Abstract
Patients with diabetes have physical and psychological issues due to chronic illness. According to the guidelines of the Chinese Diabetes Society, after the diagnosis of patients with diabetes, they should receive routine health education, but this is the passive installation method of education. Nurses have made important contributions to the follow-up, education, and support of patients with diabetes and their families. The objective of this study was to evaluate the effectiveness of nurse-led follow-up care in routine health education and follow-up for patients with diabetes. Medical records of 721 patients with type 1 and type 2 diabetes were reviewed. Patients received nurse-led follow-up care including educational programs + Tai Chi exercises (patients received nurse-led follow-up care including educational programs for 6 months, n = 108), routine health education and follow-up + Tai Chi exercises (patients received routine health education and follow-up for 6 months, n = 205), or Tai Chi exercises only, but did not receive nurse-led follow-up care or routine health education and follow-up (patients received Tai Chi exercises only for 6 months, n = 408) for 6-months. The Zung Self-Rating Depression and Anxiety Scale and Summary of Diabetes Self-Care Activities were used to evaluate anxiety, depression, and self-care activities, respectively. Before the start of follow-up care (BFC), knowledge regarding diabetes and its threat was ≤1.75, anxiety and depression scores were ≥52 each, and self-care activities were ≤37. After 6 months of follow-up care, patients in the patients received nurse-led follow-up care including educational programs for 6 months improved their knowledge regarding diabetes and its threat, anxiety, depression, and self-care activities as compared to their before the start of follow-up care conditions and patients in the RF and patients received Tai Chi exercises only for 6 months at after 6 months of follow-up care conditions (P < .001 for all). Chinese type 1 or 2 diabetes patients had worse physical and psychological conditions and less knowledge regarding diabetes and its threat. Nurse-led aftercare, including educational programs with Tai Chi exercises for 6 months, decreased anxiety and depression and improved knowledge regarding diabetes and its threat and self-care activities in diabetic patients (Level of Evidence: IV; Technical Efficacy: Stage 5).
Keywords: aftercare, anxiety, chronic disease, depression, diabetes, follow-up care, nurse practitioners, routine health education, self-care activities
1. Introduction
Diabetes, especially type 2 diabetes, is common in China.[1] Type 1 diabetes has a low incidence, but its absolute numbers are high in the Republic of China.[2] In addition, a large number of prediabetic patients in China are at risk of diabetes.[1] Compared to the United States of America, China has less awareness, diagnosis, treatment, and control of diabetes.[3] Because of chronic illness, diabetic patients suffer not only from physical conditions but also from psychological issues[4] regarding mental health, such as diabetes distress and anxiety,[5] depression[6] and disordered eating.[5] Glucose control in patients with diabetes requires drug treatment and intensive health education.[7] Intensive health education and care for patients with diabetes are provided to reduce healthcare burden.[8]
According to the guidelines of the Chinese Diabetes Society, after the diagnosis of patients with diabetes, they should receive routine health education.[9] In China, routine health education and follow-up for patients with diabetes include lectures from health professionals at institutes.[10] However, this is a passive installation method in education. Besides instructions, there are several factors and measures required to count patients with diabetes for health management to overcome risks and complications.[8,11] There is a lack of active learning and a need for comprehensive health education and follow-up of Chinese diabetes patients.[12]
Nurses have important contributions to the follow-up of patients, education of patients, and support of patients with diabetes. In addition, nurses provide moral support to families and significant others of patients.[13] Nurses play a crucial role in providing essential support[4] and managing the behavior of patients[14] with chronic diseases, such as diabetes. Nurse-led care has been reported to improve glycemic control in adults with diabetes in Latinos[15] and Hispanic[16] population. The American Association of Clinical Endocrinology Clinical Practice Guidelines recommend the accomplishment of behavioral intervention packages for diabetic patients through nurses, if required.[17]
The objectives of the medical record analyses were to evaluate the knowledge regarding diabetes and its threat, anxiety, depression, blood sugar and HBA1c (glycated hemoglobin) levels, and self-care activities of type 1 and 2 diabetes patients who received nurse-led follow-up care with Tai Chi exercises for 6 months against those who received routine health education and follow-up with Tai Chi exercises for 6 months.
2. Materials and methods
2.1. Ethics approval and consent to participate
The protocols of the established study were prepared by the authors themselves and approved by the Chongqing University Affiliated Central Hospital Review Board and the Chinese Diabetes Society (approval number: 15CUACHm dated December 15, 2020). The study follows the laws of China and the v2008 Declarations of Helinski. This study analyzed medical records. Therefore, registration in the Chinese clinical trial registry and written informed consent of patients were waived by the Chongqing University Affiliated Central Hospital review board.
2.2. Inclusion criteria
Patients aged ≥ 18 years with type 1 and 2 diabetes, defined according to the guidelines of the Chinese Diabetes Society[9] were included in the study. Patients should be able to write, speak, and understand the Chinese language.
