1. Impact of using team-based learning in patient education on
diabetes outcomes
Tracy R Frame1, Juanita A Draime2, Thaddeus T Franz3
1 PharmD, BCACP, Belmont University; 2BSPS, MA, PharmD Candidate 2016, Cedarville University; 3PharmD, Cedarville University
BACKGROUND
Diabetes (DM)
• DM is a prevalent, chronic disease in the US (25.8 million people had Type 2 in 2010).1,2
• Impacts patient quality of life and has significant financial implications for the US.3
• Maintaining control using appropriate self-care management can help reduce healthcare costs and
improve patient outcomes by decreasing morbidity and mortality.
Traditional Diabetes Education and the Pharmacist’s Role
• DM self-management education (DSME) is an ongoing process of teaching patients the knowledge,
skills, and abilities necessary for diabetes self-care.4,5
• Group education has been shown to improve outcomes; however, this typically consists of lecture-
based presentations with some interactive group discussion.6,7
• Studies have shown improvement of patient outcomes with a pharmacist-led DM care program.8,9
Team-Based Learning (TBL)
• In academic settings, institutions are increasingly using TBL for student mastery of concepts.
• TBL has been shown to be a more useful tool than lecture-based or group discussion formats.10,11
• Results in better recall and knowledge retention.
• TBL has limited incorporation into patient education.
Purpose:
• To compare the effects of a 12-week team-based learning (TBL) diabetes education intervention
versus traditional, lecture-based education on patient outcomes.
Primary Objective:
• To assess the changes in clinical lab markers (FBG, HgA1C, BP, weight) of Type 2 diabetes patients.
Secondary Objectives:
• To assess changes in patient knowledge.
• To assess changes in quality of life (QOL).
• To assess self-management adherence.
PURPOSE AND OBJECTIVES
METHODS
Discussion/Conclusions
• The control arm showed a significant difference with the A1C between the control and TBL arm at 6 months . Within groups, the TBL arm showed significant improvement
in systolic blood pressure and self-efficacy scores. The control group was significant for an increase in weight. Both the TBL and control group showed improvement or gains
in QOL, diabetes knowledge, and diastolic blood pressure.
• Overall, TBL in patient education changes the way patients typically learn when attending education classes.
• Patients in this setting were able to ask many questions, hear other patient questions, and learn the same information multiple times in different ways and identify a
support system with other teammates.
• Utilizing TBL in patient education can improve clinical markers and retention of diabetes knowledge.
• While traditional education is clearly beneficial for patients, TBL-based education provides an opportunity to apply information learned and improve personal outcomes.
• It would be very helpful to perform this study on a much larger population.
• Health care providers should consider utilizing TBL when teaching not only diabetes education, but also for other patient educational programs as well.
Limitations
• Loss of patients (i.e., attrition) over the 6 month period, A1C now machine malfunction (requiring clinic DCA Vantage Analyzer) which could have impacted the results.
• Prior to this study, no diabetes education had been offered or provided to patients at this healthcare center. Due to this, patients that enrolled in the study could have been
more motivated to make changes which could impact their quality of life and desire to learn.
RESULTS
CONCLUSIONS
1. CDC National diabetes fact sheet: national estimates and general information on diabetes and prediabetes
in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, CDC, 2011.
2. Diabetes Statistics resources page. http://www.diabetes.org/living-with-diabetes. Accessed July 18, 2013.
3. ADA. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2008;31:596–615.
4. Loveman E, Frampton GK, Clegg A. The clinical effectiveness of diabetes education models for type 2
diabetes: A systematic review. Health Technol Assess. 2008;12(9):1-136.
5. Funnell MM, et al. National standards for DSME. Diabetes Care. 2011;34:S89–S96.
6. Rickheim PL, et al. Assessment of group versus individual diabetes education: a randomized study. Diabetes
Care. 2002;25(2):269-274.
7. Willens D, et al. Interdisciplinary team care for diabetic patients by primary care physicians, advanced
practice nurses, and clinical pharmacists. Clin Diabetes. 2011;29(2):60-68.
8. Rothman R, et al. Pharmacist led, primary care-based disease management improves hemoglobin A1c in
high-risk patients with diabetes. American Journal of Medical Quality. 2003;18(2):51-58.
9. Scott DM, Boyd ST, Stephan M, Augustine SC, Reardon TP. Outcomes of pharmacist-managed diabetes care
services in a community health center. AJHP. 2006;63(21):2116-2122.
10. Tribe, D. (1994). An overview from higher education. In L. Thorley, & R. Gregory (Eds.), Using group based
learning in higher education (pp. 25-31). London: Kogan Page.
11. Garland, D. (1994). Assessment issues in group work. In H. C. Foot, et all (Eds.), Group interactive learning
(pp. 417-422). Southampton: Computational Mechanics Publications.
Funding for this project was from the New Investigator’s Award through AACP
as well as an internal grant from Cedarville University School of Pharmacy.
Thank you to Dr. Aleda M Chen for guidance in statistical analysis . Thanks to
the many students who volunteered to help with survey collections and helping
to facilitate TBL groups.
