A Little Education Goes a Long Way




The burden of type 2 diabetes is staggering. Close to 20 million people in the United States are diagnosed with type 2 diabetes, and total costs related to diabetes are creeping toward $200 billion annually. Programs to prevent and treat diabetes are numerous, but the effectiveness of various types of programs and modes of education are unclear. Now, a report in the British Medical Journal (BMJ) suggests that an education and self-management program for patients with type 2 diabetes is a cost-effective intervention.

The authors of the BMJ study conducted a cost-utility analysis using data from the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) intervention, a 12-month multicenter randomized trial that evaluated the effectiveness of a structured 6-hour group education program for 824 newly-diagnosed diabetes patients. The results of the DESMOND trial previously reported that patients participating in the education program had significant improvements in weight, smoking cessation, illness beliefs, and depression scores. (Hemoglobin A1c — the traditional measure of long-term diabetes control — was not significantly improved by DESMOND.) The current analysis modeled outcomes in terms of treatment costs, mortality and complication rates, and effects on health-related quality of life.

Based on trial data, the mean incremental lifetime cost of the DESMOND intervention was approximately $326, with a mean incremental cost of approximately $8400 for each quality-adjusted life year (QALY) gained. A real-world analysis calculated a lifetime incremental cost of $127, with a mean incremental cost per QALY of $3263. Overall, the authors report that participants gained the equivalent of half of a month of full health. A one-way sensitivity analysis suggested that DESMOND would be a cost-effective intervention, even if the benefits were lost after 1 year. The economic benefits realized were primarily a result of reductions in body weight and smoking cessation.

Lifestyle interventions, including changes in diet, smoking and exercise habits, are the cornerstone of diabetes management, particularly for newly-diagnosed patients. Many studies and trial programs have attempted to define the best method for educating patients with diabetes, but it is often difficult for patients to implement and maintain the advice offered by health care providers. Several studies have actually shown only negligible benefits of diabetes education and self-management when compared with traditional care and routine treatment; group-based training seems to have better outcomes than individual education. Interestingly, a few studies have actually reported no benefit — and even some disadvantages — to self-monitoring of blood glucose by patients, a task typically thought of as critical to diabetes management.

So what makes DESMOND different? First, the current intervention targets multiple risk factors for diabetes-related morbidity. It is possible that a lot of little changes added up to a significant benefit among the patients evaluated. Also, patients enrolled in DESMOND were encouraged to set their own goals, rather than a health care practitioner issuing stringent guidelines.  This more facilitative and less didactic approach has proved to be a positive educational style in similar programs.

While the modest gains realized by the DESMOND educational program do not appear to be entirely game-changing in battle with diabetes, the improvement in self-management and treatment satisfaction among diabetes patients may prove beneficial in the long-term as the burden of type 2 diabetes grows. As this study showed, when health care providers are overburdened with patients with chronic diseases and society is faced with treatment costs, lost productivity, and pain and suffering related to diabetes, every little bit helps.

References

American Diabetes Association (2008). Economic costs of diabetes in the U.S. In 2007. Diabetes care, 31 (3), 596-615 PMID: 18308683

Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Dallosso HM, Daly H, Doherty Y, Eaton S, Fox C, Oliver L, Rantell K, Rayman G, Khunti K, & Diabetes Education and Self Management for Ongoing and Newly Diagnosed Collaborative (2008). Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ (Clinical research ed.), 336 (7642), 491-5 PMID: 18276664

Deakin T, McShane CE, Cade JE, & Williams RD (2005). Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane database of systematic reviews (Online) (2) PMID: 15846663

Deakin TA, Cade JE, Williams R, & Greenwood DC (2006). Structured patient education: the diabetes X-PERT Programme makes a difference. Diabetic medicine : a journal of the British Diabetic Association, 23 (9), 944-54 PMID: 16922700

Duke SA, Colagiuri S, & Colagiuri R (2009). Individual patient education for people with type 2 diabetes mellitus. Cochrane database of systematic reviews (Online) (1) PMID: 19160249

Farmer AJ, Wade AN, French DP, Simon J, Yudkin P, Gray A, Craven A, Goyder L, Holman RR, Mant D, Kinmonth AL, Neil HA, & DiGEM Trial Group (2009). Blood glucose self-monitoring in type 2 diabetes: a randomised controlled trial. Health technology assessment (Winchester, England), 13 (15) PMID: 19254484

Gillett M, Dallosso HM, Dixon S, Brennan A, Carey ME, Campbell MJ, Heller S, Khunti K, Skinner TC, & Davies MJ (2010). Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis. BMJ (Clinical research ed.), 341 PMID: 20729270

Loveman E, Cave C, Green C, Royle P, Dunn N, & Waugh N (2003). The clinical and cost-effectiveness of patient education models for diabetes: a systematic review and economic evaluation. Health technology assessment (Winchester, England), 7 (22) PMID: 13678547

O’Kane MJ, Bunting B, Copeland M, Coates VE, & ESMON study group (2008). Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ (Clinical research ed.), 336 (7654), 1174-7 PMID: 18420662

Skinner TC, Carey ME, Cradock S, Dallosso HM, Daly H, Davies MJ, Doherty Y, Heller S, Khunti K, Oliver L, & DESMOND Collaborative (2008). ‘Educator talk’ and patient change: some insights from the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) randomized controlled trial. Diabetic medicine : a journal of the British Diabetic Association, 25 (9), 1117-20 PMID: 19183318

Urbanski P, Wolf A, & Herman WH (2008). Cost-effectiveness of diabetes education. Journal of the American Dietetic Association, 108 (4 Suppl 1) PMID: 18358259

Jennifer Gibson, PharmD

Jennifer Gibson, PharmD, is a practicing clinical pharmacist and medical writer/editor with experience in researching and preparing scientific publications, developing public relations materials, creating educational resources and presentations, and editing technical manuscripts. She is the owner of Excalibur Scientific, LLC.
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