GMU Wk4 EB Metabolic Syndrome Prevention & Treatment Program Article Discussion Implementing an Evidence-Based Metabolic Syndrome Prevention and Treatment | Course Hero

GMU Wk4 EB Metabolic Syndrome Prevention & Treatment Program Article Discussion Implementing an Evidence-Based Metabolic Syndrome Prevention and Treatment Program Utilizing Group Visits

In this study, the researchers looked at changes in patients understanding of risk factors associated with metabolic disease and changes in habits to decrease those risks. Through a model curriculum, participants were provided information about how their decisions were influencing the development and progression of metabolic disease. .

This is an interesting study because here we see the use of both repeated measures t-tests as well as independent t-tests. How did the researchers use both types of t-tests in light of the fact that we discussed you should choose one or the other?
Discuss the sample size in the Sumter County sample. Using a a source, discuss the validity of the design with just 5 participants?
In the article, the authors indicate that some data are positively-skewed. Discuss the meaning of that, and why would the skew of data interfere with using it in the t-tests? (In your response, consider the distribution of the test statistic).

Hospital Rates of People Living with HIV in the United States, 2009

The authors use confidence intervals (CI) throughout their results.
Using an example from the article, explain the meaning of the CI for the specific case you selected.
How could you decrease the range of a confidence interval?
Review Figure 1 carefully. Notice that the CI is given as whiskers on the plot. Using the data in the text about this figure and the overlapping nature of the confidence intervals and the means, explain why there is a significant difference between Black and White but not White and Hispanic.
In Table 2 the authors present data surrounding the hospitalization rates based on sex both by OIs (preventable and non-preventable).
Research the rate ratio and discuss it for the preventable OIs data.
Construct an appropriate graphical representation of the data in Table 2 RESEARCH
Implementing an evidence-based metabolic syndrome
prevention and treatment program utilizing group visits
Deborah M. Greer, DNP, ARNP1 & Dawn C. Hill, DNP, ARNP, CDE2
1 Cardiovascular Services, LLC, Inverness, Florida
2 Osceola Council on Aging, Kissimmee, Florida
Keywords
Behavior modi?cation; cardiovascular disease;
diabetes type 2; disease prevention; group
medical appointments.
Correspondence
Deborah M. Greer, DNP, ARNP,
212 S. Pine Ave., Inverness, Fl 34452.
Tel: 352-476-4879;
Fax: 352-419-6541;
E-mail: deb_fnp@yahoo.com
Received: July 2009;
accepted: July 2010
doi: 10.1111/j.1745-7599.2010.00585.x
Abstract
Purpose: To develop and implement a pilot program designed as a shared
medical group visit targeting metabolic syndrome prevention in two ethnically
diverse patient populations.
Data sources: The Cooperative Health Care Clinics (CHCC) module was
utilized for group sessions to focus on interactive discussions following the
L.E.A.R.N. format in order to encourage healthy lifestyle changes. Participants
completed a pre- and postknowledge base test that encompassed information
on healthy lifestyle changes in addition to disease processes associated with
metabolic syndrome. Each didactic session was evaluated using mean ± standard deviation for the knowledge tests. Analysis of variance was used in determining body mass index (BMI) and weight measured at weeks 1, 5, and 10.
Participants completed a 5-point Likert scale satisfaction survey on week 10.
Independent means t-test compared clinic results along with the Satterthwaite
approximate t-test because of unequal sample sizes to evaluate differences in
means.
Conclusions: There were no significant statistical differences in mean weight
or BMI on weeks 1 and 5. However, on week 10, there was a statistically significant difference for waist circumference in both clinics (p = .0466). Knowledge base improved in both clinics with a premean (0 score = 87 ± 18) and
postmean (0 score = 93 ± 14). Both sites received high scores for patient
satisfaction.
Implications for practice: The shared medical group visits program implemented in both clinic sites demonstrated that this is an effective model in
which to provide intensive patient education, foster peer support, and facilitate health-related behavioral changes. Peer support, self-management, and
continuity appear to be important factors in behavior change and improved
knowledge.
