Main Issue September 2007

AADE National Diabetes Education Practice Survey: Toward Describing the Practice of Education

This represents the first national effort to describe the variations in diabetes education practice.

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The American Association of Diabetes Educators (AADE) has undertaken the first comprehensive survey of diabetes educators and their practice settings in the United States. As the result of an environmental scan, the AADE identified significant changes in the practice of diabetes education in 2004, prompting the administration of the National Diabetes Education Practice Survery (NPS) to AADE membership in 2005 and 2006. The results appeared in The Diabetes Educator.1

Malinda Peeples, RN, MS, CDE, and Mary M. Austin, MA, RD, CDE, who served on the NPS development task force, reported on the findings. The survey was created to elicit information about the structure, process, and outcomes of diabetes education practice from both program managers and diabetes educators.

"Through this baseline description of diabetes education practice and program design, opportunities were identified for broadening the patient referral base, enhancing cost-effectiveness and educator productivity activities, improving program access to all populations, developing innovative delivery methods, improving patient outcomes, and striving for sustainable funding sources," the coauthors wrote.

For the purposes of the survey, a diabetes education program was defined as any structured, organized delivery of diabetes education occurring in any practice setting.

In 2004, the AADE conducted an environmental scan to gather information about trends in diabetes education. The results provided qualitative data to capture key trends affecting diabetes education and the diabetes educator. These findings included:

  • Diabetes educators now work with their patients to address a broader continuum of diabetes and other comorbid conditions.
  • Diabetes education is being done in a much wider array of settings and modalities.
  • Diabetes educators appear to be entering the field from more varied and diverse backgrounds.
  • Diabetes education payment sources are becoming more diverse, and the reimbursement environment is changing.

A need for a more descriptive analysis of diabetes education provided by educators was identified. Therefore, in 2005, the AADE NPS sought to describe the current diabetes education practice along with specific interventions and responsibilities of diabetes educators. The survey was conducted again in 2006, according to the report. The survey sought to address three areas:

  1. What is the current diabetes education structure?
  2. What are the current diabetes education program processes and interventions?
  3. What outcomes of diabetes education are being collected and how are the reports being used?

Both years' surveys were hosted online, with 1,781 respondents in 2005 (20.9% response rate) and 2,709 respondents in 2006 (31%) (Table 1).

Program setting. (Numbers in parentheses represent 2006 data.) About 62% (61%) of respondents indicated that their programs served a single location, more than 34.8% (39%) chose hospital outpatient as the primary setting, and 12% (12%) chose physician office.

Patient populations. The survey found that 39% (41%) of patients in programs were adults aged 45 to 64 years. More than 71.2% (76%) of patients had type 2 diabetes, 10.4% (8.9%) had type 1 diabetes, 7.2% (8.9%) had gestational diabetes, and 6.9% (5.6%) had prediabetes. About 46% (45%) were newly diagnosed patients, according to the report. Whites made up 60.8% (61%) of patients, 15% (16%) were black, 10% (10%) were Hispanic, and 3% (2%) were Asian. About 90% (90%) of patients spoke English and one-third (37%) had a high school or GED degree as the highest level of education.

Program administration. The percentage of programs that reported seeing ≤200 patients per year was 36.4% (29%), and about 38% (42%) reported ≤1,001 patient visits per year (Table 2). About 26% (29%) of programs were administered by Medicare, and 19% (20%) were reimbursed by managed care. The survey found that 42% (39%) of programs operated at a financial loss, and only 14% (13%) reported a profit. Additionally, 63% (66%) of respondents indicated that their program is recognized by the American Diabetes Association Education Recognition Program, 9% (9%) by a state agency, 1% (0.4%) by the Indian Heath Service, and 24% (19%) are not recognized (some sites have recognition from more than one organization, the report found).

