Nursing Research

119The Journal of Continuing Education in Nursing · Vol 51, No 3, 2020

Improving Glycemic Control and Quality of Life With Diabetes Self-Management Education: A Pilot Project Djurdja Andrich, DNP, ARNP, FNP-C; and Cynthia Foronda, PhD, RN, CNE, CHSE, ANEF

Type 2 diabetes mellitus (T2DM) and associated complications are leading causes of death in the United States (American Diabetes Association [ADA], 2017). T2DM is a prominent chronic disease in the United States, with the total medical cost of diagnos- ing and treating diabetes exceeding $245 billion per year (Centers for Disease Control and Prevention, 2015). In 2012, the ADA (2017) reported 29.1 million Americans had T2DM, representing 9.3% of the overall population. Estimates indicate as many as 25.9% of American older

adults age 65 and older have T2DM (ADA, 2017). T2DM and its related complications present major so-

cial and economic burdens for society, and 1.4 million new cases of T2DM are diagnosed every year (ADA, 2017). Despite new pharmacological innovations and advances in diabetes research, only 14.3% of patients with diabetes are at their glycemic goal (ADA, 2017). The ADA and the American Association of Clinical Endocrinologists re- leased standards of care for individuals with T2DM, and both of these standards include DSME/S at their core (Powers et al., 2015).

The patient-centered care aspect of DSME/S relies on five guiding principles of patient engagement. These guid- ing principles are: (a) information sharing, (b) psychoso- cial support, (c) behavioral support, (d) multidisciplinary integration of care, and (e) care coordination (Powers et al., 2015). This practice change initiative integrated all of these aspects in the care of patients with T2DM, specifi- cally targeting patients age 65 and older. The behaviors in- volved in DSME/S are culturally sensitive, dynamic, and multidimensional, which play a significant role in setting goals and developing a plan of care (Powers et al., 2015). In this context, each patient received specific, individual- ized, and attainable goals to follow for a period of 4 weeks and beyond.

abstract Diabetes self-management education and support

(DSME/S) has been demonstrated as an effective inter- vention and a billable service; however, DSME/S has yet to be successfully translated and diffused into main- stream practice. This project sought to improve glyce- mic control (measured by A1C or fasting blood glucose [FBG]) and quality of life (QOL) of Medicare patients age 65 years and older with type 2 diabetes (T2DM) using DSME/S. DSME/S included information sharing between patients and providers, psychosocial support, behavioral support with lifestyle modification, multi- disciplinary integration, and care coordination. Patient- specific data were compared before and 4 weeks after project implementation. Use of DSME/S increased by 15% (p < .005). Participants demonstrated a statisti- cally significant decrease in mean FBG and a statisti- cally significant increase in QOL. This project demon- strated the successful translation of evidence related to DSME/S into practice through improving diabetes care and promoting continuing education for all of the providers. [J Contin Educ Nurs. 2020;51(3):119-123.]

Dr. Andrich is Cardiovascular and Metabolic Clinical Science Liaison, AstraZeneca Medical Affairs, Zionsville, Indiana, and Dr. Foronda is Associate Professor of Clinical, University of Miami School of Nursing and Health Science, Schwartz Center for Nursing and Health Studies, Coral Gables, Florida.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Djurdja Andrich, DNP, ARNP, FNP-C, Cardiovascular and Metabolic Clinical Science Liaison, AstraZeneca Medical Affairs, 7379 Fox Hollow Ridge, Zionsville, IN 46077; e-mail: [email protected].

Received: November 1, 2018; Accepted: September 23, 2019 doi:10.3928/00220124-20200216-06

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DSME/S is the foundation for diabetic patient-cen- tered care and assists individuals with diabetes in manag- ing their disease and lifestyle choices to improve health outcomes (Powers et al., 2015). The overall objectives of DSME/S are to ensure “informed decision making, self-care behaviors, problem solving, and active collabo- ration” among all members of the health care team to achieve optimal health status and a better quality of life (QOL) (Powers et al., 2015). The ADA (2017) includes DSME/S in standards of care for all individuals with dia- betes either at the time of initial diagnosis or as needed thereafter. DSME/S is effective in reducing overall health care costs associated with diabetes and diabetes-related complications, and offers the opportunity for the U.S. health care system to save money and improve care (Rob- bins, Thatcher, Webb, & Valdmanis, 2008).

