NEW YORK – More than 40% of Americans with type 2 diabetes never receive any formal education in self-management of their disease, a situation that is likely to only get worse as the population gets older and more obese, according to diabetes educator Dr. Sandra Drozdz Burke.
The Affordable Care Act is expected to bring millions more patients – many with diabetes – into the health care system through the expansion of Medicaid rolls. "When we have that much diabetes to deal with, we’re going to need to have lots of people who know how to take care of themselves," said Dr. Burke, director of the University of Illinois College of Nursing at Urbana-Champaign.
She noted that the number of Americans with diabetes is projected to grow from 23.7 million in 2008 to 44.1 million in 2034, and annual U.S. spending on diabetes is projected to triple – from $113 billion to $336 billion – over the same period (Diabetes Care 2009;32:2225-9).
In 2011, approximately 30,000 people were working as diabetes educators in the United States, which is 24,000 short of the estimated 54,000 projected to be needed by the year 2025, Dr. Burke said at the annual advanced postgraduate course held by the American Diabetes Association.
Most diabetes patients get their care from primary care practitioners, and many are typically referred to specialty care "only at the end of the road," when complications of diabetes are advanced and irreversible, she said. But in clinical practice – in the 8- to 12-minute encounter – there is little time to cram in everything a patient with diabetes needs to know about healthy eating, exercise and physical activity, medication, self-monitoring of blood glucose, risk reduction, and mental health.
"We know that diabetes educators, when they are embedded in primary care, work. We’ve seen research about that for the last several years," she said. "If we want to improve the care of patients with diabetes, we need to be in primary care," she said.
As the health care economy makes the transition from the fee-for-service model to accountable care organizations and patient-centered medical homes, diabetes educators will become even more important, Dr. Burke said. She proposed a patient-centered medical home model designed specifically for patients with diabetes, the metabolic syndrome, or people who are at risk for diabetes. Such a system could include diabetes educators, nutritionists, endocrinologists, physician assistants, pharmacists, and other clinicians who could help patients to manage their health and reduce the need for specialty care.
National standards revised
In a separate talk, Janice L. Koshinsky, diabetes program manager for the University of Pittsburgh’s Lions Diabetes Center in McKeesport, Pa., highlighted changes to recently published national standards for diabetes self-management education (DSME) and diabetes self-management support (DSMS) that may help to increase the ranks of diabetes educators.
The new standards include emphasis on ongoing self-management support and diabetes prevention (including treatment of gestational diabetes and prediabetes). Although most of the changes are minor, generally involving clarification of terms, one of the standards broadens the definition for instructional staff.
Previously, the standards held that at least one of the instructors in a diabetes self-management program should be a registered nurse, dietitian, or pharmacist.
The new standard, however, states that "one or more instructors will provide DSME, and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be an registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE [certified diabetes educator] or BC-ADM [board-certified advanced diabetes manager]. Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes, and with supervision and support."
With the previous standards, "we were really excluding some other health care professionals who may be certified in diabetes education, especially if they were in a standalone program," Ms. Koshinsky said.
Dr. Burke reported being a consultant to Janssen Pharmaceuticals and Genentech. Ms. Koshinsky reported being a consultant to Healthy Interactions and Merck.