Achieving Better Hemoglobin A1c Results in the Management of Type II Diabetes

Diabetes Mellitus Type 2 (Type 2 DM) is a chronic, but often preventable disease which continues to be on the rise in spite of all the available information, medications, education, and interventions (Alvarez, 2014; Dunphy, Winland-Brown, Porter, & Thomas, 2015). In the United States alone, Type 2 DM is reported to be the fifth leading cause of death, not counting the deaths attributable to other causes but which were most probably a result of the presence of Type 2 DM as a co-morbidity (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
Feinman et al. (2105) stated that ?The best predictor of microvascular and, to a lesser extent, macrovascular complications in patients with Type 2 diabetes is glycemic control (HbA1c)? (Pg. 9). The complications which occur in Type 2 DM, have been shown by multiple clinical trials to be significantly reduced or even delayed in the presence of careful glycemic control (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Hemoglobin A1c (HbA1c) levels show a patient?s average blood glucose level over a three-month period, which subsequently reveals how well the patient is doing with glycemic control (Dunphy, Winland-Brown, Porter, & Thomas, 2015; Feinman et al., 2015). The purpose of this paper is to discuss how the care and interventions provided by a Family Nurse Practitioner (FNP) could lead to the achievement of better HbA1c results in adult patients with Type 2 DM which would ultimately lead to better outcomes for the patient.

Identification of outcome
Type 2 DM is a disease with astronomical costs in the United States. The American Diabetes Association (ADA) shares the following statistics related to the cost of this disease:
? Nearly 30 million Americans have diabetes
? $1 in $3 Medicare dollars is spent caring for people with diabetes
? Diabetes and prediabetes cost America $322 billion per year
? 86 million Americans have prediabetes
? $1 in $5 health care dollars is spent caring for people with diabetes
? Today, 3,835 Americans will be diagnosed with diabetes. Today, diabetes will cause 200 Americans to undergo an amputation, 136 to enter end-stage kidney disease treatment and 1,795 to develop severe retinopathy that can lead to vision loss and blindness (American Diabetes Association, n.d.).
Kleinpell (2013), identified clinical outcomes such as ?symptom control and health status indicators? as some of the outcomes which can be measured (p. 5). Based on Kleinpell?s suggestion, one of the patient/client outcomes which can be measured in diabetes management is Hemoglobin A1c levels. As earlier stated, HbA1c control has a direct impact on the clinical outcomes of patients with diabetes. In order to put a lid on the rising cost of this disease, primary health care providers will have to devise practical and effective means of helping diabetic patients achieve better glycemic control.
Structure Component
Patient variables affecting outcome
Chaudoir, Dugan, and Barr (2013) stated that ?Patient-level variables are important to examine as predictors, because they inevitably impact the outcomes of implementation efforts? (p. 3). Some of the patient variables which could contribute to achievement of better A1c results in the management of diabetes are:
Severity of presentation of problem. The severity of the disease when the patient first presents to the clinic is one of the things listed as a patient variable by Irvine, Sidani, & Hall,1998. For instance, if the patient?s A1c is around 6.3 or 6.4, they are not considered diabetic but pre-diabetic (Dunphy, Winland-Brown, Porter, & Thomas, 2015). However, this pre-diabetic phase could very well be a harbinger of actual Type 2 DM if the right education and intervention is not instituted in a timely manner. This pre-diabetic stage would be a good time to start talking to the patient about lifestyle modifications which could prevent them from going from a pre-diabetic patient to a diabetic patient. If the patient is presented with the facts about the disease early enough and they are compliant with their management plan, the desired outcome of lower HbA1c and possible diabetes prevention could invariably be achieved. Also, even if a patient has already been diagnosed with the Type 2 DM, discussing with the patient about how their blood glucose can be better controlled in order to prevent it from becoming more severe, could lead to achieving better outcomes such as preventing or delaying the development of chronic complications.
Physical Function. Exercise has been proven to be one of the most important lifestyle modifications which can be inculcated into a diabetic patient?s daily regimen in order to achieve an outcome such as lower A1c in the management of Type 2 DM. However, exercise can worsen microvascular and macrovascular complications which may be present in the patient. In order to prevent this mishap, patients who are screened and found to have these complications might have to be excluded from doing certain exercises which would have had a more significant impact on the goal of achieving better A1c results (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
Language Barriers. Alvarez (2014) reported that many people from other cultures neither have access to needed diabetes education written in their primary language nor do they have the kind of support needed for optimal management of their health due to cultural and socioeconomic factors which makes it difficult for them to access resources needed to manage medical conditions (p. 41). In a clinical trial in which the language and cultural differences of a Latino population were put into consideration in the development of a diabetic self-management program, in comparison to the control group, a reduction of HbA1c was demonstrated among the treatment group (Alvarez, 2014).

