Type 2 diabetes mellitus (T2DM) and associated complications are leading causes of death in the United States (American Diabetes Association [ADA], 2017). T2DM is a prominent chronic disease in the United States, with the total medical cost of diagnosing and treating diabetes exceeding $245 billion per year (Centers for Disease Control and Prevention, 2015). In 2012, the ADA (2017) reported 29.1 million Americans had T2DM, representing 9.3% of the overall population. Estimates indicate as many as 25.9% of American older adults age 65 and older have T2DM (ADA, 2017).
T2DM and its related complications present major social and economic burdens for society, and 1.4 million new cases of T2DM are diagnosed every year (ADA, 2017). Despite new pharmacological innovations and advances in diabetes research, only 14.3% of patients with diabetes are at their glycemic goal (ADA, 2017). The ADA and the American Association of Clinical Endocrinologists released standards of care for individuals with T2DM, and both of these standards include DSME/S at their core (Powers et al., 2015).
The patient-centered care aspect of DSME/S relies on five guiding principles of patient engagement. These guiding principles are: (a) information sharing, (b) psychosocial support, (c) behavioral support, (d) multidisciplinary integration of care, and (e) care coordination (Powers et al., 2015). This practice change initiative integrated all of these aspects in the care of patients with T2DM, specifically targeting patients age 65 and older. The behaviors involved in DSME/S are culturally sensitive, dynamic, and multidimensional, which play a significant role in setting goals and developing a plan of care (Powers et al., 2015). In this context, each patient received specific, individualized, and attainable goals to follow for a period of 4 weeks and beyond.
DSME/S is the foundation for diabetic patient-centered care and assists individuals with diabetes in managing their disease and lifestyle choices to improve health outcomes (Powers et al., 2015). The overall objectives of DSME/S are to ensure “informed decision making, self-care behaviors, problem solving, and active collaboration” among all members of the health care team to achieve optimal health status and a better quality of life (QOL) (Powers et al., 2015). The ADA (2017) includes DSME/S in standards of care for all individuals with diabetes either at the time of initial diagnosis or as needed thereafter. DSME/S is effective in reducing overall health care costs associated with diabetes and diabetes-related complications, and offers the opportunity for the U.S. health care system to save money and improve care (Robbins, Thatcher, Webb, & Valdmanis, 2008).
Diabetes education has been associated with improved glycemic control as well as with overall health status. Research suggests incorporating practical and feasible educational sessions in diverse settings among patients with diabetes will enhance their glycemic control, with A1C reduction ranging from 0.5% to 1.2% (Chrvala, Sherr, & Lipman, 2016; Gold et al., 2008; White, Manning, Brawer, & Plumb, 2014). Patients who effectively engaged in carbohydrate counting or portion control achieved modest weight loss that may have contributed to improved glycemic control and likely contributed to overall health status improvement (Bowen et al., 2016). For DSME/S to be beneficial in achieving glycemic control and desired QOL, it must occur initially on T2DM diagnosis followed by ongoing DSME/S sessions through community programs or provider follow-up visits (Tang, Funnell, & Oh, 2012).
The purpose of this project was to improve glycemic control and QOL of Medicare patients age 65 years and older with T2DM. The project aims were to:
- Develop a brochure based on the literature to facilitate DSME/S implementation.
- Make the Algorithm of Care (ADA, 2017) available to providers to facilitate DSME/S.
- Increase providers' utilization of DSME/S.
- Improve patients' fasting blood glucose (FBG).
- Improve QOL for patients with T2DM.
- Improve revenue generation for the practice in the long term (not assessed in this project).
This practice improvement project used a pretestposttest design implementing principles of quality improvement to assess FBG and QOL. The Plan-Do-Study-Act (PDSA) cycle was used as a framework to guide the project (Institute for Healthcare Improvement, 2019). The project protocol was submitted to the University of Miami Human Subjects Research Office where it was reviewed and was deemed not to be human subjects research; therefore, Institutional review board approval was not required.
Eligible Medicare patients age 65 and older with T2DM in an endocrinology clinic participated in this project during their 3-month follow-up visit for diabetes management. Only patients who had a preexisting T2DM diagnosis with A1C at or greater than 7% (53 mmol/mol) were included. Patients interested in participating in this project provided verbal consent and agreed to follow up in 4 weeks.
Diabetes self-management education, support, and goal setting sessions were conducted during a 3-day period at the clinic, and participants engaged in one session only. Each session included: information sharing about disease management, psychosocial support as it relates to disease management, behavioral support in managing T2DM including glucose monitoring, diet, and lifestyle modification, multidisciplinary integration of care, and care coordination including referrals to an optometrist, registered dietician, or podiatrist as needed.
Patients participated in a 20-minute DSME/S and goal setting session at baseline when preintervention data were collected. Baseline assessment included A1 and FBG levels for the previous week, and the Diabetes-39 (D-39) scale. Patients brought records of their FBG levels from a week prior to their office visit in either a written form or recorded in their glucose monitors. Patients also were provided with appropriate referrals at that time, if needed. FBG levels also were collected after 4 weeks through patient blood glucose monitoring at home. All data were collected by one of the researchers.
