Seven diabetes self-management behaviors such as healthy eating, physical activity, and blood sugar monitoring have been found to be positively correlated with good glycemic control, reduction of complications, and improved quality of life. In addition to physical health outcomes, self-management behaviors have been shown to have relationships with mental health outcomes. A previous study found major depression was negatively associated with patient-initiated selfcare behaviors that are difficult to maintain (exercise, diet, medication adherence). Alternatively, another study found no noticeable value to existing care from an intervention to enhance self-management support for long term conditions. These mixed results indicate need for better understanding of active components required for effective self-management support in both primary care and patients’ everyday lives.
The goal of this paper is to understand the relationship between self-management behaviors and health outcomes among low-income minority patients who participated in a comparative-effectiveness trial of 3 care-management models. This would provide knowledge about mechanisms that are helping improve self-management behaviors for these vulnerable patients with comorbid diabetes and depression where there’s currently limited knowledge. It is hypothesized that both care-management interventions and patient self-management habits may influence health outcomes, specifically: (1) subjects who performed better self-management behaviors than average would result in greater improvement in health outcomes, and (2) the rate of change of health outcomes could vary by study group.
This study analyzed patient data from the Diabetes-Depression Care-Management Technology Trial, “DCAT,” a quasi-experimental trial. DCAT tested an automated telephonic assessment and provider (social worker and nurse team) notification technology to facilitate depression care-management (TC, n=435) in comparison to telehealth team-supported depression care (SC, n=474) and usual primary care (UC, n=484) for type 2 diabetic patients. The available selfcare data includes exercise, diet, glucose monitoring, and foot inspection. The available health outcomes include HbA1C, body-mass-index (BMI), cholesterol, and PHQ-9 score for depression. Data was recorded at baseline, 6-, 12- and 18-months through patient interviews and electronic medical records.
Multi-level modeling was used to analyze the relationship between self-management behaviors, study group, and health outcomes over time, controlling for baseline and selfcare habits. Missing data was imputed using multiple stochastic imputation.
It was found that, over the course of the 18-months of DCAT, subjects in the TC group significantly improved self-management behaviors compared to the UC group. Subjects in the TC and SC groups saw significant reductions in HbA1C value and cholesterol compared to UC. Additionally, patients in the TC group saw significant improvements in PHQ-9 score compared to UC. Subjects who performed better selfcare than the grand mean selfcare score saw significant reductions in cholesterol. Consistent with the literature, there was little change in BMI throughout the intervention.
Conclusions and Implications
Improved selfcare behaviors contributed to improved health outcomes observed in intervention groups of DCAT. The results indicate elements of the automated technological interventions, such as increased frequency of assessment and notification of providers to follow-up with patients, significantly enhanced self-management behaviors for a population with greater challenges in selfcare and access to care.