Week 7 Synthesis Paper – With Solution

Week 7 Synthesis Paper

Assignment

Purpose

The purpose of this assignment is to present a revised evidence synthesis paper using the Week 5 submission, integrating course faculty feedback. This includes revising all parts of the assignment as recommended as well as the Johns Hopkins Individual Evidence Summary Tool. Also, please add new content identified below (Selection of Translation Science Model – 6f).

Instructions

Follow these guidelines when completing the assignment. Contact your course faculty if you have any questions.

1. Review the directions and complete the Johns Hopkins Individual Evidence Summary Tool. Use the 3 articles: 2 quantitative and 1 qualitative used in Weeks 3, 4, and 5. These must be recent research articles less than 5 years old and be related to a National Practice Problem.
   1. Link (Word doc): Johns Hopkins Individual Evidence Summary Tool (Links to an external site.).
2. Use the most current version of Microsoft Word that is the format for all Chamberlain University College of Nursing. You can tell the document is saved as the current version because it will end in “docx.”
3. All Chamberlain University policies related to plagiarism must be observed. This written assignment will be screened for originality by Turnitin.
4. Revise the paper from Week 5, including course faculty feedback and adding the new section (6f).
5. Review the rubric for the grading criteria.

The assignment includes the following components:

1. Title Page
2. Introduction
   1. Introduce the practice problem.
   2. Discuss sources of research evidence identified in Weeks 3, 4, and 5.
3. Analysis of the Practice Problem (1-2 paragraphs)
   1. Present the significance of the practice problem.
   2. Present the prevalence of the practice problem from the selected articles.
4. Evidence Synthesis: Using the three articles (2 quantitative and 1 qualitative), write a synthesis of evidence to address the selected practice problem. In the synthesis of evidence include the following:
   1. Identify the main themes and salient evidence that emerge from the sources. (Cited)
   2. Compare and contrast the main points from all sources. (Cited)
   3. Present an objective overarching discussion of evidence about the practice problem.
5. Appraisal of the Evidence to Address the Practice Problem: Include the following:
   1. Identify the level of evidence.
   2. Provide a quality rating of the evidence.
   3. Appraise and support the suitability of the evidence to address the practice problem.
6. Selection of a Translation Theory or Model (1-2 paragraphs)
   1. Present the components of the theory.
   2. Discuss how stakeholders are integrated into the design of the theory or model.
7. Conclusion
   1. In one concise paragraph, provide a clear and logical conclusion summarizing the paper.
8. Summary Table: Complete all sections of the Summary Tables of Evidence using the Johns Hopkins Individual Evidence Summary Tool. Include the following:
   1. Two Quantitative Research Studies (identified in Week 3 & 4 Discussion).
   2. One Qualitative Research Studies (identified in Week 5 Discussion).
   3. Complete all sections completely and identify the quality and the levels of evidence.
9. Appendix A
   1. Attach the completed Johns Hopkins Summary Tool as Appendix A.

Writing Requirements (APA format)

• Length: 5-7 pages (not including title page or references page)
• 1-inch margins
• Double-spaced pages
• 12-point Times New Roman or 11-point Arial font
• Headings & subheadings
• In-text citations
• Title page
• References page
• Standard English usage and mechanics
• Revisions based on course faculty feedback from Week 5 Assignment

Course Outcomes

This assignment enables the student to meet the following course outcomes:

1. Appraise the role of the DNP-prepared nurse in leading collaborative teams across the diverse healthcare systems. (POs 1, 2, 4, 7, 8, 9)
2. Critically appraise literature for level and quality of evidence to support practice change. (POs 1, 3, 5, 6, 7)
3. Appraise global healthcare practice problems and DNP practice relevant to advanced nursing practice. (POs 1, 3, 9)
4. Evaluate and integrate ethical principles and theories relevant to translation science theories and quality improvement (QI) methods. (POs 3, 4, 5, 6, 7)
5. Evaluate the structure and function of the interprofessional team and stakeholders in the translation of evidence. (POs 4, 6, 8, 9)

Due Date

• By 11:59 p.m. MT on Sunday
• Late Assignment Policy applies

Rubric

W7 Assignment Grading Rubric

W7 Assignment Grading Rubric

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeIntroduction

Requirements:1. Introduce the practice problem.2. Discuss sources of research evidence selected in Weeks 3, 4, and 5.

