By Christina R. Whitehouse, PhD, AGPCNP-BC, CDCES
Assistant Professor, M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA
Nurse Practitioner, Clinical Practices of the University of Pennsylvania, Penn Medicine, Philadelphia, PA
DSMES Benefits and Barriers
As diabetes care and education specialists (DCESs), we understand the positive influence of diabetes self-management education and support (DSMES) on the lives of those living with and caring for persons with diabetes. It is important to share its effectiveness with others so that we can continue to provide DSMES services and increase access to this greatly underutilized benefit. When determining how to illustrate the impact of DSMES, we must consider our audience: Is it other healthcare professionals? Patients? Insurers? Healthcare administrators? Caregivers? Policymakers? When I think about the impact of DSMES I consider who matters most. Right now you may be saying to yourself, “Well of course, it’s the person living with diabetes.” I do not deny that persons with diabetes (PWD) will always be my true focus – and financial impact to PWD is exceedingly important – for more details about financial stress among PWD please listen to The Huddle podcast episode “Overcoming Cost Barriers in Diabetes Care”. Dr. Michelle Litchman and Dr. Julia Blanchette take us through their important and devastating research findings on this topic.
DSMES not only empowers PWD to problem solve issues such as financial barriers to diabetes self-management, but research has shown the psychological and metabolic benefits as well. We know DSMES works for PWD so then why, with all this evidence, does it continue to be underutilized? A recent study utilizing electronic health records (EHR) showed that despite the need for DSME among adult patients less than 7% of provider encounters resulted in a referral.1 Unfortunately the reasons for decreased use are multifactorial and relate to issues beyond provider referral, such as knowledge of programs, patient and provider beliefs of DSMES benefits, patient access issues, availability of programs, transportation, co-pays, and additional impact of social determinants of health. In order to maintain and sustain any program, we need to demonstrate value, not only through individual diabetes outcomes, but also to additional stakeholders who have a role in DSMES – most importantly this comes down to the simplest of terms – money.
Measuring the Impact of DSMES
There have been numerous studies on the impact of DSMES as it relates to medication adherence,2 hypoglycemia outcomes,3 psychological health,4 as well as improvements in multiple cardiometabolic health outcomes.5–8 These studies and numerous others demonstrate the value of DSMES but we also need to determine economic measures of value, how much can better utilization of DSMES save individuals, insurance providers, government agencies, etc.. Measuring the value of any service can be challenging, especially if you do not possess the knowledge or tools to complete an analysis. As DCESs we know the importance of collaboration for the care of PWD, this collaboration must extend into program evaluation and its economic impact. As you read further please consider what resources you may have or need to develop in evaluating the economic impact of your program. If you do not possess these skills reach out to an expert in healthcare economics to help you!
The financial impact of diabetes in the United States was estimated at $327 billion in 2017, with 1 of every 7 healthcare dollars being used for treating diabetes and its related complications. Diabetes care and management consists of multiple interventions including medications and non-pharmacological recommendations for PWD. DSMES utilizes the ADCES7 Self-Care BehaviorsTM framework to empower PWD to manage their diabetes with self-efficacy. To show the potential economic impact of DSMES use on healthcare use, we conducted a review of all available research literature where diabetes education included at least one component of the ADCES7. In preparation for this review and analysis, we developed a protocol with an interprofessional team of experts.9
We identified over 14,000 articles that potentially met our review criteria and after further screening and evaluation of study quality we narrowed our review to focus 22 studies that were presented in our analysis. To summarize our findings, there was great variability in each study from the study site location, intervention time and interventionist. There was also variability in the delivery of education including time, in-person versus telehealth, and individual versus group or shared appointments. Additionally, many studies included additional intervention components beyond the diabetes education making it difficult to isolate the impact of any sole component. Despite the variability in study methods over two-thirds (14) of the interventions utilized all of the ADCES7 in their intervention. Fifty percent of studies showed a positive association with DSMES, meaning that there was a cost savings (e.g. decreased emergency department visits, hospitalizations, pharmacy or overall medical costs), only one showed a negative association while the remainder of studies were uncertain. The evidence suggests that DSMES lowers overall healthcare utilization and medical costs; however, more research is needed.10 Co-author Andrew Bzowyckyz, PharmD, BCPS, CDCES highlights these findings in EndocrineToday and the full article can be found in the December issue of The Science of Diabetes Self-Management and Care.
