Access to Diabetes Education: An AADE Foundation Funded Project

1. Access to Diabetes Education:An AADE FoundationFunded Project Mark Peyrot, PhD MPeyrot@loyola.edu

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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

8. DSME Content

9. 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)

10. 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

11. 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

12. 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

13. DSME Experience and Assessment

14. 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

15. 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

16. 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

17. 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%

18. 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

19. 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

20. 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

21. Barriers to DSME

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Educator Practice & Strategies

29. 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

30. 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

31. 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%

32. 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

33. 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

34. Summary & Implications

35. 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

36. 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

37. 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

38. 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