20 pts

Includes all requirements and provides an excellent introduction.

18 pts

Includes all requirements with a very good introduction.

16 pts

Includes all requirements with a basic introduction.

0 pts

Poor introduction and/or includes 1 or fewer requirements.

20 pts

This criterion is linked to a Learning OutcomeAnalysis of the Practice Problem

Requirements:1. Present the significance of the practice problem.2. Present the prevalence of the practice problem.

20 pts

Includes all requirements and an provides an excellent analysis of the practice problem and prevalence.

18 pts

Includes all requirements and a very good analysis of the practice problem and prevalence.

16 pts

Includes all requirements with a basic analysis of the practice problem and prevalence.

0 pts

Includes 1 or fewer requirements and/or with a poor analysis of the practice problem or prevalence.

20 pts

This criterion is linked to a Learning OutcomeEvidence Synthesis

Requirements:1. Present main themes, and salient findings that emerge from the sources (Cited).2. Compare and Contrast the main points from all sources (Cited).3. Present an objective overarching discussion of evidence about the practice problem and prevalence.

50 pts

Includes all requirements and provides an excellent evidence synthesis.

45 pts

Includes all requirements and provides a very good evidence synthesis.

40 pts

Includes no fewer than 2 requirements with a basic evidence synthesis.

0 pts

Includes 1 or fewer requirements and/or provides a poor evidence synthesis.

50 pts

This criterion is linked to a Learning OutcomeAppraise the Evidence

Requirements:1. Level of evidence.2. Quality rating of evidence.3. Appraise and support the suitability of the evidence to address the practice problem.

20 pts

Includes all requirements and provides an excellent appraisal of the evidence.

18 pts

Includes all requirements and provides a very good appraisal of the evidence.

16 pts

Includes no fewer than 2 requirements and provides a basic appraisal of the evidence.

0 pts

Includes 1 or fewer requirements and/or provides a poor appraisal of the evidence.

20 pts

This criterion is linked to a Learning OutcomeSelection of a Translation Theory or Model

Requirements:1. Present the components of the theory.2. Discuss how stakeholders are integrated into the design of the theory or model.

50 pts

Includes all requirements and provides an excellent discussion of translation model and/or stakeholders integration into theory model.

45 pts

Includes all requirements and provides a very good discussion of translation model and/or how stake holders integration into theory model.

40 pts

Includes all requirements and provides a basic discussion of translation model and/or how stake holders integration into theory model.

0 pts

Includes 1 or fewer requirements and/or provides a poor presentation of components of translation theory and how stake holders are integrated into the theory model.

50 pts

This criterion is linked to a Learning OutcomeConclusion

Requirements:In one concise paragraph, provide a clear and logical conclusion that summarizes the paper.

10 pts

Includes all requirements and provides an excellent conclusion.

9 pts

Includes all requirements and provides a very good conclusion.

8 pts

Includes all requirements and/or provides a basic conclusion.

0 pts

Provides a poor conclusion.

10 pts

This criterion is linked to a Learning OutcomeRevisions

Requirements:Revisions done based on course faculty feedback from Week 5 Assignment .

50 pts

Substantial revisions have been made based on course faculty feedback on the week 5 paper.

0 pts

Limited or no revisions have been made based on faculty feedback on the week 5 paper.

50 pts

This criterion is linked to a Learning OutcomeSummary Table

Requirements:1. Two quantitative research studies2. One qualitative research studies3. Complete all sections completely and identify the quality and the levels of evidence.

15 pts

Includes all requirements and provides an excellent summary table.

13 pts

Includes all requirements and provides a very good summary table.

12 pts

Includes no fewer than 2 requirements or a basic summary table.

0 pts

Includes no requirements or a poorly completed summary table.

15 pts

This criterion is linked to a Learning OutcomeAppendix A

Requirements:Attach the completed Johns Hopkins Summary Tool as Appendix A.

10 pts

Includes tool in the appendix.

0 pts

Does not include the tool in the appendix.

10 pts

This criterion is linked to a Learning OutcomeAPA Style and Standards

Requirements:1. Use appropriate Level I headers.2. Reference and citations are in current APA style.3. Paper length is 5-7 pages excluding title, reference pages, and appendix.

