Issue 174 Item 9 Diabetes Self-Management Services Are Underutilized,

Even Where Widely Available Diabetes self-management training is underused in primary care, even where it’s readily available.

Strong evidence shows improved outcomes when diabetic patients are trained in self-management, said Ms. Piatt of the department of epidemiology at the University of Pittsburgh.

“Management of diabetes relies on the patient, outside of provider control. … With chronic illnesses, the role of the provider needs to include providing direct medical care, along with facilitating self-management,” she said.

But shortcomings in this area were seen in a study based on chart audits of all diabetic patients (types 1 and 2) seen at 2 urban academic primary care group practices, 11 suburban practices (7 group, 4 solo), and 1 rural practice.

Referral for diabetes self-management training (DSMT) by a diabetes educator was recorded in 9% of the 762 patients seen in the suburban setting, 6% of 322 patients in the urban practices, and none of 104 patients in the rural practice.

The absence of referrals for DSMT in the rural community can be attributed to lack of access to services, but that is not the case for the suburban or urban communities.

The study also showed low rates for counseling by the physician regarding nutrition and physical activity, as indicated by any chart notation such as “ADA 1,800-calorie diet,” or “Patient asked to walk three times per week.” The highest rate, 57%, was for nutrition counseling in the urban practices, followed by 47% for physical activity counseling. In the suburbs, those rates were 38% and 23%, respectively. In the rural practice, 7% of charts reflected any mention of nutrition counseling and 3% indicated any counseling on physical activity, Ms. Piatt reported.

A second part of the study examined the physicians’ attitudes toward DSMT. All participating physicians took the Diabetes Attitude Scale, which comprises five subscales: Need for special training, perceived seriousness of type 2 diabetes, value of tight glucose control, psychosocial impact of diabetes, and patient autonomy.

Using a scale of 1 (strongly disagree) to 5 (strongly agree), physicians in all three communities scored relatively high on the need for training, seriousness, and psychosocial subscales. Agreement on the value of tight glucose control was slightly lower, ranging from 3.9 in the suburbs to 4.1 in the urban academic setting.

The statement “People with diabetes should have the final say in setting their own blood glucose values” drew exceptionally low agreement, with scores ranging from 3.2 among the urban physicians to 1.7 in the rural practice. Other statements scoring somewhat higher included “People with diabetes have a right to decide how hard they will work to control their blood sugar”, and “People with diabetes should learn a lot about the disease so they can be in charge of their own diabetes care”.

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