The current diabetes education experience: Findings of a cross-sectional survey of adults with type 2 diabetes
Introduction
Diabetes is a complex chronic medical condition which impacts over 34 million Americans [1]. To successfully manage this condition, the person with diabetes (PWD) must make multiple daily self-management decisions and perform complex health care activities. PWD spend an average of less than 20 min per visit 3–4 times a year with a health care provider and therefore must self-manage this condition the rest of their 6000+ waking hours [2]. Diabetes self-management education and support (DSMES) empowers PWD to adopt healthy self-care behaviors and problem-solving skills which are essential to living well with diabetes [3].
DSMES is defined as the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care [4]. The Association of Diabetes Care and Education Specialists (ADCES) and the American Diabetes Association (ADA) delineate National Standards for DSMES in the US [5]. A comprehensive DSMES process incorporates the needs, goals, and life experiences of the PWD. The ADCES and ADA recognize four critical times for DSMES referral, namely at time of diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop, and at transitions in life and care [4].
There is a robust evidence base which supports the value of DSMES. DSMES alone improves hemoglobin A1C (A1C) by as much as 1 unit (1.0%) in PWD [4], [6], [7], [8]. When DSMES is combined with intensive diabetes medications management facilitated by remote patient monitoring, even greater reductions in A1C have been shown [9], [10], [11], [12], [13], [14]. DSMES has a positive effect on other clinical, psychosocial, and behavioral outcomes [4], [7]. It has also been shown to be cost-effective via reduction in hospitalizations and by reducing estimated lifetime health care costs related to a lower risk for complications [9], [15].
Despite the strong body of evidence for the effectiveness of DSMES and recommendations for its utilization in the ADA’s Standards of Medical Care in Diabetes [16], it remains underutilized as a service in the US [17], [18], [19], [20], [21]. Underutilization has been attributed to barriers at multiple levels, including the health system/program, providers, PWD willingness to participate, and the environment [4]. While lack of insurance coverage has been identified as a barrier to DSMES, these services are underused even in insured populations [19], [21].
In a regional US health care system, the Certified Diabetes Care and Education Specialists (CDCES) have identified significant gaps in knowledge of diabetes self-care behaviors among PWD referred for services [9], [22]. Examples include a lack of understanding of how to recognize and treat low blood glucose (BG), how to self-administer insulin properly, the need for avoiding sugary beverages, the importance of checking BG levels, how to take diabetes medications safely, including on sick days, and when to call the doctor or go to the emergency room. Anecdotally, many PWD in the system reported either never having received any diabetes education or having not had an education update for many years. Even when the PWD reports that they have “had diabetes education,” significant deficits in knowledge and self-care skills often still exist.
To better design DSMES efforts to reach and engage PWD and to close knowledge gaps, it is important to understand the PWD experience of diabetes education. In this study, we conducted a diabetes education experience survey among adults with type 2 diabetes receiving primary care services and/or referred for DSMES in a mid-Atlantic regional US health care system. We sought to explore the variety of diabetes education experiences the members of such a cohort have had. The primary aim was to establish a baseline of patient experiences of diabetes education, including occurrence rates and dose of diabetes education, content areas taught, educator delivering the content, education modality, and education setting. In addition, the study aimed to determine whether any patient characteristics are predictive of receiving diabetes education and whether any education characteristics are predictive of diabetes outcomes, specifically A1C.
Section snippets
Research design
A cross-sectional descriptive study was conducted in which a convenience sample of adults with type 2 diabetes were surveyed between January 1 and December 31, 2020. The study and all study procedures were approved by the local institutional review board (MedStar Health Research Institute IRB). The study protocol met the US requirements for the ethical conduct of human subjects research and the appropriate protection of personal health information, as well as the HIPAA Privacy Rule. A “waiver
Sample characteristics
A total of 510 participants enrolled in the study. Twelve did not indicate whether they had ever received diabetes education, so were excluded from further analysis. The participants included in the analysis (n = 498) were majority female, African American, and non-Hispanic (Table 1). More than a quarter of participants reported receiving their diabetes diagnosis within the last year, while almost half received the diagnosis more than five years ago. Most reported having a BG meter, checking BG
Discussion
This survey of adults with type 2 diabetes receiving care in a mid-Atlantic US regional health care system established a baseline of patient diabetes education experiences and highlighted actionable areas for improvement. Evidence-based best practices for effective DSMES recommend both initial and ongoing education for PWD. Our study revealed that many PWD had never received education, and of those who did, many did not receive ongoing education. There are national and system efforts to
Conclusion
The findings of this cross-sectional survey of a diverse population of PWD shed light on the diabetes education experience provided across a regional US health care system. In aggregate, the evidence demonstrated a variety of diabetes education experiences in terms of education content, modality, setting, and education provider. Consistent with national data, rates of receipt of diabetes education were low, with one half of the sample not having previously experienced any education. Even for
Funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Kelley Baker: Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Carine Nassar: Methodology, Validation, Data curation, Project administration, Writing – original draft, Writing – review & editing. Neelam Baral: Data curation, Writing – original draft; Michelle Magee: Conceptualization, Methodology, Validation, Writing – review & editing, Supervision.
Declaration of conflicting interest
The authors have no conflicts of interest to declare.
Acknowledgments
We thank all patients who donated their time to complete the survey, the CDCES who recruited participants and administered the survey, Clayton Bourges, MS, for participant recruitment, survey administration and data entry, and Gretchen Youssef, MS, RD, CDCES, and Joan Bardsley, MBA, RN, CDCES, for their assistance in developing the study survey.
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