10 pts

Includes all requirements and presents excellent APA style and standards.

9 pts

Includes 3 requirements and very good APA style and standards.

8 pts

Includes no fewer than 2 requirements of APA style and standards.

0 pts

Includes 1 or fewer requirements of APA style and standards.

10 pts

This criterion is linked to a Learning OutcomeClarity of Writing

Requirements:1. Use standard English grammar and sentence structure.2. No spelling or typographical errors.3. Organized presentation of ideas.

20 pts

Includes all requirements and demonstrates excellent clarity of writing.

18 pts

Includes all requirements and demonstrates very good clarity of writing.

16 pts

Includes no fewer than 2 requirements and/or demonstrates basic clarity of writing.

0 pts

Includes 1 or fewer requirements and/or demonstrates poor clarity of writing.

20 pts

Total Points: 275

Solution

Synthesis Paper

The purpose of this paper is to present a revised evidence synthesis assignment using the week five submission while integrating faculty feedback.

Diabetes as National Problem

The national practice problem chosen for this assignment is diabetes. The most recent report by the Centre for Disease Control and Prevention indicates that about 34.2 million (i.e., over 1 in 10 Americans) and 88 million (i.e., 1 in 3 Americans) have diabetes and prediabetes, respectively (CDC, 2020). Individuals incur significant health burdens and costs associated with a diabetes diagnosis (Arslanian et al., 2018). Equally, the government incurs the impact of the loss of labor productivity and income tax revenue, direct healthcare costs, and increased payments in welfare.  Therefore, diabetes requires adequate and quality care consistent with patient-centeredness and care across the lifespan and patient advocacy.

The purpose of this assignment is to present a synthesis of selected diabetes management evidence. Two studies, one quantitative and one qualitative was identified to establish evidence on the importance of and necessity of effective self-management education and support for patients diagnosed with type 2 diabetes (T2D). The quantitative studies are graded as level I, high-quality research study, and the qualitative article is Level III, quality A.

Analysis of the Practice Problem

Diabetes is the increasingly growing metabolic threat of our contemporary era. To find out the incidence of diabetes in the US, I searched for the prevalence and incidence of diabetes in the USA in the CDC database, from which I clicked on the link for the National Diabetes Statistics Report of 2020. I also googled and identified the top five information sources on the incidence of diabetes in the USA. The information sources identified were related to the incidence, prevalence, mortality, and cost of the diabetes epidemic. The findings are as discusses hereunder.

Globally, T2D diabetes is a common condition with complex etiology. Irreversible T2D risk factors include aging, racial affiliation, and ethnicity, while reversible factors include an individual’s diet, smoking, and sedentary lifestyle (Rodriguez-Saldana, 2019). Diabetes is considered the seventh leading cause of mortality in the USA. About 83,564 deaths were attributed to diabetes as a secondary factor and 270,702 deaths as a primary factor in the year 2017 (ADA, 2021). An estimated 24.7 million people in the US are diagnosed with diabetes (ADA, 2018).  As a result, the government spends about $327 billion on lost productivity due to unemployment, work absenteeism, premature mortality, chronic disability, and direct healthcare costs attributed to diabetes. Significantly, the direct medical costs of diabetes, such as insulin, antidiabetic agents, and associated diseases, contribute 43% of the expenditure.

Diabetes progression accompanied by poor glycemic control cause numerous life-threatening complications, including amputations due to hard to health diabetic foot ulcers, stroke, kidney failure, and heart diseases (Rodriguez-Saldana, 2019). About half of adults diagnosed with kidney disease have diabetes, at least 9.8% of diabetic patients have had a heart attack, and about 9.1% are diagnosed with coronary heart disease (Trikkalinou, Papazafiropoulou, & Melidonis, 2017). Moreover, about 7.9% of diabetic patients have congestive heart failure, 18.9% have eye damage, and 22.9% have diabetic foot problems. Together with metabolic deteriorations, these complications affect the quality of life and require adequate management.

