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OBJECTIVE | This study aimed to systematically review the existing literature on the relationship between self-efficacy and diabetes self-management in middle-aged and older adults in the United States and to determine whether the relationship applies across race and ethnicity. METHODS | Study selection followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. Studies published between 1990 to 2018 that investigated self-efficacy and diabetes self-management in middle-aged and older adults were searched using eight search engines: PsycINFO, CINAHL, SocIndex, AgeLine, MedLine, Social Science Citation Index, Cochrane Library, and Academic Search Complete. Only quantitative studies were included. RESULTS | Eleven studies met the inclusion criteria. Ten studies found significant association between self-efficacy and at least one self-management behavior, which included exercise, healthy diet, adherence to medication, blood glucose testing, and foot care. Findings were mixed regarding the role of self-efficacy in exercise and medication adherence. Higher self-efficacy in Mexican Americans predicted better self-management behaviors, whereas no relationship between self-efficacy and diabetes self-management was found in a sample of Black and White participants. The methodological quality of the studies was assessed. In general, the included studies demonstrated moderate methodological quality. Their limitations included inconsistency in the self-efficacy measures, a lack of longitudinal studies, and confounding bias. CONCLUSION | Self-efficacy has significant effects on self-management in middle-aged and older adults, but the effects may differ by race. Efforts to improve self-efficacy and deliver culturally appropriate services could potentially promote self-management behaviors in middle-aged and older adults with diabetes.

OBJECTIVE The aim of this systematic review is to summarize and synthesize existing research on the economic impact of Diabetes Self-Management Education and Support. INTRODUCTION Diabetes Self-Management Education and Support is an essential component of diabetes care, yet it continues to be underutilized. A gap exists regarding the true measured economic impact of this intervention. INCLUSION CRITERIA This review will consider studies that report the measured economic impact and health care utilization of Diabetes Self-Management Education and Support for persons with diabetes or their caregivers. The inclusion criteria are as follows: quantitative studies providing measured data on the economic outcomes and health care utilization of Diabetes Self-Management Education and Support interventions that include at least one of the Association for Diabetes Care and Education Specialists Seven Self-Care Behaviors (ADCES7). METHODS The review will search the following databases: MEDLINE; Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Daily and Versions; Embase; Scopus; CINAHL; ERIC, Cochrane Database of Systematic Reviews; and the Cochrane Register of Controlled Trials. Additionally, a search of the grey literature will be performed using Google Scholar. Date limitations will be from January 2006 to May 2020. Two members of the research team will independently screen abstracts and full texts, and extract data. The screening process will be described using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Articles will be assessed for risk of bias using the JBI critical appraisal tools. Data will be narratively summarized. SYSTEMATIC REVIEW REGISTRATION PROSPERO (CRD42020166743).

PurposeValue-driven outcomes are important because health systems determine sustainability of diabetes self-management education and support (DSMES) programming. Health care utilization and clinical outcomes are critical factors when considering the impact of DSMES programs.ObjectiveThe aim of this systematic review was to describe studies that report on the economic and health care utilization outcomes of diabetes self-management programs.MethodsA systematic literature review was performed in multiple databases. Studies reporting economic and health care utilization outcomes related to DSMES and including 1 or more of the ADCES7 Self-Care BehaviorsTM from January 2006 to May 2020 were included. Eligible articles needed to compare the intervention and comparison group and report on economic impact. The methodological quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist specific to each individual study design.ResultsA total of 22 of 14 556 articles published between 2007 and 2020 were included. Cost benefits varied, and there were considerable methodological heterogeneity among design, economic measures, population, perspective, intervention, and biophysical outcomes.ConclusionDSMES interventions may positively impact economic outcomes and/or health care utilization, although not all studies showed consistent benefit. This review highlights an evidence gap, and future health economic evaluations are warranted.

Mothers of infants in the neonatal intensive care unit (NICU) face stressors including turbulent emotions from their pregnancy/unexpected preterm delivery and their infant's unpredictable health status. The study purpose was to examine the psychological state of mothers prior to the discharge of their technology-dependent infants (eg, feeding tubes, supplemental oxygen) from the NICU to home. The study sample consisted of mothers (N = 19) of infants dependent on medical technology being discharged from a large Midwest NICU. A descriptive, correlational design using convenience sampling was employed to recruit mothers to examine associations of infant and maternal factors, resourcefulness, and stress with psychological state (depressive symptoms, posttraumatic stress symptoms). Forty-two percent of mothers were at high risk for clinical depression, with 37% in the clinical range for posttraumatic stress disorder. Increased maternal depressive symptoms were significantly associated with the increased frequency and perceived difficulty of their stress and posttraumatic stress symptoms. Increased posttraumatic stress symptoms were significantly associated solely with elevated depressive symptoms. This study identified factors associated with the mothers' increased psychological distress, providing beginning evidence for future interventions to employ prior to their technology-dependent infant's NICU discharge.

