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Read the attached article and answer below:

 a. Did the authors appropriately describe the outcome measures, instruments, and data analysis? Why or why not?

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b. Define and discuss the significance of independent and dependent variables. Provide an example related to your area of interest and provide details of what data would be used as your

§ Dependent variable.

§ Independent variable.

c. Cite references in APA format to substantiate your response when appropriate


Fully addressed the discussion topic posted

All responses were organized and written at a graduate level

Correct spelling and grammar

Correct APA format (text and references, if applicable)

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Nurse Practitioner Perceptions of a Diabetes
Risk Assessment Tool in the Retail Clinic Setting
Kristen L. Marjama, JoAnn S. Oliver, and Jennifer Hayes

Diabetes is the seventh leading
cause of death in the United
States, burdening society with

high costs for treatment and placing
increased demand on the health care
system (1). According to the 2014
National Diabetes Statistics Report,
an estimated 29.1 million people in
the United States have diabetes, and
8.1 million of them are undiagnosed
(2). The lack of screening for early
identification of patients at risk for
type 2 diabetes is a significant clin-
ical problem. Health care providers
(HCPs) need to be aware of the in-
creasing diabetes burden and to pri-
oritize the screening of patients who
may be at risk. Screening for risk
can aid in both efforts to prevent the
development of diabetes and early
management of the disease to reduce
complications. Clinical trials have
demonstrated that type 2 diabetes can
be delayed or prevented through life-
style modification or pharmacother-
apy for people at increased risk (3).

In order to reduce risk for those
at risk of developing diabetes, screen-
ing is a priority that will raise patient

awareness. Many patients are not
aware of their risk for type 2 dia-
betes until they receive a confirmed
diagnosis from their HCP. There
are numerous health care settings
in which screenings can be imple-
mented, including but not limited to
primary care practices, urgent care
centers, hospital emergency depart-
ments, and retail health clinics.

Retail clinics are located in retail
supermarket and pharmacy chains to
provide high-quality, affordable, and
easily accessible health care services
for communities. A true measure of
quality in retail clinics is their degree
of adherence to several measures iden-
tified in the Healthcare Effectiveness
Data and Information Set (4).
Services in this type of setting may
include treatment of acute episodic
conditions, physical examinations,
vaccinations, health screenings,
and prevention and management of
chronic conditions (5). Retail clinics
provide services to patients with or
without insurance or a primary care
“home.” Patients’ visits to a retail
clinic afford the opportunity to assess

■ IN BRIEF This article describes a study to gain insight into the utility and
perceived feasibility of the American Diabetes Association’s Diabetes Risk
Test (DRT) implemented by nurse practitioners (NPs) in the retail clinic setting.
The DRT is intended for those without a known risk for diabetes. Researchers
invited 1,097 NPs working in the retail clinics of a nationwide company to
participate voluntarily in an online questionnaire. Of the 248 NPs who sent
in complete responses, 114 (46%) indicated that they used the DRT in the
clinic. Overall mean responses from these NPs indicated that they perceive
the DRT as a feasible tool in the retail clinic setting. Use of the DRT or similar
risk assessment tools in the retail clinic setting can aid in the identification of
people at risk for type 2 diabetes.

University of Alabama, Capstone College of
Nursing, Tuscaloosa, AL

Corresponding author: Kristen L. Marjama,
[email protected]

DOI: 10.2337/cd15-0054

©2016 by the American Diabetes Association.
Readers may use this article as long as the work
is properly cited, the use is educational and not
for profit, and the work is not altered. See http://
for details.


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1 8 8 C L I N I C A L . D I A B E T E S J O U R N A L S . O R G


their risk for diabetes and focus on
wellness and prevention strategies.

A multifaceted approach is needed
to alter the current diabetes trend in
the United States. One important
factor is the engagement of HCPs in
screening and communicating health
risk information to their patients
(6). Using a diabetes risk assessment
tool in the retail clinic setting may
help to identify patients who are at
risk, improve or complement other
risk assessment approaches used by
HCPs, and enhance communication
between HCPs and their patients
regarding type 2 diabetes risk. This
study aimed to explore the utility
and perceptions of a diabetes risk
assessment tool implemented by
nurse practitioners (NPs) in the retail
clinic setting.

