Barriers and Attrition in Diabetes Self-management Education
How many times have you heard a potential client offer excuses, aka, barriers, about why they cannot attend DSME? After adjusting my programs calendar to include day, evening, and weekend classes, the barrier of not wanting to take off from work has dropped significantly. From time-to-time, I still have a client complain that they would never consider attending all five of the DSME classes, as this would be too time consuming. By far, the barrier I hear the most is that they cannot afford the co-pays or the deductible. But, these barriers just apply to clients that actually make an appointment and show-up.
That brings me to my next point. What is your capture and retention rate? In my practice, I have a 58% capture rate for an initial appointment. Of that 58%, only 33% attend all five classes. Note, ‘graduates’ sing our praises and we have a positive clinical effect on all of the ten clinical markers we track, year after year.
The statistics released by the American Diabetes Association (ADA) in 2017 state that 12.3% of adults have diabetes and another 33% have prediabetes. Diabetes educators should be inundated with clients, attempting to accommodate 45% of the adults in the United States at least once a year, which is the recommendation of the Joint Position Statement of 2015 (Powers et al.). Yet, recently, I have heard of several facilities closing diabetes programs or asking the diabetes educators to take on additional non-diabetes related clinical roles to decrease the staffing footprint. Diabetes educators should be in high demand! These facts have led me to seriously think about barriers. What are they, and how can we, as educators, overcome them?
Searching the medical databases turns up numerous journal articles about the phenomenon of barriers to DSME. We all know the barriers, we hear them every day. In 2008, Gucciardi, DeMelo, Offenheim, and Stewart studied the barriers in Toronto. Remember, in Canada, the issues of deductibles and co-pays are moot, but the authors still reported a 44% attrition rate. This study stated the four top reasons for lack of participation in DSME (once finances are eliminated) are; apathy, low perceived seriousness of the disease, regular appointments with the physician, and forgetfulness.
Seeing a physician regularly and forgetfulness are understandable barriers. They are not great excuses, but let’s move on. So, let’s talk about apathy and lack of perceived seriousness of the disease. Where does this stem from? Going back to the ADA Fast Facts (2017) we read “diabetes kills more Americans every year than AIDS and breast cancer combined.” Do I need to repeat that quote? How many patients would put learning about diabetes on the back burner, saying, “I have a touch of diabetes” if they were told of the seriousness of the complications of uncontrolled diabetes? We all know that if we told our patients they had breast cancer or AIDS they would be in contact with a specialist by the end of the day!
In another article by the same group (Gucciardi, DeMelo, Booth, Tomlinson, and Stewart (2009) they suggest that the lack of symptoms at the onset of the disease could be a contributing
factor to lack of utilization of DSME. As educators, we often see clients who are now experiencing complications after years or decades of diabetes seeking to make changes that will help alleviate the damages. Unfortunately, sometimes it is too late, thus the Joint Position Statement’s (2015) stance that patients see a diabetes educator at diagnosis. Gucciardi et al. (2009) suggest that we not wait for referrals to diabetes education, but go directly to the public to promote DSME.
The opinions (and frustrations) in this blog are my own. What are your opinions or suggestions on the topics of barriers and attrition? I would like to hear from you.
References
American Diabetes Association. (2017). Fast facts: data and statistics about diabetes. Located at: https://professional.diabetes.org/sites/professional.diabetes.org/files/media/fast_facts_8-2017_pro_3.pdf
Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Hess Fischl A,…Vivian E. (2015). Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educucation 41(4):417-430.
Gucciardi, E., DeMelo, M., Booth, G., Tomlinson, G. & Stewart, D.E.. (2009). Individual and contextual factors associated with follow-up use of diabetes self-management education programmes: a multisite prospective study. Diabetes UK 26: 510-517.
Gucciardi, E., DeMelo, M., Offenheim, A., & Stewart, D.E.. (2008). Factors attributing to attrition behavior in diabetes self-management programs: a mixed method approach. BMC Health Services Research 8:33.