2.3. Exclusion criteria
Individuals with cognitive impairments, psychological disturbances, and those taking steroids and other drugs that directly or indirectly affect blood sugar levels were excluded from the study.
2.4. Cohorts
A total of 108 patients received nurse-led follow-up care, including educational programs, for 6 months (NE cohort). A total of 205 patients received routine health education and follow-up for 6 months (RF cohort). A total of 408 patients did not receive nurse-led follow-up care or routine health education and follow-up care for 6 months (patients received Tai Chi exercises only for 6 months, TC cohort). In addition to nurse-led follow-up care or routine health education and follow-up care for 6 months, patients received treatment(s) for diabetes as prescribed by physicians. In addition to nurse-led follow-up care or routine health education, during follow-up care for 6 months is instructed to perform Tai Chi exercise at home. However, Tai Chi exercise classes were also available at the institute for 30 minutes in the morning from Monday to Saturday. The decision of patients receiving nurse-led follow-up care or routine health education and follow-up care for 6 months was based on the availability of healthcare professionals in institutes.
2.5. Nurse-led follow-up care including educational programs
This included regular visits by physician(s) and monthly blood chemistry. Counseling and education of patients through lectures by nurses, videos, and literature regarding diabetes knowledge, diet, and exercise education. Nurses were available for half an hour for each patient every 15 days for counseling and to address queries regarding the physical and psychological health of the patients.
2.6. Routine health education and follow-up care
This included blood chemistry every month. Regular monthly visits by physicians at the institute(s). Counseling and education of patients along with education in the literature were provided to patients during hospital visits, including physician(s) and/or nurse(s) visits. In addition, lectures of health professionals at institutes regarding diabetes knowledge, diet, and exercise education should be conducted.
2.7. Outcome measures
2.7.1. Demographic and clinical outcomes
Demographic, anthropological, social, and clinical characteristics of the patients were collected from their hospital records and analyzed.
2.7.2. Knowledge regarding diabetes and its threat
Knowledge regarding diabetes and its threat was evaluated by the nursing staff at the institute. The institute has questionnaires to evaluate knowledge regarding diabetes and its threat, as described in Table 1 (questionnaires are not yet published). The total score is 6. The higher the score, the higher the knowledge regarding diabetes and its threat.
Table 1.
Questionnaires to evaluate knowledge regarding diabetes and its threat (English version).
| Number | Question | Score |
|---|---|---|
| 1. | What is diabetes? | |
| Options | Diabetes is a condition that affects the body and blood sugar levels are increased. | 1 |
| In diabetes, only blood sugar level is increased. | 0.5 | |
| I have no much information about the same | 0 | |
| 2. | Do frequent urination, often thirst, weight loss, blurry vision, and tingling of hands and/ or feet symptoms of diabetes | |
| Options | Yes | 1 |
| No | 0 | |
| 3. | What is the cause of diabetes? | |
| Options | Eating too much sugar, fats, and alcohol | 1 |
| Family history | 0.25 | |
| Alcohol | 0.25 | |
| I have no much information about the same | 0 | |
| 4. | Do exercise and lifestyle modifications improve symptoms? | |
| Options | Yes | 1 |
| No | 0 | |
| 5. | Do antidiabetic drugs have adverse effects? | |
| Options | Yes | 1 |
| No | 0 | |
| 6. | Does diabetes on a long route diabetes cause damage to kidneys, eyes, and hearts? | |
| Options | Yes | 1 |
| No | 0 |
Questionnaires to evaluate knowledge regarding diabetes and its threat were evaluated by the nursing staff of the institute.
The total score is 6. The higher the score higher is knowledge regarding diabetes and its threat.
2.7.3. Anxiety and depression
The Zung Self-Rating Depression and Anxiety Scale was used to evaluate anxiety and depression in the enrolled patients. A total of 20 questions were applied for anxiety and 20 questions were applied for depression. Answers to each question were scored as follows: always, 4; very often, 3; sometimes, 2; rare, 1; absent, 0. A total score of 20 items of anxiety and 20 items of depression were multiplied by 1.25 for a standard score. A score of 50 or more was considered anxiety, and a score of 50 or more was considered depression.[18]
2.7.4. Glycemic control
Fasting venous blood samples were also collected. Blood sugar and % HBA1c levels were also measured. blood glucose level of 5.5 mmol/L (99 mg/dL) and/ or more and HBA1c 7% or more was considered as diabetes.[19]
2.7.5. Self-care activities
The Chinese version of the Summary of Diabetes Self-Care Activities was used to evaluate self-care activities. The questionnaire included 7 items (general diet, foot care activities, medication adherence, self-monitoring blood glucose level, any specific diet, and follow-up care); each item has a 0 to 7 scale. The higher the score, the higher the self-care activities (maximum value 49).[20]
2.7.6. Adverse effects
Any adverse effects during the 6-month follow-up period were evaluated. In addition, development of diabetic retinopathy, nephropathy, cardiomyopathy, and foot ulcer(s) were evaluated.