Providers? variables affecting the outcome
Providers? variables which can affect the outcome include factors like:
Skill level of the provider. A provider in this context, includes anyone involved in the direct care of the patient as it has to do with achieving the goal of a lower HbA1c, including Nurse Practitioners, physicians, dieticians, endocrinologists, nurses etc. (Chadoir., Dugan, & Barr, 2013). For instance, a provider who has been seeing patients for a long time might be more adept at assessing for complications which could indicate poor glycemic control, compared to a brand new FNP. Also a nurse who has worked with diabetic patients for a long time has a better understanding of what to look for in the provider?s orders, such as a lab draw for HbA1c for a patient whose diabetes is not being very well controlled and whose last clinic visit was four months ago.
Attitudes towards evidence-based practice. Feinman et al. (2015) extensively discusses the impact of low carbohydrate diet on the management of diabetes, the writers also expressed frustration over the fact that in spite of all the facts pointing to the benefits of low carbohydrate diet in the management of HbA1c, many health care providers continue to stick to the old way of doing things such as placing the patient with poor glycemic control on insulin therapy without first trying them out on a low carbohydrate diet. If more providers are willing to try out new evidence-based practice, the chances of seeing better outcomes will be increased.

Organizational/system variables affecting the outcome
The organizational variables which can affect outcome include adequate staffing and staff satisfaction (Chadoir et al., 2013).
Adequate staffing. In order for positive patient outcomes to be realized in the management of Type 2 DM, enough staff would have to be on hand to meet the demands of provider quality and effective care for the diabetic patient. Type 2 DM is a disease which can be managed well without the development of complications, but this would entail providing practical and appropriate education for the patient. If there is not enough staff to give the patients the kind of care and education they need, they will not be able to achieve the desired goal of good glycemic control.
Staff satisfaction. Organizations which create an environment in which staff members are not only encouraged to follow evidence-based practices but also rewarded for doing so, will have staff members who are satisfied with their jobs. Such organizations will have better success at seeing patients who are well attended to and thus more willing to follow instructions and recommendations given to them by a caring and available staff (Chadoir et al., 2015)

Process Component
Independent role function and activities
Independent role functions include things such as nursing staff checking the patient?s blood sugar on arrival to the clinic, nurses making follow up calls to patients to remind them about diabetic education classes scheduled for them, dieticians making follow up calls on patients to ensure that dietary recommendations are being followed etc.
Medical care-related role functions and activities
Medical care-related role functions and activities include activities which the FNP can do such as prescribing medications like Glucagon-Like peptide-1 receptor agonists (GLP-1 RAs) in conjunction with basal insulin, early on in the course of the disease, and/or in a situation where oral diabetic medications and/or basal insulin therapy are not producing lower glycemic index control (Gallwitz & Bretzel, 2013). The FNP can also consult an endocrinologist to assist in the management of the patient in order to help the patient achieve better glycemic control.

Interdisciplinary role functions and activities
An interdisciplinary role function or activity that could contribute to achievement of good outcomes in diabetic management is collaboration and involvement of other members of the health care team in the management of the patient?s condition (Irvine, Sidani, & Hall,1998). For instance, because lifestyle modification such as nutritional therapy is one of the most important interventions in the management of diabetes, involving a dietician and/or a diabetic educator in the care of the patient early on in the disease process, could make a huge difference in outcome achievement (Alvarez, 2014; Dunphy, Winland-Brown, Porter, & Thomas, 2015).

Model/Figure/Diagram (accurately depict components/relationships of all identified components

Policy Implications: Identify one organizational, local, or national policy that affects or is affected by this outcome
The Affordable Care Act (ACA) was signed into law by President Obama on March 23, 2010, and on June 28, 2012, a final decision was rendered by the the Supreme Court to uphold the heath care law (U.S. Department of Health and Human Services, 2015). Health care is a very expensive undertaking in the United States, and most uninsured people avoid seeking health care, due to the high cost, unless it is absolutely necessary. One of the most important benefits of this policy was that people who were previously denied insurance coverage because of pre-existing conditions like diabetes, can now have insurance without regard to any pre-existing conditions. This is a major step in the right direction for healthcare. Whereas, previously, people with diabetes would not go seeking healthcare unless they absolutely needed it, which means they were not getting proper and routine care for their diabetes, they now have the opportunity to get the care they need before complications ensue. This means that diabetes can be diagnosed and treated early on before any complications begin to set in (Herman & Cefalu, (2015).
In conclusion, Type 2 DM is a disease which is currently wrecking havoc in the lives of multiple people all over the world. The economic cost of this disease is enormous. However, with careful glycemic control and proper guidance from health care providers and interdisciplinary health care teams, patients with this disease can actually have a chance at achieving good outcomes such as better HbA1c results