The number of adults with dia-
betes in the United States increased
from 5.5 million in 1980 to 21.3 mil-
lion in 2012 (7). In 2012, the Centers
for Disease Control and Prevention
(CDC) estimated that 86 million
adults (one in three) had prediabe-
tes, which is a condition that places
people at risk for developing type 2
diabetes (7). From 2008 to 2012,
the cost of diabetes increased 41%,
from $176 million  to $245 million
(8). Thus, it has become increasingly
important to identify individuals who
would benefit from interventions
aimed at preventing the development
of diabetes.

The Problem
HCPs play a major role in improving
the quality of health care and thus
increasing the value of services pro-
vided (9). Such quality improvement
occurs primarily at the level of inter-
action between HCPs and patients.
Providers need evidence-based tools
and resources to aid them in initiating
important conversations and provid-
ing high-quality care to every patient.

However, studies have identified
barriers to HCPs’ use of type 2 dia-
betes risk assessment tools. These
barriers include attitudes about avail-
able tools, the impracticality of their

use, and a lack of reimbursement for
administering them (10). A diabe-
tes risk assessment tool that can be
completed by patients while they are
waiting to be seen at a clinic could be
an effective way to screen all patients.
A tool that is easy for patients to use
and understand can play a major role
in increasing patients’ awareness of
their risk for diabetes.

One Solution
Dealing with the demands of the di-
abetes epidemic requires health care
organizations to develop innovative,
coordinated approaches to prevention
and care (11). Several health care or-
ganizations operate retail clinics. This
study was implemented with NPs em-
ployed by one national retail clinic
organization. Primary prevention and
health promotion, discussed at every
clinic encounter regardless of the rea-
son for the visit, can be successful at
reducing disease occurrence and im-
proving health (12). Currently, there
is no evidence in the literature regard-
ing the use and feasibility of a diabe-
tes risk assessment tool in the retail
clinic setting. Understanding the per-
ceptions of a diabetes risk assessment
tool used by NPs in the retail clinic
setting will provide a framework to
assist in the development of a diabe-
tes screening program. Assessing NPs’
perceptions of this intervention also
may lead to increased or continued
use of the risk assessment tool and
identify factors that are negatively in-
fluencing its continued use. The re-
sults may encourage other retail clinic
organizations to adopt the use of a di-
abetes risk assessment tool in practice.

The American Diabetes Associa-
tion (ADA) and the U.S. Preventive
Services Task Force (USPSTF) have
established guidelines for detecting
prediabetes and type 2 diabetes for
the purposes of prevention and early
intervention. A study comparing
these guidelines found that the ADA
guidelines detected 38.9% more cases
of prediabetes and 24.3% more cases
of type 2 diabetes than the USPSTF
guidelines (13). ADA recommends

the Diabetes Risk Test (DRT) as a
tool for assessing patients’ risk for
type 2 diabetes (14). The DRT is
currently used in the retail clinic
organization selected for this study.
This diabetes risk assessment tool has
also been adopted by the National
Institutes of Health/CDC National
Diabetes Education Program (15).
Since 20 November 2014, the retail
organization involved in this study
has encouraged having patients
complete the DRT in its retail clinic
waiting rooms.

The DRT is a one-page form con-
taining seven questions regarding
patients’ age, sex, history of gesta-
tional diabetes, family history of
diabetes, history of hypertension,
physical activity, and weight (14).
Patients are instructed to add up
the scores based on their answers to
determine whether they are at risk for
type 2 diabetes. Those whose scores
indicate that they are at risk are
encouraged to participate in a diabe-
tes screening visit at the retail clinic.

