The nursing practice issue

NB—-issue to be examined will be on the attachment section. all numbers to answered based on weight they carry as a separate topic…

Rubric- Examining the Evidence

The paper should be carefully written in a formal style, based on primary sources, provide an integration of ideas, and be no more than 5-6 pages in length, excluding title page, reference list, and evidence matrix (any appendix). Organized flow, logical progression of ideas, and clarity in thought are essential. Only include evidence related to this assignment and not all of the evidence you have rated since doctoral school. Since you started to think about a practice issue/problem, I expect your investigation to evolve over time and will take into consideration the similarity from the Turnitin report. You MUST have headings corresponding to rubric points.

Examining the evidence

1          Introduction

The nursing practice issue to be examined is: the screening of youngsters for type 2 diabetes mellitus in primary care. Generally, youngsters to be screened comprise adolescents and children. In this paper, the purpose is basically to examine the evidence: this entails examining the aforementioned nursing practice issue. This paper explains the reason why the practice issue is significant; why it is a quality and/or safety issue; and if anything has been done to address it. A PICO question is constructed and key search terms that relate to the question are identified. In addition, a synthesis of the evidence related to the topic of concern is provided. Three interventions for improving the practice issue are explained in detail and a synthesis of the supporting evidence is also provided.   

2          Background

The practice issue is significant because it will help to identify and treat adolescents as well as children with type 2 diabetes mellitus (T2DM) and improve long-term outcome. The selected issue is a quality and/or safety issue because if diabetes mellitus is not treated, or if it is not treated properly, it could result in blindness, early death, coronary artery disease, renal failure, neuropathy, as well as peripheral vascular disease (Nesmith, 2009; Willi et al., 2004). In addition, screening adolescents and children who have particular risk factors could detect diabetes as well as insulin resistance early during the progression of the illness. It is noteworthy that early detection and treatment could promote treatment and/or alterations in lifestyle before serious complications arise (Bowen & Rothman, 2010). To address the issue in my practice, what has been done is the screening of type 2 diabetes with the use of glycated hemoglobin (HbA1c) and fasting plasma glucose. In my present nursing practice, the problem which I have awareness of is that there is inadequate knowledge regarding how to manage type 2 diabetes in children and in adolescents in primary care.

3          Using model

I will use the Institute of Medicine (IOM) model in my quality improvement initiative by ensuring that there is provision of quality care to children and adolescents with T2DM. The quality of care will comprise the following 4 imperative attributes: patient-centeredness, which basically centers on the patient’s experience of the disease and health care, and the extent to which systems succeed or fall short in satisfying the needs of the patient (Wald et al., 2012). Timeliness focuses on reducing delays and long waits. Safety of patient is an important element to high-quality healthcare, and effectiveness whereby effective care implies that patients do not get healthcare which is unable to assist them and/or where risks of health care outweigh benefits (Eriksson, Lindstrom & Tuomilehto, 2013). This model fits because by maintaining these characteristics, youngsters with T2DM will continue to stay healthy and keep getting better as they live with the disease. Another conceptual model that is guiding me in the process is Access to Care. This essentially focuses on healthcare utilization as well as barriers and facilitators to care. This model fits because by overcoming barriers to care and facilitating care to ensure effective healthcare utilization, the outcomes of children and adolescents with type 2 diabetes mellitus will improve (Reinehr, 2013).

4          PICO

The Patient, Intervention, Comparison, and Outcome (PICO) question is as follows: In children and adolescents with type 2 diabetes mellitus, will the use of metformin as initial therapy for the patients lead to better HbA1c control than glyburide? The key search terms which relate to the question are: diabetes type 2 therapy; HbA1c control; metformin; diabetic children; and glyburide. I determined the terms by listing down the words, which closely match with the PICO question, and then searched them on electronic databases. Using the key terms, I got 23 hits; seven of them were broad but 16 of them were close to my question. As such, I did not refine the question because there was no need.

