2016 Q1 AACE STUDY
WHEN THE DE'S ROLE EXPANDS, PATIENT OUTCOMES IMPROVE
Diabetes educators formally trained and overseen by endocrinologists can successfully instruct and guide patients' treatment at the primary care level—even without the patients being seen by an endocrinologist. In a recent study [Al-Atrash et al] presented at the American Association of Clinical Endocrinologists' (AACE's) 24th Annual Scientific and Clinical Congress, researchers reported that these specially trained certified diabetes educators (called CDE-Ambassadors, or CDE-As) induced significant improvements in patient outcomes, including:
- Glycemic control (as measured by A1C);
- Body weight/body mass index (BMI);
- Blood pressure (BP); and
- Lipid concentrations
ABOUT THE STUDY
The retrospective review included 100 patients with type 2 diabetes (T2D) who were referred by their primary care physician (PCP) to consult with a CDE-A at an endocrinology practice. None of the patients was seen directly by an endocrinologist. The CDE-As received training from endocrinologists for 3 months prior to the study start.
The patients' clinical outcomes were compared to 45 patients with T2D from the same practice who were not referred to a CDE-A. Researchers tracked glycemic control, cardiovascular risk factors, and other clinical measures during an average study period of 4.6 months, starting with the first CDE-A visit and ending with each patient's regularly scheduled follow-up appointment with his or her PCP. During that time, most patients met with the CDE-A 2 times.
Overall, the patients who were under the care of a CDE-A saw the following improvements:
- Glycemic control: A1C dropped from 8.4% ± 2%, to 6.8% ± 1%
- Weight/BMI: Weight decreased by 2.8 kg, and BMI by 0.96 (P <0.0001 for all).
- BP: Systolic BP decreased from 134 ± 17 mm Hg to 128 ± 13 mm Hg, and diastolic BP dropped from 80 ± 10 mm Hg to 77 ± 9 mm Hg (P <0.005 for both).
- Lipid concentrations: Low-density lipoprotein-cholesterol (LDL-C) fell from 108 ± 36 mg/dL to 96 ± 36 mg/dL, and triglycerides decreased from 189 ± 121 to 162 ± 90 mg/dL (P <0.005 for both).
- Albuminuria: The urine microalbumin/creatinine ratio dropped from 64 ± 536 to 27 ± 153 mg/g (however, that number was not statistically significant at P = 0.33).
"These changes were dependent on changes in dietary habits and drug therapy, including the addition or optimization in the doses of anti-diabetic drugs and insulin doses," the authors wrote. They noted that the improvements in lipid concentrations occurred without any changes in statin therapy, theorizing that enhanced adherence may have been a factor.
In contrast, the 45 comparator patients who were not under the care of a CDE-A during a similar follow-up period did not see any significant changes in any of these indices.
FUTURE RESEARCH & FOLLOW-UP
The researchers stated that they are considering conducting prospectively randomized studies to compare centers that are supported with CDE-As and those that are not, with a focus on measuring the durability of these effects as well as cost considerations—including possible cost savings.
"The changes in glycemia, blood pressure, lipids, and body weight would potentially result in a significant reduction in microvascular and macrovascular complications and improvement in the quality of life of these patients," the authors stated. "In addition, it will reduce the magnitude of expenditure which currently occurs in the management of these complications."
DIABETES EDUCATOR TAKE-HOME POINT FROM LAUREL MESSER, RN, MPH, CDE: The improvement in health metrics that patients in this study experienced is good news for both patients and DEs. There is no question that when healthcare professionals spend time with their patients, patient education, understanding, and outcomes improve. This study demonstrates exactly that, with an exciting applicability to DEs and the important role we can play in improving patient outcomes.
Here are some thoughts on how the CDE-Ambassador model can be translated and replicated for wider use:
- More PCPs could employ professionals in a CDE-Ambassador type role to work in conjunction with local endocrinologists for ongoing training. With a shortage of practicing endocrinologists in this country, this is a creative way to ensure that patients with diabetes receive comprehensive care in a primary care setting.
- Perhaps a DE in your practice (such as yourself!) could initiate a conversation about how to expand the DE role to make a version of the CDE-Ambassador a local reality. Opportunities abound, and clinical research such as this study backs up the life-changing difference that DEs can make.
In a healthcare environment that discourages providers from spending adequate time with patients, maximizing the role of DEs to deliver first-rate healthcare is inspired. As DEs, we consistently strive to utilize our advanced knowledge to achieve better patient outcomes—so it's a perfect fit.
- Al-Atrash F, Mersereau M, Bierbrauer M, et al. The CDE-Ambassador: A novel approach to control diabetes at the primary care level leads to significant improvement in glycemic control and cardiovascular risk factors [Abstract]. Presented at: American Association of Clinical Endocrinologists' 24th Annual Scientific and Clinical Congress; May 13-17, 2015; Nashville, TN. http://journals.aace.com/doi/pdf/10.4158/1530-891X-21.s2.1. Accessed May 20, 2015.
- 24th Annual Clinical & Scientific Congress. American Association of Clinical Endocrinologists. http://am.aace.com/. Accessed May 20, 2015.