Delivering Diabetes Self-Management Education (DSME) in Primary Care

Dis Manage Health Outcomes 2008; 16 (4): 267-272ORIGINAL RESEARCH ARTICLE 1173-8790/08/0004-0267/$48.00/0

© 2008 Adis Data Information BV. All rights reserved.

Delivering Diabetes Self-ManagementEducation (DSME) in Primary CareThe Pittsburgh Regional Initiative For Diabetes Education (PRIDE)

Linda M. Siminerio,1 Kristine Ruppert,1 Sharlene Emerson,1 Francis X. Solano2 and Gretchen A. Piatt1

1 University of Pittsburgh Diabetes Institute, Pittsburgh, Pennsylvania, USA2 University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA

Background: Diabetes self-management education (DSME) is a critical component of the clinical managementAbstractof diabetes mellitus. Although DSME is recognized as important, the number of patients with diabetes whoreceive education is disproportionately small. Several barriers to receiving diabetes education exist, includingaccess and DSME delivery approaches.Objective: The purpose of this project was to explore opportunities to meet the Healthy People 2010 goal ofincreasing the proportion of people with diabetes mellitus who receive diabetes education from 40% (as it was in1998) to 60% (in 2010). Our objectives were to examine the provision of DSME in primary care, to determine ifDSME delivery in primary care increases the number of people who receive DSME, and to evaluate the effect ofDSME on glycosylated hemoglobin (HbA1c) and low-density lipoprotein-cholesterol (LDL-C) levels. DSMEwas delivered in primary care practices as part of the Pittsburgh Regional Initiative for Diabetes Education(PRIDE).Research design and methods: A nurse who was a certified diabetes educator (CDE) was deployed to providePoint-Of-Service diabetes Education (POSE) to four University of Pittsburgh Medical Center (UPMC) Com-munity Medicine Practices (CMI) primary care practices. The group of patients who received POSE wascompared with patients from the same practices who were identified as having diabetes and who received usualcare. The number of patients was computed and a percentage calculated for comparison against Healthy People2010 goals. The HbA1c values of patients were tracked from January 2003 through December 2006, during thetimeframe that POSE was provided.Results: Of the 5344 diabetes patients in the four practices, 784 received POSE. Mean HbA1c values were higherat baseline in those patients who received POSE than those who received usual care. There was a significantdecrease in HbA1c and LDL-C levels in both groups. Although there was not a significant between-groupdifference in HbA1c, those who received POSE had significant improvement in LDL-C levels compared with theusual care group.Conclusions: Providing DSME in primary care is feasible and offers the opportunity to reach patients who maynot be receiving DSME services. However, further research is needed to evaluate other methodologies toincrease access to DSME and other factors that may influence improvement in clinical outcomes.

Background Although DSME is recognized as important, the number of

patients who receive diabetes education is disappointinglyDiabetes self-management education (DSME) is considered an

small.[5-7] Access to education has been proposed as a potentialimportant part of clinical management for diabetes mellitus.[1-3]

barrier, particularly in communities where the closest DSMEThe goals set for Healthy People 2010[4] include increasing theprogram may be miles away.[8] Another potential problem may benumber of people who receive diabetes education from 40% (in

1998) to 60% (in 2010). the traditional way in which education is prescribed and delivered.

268 Siminerio et al.

Currently, physicians are expected to refer diabetes patients to a Diabetes Self-Management Education Servicehospital-based DSME program.

The POSE intervention included the deployment of one nursePatients frequently have many barriers to following through oncertified diabetes educator (CDE) to four CMI practices that hadreferrals, including a lack of understanding of the need of thebeen identified as having a high volume of diabetes patients andservice, distance, scheduling constraints, cultural and languagethat represented a mix of internal medicine and family medicinechallenges, and a reluctance to attend a program in a hospitalpractices. Practices were added into the initiative over time. Thesetting.[8-10] Although over 90% of patients with diabetes are carednurse CDE was available on ‘diabetes days’ in order to maximizefor by primary care physicians,[11] DSME is rarely available in theefficiency and to provide the added benefit of the focused visits forprimary care office.[12,13] Thus, there is a compelling need andthe practice. The nurse CDE worked with the office staff togreat opportunity for the delivery of DSME in primary careschedule diabetes days and DSME appointments that best met thesettings, but implementation and evaluation of such services inneeds of the practice. The nurse CDE initiated the program at eachthese settings are limited.[14,15]