5          Synthesis of the evidence

In relation to the screening of diabetes type 2 in children and adolescents, three of the ten studies reviewed pointed out that obesity is the primary indicator. Nurses within primary care settings are in a perfect position to spot adolescents as well as children who are at risk for T2DM and to begin suitable screening (Bowen & Rothman, 2010; Gahagan & Silverstein, 2003; Reinehr, 2013). However, one study revealed that providers of primary care such as nurses fail to identify the primary indication of T2DM screening, which is obesity (Hansen, Fulop & Hunter, 2009). It is recommended that the screening of type 2 diabetes should be done whenever obesity is seen and the youngster has at least two of the risk factors of this disease (Cox, Karen & Polvado, 2008).

With regards to the preferred method of testing, 2 of the 10 studies emphasized that fasting plasma glucose is the preferred one and it needs to be collected after every 24 months as long as the risk factors of the disease are still present (Eriksson, Lindstrom & Tuomilehto, 2013; Pozzo & Kemp, 2012). One of the studies pointed that notwithstanding the publication of screening recommendations for T2DM for the pediatric population, the rates of screening in adolescents and children who have the risk factors are very low (Willi et al., 2004). Five of the studies concluded that recognizing the relationship between fatness and T2DM in youngsters is a crucial initial step in the identification of youngsters at risk (Gahagan & Silverstein, 2003; Pozzo & Kemp, 2012; Wald et al., 2005; Eriksson, Lindstrom & Tuomilehto, 2013; Cox, Karen & Polvado, 2008). However, there is a gap in evidence: a review of the studies reveals that providers of healthcare are not conversant with the suitable time to begin screening or the recommendations of American Diabetes Association (ADA). Additionally, there is scarcity of research concerning the screening practices of primary care providers with regards to T2DM in children and adolescents. Three of the 10 reviewed studies highlighted that screening for this disease is vital since if T2DM is not treated, or treated poorly, it could result in end-stage renal disease, peripheral vascular disease, coronary artery disease and blindness (Pozzo & Kemp, 2012; Bowen & Rothman, 2010; Hansen, Fulop & Hunter, 2009).  

6          3 best interventions/strategies

The three best interventions that I identified from the literature for improving the practice issue include the following. First, is lifestyle modifications, and this entails maintaining a weight that is healthy; increasing the everyday physical activity; and eating diet that is healthy (Hansen, Fulop & Hunter, 2009; Bowen & Rothman, 2010; Cox, Karen & Polvado, 2008). Second intervention measure entails screening for T2DM with the use of glycated hemeoglobin (HbA1c), two-hour oral-glucose tolerance test, and fasting plasma glucose (FPG) (Wald et al., 2005; Eriksson, Lindstrom & Tuomilehto, 2013; Bowen & Rothman, 2010). Third intervention is risk assessment basing on the presence of conditions or signs of related insulin resistance, personal and family history of the child or adolescent, and body mass index (BMI). (Hansen, Fulop & Hunter, 2009; Pozzo & Kemp, 2012; Gahagan & Silverstein, 2003; Willi et al., 2004)

From the reviewed studies on intervention, 2 of them emphasized that impaired fasting glucose (IFG) is diagnosed with a FPG between 6.1mmol/l – 6.9 mmol/l. Impaired glucose tolerance (IGT) is diagnosed using a FPG <7 mmol/l (Hansen, Fulop & Hunter, 2009; Bowen & Rothman, 2010). One study pointed out that lifestyle change is associated with positive safety profile and does not have any adverse effects. Moreover, lifestyle modification is more cost-effective and has other beneficial health-related effects (Cox, Karen & Polvado, 2008). Two of the studies revealed that aiming for BMI of <15 kg/m² is an effective intervention measure for this population that comprises children and adolescents with T2DM (Gahagan & Silverstein, 2003; Willi et al., 2004). Four reviewed studies concluded that using glycated hemoglobin (HbA1c) in screening T2DM and fasting plasma glucose is appropriate in screening this disease (Hansen, Fulop & Hunter, 2009; Pozzo & Kemp, 2012; Wald et al., 2005; Willi et al., 2004).    