A substantial portion of the cardiovascular disease (CVD)
resulting from obesity is mediated by type 2 diabetes
mellitus and the closely related condition of metabolic
syndrome. Metabolic syndrome is an aggregation of
symptomless biochemical and physical conditions (Leslie,
2005) that is highly associated with obesity. Abdominal obesity is the form of obesity most strongly associated with the metabolic syndrome (Grundy, Brewer,
Cleeman, Smith, & Lenfant, 2004). People with metabolic
syndrome are at an increased risk for developing diabetes mellitus and CVD, as well as increased mortality
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from CVD and all-cause mortality (Ford, Giles, & Dietz,
2002). Obesity can be defined as an excess of body fat
(Grundy, 2004). A surrogate marker for body fat content
is the body mass index (BMI). The best way to estimate
central obesity in clinical practice is to measure waist circumference. This is because an excess of abdominal fat is
most closely associated with the metabolic risk factors.
Metabolic syndrome relates increasingly to obesity and
sedentary lifestyles, and attention must be given to
individual modification of lifestyle behaviors (Alberti
et al., 2009). In the Framingham cohort, when the risk
C 2011 The Author(s)
Journal of the American Academy of Nurse Practitioners 23 (2011) 76–83
C 2011 American Academy of Nurse Practitioners
Journal compilation
Implementing an evidence-based metabolic syndrome treatment program
D.M. Greer & D.C. Hill
RESEARCH SPOTLIGHT
OUTCOMES RESEARCH
Sample
A convenience sample of 22 patients with metabolic syndrome from two community-based free
clinics in Florida serving the uninsured. One clinic population was comprised of primarily
Caucasian and African American (n = 5) patients, while the other population was comprised
of primarily Hispanic patients (n = 17).
Informed Consent
Informed consent was obtained from all participants prior to initiation of the ?rst didactic
session. HIPAA consent was also obtained due to the utilization of clinical group visits.
Type of Data
Quantitative outcomes on multiple measures obtained from a pilot study of group visits at two
clinics. Speci?c data included pre- and posttests of knowledge attainment, objective
measurements from weeks 1, 5, and 10, and patient program satisfaction survey at week 10.
Data Collection Instruments or Tools
r Research-developed patient satisfaction instrument.
r Objective measures of weight, height, and waist circumference were obtained at weeks 1, 5,
and 10.
r Weekly pre- and posttesting of L.E.A.R.N. knowledge about weight control (Brownell, 2005).
r The Cooperative Health Care Clinics Module was utilized for group sessions (Clancey et al.,
2003; Jaber et al., 2006; Trento et al., 2001).
Types of Analyses
Strengths & Limitations
Repeated measures analysis of variance using the Satterthwaite approximate t-test due to
unequal sample size so as to evaluate differences in means on weight, body mass index, and
waist circumference at weeks 1, 5, and 10. Descriptive analysis of pre- and
post-knowledge-based test at each didactic session, and patient satisfaction at end of
program.
r Strength: Clinically signi?cant reduction in BMI and weight over 10-week program and high
patient satisfaction.
r Limitations: Small convenience sample size for pilot study, short duration of program, two
non-similar implementation sites, and no comparison group.
Brownell K. (2004) The L.E.A.R.N. program for weight management (10th ed.). Dallas, TX: American Health Publishing Company.
Clancey D, Brown, S. B., Magruder, K. M., & Huang, P. (2003). Group visits in medically and economically disadvantaged patients with type 2 diabetes
and their relationship to clinical outcomes. Topics in Health Information Management, 24, 8–14.
Jaber, R., Braksmeyer, A., & Trilling, J. (2006). Group visits for chronic illness care: Models, bene?ts and challenges. Family Practice Management,
13, 37–40.
