People with diabetes must make what some perceive as being overwhelming lifestyle changes, yet their failure to accept these changes may result in inadequate diabetes control. Emotions related to the psychological burden of diabetes, such as anxiety, depression, and poor self-confidence, have been shown to be associated with poor control (13,30,31,32,33). Thus, a properly designed education program not only should present facts but also should address the emotional responses to diabetes.

Education improves self-care practices (16,17,22,34) but a mere increase in knowledge and skills does not guarantee an improvement in metabolic parameters (14). Several psychological factors, having been implicated as barriers to improved glycemic control, play an important role in translation of knowledge and skills into the desired metabolic results. These factors include emotion-based coping styles (35,36), diabetes-related emotional distress (33), and lack of readiness to change (37). For individuals to be willing and able to make all the necessary lifestyle changes, they must have knowledge and skills plus a positive emotional outlook about their diabetes, believing that the changes they make will lead to better health.

An educational program that demonstrably improves parameters of emotional well-being in addition to addressing self-care practices has been shown to lead to improved metabolic control that was sustained over 6 months (38,39). The authors of these studies suggested that emotional well-being itself may contribute to improved self-care (38). Others contend that, for many patients, education about diabetes and self-care alone enhances emotional well-being (40,41,42), which further boosts self-care ability. In the first randomized controlled trial to demonstrate an additive effect of psychological intervention on glycemic control, Grey and her colleagues (43,44) demonstrated that adolescents who received training in coping skills along with methods of intensive diabetes treatment improved glycemic control and self-care behaviors more than did adolescents who received only intensive treatment instruction. However, whether emotional well-being leads to improvement in self-care or vice versa has not been clearly determined. More research is needed to clarify the associations among education, improved self-care, and improved emotional outlook.

Even after one accepts that emotional well-being is a crucial component of the educational intervention, the complexity of the diabetes treatment regimen itself often leads to confusion and misunderstanding that interferes with the ability to manage one’s diabetes. Diabetes education can play an important role in clarifying the treatment regimen, reinforcing the skills necessary to successfully manage diabetes, and supporting efforts to integrate self-management behaviors into one’s life. Several meta-analyses and clinical trials examining the effects of diabetes education found that education leads to improved self-care behaviors as well as to improved knowledge, and metabolic and psychological outcomes (15,16,17,19,22,34,38,45). Rubin and his colleagues (45) noted a differential effect among self-care behaviors: behaviors requiring changes in lifestyle such as in diet and exercise were more difficult to maintain over time than were less-demanding behaviors such as self-monitoring of blood glucose (SMBG).

The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) established the principle that improvement in glycemic control is beneficial and that maintaining glucose levels as near to normal as possible results in reduction in the risk of development and progression of serious microvascular complications. The importance of education to the training of patients with diabetes about their treatment and to supporting their self-management efforts to improve their glycemic control became apparent early during the 9-year course of the DCCT (46,47). Moreover, the importance of a multidisciplinary team consisting of at least one healthcare practitioner/educator such as a registered nurse or nutritionist was definitively documented (46,47,48). The roles of
other team members, such as the podiatrist, psychologist, ophthalmologist, pharmacist, exercise physiologist, among others, are now being recognized as well (12,20,21,22,38,39,49,50,51).

Although initial studies attempting to demonstrate that education improves diabetes control produced variable results, again it was through meta-analyses that examined the cumulative evidence that the conclusion can be drawn that diabetes education can result in a moderate to large effect on improving glycemic control (15,16,17,18,19). For glycemic control, the magnitude of this effect was particularly evident in studies that were completed after measurements of glycosylated hemoglobin (HbA_1c) came into widespread use (15). Traditional diabetes education also resulted in improved knowledge and self-care behaviors with a small effect on psychological outcomes (17). Padgett and coworkers (16) found that diet instruction had the largest effect size while relaxation training had the weakest.

