October 10, 2019
3 min read

Lower socioeconomic status, more complicated disease influence decision to skip diabetes education sessions

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Factors that may impede attendance at diabetes self-management education and support, or DSMES, sessions include lower socioeconomic status, required copayments, higher HbA1c, multiple medications and the use of insulin, according to findings published in Diabetes Educator.

Andrew S. Bzowyckyj

“Many people are living with diabetes, yet the uptake of diabetes self-management education and support by both patients and payer systems is extremely low, despite its documented efficacy,” Andrew S. Bzowyckyj, PharmD, BCPS, CDE, an associate professor at the University Oregon School of Pharmacy in Hillsboro, Oregon, told Endocrine Today. “More work is needed in this area to solve this urgent public health need by accurately identifying and removing barriers to participation in DSMES.”

Bzowyckyj and colleagues retrospectively reviewed electronic medical records from Truman Medical Centers in Kansas City, Missouri, to collect data on age, race, sex, insurance type and copayments, HbA1c, blood pressure, lipids, BMI, estimated glomerular filtration rate and diabetes medication prescriptions from 1,375 adults with type 2 diabetes (mean age, 53.2 years; 60% women). All individuals were scheduled to attend DSMES program sessions at Truman Medical Centers from March 2013 to June 2017, according to the researchers. Among the cohort, 580 attended none of the three 3-hour, small group sessions in the program.

The researchers found that the odds of attending the first session were lower if a copayment was required vs. no copayment (OR = 0.62; 95% CI, 0.49-0.79).

Diabetes syringe and stethoscope 2019 adobe 
Factors that may impede attendance at diabetes self-management education and support, or DSMES, sessions include lower socioeconomic status, required copayments, higher HbA1c, multiple medications and the use of insulin.
Source: Adobe Stock

“To address the copayment barrier, diabetes educators and representative organizations need to continue to advocate to health system administrators and third-party payers for the elimination of the DSMES copayment,” the researchers wrote.

Compared with those who used Medicare or private health insurance, the odds of attending a session were lower for those who used Medicaid or a discount at Truman Medical Centers (OR = 0.69; 95% CI, 0.53-0.9). The researchers considered those using Medicaid or the discount to be “of a lower socioeconomic status.”

“To assist individuals with low socioeconomic status, additional investigation is needed to identify the exact patient-specific barrier(s), such as lack of childcare, sporadic work schedules and transportation barriers,” the researchers wrote.

The researchers also observed an association between higher HbA1c and lower odds of DSMES attendance (OR = 0.95; 95% CI, 0.91-0.99). The odds of attending a session were lower for adults with an HbA1c of 8.5% or more vs. less than 8.5% (OR = 0.78; 95% CI, 0.62-0.97) with the odds of attending a session decreasing by 4.3% with every 1% rise in HbA1c. The odds of attending a session also were lower for adults with vs. without an insulin prescription (OR = 0.57; 95% CI, 0.45-0.71) and for those with vs. without a bolus insulin prescription (OR = 0.67; 95% CI, 0.47-0.95). The odds of attending a session were reduced by 12.7% for every diabetes drug added to a medication regimen (OR = 0.87; 95% CI, 0.76-0.99).


The only factor predicting better attendance was older age, with the odds of attendance higher for those aged at least 55 years vs. younger than 55 years (OR = 1.57; 95% CI, 1.27-1.95).

“Certain patient characteristics are associated with a decreased likelihood of attendance to a group DSMES program, including higher HbA1C, required copayment for DSMES, low socioeconomic status and certain characteristics of the patient’s medication regimen,” Bzowyckyj said. “Unfortunately, these are some of the patients that are most likely to benefit from DSMES services, so more targeted outreach to these individuals and more research for how to meet their needs are necessary.”

In addition to these findings, Bzowyckyj emphasized the value of electronic medical records when it comes to identifying patient characteristics and urged their use to improve adherence.

“At a minimum, other DSMES programs can work with their information technology departments to develop a report functionality that includes the patient-specific characteristics we identified to be associated with non-attendance to a DSMES program,” Bzowyckyj said. “With this functionality enabled, diabetes care and education specialists can quickly identify individuals at high risk for not attending with the click of a few buttons and subsequently perform targeted outreach to increase their likelihood for attending or find alternative strategies to help these individuals.” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.