Assessing the Value of Diabetes Education

T he impact of diabetes on the nation’s health is immense. The Centers for Disease Control issued a report last year stating the prevalence of diabetes has grown to 8% of the population, or 24 million people. In addition, another 57 million individuals have pre-diabetes. During these trying economic times, it has become increasingly important to demonstrate to health care administrators and government policy makers the value diabetes education brings to the health care system. Health care administrators and government policy makers need to understand that millions of dollars in diabetesrelated health costs can be saved based on data supporting the success of self-management education centered on cost-effective interventions provided by diabetes educators. In this issue of The Diabetes Educator, Duncan et al examines 3 years of commercial and Medicare payerderived datasets to evaluate the impact of diabetes selfmanagement education/training on financial outcomes (cost of patient care). Duncan and colleagues hypothesized that patients who participated in diabetes education were more likely to follow diabetes care standards and have lower claims compared to patients who did not participate in diabetes education. Because data were observational, a standard actuarial technique, risk adjustment, was used to ensure equivalence between the groups. Results from the study indicated that patients using diabetes education had lower average costs compared to patients who did not participate in diabetes education. In addition, diabetes education was associated with increased use of primary and preventive services with lower use of acute, inpatient hospital services. Read over the article for a more detailed discussion of overall outcomes and longitudinal analyses. In addition to Duncan’s article, Boren and colleagues have likewise completed a literature review and found that a large percentage of papers reported findings that associated diabetes education (and disease management) with decreased cost, cost saving, cost-effectiveness, or positive return on investment. With available data demonstrating the cost-effectiveness of diabetes education, such knowledge has not translated into increased resource allocation for diabetes health care services. As diabetes educators, we need to be ever so vigilant and continue to document the cost-effectiveness associated with outcome-based diabetes education. This will go a long way in helping determine the delivery of diabetes education, including prevention, diagnosis, and treatment.

816-P: Diabetes Education and Cost Savings with Telemedicine Delivery in Rural Communities

The purpose of this study was to evaluate the effectiveness of diabetes self-management education or training provided by diabetes educators in reducing complications and improving quality of life. Commercial and Medicare payer-derived claims data were used to assess the relationship between DSME/T and cost. Unlike the prior study that examined diabetes education provided by all professionals, the current study focused on the value of interventions performed as part of formal accredited/recognized diabetes education programs provided by diabetes educators only. Specifically, the current study focused on diabetes education delivered in diabetes self-management training programs based on 2 codes (G0108 and G0109). Results of the study provide insights into the differences in trends between participants and nonparticipants in DSMT. People with diabetes who had DSMT encounters provided by diabetes educators in accredited/recognized programs are likely to show lower cost patterns when compared with a control group of people with diabetes without DSMT encounters. People with diabetes who have multiple episodes of DSMT are more likely to receive care in accordance with recommended guidelines and to comply with diabetes-related prescription regimens, resulting in lower costs and utilization trends. Conclusions and Policy Implications The collaboration between diabetes educators and patients continues to demonstrate positive clinical quality outcomes and cost savings. This analysis shows that repeated DSMT encounters over time result in a dose-response effect on positive outcomes.

The purpose of this article was to review the published literature and evaluate the economic benefits and costs associated with diabetes education. The Medline database (1991--2006) and Google were searched. Articles that addressed the economic and/or financial outcomes of a diabetes-related self-care or educational intervention were included. The study aim, population, design, intervention, financial and economic outcomes, results, and conclusions were extracted from eligible articles. Twenty-six papers were identified that addressed diabetes self-management training and education. Study designs included meta-analysis (1); randomized controlled trials (8); prospective, quasi-experimental, and pre-post studies (8); and retrospective database analyses (9). The studies conducted cost analyses (6), cost-effectiveness analyses (13), cost-utilization analyses (7), and number needed to treat analyses (2). More than half (18) of the 26 papers identified by the literature review reported findings that associated diabetes education (and disease management) with decreased cost, cost saving, cost-effectiveness, or positive return on investment. Four studies reported neutral results, 1 study found that costs increased, and 3 studies did not fit into these categories. The findings indicate that the benefits associated with education on self-management and lifestyle modification for people with diabetes are positive and outweigh the costs associated with the intervention. More research is needed to validate that diabetes education provided by diabetes educators is cost-effective.