Trento., M., Passera, P, Tomalino, M, Bajardi, M, Pomero Fulvio,. . ..Porta, M. (2001). Groups visits improve metabolic control in type 2 diabetes: A
2-year follow-up. Diabetes Care, 24, 995–1000.
for new onset of diabetes was examined in both men and
women, the presence of metabolic syndrome was highly
predictive of new-onset diabetes (Ford et al., 2002). The
clinical management of obesity requires considerable patient education, intensive patient self-management, and
behavior modification, which is difficult for the healthcare provider to achieve in the traditional 15-min office
visit. Obesity may represent a modifiable risk factor for
the development of metabolic syndrome that can best
be addressed through a supportive group visit model of
healthcare delivery.
With this information in mind, the purpose of this report is to discuss findings of a study using group visits
to prevent/treat metabolic syndrome. The aims of the
study were to: (a) design a pilot shared medical visit program employing the Lifestyle, Exercise, Attitudes, Re-
lationships, Nutrition (L.E.A.R.N.) weight management
curriculum in two ethnically diverse, underserved clinics; (b) compare program feasibility, implementation, and
obesity-related outcomes in the two clinics; and (c) develop a packaged program for shared medical visits targeting metabolic syndrome in the primary care settings.
The methodology box summarizes reasons for selection
of this approach.
Review of literature
De?nition of metabolic syndrome and obesity
Metabolic syndrome is an increasing health concern
and a common problem encountered by healthcare
providers. The American Heart Association (AHA) estimated that over 50 million Americans have metabolic
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Implementing an evidence-based metabolic syndrome treatment program
syndrome, with the dominant risk factor being abdominal obesity (AHA, 2010). In the United States, 72 million adults are obese; this has increased by 2.4 million
adults from 2007 to 2009 (Centers for Disease Control
and Prevention [CDC], 2010). The American Diabetes
Association (ADA) stated in 2007 that 8% of the population, or over 23.6 million people, have diabetes
(Clancy, Yeager, Magruder, & Huang, 2007). Furthermore, metabolic syndrome tends to include inactivity,
aging, hormonal imbalance, and elicit insulin resistance,
which leads to diabetes mellitus (AHA, 2010).
For this project, we used the National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP
III) criteria to evaluate patients for the metabolic syndrome. According to the NCEP/ATP III criteria, a person
has a diagnosis of metabolic syndrome if they have three
or more of the following criteria (Expert Panel On Detection, Evaluation and Treatment of High Cholesterol in
Adults, 2001):
(1) Abdominal obesity: waist circumference >
40 inches (102 cm) in men > 35 inches (88 cm)
in women.
(2) Hypertriglyceridemia: ? 150 mg/dL (1.69 mmol)
(3) High-density lipoprotein (HDL) cholesterol: < 40 mg/dL (1.03 mmol) in men and < 50 mg/dL (1.28 mmol) in women. (4) High blood pressure: ? 130 mmHg systolic, ? 85 mmHg diastolic, or both. (5) Elevated fasting blood glucose: ? 110 mg/dL (6.1 mmol/L). Prevalence of metabolic syndrome Several studies have been conducted to explore the relationship between metabolic syndrome and obesity. One study, conducted at an obesity clinic, used the International Diabetes Federation Criteria. The overall prevalence of metabolic syndrome among the 102 obese patients was 40.2%. The prevalence was higher in females than males (43.7% vs. 32.3%). The presence of metabolic syndrome was noted to increase with increasing BMI (Termizy & Mafauzy, 2009). In another study, the prevalence of the metabolic syndrome was assessed in 304 patients with nonalcoholic fatty liver disease. The prevalence of metabolic syndrome in these patients increased with increasing BMI, from 18% in normal-weight subjects to 67% in those with obesity (Marchesini et al., 2003). To estimate the prevalence of metabolic syndrome in the United States as defined by the ATP III criteria, data on 8814 men and women aged 20 and older from the Third National Health and Nutrition Examination Survey (NHANES III) were analyzed. 