Evidence of the Month

Commentaries on both new and classic studies of importance for the treatment of diabetes are posted here monthly.

Petra-Maria Schumm-Draeger Klinik für Endokrinologie, Diabetologie und Angiologie Klinikum Bogenhausen Munich, Germany	Click here to download PowerPoint slides of this commentary.
	Click here for the programme evaluation and post-test.

Background
Diabetes self-management education (DSME) is the continuous process of assuring that patients have the knowledge and skills to perform diabetes self-care. It is widely acknowledged to be critical to achieving positive health outcomes, including metabolic control, prevention of short-term and long-term complications, adherence to treatment, lifestyle improvements, better quality of life, and affordability of care (Mensing et al, 2000; Norris et al, 2002). In the United States, DSME is considered so important that increasing its reach, especially to rural, Latino, and less educated populations, is a primary objective of the Healthy People 2010 programme of the U.S. Department of Health and Human Services. The goal is to increase the proportion of individuals who receive formal DSME from 45% (the rate in 1998) to 60% by 2010 (Healthy People 2010).

The structure, process, and outcomes of DSME in the United States have been the continuing subjects of standards authored jointly by organizations including the American Diabetes Association (ADA), American Association of Diabetes Educators (AADE), Centers for Disease Control and Prevention, and U.S. Veterans Health Administration, as well as by individual health professionals and people with diabetes. The current report by Funnell and co-authors, published in January 2008, is a review and revision of evidence-based standards published in 2000 under ADA leadership (Mensing et al, 2000). It does not depart significantly from the format or substance of the earlier standards. Rather, this version serves to advance and strengthen DSME as a strategy for self-determination and individual empowerment.

Methods and Key Results
The 2008 DSME standards were reviewed by a task force formed in 2006 by the ADA and AADE. Task force members considered the appropriateness, relevance, and best scientific basis for the standards according to available evidence and expert consensus.

The revised report maintained the DSME categories of structure, process, and outcomes but added new sections on the definition/objectives of DSME and the guiding principles of the review process. Salient points of these categories are as follows:

Guiding principles—The task force proceeded on the principle that DSME is clinically effective at least in the short term and that it is based on empowering rather than merely teaching individuals with diabetes to maintain self-care. While acknowledging the demonstrated effectiveness of DSME based on behavioural and psychosocial strategies, group education, and programmes tailored to specific cultural and age groups, the task force also asserted that there is no single ‘best’ programme or approach to DSME. Goal setting and ongoing support during DSME were also recognized as critical to effective education.

Objectives—The authors stated that DSME should support informed decision making by individuals with diabetes and promote self-care behaviours, problem solving, and active collaboration with the healthcare team.

DSME structure—The 4 standards for DSME structure address elements in the framework of DSME programmes. Taking its direction from literature on business organization and continuous quality improvement, the task force emphasized the necessity of written documentation of DSME programme policies, processes, goals, commitments, and outcomes. It established the importance of a broad-based advisory group (with health professionals as well as consumers) to promote DSME quality and to assure individualized, culturally relevant programmes. The task force also endorsed needs assessment and resource identification for target DSME populations and stated that a programme coordinator (trained or experienced in healthcare, education, and programme management) is essential to systematic DSME delivery and evaluation.

DSME process—The 4 standards for process address personnel, delivery, and follow-up of DSME programmes. The task force said that DSME should be provided by at least one instructor (a multi-disciplinary team is preferable) who is a registered nurse, dietitian, or pharmacist and who obtains regular continuing education specific to diabetes management (such as certification as a diabetes educator). The instructor(s) should follow a written curriculum that is individualized to the person with diabetes and includes criteria for evaluating outcomes. The instructor(s) and individual should collaborate on needs assessment, specific educational plans, and support strategies, all of which require documentation in the DSME record. A follow-up plan with the goal of sustaining self-management should also be individualized and take shape collaboratively; strategies for follow-up include nurse case management, community-based programmes, and support groups.

DSME outcomes—The 2 standards for DSME outcomes address measurement of goal attainment by the individual with diabetes and the DSME programme itself. The task force emphasized the need for DSME to regularly measure the goals and progress of the individual and to communicate the results to the DSME team and referring provider. At the core of this assessment is the achievement of self-management behaviour such as physical activity, healthy eating, blood glucose self-monitoring, and problem solving. For DSME programme evaluation, the task force emphasized the need to follow a written continuous plan for quality improvement. The goal here is to keep the programme current and responsive to changes in evidence, to assure that the programme is accomplishing its mission and objectives, and to identify improvement projects.

Clinical Implications
The goal of empowering the individual with diabetes has driven DSME development for more than a decade. The idea is to convert DSME from a short-term programme that teaches self-management skills with limited follow-up to a lifelong programme that supports continuous, individualized, accessible self-management interventions. The current DSME update strengthens this approach in several ways. It introduces objectives that repeatedly stress individual autonomy and active collaboration with the healthcare team, it specifically lists the empowerment philosophy in its set of guiding principles, and it incorporates individual-centered and individual-defined parameters.

Several points made by the DSME task force deserve further emphasis, especially from a European perspective. Individualization of ‘targets’ is crucial, as is the implementation of continuous follow-up, which should be guaranteed by the process and infra-structure of the DSME programme. Further, it is well documented that physical activity and lifestyle change are of utmost importance in diabetes management. Although these interventions are basic to any DSME curriculum, they should also be a focus when individualizing targets and in continuous follow-up. In Germany, the empowerment model is less commonly implemented than are ‘structured teaching’ programmes. These are developed by a variety of sources (including diabetes experts, working groups from diabetes associations, university departments, and health insurers) and delivered by individual institutions such as private practices, hospitals, and diabetes academies. There are no national or regional programmes but rather a wide field of ‘homegrown’ programmes directed usually by the general physician, internist, or diabetes specialist and involving a diabetes nurse and nutrition consultant.

Many communities worldwide lack access to formal diabetes education of any sort. Applying empowerment-based DSME requires not only accessibility but opportunities for ongoing education and support regardless of the socioeconomic, educational, or racial circumstances.
The current report points out that community-based programmes, support groups, health community workers, disease management programmes, trained peers, and use of technology have all been effective avenues for providing DSME. The hope is that these and other innovative approaches will be expanded to improve self-determination and self-care for much greater numbers of people with diabetes.