Value-driven outcomes are important, especially when health systems are determining sustainability of Diabetes Self-Management Education & Support (DSMES). We conducted a systematic review to synthesize existing research of the economic outcomes and healthcare utilization for interventions that incorporate DSMES in the US. Seven databases were searched for relevant published studies that included of at least one component of the Association of Diabetes Care and Education Specialists 7 Self-Care Behaviors (ADCES7). Reviewers independently selected articles, extracted data and assessed the methodological quality of included studies. In total, 14,804 records were identified, 25 articles met the inclusion criteria. Three articles were determined to have poor quality and were not included in the final analysis. Our findings are based on a total of 22 articles describing 21 studies. DSMES interventions varied widely, including face-to-face education, group classes, home visits with community health workers, telemedicine visits, education modules, and/or visits with registered dietitians, nurses and/or pharmacists. A majority of the studies were not specifically designed for health economic evaluation. Seven studies reported a statistically significant decrease in either total health care costs, hospital or emergency utilization, outpatient medical costs, and/or medication costs. Four of the seven studies utilized all components of the ADCES7. Clinical impact across studies varied. Studies that measured HbA1c found a decrease over their study time frame. The methodological heterogeneity among studies was considerable; therefore, a meta-analysis was not conducted. Our review highlights DSMES interventions may positively impact economic outcomes and/or healthcare utilization, though not all studies showed consistent benefit. This review highlights an evidence gap and future full health economic evaluations are warranted. Disclosure C. Whitehouse: None. A. Bzowyckyj: None. S. B. Srivastava: None. A. I. Kauwe tuitama: None. J. E. Blanchette: Board Member; Self; JDRF, Consultant; Self; Insulet Corporation, Other Relationship; Self; Insulet Corporation, Tandem Diabetes Care, Research Support; Self; Association of Diabetes Care and Education Specialists. S. A. Haydon-greatting: None. V. J. Brady: None. T. Smith: None. M. L. Litchman: Research Support; Self; Abbott Diabetes. K. E. Yehl: None.

Over 25% of adults with diabetes have reported rationing insulin in the United States. Emerging adults, ages 18-25, may be even more vulnerable to rationing as they grapple with financial instability during this developmental period of increasing independence coupled with the rising cost of healthcare. The purpose of this study was to explore factors related to insulin and diabetes supply rationing in a sample of emerging adults with type 1 diabetes (T1D). Content analysis was used to examine a single open-ended response to the question, “Please tell me about your experiences rationing insulin or diabetes supplies,” in a parent cross-sectional study. The parent study explored financial stress factors, psychological factors, and self-management outcomes in 413 emerging adults from the T1D Exchange Clinic Registry. Chi-square tests were utilized to understand if rationing (yes or no) differed based on gender, race/ethnicity, employment status, type of health insurance, insulin pump usage, CGM usage, and A1c level (9.0%). Alpha was set at .05. A total of 268 participants responded to the open-ended question about rationing. Over one-third of respondents (N=99, 36.9%) reported rationing insulin or diabetes supplies. Lack of private health insurance X2(3, N=224)=8.38, p Disclosure J. E. Blanchette: Board Member; Self; JDRF, Consultant; Self; Insulet Corporation, Other Relationship; Self; Insulet Corporation, Tandem Diabetes Care, Research Support; Self; Association of Diabetes Care and Education Specialists. V. B. Toly: None. J. R. Wood: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Insulet Corporation, Speaker’s Bureau; Self; Xeris Pharmaceuticals, Inc. M. L. Litchman: Research Support; Self; Abbott Diabetes. Funding Sigma Theta Tau Alpha Mu; Frances Payne Bolton School of Nursing

