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| ID | Type | Description | Link |
|---|---|---|---|
| 7-25-ICTSAD-414 | Other Grant/Funding Number | American Diabetes Association |
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| Name | Class |
|---|---|
| American Diabetes Association | OTHER |
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This study is designed to test the preliminary efficacy of a three-stage continuous glucose monitor (CGM) integration program for older adults who are taking insulin. This study will learn if a three-stage CGM integration program ("intervention") that includes sessions focused on CGM technology skills, data skills, and lifestyle skills impacts CGM wear-time, glycemic metrics, and participant-reported outcomes, compared to two standard CGM training approaches ("comparators").
Following a screening visit and baseline data collection, participants will be randomized to either the intervention or one of the two comparator arms for 6 weeks. The intervention involves three educational sessions over 4 weeks. The first session will be in-person and subsequent sessions will be virtual. Participants in the intervention may receive 1-2 additional individualized training sessions to review CGM skills. The first comparator (Comparator A) will receive a one-time clinic-based CGM training. The second comparator (Comparator B) will be provided with a comprehensive informational pamphlet about CGM. All participants will complete outcomes data collection at 6 weeks.
The study will also explore participant experiences through a series of semi-structured interviews with a subset of purposively selected participants and their care partners to identify opportunities for scaling the intervention to a broader population. An extension phase of the study will evaluate long-term CGM use and associated outcomes 3- and 6-months post-intervention.
Lastly, we will run an additional small sub-study where consented care partners of participants will attend the intervention or comparator sessions alongside the study participant and provide care partner-specific data.
This study will assess the preliminary effectiveness of a continuous glucose monitor (CGM) integration program ("intervention") in a 6-week randomized pilot study among 144 older adults with diabetes using insulin. The CGM integration program (48 participants) will be compared to two versions of usual care: 1) one-time clinic-based CGM training (Comparator A; 48 participants) and 2) self-directed CGM training (Comparator B; 48 participants). Following a screening visit and baseline data collection, participants will be randomized to one of the three groups in a 1:1:1 ratio by computer-generated sequence. All participants will be provided with 6-week supply of unblinded CGM sensors.
Participants who are randomized to the intervention group will attend three closed group sessions over 4 weeks. Session 1 (Day 1) will be held in-person, where participants will receive technical training related to CGM sensor insertion, transmitter pairing, and receiver operation. Session 2 (Day 14) will be held virtually and will consist of training in how to read and understand CGM data, customize target ranges, alerts, and alarms, export and review historical data, and share CGM data with care partners. Session 3 (Day 28) will also be held virtually and will consist of training in strategies to utilize CGM for improved safety and quality of life. Between each session, participants will be remotely assessed for CGM use and glucose trends. Based on these remote assessments, participants may receive 1-2 additional individualized training sessions to review CGM technical skills, as well as data and self-management strategies associated with CGM use.
Participants randomized to the one-time clinic-based CGM training group (Comparator A) will complete a one-hour visit with a clinic-based educator on Day 1 of the trial. This group will be provided with basic CGM training and be advised to follow up with their usual diabetes care team as needed for questions or issues throughout the 6-week trial period. Participants randomized to the self-directed CGM training (Comparator B) will be provided with a comprehensive informational pamphlet about CGM on Day 1 of the trial. They will also be provided with a list of online resources for CGM self-training and be advised to follow up with their usual diabetes care team as needed for questions or issues throughout the 6-week trial period.
At the end of the 6-week trial, all participants will provide primary endpoint data related to wear-time and use of the CGM device. In addition, secondary patient-reported outcomes and glycemic metrics will be assessed. We will conduct semi-structured interviews with a subset of purposively sampled participants (up to 20) and their care partners (up to 10) after their final endpoint visit to probe effective aspects of the intervention, challenges, struggles, and needs that were not addressed by the intervention, and strategies to improve the accessibility, acceptability, and effectiveness of the intervention for future older adults.
