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Research ArticleOriginal Research

Examining Variations in Action Plan Quality Among Adults With Type 2 Diabetes in Primary Care

Pernille H. Kjaer, Lawrence Fisher, Michael B. Potter, Mansi Dedhia, José Parra, Niels Ejskjaer, Søren Skovlund and Danielle Hessler
The Journal of the American Board of Family Medicine May 2021, 34 (3) 608-617; DOI: https://doi.org/10.3122/jabfm.2021.03.200285
Pernille H. Kjaer
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
BS
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Lawrence Fisher
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
PhD
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Michael B. Potter
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
MD
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Mansi Dedhia
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
MPH
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José Parra
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
BS
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Niels Ejskjaer
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
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Søren Skovlund
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
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Danielle Hessler
From the Department of Endocrinology, Aalborg University Hospital, Denmark (PHK, NE); Department of Clinical Medicine, Aalborg University, Denmark (PHK, NE, SS); Department of Family and Community Medicine, University of California-San Francisco, USA (PHK, LF, MBP, MD, JP, DH); Steno Diabetes Center North Denmark, Aalborg University Hospital (NE, SS).
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  • Article
  • Figures & Data
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Article Figures & Data

Figures

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    Figure 1.

    Self-management Problems Used as Goals in Action Plans.

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    Figure 2.

    Outline of the Connection to Health Steps. Abbreviation: PWD; person with diabetes.

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    Figure 3.

    Most Prevalently Selected Self-Management Areas; (n = 725).

Tables

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    Table 1.

    Patient Characteristics

    CharacteristicNn (%)Mean ± SD
    Age, years71555.6 ±12.0
    Sex (% female)725433 (59.7)
    Education725
        Less than high school297 (41.0)
        High school or higher428 (59.0)
    Race and ethnicity1*725
        Latinx511 (70.5)
        Non-Latinx white64 (8.8)
        Black or African American55 (7.6)
        Asian43 (5.9)
        Native Hawaiian or Other Pacific Islander12 (1.7)
        Native American or Alaska Native4 (0.4)
        Multi-racial36 (5.0)
    Primary language (% Spanish, remaining English)725409 (56.4)
    Health literacy (confidence in filling out medical forms?) *724
        Not at all confident109 (15.1)
        A little bit99 (13.7)
        Somewhat135 (18.6)
        Quite a lot146 (20.2)
        Extremely confident235 (32.5)
    Depression
        PHQ-8 score7243.23 ± 5.76
        Elevated depression symptoms (PHQ-8 ≥ 10)711112 (15.8)
    Health distress*721452 (62.7)
    General life stress*723342 (47.3)
    Social risks (≥ 1)725336 (46.3)
        Food insecurity723144 (19.9)
        Inability to pay bills723196 (27.1)
        Difficulty with transportation to medical appointments723100 (13.8)
        Unstable housing72374 (10.2)
        Physical abuse in the last year72524 (3.3)
        Feel unsafe where living*72580 (11.0)
    • SD, standard deviation; PHQ-8, Patient Health Questionnaire-8.

    • ↵* These are significantly different in the two intervention arms: Connection to Health (CTH) and Enhanced Engagement-CTH (EE-CTH) at a significance of P < .05).

    • View popup
    Table 2.

    Goalsetting Evaluation Tool for Diabetes (GET-D)50

    Elements in the GET-DPointsMean ± SD
    1. Is the goal a diabetes-related self-management task?1.001.00 (0.00)
    2. Does the goal identify a specific time frame for achieving the goal?3.003.00 (0.00)
    3. Is the action plan related to the stated goal?1.000.72 (0.45)
    4. Does the plan identify a single specific action?3.002.52 (1.10)
    5. Does the plan identify how often the action will take place?3.002.03 (1.40)
    6. Does the plan identify a location for the action?3.001.36 (1.49)
    7. Does the plan identify the time it will take place?3.001.44 (1.50)
    8. Does the plan identify how the action will be monitored?3.002.73 (0.86)
    • SD, standard deviation.

