Costs and effects of a telephonic diabetes self-management support intervention using health educators.

BACKGROUND: Self-management is crucial to successful glycemic control in patients with diabetes, yet it requires patients to initiate and sustain complicated behavioral changes. Support programs can improve glycemic control, but may be expensive to implement. We report here an analysis of the costs of a successful telephone-based self-management support program delivered by lay health educators utilizing a municipal health department A1c registry, and relate them to near-term effectiveness. METHODS: Costs of implementation were assessed by micro-costing of all resources used. Per-capita costs and cost-effectiveness ratios from the perspective of the service provider are estimated for net A1c reduction, and percentages of patients achieving A1c reductions of 0.5 and 1.0 percentage points. One-way sensitivity analyses of key cost elements, and a Monte Carlo sensitivity analysis are reported. RESULTS: The telephone intervention was provided to 443 people at a net cost of $187.61 each. Each percentage point of net A1c reduction was achieved at a cost of $464.41. Labor costs were the largest component of costs, and cost-effectiveness was most sensitive to the wages paid to the health educators. CONCLUSIONS: Effective telephone-based self-management support for people in poor diabetes control can be delivered by health educators at moderate cost relative to the gains achieved. The costs of doing so are most sensitive to the prevailing wage for the health educators.

Upending the social ecological model to guide health promotion efforts toward policy and environmental change.

Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere.

Nurse led versus lay educators support for those with asthma in primary care: a costing study.

BACKGROUND: Regular review and support for asthma self-management is promoted in guidelines. A randomised controlled trial suggested that unscheduled health care usage was similar when patients were offered self management support by a lay-trainer or practice nurses. METHODS: Following the RCT, a costing study was undertaken using the trial data to account for the cost of delivery of the service under both strategies and the resulting impact on unscheduled healthcare (measure of effectiveness) in this trial. RESULTS: One year data (n = 418) showed that 29% (61/205) of the nurse group required unscheduled healthcare (177 events) compared with 30.5% (65/213) for lay-trainers (178 events).The training costs for the lay-trainers were greater than nurses (£36 versus £18 respectively per patient, p<0.001), however, the consultation cost for lay-trainers were lower than nurses (£6 per patient versus £24, p<0.001). If the cost of unscheduled healthcare are accounted for then the costs of nurses is £161, and £135 for lay-trainers (mean difference £25, [95% CI = -£97, £149, p = 0.681]). The total costs (delivery and unscheduled healthcare) were £202 per patient for nurses versus £178 for lay-trainers, (mean difference £24, [95%CI = -£100, £147, p = 0.707]). CONCLUSIONS: There were no significant differences in the cost of training and healthcare delivery between nurse and lay trainers, and no significant difference in the cost of unscheduled health care use.

A motivational peer support program for type 2 diabetes prevention delivered by people with type 2 diabetes: the UEA-IFG feasibility study.

PURPOSE: The purpose of this study was to develop a peer support program for individuals at high risk of type 2 diabetes as part of a novel Diabetes Prevention Programme (The UEA-IFG Study). Lay members of the public with existing type 2 diabetes volunteered as peer supporters (termed type 2 trainers) for participants at high risk of developing type 2 diabetes. The feasibility of type 2 trainer recruitment, training, and retention was tested. METHODS: Between January and September 2009, 1500 potential type 2 trainers with existing type 2 diabetes were contacted and 168 (11%) expressed an interest. From this group, 26 type 2 trainers were appointed to begin training. All completed 7 training seminars, covering diabetes prevention, nutrition, physical activity, listening skills, motivation, and goal planning. Motivational calls were made every 12 weeks to each study participant by each type 2 trainer in addition to health care professional-delivered education sessions. RESULTS: Twenty-six type 2 trainers were recruited to enter the program. One type 2 trainer withdrew before beginning their role. The retention rate was high, with 22 (89%) of the type 2 trainers continuing until study end (July 2010; 20 months), with a total of 240 phone calls made. CONCLUSION: The recruiting and training of lay volunteers with existing type 2 diabetes as type 2 trainers to support study participants at risk of developing the same condition was a cost-effective strategy in comparison to employing salaried health care professionals and warrants further investigation on health outcomes.

Exploring the cost and clinical outcomes of integrating the registered nurse-certified diabetes educator into the patient-centered medical home.

PURPOSE: The purpose of this study was to implement and evaluate a care delivery model integrating the registered nurse-certified diabetes educator into the patient-centered medical home to assist in achieving positive clinical and cost outcomes in diabetes care. METHODS: A 1-group pretest-posttest research design was used. Patients were recruited from 2 patient-centered medical home designated/nominated primary care offices. Inclusion criteria were as follows: diagnosis of type 1 or type 2 diabetes, aged 18 to 80 years, A1C ≥ 8%, English speaking, and no diabetes education within 6 months. There were 34 participants (men, n = 22; women, n = 12) with a mean age of 53.24. The intervention incorporated an assessment, 4 patient-centered monthly group sessions, and 4 individual follow-up sessions. Study measures included program surveys, participation and satisfaction rates, Healthcare Effectiveness Data and Information Set attainment rates, and the following physiologic measures obtained from the medical record: A1C, fasting blood glucose, LDL, urine microalbumin, blood pressure, retinal eye exam, and body mass index. Cost-effectiveness measures included program costs, performance incentives, revenue, provider time saved, and patient health care utilization. RESULTS: Paired-samples t tests identified significant improvements in A1C, fasting blood glucose, and LDL. Patients and providers were highly satisfied with the program. Cost-benefit analysis revealed a net pretax program benefit. CONCLUSIONS: Results of the study indicated that integrating the registered nurse-certified diabetes educator in the patient-centered medical home improves clinical outcomes and is cost-effective. Diabetes education and support are integral components of diabetes management.