We will conduct an extension study in which we evaluate the following metrics at 3- and 6-months post-intervention: 1) CGM prescribing patterns post-study, including the proportion of participants with a CGM order at 3 and 6 months after study endpoint; 2) Clinical and patient-reported outcomes, such as glycemic indicators, severe hypoglycemia, device satisfaction (if applicable), barriers to sustained CGM access, integration of CGM into care and self-management, and unmet needs; 3) provider documentation of clinical rationale, perceived benefits, and barriers to CGM use across diverse care settings (internal medicine, family medicine, geriatrics, endocrinology).
Lastly, this study will involve a care partner sub-study. The aim of the care partner sub-study is to understand how the intervention improves or changes the knowledge and attitudes around CGM and diabetes management in care partners of older adults with diabetes. Consented care partners will be invited to attend any session their partner participant is assigned to. Care partners will be asked to complete care partner-specific questionnaires at baseline, at the end of the 6-week trial, and at 3- and 6-months post-intervention.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention | Experimental | Three-stage CGM integration program |
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| Comparator A | Active Comparator | One-time clinic-based CGM training |
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| Comparator B | Active Comparator | Self-directed CGM training |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Three-stage CGM integration program | Behavioral | Participants (and their consented care partner, if applicable) who are randomized to the intervention group will attend three closed group sessions over four weeks. Session 1 (Day 1) will be held in-person, where participants will receive technical training related to CGM sensor insertion, transmitter pairing, and receiver operation. Session 2 (Day 14) will be hybrid and will consist of training in how to read and understand CGM data, customize target ranges, alerts, and alarms, export and review historical data, and share CGM data with care partners. Session 3 (Day 28) will also be hybrid and will consist of training in strategies to utilize CGM for improved safety and quality of life. Between each session, participants will be remotely assessed for CGM use and glucose trends. Based on these remote assessments, participants may receive 1-2 additional individualized training sessions to review CGM technical skills, as well as data and self-management strategies associated with CGM use. |
| Measure | Description | Time Frame |
|---|---|---|
| CGM Wear Time | CGM wear time will be calculated as the percentage of time that the sensor is in use and providing data, relative to the total time it could have been worn, with a total of 6-weeks of total possible wear during the active intervention period. | Week 6 |
| CGM Use at 6 Weeks | CGM use will be determined as a yes/no binary response as to whether the study participant is wearing a CGM at the 6-week endpoint of the study intervention. | Week 6 |
| Measure | Description | Time Frame |
|---|---|---|
| Change in Core Diabetes Distress using the Type 1 Diabetes Distress Assessment System (T1-DDAS) Core Score | The T1-DDAS will be administered to participants with Type 1 Diabetes. Self-reported core diabetes distress will be measured using the 30-item Type 1 Diabetes Distress Assessment System (T1-DDAS) Core Score. The scale yields a core score that is the average of all core questions (first 8 items) responses rated on a 5-point Likert scale for all 8 items, ranging from 1 (not a problem) to 5 (a very serious problem). Higher scores indicate higher distress. A score >= 2.0 is considered clinically significant diabetes distress. |
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Participant Inclusion Criteria:
Participant Exclusion Criteria:
Care Partner Inclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Marcy Menard, MS, RD, LDN, CDCES | Contact | 919-843-9977 | mmenard@unc.edu | |
| Angela Fruik, MPH, RD, LDN | Contact | 919-962-6348 | angela.fruik@unc.edu |
| Name | Affiliation | Role |
|---|---|---|
| Anna Kahkoska, MD, PhD | University of North Carolina, Chapel Hill | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of North Carolina at Chapel Hill | Chapel Hill | North Carolina | 27599 | United States |
Deidentified individual data that supports the results will be shared beginning 6 to 18 months following publication provided the investigator who proposes to use the data has approval from an Institutional Review Board (IRB), Independent Ethics Committee (IEC), or Research Ethics Board (REB), as applicable, and executes a data use/sharing agreement with UNC.
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Beginning 6 and continuing for 18 months following publication
Investigator has approved IRB, IEC, or REB and an executed data use/sharing agreement with UNC.
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The interventionist, project manager, and data manager will be unblinded to participant treatment assignment to permit proper intervention delivery and study operations. The PI, clinical collaborators, and the study statistician will be blinded to allocation for the duration of the trial.