DSMES Sustainability Starts with Measurement
The importance of evaluative measures of any program cannot be understated. The CDC provides a framework for program evaluation that can be utilized across multiple programs including DSMES. Additionally the CDC has developed the DSMES Toolkit that specifically offers information about the business side of DSMES, an important consideration to have as educators for program sustainability. Financial discussion can be challenging, especially when it comes to the future of your program but having the discussion early in program development is vital. We must take measurements beyond A1C and diabetes knowledge, such as financial impact measures including alternate measures other than costs accrued from insurance reimbursement and evaluate dollars saved from reduction of hospital and emergency room utilization.
As a DCES and member of a team we need to have a seat at the table and discuss these potential economic impacts to stakeholders during the development and maintenance of all DSMES programs. Many of these measures are collected for programs that are accredited but many education programs are not accredited. Costs matter and we need to examine the economic impact from not only cost of services provided but savings as well. Too often an unanticipated event such as a hospitalization will set off a downward spiral of healthcare utilization that could have been averted from appropriate DSMES. Show the value of your program through cost savings and continue to grow your program so PWD can share in these benefits.
1. Brittany L. Brown-Podgorski P, Yunfeng Shi P, Joshua R. Vest P. Patient Need and Provider Referrals to Diabetes Self-management Education. Published online June 15, 2021. Accessed January 26, 2022. https://www.ajmc.com/view/patient-need-and-provider-referrals-to-diabetes-self-management-education
2. Enricho Nkhoma D, Jenya Soko C, Joseph Banda K, Greenfield D, Li YCJ, Iqbal U. Impact of DSMES app interventions on medication adherence in type 2 diabetes mellitus: systematic review and meta-analysis. BMJ Health Care Inform. 2021;28(1):e100291. doi:10.1136/bmjhci-2020-100291
3. LaManna J, Litchman ML, Dickinson JK, et al. Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature. Diabetes Educ. 2019;45(4):349-369. doi:10.1177/0145721719855931
4. Peña-Purcell N, Han G, Lee Smith M, Peterson R, Ory MG. Impact of Diabetes Self-Management Education on Psychological Distress and Health Outcomes Among African Americans and Hispanics/Latinos With Diabetes. Diabetes Spectr. 2019;32(4):368-377. doi:10.2337/ds18-0081
5. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient education and counseling. 2016;99(6):926-943. doi:10.1016/j.pec.2015.11.003
6. Adam L, O’Connor C, Garcia AC. Evaluating the Impact of Diabetes Self-Management Education Methods on Knowledge, Attitudes and Behaviours of Adult Patients With Type 2 Diabetes Mellitus. Can J Diabetes. 2018;42(5):470-477.e2. doi:10.1016/j.jcjd.2017.11.003
7. Hildebrand JA, Billimek J, Lee JA, et al. Effect of diabetes self-management education on glycemic control in Latino adults with type 2 diabetes: A systematic review and meta-analysis. Patient Educ Couns. 2020;103(2):266-275. doi:10.1016/j.pec.2019.09.009
8. Azami G, Soh KL, Sazlina SG, et al. Effect of a Nurse-Led Diabetes Self-Management Education Program on Glycosylated Hemoglobin among Adults with Type 2 Diabetes. J Diabetes Res. 2018;2018:4930157. doi:10.1155/2018/4930157
9. Whitehouse CR, Haydon-Greatting S, Brady VJ, et al. Economic impact and health care utilization outcomes of diabetes self-management education and support interventions for persons with diabetes: a systematic review protocol. JBI Evidence Synthesis. 2022;20(1):238-248. doi:10.11124/JBIES-20-00550
10. Whitehouse CR, Haydon-Greatting S, Srivastava SB, et al. Economic Impact and Health Care Utilization Outcomes of Diabetes Self-Management Education and Support Interventions for Persons With Diabetes: A Systematic Review and Recommendations for Future Research. The Science of Diabetes Self-Management and Care. Published online November 3, 2021:263501062110475. doi:10.1177/26350106211047565
ADCES Perspectives on Diabetes Care
The Association of Diabetes Care & Education Specialists Perspectives on Diabetes Care covers diabetes, prediabetes and other cardiometabolic conditions. Not all views expressed reflect the official position of the Association of Diabetes Care & Education Specialists.
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