This study examined how NPs in
this retail clinic setting perceive the
merit of the DRT in terms of adding
value to screening for type 2 diabe-
tes and whether NPs perceive that it
initiates, complements, and improves
risk-related conversations between
patients and providers. The study also
assessed how NPs perceive patients’
use of and satisfaction with the DRT.
The DRT was made available for use
as a resource 5 months before the ini-
tiation of this study.

An online questionnaire to assess NPs’
use and perceptions of the DRT was
developed using Survey Monkey, a
Web-based survey tool (16). Retail
clinics in 26 markets were selected
for this project, and 1,097 NPs were
invited to participate. All NPs in the
selected markets were sent an email
message describing the purpose of the
study, the time required for participa-
tion, and an Internet link they could
open to complete the questionnaire.
NPs’ participation was voluntary,


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V O L U M E 3 4 , N U M B E R 4 , F A L L 2 0 1 6 189

m a r j a m a e t a l .







consent was obtained from all partic-
ipants, and all survey responses were
anonymous. NPs could withdraw
from completing the survey at any
point without any consequences.

The questionnaire consisted of
15 items. The first three gathered
demographic information, including
practice location, years of clinical
experience as an NP, and average
number of patients seen per day. The
fourth asked whether the NP had
used or was currently using the DRT.
If the answer was no, the partici-
pant was not asked to complete the
remaining 11 items, and the survey
was considered complete. Participants
who had used or were currently
using the DRT proceeded through
the remaining items, which assessed
their perceptions of use of the DRT
(Table 1).

The survey items were developed
to assess perceptions of the feasibility
and value of a risk assessment tool
(17). Several concepts were used to
measure feasibility, including per-
ceptions of patient use, provider
approach, and patient-provider inter-
action. For each item, respondents
used a 5-point Likert scale (Strongly
Disagree, Disagree, Neutral, Agree,
or Strongly Agree) to indicate the
degree to which they agreed with the
given statement.

Participants completed surveys
from 15 April 2015 through 29 April
2015. Of the 1,097 NPs who were
invited to participate, 258 returned
responses. Ten responses contained
no data and were therefore deleted,
leaving 248 responses for analysis
(response rate of 22.61%).

SPSS Statistics version 22 com-
puter software (IBM, Armonk, N.Y.)
was used for descriptive and inferen-
tial statistical analyses. All variables
were examined for accuracy of
data entry. Mean responses to each
question were examined to facili-
tate discussion of the results; mean
responses are a good indicator of the
aggregate direction toward the two
ends of the scale for each question.
With responses restricted to a 5-point

Likert scale, a mean response value
of 3 is the midpoint value of the scale
and implies a neutral stance. A mean
response of <3 implies that responses
were in the “disagree” direction, and
a mean of >3 indicates that responses
were in the “agree” direction. For
analysis, a Pearson correlation coef-
ficient was used to determine the
presence of a correlation between

Of the 248 responses available for
analysis, the highest response rates
came from Chicago, Ill., with 27 re-
sponses (10.89%); Atlanta, Ga., with
26 responses (10.48%); and Orlando,
Fla., with 23 responses (9.27%). A to-
tal of 243 participants indicated that
they were NPs. Of these, 80 (32.92%)
had 0–5 years of clinical experience,
65 (26.75%) had 6–10 years, 41
(16.87%) had 11–15 years, and 57
(23.46%) had ≥15 years of experience
(Figure 1). Of the 246 participants
who responded to the question about
the number of patients they see on
average each day at their retail clinic,
163 (66.26%) reported seeing 11–20
patients per day, 57 (23.17%) report-
ed seeing 0–10 patients, 24 (9.76%)
reported seeing 21–30 patients, and 2
(0.81%) reported seeing ≥31 patients
per day.

Of the 248 respondents who
reported on their use of the DRT in
their retail clinic, 134 (54.03%) indi-
cated that they did not use the DRT,
whereas 114 participants (45.97%)
reported that they did. Of the 114
participants who did use the DRT,
106 provided responses to the 11
perception questions regarding the
feasibility of DRT use in their retail
clinic setting. The majority of those
106 respondents were NPs with 1–5
years of experience (34.9%) who
reported seeing 11–20 patients per
day (61.3%).

