Contents
Introduction
Clinical Question
Evidence Summary
Conclusions
Recommendations
Assessment of Patient Preferences
Outcomes
Implementation and Outcomes Assessment
Sample Data Form
Summary
Introduction
Hello, my name is Kristen Ryland. I am a graduate student at Virginia Commonwealth University in the School of Nursing. One of the courses I am taking this semester is a graduate research course called NURS 512: Advanced Nursing Science. The purpose of this course is to prepare us as future practitioners to be able to critique research studies, glean important information and decide if we should apply this information to our practice. During the course of the semester, we also completed an evidence-based project. This project involved developing a clinical question, reviewing current literature for evidence relating to the question, and making conclusions and recommendations based on this evidence. We also devised decision aids to help patients and healthcare workers determine if the treatment or intervention would be desirable to them. Finally, we developed standards in which to measure outcomes. This will enable us to see if the therapy is making a difference in the lives of our patients.

Why evidence-based practice? As our society evolves in the Information Age, practitioners are showered with many various types of information regarding therapies, treatments and interventions on a regular basis. Evidence-based practice helps the practitioner to shuffle through to find the best evidence regarding that therapy. By critiquing evidence from the highest quality studies (or any study), a practitioner will be better able to make sound decisions regarding treatments for a population of patients. Ideally, evidence-based guidelines, meta-analyses, and double-blind randomized controlled trials could provide a practitioner with the best information to inform practice. However, if these are not available, other types of studies may be critiqued for their usefulness.

No matter what type of information one has, it is important to carefully critique it according to the proper elements of critique for that study type. Our class used a well-written text called “Evidence-based practice: A primer for health care professionals” by Martin Dawes to learn how to critique various studies. By asking a clinical question, finding evidence and critiquing evidence related to that question, one is able to draw conclusions and make recommendations to improve the quality of their practice. I hope that you find my evidence-based project useful in your practice.

Clinical Question

The clinical question I chose to answer is:
In adult patients with non-insulin dependent type 2 diabetes, do people who check their blood sugar using a glucometer everyday have lower HbA1c levels than those who test less often (less than daily)?

Keeping this specific question in mind, I began a review of the evidence. I used the VCU library resources to check databases such as PubMed/MEDLINE, CINAHL, Cochrane Library, and Academic OneFile. I used other resources such as American Diabetes Association website and www.guidelines.gov. I found many articles relating to diabetes and blood sugar monitoring. However, I only included the studies pertinent to my very specific question, namely blood sugar monitoring using a glucometer (versus urine testing), in adult type 2 diabetics (non-insulin requiring), and using HbA1c levels as the measure of glycemic control. See the evidence summary table below.

Evidence Summary

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Stetler’s Rating Scale from:
Stetler, C. B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4), 195-206.

  • Two components of score:
  • Type/ DESIGN of study = Levels I – VI
  • Quality of study = A – D
  • Design of study:
  • Level I – Meta-analysis of multiple controlled studies
  • Level II – Individual experimental study/ RCTs
  • Level III – Quasi-experimental study
  • Level IV – Non-experimental study, including descriptive and qualitative studies
  • Level V – Case report or program evaluation/ QI data
  • Level VI – Opinion of respected authorities
  • Quality of study
  • A = Very well-designed study; no relevant flaws
  • B = Fairly well-designed study; a minor flaw or two
  • C = Moderate flaws in design or implementation of design
  • D = Major flaw(s) raise serious questions about credibility of findings

 

Conclusions
Here are the conclusions I reached based on the evidence in the above table. Each statement is referenced according to the number of the study in the table.

  • In adult patients with non-insulin dependent type 2 diabetes, self-monitoring of blood glucose does not improve HbA1c levels (1, 4, 5, 6, 8).
  • (Note: The results of study 1 are most trustworthy because of the strength of the study. Other lower quality studies in the evidence summary reached the same conclusions; however, the results may not be as reliable.)
  • Blood glucose monitoring in type 2 diabetics may be helpful in monitoring postprandial blood glucose values (3).
  • (Note: This statement is based on expert opinion in article 3 above in the table. While evidence-based practice is the gold standard, clinical experience can also dictate aspects of practice.)

Recommendations
Here are recommendations taken from article 3:
American Diabetes Association. (2007). Standards of medical care in diabetes – 2007. Diabetes Care, 30, S4-S41.

