Diabetes Self-Management Education May Have Received a Boost

Can anyone say 'pipe dream'?  That was my first thought when I read this.  No, I am not kidding.  Yes, there are some advantages for some people with diabetes that live in some of the larger metropolitan areas.  Those people living in rural areas will still not have an advantage and may not even be able to utilize the increased educational opportunities. 

What is a surprise is that the joint statement by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND) focuses primarily on type 2 diabetes while the general principles apply to everyone with diabetes.  The joint statement is primed to fill the gap not covered by other guidelines addressing medication use and HbA1c targets. 

The joint statement calls for referrals to accredited diabetes education programs at four key points: at diagnosis of diabetes, on an annual basis, when new complicating factors (diabetes-related, or not) influence self-management, and at the time of transitions in care, such as from pediatric to adult or for an adult to nursing home.  The document provides detailed guidance for issues that should be addressed at each of those points.

It is noteworthy that the Academy of Certified Diabetes Educators is excluded from the joint statement.  Whether they will shirttail on the joint statement remains to be seen.  Either way, this still leaves the total number of CDEs way short of what will be needed to meet the goals of the joint statement, especially the people with type 2 diabetes. 

Other factors affecting the joint statement include:

     1.  Many CDEs do not live in largely rural areas.
     2.  Many doctors have had unfavorable encounters with CDEs and won't use them.
       3.  Many CDEs will not work with some doctors and contradict much of what the doctor has ordered creating additional problems.
     4.  Most CDEs do not want to work with people with type 2 diabetes that          are managing their diabetes well.
     5.  Many CDEs are also registered dietitians (RDs) and often will not work with the new nutrition guidelines, especially the low-carb/high-fat food plans.
     6.  Many RDs do not accept the exclusion of whole grains, again leaving many people with diabetes out of the education.  This is because the RDs often will not do any education for those of us excluding wheat.
     7.  Many doctors also promote low fat and whole grains because they still in believe Keyes and will not accept that he has been disproven.

The following is contrary to what the Society of General Internal Medicine (SGIM) promotes.  The SGIM does not believe in education for people with diabetes and follows statements made by prior influential people in the ADA and American Association of Clinical Endocrinologists advocating that people with type 2 diabetes, not on insulin rely on their HbA1c results to manage their diabetes.

Surprisingly, Martha M Funnell, RN, research scientist and adjunct nursing lecturer at the University of Michigan, Ann Arbor stated, "There is actually a substantial body of research on the value of education, including lowering hemoglobin A1c levels, reducing the onset or advancement of diabetes complications, improving lifestyle behaviors, reducing diabetes-related distress, and improving quality of life."

Ms Funnell continued, "The literature also shows that diabetes education is cost-effective, particularly in reducing hospital admissions and readmissions. Studies have also shown that patients who receive diabetes education are more likely to receive kidney and eye screenings."

Medication costs typically go up with diabetes education, "but that's because people are actually taking their medications and getting their prescriptions refilled. So, diabetes education works," Ms Funnell noted.

But despite the benefits, one recent study showed that among adults aged 18 to 64 years with diabetes, less than 7% had received formal diabetes education. "While less than 7% is a great A1c number, it's a really lousy number for the number of people who get education," Ms Funnell quipped.

Be Careful of Patient-Centered Clinical Consultations

This is an interesting study for the way it is presented. Yes, it is only a press release and only the abstract is available without a fee. It is interesting because this idea of “patient-centered” is being talked about by clinicians and other physicians,  Until recently, this was not widely discussed other than by patients who wanted doctors to talk with them instead of at them. Patients have wanted to be included in the decision-making and given sources of education to help them understand more about their illness or disease.

We still have many doctors that will not consider patient-centered activity and will not accept patients that are proactive in their care. These doctors are slowly decreasing and many are retiring. More and more doctors are working for patient-centered consultations and even a few are taking it further with shared medical appointments (SMAs) to be able to educate more patients and get patient-to-patient input and interaction. Often this shared time brings on increased satisfaction from patients and allow patients to become more involved and knowledgeable about their illness or disease.

The study does not cover any of the above, but does discuss the communication problems in health care that may arise when providers (generally doctors) focus on diseases and their management. This means that they are not focusing on people (the patients) and their health problems. Patient-centered care in the patient visit is increasingly being sought by the patients, more doctors, and is being incorporated into training for health care providers. The consequences of these interactions on clinical encounters and indirectly on patient satisfaction, health care behavior, and health status has not been properly evaluated.

I will let you read information on the data and collection methods if you desire and move on to the conclusions. Interventions to promote patient-centered care within clinical consultations are effective across studies in transferring patient-centered skills to providers. However the effects on patient satisfaction, health behavior and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behavior and health status. These outcomes have not been assessed in studies reviewed previously.

Training providers has improved their ability to share control with patients and for most patients to have success in consultations with providers that have been trained with new skills. Short-term training of less than 10 hours is as successful as long-term training. Yes, results are mixed at this point and will continue to be until providers are confident that the new skill will work for the long-term. The disappointment has to be the small number of these multi-faceted studies. To have more confidence, more studies are needed. This should help patients and doctors.