    • View popup
    Table 3.

    Associations Between Action Plan Quality and Patient Characteristics. Analyzed Using Generalized Linear Mixed Models With Random Effect for Clinic, Adjusting for Intervention Arm

    CharacteristicNßSE95% CIP Value
    Age, years715−0.0060.012−0.029 to 0.016.597
    Sex725−0.1870.308−0.790 to 0.416.543
    Education (binary)725−0.2580.336−0.916 to 0.401.444
    Race (compared to Latinx)1
        Non-Latinx white725−0.1270.669−1.437 to 1.184.850
        Black or African American7250.1910.765−1.308 to 1.689.803
        Asian725−0.2750.577−1.407 to 0.856.634
        Native Hawaiian or Other Pacific Islander725−1.8890.993−3.834 to 0.056.057
        Native American or Alaska Native725−0.9800.936−2.815 to 0.854.295
        Multi-racial725−1.5310.764−3.028 to -0.035.045
    Language7250.0060.442−0.859 to 0.871.990
    Health literacy (Confidence in filling out medical forms? compared to “Not at all confident”)
        “Extremely confident7241.1840.4380.326 to 2.041.007
        “Quite confident”7241.0160.4290.176 to 1.856.018
        “Somewhat confident”7241.0050.4670.090 to 1.920.031
        “A little bit confident”7241.1150.4640.205 to 2.025.016
    Depression (PHQ-8 score)724−0.0290.024−0.077 to 0.018.225
    Health distress (binary)721−0.2260.275−0.766 to 0.313.411
    General life stress7230.2080.266−0.313 to 0.613.434
    Social risks (≥ 1)7250.4160.1810.062 to 0.770.021
        Food insecurity7230.4240.2660.096 to 0.945.110
        Inability to pay bills7230.3520.212−0.063 to 0.767.096
        Lack of transportation7230.3510.567−0.759 to 1.462.535
        Unstable housing7230.6510.385−0.139 to 1.368.110
        Physical abuse7252.3020.9870.367 to 5.439.020
        Unsafe at home725−0.2960.638−1.545 to 0.953.642
    • CI, confidence interval; PHQ-8, Patient Health Questionnaire-8.

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The Journal of the American Board of Family     Medicine: 34 (3)
The Journal of the American Board of Family Medicine
Vol. 34, Issue 3
May/June 2020
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Examining Variations in Action Plan Quality Among Adults With Type 2 Diabetes in Primary Care
Pernille H. Kjaer, Lawrence Fisher, Michael B. Potter, Mansi Dedhia, José Parra, Niels Ejskjaer, Søren Skovlund, Danielle Hessler
The Journal of the American Board of Family Medicine May 2021, 34 (3) 608-617; DOI: 10.3122/jabfm.2021.03.200285

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Examining Variations in Action Plan Quality Among Adults With Type 2 Diabetes in Primary Care
Pernille H. Kjaer, Lawrence Fisher, Michael B. Potter, Mansi Dedhia, José Parra, Niels Ejskjaer, Søren Skovlund, Danielle Hessler
The Journal of the American Board of Family Medicine May 2021, 34 (3) 608-617; DOI: 10.3122/jabfm.2021.03.200285
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  • Article
    • Abstract
    • Introduction
    • Methods
    • Measures
    • Action Plan Quality
    • Data Analysis
    • Results
    • Quality of Action Plans in Primary Diabetes Care
    • Patient Characteristics Associated with Action Plan Quality
    • Action Plan Quality and Patient-Reported Confidence in Carrying Out the Plan
    • Discussion
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Keywords

  • Chronic Disease
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  • Health Literacy
  • Health Surveys
  • Patient Participation
  • Patient-Centered Care
  • Patient-Reported Outcome Measures
  • Primary Health Care
  • Self-Management
  • Type 2 Diabetes Mellitus

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