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Evidence Synthesis

The global prevalence of T2D is steadily rising, affecting health services and leading to high morbidity, mortality, and economic burden associated with complications (International Diabetes Federation as cited in Pal et al., 2018). Diabetic foot ulcers are a common diabetes complication and have a prevalence of 4-10% among elderly patients (Abbott et al., as cited in Elsaid et al., 2020). Up to 80% of DFU health, while between 10-20 percent are persistent (Alexiadou et al., as cited in Elsaid et al., 2020). About 24% of DFU cases result in limb amputation (Elsaid et al., 2020). The risks of DFU increase with age and duration of diabetes. Therefore, diabetes management is essential in preventing the negative impacts on patients and caregivers.

Novel solutions to DFU such as growth factor therapy, skin substitutes, extracellular and metalloproteinase matrix contribute to its effective management (Prompers et al., as cited in Elsaid et al., 2020). Moreover, diabetes self-management education (DSME) and behavioral provides a short-term solution to diabetes complications and improves glycemic control (Norris et al., Deakin et al., & Powers et al. as cited in Pal et al., 2018; Boels et al., 2019). However, the uptake of DSME and behavioral support is low. In the US, less than half of diabetes patients attend or receive DSME. Reasons for the low use of DSME include associated inconveniencies, societal stigma, and lack of knowledge of its potential benefits (Coonrod et al., as cited in Pal et al., 2018). According to Boels et al. (2019), Using mobile health (mHealth) to deliver diabetes-related healthcare is vital to self-management education and support (DSME/S).

The study by Elsaid et al. (2020) aimed to assess the impact of gel form platelet-rich plasma (PRP) in treating non-infected and non-healing DFU compared to the standard saline dressing. The authors found out that platelet-rich plasma (PRP) dressing contributes to optimal healing and reducing DFU size. However, other factors such as response to therapy, the type of treatment used, and wound chronicity could limit the exclusive application of the article’s solution.

On the other hand, Pal et al. (2018) explored the patients’ views on diabetic unmet needs crucial for effective diabetes self-management. The authors found out that diagnosis with T2D places a significant on patients and their families, and the associated negative impacts on their social life, emotional, and physical health. Moreover, even the best health care, including medication regime, patient education, and information programs, cannot comprehensively support patients’ emotional, psychological, and behavioral impact of T2D diagnosis, thus, the need for self-management. Significantly, digital health interventions can help address unmet needs by emphasizing emotional management, availability of health care personnel, providing updated evidence-based patient guide, availability of professional and peer advice.

Lastly, Boels et al. (2019) investigated the outcome of diabetes self-management education and clinical support on individuals put on insulin therapy. The authors found a significant effect of smartphone app-enabled DSME/S on individuals undergoing insulin therapy. Half of the participants found the interventions helpful, and the other half did not find the intervention helpful. The authors attribute the findings to the poor design of the messages to meet individual needs. Therefore, mHealth should be tailored to account for individuals needs that vary from one diabetic patient to another.

Appraisal of the Evidence to Address the Practice Problem

Elsaid et al. (2020) is a level I and high-quality quantitative research study. The study is well organized, consistent, and the thesis well documented. The study has an introductory paragraph and a well-developed body, including methodology, results, discussion, conclusion, and recommendations. The study design, sample size, and control measures are adequate for a quantitative RCT. The sample size is reasonably large and crucial for obtaining accurate results in experimental research designs. While the study’s control treatment is standard for dressing within the experiment setting, it is not valid for other treatment settings everywhere, limiting its generalizability. Moreover, the authors provide definitive conclusions and consistent recommendations based on tested conceptual frameworks and empirical evince.

Lastly, the article is supported by scientific evidence from peer-reviewed journal articles, with at least five percent published in the last five years. The study provides reasonably consistent and generalizable results. The results are founded on experimental data and a comprehensive population sample. The points discussed in the paper are factually grounded, and conclusions are based on empirical evidence. Lastly, the paper includes a significant number of articles from peer-reviewed with at least 5% in the last five years. Being an open-label study, the validity of evidence could be influenced by participant bias. Equally, the study findings could have been limited by using saline dressing which is not a baseline dressing intervention for DFU in other clinical settings.

Pal et al. (2018) is a level III quantitative research. The study is rated as Quality A/B High/Good Quality. Pal et al. (2018). The study based the findings on a broad sample consisting of four focus groups with 20 patients. The study first assessed patient needs/wants basing on the Corbin and Strauss model to identify self-management needs and rolled out a web-based intervention for adults diagnosed with type two diabetes. Together, these findings are crucial for patient self-management support and education programs to help reduce complication risks and improve glycemic control.

