Gaps in diabetes care identified

Jun 17 2007

A symposium, sponsored by the American Journal of Nursing (AJN) in collaboration with the American Diabetes Association, the American Association of Diabetes Educators, Joslin Diabetes Center and the University of Pennsylvania School of Nursing identified barriers to, and strategies for, more effective diabetes self management and reaffirmed the nurse's critical role to facilitate better patient self care.

These results are published in a special supplement to the June issue of AJN.

"We as health care professionals expect a lot from people with diabetes," said Katie Weinger, EdD, RN, co-editor of the report, director of the Center for Innovation in Diabetes Education and the Office of Research Fellow Affairs at Joslin Diabetes Center and an assistant professor at Harvard Medical School, Boston. "They need to follow a structured meal, exercise and medication regimen. Newer treatments to prevent complications can make self-care even more complex causing even the most conscientious patients frustration and leading clinicians to think that they are not properly managing their care."

For the nearly 21 million Americans who have diabetes1, and estimated 39 million who will have it by the year 20502, the challenge is to juggle the many aspects of their lives with the demands of therapy. The Agency for Healthcare Research and Quality (AHRQ) estimates that costs during 2001, for in-patient treatment of patients with complications from diabetes, were almost $3.8 billion. AHRQ also estimates that two-thirds of this amount ($2.5 billion) were for preventable conditions.

"For those with diabetes and conditions like depression, heart disease or retinopathy, self-care can be even more challenging," said Jane Jeffrie Seley, MPH, MSN, NP, CDE, co-editor of the AJN report and diabetes nurse practitioner at New York Presbyterian-Weill Cornell Medical Center, NYC. "Someone who is depressed may be less likely to perform self-care. Poor vision makes it hard to measure the correct amount of insulin. Those with multiple disorders may have to contend with additional dietary restrictions and medications. Poverty, a patient's literacy and health insurance can further complicate the situation."

The symposium, "State of the Science on Nursing Best Practices for Diabetes Self-Management," was held in Philadelphia. The planning committee included representatives from the American Journal of Nursing (AJN), American Association of Diabetes Educators, American Diabetes Association, Joslin Diabetes Center in Boston and University Of Pennsylvania School Of Nursing. The 50 participants were nurses and representatives from other health care disciplines including: nutrition, pharmacy, psychology, government health, research and regulatory agencies and the pharmaceutical industry. The following are some of the identified barriers to, and strategies for, diabetes self-care:

Barriers to Optimal Patient Care and Strategies to Overcome Them

• Difficulty navigating the health care system
  • Provide information and support to help patients and use a "patient navigator" to help patients and families work their way through the healthcare system.
• Diagnosis of diabetes does not automatically lead to self-management education
  • Make a referral for diabetes self-management education a standard component of care.
  • Develop a process for tracking it in the inpatient or outpatient setting.
• Time to see provider is limited; episodic versus comprehensive focus (acute versus chronic care)
  • Use time in the waiting or examination room for education, incorporating audiovisual and creative techniques (such as computer-assisted education).
  • Prioritize visit time on the basis of the patient's concerns and health care needs.
• Patient education is undervalued by the health care system and payors
  • Create a public relations awareness campaign for all stakeholders.
  • Promote grassroots advocacy to support reimbursement for diabetes education programs.
  • Conduct research to determine the cost-effectiveness of patient education.
• The complexity of diabetes education
  • Identify the components of diabetes self-management education (such as behavioral goal setting, skill training).
  • Develop and disseminate evidence-based approaches to delivering education programs and teaching self-management skills.
• Low level of health literacy
  • Assume a low level of health literacy when choosing and developing educational materials.
  • Use other media (such as DVDs) in addition to print.

"With diabetes and prediabetes continuing to grow at unprecedented rates, addressing the disease as a public health concern is critical," said Ann Albright, PhD, RD, president, Health Care & Education for the American Diabetes Association and the director of the Division of Diabetes Translation, Centers for Disease Control and Prevention. "For people with diabetes, it is important to evaluate medical, lifestyle, family, psychosocial, cultural and economic issues. Assessment and monitoring of diabetes through surveillance data collected at the national, state and county levels are all necessary steps in defining and ultimately reducing the burden of this major health problem."