Diabetes educators: implementing the chronic care model

A Coordinated Population Health Approach to Diabetes Education in Primary Care

PURPOSE

The purpose of this feasibility study was to determine the effectiveness of an insurer-based diabetes educator (DE)-driven intervention that relies on systematic restructuring of primary care (PC) linking DE services through population health, practice redesign, and coordinated care for patients with diabetes mellitus (DM) identified as high risk.

METHODS

Two DEs were introduced as members of PC teams and worked with practice-based care managers (PBCMs) to identify and refer DM patients considered at high risk, A1C >9%, DM-related emergency room visit or hospitalization, or reported barriers to care. Elements shown to ensure quality, including population management, diabetes self-management education and support (DSMES), and coordinated patient-centered team-based PC, were central to intervention. A1C, low-density lipoprotein (LDL), and body mass index (BMI) were collected at baseline and outcomes were followed at 3, 6, 9, and 12 months after intervention.

RESULTS

For patients who received intervention, A1C decreased on average 1.2% (95% confidence interval [CI], 0.8-1.5) from 9.6% (81 mmol/mol) to 8.4% (68 mmol/mol) over 6 months and by 1.1% (95% CI, 0.7-1.5) from 9.2% (77 mmol/mol) to 8.1% (65 mmol/mol) over 12 months, indicating durable improvement in glycemic control. There was no significant change in BMI, and LDL improvement observed at 9 months was lost by 12-month follow-up.

CONCLUSION

Findings support the feasibility of a DE-driven intervention for patients with DM at high risk through a coordinated PC approach that improves glycemic control. The feasibility and clinical outcome of this model warrant consideration of a fresh role for DEs in the complex environment of value-based care.

Dulaglutide in the treatment of adult type 2 diabetes: a perspective for primary care providers

Approximately 90% of T2D patients in the US are diagnosed and treated in the primary care setting, and the majority of the burden of disease management falls to primary care providers. Here, we discuss the clinical data for once weekly dulaglutide, e.g. the results of seven completed Phase 3 trials, patient preference studies, patient reported outcomes (PRO), and clinical data surrounding the dulaglutide administration device. Dulaglutide 1.5 mg once weekly demonstrated superiority to placebo, metformin, sitagliptin, exenatide BID, and insulin glargine (in 2 trials), and non-inferiority to liraglutide in reduction of HbA1c from baseline, with an acceptable safety profile. Dulaglutide-treated patients achieved the composite endpoint of an HbA1c <7.0% with no hypoglycemia, no severe hypoglycemia, and no weight gain significantly more than metformin, sitagliptin, exenatide BID or insulin glargine treated patients. Dulaglutide consistently showed an early onset of glycemic control, lasting up to 104 weeks. Additionally, PRO and patient preference data support the benefit of once weekly dulaglutide for the treatment of T2D.

Exploring interprofessional collaboration during the integration of diabetes teams into primary care

Background

Specialised diabetes teams, specifically certified nurse and dietitian diabetes educator teams, are being integrated part-time into primary care to provide better care and support for Canadians living with diabetes.

This practice model is being implemented throughout Canada in an effort to increase patient access to diabetes education, self-management training, and support. Interprofessional collaboration can have positive effects on both health processes and patient health outcomes, but few studies have explored how health professionals are introduced to and transition into this kind of interprofessional work.

Method

Data from 18 interviews with diabetes educators, 16 primary care physicians, 23 educators’ reflective journals, and 10 quarterly debriefing sessions were coded and analysed using a directed content analysis approach, facilitated by NVIVO software.

Results

Four major themes emerged related to challenges faced, strategies adopted, and benefits observed during this transition into interprofessional collaboration between diabetes educators and primary care physicians: (a) negotiating space, place, and role; (b) fostering working relationships; (c) performing collectively; and (d) enhancing knowledge exchange.

Conclusions

Our findings provide insight into how healthcare professionals who have not traditionally worked together in primary care are collaborating to integrate health services essential for diabetes management. Based on the experiences and personal reflections of participants, establishing new ways of working requires negotiating space and place to practice, role clarification, and frequent and effective modes of formal and informal communication to nurture the development of trust and mutual respect, which are vital to success.