Diabetes-specific QOL was assessed using the D-39 scale, which was administered by one of the researchers. The D-39 scale was developed in 1997 based on the pool of items from the QOL 92-item scale (Boyer & Earp, 1997). The scale addressed energy and mobility, diabetes control, anxiety and worry, social burden, and sexual function. Each domain received a raw score, which was further transformed to a 0 to 100 scale using a linear transformation. Lower scores indicate better QOL. Cronbach's alpha for the individual domains of D-39 scale ranged from 0.81 to 0.92. QOL was assessed in person at baseline and via telephone 4 weeks after DSME/S. Permission to use the scale was obtained from the author of the scale (Dr. J. Gregory Boyer).
Providers at the clinic received in-service education on DSME/S and the ADA Standards of Medical Care in Diabetes algorithm (ADA, 2017) to facilitate the project and continue implementation of DSME/S after the initial data collection period. The in-service education included evidence-based recommendations on DSME/S use, project goals and project plan, written material such as a brochure and algorithm of care, and cost analysis with reimbursement opportunities for DSME/S. Provider use of DSME/S was assessed pre- and postintervention by reviewing 40 charts of patients who were seen at the clinic during baseline data collection and at follow-up. These 40 charts did not include the 24 patients who participated in this project. The long-term goal for the project was increased revenue generation for the practice due to implementation and billing for DSME/S. However, revenue generation was not assessed as a part of this project.
Data were analyzed using IBM® SPSS® version 25.0 statistical software. Descriptive statistics were used to report demographic data and utilization data. Because FBG levels were normally distributed pre- and post-DSME/S, means were compared using a dependent sample t test. For QOL, scores for each domain were not normally distributed; therefore, mean scores for pre- and post-DSME/S were compared using Wilcoxon signed rank test (p < .05). Z scores were based on negative ranks. There was no overall QOL score; instead, scores for each domain were reported.
The demographic characteristics of the participants are summarized in Table 1. A total of 24 patients were observed for a period of 4 weeks. All 24 participants completed the project. The majority of participants were male (62.5%). Average age of participants was 74 years (SD = 6.4). All participants had a diagnosis of T2DM with an average duration of 7.5 (SD = 5.4) years and an average A1C of 7.7% (61 mmol/mol) (SD = 0.8).
Demographic Characteristics of Participants (N = 24)
Based on the review of 40 charts, utilization of DSME/S was 20% prior to this project. Compliance with using DSME/S increased to 35% after the DSME/S practice change initiative. This increase did not meet the objective of increasing utilization to 50%; however, the increase was statistically significant (p < 0.05).
Fasting Blood Sugar
The decrease in mean FBG levels pre- and postintervention was statistically significant (p < 0.05). Baseline and postimplementation data are summarized in Table 2.
Assessment Data at Baseline and After DSME/S Intervention (N = 24)
Quality of Life
Overall QOL improved following DSME/S. The difference was statistically significant for patients' mean scores in diabetes control, anxiety and worry, social burden, sexual functioning, and energy and mobility. Baseline and postimplementation data are summarized in Table 2.
This project demonstrated the successful implementation of an ARNP-led DSME/S program. The approach of translating the evidence from the existing research to spearhead this practice change initiative led to significant improvements in staff adoption, improved patient FBG level, and importantly, improved patient QOL. As the science of improved self-care management continues to evolve, nurses can anticipate further development and growth of these programs in the future.
The findings of this study indicate DSME/S significantly improved FBG levels. The number of patients who participated in this practice improvement initiative (N = 24) was small enough to allow individualized attention and support. Information sharing, psychosocial support, and behavioral encouragement were provided on a weekly basis or more often as needed. More providers need to be educated on how to properly bill for their services, which will serve as an incentive to allocate more time and resources for DSME/S. Therefore, practice protocol changes combined with billing practices must be put in place to support DSME/S and further improve outcomes of patients with diabetes.
Diabetes self-management education and support is a billable service. The reimbursement opportunities require the creation of a care plan that is patient-centered and comprehensive, and includes behavioral and mental health (U.S. Department of Health and Human Services [USDHHS], 2015). In addition, the care plans need to be accessible to patients electronically, such as through a mobile app or patient portal and documented in the electronic medical record (USDHHS, 2015). This is a step forward for this endocrinology practice in reaching all patients with diabetes and implementing DSME/S more effectively and efficiently.
Evidence demonstrates DSME significantly improves QOL in patients with diabetes, and this project reinforces this notion. Achieving set goals such as lowering FBG improves patients' perceived diabetes control, self-esteem, and energy level (Tang et al., 2012). Patients who participated in this project experienced improved scores in all five aspects of the D-39 scale. Patients reported statistically significant increases in perceived diabetes control, lower anxiety and worry, lower sense of social burden, and increased energy and mobility. Although statistically significant improvement was observed in the sexual functioning domain, this improvement was not as drastic as in the other four domains. This may be due to the short period of observation or to altered sexual functioning caused by issues other than diabetes.