ACKNOWLEDGEMENTS
REFERENCES
Demographics
Lecture
Arm
N(%)
TBL Arm
N(%)
Enrolled Patients at baseline 27 (47%) 30 (53%)
Patients who returned at 3 mths 21 20
Patients who returned at 6 mths 11 15
Male 11 (52%) 10 (48%)
Female 16 (44%) 20 (56%)
Age, Mean (SD) 48.96 (±9.4) 51.6 (±9.7)
Marital Status (N=56)
Never Married 4 (15%) 8 (28%)
Married 8 (30%) 4 (14%)
Separated/Divorced 13 (48%) 13 (45%)
Widowed 2 (7%) 4 (14%)
Ethnic Origin/race (N=57)
White 14 (47%) 15 (56%)
Black 15 (50%) 10 (37%)
Native American 0 (0%) 2 (7%)
Other 1 (3%) 0 (0%)
Education (N=57)
8th grade or less 0 (0%) 1 (3%)
Some high school 6 (22%) 5 (17%)
HS graduate or GED 13 (48%) 9 (30%)
Some college 6 (22%) 14 (47%)
Bachelor’s Degree 1 (4%) 0 (0%)
Graduate Degree 1 (4%) 1 (3%)
Insurance Status (N=55)
Individual Plan – member
pays plan premium
2 (8%) 0 (0%)
Military, CHAMPUS, VA 0 (0%) 3 (10%)
Medicaid 9 (36%) 14 (47%)
Medicare 1 (4%) 4 (13%)
Medicaid & Medicare 2 (8%) 0 (0%)(
No insurance in last 12
months
11 (44%) 9 (30%)
Prior DM Education? (N=56)
No 15 (55.6%) 17 (58.6%)
Yes 9 (33.3%) 12 (41.4%)
Not sure 3 (11.1% 0 (0%)
Research Logistics
• IRB approval was obtained.
• 12 week randomized, pretest-posttest control group study.
• Patients were recruited from a FQHC in Springfield, OH (Rocking Horse Community Health Center).
• Patients with diabetes (≥18 years of age, able to read/speak English) who attended a primary care
visit during January and February 2013 were invited to participate.
• Patients completed a survey on availability  determined top two days most patients could attend
 assigned one day as control (lecture-based) and the other intervention (TBL).
Education Provided
• Control group: traditional lecture-based education by clinical pharmacists and professional pharmacy
students using PowerPoint lecture during 4, 1-hour bi-weekly group sessions over 8 of 12 weeks.
• Intervention group: TBL provided by clinical pharmacists and professional pharmacy students during
4, 2-hour bi-weekly group sessions over 8 of 12 weeks.
• Patients assigned to teams of 5-6.
• Given literacy-level appropriate preparation materials to read prior to each session.
• TBL process at each session:
• Patients completed multiple choice individual readiness assurance tests (IRATs).
• Same test completed in their teams (TRATs).
• Mini-lecture was then given to address confusing topics to whole group.
• Teams then did application activities to apply concepts (patient cases, worksheets).
• Both groups covered all recommended information per DSME.
• Patient outcomes measured at baseline, 3 months (diabetes education completion), and 6 months.
• Included: patient knowledge (assessed using the Spoken Knowledge in Low Literacy in Diabetes
Scale), self-management behaviors (assessed using the Self-Efficacy of Diabetes survey), and
QOL (assessed using the Ferrans and Powers Quality of Life Index Diabetes Version III), as well as
clinical lab markers (fasting blood glucose, Hemoglobin A1c, weight and blood pressure).
Analysis
• To achieve a power of 0.8, with an α=0.05, and δ=0.8 (large effect size), a minimum of 30 patients
were recruited for each group to allow for attrition (total N = 60).
• Performed in SPSS v.21 (Armonk, NY) and included descriptive statistics (frequencies, medians).
• Parametric data (clinical lab markers, knowledge): paired t-tests for within-group, unpaired t-test for
between-group changes, repeated measures ANOVA for longitudinal changes
• Nonparametric data (self-management, QOL): Wilcoxon test for within-group, Mann-Whitney U test
for between-group changes, Friedman test for longitudinal changes
82
78
83
86
81
76
70
72
74
76
78
80
82
84
86
88
Baseline 3 Months 6 Months
Blood Pressure - Diastolic
Control TBL
No significant differences between groups OR
within groups cross-sectionally or longitudinally
9.2
8.4 8.0
9.1 8.8
9.7
0
2
4
6
8
10
12
Baseline 3 Months 6 Months
HgA1c
Control TBL
239
245
249
231
239
245
220
225
230
235
240
245
250
255
Baseline 3 Months 6 Months
Weight
Control TBL
134
129
132
141
131
125
115
120
125
130
135
140
145
Baseline 3 Months 6 Months
Blood Pressure - Systolic
Control TBL
210 216
175
227 226 240
0
50
100
150
200
250
300
Baseline 3 Months 6 Months
Fasting Blood Glucose
Control TBL
51
57
61
43
58
63
0
10
20
30
40
50
60
70
Baseline 3 Months 6 Months
SKILLD Scores
Control TBL
6
7.2 7.5
6.3
7.6
11.7
0
2
4
6
8
10
12
14
Baseline 3 Months 6 Months
Self-Efficacy Scores
Control TBL
18.75
21.25
22.26
18.95
20.41
21.24
16
17
18
19
20
21
22
23
Baseline 3 Months 6 Months
Overall QOL Scores
Control TBL
Baseline-3 months TBL: p=0.030
Control vs. TBL 6 months: p=0.021
Baseline-3 months Control: p=0.034
3-6 months Control: p<0.001
3-6 months Control: p=0.020
Longitudinal Control, TBL: p=0.031, p=0.003
Baseline-3 months TBL: p=0.002
Longitudinal TBL: p<0.001
Baseline-3 months TBL: p=0.006
Baseline-6 months TBL: p=0.001
Longitudinal Control: p=0.002
Baseline-3 months Control: p<0.001
Baseline-6 months Control, TBL: p=0.004, 0.031
Longitudinal Control, TBL: p=0.017, p=0.003
Baseline-3 months TBL: p=0.001
Baseline-6 months TBL: p=0.008
Longitudinal TBL p=0.013
Baseline-3 months Control, TBL: p=0.009, 0.004