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Access to Diabetes Education: An AADE Foundation Funded Project. Mark Peyrot, PhD [email protected] Study Purpose and Approach. To investigate factors associated with patients’ obtaining DSME Multi-focus approach Supply side issues – availability of DSME

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study purpose and approach
Study Purpose and Approach
  • To investigate factors associated with patients’ obtaining DSME
  • Multi-focus approach
    • Supply side issues – availability of DSME
    • Demand side issues – physician referral to and patient consumption of DSME
  • Multi-constituency approach
    • Educators, physicians, patients
study design
Study Design
  • Two-phase design
    • Telephone focus groups (2 each for patients, educators, physicians)
    • Internet surveys (patients, educators, physicians)
  • Parallel questions asked of all constituencies where appropriate
  • Today’s presentation focuses on preliminary survey results (surveys still in progress when data pulled)
survey topics
Survey Topics
  • Nature of DSME received by patients (according to reports of each constituency)
  • Perceptions of DSME
    • Impact, satisfaction, perceived quality
  • Barriers to obtaining DSME
    • Physician and patient beliefs, organizational factors
  • Strategies for enhancing access/demand
    • New services, new sources, increased recruiting
patient sample
Patient Sample
  • Sample drawn from community survey panel
  • Quotas = minimums of 500 who have and 500 who have not had DSME course/class
  • N = 1169 adults with physician diagnosed diabetes (self-report)
  • 85% RX, 69% OHA, 27% insulin (~10% Type 1)
  • Mean age = 55, 57% men, 89% white, 59% college degree, 96% insurance coverage
  • 44% no DSME, 26% only at DX, 24% multiple
educator sample
Educator Sample
  • Respondents drawn from full AADE membership
  • N = 1672, no quotas or exclusions
  • 65% nursing, 28% dietitian/nutritionist
  • Approximately equal # see patients 1-10, 11-20, 21-30 and 30+ hrs/wk
  • 48% hospital setting, 14% physician office, 13% independent/free-standing
  • Median monthly DSME population ~ 90
  • Mean facility maximum DSME population ~ 95
physician sample
Physician Sample
  • Sample drawn from physician panel
  • Exclusion = <5 DM Pt/mo, <75% clinical practice
  • Quotas = 400 PCP, 200 Endo/Diabetology
  • N = 629
  • 39% FamPrac, 27% Gen/Int Med, 34% Specialist
  • Median monthly DM population ~ 75
dsme content1
DSME Content
  • Parallel questions asked of patients, educators, physicians regarding DSME “course/class”
    • Patients: Did your education include…
    • Educators: What % of your DSME patients receive …
    • Physicians: What % of your patients that you refer for DSME do you want to receive …
  • PCP more likely than Endo to want topics covered (8/14 p<.05)
  • For patients, DSME at DX more likely than for most recent repeat (8/14 p<.05)
dsme content2
DSME Content

Pt Ed MD

  • What diabetes is 74 90 83
  • How diabetes causes complications 68 89 83
  • How diet/exercise help manage DM 74 95 90
  • How meds help manage DM 53 88 77
  • How SMBG help manage DM 64 94 84
  • How to SMBG 60 77 84
  • How to administer insulin 20 41 71
  • How to self-adjust insulin 13 32 65
dsme content cont d
DSME Content (cont’d)

Pt Ed MD

  • Create a personal diet plan 66 72 84
  • Create a personal exercise plan 48 65 76
  • Create a personal glucose monitoring plan 46 80 77
  • Create a personal medication regimen 34 58 64
  • Use behavior change strategies 42 82 78
  • Develop strategies for coping with diabetes 45 78 79
dsme content summary
DSME Content: Summary
  • Educators report content covered more often than patients report
    • May represent different populations
    • Patients may nor recognize/remember
    • Large gaps for coping and behavior change strategies
  • Educators report content covered more often than physicians want it covered
    • Exception: Physicians want self-management support topics covered more than educators report covering them
dsme providers at dx
DSME Providers at DX