Diabetes affects 7.8% of Americans, nearly 24 million people, and costs $174 billion yearly. People with diabetes benefit from self-management; disease management (DM) programs are effective in managing populations with diabetes. Little has been published on the intersection of diabetes education and DM. Our hypothesis was that diabetes educators and their interventions integrate well with DM and effectively support providers' care delivery. A literature review was conducted for papers published within the past 3 years and identified using the search terms "diabetes educator" and "disease management." Those that primarily addressed community health workers or the primary care/community setting were excluded. Two case studies were conducted to augment the literature. Ten of 30 manuscripts identified in the literature review were applicable and indicate that techniques and interventions based on cognitive theories and behavioral change can be effective when coupled with diabetes DM. Better diabetes self-management through diabetes education encourages participation in DM programs and adherence to recommended care in programs offered by DM organizations or those that are provider based. Improved health outcomes and reduced cost can be achieved by blending diabetes education and DM. Diabetes educators are a critical part of the management team and, with their arsenal of goal setting and behavior change techniques, are an essential component for the success of diabetes DM programs. Additional research needs to be undertaken to identify effective ways to integrate diabetes educators and education into DM and to assess clinical, behavioral, and economic outcomes arising from such programs.

33-LB: Using Telehealth to Deliver Diabetes Self-Management Education and Support (DSMES) In Rural Communities

To estimate savings in the cost of caring for patients with Alzheimer's disease (AD) during 6 months, 1 year and 2 years of treatment with rivastigmine. An intermediate objective was to estimate the relationship between disease progression and institutionalisation. We assessed the relationship between Mini-Mental State Examination (MMSE) score and institutionalisation using a piecewise Cox proportional hazard model. To estimate cost savings from treatments lasting 6 months, 1 year and 2 years, estimates of the probability of institutionalisation were integrated with data from two 6-month phase III clinical trials of rivastigmine and a hazard model of disease progression. Our data suggest that savings in the overall cost of caring for patients with mild and moderate AD can be as high as $US4839 per patient after 2 years of treatment. Furthermore, the probability of institutionalisation increases steadily as MMSE score falls. Among our study individuals, age, race, level of education and marital status were significant predictors of institutionalisation, whereas gender had little effect. Using rivastigmine to treat AD results in a delay in disease progression for patients who begin treatment during the mild or moderate stages of the disease. By delaying the probability that a patient will be institutionalised, the cost of caring for AD patients can be significantly reduced.

Reducing the rates of diabetes across the United States

Diabetes Self-management Education and Support in Adults With Type 2 Diabetes: A Consensus Report of the American Diabetes Association, the Association of Diabetes Care and Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association

The US health care system's focus on high-quality, efficient, and cost-effective care has led payers and provider groups to identify new models with a shift toward value-based care. This perspective on clinical practice describes the population health movement and the opportunities for diabetes educators beyond diabetes self-management education, as well as steps to engage in and drive new care models to demonstrate individual, organizational, and payer value. Diabetes educators have an opportunity to position themselves as diabetes specialists for diabetes management, education, and population health care delivery. With expertise that extends beyond diabetes self-management education and with a wide variety of skills, diabetes educators recognize that there is a range of personal, social, economic, and environmental factors that influence diabetes health outcomes. Diabetes educators should align with organizational strategic plans and support the population-level performance measures and quality initiatives, thus enhancing the value that diabetes educators bring to health care organizations.

This study was conducted to identify accessibility and related psychosocial issues in diabetes care and education for visually impaired adults who have diabetes. Two focus groups of adults with visual impairment and diabetes were conducted; data were recorded and analyzed. The 3 main issues identified were lack of access to up-to-date diabetes information in an accessible format, lack of understanding by healthcare providers of the needs and competencies of people with both visual impairment and diabetes, and lack of access to nonvisual diabetes self-management equipment. This study provides qualitative support for the view that visually impaired people in the United States may, as a group, be systematically excluded from receiving high quality diabetes care and education. Equal access to diabetes care and education for visually impaired people requires increased accessibility of diabetes care and education programs, and increased professional and public awareness that the diabetes programs are accessible. Some specific recommendations are to make all patient education materials available in low-vision/nonvisual formats and to teach all diabetes education professionals how to work effectively with visually impaired people.

Chapter 2 - Diabetes education reimagined: educator-led, technology-enabled diabetes population health management services

Savings in the cost of caring for patients with Alzheimer's disease in Canada: An analysis of treatment with rivastigmine