I discovered two evidence-based guidelines/protocols: The first one is a clinical practice guideline for screening adolescents and children for T2DM in primary care. The second one is developed by the American Diabetes Association, titled: Evidence-Based Clinical Decision Making, which is fundamentally a framework for guiding clinical practice. There is enough quality evidence to support the three strategies. In assessing the quality of evidence, the following method was utilized: Weighting According to a Rating Scheme. The evidence is Good: it consists of reliable results from studies that were designed and carried out very well in representative populations that in a direct manner, evaluate effects on health outcomes. The tool used to level the recommendations and evidence is the United States Preventive Services Task Force (USPSTF). A copy of the tool used to rate the evidence is provided as a separate appendix.

7          Conclusions

In conclusion, the practice issue is significant since it will help to identify and treat adolescents and children with T2DM and improve long term outcome. The selected issue is a quality and/or safety issue because if diabetes mellitus is not treated, or if it is not treated properly, it could result in blindness, early death, coronary artery disease or renal failure. Early detection and treatment could promote treatment and/or alterations in lifestyle before serious complications arise. Intervention measures for this issue include lifestyle modifications; screening with the use of fasting plasma glucose and HbA1c; and risk assessment basing on family history and BMI. The evidence use is rated as Good. I will build on this beginning research by applying the intervention measures on children and adolescents with T2DM and using evidence-based guidelines in my practice.

8          Matrix of evidence

Author/ Year	Title	Question/Purpose	Design	Sample	Data Collection	Findings	Level of Evidence
Eriksson, J., Lindstrom, J., & Tuomilehto (2013).	Potential for the Prevention of Type 2 Diabetes.	To identify successful prevention strategies for T2DM	Prospective observational	2,400 children and adolescents with T2DM	Not stated	Altering  the lifestyle and screening youngsters at high risk of T2DM is an effective strategy	High. Good sample size used,
Bowen, M. E., & Rothman, R. L. (2010).	Multidisciplinary Management of Type 2 Diabetes in Children and Adolescents	Multidisciplinary healthcare management in youth with type 2 diabetes	Prospective observational	4,100 youth with type 2 diabetes	Not specified	Effective treatment of T2DM calls for a mix of medications and lifestyle change	High, sample size is good,
Reinehr, T. (2013).	Type 2 Diabetes in Children and Adolescents	Diagnosis and screening for T2DM in adolescents and children	Comparison	6,900 children and adolescents with T2DM	Not stated	Screening is meaningful particularly in high risk groups like obese adolescent and children. Treatment of choice is lifestyle intervention and pharmacological treatment such as metformin	High. Large number of sample size
Hansen, J. R., Fulop., M. J., & Hunter, M. K. (2009).	Type 2 Diabetes in Youth: A Growing Challenge	How to combat the increasing prevalence of obesity that underlies the increase in T2DM in adolescents and children.	Prospective observational	4,633 children and adolescents with T2DM	The 3 authors collected all the data	Best prevention strategy in pediatric population is to identify obese youngsters who are at risk and intervening with regular healthy eating and exercise	High. Large sample size.
Cox, D., Karen, J., & Polvado, N. P. (2008).	Type 2 Diabetes in Children and Adolescents.	How should children and adolescents with T2DM be treated?	Prospective observational	9,441 adolescents and children with T2DM	Experiment	Interventions include pharmaceutical therapy, lifestyle changes, monitoring for complications, hyperlipidmia and hypertension treatment	High Large sample size employed
Pozzo, A. M., & Kemp, S. (2012).	Pediatric Type 2 Diabetes Mellitus.	Screening for T2DM in children and adolescents	Comparison	1,900 youths with T2DM	2 investigators collected the data	Screening should be done after every 24 months, the optimal screening study is a fasting plasma glucose	Moderate. modest sample size used
Gahagan, S., & Silverstein, J. (2003).	Prevention and Treatment of Type 2 Diabetes Mellitus in Children, With Special Emphasis on American Indian and Alaska Native Children.	Preventive efforts, early diagnosis and collaborative care of American native  and Alaskan children with T2DM	Comparison	1,200 American native and Alaskan children with T2DM	2 investigators collected data from the Indian and Alaskan children	Early screening and lifestyle modification are effective interventions	Moderate. reasonable sample size used
Wald, E. R., Moyer, S. C. L., Eickhoff, J., & Ewing, L. J. (2012).	Treating Childhood Obesity in Primary Care	To assess an intervention for children (9-12 years old) with obesity and their families delivered in primary care	To determine the appropriateness of primary care in identifying and treating obese children	78 children entered treatment	The investigators collected the data	Primary care is a suitable place for identifying and treating children with obesity	Moderate Small low sample size used
Willi, S. M., Martin, K., Datko, F. M., & Brant, B. P. (2004).	Treatment of Type 2 Diabetes in Childhood Using a Very-Low-Calorie Diet.	To assess the use of a ketogenic, very-low-calorie-diet (VLCD) in the treatment of type 2 diabetes	Comparison	20 pediatric patients with T2DM	The researchers conducted a chart review of 20 children who consumed VLCD in the treatment of T2DM	Ketogenic VLCD is an effective therapy for pediatric patients who have T2DM	Low. Small sample size used
Nesmith, D. J. (2009).	Type 2 Diabetes Mellitus in Children and Adolescents.	To describe the treatment for T2DM.	Prospective observational	2,512 pediatric patients with T2DM	Not stated.	Screening is important to patients who are at great risk of T2DM. Treatment options range from exercise and diet modifications to medications including insulin and oral agents.	High. Good sample size used