Knowledge regarding diabetes and its threat, anxiety, depression, blood sugar, HBA1c levels, and self-care activities of patients was evaluated before the start of follow-up care (BFC) and after 6 months of follow-up care (AFC).
2.8. Statistical analyses
InStat 3.01 GraphPad Software, Inc., San Diego, CA was used for statistical analysis. The Quartile Calculator (https://www.calculatorsoup.com/calculators/statistics/quartile-calculator.php) was used to calculate Q3 (third quartile) and Q1 (first quartile) values. Continuous normal, continuous non-normal, categorical variables, and ordinal data are depicted as mean ± standard deviation, medians with Q3–Q1 in parentheses, and frequencies with percentages in parentheses, respectively. The chi-squared test or Fisher exact test was used for categorical variables for statistical analyses. Unpaired t-test, paired t-test, repeated measures of analysis of variance (ANOVA), or one-way ANOVA were preferred for normal continuous and ordinal variables for statistical analyses. If at least 1 column failed the normality test (P < .05), then Mann–Whitney test or Wilcoxon matched-pairs signed-ranks test (Wilcoxon test), Kruskal–Wallis’ test (nonparametric ANOVA), or Friedman test (nonparametric repeated measures of ANOVA) was preferred for statistical analyses. The Kolmogorov–Smirnov method was used to check the normality of the continuous and ordinal variables. Tukey test (for normal continuous and ordinal variables) or Dann multiple comparison test (for non-normal continuous and ordinal variables) was preferred for post hoc analyses. All results were considered significant if the P-value was <.05.
3. Results
3.1. Study population
Medical records from December 15, 2019, to July 12, 2023, were reviewed. A total of 736 patients with type 1 and type 2 diabetes visited Chongqing Fourth People’s Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China, and the referring institutes. Among them (736 patients), 5 individuals had cognitive impairments, 7 individuals had psychological disturbances, 2 patients were taking steroids, and 1 patient was taking drugs that directly or indirectly affected blood sugar levels. Therefore, data (of 15 patients) were excluded from the study. Knowledge regarding diabetes and its threat, anxiety, depression, blood sugar, HBA1c levels, and self-care activities of 721 patients with type 1 or type 2 diabetes were included in the analyses. A flow diagram of the medical record analyses of this retrospective study is shown in Figure 1.
Figure 1.
The flow diagram of the medical record analyses of the retrospective study.
3.2. Outcome measures
3.2.1. Demographic and clinical outcomes
The male-to-female ratio was almost 1:1. Most of the patients were Han Chinese, had primitive education, were married, and were currently employed. A total of 93% of patients had type 2 diabetes. At BFC condition, knowledge regarding diabetes and its threat was 0.75 (1–0.5)/patient, patients had diabetes knowledge and its threat score were 1.75 for fewer, anxieties were 62 (63–61)/patient, depressions were 58 (60–55)/patient, none of the patient with <50 Zung Self-Rating Depression and Anxiety Scale for anxieties and depression, Zung Self-Rating Depression and Anxiety Scale for anxieties was 52 or more for patients and that for depression was 52 or more for patients, blood glucose level 5.7 mmol/L or more, % HbA1c was 7.5 or more, and the summary of Diabetes Self-Care Activities Chinese version was 37 or fewer. The patient did not report nephropathy or neuropathy. Gender, age, ethnicity, graduation level, marital status, employment status, and knowledge regarding diabetes and its threat were comparable among cohorts. The demographic, socioeconomic, and clinical parameters are reported in Table 2.
Table 2.
Demographic, socioeconomic, and clinical parameters of diabetic patients before the start of follow-up care.