Safety and efficacy of dulaglutide, a once weekly GLP-1 receptor agonist, for the management of type 2 diabetes

BACKGROUND

Type 2 diabetes (T2D) is an increasingly common endocrine disorder that is characterized by chronic hyperglycemia and tissue compartment abnormalities, including macrovascular and microvascular complications. More than 90% of patients with T2D will be diagnosed and treated in the primary care setting. One of the relatively recent additions to the increasing array of approved antidiabetic medications is the glucagon-like peptide-1 receptor agonist class. Mechanisms of action for glucagon-like peptide-1 receptor agonists include: 1) stimulation of insulin secretion through β-cells, though only when glucose levels are elevated (hence, minimizing risk for hypoglycemia); 2) blunting of glucagon secretion; 3) increased satiety; and 4) decreased rate of release of gastric contents into the small intestine, thereby reducing glycemic load. Recent T2D treatment guidelines encourage individualization of therapy. Many patients still do not achieve optimal glycemic control. Therefore, other treatment options are important.

METHODS

A literature search was performed using PubMed and MEDSCAPE to retrieve abstracts and articles pertinent to topics discussed in this review. Original research articles, reviews, and clinical trial manuscripts were identified based on relevance. Only English language articles were considered. Results In 3 phase 3 registration trials in patients with T2D, once-weekly dulaglutide demonstrated superior efficacy at the primary endpoint to metformin as monotherapy, to sitagliptin as add-on to metformin, and to exenatide twice daily as add-on to metformin and pioglitazone. The safety profile of dulaglutide in these trials is similar to currently available glucagon-like peptide-1 receptor agonists, characterized predominantly by gastrointestinal symptoms (ie, nausea, vomiting, and diarrhea). Based on these results, once-weekly dulaglutide should be a relevant additional treatment option for the management of T2D.

Sustained effects of a nurse coaching intervention via telehealth to improve health behavior change in diabetes

BACKGROUND

Diabetes educators and self-management programs are scarce in rural communities, where diabetes is the third highest-ranking health concern. The goal of this study was to evaluate the benefits of nurse telehealth coaching for persons with diabetes living in rural communities through a person-centered approach using motivational interviewing (MI) techniques.

MATERIALS AND METHODS

A randomized experimental study design was used to assign participants to receive either nurse telehealth coaching for five sessions (intervention group) or usual care (control group). Outcomes were measured in both groups using the Diabetes Empowerment Scale (DES), SF-12, and satisfaction surveys. Mean scores for each outcome were compared at baseline and at the 9-month follow-up for both groups using a Student's t test. We also evaluated the change from baseline by estimating the difference in differences (pre- and postintervention) using regression methods.

RESULTS

Among the 101 participants included in the analysis, 51 received nurse telehealth coaching, and 50 received usual care. We found significantly higher self-efficacy scores in the intervention group compared with the control group based on the DES at 9 months (4.03 versus 3.64, respectively; p<0.05) and the difference in difference estimation (0.42; p<0.05).

CONCLUSIONS

The nurse MI/telehealth coaching model used in this study shows promise as an effective intervention for diabetes self-management in rural communities. The sustained effect on outcomes observed in the intervention group suggests that this model could be a feasible intervention for long-term behavioral change among persons living with chronic disease in rural communities.

Association between socioeconomic status, type 2 diabetes and its chronic complications in Argentina

AIM

To compare the socioeconomic status (SES) of people with type 2 diabetes (T2DM) in Argentina (Córdoba) with and without major chronic complications of diabetes, with that recorded in persons without diabetes matched by age and gender.

METHODS

For this descriptive and analytic case-control study, potential candidates were identified from the electronic records of one institution of the Social Security System of the city of Córdoba. We identified and recruited 387 persons each with T2DM with or without chronic complications and 774 gender- and age-matched persons without T2DM (recruitment rate, 83%). Data were obtained by telephone interviews and supplemented with data from the institution's records. Group comparisons were performed with parametric or non-parametric tests as appropriate. We used ordinary least squares to regress household income and the difference between income and household expenses on diabetes status, age, sex, education and body mass index.

