In that study, the feasibility of quality improvement approaches being used in other aspects of primary care, such as population management, electronic communication, and practice redesign, was evaluated in the context of diabetes education, according to Linda Siminerio, Ph.D., of the University of Pittsburgh.
Three CDEs were introduced to practices in their respective urban, suburban, and rural communities, and they proactively identified patients who might benefit from diabetes education, such as those at high risk for complications or with newly diagnosed diabetes, and those with frequent emergency department visits or hospitalizations. They arranged for referral and diabetes education visits and worked with primary care physicians on treatment plans.
Of 141 patients with type 2 diabetes who met with a CDE for diabetes education during the course of the study, those with pre-education HbA1c levels at or below 7% maintained those levels at 6 months and at 12 months. Those with pre-education HbA1c between 7% and 9% experienced significant reductions in HbA1c at 6 months, and the levels were maintained at 12 months.
Those at highest risk – with pre-education HbA1c greater than 9% – also experienced significant reductions in HbA1c at 6 months, with maintenance of the improvements at 12 months.
Overall the population also experienced significant improvements in triglycerides and total cholesterol levels, but systolic blood pressure and weight did not change significantly.
“These findings demonstrate the feasibility and potential effectiveness of this novel education practice–based approach to improving glycemia in type 2 diabetes patients and lowering triglycerides (which could be indicative of a positive impact from lifestyle changes that were supported by the diabetes educator), reaffirming the benefit of education in all patients, particularly those at highest risk,” said Dr. Siminerio, who also is chair of the National Diabetes Education Program.
This model, known as Glucose to Goal program, reflected a team approach with the provider and educator both contributing to possible initiation of supportive therapy, she said, noting that the approach was somewhat similar to that used in Dr. Zgibor’s study, except protocols weren’t used.
“That’s because we didn’t have them available, but we hope to have them soon. We will be partnering on this and deploying this model across our whole health system,” she said.
Dr. Siminerio noted a number of “anecdotal undocumented successes,” including patient reports of better communication and support, educator reports of an increase in patient access and volume of patients reached, and primary care physician support for the program and reports of quality improvement and reduced workload.
This approach holds promise to support diabetes care that is cost effective and scalable, she said, noting that it “integrates team care while leveraging existing infrastructure.”
Additional research is needed to assess long-term effectiveness, she said, noting that developing effective diabetes education programs is imperative, as diabetes self-management and time spent with diabetes educators has repeatedly been shown to improve clinical, psychological and behavioral outcomes, yet diabetes education is underutilized.
“Nationally, only 6.8% of individuals with newly diagnosed type 2 diabetes participate in diabetes self-management education within 12 months of diagnosis, and, only 4% of Medicare participants are reported to have received DSME [diabetes self-management education] and/or medical nutrition therapy,” she said.
Of note, the ADA and AADE, along with the Academy of Nutrition and Dietetics, released a joint position statement on DSME during the ADA annual scientific sessions.
The statement, jointly published online in Diabetes Care, The Diabetes Educator, and the Journal of the Academy of Nutrition and Dietetics, highlighted four critical times for assessing the need for DSME and support referral: at diagnosis, on an annual basis, when new complicating factors influence self-management and transitions in care occur. The statement provides guidance on the type of information and support patients might need at theses “critical junctures,” and outlines the appropriate content, roles, and action steps for both the referring provider and the diabetes educators (Diabetes Care 2015 June 5 [doi:10.2337/dc15-0730]).
A major gap in diabetes education is in the area of referrals; there aren’t many providers routinely referring patients to diabetes educators, because either they don’t know how to refer, can’t find an educator, or aren’t aware of the value of diabetes education, according to a press release on the statement.
“Yet those referrals are critical,” Dr. Siminerio said in the release.
“Referrals influence patient behavior a great deal. When providers refer patients to diabetes education, we see an 83% participation rate, but without those referrals participation is abysmally low. If patients believe their physicians think diabetes education is important, they take it a lot more seriously. Patients trust their providers,” she said.