Research ArticleOutcome Analysis of Hemoglobin A1c, Weight, and BloodPressure in a VA Diabetes Education ProgramSusan L. North, RD, MPH; Glen A. Palmer, PhD, ABNABSTRACTObjective: Todeterminetheeffectofaspecicdiabeteseducationclass(Basics)onhemoglobinA1cvalues, weight, and systolic blood pressure.Design: Inthisretrospectivestudy, theresearcherscompared2groupsofmaleveteranswitharecentdiagnosisoftype2diabetes. Onegroupreceiveddiabetesgroupeducation(n 175)overa4-monthperiod, and the other received standard diabetes management follow-up (n 184).Setting: Outpatient clinic setting in the Midwest.Interventions: Basics class compared with standard level of care.MainOutcomeMeasures: Pre-andpost-laboratoryvaluesforhemoglobinA1c,weight,andsystolicblood pressure.Analysis: Multivariate analysis of covariance and follow-up univariate statistics for signicant differences.Results: Findings revealed signicant differences in hemoglobin A1c (P 4months' follow-up. Theyalsonoted that HbA1c decreased morewith additional contact time betweenparticipantandeducator. Adecreaseof 1% was noted for every additional23.6hours of contact. One percentdrop in HbA1c is associated withimproved outcomes.7Ina meta-analysis of 153studiespublished between 1977 and 1994evaluatingtheeffectiveness of inter-ventions designed to improve patientcompliance with medical regimen,Roteretal8concludedthatnosingleintervention strategy appeared consis-tentlystrongerthananyother.How-ever, the authors noted that the morecomprehensivetheprogramwas, themoreeffectivetheoutcomewas, andthe most benecial interventionsincluded3comprehensiveelements:educational, behavioral, and affective.Offering groupeducationtopatientsmayprovetobemorecost-effective.9Duncanet al10reviewedcommercialand Medicare claims payer-deriveddatasetsandconcludedthatpatientswho participated in diabetes educationhad lower average costs thanthosewho didnot participate indiabeteseducation. In addition, diabetes educa-tionparticipants weremorelikelytofollow recommendations for care thansimilar patients who did not participatein diabetes education. The authorsconcludedthatqualityofcarecanbeimproved and costs reduced, specif-ically among men and people in disad-vantaged areas.TheBasicsprogramisusedattheVAhealthcare systemfromwhichthis retrospective chart review wasconducted. This curriculum originatesfromoneof the rst outpatient dia-beteseducationcenters. Clinical andeducational guidance was providedbyaregistereddietitian, aregisterednurse, andaphysician. Thephiloso-phy at the heart of the program is therecognitionthatthepatientisatthecenterofthisteamandcanlearntoself-manage diabetes. Four educationalmodels are applied to the curriculum:adult learning theory,11the trans-theoretical model (stages of change),12the healthbelief model,13and the pub-lichealthnursingmodel.14Thepro-grammeets the National StandardsforDiabetesSelfManagementEduca-tion Programs.15A detailed descriptionand philosophy of the program can befound in Diabetes Basics: education,innovation, revolution.16The targetaudienceforthecurriculumisnewlydiagnosed persons with type 2 diabeteswhohave receivedlittle or noself-management education. The objec-tivesoftheprogramarethreefold:toimprove glycemic control, to enhanceknowledge of diabetes management,and, for patients, to implement at least1 positive behavior change.In the mid 1990s, a team from theInternational Diabetes Center in Min-neapolis, MN, conducteda randomizedcontrolledtrial to compare diabetesgroup education using the Basics cur-riculum(n 87)withindividual in-struction(n 83). Subjects receivededucation in 4 sequential sessionsover 6 months. Outcomes reviewedincluded change in knowledge,self-management behaviors, weight,BMI, HbA1c, health-related qualityoflife, patient attitudes, and medicationregimen. Results showedsimilar im-provement inknowledge, BMI, andhealth-related quality of life. Hemoglo-bin A1c decreased in both groupsalthough the decrease was marginallygreaterin groupeducationthanindi-vidual instruction. This study demon-strated that group education andindividual education are equally effec-tive at providing the outcome ofimproved glycemic control.17In this particular VA outpatientclinic setting, veterans are typicallyreferred to classes by a diabetes educa-tionconsultplacedbytheirprimarycareprovider. TheBasicsprogramispresented by a registered dietitianandaregisterednursein3sessions.Sessions 1 and 2 are planned forapproximately 2 weeks apart to allowpatientstodeneandfocustheiref-forts for behavior change. Session3is held3months after session2toreneandpracticeeffortsfurtherto-wardlong-termbehavior change inthose areas the patient has identied.Figure 1 shows the content of each in-dividual session. The three sessionlengths are 2.5, 2, and 1.5 hours.Before each session, vital signs aretaken and recorded in the medical re-cord. The dietitianweighs eachpa-tient ona calibratedscale. Patientsareweighedfullyclothed.Thenursetakes a bloodpressure reading beforeclass. An elevated blood pressure(>140/90) is rechecked before theend of the session.Althoughtheprimarygoal oftheBasics programis glycemic controlfor the patient, management ofweight andbloodpressuremayalsoprovide signicant health benets.Atracking and goal setting toolcalledMySuccess Plan