78 D.M. Greer & D.C. Hill Among men, whites and Mexican Americans had the highest prevalence of abdominal obesity, hypertriglyceridemia, and low-HDL cholesterol. African American men had the highest age-adjusted prevalence of hypertension, and Mexican American men had the highest age-adjusted prevalence of hyperglycemia (Ford, Giles, & Dietz, 2002). Mexican American and African American women had the highest age-related prevalence for abdominal obesity. African American women had the highest age-related prevalence for high blood pressure, while Mexican American women had the highest age-adjusted prevalence of hypertriglyceridemia, low HDL, and hyperglycemia. The prevalence of metabolic syndrome increased from 6.7% among participants 20 through 29 years to 43.5% and 42% for participants aged 60 through 69 and 70 years or older, respectively (Ford et al., 2002). Regardless of diagnostic criteria used, there is full agreement that therapeutic lifestyle change, with emphasis on weight reduction, constitutes first-line therapy for the metabolic syndrome (Grundy et al., 2004). An increase in physical activity may help improve glycemic control, reduce blood pressure, and positively affect coronary heart disease (Barrett, Plotnikoff, Courneya, & Raine, 2007). Without a doubt, successful treatment of metabolic syndrome is multifactorial and requires significant patient education, which is best supported by a multidisciplinary team approach. Barriers such as lack of family support, lack of resources, cost issues, lack of provider time, health literacy, and complexities of comorbidities are all cited as barriers to improved outcomes in the underserved population (Powell, Hill, & Clancy, 2007; Wen, Shephard, & Parchman, 2004). Group visits are a way to minimize these barriers as they have been shown to improve patient outcomes for the management of chronic disease states and to improve quality of life indicators through the utilization of a holistic approach to patient care and disease management (Epling et al., 2007; Jaber, Braksmeyer, & Trilling, 2006; Martin, Wu, Taveira, Eaton, & Shurma, 2007; Weinger, 2003). The purpose of this study, therefore, was to implement and examine a therapeutic lifestyle change program delivered during group visits for the treatment of metabolic syndrome; the main outcomes of interest were patient satisfaction, weight loss, and changes in waist circumference. Curriculum The model for the intervention was the L.E.A.R.N. manual, an adult weight management program utilizing a therapeutic lifestyle change approach (Brownell, 2004). The program has evidence-based research to support the effectiveness of the curriculum that addresses nutrition, D.M. Greer & D.C. Hill physical activity, lifestyle changes, goal setting, recording, and helpful devices to achieve goals in an interactive format. The material is written at an eighth grade level. The L.E.A.R.N. program is a 13-week program, which we modified into a 10-week program. Ashley et al. (2001) used the L.E.A.R.N. program in a randomized controlled trial of 113 overweight premenopausal women and compared it with traditional physician office-based intervention groups. Seventy-four of the 113 participants completed the year-long intervention with clinically significant difference in weight loss between the L.E.A.R.N. program and the traditional physician office-based program (7.7 ± 7.8 kg, 3.4 ± 5.4 kg). Anderson et al. (1999) conducted a randomized controlled study to evaluate 40 obese women with a mean age of 42.9. Women were assigned to a lifestyle group utilizing the L.E.A.R.N. program (n = 20) versus an aerobic exercise group (n = 20). The lifestyle group had a statistically significant weight loss (p < .001) and lost significantly more fat (p < .03) than the aerobic exercise group. The pre- and posttests utilized during our sessions were derived from the L.E.A.R.N. curriculum. Group medical visit models Group medical visits have been found to provide a forum through which healthcare providers can deliver extensive patient education and self-management instruction while also allowing for increased revenue productivity. For this project, we used the Cooperative Health Care Clinics (CHCCs) model, which provides care to patients with chronic conditions as a shared medical visit (Clancey, Brown, Magruder, & Huang, 2003; Jaber et al., 2006; Trento et al., 2001). The group sessions focus on interactive discussions that lead to patient self-management. The healthcare provider delivers individual care and health assessments in 5-min intervals with each patient participant in the group; typically the group contains 10–20 participants. The balance of the 90- to 120-min session is then focused on discussion and in providing educational curricula and materials to the participants. Methods Each shared medical visit was scheduled