DSME/S is a continuous process that involves ongoing assessment and continued support. Although DSME/S has been shown to be beneficial in this project, its duration of only 4 weeks does not provide information regarding the sustainability of this intervention. Patients must be actively engaged in their diabetes management through shared decision making, patient-centered care, and collaboration (Powers et al., 2015). For DSME/S to be the most beneficial in achieving glycemic control and desired QOL, it should occur initially on diabetes diagnosis and then followed by ongoing DSME/S sessions through community services or provider follow-up visits (Tang et al., 2012). Therefore, the 4-week duration was a limitation for this practice initiative project. In addition, the full benefits of DSME/S, evaluating A1C, could not be observed until 3 months after project implementation; this was a limitation due to time constraints.
Implications for Continuing Education
This project provides recommendations on incorporating DSME/S more effectively during diagnosis and follow-up of patients with diabetes. Key impacts of the project include an improvement in providers' understanding, attitude, and perception of DSME/S as evident by their effective utilization of DSME/S recommendations for glycemic control and QOL improvement. This can be achieved only through continuing education and keeping abreast with new guidelines and innovations.
Another key component is educating providers on government agencies that promote and support diabetes education and prevention. The Florida Department of Health (DOH) advocates for quality DSME/S programs that are aligned with recommended national standards (Florida Diabetes Advisory Council, 2017). The Florida DOH also provides awards to organizations that want to develop framework for obtaining ADA recognition or American Association of Diabetes Educators accreditation (Florida Diabetes Advisory Council, 2017). This is a great opportunity for improving diabetes care, increasing practice revenue, and promoting continuing education for all providers, including ARNPs.
The effectiveness of DSME/S has been demonstrated in the literature. This practice improvement project showed increasing utilization of DSME/S improved patients' glycemic control and QOL. Although the duration of the project was not long enough to evaluate sustainability of this practice change initiative, the significant increase in utilization of DSME/S was promising.
During this 4-week project, patients demonstrated success in significantly lowering their FBG. They followed recommendations as per DSME/S and demonstrated the effectiveness of these guidelines in improving glycemic control. QOL was assessed using the five domains of diabetic control, anxiety and worry, social burden, sexual functioning, and energy and mobility, with all areas being affected positively. These aspects are vital in assessing life satisfaction of patients with diabetes as diabetes affects many aspects of an individual's personal and social life. DSME/S was beneficial during the 4-week implementation period; however, sustainability of DSME/S success would require assessment for a period of 3 months or longer.
DSME/S plays a vital role in achieving desired glycemic control and QOL for patients with T2DM; however, evidence shows DSME/S is not used effectively in practice. This practice change initiative was one small step in trying to increase DSME/S utilization in an endocrinology practice. Making providers aware of the reimbursement potential and health benefits of DSME/S should help make DSME/S a priority in diagnosis and treatment.
- American Diabetes Association. (2017). Classification and diagnosis of diabetes. Diabetes Care, 40(Suppl. 1), S11–S24. doi:10.2337/dc17-S005 [CrossRef]
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- Boyer, J.G. & Earp, J.L. (1997). The development of an instrument for assessing the quality of life of people with diabetes: Diabetes-39. Medical Care, 35, 440–453.
- Centers for Disease Control and Prevention. (2015). Diagnosed diabetes. Retrieved from https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html
- Chrvala, C.A., Sherr, D. & Lipman, R.D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Education and Counseling, 99, 926–943. doi:10.1016/j.pec.2015.11.003 [CrossRef]
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- Institute for Healthcare Improvement. (2019). Science of improvement: Testing changes. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
- Powers, M.A., Bardsley, J., Cypress, M., Duker, P., Funnell, M.M., Fischl, A.H. & Vivian, E.(2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 41, 417–430. doi:10.1177/0145721715588904 [CrossRef]
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- White, N., Manning, M.L., Brawer, R. & Plumb, J. (2014). Using accreditation standards as a framework to evaluate and improve a community-based diabetes self-management education program. Population Health Management, 17(1), 8–5. doi:10.1089/pop.2013.0044 [CrossRef]
Demographic Characteristics of Participants (N = 24)
| Female (%)||9 (37.5)|
| Male (%)||15 (62.5)|
|Age, mean (SD), y||74 (6.4)|
|T2DM duration (y), mean (SD)||7.5 (5.4)|
|A1C level, mean (SD)||7.7% (0.8)|
Assessment Data at Baseline and After DSME/S Intervention (N = 24)
|Assessment||Baseline, Mean (SD)||Post-DSME/S, Mean (SD)||t score/z score||p|
|FBG level (mg/dL)||146.2 (18.7)||136 (17.1)||6.351||.000|
|Quality of life|
| Diabetes control||68.3 (10.5)||59.8 (10.0)||−4.017a||.000|
| Anxiety and worry||51.3 (15.8)||43 (14.0)||−3.799a||.000|
| Social burden||21 (5.4)||18.3 (4.8)||−3.103a||.002|
| Sexual functioning||44.2 (19.6)||42.6 (17.4)||−2.032a||.042|
| Energy and mobility||60 (13.0)||47.6 (12.2)||−3.819a||.000|