| Parameters | Total | Cohorts | Comparisons between cohorts | |||||
|---|---|---|---|---|---|---|---|---|
| NE | RF | TC | ||||||
| 6-months follow-up care | – | Nurse-led follow-up care + educational programs + Tai Chi exercises | Routine health education and follow-up care + Tai Chi exercises | Tai Chi exercises only | ||||
| Number of diabetic patients | 721 | 108 | 205 | 408 | P-value | df | Test value | |
| Gender | Male | 351 (48) | 48 (44) | 95 (46) | 218 (53) | .1135 (χ2-test for Independence) | 2 | 4.351 |
| Female | 370 (51) | 60 (56) | 110 (54) | 190 (47) | ||||
| Age (years) | 38 (41–33) | 40 (44–35.5) | 39 (41–36) | 38 (41–33) | .0529 (Kruskal–Wallis’ test) | N/A | 5.877 | |
| Diabetes type | ||||||||
| Type 1 | 674 (93) | 101 (94) | 190 (93) | 383 (94) | .8534 (χ2-test for independence) | 2 | 0.3172 | |
| Type 2 | 47 (7) | 7 (6) | 15 (7) | 25 (6) | ||||
| Ethnicity | ||||||||
| Han Chinese | 662 (92) | 100 (93) | 180 (92) | 373 (92) | .9893 (χ2-test for independence) | 6 | 0.8948 | |
| Mongolian | 52 (7) | 7 (6) | 15 (7) | 30 (7) | ||||
| Tibetan | 7 (0.9) | 1 (1) | 2 (1) | 4 (0.9) | ||||
| Uyghur Muslim | 1 (0.1) | 0 (0) | 0 (0) | 1 (0.1) | ||||
| Education level | ||||||||
| Primitive | 250 (35) | 30 (28) | 70 (34) | 150 (37) | .0589 (χ2-test for independence) | 6 | 12.141 | |
| Below higher secondary | 286 (40) | 48 (44) | 80 (39) | 158 (39) | ||||
| Below graduate | 108 (15) | 20 (19) | 33 (16) | 55 (13) | ||||
| Graduate and above | 77 (10) | 10 (9) | 22 (11) | 45 (11) | ||||
| Marital status | ||||||||
| Married | 508 (70) | 78 (72) | 147 (72) | 303 (74) | .7706 (χ2-test for independence) | 2 | 0.5212 | |
| Single | 213 (30) | 30 (28) | 58 (28) | 105 (26) | ||||
| Current Employment | ||||||||
| Yes | 541 (75) | 83 (77) | 155 (76) | 303 (74) | .8371 (χ2-test for independence) | 2 | 0.3557 | |
| No | 180 (25) | 25 (23) | 50 (24) | 105 (26) | ||||
| *Knowledge regarding diabetes and its threat | 0.75 (1–0.5) | 0.75 (1–0.5) | 0.5 (1–0.5) | 0.75 (1–0.5) | .2575 (Kruskal–Wallis’ test) | N/A | 2.713 | |
| †Anxiety | 62 (63–61) | 62 (63–60) | 62 (63–60) | 62 (63–61) | .1017 (Kruskal–Wallis’ test) | N/A | 4.571 | |
| †Depression | 58 (60–55) | 58 (60–55) | 58 (61–55) | 58 (60–56) | .7625 (Kruskal–Wallis’ test) | N/A | 0.5422 | |
| Fasting blood sugar (mmol/L) | 5.8 (5.83–5.72) | 5.8 (5.83–5.72) | 5.8 (5.83–5.72) | 5.8 (5.83–5.72) | .91 (Kruskal–Wallis’ test) | N/A | 0.1885 | |
| % HBA1c | 8 (8–7.5) | 8 (8–7.5) | 8 (8–7.5) | 8 (8–7.5) | .716 (Kruskal–Wallis’ test) | N/A | 5.274 | |
| ‡Self-care activities | 34 (35–33) | 34 (35–33) | 34 (35–33) | 34 (35–33) | .7904 (Kruskal–Wallis’ test) | N/A | 0.4706 | |
Continuous non-normal and categorical variables and ordinal data are depicted as medians with Q3–Q1 in parenthesis and frequencies with percentages in parenthesis, respectively.
All results were considered significant if the P-value was <.05.
χ2-test = Chi-square test, df = degree of freedom, N/A = not applicable.
Test value (χ2-value for χ2-test; Kruskal–Wallis’ statistics for Kruskal–Wallis’ test).
Higher the score higher is knowledge regarding diabetes and its threat (total score is 6; evaluated by nursing staff; the institute has its questionnaires).
Zung Self-Rating Depression and Anxiety Scale (Zung Self-Rating Depression and Anxiety Scale; a score of ≥ 50 is considered as anxiety; a score of ≥ 50 is considered as depression).
The higher the score higher the self-care activity (maximum value 49).
3.2.2. Knowledge regarding diabetes and its threat
The AFC conditions of patients in the NE and RF cohorts improved knowledge regarding diabetes and its threat as compared to their BFC conditions (P < .001 for both, Friedman test) and patients in the TC cohort at their AFC conditions (P < .001 for both, Kruskal–Wallis’ test). Under AFC conditions, patients in the NE cohort had improved knowledge regarding diabetes and its threat compared to patients in the RF cohorts (P < .001, Kruskal–Wallis’ test).