Appendix 1: The IOM model used that aims for quality care – QR/DR Conceptual Framework (Reinehr, 2013).

Access to Care	Quality to care
Facilitators and barriers to Care	Health Care Utilization	Safety	Patient-centeredness	Effectiveness	Timeliness
Remaining healthy	Remaining healthy
Getting better	Getting better
Living with disability or disease	Living with disability or disease
Dealing with the End of Life	Dealing with End of Life

Appendix 2: A copy of the tool utilized in rating the evidence.

The USPSTF was used in grading the quality of the evidence on a three-point scale.

Rating
Low	Evidence is inadequate in assessing the effects on health outcomes due to insufficient number of studies, errors in their design, lack of information on essential health outcomes, or chain of evidence having gaps
Moderate	Evidence is adequate in determining the effects on health outcomes. However, the evidence strength is restricted by the generalizability to usual practice; uniformity, quality or number of individual studies; or indirect nature of the evidence.
High	The evidence comprises studies that were carried out and designed properly in representative populations that assess directly the effects on health outcomes.

Reference

Bowen, M. E., & Rothman, R. L. (2010). Multidisciplinary Management of Type 2 Diabetes in Children and Adolescents. Journal of Multidisciplinary healthcare, 21(3): 113-124.

Cox, D., Karen, J., & Polvado, N. P. (2008). Type 2 Diabetes in Children and Adolescents. Advance Healthcare, 16(11): 43.

Eriksson, J., Lindstrom, J., & Tuomilehto (2013). Potential for the Prevention of Type 2 Diabetes. British Medical Bulletin, 60(1): 183-199.

Gahagan, S., & Silverstein, J. (2003). Prevention and Treatment of Type 2 Diabetes Mellitus in Children, With Special Emphasis on American Indian and Alaska Native Children. PEDIATRICS, 112(4): 188.

Hansen, J. R., Fulop., M. J., & Hunter, M. K. (2009). Type 2 Diabetes in Youth: A Growing Challenge. Clinical Diabetes, 18(2): 174-177.

Nesmith, D. J. (2009). Type 2 Diabetes Mellitus in Children and Adolescents. PEDIATRICS IN REVIEW, 2(5): 147-152.

Pozzo, A. M., & Kemp, S. (2012). Pediatric Type 2 Diabetes Mellitus. Medscape, 33(2): 72-81.

Reinehr, T. (2013). Type 2 Diabetes in Children and Adolescents. World Journal of Diabetes, 4(6): 270-281.

Wald, E. R., Moyer, S. C. L., Eickhoff, J., & Ewing, L. J. (2012). Treating Childhood Obesity in Primary Care. SAGE Journals, 74(4): 123-129.

Willi, S. M., Martin, K., Datko, F. M., & Brant, B. P. (2004). Treatment of Type 2 Diabetes in Childhood Using a Very-Low-Calorie Diet. Diabetes Care, 27(2): 348-353.