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| One-time clinic-based CGM training | Behavioral | Participants (and their consented care partner, if applicable) randomized to the one-time clinic-based CGM training group (Comparator A) will complete a one-hour visit with a clinic-based educator on Day 1 of the trial. This group will be provided with basic CGM training and be advised to follow up with their usual diabetes care team as needed for questions or issues throughout the 6-week trial period. |
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| Self-directed CGM training | Behavioral | Participants randomized to the self-directed CGM training (Comparator B) will be provided with a comprehensive informational pamphlet about CGM on Day 1 of the trial. They will also be provided with a list of online resources for CGM self-training and be advised to follow up with their usual diabetes care team as needed for questions or issues throughout the 6-week trial period. Consented care partners will not be directly involved, as there is no session visit to attend. |
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| Baseline, Week 6, Month 3, Month 6 |
| Change in Core Diabetes Distress using the Type 2 Diabetes Distress Assessment System (T2-DDAS) Core Score | The T2-DDAS will be administered to participants with Type 2 Diabetes. Self-reported core diabetes distress will be measured using the 29-item Type 2 Diabetes Distress Assessment System (T2-DDAS) Core Score. The scale yields a core score that is the average of all core questions (first 8 items) responses rated on a 5-point Likert scale for all 8 items, ranging from 1 (not a problem) to 5 (a very serious problem). Higher scores indicate higher distress. A score >= 2.0 is considered clinically significant diabetes distress. | Baseline, Week 6, Month 3, Month 6 |
| Change in Sources of Diabetes Distress using the Type 1 Diabetes Distress Assessment System (T1-DDAS) Source Score | The T1-DDAS will be administered to participants with Type 1 Diabetes. Self-reported sources of diabetes distress will be measured using the 30-item Type 1 Diabetes Distress Assessment System (T1-DDAS) source scale. Responses are rated on a 5-point Likert scale, ranging from 1 (not a problem) to 5 (a very serious problem). Higher scores indicate higher impact that the source is likely to have in contributing to diabetes distress. | Baseline, Week 6, Month 3, Month 6 |
| Change in Sources of Diabetes Distress using the Type 2 Diabetes Distress Assessment System (T2-DDAS) Source Score | The T2-DDAS will be administered to participants with Type 2 Diabetes. Self-reported sources of diabetes distress will be measured using the 29-item Type 2 Diabetes Distress Assessment System (T2-DDAS) source scale. Responses are rated on a 5-point Likert scale, ranging from 1 (not a problem) to 5 (a very serious problem). Higher scores indicate higher impact that the source is likely to have in contributing to diabetes distress. | Baseline, Week 6, Month 3, Month 6 |
| Change in Impact of Diabetes Quality of Life-Brief Clinical Inventory (DQOL) Score | Self-reported DQOL 15-item survey will be measured. Responses are rated on 5-point Likert scale. 7 questions ask about the frequency of negative impacts of diabetes or diabetes treatment and are scored from 1 (Never) to 5 (All the Time). 8 questions ask about satisfaction with treatment and quality of life and are scored from 1 (Very Satisfied) to 5 (Very Dissatisfied). Scoring is done by adding the numeric responses to the 15 questions, and can range from 15-75, with a higher score indicating a higher problem frequency or more dissatisfaction. | Baseline, Week 6, Month 3, Month 6 |
| Change in Self Care Inventory-Revised Version (SCI-R) Score | Self-reported SCI-R 15-item survey will be measured. Responses are rated on a 5-point Likert scale ranging from 1 (never) to 5 (always). For scoring, items are averaged and converted to a 0- to 100-point scale. Items that are not rated (or not applicable) are not included in the scoring. Higher scores indicate a better self-care. | Baseline, Week 6 |
| Change in Glucose Monitoring System Satisfaction Survey (GMSS) Type 1 Diabetes version Score | The GMSS Type 1 Diabetes version will only be administered to participants with Type 1 Diabetes. Self-reported glucose monitoring system satisfaction will be measured using the 15-item questionnaire. Responses are rated on a 5-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). Scoring is done by calculating the mean score across responses. Certain items need to be reverse coded. A higher total score indicates greater satisfaction. | Baseline, Week 6 |