Engagement in Diabetes Online Communities (DOCs) and diabetes online resources have proven benefits, including improved psychosocial, behavioral and clinical outcomes. However, patients report that finding credible and relevant information can be daunting. The aim of this study was to co-design an intervention with people with diabetes (PWD) to train “Peer Connectors” to help adults with type 1 and type 2 diabetes navigate DOCs and diabetes online resources to improve social support. A community advisory board (CAB) of 11 diverse (race, ethnicity, age, diabetes type, diabetes duration) PWD who were active in a variety of DOCs convened over four 2-hour meetings to discuss and prioritize intervention components and outcome measures. Field notes and audio recordings were analyzed to guide development of the D-COPES (Diabetes - Connecting Online Peers to Enhance Support) intervention. The CAB recommended three intervention components: 1) pairing participants to trained Peer Connectors based on matching characteristics/interests, (2) Peer Connectors delivering a small group intervention to orient participants to DOCs and online resources, and (3) Intervention content that includes tailoring to participants’ individual needs and how to identify misinformation. Recommended outcome measures focused on psychosocial (diabetes distress, empowerment), behavioral (self-efficacy, self-care), and clinical outcomes (A1C as secondary outcome), as well as usage of DOCs and online resources. The co-design process centered the D-COPES intervention on avoidance of misinformation and provided strategies to expand the benefits of DOCs to PWD who might not otherwise have the knowledge and skills to engage most effectively. Co-design also served as a form of social validation, ensuring the intervention itself would be of interest and socially relevant to PWD. The D-COPES intervention will be iteratively piloted with 12 participants over 12 weeks. Disclosure M. L. Litchman: Research Support; Self; Abbott Diabetes. T. Oser: Advisory Panel; Self; Cecelia Health, Dexcom, Inc., Advisory Panel; Spouse/Partner; Cecelia Health, Dexcom, Inc. C. Shockley: None. E. Grigorian: None. H. R. Walker: None. E. Wilson: None. A. Thompson: None. J. E. Blanchette: Board Member; Self; JDRF, Consultant; Self; Insulet Corporation, Other Relationship; Self; Insulet Corporation, Tandem Diabetes Care, Research Support; Self; Association of Diabetes Care and Education Specialists. C. Rice: None. M. E. Hilliard: None. Funding Dick and Timmy Burton Foundation

OBJECTIVE To describe the relationships among financial stress factors (perceived stress, financial stress, and financial independence) and psychological factors (depressive symptoms, trait anxiety, and diabetes distress) on self-management outcomes (HbA1c and diabetes-related quality of life) in emerging adults with type 1 diabetes. RESEARCH DESIGN AND METHODS A descriptive, correlational, cross-sectional study examined 413 emerging adults, ages 18-25, from the Type 1 Diabetes Exchange Clinic Registry. Data were collected via REDCap surveys using the Personal Financial Well-Being Scale, Willingness to Pay Scale, Financial Independence Visual Analog Scale, Center for Epidemiological Studies-Depression Inventory, State-Trait Anxiety Inventory, The Type 1 Diabetes Distress Scale, and Diabetes Quality of Life Measure. Hierarchical Multiple Regression analyses explored significant barriers to self-management outcomes. RESULTS Hierarchical Multiple Regression analyses revealed that 20.6% of variance in HbA1c (F = 15.555, p

Background: Personal continuous glucose monitoring (CGM) is patient owned and often inaccessible due to cost and insurance requirements. Professional CGM is clinic owned, worn for 3-14 days and is an affordable, underutilized option. The present study combined diabetes education and professional CGM into a shared medical appointment (SMA). The SMA allows providers to deliver diabetes education in the setting of medical management and peer support. It was hypothesized that the SMA method of delivering professional CGM would positively impact clinical outcomes (improvements in self-efficacy, A1c and medication doses). Methods: Adults with type 1 and type 2 diabetes who attended the two-part CGM SMA at a large academic medical center were included in this retrospective, single-center study. The CGM SMA included 4-6 patients, diabetes educator and pharmacist. Participants wore professional CGM for 7 days. The primary outcome was change in diabetes self-efficacy through a validated 8-item Likert scale. Secondary objectives were changes in A1c, and changes in diabetes medications (dosage adjustments, time of administration). Paired t-tests were used to analyze change in A1c and diabetes self-efficacy scores. Results: Diabetes self-efficacy scores increased by a mean of 1.63 ± 2.09 points (p 8.0% (n=101). Participants utilizing the real time device (n=133) experienced a decrease in A1c by 0.75% compared to 1.0% in those with the blinded device (n=38). Most medication changes made in the CGM SMA were dosage adjustments and changes in administration time. Discussion: The CGM SMA is a novel practice model incorporating diabetes education, peer support, professional CGM, and inter-professional care that demonstrated improvements in diabetes self-efficacy and A1c. Disclosure D. Isaacs: Consultant; Self; Companion Medical, LifeScan, Inc. Speaker’s Bureau; Self; Dexcom, Inc., Novo Nordisk Inc., Xeris Pharmaceuticals, Inc. A. Simonyan: None. J.E. Blanchette: Other Relationship; Self; Tandem Diabetes Care. S. Lekic: None. D. Noe: Consultant; Self; Pyure Organic Stevia. N.R. Galloway: None.