Mission Hospital is an 800-bed, not-for-profit, independent community hospital system located in Asheville, North Carolina. The Health Education Center, an outpatient program of Mission, includes the Diabetes Center, which is accredited through the American Diabetes Association. The Diabetes Center has a sister diabetes program at McDowell Hospital, in Marion, North Carolina, that provides diabetes education for adults in that region. For patients with or at risk for diabetes, one of the advantages conferred by the Diabetes Center’s relationship with Mission Hospital is that the center shares the hospital’s mission of serving all individuals in western North Carolina and the surrounding region. A second advantage is that the Health Education Center has the financial backing to conduct yearly community programs to reach underserved and minority populations, with no charge to the participants. The events serve 100-300 people each year and include screening for hyperglycemia, measurement of high blood pressure, and calculation of body mass index. Education in the areas of basic diabetes pathophysiology, nutrition, and exercise is provided by certified diabetes educators and physicians. Participants also receive healthy snacks and recipes and are given blood glucose meters and taught how to use them. Mission sees value in educating health professionals about diabetes. Since 2000, Mission, along with the Mountain Area Health Education Center and other community and regional organizations, has planned and held an annual professional diabetes clinical workshop for medical, nursing, pharmacy, and nutrition professionals. This workshop reaches 180-250 health professionals per year and covers the most up-to-date research and trends in diabetes care. Twenty-four percent of inpatients discharged from Mission have a diagnosis of diabetes or hyperglycemia. Two years ago, Mission started a diabetes-resource program for nurses. This is a comprehensive diabetes education program for bedside nurses, who, by expanding their knowledge base, are thus better equipped to provide education about diabetes-associated survival skills to inpatients with diabetes. Part of this training is to reinforce the importance of ensuring that patients receive a referral to outpatient diabetes selfmanagement training at the time of discharge, either at one of Mission’s diabetes centers or at another outpatient education center in the region. Another advantage of being based in a hospital system is that patients can receive care and services from a multidisciplinary team of professionals. Our outpatient diabetes education team includes an endocrinologist, who serves as our medical director, and 10 certified diabetes educators from the nursing, nutrition, and pharmacy professions. Our team also includes an exercise specialist and a clinical social worker. The ability to refer patients for multiple types of services within the same program is convenient for both patients and clinicians. Also, having professionals with multiple backgrounds available to discuss issues such as treatments, disease cases, and patient-related challenges is a tremendous advantage for the clinicians/educators. Having such a large team also enables us to offer comprehensive services, including diabetes self-care classes, an insulin pump course, a gestational diabetes course, medical nutrition therapy, initiation of continuous glucose monitoring, a program on pediatric diabetes, individual consultations for diabetes and nutrition education, diabetes support groups, and employersponsored disease management programs. Of note, patients participating in the disease management programs undergo long-term follow-up by our clinicians and are seen quarterly for clinical assessment, goal setting, monitoring, and drug therapy review. In this population, we have seen significant improvements in hemoglobin A1c and lipid levels, decreased per-patient medical costs, and reduced numbers of sick days. These services are not a significant source of revenue for Mission. Their value is instead found in the community-level health and wellness benefits they yield, as well as in the satisfaction exhibited by the patients who visit us and by the team of professionals available to care for them.

The National Practice Study (NPS) is conducted biannually to assess current diabetes education practices in the United States with the goal of understanding current trends in the work in which diabetes educators engage. The 2015 NPS contained 54 questions about the individuals providing diabetes education, people with diabetes participating in education, and programs providing the education. The survey was sent electronically to approximately 21 975 people who were members of the American Association of Diabetes Educators (AADE) or who were Certified Diabetes Educators with the National Certification Board for Diabetes Educators but were not currently AADE members. In addition, both the AADE and the National Certification Board for Diabetes Educators promoted participation in the NPS via social media. The combination of efforts resulted in completion of the survey by 4855 respondents. Testing was completed with a significance level of 0.05 or 95% confidence. Diabetes educators continue to represent a diverse group of health care professionals-nurses (50%), dietitians (35%), pharmacists (6%), and others (6%). By far, the most commonly held credential for the specialty continues to be the Certified Diabetes Educator (86%), with only 5% of survey respondents indicating that they held the Board Certified-Advanced Diabetes Management credential. Diabetes educators are working with individuals across the diabetes continuum, as well as with people who do not have diabetes but have other chronic conditions. The data demonstrate that much of the diabetes educator's work with people with diabetes is beyond the first year of diagnosis. Diabetes educators are increasingly seen to be providing a broader array of the integrated AADE7 Self-Care Behaviors™. The specialty of diabetes educator continues to be populated by a professionally diverse workforce, meeting the needs of people across a wide spectrum. Diabetes educators can be found providing services in primary prevention of diabetes, education and management for those diagnosed with diabetes, prevention of secondary complications, and more complex management of diabetes and its secondary complications. While diabetes educators were found to work with those newly diagnosed with diabetes, they continue to engage with people with diabetes at various times other than the year that they were diagnosed. There are still issues with participant readiness, as evidenced by program completion rates. Nonetheless, diabetes educators are increasingly seen to be providing the integrated engagement that is needed to better ensure that people with diabetes attain and maintain competency in self-management skills.