RESULTS

Persons with T2DM, particularly those with complications, reported fewer years of general education (13.6±4.2 years vs. 12.2±4.4 years), a lower percentage of full time jobs (43.0% vs. 26.9%), lower salaries and monthly household income among those with full-time jobs (> 5000 ARG$: 52.6% vs. 24.5%), and a higher propensity to spend more money than they earned (expenditure/income ratio≥1: 10.2% vs. 16.0%). The percentage of unmarried people was also higher among people with type 2 diabetes (7.0% vs. 10.9%).

CONCLUSION

T2DM and the development of its complications are each positively associated with lower SES and greater economic distress in Argentina.

A new DAWN: Improving the psychosocial management of diabetes

AIMS

The second Diabetes Attitudes, Wishes and Needs (DAWN-2) study assessed psychosocial issues and health-care provision of people with diabetes, their family members and health-care professionals.

MATERIALS AND METHODS

Participants completed an online, telephone or in-person survey designed to assess health-related quality-of-life, self-management, attitudes/beliefs, social support and priorities for improving diabetes care as well as health-care provision and the impact of diabetes on family life.

RESULTS

A total of 8596 adults with diabetes, 2057 family members of people with diabetes and 4785 health-care professionals across 17 countries completed the survey. There were significant between country differences, but no one country's outcomes were consistently better or worse than others. A high proportion of people with diabetes reported likely depression (13.8%) and poor quality-of-life (12.2%). Diabetes had a negative impact on many aspects of life, including relationships with family/friends and physical health. A third of family members did not know how to help the person with diabetes, but wanted to be more involved in their care. Many health-care professionals indicated that major improvements were needed across a range of areas including health-care organization, resources for diabetes prevention, earlier diagnosis and treatment and psychological support.

CONCLUSIONS

DAWN-2 is a multinational, multidisciplinary systematic study that compared unmet needs of people with diabetes and those who care for them in 17 countries across four continents. Its findings should facilitate innovative efforts to improve self-management and psychosocial support in diabetes, with the aim of reducing the burden of disease. The implications for India are discussed.

Exenatide once weekly: opportunities in the primary care setting

Type 2 diabetes mellitus is a pandemic, with millions of new diagnoses made each year. In the United States, > 90% of patients with type 2 diabetes mellitus are cared for by primary care physicians who bear the primary responsibility of diagnosing and treating this disease. Building an optimal treatment regimen for a patient from the many choices available depends on many factors, including the ability of a given therapy to safely and effectively lower blood glucose levels, and potential benefits on body weight, cardiovascular risk factors, and hypoglycemia risk. With these considerations at the forefront, this article provides an overview of exenatide once weekly (EQW), a recently available antidiabetes therapy in the glucagon-like peptide-1 receptor agonist class designed to provide continuous glycemic control with once-weekly dosing. We discuss the clinical trials that have demonstrated the ability of EQW to effectively lower blood glucose levels and body weight with a minimal risk of hypoglycemia. In addition, we examine other issues likely to be relevant in a primary care setting, including safety and tolerability profiles, pharmacology and dosing, ease of use, recommended place in treatment, and patient perceptions of EQW.

Diabetes Attitudes Wishes and Needs 2 (DAWN2): a multinational, multi-stakeholder study of psychosocial issues in diabetes and person-centred diabetes care

AIMS

The Diabetes Attitudes Wishes and Needs 2 (DAWN2) study aims to provide a holistic assessment of diabetes care and management among people with diabetes (PWD), family members (FM), and healthcare professionals (HCPs) and explores potential drivers leading to active management.