The data was collected, and more than two researchers coded transcripts to minimize participant and collection bias. Moreover, the authors ensured the credibility of the study by analyzing research data in a multidisciplinary team. The authors read the data transcripts independently and the emerging themes discussed in a multidisciplinary meeting to minimize interpretation bias. Lastly, the authors adopted the Corbin and Strauss sociological theory on chronic illness to encourage a holistic participant perspective and minimize subjective bias from researchers.

Boels et al. (2019) is a level I and a high-quality quantitative research study. The study has a solid structure, is consistent, and has generalizable results. The research sample is large enough to prvide more accurate and generalizable results. The authors adopted fixed block randomization to minimize selection and accidental bias. Moreover, the authors employed an adequate control group that allowed the researchers to assess  the influence of education and support frameworks on diabetes management. The study’s credibility was further maintained by adopting multiple manipulations and excluding participants with missing data to eliminate bias.

 

Translation Model: The Knowledge-to-Action (KTA) Process Framework

The Knowledge-to-Action Process Framework was adopted to facilitate knowledge use by different stakeholders. It consists of two components, including knowledge creation and action. In KTA, knowledge translation is research-based. KTA process encompasses empirical evidence, and emphasizes collaboration among knowledge producers and users. Stakeholders are involved in knowledge creation, synthesis, and dissemination (Boaz et al., 2018). For instance, stakeholders contribute to tailoring research questions to address a specific problem and customizes the language and methods of knowledge dissemination.

 

Summary Table

Article Number	Author and Date	Evidence Type	Sample, Sample Size, Setting	Findings That Help Answer the EBP Question	Observable Measures	Limitations	Evidence Level, Quality
31811339	Elsaid, A., El-Said, M., Emile, S., Youssef, M., Khafagy, W., & Elshobaky, A. 06/12/2019	Quantitative	24 patients The General Surgery Department of Mansoura University Hospital (MUH)	·         PRP gel dressing is superior in reducing the surface area of ulcers and accelerating healing compared to saline dressing. ·         Wound status and response to therapy can influence the efficacy of PRP gel dressing compared to saline dressing.	Percentage reduction in the size of DFU.	·         Differences in patient characteristics. ·         The saline dressing compared to PRP. The former is not usually considered an optimal DFU treatment. ·         Researcher bias.	Level I, High-quality rating.
e000981	Boels, A. M., Vos, R. C., Dijkhorst-Oei, L. T., & Rutten, G. E.. 9/ 11/ 2019	Quantitative	228 patients Outpatient practices and clinics across the Netherlands	·         Smartphone-enabled digital self-management education and support are vital for individuals under insulin therapy. ·         DSME/S should be tailored to meet individual patient needs.	Glycemic (HbA1c) and patient rating of intervention usability and applicability.	·         The results have generalizability. ·         Individual use of diabetes apps was not monitored.	Level I, High-quality rating.
1438-8871	Pal, K., Dack, C., Ross, J., Michie, S., May, C., Stevenson, F., … & Murray, E. 31/12/ 2020	Qualitative	Four focus groups, each having between three and six participants Community centers outside health care settings in England	·         Crucial healthcare needs for diabetic patients are related to role, medical, and emotional management. ·         Crucial components of diabetes management include appropriate diet, physical activity, and medicine administration. ·         Integrating these needs in diabetes self-management education can help individuals manage diabetes.	Patient perspectives on unmet needs	Sample overrepresented patients already motivated and educated on diabetes self-management.	Level III, Quality A/B High/Good Quality

 

References

American Diabetes Association. (2018). Economic costs of diabetes in the US in 2017. Diabetes care, 41(5), 917-928. https://doi.org/10.2337/dci18-0007

American Diabetes Association. (2021). Statistics About Diabetes: Overall numbers. Retrieved 3 October 2021, from https://www.diabetes.org/resources/statistics/statistics-about-diabetes

Boaz, A., Hanney, S., Borst, R., O’Shea, A., & Kok, M. (2018). How to engage stakeholders in research: design principles to support improvement. Health Research Policy and Systems, 16(1), 1-9. https://doi.org/10.1186/s12961-018-0337-6