Other studies also have underscored the importance of selecting the right outcome criteria for measurement. If the wrong outcomes are measured, education may not appear to be responsible for the desired improvements, both when looked at in relation to various outcomes other than metabolic control (52) and when examined over extended periods (34,53). For example, the Diabetes Education Study reported minimal differences between the education and control groups in measurements of their knowledge but found numerous, significant differences in their skills and self-care behaviors. Such studies suggest that adult learning theory holds true: Individuals tend to learn what is important to them and what they can relate to their own life experience (54). Not surprisingly, discrepancies may exist between what healthcare providers teach and what individuals with diabetes perceive as important. These studies also point out the difficulties of measuring the effects of education after a single educational intervention that focuses primarily on facts about diabetes rather than on behaviors and that does not include ongoing follow-up (55) or that measures outcomes in terms of selected metabolic parameters only. Such limited studies often fail to detect all the potential long-term benefits of an ongoing educational experience (56). Others have made the important point that improved glycemic control may not be apparent unless other treatment factors, such as the treatment regimen and individual metabolism, are taken into account (57).

Although the studies cited suggest that education does improve metabolic control, most studies do not examine education in isolation. In an extensive review of the diabetes education literature, Clement (58) emphasized that negative studies did not examine diabetes education that was integrated into medical treatment. Therefore, one must conclude that education alone does not improve metabolic control. This point was nicely demonstrated in a randomized controlled study of nurse case management that included a 12-hour education program. After 1 year, the combined medical/education case management approach led to a greater improvement in glycemic control as measured by HbA_1c of 1.1% as compared with the control group receiving the usual care (21). These data and the emphasis that the DCCT placed on education to help patients reach glycemic targets (46,48,59,60,61) support the suggestion that the maximal benefit of diabetes education is realized when education is integrated into diabetes care.

Evidence is now emerging that diabetes education plays an important role in the prevention and early detection of diabetes complications. In fact, the Revised National Standards for Diabetes Self-Management Education have included prevention, detection, and treatment of both acute and chronic complications among the ten content areas for diabetes education (4).

A case-control study of 886 subjects with long-term diabetic complications and 1,888 control subjects without complications found that, in addition to being male, older, and having type 1 or insulin-treated type 2 diabetes, patients who did not receive any kind of educational intervention were at increased risk of developing complications. Furthermore, self-management of insulin, a skill that is usually dependent on receiving diabetes education, had a protective effect on the risk of complications (62).

In a randomized control trial of 352 patients and four healthcare provider practice teams, Litzelman and her colleagues (23) found that patients with type 2 diabetes who were assigned to an educational intervention with patient, healthcare provider, and educational systems were less likely to have serious foot lesions and more likely to report appropriate self-care behaviors than were patients assigned to usual care. In addition, healthcare providers who received practice guidelines, informational flow sheets on foot-related risk factors, and who had reminder notices placed on their patients charts were more likely to examine patients’ feet and to refer patients for podiatry appointments.

This statement by Joslin’s Dr. Leo Krall (63) opened the section in earlier editions of this text that discussed how education could decrease the cost of diabetes care. Finally, in this edition, the evidence is beginning to accrue that, indeed, Dr. Krall’s wish for data may be coming true. However, the path to this conclusion has followed a difficult and convoluted route, and the conclusion has been slow to gain acceptance among many, particularly those responsible for paying the bills. In addition, as Krall pointed out at the Joslin symposium held at the 2000 International Diabetes Federation meetings, from a worldwide perspective, economic environments vary—not all of them resembling that of the United States.

Yet, spurred by the managed-care movement, cost-effectiveness and the impact on quality of life are now being measured, and slowly the recognition that diabetes education is a reasonable expense is beginning to gain acceptance. This trend is seeing a confluence of endpoints. Medical professionals are looking to improve parameters such as HbA_1c values or complication rates, assuming that the good stemming from improvements in these numbers is justification in and of itself. However, the people who pay the bills—the managed-care executives initially and, ultimately, the consumers of healthcare services—view parameters such as dollars and cents and, in particular, impact on quality of life for dollar spent to ensure that the benefits reaped by an intervention such as education warrant the expense.

