Not as easy as it looks

Not as easy as it looks

For years Diabetic Investor has been extolling the virtues of patient education, how education leads to improved outcomes. Numerous studies have been published on the subject with the majority concluding that education is the most effective tool for producing better outcomes. Today we were surprised to learn of a study which seems to indicate that education while beneficial did not lead to better outcomes.

Published in Health Services Research, Rosa Solorio, M.D., an assistant professor at the University of Washington, and her colleagues sought to determine whether using Chronic Care Coordinators (CCCs) improves health outcomes for type 2 diabetes patients. The researchers studied nearly 1,500 patients receiving diabetes care in 2009 at six clinics for low-income patients in western Washington State. The clinics all used electronic medical records (EMRs) to track patient data which gave the researchers access to detailed care information.

Patients were assigned to one of two groups: Those who saw a CCC at least once over the course of a year and those who never saw a CCC. More than half of the patients were non-white Hispanics.

The researchers found that patients who saw a CCC had significantly more A1C tests, kidney function tests, eye exams, foot exams and primary care provider visits than the non-CCC group. However, neither group showed improved blood-sugar control.

At first glance these results appear to contradict the many studies which show a direct line between patient education and improved outcomes.  That is until one considers the level or amount of education these patients received as the standard was at least one visit with a CCC. Perhaps this why the authors of the study concluded; “CCC interventions offer promise in improving process measures within community health centers but need to be modified to improve metabolic control.”

Another factor that needs to be considered is not just the amount of education but also location or where the patient needs to be to receive the education.  In this study patients went to a community health center not necessarily an impediment but not exactly an ideal location. The simple fact is when it comes to education the easier it is for the patient to access this information the better and more effective it is. This is why Diabetic Investor has long been a proponent of online education as a patient can receive the education when they want and were they want.

Also not considered in this study was what would motivate or engage these patients other than the education did not cost anything.  This is why Diabetic Investor has long promoted the use of incentivizes, as these incentivizes whether actual money or merchandise, help engage the patient in the education process.

Finally there is the unknown of what the education was focused on.  The way it appears to Diabetic Investor the education was centered on the collection of data, not what to do with the data once it was obtained.  This is a common mistake as far too often education efforts aren’t tied to verifiable, measurable results. Think of what it would mean to the patient if they were motivated not just to collect the data but to turn this data into actionable information and then be incentivized for improvements, i.e. better outcomes.

This is particularly true when it comes to patients with Type 2 diabetes, the focus of this study. One of the biggest issues with patients with Type 2 diabetes is they can be completely out of control yet not physically feel like anything is wrong. It’s not until things are too late that the out of control Type 2 patient feels any physical discomfort. We’ve said it a thousand times uncontrolled diabetes is not like chronic back pain where the patient actually feels discomfort which leads the patient to do whatever they can to get out of pain.

Another issue with Type 2 patients is that even with education they must be proactive with their physician when it comes to making changes to their therapy regimen. For non-insulin Type 2’s this is even more problematic as they cannot simply adjust insulin dosing in an attempt to improve outcomes. The harsh reality is the majority of physicians follow the treat to failure approach before making changes to the patient’s therapy regimen.

The fact is education does work when it’s ongoing, easy to use and provides the patient with some type of reward, and we’re sorry but better outcomes are not a reward, yes this is the goal but in all honesty better outcomes are not something tangible a patient can see or feel. This is perhaps the most common misconception when it comes to patient education the thought by many that patients actually care or understand what better outcomes mean. Far too often the standard motivator is guilt, that if you don’t do this you’ll lose your eye sight or limbs.

From the perspective of the patient, Type 2’s in particular, they know this can happen but seem to think it will happen to the other guy or won’t happen until sometime in the distant future. This is why it’s critical that these patients not only get engaged with their education but receive something tangible for their efforts. That they receive constant, positive reinforcement and not guilt or fear tactics, tactics which only push the patient further away from becoming more engaged.

Honestly why would anyone want to sit and listen to a doctor or nurse list all the negatives that can happen when the patient doesn’t practice good diabetes management. This makes no sense and flat out doesn’t work. The patient should be made aware of what could happen but also be rewarded and congratulated for making the effort to control their diabetes.

We’ve said it before and we’ll say it again for the vast majority of patients, Type 1 or Type 2, they want to live their lives with diabetes not for their diabetes. They understand that diabetes should be taken seriously but don’t want diabetes to run their already busy lives. Yes good diabetes management is job with no days off but there is nothing written anywhere that says it has to be Herculean task.

As well intentioned as many of these education efforts are, they lack the basic knowledge of what a patient goes through each and every day of their lives. They are based on the false assumption that patients understand what better control really means.  They focus too much on the collection of data and not enough on what to do with this data. Worst of all they don’t acknowledge the effort and hard work the patient puts into their diabetes management. Bottom line they aren’t putting the patient first and that’s the biggest mistake of all.