Purpose The purpose of the study was to examine the association between 3 lifestyle behaviors (smoking, physical activity, and fruit and vegetable consumption) and health-related quality of life (HRQOL) among older adults diagnosed with diabetes. Methods A sample of the US population 65 years and older who were diagnosed with diabetes from the 2015 Behavioral Risk factor Surveillance System (N = 11 503) was analyzed. The 4 HRQOL measures were self-rated health, physically unhealthy days, mentally unhealthy days, and impaired activity days in the past month. Multiple logistic regression analysis was conducted to predict HRQOL. Results The multiple logistic regression results showed that smoking and lack of physical activity were significant predictors for higher odds of fair or poor self-rated health, more physically unhealthy days, more mentally unhealthy days, and more impaired activity days during past 30 days. No significant relationship was found between fruit and vegetable consumption and any HRQOL measure. Conclusions Findings imply that diabetes education could continue and enhance efforts in smoking cessation and increase physical activity to promote the HRQOL among older adults diagnosed with diabetes. In addition, the measure of fruit and vegetable consumption should be further studied to reflect the needs of older adults with diabetes.

Technology-dependent (TD) children require complex care and are dependent on medical technology. Approximately 75% of families, in the United States, who are caring for a TD child, also care for a well child. Well siblings are likely to be affected by the experience of living with a TD sibling as the process of family normalization is described as a family affair. The experiences of well siblings are not well described. The purpose of this qualitative analysis was to describe the experiences of well siblings who are living in a family with a TD child. Mothers were interviewed about the experiences of their well children and were digitally audio recorded. The interviews were transcribed, and content analysis was conducted. Content analysis from the interviews revealed the major themes of well sibling adjustment within the family unit, upside (altruistic, prosocial behaviors) and downside (negative internal and external processing behaviors). These results can be applied to advance the delivery of family nursing care offered to these families.

Introduction: Adolescents and young adults (AYA) transitioning from pediatric to adult T1D care struggle with glycemic control and continuity of care while experiencing psychosocial complexities. The purpose of this review was to examine associations between transition interventions and relevant outcomes. Methods: A predefined search strategy was used to retrieve papers published in the past five years evaluating transition programs for AYA with T1D. Nine observational studies and eight controlled trials were independently reviewed by two authors, with discrepancies addressed by a third. Results: A total of 1491 AYA with T1D aged 12-39 (mean 18.5) years were represented in 17 publications. The most frequent intervention components included a transition coordinator (7), transition education (5), a multidisciplinary appointment (4), and a virtual transition program (4). Outcomes most frequently reported included HbA1c (12), satisfaction (10), psychological well-being (7), and continuity of care (7). Associations between interventions and outcomes are presented in Table 1. Conclusions: There is a paucity of recent RCTs evaluating T1D transition interventions. While AYA with T1D reported satisfaction with a variety of interventions, programs including a transition coordinator and multidisciplinary appointment may also positively impact HbA1c, psychological well-being, and continuity of care. Disclosure E.L. Lundgrin: None. J.E. Blanchette: Consultant; Self; Dexcom, Inc., Tandem Diabetes Care. A. Mucci: None.