Diabetes education has been associated with improved glycemic control as well as with overall health status. Research suggests incorporating practical and feasible educational sessions in diverse settings among patients with diabetes will enhance their glycemic control, with A1C reduction ranging from 0.5% to 1.2% (Chrvala, Sherr, & Lipman, 2016; Gold et al., 2008; White, Man- ning, Brawer, & Plumb, 2014). Patients who effectively engaged in carbohydrate counting or portion control achieved modest weight loss that may have contributed to improved glycemic control and likely contributed to overall health status improvement (Bowen et al., 2016). For DSME/S to be beneficial in achieving glycemic con- trol and desired QOL, it must occur initially on T2DM diagnosis followed by ongoing DSME/S sessions through community programs or provider follow-up visits (Tang, Funnell, & Oh, 2012).

The purpose of this project was to improve glycemic control and QOL of Medicare patients age 65 years and older with T2DM. The project aims were to: • Develop a brochure based on the literature to facilitate

DSME/S implementation. • Make the Algorithm of Care (ADA, 2017) available to

providers to facilitate DSME/S. • Increase providers’ utilization of DSME/S. • Improve patients’ fasting blood glucose (FBG). • Improve QOL for patients with T2DM. • Improve revenue generation for the practice in the long

term (not assessed in this project).

METHOD This practice improvement project used a pretest-

posttest design implementing principles of quality im- provement to assess FBG and QOL. The Plan-Do-Study- Act (PDSA) cycle was used as a framework to guide the project (Institute for Healthcare Improvement, 2019).

The project protocol was submitted to the University of Miami Human Subjects Research Office where it was reviewed and was deemed not to be human subjects re- search; therefore, Institutional review board approval was not required.

Eligible Medicare patients age 65 and older with T2DM in an endocrinology clinic participated in this project during their 3-month follow-up visit for diabetes management. Only patients who had a preexisting T2DM diagnosis with A1C at or greater than 7% (53 mmol/mol) were included. Patients interested in participating in this project provided verbal consent and agreed to follow up in 4 weeks.

Diabetes self-management education, support, and goal setting sessions were conducted during a 3-day pe- riod at the clinic, and participants engaged in one ses- sion only. Each session included: information sharing about disease management, psychosocial support as it relates to disease management, behavioral support in managing T2DM including glucose monitoring, diet, and lifestyle modification, multidisciplinary integra- tion of care, and care coordination including referrals to an optometrist, registered dietician, or podiatrist as needed.

Patients participated in a 20-minute DSME/S and goal setting session at baseline when preintervention data were collected. Baseline assessment included A1 and FBG levels for the previous week, and the Diabetes-39 (D-39) scale. Patients brought records of their FBG levels from a week prior to their office visit in either a written form or record- ed in their glucose monitors. Patients also were provided with appropriate referrals at that time, if needed. FBG lev- els also were collected after 4 weeks through patient blood glucose monitoring at home. All data were collected by one of the researchers.

Diabetes-specific QOL was assessed using the D-39 scale, which was administered by one of the researchers. The D-39 scale was developed in 1997 based on the pool of items from the QOL 92-item scale (Boyer & Earp, 1997). The scale addressed energy and mobility, diabetes control, anxiety and worry, social burden, and sexual func- tion. Each domain received a raw score, which was further transformed to a 0 to 100 scale using a linear transforma- tion. Lower scores indicate better QOL. Cronbach’s al- pha for the individual domains of D-39 scale ranged from 0.81 to 0.92. QOL was assessed in person at baseline and via telephone 4 weeks after DSME/S. Permission to use the scale was obtained from the author of the scale (Dr. J. Gregory Boyer).