3.2.3. Anxiety and depression
Under AFC conditions, anxiety and depression in patients in the NE, RF, and TC cohorts were relieved compared to their BRF conditions (P < .001 for all, Friedman test). Under AFC conditions, anxieties and depressions of patients in the NE and RF cohorts were relieved compared to those of patients in the TC cohort under their ARF conditions (P < .001 for all, Kruskal–Wallis’ test). Under AFC conditions, anxieties and depressions of patients in the NE cohort were relieved compared with those of patients in the RF cohort (P < .01 both, Kruskal–Wallis’ test). In ARF condition, 0 (0%), 8 (7%), and 1 (1%) patient had Zung Self-Rating Depression and Anxiety Scale for anxieties <50 for the TC, NE, and RF cohorts, respectively. At ARF, higher number of patients had Zung Self-Rating Depression and Anxiety Scale for anxieties <50 for the NE cohort than those of the RF (P = .0011, 95% confidence interval: 0.02603 to 1.053 (using the approximation of Katz.)) and TC cohorts (P < .0001). The ARF numbers of patients with Zung Self-Rating Depression and Anxiety Scale for anxieties <50 were statistically the same between the RF and TC cohorts (P = .3344, 95% confidence interval: 2.682 to 3.356 (using the approximation of Katz.)). In the ARF condition, none of the patients from any cohorts with <50 Zung Self-Rating Depression and Anxiety Scale for depression.
3.2.4. Glycemic control
None of the patients with ARF had blood glucose levels <5.5 mmol/L and % HbA1c had <7.
3.2.5. Blood glucose
Patients in the NE and RF cohorts had decreased blood glucose levels at ARF as compared to BRF conditions (P < .001 for both, Friedman test) and those of patients with TC under ARF conditions (P < .01 both, Kruskal–Wallis’ test). Patients with NE had decreased blood glucose levels at ARF as compared to those with TC (P < .05, Kruskal–Wallis’ test).
3.2.6. % HbA1c
None of the patients in any cohort had decreased % HbA1c under ARF conditions as compared to BRF conditions (P > .05, Friedman test). Patients in the NE and RF cohorts did not show a decrease in % HbA1c under ARF conditions as compared to those in the TC cohort (P > .05, Kruskal–Wallis’ test), and patients in the NE cohort did not show a decrease in % HbA1c under ARF conditions as compared to those in the RF cohort (P > .05, Kruskal–Wallis’ test).
3.2.7. Self-care activities
Patients with ARF in all cohorts showed improved self-care activities compared to their BRF conditions (P < .01 all, Friedman test). Patients in the NE and RF cohorts improved self-care activities as compared to those in the TC cohorts at ARF (P < .01 both, Kruskal–Wallis’ test). At ARF, self-care activities between patients in the NE and RF cohorts were statistically similar.
The details of outcome measures are reported in Table 3.
Table 3.
Outcome measures.
| Parameters | Cohorts | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TC | NE | RF | Comparisons between NE and RF cohorts at AFC | |||||||||||||||
| 6-months follow-up care | Tai Chi exercises only | Comparisons between BFC and AFC | Nurse-led follow-up care + educational programs + Tai Chi exercises | Comparisons between BFC and AFC | Comparisons between NE and TC cohorts at AFC | Routine health education and follow-up + Tai Chi exercises | Comparisons between BFC and AFC | Comparisons between RF and TC cohorts at AFC | ||||||||||
| Level | BFC | AFC | BFC | AFC | BFC | AFC | ||||||||||||
| Number of diabetic patients | 408 | 408 | P-value | Test value | 108 | 108 | P-value | Test value | P-value | Test value | 205 | 205 | P-value | Test value | P-value | Test value | P-value | Test value |
| *Knowledge regarding diabetes and its threat | 0.75 (1–0.5) | 0.75 (1–0.5) | >.05 (Friedman test) | 91,227 | 0.75 (1–0.5) | 2 (2–1.5) | <.001 (Friedman test) | 147.12 | <0.001 (Kruskal–Wallis’ test) | 217.64 | 0.5 (1–0.5) | 1 (1.25–0.75) | <.001 (Friedman test) | 384.04 | <.001 (Kruskal–Wallis’ test) | 50.621 | <.001 (Kruskal–Wallis’ test) | 167.82 |
| †Anxiety | 62 (63–61) | 61 (62–60) | <.001 (Friedman test) | 37.334 | 62 (63–60) | 57 (58–55) | <.001 (Friedman test) | 155.91 | <0.001 (Kruskal–Wallis’ test) | 261.8 | 62 (63–60) | 60 (61–58) | <.001 (Friedman test) | 97.008 | <.001 (Kruskal–Wallis’ test) | 126.3 | <.001 (Kruskal–Wallis’ test) | 304.26 |
| †Depression | 58 (60–56) | 58 (59–55) | <.001 (Friedman test) | 18.072 | 58 (60–55) | 56 (58–53) | <.001 (Friedman test) | 208 | <0.001 (Kruskal–Wallis’ test) | 43.709 | 58 (61–55) | 57 (59–55) | <.001 (Friedman test) | 294 | <.001 (Kruskal–Wallis’ test) | 18.537 | <.01 (Kruskal–Wallis’ test) | 19.982 |
