Ongoing education key to diabetes control
Self-management could cut costs by 50%
Diabetes education is key to controlling acute exacerbations of diabetes, but not all education works equally well. The education must be part of the patient's medical therapy.
"Diabetes education has to be an actual extension of the physician's care, not a piece that is added on to the care," says Stanley Feld, MD, FACE, MACE, past president of the Jacksonville, FL-based American Association of Clinical Endocrinologists (AACE).
The AACE recommends a system of intensive-diabetes self-management in which the patient follows a program of nutrition, exercise, medication, and self-monitoring with the guidance of a physician-led diabetes team. "The patient, physician, diabetes educator, dietitian, and pharmacist have to work together," explains Feld. To alert physicians, health care professionals, and diabetes patients to this concept, the association launched a campaign in June 1998, Patients First '98: You Can Do It!
The campaign was initiated following the results of two studies that used the intensive diabetes self-management approach to educating patients. Feld compiled data on 586 of his patients with Type II diabetes over a period of 1½ years and found that patients involved in this intensive education process were able to reduce their average glycosylated hemoglobin level (a measure of the body's long-term ability to control blood sugar) to 6.88%.
The findings were significant because in 1993, a trial sponsored by the Bethesda, MD-based National Institutes of Health predicted that, on average, patients who achieve near normal glycosylated hemoglobin levels of about 7% can decrease complications more than 50%, delay the onset of complications 15 years, and increase life span five years.
Richard Hellman, MD, FACE, studied 708 of his patients with both Type I and Type II diabetes over 14 years. He compared 209 of his patients who stayed in intensive diabetes self-management a median of 11 years, with 571 patients who were in such care for less than a year. When he examined the rate of death for patients who were under age 65 at the start of his study, he found a 48% lower death rate after 14 years for those who remained in a system of intensive diabetes self-management compared to the rate for those who did not.
The annual cost of treating diabetes is $120 billion nationally. The cost is high because patients with diabetes have complications such as heart disease or kidney problems, says Feld. "If we could effectively teach patients how to get their blood sugars normal, we could decrease the complication rate by more than half and reduce the cost," he explains.
Education must be individualized
Blood glucose levels can only be controlled if education is part of the medical therapy, because diet, exercise, and medications affect the blood glucose levels of each patient differently. Patients must learn what they need to do to control their blood sugar; it is not a one-size-fits-all education approach. "It is important that patients be empowered to take care of themselves," says Feld.
When several physicians with diabetes patients are located in the same clinic, a diabetes education team can be conveniently located at the clinic. The team would work with the patient following his or her physician appointment. The physician would provide instructions on what needs to be taught.
Physicians that don't have an education team available can work with diabetes education centers at a hospital directing the patient's education, notes Feld. "It has to be an extension of the doctor's care. It can't be a separate caregiving entity that has nothing to do with the physician," he says.
To help motivate both the patient and physician, the AACE developed a patient-physician contract. The contract reaffirms the patient's commitment to a system of nutrition, exercise, medication, and self-monitoring, and the physician's promise to provide leadership for the diabetes team. The contracts can be downloaded off the association's Internet site or by calling a toll-free number. (For details, see editor's note at the end of this article.)
The association also is working on an Internet program that will enable patients and their physicians to consult on-line between office visits. Patients monitoring their blood glucose levels and other medical information at home can e-mail the results to their physician and receive feedback.
"Diabetes education has to be a continuum of care where physicians are constantly bothering patients to take care of themselves. It can't be a one-time teaching process," says Feld.
For more information on the Patients First '98 campaign, contact:
American Association of Clinical Endocrin- ologists, 1000 Riverside Ave., Suite 205, Jacksonville, FL 32204. Telephone: (888) 50-SUGAR. Web site: http://www.aace.com.
Stanley Feld, MD, FACE, MACE, Past President of the American Association of Clinical Endocrin- ologists, 7310 Hillwood Lane, Dallas, TX 75248. Telephone: (972) 233-3057. Fax: (972) 233-3057. E-mail: [email protected].
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