office by providing the program services 1 day per week. How-The University of Pittsburgh Medical Center (UPMC) em-ever, as the program evolved, the nurse CDE tailored the visitsbarked on a quality-improvement initiative in an attempt to meetbased on practice demand, so that services were provided in someHealthy People 2010 diabetes goals. Patients and physicians at thepractices weekly and every 1–3 weeks in others. The nurse CDEUPMC identified poor access to education as a barrier to themet with physicians to make them aware of the DSME servicespromotion of quality diabetes care. When reports of limited accessavailable and to determine the best methods for communicationwere brought to the attention of the leadership, the UPMC began toand documentation. The nurse CDE encouraged education visitsaddress support services for primary care and began to implementfor all patients diagnosed with diabetes in the practice. SincePoint-Of-Service diabetes Education (POSE) in primary care of-DSME is reimbursed for 10 hours of initial education and 2 hoursfices.annually for follow-up, services were encouraged for follow-up

Our objective was to examine the implementation of POSE inmaintenance visits, newly diagnosed patients, patients learning

primary care and to determine whether it increased the number ofnew skills and medication routines, patients with complex regi-

people who receive DSME, and would therefore assist in meetingmens, and patients who were having diabetes management issues.

Healthy People 2010 goals. We also evaluated the effects of POSENotices regarding DSME services were posted in each of the

on glycosylated hemoglobin (HbA1c) and low-density lipoprotein-offices.

cholesterol (LDL-C) levels over the period January 2003 to De-Because of space constraints in the offices, DSME was deliv-cember 2006.

ered on an individual basis at the start of the initiative. Group visitswere facilitated later on in the project when the space was avail-Methodsable. The American Diabetes Association (ADA) Medical Stan-dards of Care[17] and the National Standards for DSME[18] were

Setting used to provide consistency and benchmarking for the provision ofDSME within the practices. Along with providing patient educa-

The UPMC is an integrated health system that includes 19 tion, the nurse CDE also provided the practice with updates onacademic, specialty, and community hospitals, as well as a physi- new therapies, and treatment algorithms, reminders on meetingcian division with 166 primary care and 1400 academic physicians standards of care, and literature for both staff and patients.providing services for approximately 106 000 people with diabe-tes in western Pennsylvania, USA. UPMC Community Medicine PopulationInc. (CMI) is the physician division that manages 215 acquiredprimary care physicians and their practices in urban, suburban, and Four CMI primary care practices were involved in this initia-rural communities. The UPMC focused on diabetes as part of a tive. Two were located in an urban academic medical center, andregional quality-improvement initiative entitled the Pittsburgh Re- two were suburban practices located in surrounding communities.gional Initiative for Diabetes Education (PRIDE). Diabetes educa- Patients with diabetes who were aged ≥18 years were identifiedtion is referred to in the broadest sense: diabetes education for for the period January 2003 through December 2006 using Inter-providers, patients, and the community. The initiative included national Classification of Disease – version 9 (ICD-9) codesprovider education, enhanced reminder and tracking systems, 250.xx. The two urban practices had a combined total of 2432POSE, and public awareness campaigns. Details on the entire individuals with diabetes (urban practice 1: n = 624; urban prac-initiative are described elsewhere.[15,16] tice 2: n = 1808), while the two suburban practices had a total of

© 2008 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2008; 16 (4)

Delivering DSME in Primary Care 269

UPMC community medical incorporated

primary carepractices (n = 215 practices)

Individuals withdiabetesn = 1808




n = 1808

POSEn = 76

No POSEn = 548

POSEn = 222

No POSEn = 1586

POSEn = 223

No POSEn = 634

POSEn = 263

No POSEn = 1792

Urban practice 1n = 2890

Urban practice 2n = 6398

Suburban practice 1n = 3739

Suburban practice 2n = 10 237

Fig. 1. Study design: January 2003–December 2006. POSE = Point-Of-Service diabetes Education; UPMC = University of Pittsburgh Medical Center.

2912 patients with diabetes (suburban practice 1: n = 857; subur- into all models. To detect a mean difference in HbA1c of 1%, 104ban practice 2: n = 2055) [figure 1]. During the study, individuals patients per study group were required. p-Values of less than 0.05with diabetes were identified as having received POSE through were considered statistically significant. All analyses were con-documentation by the nurse CDE carrying out the initiative. To be ducted using SAS v8.2; (SAS Institute, Cary, NC, USA).eligible for inclusion in each respective analysis, patients had to

Resultshave at least one HbA1c and/or LDL-C value prior to receivingDSME. All other laboratory values were collected and reported

From January 2003 through December 2006, 17.2% (784 ofafter DSME was delivered, within the timeframe of the project.