to meet once per week for 90–120 min over a consecutive 10-week period. Trial visits were conducted at each clinic prior to initiation of the study to gain acceptance by the clinic directors and institutional approval was obtained. One aim of the study was to compare two ethnically diverse populations who met the criteria for metabolic syndrome under the NCEP/ATP III criteria. Study participants were recruited by their healthcare providers to Implementing an evidence-based metabolic syndrome treatment program Table 1 Course curriculum Facilitators for all programs: Dr. Deborah Greer—Sumter County Dr. Dawn C. Hill—Osceola County Week 1- Introduction and discussion of metabolic syndrome Week 2- Exercise and foot wear Week 3- Nutrition Week 4- Cardiovascular disease Week 5- Cholesterol Week 6- High blood pressure Week 7- Diabetes and blood sugar control Week 8- Daily stressors Week 9- Kidney, feet, and nerve disease Week 10- Putting it all together—Summarized all weeks of program participate in the program based on established inclusion/exclusion criteria at each clinic. Clinic patients 18 years of age or older who met the NCEP/ATP III diagnostic criteria for established metabolic syndrome or who were at risk for metabolic syndrome (waist circumference men > 40 inches or women > 35 inches, or BMI > 27)
were eligible to attend the program. Two male participants were diagnosed with the metabolic syndrome based
on NCEP/ATP III criteria but were of normal waist circumference and BMI (Davis, Sawyer, & Vinci, 2008). Because of the close association with metabolic syndrome,
patients with one of the following diagnoses were also
recruited to participate: diabetes, hyperlipidemia, hypertension, central obesity, and/or CVD. Prior to the firstgroup session, the researchers obtained informed consent
in addition to a Health Information Portability and Accountability Act (HIPPA) consent from participants.
During the first session, participants were given individual program notebooks to store class handouts, a carrying bag, and a pedometer, which was used to monitor
participants’ daily steps as a measure of exercise. They
were encouraged to achieve 10,000 steps per day. Each
session began with faculty and patient introductions. A
brief pretest derived from the L.E.A.R.N. manual material was administered on a preselected topic at each visit.
The pretest was followed by a didactic-type presentation
of the selected educational topic presented by the faculty
member (Table 1). Facilitated group discussions and peer
learning were encouraged during and after the presentation. Patients were encouraged to share their experiences and problem-solving strategies. Each participant’s
program “notebook” was used to collect program handouts and other learning materials to function as a “journal.” Each journal also contained an area to record participants’ medications, blood pressure readings, weight,
waist circumference, and any important lab values that
were available. At the conclusion of each session, each
participant was given a brief posttest related to the weekly
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Implementing an evidence-based metabolic syndrome treatment program
lesson and a 5-min private meeting with the healthcare
provider in order to address individual concerns. A patient satisfaction survey was given upon completion of
the 10th session at each site. Participation in this program
was considered supplementary to patients’ usual clinic
visits.
Group visit con?dentiality issues
Participants are encouraged to openly discuss their conditions with each other. Although HIPAA regulations do
not specifically address group visits, by obtaining a signed
release, the healthcare provider can have participants
agree not to reveal personal information pertaining to
other participants outside of the group setting (Clancey
et al., 2003).
Clinic setting and sample. The study’s target patient
population included uninsured patients who reside in
Sumter County and Osceola County, Florida, and attend
two community-based free clinics. At the Sumter Clinic,
15 patients were initially recruited and seven patients
agreed to participate. Of those seven, five patients completed the 10-week program (a 71% retention rate). The
Osceola Clinic site recruited 19 Hispanic participants and
17 completed the program (a retention rate of 89%).
Measures. Outcome measures included pre- and
posttests derived from weekly surveys on basic knowledge of the topics …
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