Demonstrating that education is a cost worth bearing has been promulgated over the last few decades. However, during the 1990s, enough momentum seemed to have gathered for people to finally begin to accept this principle. Prior to that, a traditional endpoint was a reduction in hospitalizations, which may not necessarily reflect the entire picture in this new millennium in which outpatient medicine and pharmaceutical costs are a focus of the cost-conscious healthcare insurance executives. Nevertheless, hospitalizations are still costly and serve as a reasonable yardstick.

To get a sense of the battle that has been waged, we should look back to 1981, at the dawn of the era of “intensive insulin therapy” heralded by the availability of SMBG and HbA_1c measurements. This quiet revolution in diabetes management gave us the tools to target normoglycemia more realistically and to monitor glucose patterns in a normal setting without the need for hospitalization, yet increasing the importance of self-care skills if these new tools were to be used to their optimal efficacy.

At that time, educational deficits were clearly a cause for increased costs of medical interventions. In 1981, Geller and Butler (64) judged that 27% of the hospital admissions for diabetes complications over a 1-year period were the result of educational deficits and that an additional 20% were due to a combination of educational, psychological, and socioeconomic deficits. In a 1985 edition of this textbook, Krall (63) recounted the classic, but not scientifically controlled, report of 100 patients surveyed who were admitted to the Joslin Diabetes Center with foot infections. Only 38% of these patients had received any diabetes education. The same year, Scott et al. (65) from New Zealand suggested that education lowers admission rates among patients with diabetes. Of a group of 902 insulin-using patients, 79 required hospitalization, of whom 11% had received education previously and 89% had not.

In a 1983 report from Maine (66), based on its experiences as one of the few states that at that time provided some reimbursement for diabetes education, 38.5% fewer people were hospitalized and 28.3% fewer hospitalizations were necessary among patients who had participated in an educational program. The experience in Rhode Island reported in 1985 by Fishbein (67) also demonstrated a reduction in the number of admissions after attendance in an outpatient education program.

However, these and other studies that have appeared over the years had seemingly not provided convincing proof that education does save money. Criticisms of various studies, exemplified by a review by Kaplan and Davis (68), typified the dilemma. Reviewing studies used by the ADA to support third-party payment for outpatient education and nutritional counseling (69), these authors identified various defects in study design such as deficiencies in the use of control groups, in patient randomization, in cost accounting, and in clearly demonstrating actual savings. They also pointed out that duration of hospital stay and rate of hospital admission can be affected by multiple factors influencing hospitalization practices that are unrelated to diabetes education or even to actual medical conditions.

The crux of the argument at that time was expressed succinctly by Anderson (70) in a reply to the Kaplan and Davis report (68), pointing out that patients appear to need education to follow their daily routine of diabetes self-care. As with the impact on medical parameters cited earlier, asking that an educational program alone results in reduction in cost without considering the other variables that affect such outcome measures is ascribing more power to educational intervention than is warranted.

However, during the 1990s we passed a significant milestone, as those who view healthcare in the aggregate, rather than one patient at a time, began to recognize that patient education was an important component of the multifactorial effort to achieve improvements in diabetes control and reductions in complications and thus achieve better outcomes. Studies such as the DCCT and UKPDS provided enough momentum to establish the economic value, albeit indirect, of patient education. Although the DCCT had already proven that intensive therapy reduces microvascular and neuropathic complications (7,71), the cost-effectiveness of intensive therapy itself was subsequently demonstrated (72). Implicitly, patient education is central to establishing a successful intensive therapy program, and thus patient education contributes to a cost-effective outcome.

Concurrently, other studies examined the costs of care for patients with diabetes in the managed-care environment. In a health maintenance organization (HMO) in which 3.6% of the patients had diabetes, these patients accounted for more than three times their allotment of costs, or 11.9% of total healthcare delivery costs, attributable in significant part to long-term and short-term complications (73). This study suggests that reducing the occurrence of complications would generate savings, accomplished through disease management, which includes to a considerable degree, of course, patient education. Other studies further underscore these economic benefits of improving diabetes control and preventing complications (74,75,76), as well as the benefit of adding quality time to a person’s life (77).