METHODS

DAWN2 survey over 16,000 individuals (∼9000 PWD, ∼2000 FM of PWD, and ∼5000 HCPs) in 17 countries across 4 continents. Respondents complete a group-specific questionnaire; items are designed to allow cross-group comparisons on common topics. The questionnaires comprise elements from the original DAWN study (2001), as well as psychometrically validated instruments and novel questions developed for this study to assess self-management, attitudes/beliefs, disease impact/burden, psychosocial distress, health-related quality of life, healthcare provision/receipt, social support and priorities for improvement in the future. The questionnaires are completed predominantly online or by telephone interview, supplemented by face-to-face interviews in countries with low internet access. In each country, recruitment ensures representation of the diabetes population in terms of geographical distribution, age, gender, education and disease status.

DISCUSSION

DAWN2 aims to build on the original DAWN study to identify new avenues for improving diabetes care. This paper describes the study rationale, goals and methodology.

Changes and consistencies in diabetes education over 5 years: results of the 2010 National Diabetes Education Practice Survey

PURPOSE

The purpose of the National Diabetes Education Practice Survey (NPS) of the American Association of Diabetes Educators (AADE) is to describe the current diabetes education practice and specific interventions and responsibilities of diabetes educators in the United States. Method The 2010 NPS contained 52 items addressing diabetes education program structure, processes, interventions, outcomes, quality improvement, and adoption of health care reform models and AADE guidelines. The survey was hosted online, with 2513 AADE members participating. The 2010 results were compared with those from previous surveys.

RESULTS

The majority of 2010 respondents provided diabetes education at one site, most commonly in a clinical outpatient/managed care setting. A wide range of services, including patient support, were provided. Team member functions, hours spent, and instructional methods also varied widely. More than half of programs measured at least one behavioral and clinical outcome in 2010. Most programs engaged in quality improvement. Many respondents were unfamiliar with the patient-centered medical home and accountable care organization models.

CONCLUSIONS

The results highlight the need for educators to increase their reporting of outcomes. Educators are also urged to raise their knowledge of health care delivery reform models. Wider adoption of AADE diabetes education practice guidelines will help ensure effective team involvement and optimal patient-centered education. Despite an increase in hours spent on diabetes self-management education and training (DSME/T) and clinical functions in diabetes education, many programs operated at a financial loss in 2010, underscoring the need for improved reimbursement of these services. Continuation of the NPS biannually is recommended.

The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to determine the effect of nurse-led diabetes self-management education (DSME) on blood glucose control and cardiovascular risk factors.

METHODS

The electronic databases PubMed and ISIS Knowledge were searched for relevant randomized controlled studies published between 1999 and 2009. Effect size was calculated for change in A1C, blood pressure, and lipid levels using both fixed- and random-effects models. Subgroup analyses were performed on patient age, gender, diabetes type, baseline A1C, length of follow-up, and study setting.

RESULTS

A total of 34 randomized controlled trials with a combined cohort size of 5993 patients was identified. Mean patient age was 52.8 years, 47% were male, and mean A1C at baseline was 8.5%. Mean change in A1C was a reduction by -0.70% for nurse-led DSME versus -0.21% with usual care (UC). This corresponded to an effect size of 0.506, using a random-effects model for nurse-led DSME versus UC. Effect size was significantly associated with patient age older than 65 years and with duration of follow-up. Nurse-led DSME was also associated with improvements in cardiovascular risk factors, particularly among male patients, among those with good glycemic control, and in studies conducted in the United States.

CONCLUSIONS

Nurse-led DSME is associated with improved glycemic control, demonstrating that programs are most effective among seniors and with follow-up periods of 1 to 6 months. Future programs tailored to the needs of patients younger than 65 years may improve the impact of DSME on blood glucose.

Disparities in diabetes self-management education for uninsured and underinsured adults

PURPOSE

To examine accessibility, availability, and quality of diabetes self-management education (DSME) for uninsured adults or those utilizing Medicaid in a community with a high poverty rate.

METHODS

A descriptive needs assessment was conducted in 8 health care agencies serving the uninsured. Face-to-face audiotaped interviews were conducted with 22 health care providers, educators, and administrators to capture descriptive characteristics about clinical care, DSME, continuity of care, and organizational function.