| Change in Glucose Monitoring System Satisfaction Survey (GMSS) Type 2 Diabetes version Score | The GMSS Type 2 Diabetes version will only be administered to participants with Type 2 Diabetes. Self-reported glucose monitoring system satisfaction will be measured using the 15-item questionnaire. Responses are rated on a 5-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). Scoring is done by calculating the mean score across responses. Certain items need to be reverse coded. A higher total score indicates greater satisfaction. | Baseline, Week 6 |
| Change in Benefits of CGM (BenCGM) Score | Self-reported BenCGM 8-item survey will be measured. The scale yields a score based on the scale mean taken across all items using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). A higher mean score indicates higher perceived benefit of continuous glucose monitor (CGM). | Baseline, Week 2, Week 4, Week 6, Month 3, Month 6 |
| Change in Burdens of CGM (BurCGM) Score | Self-reported BurCGM 8-item survey will be measured. The scale yields a score based on the scale mean taken across all items based on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). A higher mean score indicates higher perceived barriers of continuous glucose monitor (CGM). | Baseline, Week 2, Week 4, Week 6, Month 3, Month 6 |
| Change in Opinions and Beliefs about CGM Technology [Investigator-written] | Investigator-written items will assess participant opinions and beliefs about using CGM technology, with Likert scale responses to statements ranging from 1 (strongly disagree) to 6 (strongly agree). Change across each item will be calculated at key intervention milestones and used to understand efficacy of the intervention, with higher scores equating to higher confidence in CGM use and application. | Week 2, Week 4, Week 6, Month 3, Month 6 |
| Change in sleep quality affected by CGM [Investigator-written] | Investigator-written items to assess impact of CGM on sleep. Responses about sleep quality and impact will be ranked and assessed individually per item, with higher ranked responses indicating worsened impacts on sleep. | Week 2, Week 4, Week 6, Month 3, Month 6 |
| Change in quality of life affected by CGM [Investigator-written] | Investigator-written open-ended questions will explore impacts of participant CGM use on daily life. Responses will be thematically coded with standard qualitative data analysis methods. | Week 2, Week 4, Week 6, Month 3, Month 6 |
| Change in CGM satisfaction (CGM-SAT) Score | Impact of CGM intervention on CGM satisfaction will be reported at endpoint after the intervention (week 6) and at month 3 and month 6 if participant is using personal CGM at month 3 and month 6. Self-reported CGM-SAT 44-item survey will be measured. Responses are on a 5-point Likert scale with responses ranges from 1 (agree strongly) to 5 (disagree strongly). After reverse scoring some items, the mean is calculated with higher mean scores reflecting greater satisfaction with CGM. This scale also includes two open-ended questions that will be evaluated using qualitative research methods. | Week 6, Month 3, Month 6 |
| Change in Hypoglycemia Fear (Hypoglycemia Fear Survey; Worry Subscale, HFS-II W) Score | Self-reported HFS-II W 18-item survey will be measured. The scale is a 5-point Likert scale with responses ranging from 0 (never) to 4 (almost always). A score of 3 or higher on any of the 18 items indicates fear of hypoglycemia. Higher average scores indicate higher fear of hypoglycemia. | Baseline, Week 6 |
| Change in Clarke Score (Hypoglycemia Unawareness) | Self-reported Clarke Score 8-item survey will be measured. Each answer correlates with a rating of A (aware) or R (reduced). 4 or more R responses suggest reduced hypoglycemia awareness. 3 responses suggest indeterminant hypoglycemia awareness. 2 or fewer R responses suggest hypoglycemia awareness. | Baseline, Week 6 |
| Change in Barriers to Physical Activity in Type 1 Diabetes (BAPAD-1) Score | Likert-type scale questions ranging from 1 (extremely unlikely) to 7 (extremely likely) for likelihood that each of the items would keep you from practicing regular physical activity during the next 6 months. Responses across 12-items are averaged, with lower average scores indicating a low level of perceived barriers to physical activity. | Baseline, Week 6 |