Program services. Most diabetes education was provided through comprehensive programs, according to the survey. About 62% (67%) of programs reported that patients participated in a comprehensive program and 34% (25%) received only topic-specific teaching. In 2005, 79% of managers indicated that their program's primary settings of education were "one-on-one and group," and in 2006, 66% reported the same. The survey revealed that 14.5% (20%) of respondents were doing individual-only instruction, 4.2% (20.1%) were delivering group-only instruction, and 1.5% (1.2%) reported that telemedicine was their primary setting for education. Of the 1,781 (2,709) survey respondents, 56% (47%) indicated that the curriculums were designed by their staff. Also, 72% (63%) indicated that they had an ongoing edit process. Respondents reported that programs used the following instructional educational delivery methods: print, audio, visual, 71% (72%); skills demonstration labs, 46% (54%); computer assisted, 26% (26%); and telephone messaging, 23% (23%).

Program professional services. Diabetes self-management education (72% [74%]) and medical nutrition therapy (63% [63%]) were identified as the top two professional services offered. Other key services provided included case management 24% (26%), disease management 29% (30%), clinical (medical) management 34% (36%), counseling 26% (27%), health care professional education 36% (42%), home care diabetes education 10% (7%), research 11% (10%), and telephone care management 37% (28%).

Behavioral interventions. "In the past decade, diabetes programs have incorporated more behavioral strategies into their curriculum and program delivery," the authors wrote. About 69% (72%) of managers indicated that their programs used goal setting as an educational delivery method, and about 66% (67%) of managers said their programs used situational problem solving as a behavioral strategy.

Outcomes continuum. The questions about outcomes reporting reflected the framework of the outcomes continuum found in the AADE Diabetes Education Outcomes Standards.2 "Learning, behavioral, and clinical outcome measures affect the health of the individual with diabetes and are important measures of the impact of diabetes education programs," Ms. Peeples and Ms. Austin wrote.

According to the authors, the survey results form a baseline for beginning to describe the practice of diabetes education and all of its variations. The results … "validated the conclusions of the environmental scanning data of AADE, which highlighted the need for AADE and the diabetes community to examine other model(s) of diabetes education that can expand the reach of diabetes educators, improve the overall quality of diabetes care, and improve the productivity of the services," they wrote.

The survey responses generally reflected the characteristics of an education program that meets the national standards and is reimbursed by Medicare under certain conditions, according to the report. Additionally, the increased use of group-only approaches to diabetes education indicates that educators are responding to Medicare's reimbursement mandates. "Further investigation is needed, however, to determine what interventions educators are using to address the complexity of seeing patients in groups and how this format affects meeting patient population needs."

Additional survey findings revealed that educators are providing supplementary services consistent with chronic disease care such as case management, cholesterol/lipid screening, and clinical (medical) management. Further investigation along these lines should be included in the next survey, the authors said.

"AADE is actively promoting the mission of 'driving practice to promote healthy living through successful self-management of diabetes and related conditions' and will use the survey findings to guide further development of evidence-based diabetes education practice," Ms. Peeples and Ms. Austin wrote. "AADE, as a multidisciplinary organization, is uniquely positioned to promote collaboration among health care professionals to guide the practice of diabetes education toward meeting the ever-growing public health challenge of diabetes."

The survey was conducted in 2007 as well, and the AADE will be analyzing data from the past 3 years to identify emerging trends, Ms. Austin said. Going forward, according to the report, the survey will continue to be reviewed by the AADE Professional Practice Committee, and the questionnaire will be enhanced to broaden the picture of diabetes education. "For example, we need to understand more clearly what additional interventions educators are providing, what contributions they are making to physician practices and community services, and what other diseases they are addressing," the authors wrote.

"As the diabetes education landscape becomes more quantified and described, more specific strategies can be targeted to provide professional education, support advocacy efforts, and further the research agenda of the diabetes education community, with the final result of establishing evidence-based practice and improving services for all people with diabetes."

Malinda Peeples, RN, MS, CDE, and Mary M. Austin, MA, RD, CDE, are past officers of the American Association of Diabetes Educators in Chicago. Ms. Peeples may be reached at Ms. Austin is owner and President of The Austin Group in Shelby Township, Mich. She may be reached at

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