%

  • A diabetes educator 47
  • A diabetes clinic/DSME program 37
  • My family doctor 20
  • A diabetes specialist doctor 17
  • A person from product’s company 2
  • Median program exposure = 3-4 hours
    • Educators > Physicians
most recent dsme patient report
Most Recent DSME:Patient Report
  • Impetus/referral %
    • Family doctor 39
    • DM specialist doctor 25
    • Patient 24
    • Other 12
  • Occasion/reason
    • Wanted to learn more 40
    • Got a new doctor 19
    • Diabetes got worse 17
    • Started new Rx 12
dsme experience physician report
DSME Experience:Physician Report
  • 42% have a diabetes educator in their office/practice
  • 37% of patients receive 2 or more hours of DSME in office/practice
  • 45% of patients receive an out-referral for DSME
  • 66% of patients out-referred actually obtain DSME externally
  • Physician satisfaction (0-100 scoring) = 66
dsme assessment 0 100 scoring or
DSME Assessment(0-100 scoring or %)
  • Patients very interested in initial DSME 33%
    • (If interested) Pt intend to get DSME = 42%
  • Patient satisfaction – DSME at DX 72
  • Patient satisfaction – most recent DSME 73
  • More DSME would benefit Pt (some/lot) 43%
  • Pt did recommend DSME to another Pt 36%
    • (If no) Pt would recommend = 85%
  • Pt discussed DSME with own physician 56%
impact of dsme on care
Impact of DSME on Care

%

  • Changed my personal family doctor 9
  • Changed my DM specialist doctor 3
  • Started seeing a DM specialist doctor 13
  • Started seeing another specialist 18
  • Started seeing a dietitian 10
  • Started seeing an educator regularly 4
  • Any of the above 47
perceived quality of dsme by source and respondent type 0 100 scoring
Perceived Quality of DSME by Source and Respondent Type(0-100 scoring)

Pt Ed MD

  • Patient’s personal doctor 58 26 71
  • DM specialist physician 8264 72
  • DSME program/provider 84 92 80
  • Lay health care worker 46 25 39
  • The Internet 47 35 34
  • CD used on a computer at home 51 38 40
  • DVD/videotape at home 52 39 42
  • Books/magazines 51 42 39
  • Pamphlets/brochures 47 41 42
dsme experience and assessment summary
DSME Experience and Assessment: Summary
  • Minority of patients without DSME want it
  • Patients somewhat satisfied with DSME, minority see substantial benefit from more
  • Almost half of patients changed their health care as a result of DSME
  • Minority have recommended DSME to another patient, but most would if opportunity arose
  • Educator/program rated as highest quality DSME provider
    • DM specialist physician & DSME program tied in patient view
    • DE and MD rate Lay HCP and media lower than patients do
barriers to dsme use
Barriers to DSME Use
  • Parallel questions to patients, educators, physicians
    • Patients who did not follow through on referral to DSME asked whether factors were barriers; % who said “yes” is presented here
    • Educators and physicians asked how important factor was as barrier to DSME; % who said “very” is presented here
barriers to dsme use1
Barriers to DSME Use