is usedintheBasicscurriculumforthebenetof instructors and patients. With thistool, instructors guide patients tofocus on1 area of change from7deemed critical by the American Asso-ciation of Diabetes Educators. These 7areas include nutrition, physical activ-ity, medication regimens, problemsolving, stress management, bloodglucose testing, andother forms ofrisk reduction such as smoking cessa-tion. Patientsmaybenetbysettingmore measurable andspecic goalsfor behavior change, thus avoidingfrustration and confusion. Successplans helppatients prioritizeeffortsand dene expectations.Family and peer support are recog-nized as important to a patient'sself-management efforts. Therefore,veterans are encouraged to bring afamilymember suchas aspouse toparticipate in all sessions. Veteransalsomay learnfromeachother bysharing personal struggles and suc-cesses. A regularly occurring follow-upgroup is offered to veterans who havecompleted the 3 sessions. Follow-up isencouragedquarterly, biannually, orannually per the veteran's choice.Overall, basedontheliteraturere-view, diabetes groupeducationmayresult in modest improvement inHbA1c, weight, blood pressure, andother indicators of health. The primaryobjective of this retrospective chartJournal of Nutrition Education and BehaviorVolume 47, Number 1, 2015 North and Palmer 29reviewwas todetermine the associationof diabetes education classes using theBasicscurriculumwithbloodglucosemanagement, weight, and blood pres-sure outcomes. It was hypothesizedthat individuals who received diabeteseducation using the Basics curriculumwouldhaveimprovedoutcomesoverindividuals who did not participate inthese classes.METHODSThis study was a retrospective, obser-vational chart review of medicalrecords froma large VA medical centerintheMidwest that uses theBasicsprogram. The study was approvedby the VA-afliated institutionalreviewboardandresearchanddev-elopmentcommittee. Becauseoftheretrospective nature of the study, theresearchers obtained a waiver ofinformedconsent andHealthInsur-ance Portability and AccountabilityAct authorizationfromthe afliateinstitutional review board.Patient SampleThis was a retrospective analysis ofmedical records of veterans whoreceived care from a large VA medicalcenter inthe Midwest. Medical re-cords wereincludedinthis studyifthe medical record showed a diagnosisof type 2 diabetes within the previous2years.Ofthe1,626patientrecordsscreened, 1,263 were initiallyexcluded in the study. Four additionalpatientrecordswereexcludedowingtoextremeoutliers onpretreatmentscores. Themajorityof screenedpa-tient records that were excludedfromthis study did not meet thecriteriaforarecentdiagnosisoftype2 diabetes or did not have laboratoryvalues that fell within establishedtime parameters. Figure 2 shows aowchart of the selection process.A total of 359 medical records(Basics class 175 and controlgroup 184) wereacceptedfor thisstudy. The time period for this chart re-view is between the beginning ofJanuary, 2008andtheendof June,2011. Treatment group candidateswere identied froma spreadsheetkept internally by the medical center'snutrition clinic, which tracks pre- andpost-class values for HbA1c, weight,andsystolic bloodpressure andhasbeenusedforcasemanagementpur-poses within the facility. Each patientinthetreatmentgroupcompletedall3 sessions of the Basics diabetes educa-tionprogram.Thecontrolgroupwasselectedfromalist of veterans whoare patients of the medical center,whohavea diagnosis of type2diabetes,and had not beenseen ina VAdiabeteseducation clinic.The mean age of individuals in theBasics class was 65.2 years (SD, 8.87);the meanage of the control groupwas 66.8 (SD, 9.67). Most of thesubjects were Caucasian(78.9%forthe treatment group vs 73.4% for thecontrol group). There were no signi-cant differences between groups basedon age (P .11) or ethnicity (P .33).Chart ReviewFor the treatment group, the re-searchers collected data includingweight and systolic blood pressurereadingsthatareroutinelytakenandrecordedbeforesessions1and3andwere present in the medical record. If2 systolic blood pressure readingswere present in the medical record forthe same class day, the lower of the 2was taken. For thetreatment group,HbA1c values were taken fromtheclosest availablereadingbeforetreat-ment (nogreater than90days) andthe earliest reading posttreatment (nogreater than 90 days). Total length oftime between pre- and posttreat-mentwasnomorethan10months.This period was determined to beappropriate because the accuracy ofan HbA1c value is approximately6090 days. A medical record wasincludedinthestudyif theveteranhadbeengivenadiagnosisoftype2diabeteswithintheprevious2years.The researchers collected data forthe control groupincluding HbA1c,weight, and systolic blood pressurefound in the medical record at baselineandfollow-upforthesamelengthoftime as the treatment group. Data pre-sent in the medical records wereassumed to have been collectedfollowing standard VA procedure.Figure1. Educational topicspresentedintheBasicsprogrambysession.30 North and Palmer Journal of Nutrition Education and BehaviorVolume 47, Number 1, 2015Statistical AnalysisAminimumsamplesizeof 211wasdetermined as necessary to provideforapowerof0.80andeffectsizeof0.25. Alpha for this calculationwassetat P