There's a cost-efficient, effective treatment for diabetes that is significantly underused in the United States today, both in and outside of the hospital.
“We know that it can dramatically improve hemoglobin A1c. In fact, the reduction shown in meta-analysis is far greater than what's required to approve a drug by the FDA,” endocrinologist and ACP Member Robert Gabbay, MD, PhD, told attendees at the American Diabetes Association (ADA) annual meeting, held in Philadelphia in June.
Dr. Gabbay, who is director of the Penn State Hershey Diabetes Institute in Pennsylvania, was talking about diabetes self-management education, an intervention that can range from the basics of how to test blood sugar to assistance with reshaping a whole diet and lifestyle.
Speakers at the ADA meeting noted many existing obstacles to diabetes education, particularly in hospitals, but described innovative strategies they have applied to teach patients these necessary skills.
“The inpatient setting is not the ideal setting for diabetes education,” said Amy Donihi, PharmD, an associate professor and clinical pharmacy specialist at University of Pittsburgh Medical Center (UPMC) in Pennsylvania.
Inpatient education efforts are limited by severity of illness, lean staffing, time shortages and failures of planning, she added. “I can't tell you how many times I'll get a call from a frantic nurse saying, ‘I'm so sorry for the late notice, but Mr. So-and-so is going home today and we just realized he's moved to insulin. Can you please come teach him about his insulin pen?’”
However difficult it may be, inpatient education appears to be important to long-term patient outcomes. When Dr. Donihi's hospital, UPMC Presbyterian, lost its only full-time diabetes educator, negative consequences were seen.
“We heard some anecdotal reports from some of the outpatient educators, ‘The patient came to me a month after hospital discharge and didn't take any of their insulin because nobody taught them how to use their insulin prior to discharge.’ We heard some anecdotal reports that people were being readmitted because there was a gap between discharge and the first primary care visit,” she said.
Improving those results doesn't require teaching patients everything about diabetes. “By the time patients leave the hospital, they need to have a basic understanding of how to take care of themselves and their diabetes,” Dr. Donihi said. “These basic survival skills should include the ability to perform home glucose monitoring and understand the results at a basic level, the ability to detect and prevent hypoglycemia, the ability to understand basic meal planning, the ability to take medications accurately and safely, and safe use and disposal of needles and syringes.”
Without an organized diabetes education program at UPMC, these skills were sometimes neglected in favor of other, less urgent ones. “We would hear the nurse say, ‘I had a great discussion with this patient on foot care.’ Is that really important to talk to them about before they go home?” said Dr. Donihi.
To remedy this problem, and other shortcomings in diabetes education, a committee at UPMC developed a process, involving nurses, dietitians and pharmacists, for every diabetic inpatient. Under the new system, the primary nurse care coordinator of the patient's unit (who functions like a charge nurse) uses the electronic health record to identify patients with diabetes on their problem lists. She provides them with a diabetes toolkit (a book and DVD), gives them a blood glucose meter if necessary, and coordinates an appointment with an outpatient educator within 72 hours of discharge.
The bedside nurse also has a role in the system. “We couldn't add too many more responsibilities to her job, but we really focus on telling her to reinforce teaching for all of her assigned patients,” said Dr. Donihi. “Teach the patient while she's in there. Have the patient watch the 7 a.m. insulin dose, and then for the pre-lunch dose, have the patient actually demonstrate how to do it.”
The hospital dietitian sees any patient who has been newly diagnosed, has an A1c over 8%, or was admitted due to diabetes. The pharmacist sees any new diagnoses and patients being started on insulin or an oral medication for the first time.
To measure the effects of this new, organized system, UPMC surveyed patients after discharge. “About 64% remember being taught. All the patients who were new to insulin did remember being taught,” reported Dr. Donihi. More than two-thirds could name the insulin they were taking, and 84% could describe hypoglycemia symptoms. “Most patients had some knowledge regarding their insulin regimen,” she said. “We're going to use these results to improve our process,” she said.
The results do prove that inpatient, team-based education is feasible, though. “In the absence of a diabetes educator, the responsibility for diabetes education can be shared among the various disciplines,” Dr. Donihi said.
When Massachusetts General Hospital (MGH) in Boston set out to improve diabetes education, they also started with a team. This one included an endocrinologist, a certified diabetes educator and a nurse practitioner. The target patient population for their project was narrower—patients with high A1cs who were admitted to the hospital for reasons other than uncontrolled diabetes.
The team evaluated the patients and then provided them with individualized diabetes education and discharge preparation (including instructing them about medication and communicating with primary care physicians). If the patients weren't already on insulin, it was initiated.
The insulin, along with short lengths of stay and high severity of illness, was a reason that the trial had trouble recruiting many patients; only 31 were enrolled after thousands were screened. “While most of them were eligible for insulin initiation, unless somebody came in and said, ‘It's time for you to start insulin,’ it was not something they wanted to do at that moment,” said endocrinologist Deborah Wexler, MD, assistant professor at MGH.
The education involved insulin instruction and whatever else patients were ready to learn. “We took patients where they were and tried to get them to the next level,” Dr. Wexler said. When the patients were followed for a year after discharge, the results showed that those who were newly introduced to insulin had reached a new level of success. “In insulin-naïve, we did have a one-year decrease in A1c of 1%, compared to no change or worsening in the usual care group,” she said.
There were no significant changes in the patients already on insulin, but the study did provide some additional lessons. “The inpatient setting is a very high-yield time to identify high-risk patients. Intervention and education are challenging and connection to outpatient care at discharge is absolutely key,” concluded Dr. Wexler.
Managing the transition
The University of Pennsylvania's Care Transitions program targets precisely those issues, for patients with diabetes and others at high risk of returning to the hospital soon after discharge. Brian Bixby, CRNP, told ADA attendees about the program.
“Typically, our patient is the person with heart failure, COPD, diabetes,” he said. Each patient is matched with a nurse practitioner who sees him during hospitalization and then visits his home after discharge. “We will see them for six to eight weeks, eight to ten visits at home and also [go] to any follow-up visits that they have,” Mr. Bixby said. Tagging along on outpatient visits, the nurse provides an extra set of ears and a copy of inpatient records, he noted.
The program has been effective in decreasing readmissions and lowering overall health care costs, even considering the cost of the nurse practitioner's time. “The nice thing about being in the home for the six weeks is it gives them enough time to get into trouble, recognize it and work with you to develop a better plan,” he said.
The planning may include medication changes or scheduling of routine follow-up care. The visits may also allow a nurse to recognize potential trouble before a patient would. Mr. Bixby recently treated a patient who had been diagnosed with diabetes in the hospital, and during follow-up, the patient developed an abscess and a fever at a time when a primary care physician was unavailable, so Mr. Bixby sent him to the emergency department.
Right now, these services are only available to some Pennsylvania patients covered by Independence Blue Cross or Aetna, but there's potential that the program will expand to help other patients improve their self-care after hospitalization, according to Mr. Bixby. “They will be educated based on their goals and be able to move forward and perform self-management,” he said.