Providers at the clinic received in-service education on DSME/S and the ADA Standards of Medical Care in Diabetes algorithm (ADA, 2017) to facilitate the proj-

121The Journal of Continuing Education in Nursing · Vol 51, No 3, 2020

ect and continue implementation of DSME/S after the initial data collection period. The in-service education included evidence-based recommendations on DSME/S use, project goals and project plan, written material such as a brochure and algorithm of care, and cost analysis with reimbursement opportunities for DSME/S. Provid- er use of DSME/S was assessed pre- and postinterven- tion by reviewing 40 charts of patients who were seen at the clinic during baseline data collection and at follow- up. These 40 charts did not include the 24 patients who participated in this project. The long-term goal for the project was increased revenue generation for the practice due to implementation and billing for DSME/S. How- ever, revenue generation was not assessed as a part of this project.

Data Analysis Data were analyzed using IBM® SPSS® version 25.0

statistical software. Descriptive statistics were used to re- port demographic data and utilization data. Because FBG levels were normally distributed pre- and post-DSME/S, means were compared using a dependent sample t test. For QOL, scores for each domain were not normally distrib- uted; therefore, mean scores for pre- and post-DSME/S were compared using Wilcoxon signed rank test (p < .05). Z scores were based on negative ranks. There was no over- all QOL score; instead, scores for each domain were re- ported.

RESULTS The demographic characteristics of the participants are

summarized in Table 1. A total of 24 patients were ob- served for a period of 4 weeks. All 24 participants com- pleted the project. The majority of participants were male (62.5%). Average age of participants was 74 years (SD = 6.4). All participants had a diagnosis of T2DM with an average duration of 7.5 (SD = 5.4) years and an average A1C of 7.7% (61 mmol/mol) (SD = 0.8).

Provider Utilization Based on the review of 40 charts, utilization of DSME/S

was 20% prior to this project. Compliance with using DSME/S increased to 35% after the DSME/S practice change initiative. This increase did not meet the objective of increasing utilization to 50%; however, the increase was statistically significant (p < 0.05).

Fasting Blood Sugar The decrease in mean FBG levels pre- and postinter-

vention was statistically significant (p < 0.05). Baseline and postimplementation data are summarized in Table 2.

Quality of Life Overall QOL improved following DSME/S. The dif-

ference was statistically significant for patients’ mean scores in diabetes control, anxiety and worry, social bur- den, sexual functioning, and energy and mobility. Baseline and postimplementation data are summarized in Table 2.

DISCUSSION This project demonstrated the successful implementa-

tion of an ARNP-led DSME/S program. The approach of translating the evidence from the existing research to spearhead this practice change initiative led to significant improvements in staff adoption, improved patient FBG level, and importantly, improved patient QOL. As the science of improved self-care management continues to evolve, nurses can anticipate further development and growth of these programs in the future.

The findings of this study indicate DSME/S signifi- cantly improved FBG levels. The number of patients who participated in this practice improvement initiative (N = 24) was small enough to allow individualized attention and support. Information sharing, psychosocial support, and behavioral encouragement were provided on a weekly basis or more often as needed. More providers need to be educated on how to properly bill for their services, which will serve as an incentive to allocate more time and re- sources for DSME/S. Therefore, practice protocol changes combined with billing practices must be put in place to support DSME/S and further improve outcomes of pa- tients with diabetes.

Diabetes self-management education and support is a billable service. The reimbursement opportunities re- quire the creation of a care plan that is patient-centered and comprehensive, and includes behavioral and mental health (U.S. Department of Health and Human Services [USDHHS], 2015). In addition, the care plans need to

TABLE 1

DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS (N = 24)

Characteristic n

Gender

Female (%) 9 (37.5)

Male (%) 15 (62.5)

Age, mean (SD), y 74 (6.4)

T2DM duration (y), mean (SD) 7.5 (5.4)

A1C level, mean (SD) 7.7% (0.8)

Note. T2DM = type 2 diabetes mellitus.

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be accessible to patients electronically, such as through a mobile app or patient portal and documented in the elec- tronic medical record (USDHHS, 2015). This is a step forward for this endocrinology practice in reaching all patients with diabetes and implementing DSME/S more effectively and efficiently.

Evidence demonstrates DSME significantly improves QOL in patients with diabetes, and this project reinforces this notion. Achieving set goals such as lowering FBG im- proves patients’ perceived diabetes control, self-esteem, and energy level (Tang et al., 2012). Patients who par- ticipated in this project experienced improved scores in all five aspects of the D-39 scale. Patients reported statis- tically significant increases in perceived diabetes control, lower anxiety and worry, lower sense of social burden, and increased energy and mobility. Although statistically significant improvement was observed in the sexual func- tioning domain, this improvement was not as drastic as in the other four domains. This may be due to the short pe- riod of observation or to altered sexual functioning caused by issues other than diabetes.