Boels, A. M., Vos, R. C., Dijkhorst-Oei, L. T., & Rutten, G. E. (2019). Effectiveness of diabetes self-management education and support via a smartphone application in insulin-treated patients with type 2 diabetes: Results of a randomized controlled trial (TRIGGER study). BMJ Open Diabetes Research and Care, 7(1), e000981.http://dx.doi.org/10.1136/bmjdrc-2019-000981

Elsaid, A., El-Said, M., Emile, S., Youssef, M., Khafagy, W., & Elshobaky, A. (2020). A randomized controlled trial on autologous platelet-rich plasma versus saline dressing in the treatment of non-healing diabetic foot ulcers. World Journal of Surgery, 44(4), 1294-1301. https://doi.org/10.1007/s00268-019-05316-0

Pal, K., Dack, C., Ross, J., Michie, S., May, C., Stevenson, F., … & Murray, E. (2018). Digital health interventions for adults with type 2 diabetes: a qualitative study of patient perspectives on diabetes self-management education and support. Journal of Medical Internet Research, 20(2), e8439. https://doi.org/10.2196/jmir.8439 (Links to an external site.)

Rodriguez-Saldana, J. (Ed.). (2019). The Diabetes Textbook: Clinical Principles, Patient Management, and Public Health Issues. Springer.

Spooner, A. J., Aitken, L. M., & Chaboyer, W. (2018). Implementation of an evidence‐based practice nursing handover tool in intensive care using the knowledge‐to‐action framework. Worldviews on Evidence‐Based Nursing, 15(2), 88-96. https://doi.org/10.1111/wvn.12276

The Centre for Disease Control and Prevention (February 2020). National Diabetes Statistics Report 2020: Estimates of Diabetes and Its Burden in the United States. Retrieved 3 October 2021, from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Arslanian, S., Bacha, F., Grey, M., Marcus, M. D., White, N. H., & Zeitler, P. (2018). Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association. Diabetes Care, 41(12), 2648-2668. https://doi.org/10.2337/dci18-0007

Trikkalinou, A., Papazafiropoulou, A. K., & Melidonis, A. (2017). Type 2 diabetes and quality of life. World Journal of Diabetes, 8(4), 120. https://dx.doi.org/10.4239%2Fwjd.v8.i4.120

Appendix A:

Johns Hopkins Summary Tool

Article Number	Author and Date	Evidence Type	Sample, Sample Size, Setting	Findings That Help Answer the EBP Question	Observable Measures	Limitations	Evidence Level, Quality
31811339	Elsaid, A., El-Said, M., Emile, S., Youssef, M., Khafagy, W., & Elshobaky, A. 06/12/2019	Quantitative	24 patients The General Surgery Department of Mansoura University Hospital (MUH)	·         PRP gel dressing is superior in reducing the surface area of ulcers and accelerating healing compared to saline dressing. ·         Wound status and response to therapy can influence the efficacy of PRP gel dressing compared to saline dressing.	Percentage reduction in the size of DFU.	·         Differences in patient characteristics. ·         The saline dressing compared to PRP. The former is not usually considered an optimal DFU treatment. ·         Researcher bias.	Level I, High-quality rating.
e000981	Boels, A. M., Vos, R. C., Dijkhorst-Oei, L. T., & Rutten, G. E.. 9/ 11/ 2019	Quantitative	228 patients Outpatient practices and clinics across the Netherlands	·         Smartphone-enabled digital self-management education and support are vital for individuals under insulin therapy. ·         DSME/S should be tailored to meet individual patient needs.	Glycemic (HbA1c) and patient rating of intervention usability and applicability.	·         The results have generalizability. ·         Individual use of diabetes apps was not monitored.	Level I, High-quality rating.
1438-8871	Pal, K., Dack, C., Ross, J., Michie, S., May, C., Stevenson, F., … & Murray, E. 31/12/ 2020	Qualitative	Four focus groups, each having between three and six participants Community centers outside health care settings in England	·         Crucial healthcare needs for diabetic patients are related to role, medical, and emotional management. ·         Crucial components of diabetes management include appropriate diet, physical activity, and medicine administration. ·         Integrating these needs in diabetes self-management education can help individuals manage diabetes.	Patient perspectives on unmet needs	Sample overrepresented patients already motivated and educated on diabetes self-management.	Level III, Quality A/B High/Good Quality