| Fasting blood sugar (mmol/L) | 5.8 (5.83–5.72) | 5.79 (5.82–5.72) | >.05 (Friedman test) | 12,676 | 5.8 (5.83–5.72) | 5.75 (5.8–5.7) | <.001 (Friedman test) | 216 | <0.001 (Kruskal–Wallis’ test) | 42.23 | 5.8 (5.83–5.72) | 5.77 (5.81–5.72) | <.001 (Friedman test) | 300 | <.01 (Kruskal–Wallis’ test) | 23.62 | <.05 (Kruskal–Wallis’ test) | 35.663 |
| % HBA1c | 8 (8–7.5) | 8 (8–7.5) | .5 (Wilcoxon test) | N/A | 8 (8–7.5) | 7.75 (8–7.5) | >.05 (Friedman test) |
26 | 0.8729 (Mann-Whitney test) | 21,812 | 8 (8–7.5) | 8 (8–7.5) | >.05 (Friedman test) |
42 | .4031 (Mann-Whitney test) | 10,106 | .4502 (Mann-Whitney test) | 10,506 |
| ‡Self-care activities | 34 (35–33) | 34 (35–34) | <.001 (Friedman test) | 68.408 | 34 (35–33) | 35 (36–35) | <.001 (Friedman test) | 216 | <0.01 (Kruskal–Wallis’ test) | 65.397 | 34 (35–33) | 35 (36–34) | <.001 (Friedman test) | 298 | <.01 (Kruskal–Wallis’ test) | 60.115 | >.05 (Kruskal–Wallis’ test) | 51.185 |
Variables are depicted as medians with Q3–Q1 in parenthesis.
AFC = after 6 months of follow-up care, BFC = before the start of follow-up care.
All results were considered significant if the P-value was <.05.
Higher the score higher is knowledge regarding diabetes and its threat (total score is 6; evaluated by nursing staff; the institute has its questionnaires). Test value (Friedman statistic for Friedman test; Kruskal–Wallis’ statistics for Kruskal–Wallis’ test; Mann-Whitney statistics for Mann-Whitney test corrected for ties).
Zung Self-Rating Depression and Anxiety Scale (Zung Self-Rating Depression and Anxiety Scale; a score of ≥ 50 is considered as anxiety; a score of ≥ 50 is considered as depression).
The higher the score higher the self-care activity (maximum value 49).
No adverse effects reported during the 6 months of follow-up period. During the 6 months follow-up period, the patients did not report any diabetic retinopathy, diabetic nephropathy, diabetic cardiomyopathy, or foot ulcer(s).
The results of the assumption test are reported in Table 4.
Table 4.
Results of the assumption test.
| Parameters | Test for variables |
|---|---|
| Two rows and 2 columns | Sample size <40, that is, Fisher’s exact test otherwise Chi-square test (χ2-test) |
| Larger contingency table | χ2-test |
| Age (years) | Two columns failed the normality test with P < .05, that is, Kruskal–Wallis’ test |
| Knowledge regarding diabetes and its threat, anxiety, and depression (Before the start of follow-up care) | Two columns failed the normality test with P < .05, that is, Kruskal–Wallis’ test |
| Knowledge regarding diabetes and its threat, anxiety, depression, fasting blood sugar (mmol/L), % HBA1c, and self-care activities (before (BFC) and after 6 months of follow-up care (AFC)) | One or more columns failed the normality test with P < .05, that is, Wilcoxon matched-pairs signed-ranks test or Friedman test |
| Knowledge regarding diabetes and its threat, anxiety, depression, fasting blood sugar (mmol/L), % HBA1c, and self-care activities (as compared to TC cohort; between NE and RF cohorts at AFC) | One or more columns failed the normality test with P < .05, that is, Wilcoxon matched-pairs signed-ranks test or Friedman test |
| Fasting blood sugar, % HBA1c (mmol/L), and self-care activities (BFC) | All columns failed the normality test with P < .05, that is, Kruskal–Wallis’ test |
Tests for standard deviations (SDs) were not applicable.
4. Discussions
In the BFC condition, knowledge regarding diabetes and its threat was ≤1.75, anxiety and depression scores were ≥52 each, and the summary of the Diabetes Self-Care Activities Chinese version was ≤37. The results of knowledge regarding diabetes and its threat, psychological conditions, and self-care activities of patients with diabetes in the current study are consistent with those of a pilot trial on the Spanish population[8] and a trial on a Thai population.[21] Patients with type 1 or type 2 diabetes have not only worse glycemic control, but also have worse physical and psychological conditions and less knowledge regarding diabetes and its threat.
At AFC, knowledge regarding diabetes and its threat to patients improved in all patients, with the maximum for patients in the NE cohort, followed by the RF and TC cohorts. The results of knowledge regarding diabetes and its threat to diabetic patients at the AFC in the current study are consistent with those of a pilot trial on the Spanish population[8] and a trial on the Thai population.[21] Gossip during Tai Chi exercises, routine health education, follow-up, and nurse-led follow-up care, including educational programs, are successful in improving knowledge regarding diabetes and its threat to patients. However, nurse-led follow-up care, including educational programs, interacts with patients and improves their knowledge regarding diabetes and its threat to patients.