RESULTS

Twenty-nine percent of adults with diabetes were reported to be uninsured or utilizing Medicaid in these settings. Only 4% of adults received the American Diabetes Association's DSME standards of care. At 5 agencies, there was no direct access to DSME. Uninsured individuals had access to 2 programs; individuals utilizing Medicaid had access to 1 program. Certified diabetes educators were available at only 3 agencies. There were DSME programs that adhered to recommended guidelines but limited availability for these adults. The majority of education (86%) was limited to clinical encounters with providers, which were infrequent and variable in duration. Time spent on education ranged from 2 to 120 minutes depending on agency type. Education topics addressed by providers varied by agency.

CONCLUSIONS

Findings of this study suggest that adults who are utilizing Medicaid or are uninsured do not get the amount, type, or quality of DSME needed to sustain successful self-management. Limited availability and inadequate access to quality DSME place vulnerable adults at increased risk for devastating and costly complications despite the known benefits.

Assessing the value of the diabetes educator

PURPOSE

The purpose of this study was to evaluate the effectiveness of diabetes self-management education or training provided by diabetes educators in reducing complications and improving quality of life.

METHODS

Commercial and Medicare payer-derived claims data were used to assess the relationship between DSME/T and cost. Unlike the prior study that examined diabetes education provided by all professionals, the current study focused on the value of interventions performed as part of formal accredited/recognized diabetes education programs provided by diabetes educators only. Specifically, the current study focused on diabetes education delivered in diabetes self-management training programs based on 2 codes (G0108 and G0109).

RESULTS

Results of the study provide insights into the differences in trends between participants and nonparticipants in DSMT. People with diabetes who had DSMT encounters provided by diabetes educators in accredited/recognized programs are likely to show lower cost patterns when compared with a control group of people with diabetes without DSMT encounters. People with diabetes who have multiple episodes of DSMT are more likely to receive care in accordance with recommended guidelines and to comply with diabetes-related prescription regimens, resulting in lower costs and utilization trends. Conclusions and Policy Implications The collaboration between diabetes educators and patients continues to demonstrate positive clinical quality outcomes and cost savings. This analysis shows that repeated DSMT encounters over time result in a dose-response effect on positive outcomes.

Multipayer patient-centered medical home implementation guided by the chronic care model

BACKGROUND

A unique statewide multipayer ini Pennsylvania was undertaken to implement the Patient-Centered Medical Home (PCMH) guided by the Chronic Care Model (CCM) with diabetes as an initial target disease. This project represents the first broad-scale CCM implementation with payment reform across a diverse range of practice organizations and one of the largest PCMH multipayer initiatives.

METHODS

Practices implemented the CCM and PCMH through regional Breakthrough Series learning collaboratives, supported by Improving Performance in Practice (IPIP) practice coaches, with required monthly quality reporting enhanced by multipayer infrastructure payments. Some 105 practices, representing 382 primary care providers, were engaged in the four regional collaboratives. The practices from the Southeast region of Pennsylvania focused on diabetes patients (n = 10,016).

RESULTS

During the first intervention year (May 2008-May 2009), all practices achieved at least Level 1 National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) recognition. There was significant improvement in the percentage of patients who had evidence-based complications screening and who were on therapies to reduce morbidity and mortality (statins, angiotensin-converting enzyme inhibitors). In addition, there were small but statistically significant improvements in key clinical parameters for blood pressure and cholesterol levels, with the greatest absolute improvement in the highest-risk patients.

CONCLUSIONS

Transforming primary care delivery through implementation of the PCMH and CCM supported by multipayer infrastructure payments holds significant promise to improve diabetes care.

Identifying type 1 and type 2 diabetic cases using administrative data: a tree-structured model

BACKGROUND

To date, few administrative diabetes mellitus (DM) registries have distinguished type 1 diabetes mellitus (T1DM) from type 2 diabetes mellitus (T2DM).

OBJECTIVE

Using a classification tree model, a prediction rule was developed to distinguish T1DM from T2DM in a large administrative database.

METHODS

The Medical Archival Retrieval System at the University of Pittsburgh Medical Center included administrative and clinical data from January 1, 2000, through September 30, 2009, for 209,647 DM patients aged ≥18 years. Probable cases (8,173 T1DM and 125,111 T2DM) were identified by applying clinical criteria to administrative data. Nonparametric classification tree models were fit using TIBCO Spotfire S+ 8.1 (TIBCO Software), with model size based on 10-fold cross validation. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of T1DM were estimated.