4560) of individuals with diabetes received POSE in the fourThe UPMC Quality Council approved this project.

primary care practices. Of the patients who received POSE, 52.1%were female and the mean age was 61.3 years. When comparing

Analysesthe population who received POSE with the population who didnot to determine generalizability, the population that receivedThe statistical analyses incorporated both descriptive and infer-POSE had a greater proportion of women (52.1% vs 50.2%,ential techniques to determine the effect of POSE on HbA1c andrespectively; p = 0.3) and was younger than the population that didLDL-C levels over time compared with not receiving POSE. Innot receive POSE (61.3 years vs 63.5 years, respectively;order to be included in each respective analysis cohort, a patientp < 0.0001) [see table I]. The group who received POSE also hadhad to have at least two HbA1c and/or LDL values – one prior tosignificantly higher HbA1c values at baseline than the group thatreceiving DSME and one after receiving DSME within the studydid not (7.8% vs 7.2%, respectively; p < 0.0001) but did not havetime period. A total of 784 POSE patients and 3776 non-POSEsignificantly higher LDL-C levels (113.1 vs 109.6, respectively;patients were eligible for longitudinal analyses. To adjust for thep = 0.1).effect of possible confounders and to examine temporal trends

within and between groups, longitudinal mixed modeling was When the effect of POSE on HbA1c and LDL-C levels overused. These types of analyses account for possible regression to time was examined, significant decreases were observed in boththe mean, as each subject is able to serve as their own control. Age outcomes (figure 2). There was a marked decline in HbA1c levelscentered at mean age 63.0 years, sex, POSE, and time were forced in individuals who received POSE (n = 784) from January 2003 to



Table I. Baseline demographic and clinical characteristics of individuals receiving Point-Of-Service diabetes Education (POSE) and those not receivingPOSE (January 2003–December 2006)

Characteristic POSE Non-POSE p-Value(n = 784) (n = 3776)

Age (y)a 61.0 (13.3) 63.5 (14.1) <0.0001

Male patients [% (n)] 48.0 (376) 49.8 (1880) 0.3

Baseline HbA1c (%)a 7.8 (1.9) 7.2 (1.6) <0.0001

HbA1c < 7% [% (n) patients] 38.6 (303) 53.2 (2009) <0.0001

Average number of HbA1c measurementsa 11.6 (16.0) 5.1 (5.6) <0.0001

Baseline LDL-C (mg/dL) 113.1 (35.2) 109.6 (34.1) 0.1

LDL-C <100 mg/dL [% (n) patients] 41.0 (321) 39.0 (1473) 0.47

Average number of LDL-C measurementsa 9.0 (11.9) 4.1 (4.4) <0.0001

a Data presented are mean (SD).

HbA1c = glycosylated hemoglobin; LDL-C = low-density lipoprotein-cholesterol.

December 2006 (–0.29%, p < 0.0001) after adjustment for age observed in the non-POSE group: the proportion of individualsmeeting the HbA1c target of <7% significantly increased fromcentered at a mean of 63 years, sex, POSE, and time. Declines in53.2% in 2003 to 62.3% in 2006.HbA1c values in individuals not receiving POSE (n = 3776) also

LDL-C levels also decreased significantly over time in patientsoccurred during the same time period (–0.28%, p = 0.003). Therewho received (–16.1 mg/dL, p = 0.0001) and did not receive POSEwas no significant difference in HbA1c values between groups(–8.6 mg/dL, p = 0.0001) groups after adjustment for age centered(p = 0.88) [figure 2]. The proportion of individuals meeting theat a mean of 63 years, sex, POSE, and time (figure 2). A statistical-

HbA1c target of <7% also increased from 38.6% in 2003 to 55.2%ly significant difference was also observed between groups as

in 2006 (p < 0.0001) in the POSE group. The same pattern was well, with the group who received POSE experiencing an addition-al decrease of 7.1 mg/dL over time (p = 0.0002) compared with thegroup that did not (figure 2). The observed decreases in LDL-Clevels in the group who received POSE resulted in a steadyincrease in the proportion of individuals meeting the ADA LDL-Cgoal level of <100 mg/dL over time, from 39% in 2003 to 57.7% in2006 (p < 0.0001). The same pattern was observed in the non-POSE group as well (41% in 2003 to 53.3% in 2006), although thetrend was not significant. Individuals in the group that receivedPOSE also had a significantly higher average number of HbA1c

and LDL-C measurements performed over the course of the studyperiod than did the group that did not receive POSE.

