San Diego, CA—Diabetes education can play a crucial role in optimizing the management of patients with type 2 diabetes, resulting in significant cost-savings when trained nurse educators provide education and continued support in the context of a team approach and case management. This was a key message of the Outstanding Educator in Diabetes Education Award lecture on “The Long and Winding Road—My Journey in Diabetes Education,” given by Linda M. Siminiero, RN, PhD, CDE, Executive Director, University of Pittsburgh Diabetes Institute, PA, at the 2011 Scientific Sessions of the American Diabetes Association.
Motivated by her father’s untimely diagnosis and early death from type 1 diabetes in the pre–glucose-monitoring era, when little was known about how to optimize management and few treatments were available, Dr Siminiero has worked tirelessly throughout her career to improve the lot of patients with diabetes, most recently for those in rural, underserved areas.
Technological advances in blood glucose monitoring were introduced in 1986, but more than 20 years later, in 2008, the messages were the same; the availability of monitoring did not improve outcomes.
“Results of blood glucose monitoring are meaningless if people don’t know how to react to their numbers,” she said. The message was that education improved people’s knowledge scores, but did not lead to changed behaviors and outcomes. Thus, the focus of diabetes education shifted from passing on information to providing psychosocial support, with the goal of changing patients’ behaviors to improve outcomes, Dr Siminiero said.
“Many studies, including the Diabetes Control and Complications Trial, have shown that education with psychosocial support improves outcomes, but the healthcare community was slow to adopt these findings,” she said.
“Randomized controlled trials show that hemoglobin A1c levels are lowered by 3 times as much when nurses and pharmacists educate patients. Other studies have replicated this message, emphasizing that team care and case management improve outcomes. Yet fewer than 50% of patients have adequate access to nurses, pharmacists, and other professionals who can provide the support they need,” Dr Siminiero said. “Sadly these approaches are often lacking.”
Although diabetes self-management has a dramatic effect on lowering HbA1c, many studies show that the benefit of education is diminished over time. Sustained improvement requires continued support and ongoing therapy. Team-based care is the best predictor of improved glycemic control, and access to nurses improves outcomes, she stated.
Dr Siminiero said that she became interested in serving rural areas after a 2009 study of 295 patients with type 2 diabetes living in rural areas of Pennsylvania showed that 65% had no education and 76% had never gotten a referral. When 72 patients received a referral, 83% attended a clinic.
“We found we need to reach more people,” she said. “In 2011, our models were not working.”
At the University of Pittsburgh–sponsored projects and similar projects in the United States, nurse-led clinics have paid off not just in clinical improvement, but in cost-savings. Dr Siminiero and colleagues led a study showing that in a rural, underserved area of Pennsylvania, nurse educator–led clinics with advice on diet achieved significant improvement in reducing hemoglobin A1c and a cost-savings of about $500,000. “We repeated this study with the same results,” she said.
The University of Pittsburgh is currently collaborating with the University of Michigan and Penn State University to offer similar projects to underserved areas.