The ADA has participated in this argument for many years, strongly advocating proper support for patient education. Even before the DCCT results became available, the ADA stated that every patient has a right to accessible and affordable patient-education services (78) and has issued a policy statement that “supports and encourages reimbursement for outpatient education and nutrition counseling that meet acceptable standards for persons with diabetes” (69). Again, in 1990, the ADA issued a policy statement (79) that noted “the omission of outpatient education as a benefit in many insurance and healthcare financing plans constitutes a major barrier to the availability and accessibility of these services” and supported “adequate reimbursement and payment for outpatient diabetes education services that meet accepted standards.” Such lack of coverage may be the result of either the failure of insurance companies to include coverage in their policies or a choice made by employers not to include such coverage in the insurance benefits they offer their employees when arranging insurance benefits.

More recently, the ADA stated (80) that “self-management education is a critical part of the medical plan for people with diabetes, such that medical treatment of diabetes without systematic self-management education can be regarded as substandard and unethical care.” The ADA suggests that such education will ultimately reduce costs.

Throughout this period, economic factors as well as technologic advances have exerted an increasing influence on the setting for and scope of diabetes patient education. The ability to perform SMBG has eliminated the need to hospitalize a person just to monitor multiple glucose levels throughout the day. Inpatient education programs are now restricted to people with medical conditions that cannot be adequately addressed in an outpatient setting and thus justify hospitalization; the shorter hospital stays now mandated limit the extent of material that can be taught (81). Thus, diabetes education must increasingly be delivered through outpatient programs (82).

Ironically, however, the evolution from inpatient to outpatient education has been negatively influenced by economic factors as well. Inpatient education frequently was provided as part of the “overhead” service covered by the cost of hospitalization. However, because education is often inadequately covered by insurance in many states, the cost of outpatient education is often borne directly by the patient. Thus, because inpatient education is restricted and outpatient education is unaffordable, all education may be unavailable for most patients.

Outpatient education does, however, have advantages over inpatient education. There is flexibility of timing of the sessions, extension of the educational experience over weeks or months, ability to educate in a normal life setting rather than in an artificial inpatient environment, and the opportunity for follow-up
sessions. The trends of recognition of both the quality and the importance of outpatient education hopefully will continue, but until all people with diabetes can have some access to insurance-supported outpatient education, the full potential cannot be met.

In summary, we are finally reaching the point at which most people accept that patient education can improve diabetes control and decrease the risk of acute and chronic complications and thus is a significant component of an overall management plan. These results, in turn, can lead to reduced costs and improved quality of life. Patient education alone does not accomplish this, but patient education as part of a comprehensive management program does. Thus, the cost of educational services and the supplies that must accompany them, such as test strips and meters, are slowly being included in many coverage plans—not universally, but it is happening.

The following was written in the last edition of this text: “We hope that in the next edition of this textbook the report on the financing of diabetes education will be quite different!”

Well, it is! Maybe it should not be termed “quite” different, but it is different enough and definitely evolving enough in the right direction to be most encouraging!

Sensitivity to the potential for malpractice lawsuits for alleged negligence has become part of the practice of medicine. This concern also extends to the act of conveying information about diabetes. Legal precedents in United States law exist that require healthcare providers to be sure their patients receive adequate education and that outline the potential liability for either not educating or poorly educating their patients (83).

In light of the progress during the last decades in demonstrating that improved control and avoidance of complications can be accomplished through education, the risk of potential lawsuits stemming from inadequate or improper education is theoretically significant. Although economic motivation pushes healthcare organizations to recognize the need to support patient education, the humanistic approach of the healthcare providers that leads to the recommendation for such education (with, we hope, some crossover motivation in the best of all worlds!), both groups may be further encouraged by the potential for liability of not doing so.

Therefore, it is prudent for healthcare professionals to ensure that their patients receive education of proper quality. Unless a program is known to meet established standards, programs recognized by the ADA or educators certified by the National Certification Board for Diabetes Educators are the most reliable sources of proper education. Healthcare professionals should encourage patients to attend such programs and document in the patient’s record that they did so.