Discussion

In this report, we demonstrate that integrating a nurse CDE intoprimary care practices is an effective way of increasing the oppor-tunities to reach patients in need of DSME services while improv-ing clinical outcomes, especially in patients who are unable tomeet HbA1c and LDL-C goals. As the results imply, POSE had apositive influence on HbA1c. Although there was a significantoverall improvement in HbA1c values in both groups of patients,those who received POSE had higher HbA1c levels at baseline.This led us to conclude that, although there was expectation that allpatients be referred for DSME, physicians were more likely to

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6.26.46.66.87.07.27.47.67.8 POSE (n = 784)

No POSE (n = 3776)

a

HbA

1c (

%)

b

LDL-

C (

mg/

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p = 0.88

p = 0.0002

Fig. 2. Temporal trends in glycosylated hemoglobin (HbA1c) and low-densi-ty lipoprotein-cholesterol (LDL-C) levels in patients who receive Point-Of-Service diabetes Education (POSE) compared with those who did notreceive POSE in four primary care practices, January 2003–December2006. Models adjusted for age, centered at mean age 63 years, sex,POSE, and time.


Delivering DSME in Primary Care 271

refer patients for POSE within their practices if patients were not the patients who did not receive DSME, HbA1c values increasedat ADA goal levels. We suspect that these patients had long-term from 7.3 to 7.44 (p = 0.42) over the course of that study period,management challenges for a variety of reasons or were newly while those who received POSE had reductions in values. Thisdiagnosed. trend supports our position that DSME does have a positive

influence on glycemia.There is a range of possibilities that could explain why patientsThese findings reaffirm the work done by Piatt et al.,[14] whowho had higher HbA1c levels at baseline were referred and re-

conducted one of the first randomized controlled studies to evalu-ceived POSE with subsequent improvements in HbA1c values. Forate an intervention that integrated a diabetes nurse educator intoinstance, studies have shown that primary care physicians considerprimary care. In the study group in which a diabetes nurse educatordiabetes more difficult to treat than other chronic diseases, as morewas made available to primary care practices on specific ‘diabetesmonitoring and medication adjustment is required to achievedays,’ clinical and behavioral outcomes improved, as did diabetestreatment goals.[19-21] While physicians also report that they feel illknowledge. This study, which restructured the current healthequipped to counsel patients regarding behavior change,[22,23] insystem to improve diabetes care, established the effectiveness ofanother survey of physicians and nurses regarding diabetes careimplementing a diabetes educator into the primary care setting.responsibilities, nurses reported that they felt capable and ready to

assume these responsibilities.[24] They were reported to have more We acknowledge that many factors (such as physician educa-time available to spend with patients, were better listeners and tion, intensified management, tracking and reminder systems, andknew patients better, and provided better education than primary community education) in our quality initiative could have influ-care physicians. In the survey, both the physicians and the nurses enced the HbA1c and LDL-C levels. We also recognize thatagreed that nurses needed to assume more responsibility for diabe- secular trends and medications, particularly in relationship to lipidtes care.[24] We believe that the CMI physicians recognized the management where there is a plethora of effective lipid loweringvalue of this and relied on the services of the nurse CDE, especial- agents available, could have been the factors responsible for thely in their patients with more complex or challenging health needs, changes. As a result of what we learned from this feasibility study,or newly diagnosed patients. in the follow-up studies that we are now undertaking, we are

proactively measuring other parameters, such as provider andIn this project we also demonstrated the potential influence thatpatient satisfaction and whether the nurse CDE had any influencethe nurse CDE had on patient outcomes within the practice.on practice behaviors, e.g. prescribing practices. We are alsoAlthough the between-group difference was not found to be signif-stratifying the population to investigate patient-specific character-icant for HbA1c values, there was a significant between-groupistics, such as the effect of DSME for newly diagnosed patientsdifference for LDL-C levels. Since the office visit has also beenversus those with long-term problems. We presume that patientspreviously described as providing a “teachable moment,” a timewith more difficult needs may be blunting the trend line and this iswhen patients are very motivated to listen to and act on the advicewhy there was no difference in HbA1c values between the twoof the physician (and other healthcare team members), we suspectgroups. Nevertheless, one cannot ignore the potential of the addedthat patients not only found it easier to participate in an on-sitebenefit with DSME.education intervention, but they may have been more motivated

since the message to participate in POSE was conveyed directly Despite the limitations, we are encouraged by the findings offrom their physician. this project. Reports indicate that diabetes education is an under-