Descriptive statistical analysis was
performed (Table 2). The lowest mean
response to any of the 11 survey items
was for item 8 (“Contributes to the
number of repeat visits to the retail
clinic”). The mean score of 3.0000 for
that item indicates that participants
overall were neutral on this issue.
The meaningful measure for this
item was the percentage of respon-
dents strongly agreeing/agreeing
(22.6%) versus those strongly dis-
agreeing/disagreeing (23.6%). Mean
responses to each of the 11 perception
items ranged from those indicating
“neutral” to those indicating “agree.”
The highest mean response (3.8868)
was for item 3 (“Does not take long
for patients to complete”). Again, the
meaningful measure for this item

TABLE 1. Items on Perception of Feasibility
From my clinical perspective, the Diabetes Risk Test:

1. Is readily accepted by patients for completion

2. Helps patients easily understand if they are at risk for diabetes

3. Does not take long for patients to complete

4. Initiates more patient-to-provider conversation regarding diabetes

5. Complements my approach to discussing risk for diabetes with patients

6. Improves my approach to discussing risk for diabetes with patients

7. Increases patient desire to participate in the diabetes screening service
at the retail clinic

8. Contributes to the number of repeat visits to the retail clinic

9. Saves time in tailoring the discussion with patients with identified
risk factors

10. Improves the quality of the diabetes screening service offered at the
retail clinic

11. Increases patient satisfaction with care provided


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was the percentage of respondents
strongly agreeing/agreeing (81.1%)
versus those strongly disagreeing/
disagreeing (5.7%). To assess overall
feasibility of DRT use in the retail
clinic setting, the overall mean of all
11 individual mean responses was cal-
culated to be 3.6046, which indicates
that responses overall were in the
“agree” direction. Correlation of the
11 perception items of feasibility was
significant at the 0.01 level according

to the Pearson correlation coefficient
(Table 3).

Assessing the use of the DRT and
evaluating NPs’ perceptions of the
feasibility of its use can be essential
in determining whether this screening
tool for type 2 diabetes has value in
guiding the current or future health
care approach for utilization with pa-
tients and facilitating patient-provider
communication. In the setting stud-

ied here, utilization of the DRT was
recommended but not mandated,
and the majority of NPs (54.03%)
indicated that they did not use the
DRT. However, the overall mean of
responses to the perception items
from NPs who have used the DRT
indicates that these NPs agree that
using a diabetes risk assessment tool
in the retail clinic setting is feasible.
There was only one neutral response,
and it was on the DRT’s contribution

TABLE 2. Mean and Proportion Responses to Items on Perception (n = 106)
Item Mean Standard Deviation Strongly Agree/ Agree

Strongly Disagree/

Disagree (%)

1 3.4057 0.91317 52.8 17.9

2 3.8208 0.77824 76.4 5.7

3 3.8868 0.73447 81.1 5.7

4 3.8774 0.77709 79.2 6.6

5 3.8396 0.73208 76.4 4.7

6 3.7547 0.77842 70.8 6.6

7 3.3868 0.83462 43.4 11.3

8 3.0000 0.81650 22.6 23.6

9 3.5283 0.83046 60.4 13.2

10 3.6604 0.74177 67.9 7.5

11 3.4906 0.67957 52.8 5.7

Overall mean of individual
means for

all 11 items: 3.6046

■ FIGURE 1. Overall responses in each market by respondents’ years of experience (n = 243).


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m a r j a m a e t a l .







to the number of repeat patient visits
to the retail clinic. Because the DRT
was made available to patients waiting
to be seen for a separate reason, more
research is needed to determine the
number of patients who may return
based on the use of the DRT.

Although this study looked at
NPs in the retail clinic setting, there
are patients in the waiting areas of
all health care settings. The DRT
is not geared toward a particular
setting, but rather toward patients
in general. Thus, all health care
settings could use a risk assessment
tool to screen patients who may not
be aware of their potential risk for
diabetes. Implementation and uti-
lization of such a tool can be a key
component in proactively screening
patients and providing high-quality,
evidence-based care.