| Change in Healthy Eating Index (HEI) Score based on average intake across two 24-hour recalls | Participants will be contacted to self-administer two 24-hour dietary recalls (Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24)) per timepoint. Healthy Eating Index (HEI) scores will be calculated based on the recall responses using a scoring system providing cumulative points for participants eating from a select list of healthy food categories. The scores range from 0 to 100. An ideal overall Healthy Eating Index score of 100 reflects that the set of foods aligns with key dietary recommendations from the Dietary Guidelines for Americans (DGA). | Baseline, Week 6 |
| Change in carbohydrate intake based on average intake across two 24-hour recalls | Participants will be contacted to self-administer two 24-hour dietary recalls (Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24)) per timepoint. Carbohydrate intake (% of total kcal) will be calculated based on the recall responses averaged across both recalls delivered at each timepoint. | Baseline, Week 6 |
| Change in protein intake based on average intake across two 24-hour recalls | Participants will be contacted to self-administer two 24-hour dietary recalls (Automated Self-Administered 24-Hour Dietary Assessment Tool; ASA24) per timepoint. Protein intake (% of total kcal) will be calculated based on the recall responses averaged across both recalls delivered at each timepoint. | Baseline, Week 6 |
| Change in fat intake based on average intake across two 24-hour recalls | Participants will be contacted to self-administer two 24-hour dietary recalls (Automated Self-Administered 24-Hour Dietary Assessment Tool; ASA24) per timepoint. Fat intake (% of total kcal) will be calculated based on the recall responses averaged across both recalls delivered at each timepoint. | Baseline, Week 6 |
| Change in General Self-Efficacy Scale (GSE) Score | Self-reported General Self-Efficacy Scale (GSE) will be measured. Participants will be Likert-type scale questions ranging from Not at all true (1), Hardly true (2), Moderately true (3), Exactly true (4). The total score is calculated by finding the sum of all items. For the GSE, the total score ranges between 10 and 40, with a higher score indicating more self-efficacy. | Baseline, Week 6 |
| Change in Hemoglobin A1c (HbA1c) | HbA1c (%) reflects average glucose over the past 2-3 months. Value will be assessed by standardized laboratory assay at baseline and Month 3. | Baseline, Month 3 |
| Change in Percentage of Time in Range (TIR) | When using the blinded continuous glucose monitors (CGM), the percentage of sensor values between 70-180 mg/dL will be measured using 7-14 days of retrospective data at each time-point. | Baseline, Week 6 |
| Change in Percentage of Time Below Range (TBR) | When using the blinded continuous glucose monitors (CGM), the percentage of sensor values in the hypoglycemic range (<70 mg/dL) will be measured using 7-14 days of retrospective data at each time-point. | Baseline, Week 6 |
| Change in Percentage of Time Above Range (TAR) | When using the blinded continuous glucose monitors (CGM), the percentage of sensor values in the hyperglycemia range (>180 mg/dL) will be measured using 7-14 days of retrospective data at each time-point. | Baseline, Week 6 |
| Change in Percentage of Glycemic Variability | When using the blinded continuous glucose monitors (CGM), glycemic variability will be assessed using the coefficient of variation (%CV) using 7-14 days of retrospective data at each time-point. | Baseline, Week 6 |
| Change in Percentage of Time in Range (TIR) | If participant is wearing a personal/unblinded CGM, data will be collected and assessed for change from baseline and endpoint (week 6). The percentage of sensor values between 70-180 mg/dL will be measured using 7-14 days of retrospective data at each time-point. | Month 3, Month 6 |
| Change in Percentage of Time Below Range (TBR) | If participant is wearing a personal/unblinded CGM, data will be collected and assessed for change from baseline and endpoint (week 6). The percentage of sensor values in the hypoglycemic range (<70 mg/dL) will be measured using 7-14 days of retrospective data at each time-point. | Month 3, Month 6 |
| Change in Percentage of Time Above Range (TAR) | If participant is wearing a personal/unblinded CGM, data will be collected and assessed for change from baseline and endpoint (week 6). The percentage of sensor values in the hyperglycemia range (>180 mg/dL) will be measured using 7-14 days of retrospective data at each time-point. | Month 3, Month 6 |