utilized service. In a survey conducted by the American Associa-We realize that the patients in the non-POSE group may havetion of Diabetes Educators (AADE) and the ADA,[7] educators inreceived DSME in another setting and recognize this as a limita-half of the DSME programs reported an average visit volume oftion in our study. We were limited to reporting DSME services byfewer than 50 visits per month and 19% reported only 51–100tracking laboratory values and billing codes in the system. At thevisits per month.time of this study, the educator and physicians did not routinely

document DSME services and referrals. However, we do know Although all of the CMI practices have ADA-approved DSMEthat this is a very stable population and the only DSME services programs in their communities, physicians report that, althoughthat are available in this community were represented by the they routinely refer patients for DSME, patients do not receive orbilling documentation. In another project, we monitored the participate in the service. As a result of our integrating educatorsHbA1c values of patients in a remote rural community where there into offices, opportunities opened for direct access. In our PRIDEwas only one DSME program in the entire county. We found poor initiative, primary care physicians and the educators reported areferral patterns and that many of the patients with the most number of advantages to providing POSE that included increasedcomplex needs and co-morbidities had never received DSME. In communication on management plans and nurse CDE involve-



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21. Zgibor JC, Songer TJ. External barriers to diabetes care: addressing personal andPortions of this research were sponsored by funding from the US Air Forcehealth systems issues. Diabetes Spectrum 2001; (14): 23-8administered by the US Army Medical Research Acquisition Activity, Fort

22. Beaven DW, Scott RS. The organisation of diabetes care. In: Alberti KGMM, KrallDetrick, MD, USA (award number W81XWH-04-2-003). Review of materialLP, editors. The diabetes annual: 2. New York: Elsevier, 1986: 39-48

does not imply Department of the Air Force endorsement of factual accuracy23. Orlandi MA. Promoting health and preventing disease in health care settings: an

or opinion. analysis of barriers. Prev Med 1987; 16 (1): 119-30Sharlene Emerson is part of the diabetes education network for Eli Lilly, 24. Siminerio LM, Funnell MM, Peyrot M, et al. US nurses’ perceptions of their role in

Inc. Dr Piatt has received honoraria from Johnson & Johnson. Dr Siminerio diabetes care: results of the cross-national Diabetes Attitudes Wishes and Needs(DAWN) study. Diabetes Educ 2007; 23 (1): 152-62has received honoraria from Eli Lilly, Amylin, Sanofi Aventis, and Merck.

25. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health educationDr Solano has received honoraria from Sanofi Aventis. Dr Ruppert has nofor self-management in patients with chronic arthritis has sustained healthconflicts of interest that are directly relevant to the contents of this study.benefits while reducing health care costs. Arthritis Rheum 1993; 36 (4): 439-46

26. Leveille SG, Wagner EH, Davis C, et al. Preventing disability and managingchronic illness in frail older adults: a randomized trial of a community-basedReferencespartnership with primary care. J Am Geriatr Soc 1998; 46 (10): 1191-8

1. Zgibor JC, Peyrot M, Ruppert K, et al. Using the American Association of Diabetes27. Glasgow RE. A practical model of diabetes management and education. DiabetesEducators Outcomes System to identify patient behavior change goals and

Care 1995; 18 (1): 117-26diabetes educator responses. Diabetes Educ 2007; 33 (5): 839-422. Norris SL, Engelgau MM, Narayan KMV. Effectiveness of self-management

training in type 2 diabetes. Diabetes Care 2001; 24 (3): 561-87About the Author: Linda Siminerio, PhD, BSN, MS, CDE, is the Executive3. Brown AS. Interventions to promote diabetes self-management: state of theDirector of the University of Pittsburgh Diabetes Institute and holds Asso-science. Diabetes Educ 1999; 25 Suppl.: 52-61ciate Professor appointments at the University of Pittsburgh Schools of4. US Department of Health and Human Services. Healthy people 2010: understand-

ing and improving health. Washington, DC: US Department of Health and Medicine and Nursing. Dr Siminerio’s work is dedicated to improvingHuman Services, Government Printing Office, 2000 health systems and healthcare delivery for people with diabetes.

5. Hiss RG, Anderson RM, Hess GE, et al. Community diabetes care: a 10-year Correspondence: Associate Professor Linda M. Siminerio, University ofperspective. Diabetes Care 1994; 17 (10): 1124-34

Pittsburgh Diabetes Institute, 1 Ross Building, 4601 Baum Blvd, Pittsburgh,6. Coonrod BA, Betschart J, Harris MI. Frequency and determinants of diabetesPA 15213, USA.patient education among adults in the US population. Diabetes Care 1994; 17

(8): 852-8 E-mail: [email protected]


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Delivering Diabetes Self-Management Education (DSME) in Primary Care