A limitation in this study was the
small sample size. The low response
rate of 22.16% (248 completed ques-
tionnaires from 1,097 NPs invited to
participate) may be attributable to sev-
eral factors. Some of the invited NPs
were in management or educator roles
with limited opportunities for direct
patient care. It is possible that they did
not see patients during the timeframe
of the study. Some invited NPs are
per-diem employees with a require-

ment to work only one or two shifts
per month and may not have received
the emailed invitation during the
2-week timeframe, or some potential
participants may have been on paid
time off or a leave of absence. Finally,
one market included in the study does
not evaluate and treat chronic condi-
tions, which may have led to lower
utilization of a screening tool for a
chronic condition. This market was
included because it met the criteria of
being staffed by NPs and had imple-
mented the DRT as a resource.

Another limitation is that feasibil-
ity of use can be interpreted in several
ways. Concepts used to define feasi-
bility in this study included patients’
acceptance of the DRT, its ease of
understanding by patients, the time
it took patients to complete the DRT,
whether the DRT initiated conver-
sation between patients and an NP,
whether the DRT complemented
or improved the approach of NP,
whether its use led to an increase in
diabetes screening services or repeat
visits, and whether its use saved time,
improved the quality of care, or
increased patient satisfaction. Further
research is needed to translate feasi-
bility into implementation.

To address the demands of the dia-
betes epidemic, health care organi-

zations need to focus on risk factor
awareness. Evaluating NPs’ use and
perceptions of the feasibility of a dia-
betes risk assessment tool are import-
ant in determining whether such a
tool adds value in the retail clinic set-
ting. In this study, NPs who used the
DRT agreed that the use of this tool
is feasible in their setting. However,
less than half of respondents reported
having used the DRT, and increased
utilization is needed.

Using a diabetes risk assessment
tool can be a quick, efficient way
to increase patient screening, com-
plement HCPs’ approach, and help
to initiate conversations between
patients and providers. This in turn
may have an impact on the early
identification of individuals with dia-
betes and improve the quality of care
offered to these patients. The more we
can do as a health care community
to identify risk factors for diabetes,
the better our chances of preventing
disease and improving the health and
wellness of our patients.

Additional research is needed to
understand the barriers to utilization
of a diabetes risk assessment tool,
examine the use of such tools to effi-
ciently identify patients with type 2
diabetes, and explore the feasibility
of using the DRT or similar tools in
other health care settings.

TABLE 3. Pearson Correlation Coefficient of 11 Perception Items of Feasibility (n = 106)
1 2 3 4 5 6 7 8 9 10 11

1 1.0

2 0.438** 1.0

3 0.325** 0.331** 1.0

4 0.406** 0.436** 0.443** 1.0

5 0.469** 0.517** 0.533** 0.735** 1.0

6 0.436** 0.556** 0.467** 0.548** 0.816** 1.0

7 0.592** 0.357** 0.259** 0.456** 0.508** 0.426** 1.0

8 0.524** 0.345** 0.206* 0.360** 0.462** 0.405** 0.615** 1.0

9 0.318** 0.546** 0.349** 0.308** 0.532** 0.571** 0.403** 0.478** 1.0

10 0.402** 0.438** 0.313** 0.638** 0.583** 0.531** 0.522** 0.456** 0.449** 1.0

11 0.505** 0.384** 0.303** 0.494** 0.581** 0.536** 0.603** 0.463** 0.465** 0.541** 1.0

**Correlation is significant at the 0.01 level (two-tailed).
*Correlation is significant at the 0.05 level (two-tailed).


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The authors thank the NPs who partici-
pated in this study. The authors take full
responsibility for the content of this article
and participated in all stages of manuscript
development and approval of the article for

Duality of Interest
No potential conflicts of interest relevant to
this article were reported.

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