  • Blood glucose self-monitoring is helpful in achieving target blood glucose ranges in patients on oral agents or with diet-controlled diabetes.

 

  • Checking blood glucose after meals may help to achieve desired postprandial blood glucose.
  • Check HbA1c levels every 3 months in patients whose diabetes treatment plan has changed or who are outside of the target blood glucose ranges.
  • Check HbA1c levels twice a year for those patients whose blood glucose remains in target blood glucose ranges.
  • Blood glucose self-monitoring may be helpful for patients who wish to see how food or exercise directly affects their blood sugars.
  • (Note: this recommendation is from my personal experience working as a Registered Dietitian in the field of diabetes.)

Assessment of Patient Preferences
Here is a decision aid that may assist patients and healthcare providers in determining whether to use blood glucose self-monitoring as an adjunct diabetes therapy or not.

Decision Aid for Blood Glucose Monitoring

This guide can help you make decisions about the treatment your health care provider is asking you to consider.

It will help you to:

  1. Clarify what you need to decide.
  2. Consider the pros and cons of different choices.
  3. Decide what role you want to have in choosing your treatment.
  4. Identify what you need to help you make the decision.
  5. Plan the next steps.
  6. Share your thinking with your health care provider.

Step 1. Clarify what you need to decide.

Should I check my blood glucose daily using a blood glucose monitor?

When does the decision have to be made? Check one

□ Within days
           
□ Within weeks

□ Within months

How far along are you with this decision? Check one

□ I have not thought about it yet
□ I am considering the choices
           
□ I am close to making a choice
           
□ I have already made a choice

Step 2. Consider the pros and cons of different choices.

What do I think of the pros and cons of the proposed treatment?

  1. Review the common pros and cons
  2. Add any other pros and cons that are important to you
  3. Show how important each pro and con is to you by choosing a number between 1 and 5, where 1 is not important and 5 is very important to you.

Pros and Cons of Blood Glucose Monitoring

Pros

How important is it to you? (1= not,
5 = very)

Cons
(? number of people affected)

How important is this to you? (1= not, 5 = very)

Can monitor progress of diet, exercise or drug therapies.
Can note blood sugar trends over time in response to changes in your regimen.

1  2  3  4  5

Side effects: some people may have increased hypoglycemia
33 out of 150 have hypoglycemia compared with 14 out of 152 that are not testing

1  2  3  4  5

Can check your blood sugar quickly and away from your home if needed.

1  2  3  4  5

Reactions during or after testing
May cause minor pain at time of test and calluses to form on fingers after long-term testing.

1  2  3  4  5

Immediate feedback on blood sugar levels
Can see how food or exercise directly affects blood sugar.

1  2  3  4  5

Cost of blood sugar strips and insurance coverage

1  2  3  4  5

Other pros:

1  2  3  4  5

Extra clinic visits based on blood sugar results if outside of desired range

1  2  3  4  5

Testing blood sugar in certain populations has not been shown to improve blood sugar control.
Out of 301 people, there was an average decrease in HbA1c of 0.14 – 0.17 percentage points.

1  2  3  4  5

 

What do you think about this treatment? Check one

 

Willing to consider this treatment. Pros are more important to me than the cons 

Unsure

Not willing to consider thistreatmentCons are more important to me than Pros

 

Step 3. Decide the role you want to have in choosing your treatment. Check one

□ I prefer to decide on my own after listening to the opinions of others
           
□ I prefer to share the decision with: ______________________
           
□ I prefer someone else to decide for me, namely: ____________________

 

Step 4. Identify what you need to help you make the decision

Please circle your answers to these questions.

What I know

Do you know enough about your condition to make a choice?

Do you know which options are available to you?

Do you know the good points (pros) of each option?

Do you know the bad points (cons) of each option?

Yes

 

Yes

 

Yes

 

Yes

No

 

No

 

No

 

No

Unsure

 

Unsure

 

Unsure

 

Unsure

What’s  important

Are you clear about which pros are most important to you?

Are you clear about which cons are most important to you?

Yes

 

Yes

No

 

No

Unsure

 

Unsure

How others help

Do you have enough support from others to make a choice?

Are you choosing without pressure from others?

Do you have enough advice to make a choice?