RESULTS

The main predictors that distinguished T1DM from T2DM are age <40 years; International Classification of Disease, 9th revision, codes of T1DM or T2DM diagnosis; inpatient oral hypoglycemic agent use; inpatient insulin use; and episode(s) of diabetic ketoacidosis diagnosis. Compared with a complex clinical algorithm, the tree-structured model to predict T1DM had 92.8% sensitivity, 99.3% specificity, 89.5% PPV, and 99.5% NPV.

CONCLUSION

The preliminary predictive rule appears to be promising. Being able to distinguish between DM subtypes in administrative databases will allow large-scale subtype-specific analyses of medical care costs, morbidity, and mortality.

Cost-effectiveness of implementing the chronic care model for diabetes care in a military population

BACKGROUND

Applying the chronic care model (CCM) for diabetes management helps improve health outcomes and patient care. The CCM was implemented at U.S. Air Force Wilford Hall Medical Center through the Diabetes Outreach Clinic (DOC) in 2006, but its cost-effectiveness in this setting is unknown.

METHODS

We constructed a Markov decision model to estimate DOC cost-effectiveness compared with usual care (UC) over a 20-year period. Based on empirical, post-intervention demographic and clinical data, we applied United Kingdom Prospective Diabetes Study risk equations to predict long-term probabilities of developing microvascular or macrovascular complications. Health care system and societal perspectives were considered, discounting costs and benefits at 3% annually. Intervention costs and outcomes were obtained from military data, while other costs, disease progression data, and utilities were drawn from published literature.

RESULTS

From a health care system perspective, the DOC cost $45,495 per quality-adjusted life-year (QALY) compared with UC; from a societal perspective, the DOC compared with UC cost $42,051/QALY (when the model started with the uncomplicated diabetes cohort), $61,243/QALY (when starting with the DOC cohort), or $61,813/QALY (when starting with the UC cohort). In one-way sensitivity analyses, results were most sensitive to yearly costs for specialty care visits. In probabilistic sensitivity analysis, the DOC was favored in 51% of model iterations using an acceptability threshold of $50,000/QALY and in 72% at a threshold of $100,000/QALY.

CONCLUSIONS

The DOC strategy for diabetes care, performed with the CCM methodology in a military population, appears to be economically reasonable compared with UC.

Monitoring in diabetes self-management: issues and recommendations for improvement

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care. The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework. People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring.

Insights and trends in diabetes education: results of the 2008 AADE National Diabetes Education Practice Survey

PURPOSE

The purpose of this study is to describe current diabetes education practice and specific interventions and responsibilities of diabetes educators in the United States.

METHODS

The 2008 National Practice Survey (NPS) instrument consisted of 53 items addressing diabetes education program structure, processes and interventions, outcomes and quality improvement activities, and the chronic care model. The survey was hosted online for American Association of Diabetes Educators (AADE) members. Participants totaled 2447 members, constituting a 25% return rate. Data from the 2008 NPS were analyzed and compared with results from previous surveys.

RESULTS

Nearly two-thirds of respondents in 2008 provided diabetes education in a single location, most commonly in a clinical outpatient/managed care setting (39%). Most programs provided comprehensive services. Managers noted that 42% of their programs were either cost/revenue neutral or profitable. Programs varied in types of services, number of patient visits, team member functions, time spent on services, and instructional methods used. At least 50% of managers said their programs report outcome data, and 88% participate in quality/performance improvement activities. Nearly two-thirds of respondents were unfamiliar with the AADE-adopted chronic care model.

CONCLUSIONS

Many 2008 NPS results concur with those obtained in 2005 through 2007. Areas of variability among programs suggest a need for standardized interventions and practice guidelines. Educators are encouraged to report outcomes to elucidate the contributions of their programs to patient care. AADE can use the results and comparative data obtained from the 2008 survey when developing practice, research, and advocacy activities.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.