Introduction: Continuous glucose monitoring (CGM) measures glucose up to 288 times per day allowing people with diabetes (PWD) to see in real-time how medications, food, exercise, and stress, affect glucose levels. Clinicians interpret this information to make lifestyle and medication recommendations. Objective: To identify common learning outcomes and planned self-management changes resulting from CGM shared medical appointments. Study Design: A two-part CGM Shared Medical Appointment was led by certified diabetes educators (pharmacists, nurses and dieticians). Professional CGM devices were inserted and participants returned the following week for removal, discussion and education in a group format. Inclusion criteria for this study were as follows: age > 18 years, >3 days of CGM data, and attendance of both classes. A post-course survey was given with structured interview questions asking (1) “What is one thing you learned from the CGM class experience?” and (2) “Which changes do you plan to make to your diabetes care?” Questions were answered in written format. After digital transcription entry, data were coded and analyzed using content analysis to devise themes by two reviewers. Findings: A total of 170 PWD participated in the CGM class and 140 (82.35%) completed the post-course survey. Class sizes ranged from 3-6 participants. The most common learning outcomes were nutrition self-management knowledge (35.77%), pattern interpretation (18.25%) and blood glucose awareness (13.87%). The most common planned self-management changes were nutrition related (56.82%), self-management behavioral goals (24.42%) (log patterns, increase monitoring frequency) and medication adjustments (23.48%) (basal rates, carbohydrate ratios, timing and consistency of medications). Conclusion: Continuous Glucose Monitoring Shared Medical Appointments are an innovative strategy to facilitate lifestyle changes and medication adjustments for people with diabetes. Disclosure J.E. Blanchette: Consultant; Self; Dexcom, Inc., Tandem Diabetes Care. D. Noe: None. N. Galloway: None. H. Sullivan: None. A. Ha: Consultant; Self; Tandem Diabetes Care. D. Isaacs: Advisory Panel; Self; BD, Sanofi-Aventis.

The population of children who are dependent on life-sustaining medical technology in the United States is over 600,000 and continues to grow (U.S. Department of Health and Human Services, 2013). Technology-dependent children have complex, chronic conditions and are dependent on technology such as mechanical ventilation, intravenous nutrition or medication, respiratory support or nutritional support to live (Toly, Musil & Carl, 2012a; Spratling, 2015). Advances in medical technology allow technology-dependent children to live longer. Yet, the care associated with technology significantly impacts individual family members and family life on a daily basis over an indefinite period (Toly et al., 2012a; Caicedo, 2014; Caicedo, 2015). Following the technology-dependent child’s discharge to home, families begin to adjust to the change imposed by caring for a child with these complex care needs by creating a new “normal.” This new normal requires that the parent respond to the situation and adapt their lifestyle to accommodate the healthcare needs of the child (Toly et al., 2012a; Knafl & Deatrick, 2003). This process, referred to as normalization in the literature, begins with accepting the reality of the child’s condition and the potential lifestyle and family changes needed to manage the child’s condition (Deatrick, Knafl, & Murphy-Moore, 1999; Knafl et al., 2013). When normalization is present, parents feel competent in caring for the complex healthcare needs of their children and incorporating the medical management into their family lifestyle and routines (Deatrick et al., 1999; Knafl et al., 2013; Rehm, 2005). These families adopt unique solutions for solving the problems they experience and adjust the environment to provide their children with as many everyday childhood experiences as a typical, normally developing child (Leyenaar, O’Brien, Leslie, Lindenauer, & Mangione-Smith, 2017). Families caring for a technology-dependent child at home must learn to restructure goals based on balancing daily family life with their children’s required medical technology to keep the child stable and healthy while concomitantly maintaining a functioning family (Toly et al., 2012a; Toly, Musil & Carl, 2012b). When parents feel like they fully understand their children’s medical condition, they perceive the condition management as less burdensome and have greater confidence in their parenting skills (Deatrick et al., 1999; Sav et al., 2015; Smith, Cheater, & Bekker, 2015). Other families struggle in their normalization efforts and experience unresolved problems in the day-to-day medical management of their children’s condition (Gonzalez et al., 2017; Knafl & Deatrick, 2003). Parents face challenges in balancing normalcy, family life, household needs, and medical care or treatment needs of their technology-dependent child. The constant change in the care needs of the technology-dependent child and unpredictability of the child’s health status can lead parents to focus on the child’s health schedule and routine to the detriment of other family roles and responsibilities (Leyenaar et al., 2017; Smith et al., 2015). 1.1. Study Purpose The purpose of this study was to identify the day-to-day management problems and solutions employed by mothers of technology-dependent children. At this time, there is little information to assist parent caregivers with the day-to-day management problems they might experience while caring for their technology-dependent children at home (Dybwik, Tollali, Nielsen, & Brinchmann, 2011). Thus, exploring management problems and solutions to these problems is warranted.