Yes

 

Yes

 

Yes

No

 

No

 

No

Unsure

 

Unsure

 

Unsure

How sure I feel

Are you clear about the best choice for you?

Do you feel sure about what to choose?

Yes

 

Yes

No

 

No

Unsure

 

Unsure

From: Decisional Conflict Scale © A. O’Connor 1993 Revised 1999

If you answered no or unsure to many of theses questions, you should talk to your health care provider.

Step 5. Plan the next steps           

What do you need to do before you make this decision?

For example, do you need to discuss the treatment plan with your specialist provider?

 

Step 6. Share the information on this form with your health care provider.

It will help you health care provider understand what you think about this treatment.

 

Outcomes
This section details outcomes for patients.

  • We would like HbA1c levels of 7% or less (American Diabetes Association recommended level) to prevent long-term complications of uncontrolled diabetes, such as retinopathy, nephropathy and neuropathy.

 

  • The patient with type 2 diabetes will be comfortable with his/her decision to test their blood glucose and will understand reasons for doing so to promote adherence to diabetes treatment plan.

Implementation and Outcomes Assessment
This section details implementation of the plan for practitioners and ways to measure patient outcomes.

  • Patients will be requested to have a visit every 3 months to measure HbA1c levels until they are <6.5-7% range (then they can be measured every 6 months), regardless of whether they perform self-blood glucose monitoring or not. A nurse will check HbA1c level in office using a Metrika A1cNow+ kit that measures results in 5 minutes.
  • If they have decided to check their blood glucose, we will ask them to bring their blood glucose log to the office with them.
  • The practitioner will review blood sugar numbers since the previous visit or onset of monitoring, will discuss patterns and note how HbA1c level reflects (or does not reflect) these values.
  • The practitioner or nurse will count the number of blood sugars since the previous visit or onset of monitoring that are less than 180 mg/dL but are greater than 90 mg/dL (target blood glucose range according to American Diabetes Association). They will divide this number by total number of blood glucose results to get a percentage.
  • The practitioner or nurse will count the number of blood sugars since the previous visit that are greater than 180 mg/dL (out of target range according to American Diabetes Association). They will divide this number by total number of blood glucose results to get a percentage.
  • The practitioner or nurse will count the number of blood sugars that are less than 70 mg/dL (hypoglycemia according to American Diabetes Association). They will divide this number by total number of blood glucose results to get a percentage.
  • The practitioner/nurse/office staff will keep these totals with the patients’ records for review every three months to see if the percentage of numbers falling into the desired range of 90 – 180 mg/dL is rising and the percentage of numbers in the range of less than 70 mg/dL and greater than 180 mg/dL is falling.
  • The practitioner and patient should adjust diabetes therapies to help achieve desired blood glucose numbers if the current treatment plan has not shown improvement in blood sugar numbers or HbA1c levels. These adjustments can include medication, diet, activity or other lifestyle changes.
  • The practitioner will also ask patients these questions in regards to checking blood glucose:
  • How do you feel about checking your blood sugars?
  • Do you feel that checking your blood sugar is helping to control your blood sugars?
  • Are you making progress toward your personal goals for diabetes management?
  • Do you have any questions about your blood sugar readings or how to use your monitor?

Sample Data Form
This is a sample data form that clinicians may use to keep track of the patients’ blood glucose results as outlined in the above section.

Patient name:

Date:

 

 

 

 

 

 

 

 

# BG < 70

 

 

 

 

 

 

 

 

# BG >180

 

 

 

 

 

 

 

 

# BG 90-180

 

 

 

 

 

 

 

 

Total # of BG

 

 

 

 

 

 

 

 

% of BG < 70

 

 

 

 

 

 

 

 

  % of BG >180

 

 

 

 

 

 

 

 

% of BG 90-180

 

 

 

 

 

 

 

 

HbA1c

 

 

 

 

 

 

 

 

How does patient feel about checking blood sugars?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does patient feel that checking blood sugars is helping to control diabetes?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does patient feel they are making progress toward personal diabetes goals?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Does patient have questions about blood sugar readings or how to use the monitor?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Summary
Thank you for taking the time to review my evidence-based project. It is my hope that this can aid you in your practice, and I encourage you to develop your own clinical question, review available evidence, draw conclusions/recommendations and share them with other practitioners. If you have any questions about my project, feel free to email me at: rylandkl@vcu.edu.

 

 

 

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