Alvarez, S. (2014). Type 2 Diabetes Program Geared Toward Latinos Fosters More than Self Management. Generations, 38(4), 41-45.
American Diabetes Association. (n.d.). The staggering cost of diabetes in America. Retrieved from
Chadoir, S. R., Dugan, A. G., & Barr, C. H. (2013). Measuring factors affecting implementation of health innovations: A systemic review of structural, organizational, provider, patient, and innovation level measures. Implementation science, 8(22), 1-20. doi: 10.1186/1748-5908-8-22.
Dunphy, L. M., Winland-Brown, J. E. Porter, B. O. & Thomas, D. J. 2015. Primary care: The art and science of advanced practice nursing. (Fourth ed.). Philadelphia, PA: F.A. Davis
Feinman, R. D., Pogozelski, W. K., Astrup, A., Bernstein, R. K., Fine, E. J., Westman, E. C., & … Childers, A. (2015). Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition, 31(1), 1-13. doi:10.1016/j.nut.2014.06.011t
Gallwitz, B., & Bretzel, R. G. (2013). How do we continue treatment in patients with Type 2 diabetes when therapeutic goals are not reached with oral antidiabetic agents and lifestyle? Diabetes care, 36(2), 180-189. Retrieved from
Herman, W. H., & Cefalu, W. T. (2015). Health policy and diabetes care: Is it time to put politics aside? Diabetes Care, 38(5), 743-745.
Kleinpell, R. M. (2013). Outcome assessment in advanced practice nursing. (Third ed.). New York, NY: Springer.
Irvine, D., Sidani, S., Hall, L. M. (1998). Linking outcomes to nurses’ roles in health care. Nursing Economic$, 16(2), 58-64, 87. Retrieved from
Partiprajak, S., Hanucharurnkul, S., Piaseu, N., Brooten, D., & Nityasuddhi, D. (2011). Outcomes of an advanced practice nurse-led type-2 diabetes support group. Pacific Rim International Journal of Nursing Research, 15(4), 288-304

Criteria Ratings Pts
I. Introduction A. Purpose of paper: Purpose Statement is clear. Outcome is relevant to clinical track/population focus 3.0 pts
II. Identification of Outcome: Identify outcome Define outcome Report relevant mortality, morbidity, and economic implications of outcome 15.0 pts
III. Structure component: Identify and support with literature the patient variables that affect the outcome Identify and support with literature the providers? variables that affect the outcome Identify and support with literature the organizational/system variables that affect the outcome 18.0 pts
IV. Process component: Identify and support with literature the independent role functions and activities Identify and support with literature the medical-care related role functions and activities Identify and support with literature the interdisciplinary role functions and activities 18.0 pts
V. Model/Figure/Diagram: Accurately depict the components/relationships of all identified components 5.0 pts
VI. Policy Implications: Identify one organizational, local, or national policy that affects or is affected by this outcome. 8.0 pts
VII.. Organization and writing Organization: Paper flows logically purpose and development of ideas clear and adequate. Conceptual clarity is evident throughout. 5.0 pts
Writing: Grammar appropriate sentence structure clear. Appropriate use of elements of punctuation. No spelling errors. 5.0 pts
VIII. APA Guidelines: Follows APA format, 6th edition.
view longer description 13.0 pts
Use of Evidence: Sufficient and appropriate literature integrated throughout paper. Represents current evidence 0.0 pts
Citations: Sources cited correctly using APA guidelines. 0.0 pts
References: Reference page is complete. Reference page only lists sources included in paper. Reference page according to APA format. 0.0 pts
IX. Plagiarism Issues: Review pp. 15-16 and Chapter 6 in the 6th edition APA Manual. Be very cautious related to the use of quotes. Guidelines are clearly identified on p. 170-171.The Turn it In Program must be used and submitted with the paper. Any evidence of plagiarism will result in a ?0? for the paper 0.0 pts
Other I. Late submission II. Paper Length III. Faculty Grader Meeting : 1 point for every 24 hours. 1 point for every page over 10 pages of content. (excluding references and the figure/model) +/- 10 10.0 pts
Total Points: 100.0