference test not dependent on results of test under study? | N/A | |
5. | Was blinding used to prevent introduction of bias? | Yes | |
5.1. | In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? | Yes | |
5.2. | Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) | Yes | |
5.3. | In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? | N/A | |
5.4. | In case control study, was case definition explicit and case ascertainment not influenced by exposure status? | N/A | |
5.5. | In diagnostic study, were test results blinded to patient history and other test results? | N/A | |
6. | Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? | Yes | |
6.1. | In RCT or other intervention trial, were protocols described for all regimens studied? | Yes | |
6.2. | In observational study, were interventions, study settings, and clinicians/provider described? | N/A | |
6.3. | Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? | Yes | |
6.4. | Was the amount of exposure and, if relevant, subject/patient compliance measured? | Yes | |
6.5. | Were co-interventions (e.g., ancillary treatments, other therapies) described? | N/A | |
6.6. | Were extra or unplanned treatments described? | N/A | |
6.7. | Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? | Yes | |
6.8. | In diagnostic study, were details of test administration and replication sufficient? | N/A | |
7. | Were outcomes clearly defined and the measurements valid and reliable? | Yes | |
7.1. | Were primary and secondary endpoints described and relevant to the question? | Yes | |
7.2. | Were nutrition measures appropriate to question and outcomes of concern? | Yes | |
7.3. | Was the period of follow-up long enough for important outcome(s) to occur? | Yes | |
7.4. | Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? | Yes | |
7.5. | Was the measurement of effect at an appropriate level of precision? | Yes | |
7.6. | Were other factors accounted for (measured) that could affect outcomes? | Yes | |
7.7. | Were the measurements conducted consistently across groups? | Yes | |
8. | Was the statistical analysis appropriate for the study design and type of outcome indicators? | Yes | |
8.1. | Were statistical analyses adequately described and the results reported appropriately? | Yes | |
8.2. | Were correct statistical tests used and assumptions of test not violated? | Yes | |
8.3. | Were statistics reported with levels of significance and/or confidence intervals? | Yes | |
8.4. | Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? | Yes | |
8.5. | Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? | Yes | |
8.6. | Was clinical significance as well as statistical significance reported? | Yes | |
8.7. | If negative findings, was a power calculation reported to address type 2 error? | N/A | |
9. | Are conclusions supported by results with biases and limitations taken into consideration? | Yes | |
9.1. | Is there a discussion of findings? | Yes | |
9.2. | Are biases and study limitations identified and discussed? | Yes | |
10. | Is bias due to study's funding or sponsorship unlikely? | Yes | |
10.1. | Were sources of funding and investigators' affiliations described? | Yes | |
10.2. | Was the study free from apparent conflict of interest? | Yes | |