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Evidence-Based Diabetes Management September 2018

AADE Poster Presentations: A Look at Research Presented at the AADE Annual Conference

Mary Caffrey
POSTERS AT THE 2018 American Association of Diabetes Educators (AADE) Annual Conference covered updates on new therapies and technology, strategies to help patients overcome fear of using insulin, and innovations in diabetes self-management education and support. Following are a few snapshots of the research presented at AADE.

Identifying Barriers to Individualizing DSMES

The 2017 national standards for Diabetes Self-Management Education and Support (DSMES) call for individualizing patient care. Research led by Columbia University’s Elizabeth Heitkemper, PhD, RN, shows how this can be challenging, given the diversity of settings where DSMES is offered, including federally qualified health centers (FQHCs). The staff at FQHCs may address multiple health needs and patients may have barriers, including homelessness, that make diabetes self-management difficult.

Heitkemper’s project assessed whether following the Precede-Proceed model would help FQHCs quickly identify barriers to personalized DSMES. The cost-benefit framework lets healthcare planners take factors including social determinants of health into account when designing interventions. The first half of the model, the Precede portion, evaluates social, environ- mental, and educational factors that affect a population before making policy recommendations that might require changing processes in the second part, the Proceed phase.

In this project, 4 FQHCs and 1 private center offered DSMES, and Precede/ Proceed allowed investigators who conducted focus groups to identify barriers to using the usual content. Investigators identified “predisposing factors,” such as attitudes and knowledge, that participants bring to the DSMES process. The FQHCs bring “enabling factors,” such as organizational expertise or certain processes, which can help determine success and are sustained by “reinforcing factors,” including the way patients are rewarded.

Through this process, the investigators identified several characteristics unique to FQHCs that called for DSMES to be adjusted for the population they serve:
  • Staff likely need more training in shared decision making.
  • Keeping patients organized to activate their own healthcare engagement is a priority.
  • There is a need to engage community partners.
  • Using exemplary patients to act as diabetes “champions” can motivate others.
  • Creating support networks is essential.
Investigators also determined that typical educational tools like books may not be best for this population and that new DSMES approaches might be needed. The leadership of FQHCs must be engaged because these health centers typically deal with other health conditions, such as HIV. Ongoing support is needed, and some patients will need to repeat their education program; however, FQHCs have limited resources.


Heitkemper E, Smaldone A, Mamykina L. Identification of barriers and solutions to adoption of the 2017 National Standards for diabetes services at federally qualified health centers. Presented at: the 2018 AADE Annual Conference; August 17-20, 2018; Baltimore, Maryland. Poster P122.


Recognizing Pharmacists as Providers for DSMES

Pharmacists' accessibility should make them an obvious choice to deliver diabetes self-management education and support (DSMES). But in many states, laws that bar provider status, inadequate Medicaid coverage, and even lack of space keep pharmacists from fulfilling their potential on the diabetes care team, according to research presented at the 2018 American Association of Diabetes Educators Annual Conference.

An overview led by Diana Isaacs, PharmD, of the Cleveland Clinic’s Diabetes Center, discussed the potential role of pharmacists as providers, as well as the current barriers that exist. The review noted that pharmacists are the third- most-common profession to hold the certified diabetes educator credential, behind nurses and dietitians. Having pharmacists involved in diabetes care offers many advantages:

As medication options in diabetes expand, it makes sense to involve pharmacists.
  • Many people with diabetes take multiple medications, including injectable drugs.
  • Pharmacists can help people with diabetes problem solve through management of adverse effects.
  • Pharmacists are located in places where DSMES can be delivered, includ- ing hospitals and outpatient, managed-care, and long-term care settings.
  • The expansion of telemedicine offers opportunities for pharmacists to make medication adjustments to; 1 study reported a 2.0% reduction in glycated hemoglobin (A1C) at 6 months among a rural population.1
  • For all the opportunities for pharmacists to drive better medication adherence and clinical outcomes—improved A1C, lower blood pressure, and lower low-density lipoprotein cholesterol—many barriers remain, the investigators report.
Although 21 states have passed laws granting pharmacists provider status, “lack of provider status” stops pharmacists in other states from offering DSMES or being reimbursed if they do not receive a referral from a physician. Medicaid restrictions at the state level and from private payers can be cumbersome. Reimbursement models also lead to inadequate space and staffing to offer DSMES, the authors found.