DSME/S is a continuous process that involves ongoing assessment and continued support. Although DSME/S has been shown to be beneficial in this project, its dura- tion of only 4 weeks does not provide information regard- ing the sustainability of this intervention. Patients must be actively engaged in their diabetes management through shared decision making, patient-centered care, and col- laboration (Powers et al., 2015). For DSME/S to be the most beneficial in achieving glycemic control and desired QOL, it should occur initially on diabetes diagnosis and then followed by ongoing DSME/S sessions through com- munity services or provider follow-up visits (Tang et al., 2012). Therefore, the 4-week duration was a limitation for this practice initiative project. In addition, the full benefits

of DSME/S, evaluating A1C, could not be observed until 3 months after project implementation; this was a limita- tion due to time constraints.

IMPLICATIONS FOR CONTINUING EDUCATION This project provides recommendations on incorpo-

rating DSME/S more effectively during diagnosis and follow-up of patients with diabetes. Key impacts of the project include an improvement in providers’ understand- ing, attitude, and perception of DSME/S as evident by their effective utilization of DSME/S recommendations for glycemic control and QOL improvement. This can be achieved only through continuing education and keeping abreast with new guidelines and innovations.

Another key component is educating providers on government agencies that promote and support diabetes education and prevention. The Florida Department of Health (DOH) advocates for quality DSME/S programs that are aligned with recommended national standards (Florida Diabetes Advisory Council, 2017). The Florida DOH also provides awards to organizations that want to develop framework for obtaining ADA recognition or American Association of Diabetes Educators accreditation (Florida Diabetes Advisory Council, 2017). This is a great opportunity for improving diabetes care, increasing prac- tice revenue, and promoting continuing education for all providers, including ARNPs.

CONCLUSION The effectiveness of DSME/S has been demonstrated in

the literature. This practice improvement project showed increasing utilization of DSME/S improved patients’ gly- cemic control and QOL. Although the duration of the project was not long enough to evaluate sustainability of this practice change initiative, the significant increase in

TABLE 2

ASSESSMENT DATA AT BASELINE AND AFTER DSME/S INTERVENTION (N = 24)

Assessment Baseline, Mean (SD) Post-DSME/S, Mean (SD) t score/z score p

FBG level (mg/dL) 146.2 (18.7) 136 (17.1) 6.351 .000

Quality of life

Diabetes control 68.3 (10.5) 59.8 (10.0) -4.017a .000

Anxiety and worry 51.3 (15.8) 43 (14.0) -3.799a .000

Social burden 21 (5.4) 18.3 (4.8) -3.103a .002

Sexual functioning 44.2 (19.6) 42.6 (17.4) -2.032a .042

Energy and mobility 60 (13.0) 47.6 (12.2) -3.819a .000

Note. FBG = fasting blood glucose. a z score based on negative ranks.

123The Journal of Continuing Education in Nursing · Vol 51, No 3, 2020

utilization of DSME/S was promising. During this 4-week project, patients demonstrated suc-

cess in significantly lowering their FBG. They followed recommendations as per DSME/S and demonstrated the effectiveness of these guidelines in improving glyce- mic control. QOL was assessed using the five domains of diabetic control, anxiety and worry, social burden, sexual functioning, and energy and mobility, with all areas be- ing affected positively. These aspects are vital in assessing life satisfaction of patients with diabetes as diabetes affects many aspects of an individual’s personal and social life. DSME/S was beneficial during the 4-week implementa- tion period; however, sustainability of DSME/S success would require assessment for a period of 3 months or lon- ger.

DSME/S plays a vital role in achieving desired glyce- mic control and QOL for patients with T2DM; however, evidence shows DSME/S is not used effectively in prac- tice. This practice change initiative was one small step in trying to increase DSME/S utilization in an endocrinol- ogy practice. Making providers aware of the reimburse- ment potential and health benefits of DSME/S should help make DSME/S a priority in diagnosis and treatment.

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