At AFC, anxiety, depression, and self-care activities of patients improved in the NE cohort compared to their BFC conditions and those of patients in the RF and TC cohorts at AFC conditions. The results of anxiety, depression, and self-care activities of diabetic patients in the AFC conditions in the current study are consistent with those of a pilot trial in a Spanish population.[8] Nurse-led follow-up care, including educational programs and interactions with patients, improved knowledge regarding diabetes, and its threat led to decreased anxiety, depression, and self-care activities. In addition, nurses were frequently available in our institute that provided close contact with patients, leading to relief of anxiety and depression and improvement in self-care activities of patients after 6 months of nurse-led follow-up care, including educational programs.
The current study failed to improve glycemic parameters at 6 months of follow-up care (target of <5.5 mmol/L and/or <7% HBA1c). The results of the glycemic parameters in the current study are not consistent with those of a pilot trial on the Spanish population,[8] quasi-experimental trials on the Chinese population,[7] and systematic reviews on Latinos[15] and Hispanic[16] adults but are consistent with those of a trial on the Thai population.[21] Professional-led care and follow-up care alone are not enough to manage glycemic control in Chinese patients with type 1 and type 2 diabetes. There is also a need for hypoglycemic agents or insulin that reduce blood glucose levels and % HbA1c.
In the current study, anxiety, depression, and self-care activities were evaluated in addition to knowledge regarding diabetes and its threat to patients with diabetes. Anxiety and depression decrease self-care activities and increase blood glucose levels in patients.[5,8] Early screening for anxiety, depression, and self-care activities in Chinese patients with type I and type II diabetes may provide a warranty to improve healthcare outcomes.
Only patients in the NE cohort reported anxiety scales of <50 after 6 months of follow-up care. This is a novel finding of this study. The availability of nurses and counseling regarding knowledge and its threat in diabetic patients improved behavior, and patients participating in social activities led to decreased anxiety. Nurse-led follow-up care, including educational programs with Tai Chi exercises for 6 months, decreases the anxieties of diabetic patients.
There are several limitations of the study, such as non-randomized, nonintervention retrospective analyses and lack of a trial. Other limitations, such as knowledge regarding diabetes and its threat, have not been published yet and an in-house study.
5. Conclusions
Chinese patients with type 1 or type 2 diabetes not only have worse glycemic control but also have worse physical and psychological conditions and less knowledge regarding diabetes and its threat. Nurse-led follow-up care, including educational programs with Tai Chi exercises for 6 months decreases anxiety and depression, and improved knowledge regarding diabetes and its threat and self-care activities in Chinese diabetic patients. There is also a need for hypoglycemic agents or insulin in addition to follow-up care to reduce blood glucose levels and % HbA1c.
Acknowledgments
The authors are thankful to the medical and nursing staff of the Chongqing Fourth People’s Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China.
Author contributions
Conceptualization: Jiao Yan, Wanyi Zhang.
Data curation: Xi Jing, Yimin Deng.
Formal analysis: Xi Jing, Yan Chen, Yi Yuan.
Investigation: Jing Yao.
Methodology: Yan Chen, Yimin Deng, Wanyi Zhang, Yi Yuan.
Project administration: Lan Jiang, Yi Yuan.
Resources: Lan Jiang, Jiao Yan, Xi Jing, Wanyi Zhang, Yi Yuan.
Software: Lan Jiang, Jiao Yan, Xi Jing, Wanyi Zhang.
Supervision: Lan Jiang, Jiao Yan, Jing Yao, Xiaoyu Yang.
Validation: Jing Yao, Yan Chen, Yimin Deng, Xiaoyu Yang.
Visualization: Jing Yao, Yan Chen, Yimin Deng.
Writing – original draft: Xiaoyu Yang.
Writing – review & editing: Xiaoyu Yang.
Abbreviations:
- AFC
- after 6 months of follow-up care
- ANOVA
- analysis of variance
- BFC
- before the start of follow-up care
- HBA1c
- glycated hemoglobin
- NE cohort
- patients received nurse-led follow-up care including educational programs for 6 months
- RF cohort
- patients received routine health education and follow-up for 6 months
- SD
- standard deviation
- TC cohort
- patients received Tai Chi exercises only for 6 months
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Jiang L, Yan J, Yao J, Jing X, Chen Y, Deng Y, Zhang W, Yuan Y, Yang X. Nurse-led follow-up care versus routine health education and follow-up in diabetes patients: An effectiveness analysis. Medicine 2024;103:22(e38094).
LJ and JY contributed equally to this work.
Contributor Information
Lan Jiang, Email: l309792@163.com.
