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Version 4.0 o Evaluation of the patient’s progress towards the goals VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus 3. The education component should be tailored to the patient’s needs and provided by healthcare professionals who are most knowledgeable in the topic. Regardless of setting, availability of a multidisciplinary team approach is highly desirable and could include, but is not limited to, a dietitian, certified diabetes educator, registered nurse, pharmacist, psychologist, exercise physiologist, physical therapist, social worker, endocrinologist, behaviorist, ophthalmologist, optometrist, physician, podiatrist, other healthcare professionals and paraprofessionals, or other specialized physicians based on the individual patient’s needs. 4. The use of approaches such as group visits and telehealth should be considered in providing education. DISCUSSION DSME is the cornerstone of care for all individuals with diabetes who want to achieve successful health-related outcomes. The National Standards for DSME are designed to define quality diabetes self-management education that can be implemented in diverse settings and will facilitate improvement in healthcare outcomes (Mensing et al., 2000). These standards are reviewed and revised approximately every 5 years by key organizations and federal agencies within the diabetes education community to reflect advances in scientific knowledge and healthcare. The most recent revision was approved in March 2007 (Funnell et al., 2009) and identified the following as essential curricula components for DSME: • Describing the diabetes disease process and treatment options • Incorporating appropriate nutritional management • Incorporating physical activity into lifestyle • Using medications (if applicable) to achieve glycemic targets • Monitoring blood glucose, monitoring blood or urine ketones (when appropriate), and using the results to improve control • Preventing, detecting, and treating acute complications • Preventing, detecting, and treating chronic complications • Developing personal strategies to identify and address psychosocial issues and concerns • Developing personal strategies to promote health and behavior change • Promoting preconception, pregnancy, and gestational diabetes management when applicable. While the importance of a multi-disciplinary approach has been demonstrated (Borgermans et al., 2009), demonstration of the effectiveness of each of the components of a comprehensive program awaits further study. However, their inclusion is recommended based on expert opinion and research. Because research on educational interventions is complex, expensive, and time consuming, few studies have addressed the effectiveness of such programs (Jacobson et al., 1983; Merritt et al., 1983; Miller & Goldstein, 1972; Rubin et al., 1998). Moreover, it is difficult to assess the unique contribution of education independent of other factors (Colagiuri & Eigenmann, 2009). Primary care staff members have limited time to provide in-depth education. It is critical, however, to provide immediate education that will help ensure the patient’s safety until in-depth DSME can be obtained. Appendix M-1: Core Competencies (Survival Skills) for Patients with Diabetes, details the core competency content. Several studies have demonstrated the benefits and the limits of self-management training in type 2 diabetes. Ellis et al. (2004) conducted a systematic review (meta-analysis and meta-regression) of articles published from 1990 through 2000. Twenty-one RCTs with 2439 participants were included. Educational techniques represented included didactic teaching, dictated goal setting, negotiated goal setting, situational problem solving, cognitive reframing, and “other” unique teaching methods. The significant heterogeneity notwithstanding, this meta-analysis indicated that patient education improves glycemic control in patients with diabetes (net change in HbA 1 c was 0.32). Change from baseline to post intervention HbA 1 c was greater for intervention group and was significant for as long as 52 weeks, depending upon the type of analysis used. The meta-regression suggests that several attributes of patient education seem to predict improved glycemic control including face-to-face interaction, cognitive reframing teaching methods, and programs that integrated an exercise component. Norris et al., (2001) reviewed a total of 72 studies and reported a positive effect on knowledge, frequency and accuracy of self-monitoring, self-reported dietary habits, and glycemic control for studies with short follow-up. Effects on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement were sometimes effective in improving glycemic control. No studies demonstrated the effectiveness of self-management training on cardiovascular morbidity or mortality. The American College of Physicians (ACP) Journal Club review of the Norris 2001 systematic review noted that DSME is a broad term that Module M: Self-management Page 109
Version 4.0 VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus includes both effective interventions (collaborative sessions that are repeated) and ineffective interventions (single didactic sessions). A referral for in-depth DSME and diet consultation (if separate from the diabetes selfmanagement program) is recommended for all patients diagnosed with DM. Norris et al. (2002a) reviewed 31 randomized controlled trials (RCTs) that measured the impact of self-management education on adults with type 2 diabetes on HbA 1 c. Self-management education improved HbA 1 c levels at immediate follow-up and increased contact time enhanced the effect. The benefit declined 1 to 3 months after the intervention, however, suggesting that learned behaviors change over time, or that continued follow-up and reinforcement is needed. Davies et al., (2008) reported the results of a multicenter cluster randomized trial involving 824 adults with newly diagnosed type 2 diabetes (55% men, mean age 59.5 years) in 207 general practices in 13 primary care sites in the United Kingdom. The intervention was a six hour, community based, structured group education program provided by two trained healthcare educators and compared to usual care. The intervention resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in HbA 1 c levels up to 12 months after diagnosis. There is some evidence-based work on the effectiveness of MNT. In a 6-month RCT evaluating the impact of MNT on glycemic control, Franz et al. (1995) reported that 94 patients who received 3 ongoing MNT visits from registered dietitians (RD) had a mean 10.5 point lower fasting plasma glucose (FPG) level compared to a 5.3 decrease in 85 patients who had a single visit with an RD and no improvement in 62 patients who did not receive any MNT from an RD. Education may also be given in different modes. See Annotation J. EVIDENCE Recommendation Sources LE QE SR 1 Provision of comprehensive DSME and MNT education. 2 Setting behavioral goals and determining a follow-up schedule with patient. 3 Assessment of patient’s knowledge of DM and understanding about self-care. 4 Provision of specialized referrals when necessary. 5 Education provided in either individual or group settings. Davies et al., 2008 Ellis et al., 2004 Funnell et al., 2009 Colagiuri et al., 2009 Corabian & Harstall, 2001 Miller et al., 2002 Norris et al., 2001, 2002a Rickheim et al., 2002 Garcia and Suarez, 1996 Glasgow et al., 1992 Pascale et al., 1995 DCCT, 1997 UKPDS 24, 1998 Aubert et al., 1998 Franz et al., 1995 Norris et al., 2002b Sikka et al., 1999 Rickheim et al., 2002 Scain et al., 2009 Duke et al., 2009 Raji et al., 2002 I I III II-2 II-2 II-2 III I II-3 I I Good Good Good Good Fair Fair Poor Fair Fair Good Good A B B B B I Good A II-1 II-2 I II-2 I I I I LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A) Fair Fair Good Fair Fair Fair Fair Good B B B B B B Module M: Self-management Page 110
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