| Change in Percentage of Glycemic Variability | If participant is wearing a personal/unblinded CGM, data will be collected and assessed for change from baseline and endpoint (week 6). Glycemic variability will be assessed using the coefficient of variation (%CV) using 7-14 days of retrospective data at each time-point. | Month 3, Month 6 |
| Change in care partner Opinions and Beliefs about CGM Technology [Investigator-written] | Investigator-written items will assess opinions and beliefs of care partners about participant's use of CGM technology, with Likert scale responses to statements ranging from 1 (strongly disagree) to 6 (strongly agree). Change across each item will be calculated at key intervention milestones and used to understand efficacy of the intervention, with higher scores equating to higher confidence in CGM use and application. | Baseline, Week 6, Month 3, Month 6 |
| Change in care partner sleep quality affected by CGM [Investigator-written] | Investigator-written items to assess impact of participant CGM use on care partner's sleep. Responses about sleep quality and impact will be ranked and assessed individually per item, with higher ranked responses indicating worsened impacts on sleep. | Baseline, Week 6, Month 3, Month 6 |
| Change in care partner quality of life affected by CGM [Investigator-written] | Investigator-written open-ended questions will explore impacts of participant's CGM use on care partner's daily life. Responses will be thematically coded with standard qualitative data analysis methods. | Baseline, Week 6, Month 3, Month 6 |
| Change in Care Partner Diabetes Distress (Partner DDS) Score | Care partners of participants will be offered to complete the 21-item Partner Diabetes Distress (Partner DDS) questionnaire. The survey yields a mean score based on a 4-point Likert scale with responses ranging from 0 (not at all) to 4 (a great deal). Total score is calculated as the mean of the 21 items. Mean item score of 0-1.9 is considered little or no distress, between 2-2.9 is considered moderate distress, and >=3 is considered high distress. | Baseline, Week 6, Month 3, Month 6 |
| Change in Care Partner Hypoglycemia Confidence Scale (Partner-HCS) Score | Care partners of participants will be offered to complete the 12-item Partner Hypoglycemia Confidence Scale (Partner-HCS). The survey yields a mean score based on a 4-point Likert scale with responses ranging from 1 (not confident at all) to 4 (very confident). Total score is calculated as the mean of the 12 items. Higher mean score reflects higher partner hypoglycemia confidence and lower mean score reflects lower partner hypoglycemia confidence. | Baseline, Week 6, Month 3, Month 6 |
| Change in DAWN Family Experience of Patient Involvement (DFEPI) Score | Care partners of participants will be offered to complete the 4-item DAWN Family Experience of Patient Involvement (DFEPI). Two questions use a Likert scale with responses ranging from 1 (never) to 5 (always) to assess communication of support needs. Higher composite scores indicate a higher level of communication received about needs for support. Two questions use a Likert scale with responses ranging from 1 (much less involved) to 5 (much more involved) to assess preferred level of involvement of family member. Higher composite scores indicate a care partner's higher desire for involvement in the participant's diabetes care. | Baseline, Week 6, Month 3, Month 6 |
| Change in DAWN Impact of Diabetes Profile - Family Members (DIDP-FM) Score | Care partners of participants will be offered to complete the 7-item DAWN Impact of Diabetes Profile - Family Members (DIDP-FM). The survey yields a composite score based on a 7-point Likert scale with responses ranging from 1 (very negative impact) to 7 (very positive impact). N/A responses (8) are treated as missing. A composite scale score can be derived by taking the sum of items divided by the number of complete responses (i.e. not missing or N/A). Lower scale scores indicate greater negative impact and higher scale scores indicate greater positive impact of diabetes on a family member's life. | Baseline, Week 6, Month 3, Month 6 |
| ID | Term |
|---|---|
| D003922 | Diabetes Mellitus, Type 1 |
| D003920 | Diabetes Mellitus |
| D003924 | Diabetes Mellitus, Type 2 |
| ID | Term |
|---|---|
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
| D004700 | Endocrine System Diseases |
| D001327 | Autoimmune Diseases |
| D007154 | Immune System Diseases |
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