Jiao Yan, Email: w691893@163.com.
Jing Yao, Email: y089537@163.com.
Xi Jing, Email: t601614@163.com.
Yan Chen, Email: c551265@163.com.
Yimin Deng, Email: y089538@163.com.
Wanyi Zhang, Email: x160451@163.com.
Yi Yuan, Email: n734162@163.com.
References
- [1].Wang L, Peng W, Zhao Z, et al. Prevalence and treatment of diabetes in China, 2013–2018. JAMA. 2021;26:2498–506. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Li Y, Qian K, Wu D, et al. Incidence of childhood type 1 diabetes in Beijing during 2011-2020 and predicted incidence for 2025–2035: a multicenter, hospitalization-based study. Diabetes Ther. 2023;14:519–29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Wang L, Gao P, Zhang M, et al. Prevalence and ethnic pattern of diabetes and prediabetes in China in 2013. JAMA. 2017;317:2515–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Hamilton H, Knudsen G, Vaina CL, Smith M, Paul SP. Children and young people with diabetes: recognition and management. Br J Nurs. 2017;26:340–7. [DOI] [PubMed] [Google Scholar]
- [5].American Diabetes Association. 5. Lifestyle management: standards of medical care in diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S46–60. [DOI] [PubMed] [Google Scholar]
- [6].Feng Z, Tong WK, Zhang X, Tang Z. Prevalence of depression and association with all-cause and cardiovascular mortality among individuals with type 2 diabetes: a cohort study based on NHANES 2005–2018 data. BMC Psychiatry. 2023;23:490. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Huang W, Wei W, Wang J, Lyu Y, Li L. Effectiveness of a nurse-led online educational programme based on basic insulin therapy in patients with diabetes mellitus: a quasi-experimental trial. J Clin Nurs. 2022;31:2227–39. [DOI] [PubMed] [Google Scholar]
- [8].Romero-Castillo R, Pabón-Carrasco M, Jiménez-Picón N, Ponce-Blandón JA. Effects of a diabetes self-management education program on glucose levels and self-care in type 1 diabetes: a pilot randomized controlled trial. Int J Environ Res Public Health. 2022;19:16364. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Zhu D; Chinese Diabetes Society. Guideline for the prevention and treatment of type 2 diabetes mellitus in China (2020 edition). Chin J Diabetes Mellitus. 2021;13:315–409. [Google Scholar]
- [10].Ji H, Chen R, Huang Y, Li W, Shi C, Zhou J. Effect of simulation education and case management on glycemic control in type 2 diabetes. Diabetes Metab Res Rev. 2019;35:e3112. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99:926–43. [DOI] [PubMed] [Google Scholar]
- [12].Klein HA, Jackson SM, Street K, Whitacre JC, Klein G. Diabetes self-management education: miles to go. Nurs Res Pract. 2013;2013:581012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Cloete L. Diabetes mellitus: an overview of the types, symptoms, complications and management. Nurs Stand. 2022;37:61–6. [DOI] [PubMed] [Google Scholar]
- [14].Mulder BC, Lokhorst AM, Rutten GE, van Woerkum CM. Effective nurse communication with type 2 diabetes patients: a review. West J Nurs Res. 2015;37:1100–31. [DOI] [PubMed] [Google Scholar]
- [15].Hildebrand JA, Billimek J, Lee JA, et al. Effect of diabetes self-management education on glycemic control in Latino adults with type 2 diabetes: a systematic review and meta-analysis. Patient Educ Couns. 2020;103:266–75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Ferguson S, Swan M, Smaldone A. Does diabetes self-management education in conjunction with primary care improve glycemic control in Hispanic patients? A systematic review and meta-analysis. Diabetes Educ. 2015;41:472–84. [DOI] [PubMed] [Google Scholar]
- [17].Blonde L, Umpierrez GE, Reddy SS, et al. American association of clinical endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan-2022 update. Endocr Pract. 2022;28:923–1049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [18].Sun N, Lou P, Shang Y, et al. Prevalence and determinants of depressive and anxiety symptoms in adults with type 2 diabetes in China: a cross-sectional study. BMJ Open. 2016;6:e012540. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Bao Y, Zhu D; Chinese Diabetes Society. Clinical application guidelines for blood glucose monitoring in China (2022 edition). Diabetes Metab Res Rev. 2022;38:e3581. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20].Zhou Y, Liao L, Sun M, He G. Self-care practices of Chinese individuals with diabetes. Exp Ther Med. 2013;5:1137–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [21].Wichit N, Mnatzaganian G, Courtney M, Schulz P, Johnson M. Randomized controlled trial of a family-oriented self-management program to improve self-efficacy, glycemic control and quality of life among Thai individuals with Type 2 diabetes. Diabetes Res Clin Pract. 2017;123:37–48. [DOI] [PubMed] [Google Scholar]