Pt Ed MD

  • Pt doesn’t think it’s needed 45 51 28
  • Can’t fit into schedule 38 29 19
  • Insurance would not cover 21 55 62
  • Too expensive 11 38 46
  • Don’t know where to get it 2 29 14
  • No way of getting there 2 25 12
barriers to dsme use educator reports 0 100 for importance
Barriers to DSME Use: Educator Reports (0-100 for importance)
  • MD do not tell Pt DSME important 74
  • MD do not recognize program quality 55
  • MD do not want to lose control of Pt 54
  • MD do not know referral procedure 51
  • MD do not believe DSME works 48
  • MD do not know where to get DSME 44
  • Lack of financial support 60
  • Lack of clerical support 53
  • Lack of administrative support 51
physician beliefs about dsme disagree 0 agree 100
Physician Beliefs about DSME(Disagree = 0, Agree = 100)
  • Pts are told to do things I do not want 46
  • My Pts not interested in DSME 41
  • Have not enough DSME referral sources 41
  • Referral procedure is not easy 34
  • DSME programs not have quality I want 28
  • I lose Pts who attend DSME 26
  • I do not get Pts to see DSME importance 22
  • Do not know procedure for referral 19
  • Do not believe DSME works 17
patient beliefs about dsme disagree 0 agree 100
Patient Beliefs about DSME(Disagree = 0, Agree = 100)
  • My doctor tells me what I need to know 45
  • I already know everything I need to 35
  • My doctor doesn’t think it’s important 32
  • Don’t need it because I don’t have problems 25
  • DSME would not help me care for DM 19
  • DSME only for Pts on insulin 16
barriers to dsme summary
Barriers to DSME: Summary
  • Physicians and (more so) educators tend to overestimate patient barriers
    • Exception: Both (MD more so) underestimate patient scheduling issues
    • Exception: Educators accurate & MD under-estimate patient perceived need for DSME
  • Educators overestimate physician-reported barriers
change in patients seen
Change in Patients Seen
  • Recent change in # patients seen
    • Increase = 77%, decrease = 11%, stable = 13%
  • Reasons for increase/decrease (%)
    • Change in number of staff 21/18
    • Change in physical facilities 12/11
    • Changes in patient reimbursement 11/48
    • Changes in # of physician referrals 77/55
    • Changes in # of Pt self-referrals 44/16
strategies to increase patients seen new programs services
Strategies to Increase Patients Seen: New Programs/Services

(% making change; increased pt seen 0-100) % Inc

  • Any new program/service 75
  • New times of day 52 52
  • New days of the week 47 48
  • Changes in program format 57 57
  • Technology-based delivery 44 48
  • More extensive 54 58
  • Specific populations 52 52
  • New populations 43 47
  • Considering new program/service 60
strategies to increase patients seen recruitment
Strategies to Increase Patients Seen: Recruitment

Effort to Increase Recruitment

None Little/Some Lot

10% 62% 28%

Impact on # patients

seen (0-100) 42 67

Considering new recruitment efforts = 59%

likelihood of dsme use by respondent type and source 0 100 scoring
Likelihood of DSME Use by Respondent Type and Source(0-100 scoring)

Pt Ed MD

  • Patient’s personal doctor 68 70 86
  • DM clinic/center 71 81 74
  • Freestanding DSME program 63 73 62
  • Mobile van 33 59 42
  • Neighborhood community setting 36 67 52
  • The Internet 59 51 48
  • CD used on a computer at home 52 42 40
  • DVD/videotape at home 50 44 43
  • Books/magazines 52 51 44
  • Pamphlets/brochures 49 52 50
educator strategies
Educator Strategies
  • Most programs have grown recently
  • Many strategies (new programs/services and recruitment) have been used
  • All strategies are judged successful
  • Most programs plan more efforts
  • Patients do not like community settings as much as physicians & educators believe
  • Patients prefer traditional sources and media for DSME
methodological limitations
Methodological Limitations
  • Sample representativeness
    • Patient and physician samples designed for analytic purposes, not representativeness
    • Patient sample under-represents minorities & lower SES, over-represents medication users
    • Physician sample may over-represent those favorable toward DSME
    • Educator sample may over-represent successful programs (self-selection)
  • Youth with DM and/or parents not included
summary of findings
Summary of Findings
  • Paradox: Physicians want more self-management support, but complain that patients are told to do things they do not agree with
  • DSME is highly regarded among those who have received it, but not as much among those who have not received it
summary of findings1
Summary of Findings
  • Educators rate patient barriers somewhat above physician and organizational barriers, and see physicians as key to encouraging DSME use in patients
  • Most DSME programs have grown recently as a result of adding new programs/services and recruiting efforts and most programs plan more efforts
conclusions
Conclusions
  • Increasing DSME access requires a multi-faceted approach
  • Additional analysis required to determine:
    • The contribution of different barriers to restriction of DSME access
    • The contribution of different marketing strategies to increase or decrease in patient population
    • Are different strategies effective in different contexts
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