The authors called on fellow pharmacists to appeal to state legislators to authorize provider status in the remaining states and improve reimbursement models to boost availability of DSMES.2

  1. Maxwell LG, McFarland MS, Baker JW, Cassidy RF. Evaluation of the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy in a veteran population. Pharmacotherapy. 2016;36(3):348-356. doi: 10.1002/phar.1719.
  2. Isaacs D, Grossman S, Twigg G, et al. Pharmacy community of interest: recognize pharmacists as providers. Presented at: the 2018 AADE Annual Conference; August 17-20, 2018; Baltimore, Maryland. Poster P125.

Community Partnerships Lead to More Active Engagement in Diabetes Care

Investigators based out of Rutgers University in New Jersey showed attendees at the 2018 American Association of Diabetes Educators Annual Conference attendees how community partnerships expanded a hospital-based program offering diabetes self-management education into a community support program. Primarily for people with type 2 diabetes (T2D), the program began in 2014 as part of a community diabetes coalition, according to a poster presented by Alexandra Grenci, MS, RD, LDN, CDE, of the Rutgers Cooperative Extension Service, who established a support group in a suburban New Jersey community near a regional hospital.

In 2015, the county’s Division of Senior Services dictated that the support group, which had started as a short-term special nursing student project, continue due to participant demand. The support group connected patients to community partners, increased referrals between community-based and clinical services, and improved management skills, especially meal planning. A second group began meeting in the evening at a local supermarket to be more accessible for those who work during the day. This site held events such as in-store cooking demonstrations, visits from pharmacists, and diabetes-focused “tours” to help people shop for healthy items.

Government agencies advertised the support groups’ availability through the county website, social media, and newsletters.

Grenci’s report showed that some patients with diabetes who took part in the hospital’s self-management education program needed ongoing support and reminders of what they had learned. She reported several qualitative findings, including statements from participants:
  • “I was in denial about my diabetes. I forgot what I read. Repetition when necessary helps me remember and practice what’s important.”
  • “You are not alone! Take control of your life. It’s your diabetes. Support is available.”
  • “I would tell people with diabetes to go to a support group. I knew about calories, but I was overwhelmed about carbs.”

Grenci A. Moving from knowledge to action: how community-based diabetes support groups can facilitate behavior change. Presented at: the 2018 AADE Annual Conference; August 17-20, 2018; Baltimore, Maryland. Poster P101. 


Lack of Time, Transportation Limit Diabetes Education, Support

People who recently received diabetes diagnoses are most receptive to self-management education and support (DSMES), and the American Diabetes Association recommends that this group receive education regarding diabetes management. But not everyone is receptive to instruction, and a poster presented at the American Association of Diabetes Educators Annual Conference discussed the chief reasons: lack of time and transportation.

Investigators from sites in Indiana—Eskenazi Health, Purdue University College of Pharmacy, and Butler University College of Pharmacy and Health Sciences—evaluated the differences between 2 groups of patients who were offered DSMES after receiving diabetes diagnoses in 2014. Through phone calls, the team interviewed 129 engagers, defined as having taken at least 2 classes, and 40 nonengagers, who took 1 class or none. Patients with new diagnoses had until October 2016 to take classes.

The engagers had significantly greater drops in glycated hemoglobin than the nonengagers (FIGURE). Phone interviews revealed that nearly two-thirds of the nonengagers had barriers that had nothing to do with the curriculum;

16 of 40 reported time conflicts, and 12 reported transportation issues. When asked what changes they would make to the program, 19—nearly half—said they would make no changes, whereas 12 said they would change the schedule.

Digital therapeutics such as Welldoc (see cover story) and digital providers such as Omada Health, which now offers programs to help manage type 2 diabetes, can help patients get assistance with disease management and overcome the logistical challenges uncovered by the investigators.


Mathews C, Gonzalvo GD, Weber ZA, Triboletti JA, Kleyn T, Pence L. Assessing factors for engagement of participants in a diabetes self-management education and support (DSMES) program. Presented at: the 2018 AADE Annual Conference; August 17-20, 2018; Baltimore, Maryland. Poster P126.


Digital Coaching System Improves Diabetes Management, as Measured by PROs

A startup based in Birmingham, Alabama, reports positive results from users of its digital coaching tool for patients with type 2 diabetes (T2D), according to a poster presented at the American Association of Diabetes Educators (AADE) Annual Conference.

Pack Health developed its the system on the Salesforce platform, which allows people with T2D to enroll in the program online, be matched with a health advisor, and get connected to a curriculum aligned with the person’s “goals and barriers,” according to the poster. Like other digital solutions, the Pack Health system sends emails and texts with reminders about medication or offering guidance on achieving health goals, such as losing weight.

The platform is not used just for diabetes management; Pack Health also offers programs related to diabetes prevention, dyslipidemia, hypertension, and congestive heart failure, as well as pulmonary conditions, autoimmune disorders, and cancer treatment.

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