There is no doubt that Diabetes Education, or the way it's now called, Diabetes Self-Monitor Education and Support (DSMES), is the central part of any diabetes treatment program. In this post we're going to explain what it is, who can be providing it, when, how, and which benefits can be achieved with it, and which difficulties it has to be implemented
What is it? It's the knowledge (information, attitudes, skills) that every individual with diabetes must have in order to properly manage their disease. It includes general information about what diabetes is, its consequences, its causes, symptoms, short- and long-term complications, as well as the effect of the treatment including adverse effects and hypoglycemia. Information about healthy and recommended nutrition (carbs, fat, proteins etc) and physical activity to manage the disease also belong to DSMES. Skills like how to properly inject insulin or measure glycemia on a fingerstick, continuous glucose monitoring or, if necessary, insulin pumps are of course part of it.
Who provides it? Nurses, dietitians and pharmacist have proven to effectively provide DSMES. There are platforms to get certitications as diabetes educator, like www.ncbde.org or www.diabeteseducator.org.
When should it be provided? There are, according to ADA, four moments in the disease that are particularly important:
- At diagnosis
- Annually
- When complications occur
- At transitions i.e. change of doctor.
How can it be delivered to the patient? There are three different modalities to provide DSMES: individual face-to-face, in groups face-to-face, or online. All three modalities have proven to be effective, although there are intrinsic differences. Individual modality can be more patient-centered, but online strategies may reach a bigger number of patients.
Benefits. DSMES not only improves diabete knowledge and self care, it also lowers A1c, weight, improves QoL, reduces all-cause mortality and health costs. If you don't believe it, click here.
Despite all those benefits, only 5-7% of individuals eligible for DSMES in the US trough Medicare or a private insurance plan actually receive it. How is it possible that the stem of the tree, the center, the nucleus of treatment and management of diabetes is only performed by 5-7%? Can't believe it!!
I've searched the conditions for Medicare reimbursement for example (click here). Someone with diabetes with Medicare in the US has the right to an initial DSMT of 10 hours to be provided in a 12 month period, the first of which can be individual and the other 9 preferable in group, unless certain conditions are met (no groups available, communication barriers or insulin treatment and unmet skills, certified by a doctor). After that initial 10 hours, there is a 2h/year DSMT follow-up. Online education is not reimbursed.
In my country, Spain, where the vast majority of people with diabetes are treated by the public health service, DSMES includes, at least in my experience, much more patients that this 5-7% of diabetic population, although most of them do not reach by far those 10 hours the first year or 2 hours the following ones. The public policy is clearly to reach more people at the expense of incomplete DE programs.
All this reveals how difficult it is to provide proper DSMES to all diabetic individuals, and it's clearly apending subject for any health system.