A community-based diabetes prevention program: evaluation of the group lifestyle balance program delivered by diabetes educators.

PURPOSE: With growing numbers of people at risk for diabetes and cardiovascular disease, diabetes educators report increasing referrals for intervention in prevention of these conditions. Diabetes educators have expertise in diabetes self-management education; however, they are generally not prepared for delivery of chronic disease primary prevention. The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease. METHODS: Diabetes educators in 3 outpatient-hospital programs (urban, suburban, and rural) received training and support for implementation of the Group Lifestyle Balance program, an adaptation of the Diabetes Prevention Program lifestyle intervention, from the Diabetes Prevention Support Center of the University of Pittsburgh. Adults with prediabetes and/or the metabolic syndrome were eligible to enroll in the program with physician referral. With use of existing diabetes educator networks, recruitment was completed via on-site physician in-services, informative letters, and e-mail contact as well as participant-directed newspaper advertisement. RESULTS: Eighty-one participants enrolled in the study (71 women, 10 men). Mean overall weight loss was 11.3 lb (5.1%, P < .001); in addition, significant decreases were noted in fasting plasma glucose, low-density lipoprotein cholesterol, triglycerides, and blood pressure. CONCLUSIONS: These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals. Furthermore, diabetes educators, already integrated within the existing health care system, provide yet another resource for delivery of primary prevention programs in the community.

Assessing the value of the diabetes educator.

PURPOSE: The purpose of this study was to evaluate the effectiveness of diabetes self-management education or training provided by diabetes educators in reducing complications and improving quality of life. METHODS: Commercial and Medicare payer-derived claims data were used to assess the relationship between DSME/T and cost. Unlike the prior study that examined diabetes education provided by all professionals, the current study focused on the value of interventions performed as part of formal accredited/recognized diabetes education programs provided by diabetes educators only. Specifically, the current study focused on diabetes education delivered in diabetes self-management training programs based on 2 codes (G0108 and G0109). RESULTS: Results of the study provide insights into the differences in trends between participants and nonparticipants in DSMT. People with diabetes who had DSMT encounters provided by diabetes educators in accredited/recognized programs are likely to show lower cost patterns when compared with a control group of people with diabetes without DSMT encounters. People with diabetes who have multiple episodes of DSMT are more likely to receive care in accordance with recommended guidelines and to comply with diabetes-related prescription regimens, resulting in lower costs and utilization trends. Conclusions and Policy Implications The collaboration between diabetes educators and patients continues to demonstrate positive clinical quality outcomes and cost savings. This analysis shows that repeated DSMT encounters over time result in a dose-response effect on positive outcomes.

The educational and financial impact of using patient educators to teach introductory physical exam skills.

PURPOSE: Physical exam skills are essential to core competencies for physicians in training. It is increasingly difficult to secure time and funding for physician faculty to teach these critical skills. This study was designed to determine whether Patient Educators (PE) (non-physician instructors) in an introductory clinical medicine (ICM) course (1) were as effective as physician faculty in teaching the physical exam, (2) impacted consistency of student performance on a final practical exam, and (3) whether this model was cost effective. METHOD: PE were introduced into an ICM course at the University of Minnesota from 2006 to 2008. Each year, students' physical exam competencies were evaluated by a performance-based head-to-toe examination and 6 months later by an objective structured clinical examination (OSCE). Differences in test scores between years and variability (i.e., consistency) among yearly scores were assessed. The cost per student was calculated by considering a stable compensation cost per hour for the required number of physician faculty, standardized patients, and PE in each year. RESULTS: Mean student performance was statistically lower with PE, but only by two percentage points. The amount of variation within the medical student classes' physical exam skills remained stable as the use of PE expanded. Total educator salary costs per student declined from $449 in 2006 to $196 in 2008. CONCLUSIONS: In terms of sustainability and student performance, the use of trained lay educators has equivalent outcomes and is less costly for physical exam instruction in the pre-clinical years.

Reimbursement as a legitimizing strategy for health education.

The health education profession has made significant advances throughout the past few decades. However, health education is still described as an emerging profession. This article suggests strategies to move health education from its status as an emerging profession into that of an acknowledged profession. The authors assert that actively seeking direct third-party reimbursement will advance health education's emergence as a profession as well as increase its legitimacy in the eyes of other professions. The benefits of direct third-party reimbursement, experiences of the nursing profession's pursuit of direct third-party reimbursement, and the current status of health education are discussed. The article concludes by offering strategies for pursuing direct third-party reimbursement.

An evaluation of needle exchange programmes in China.

OBJECTIVES: To provide an overview of needle exchange programme (NEP) models used in China and factors associated with their use by injecting drug users (IDU). DESIGN: A cross-sectional survey. METHOD: Fifteen NEP in Sichuan and Guangxi provinces were selected for study. The managers were asked to complete a short questionnaire and participate in an interview about the services offered, including needle turnover rates, number of clients, and use of peer educators. The local senior police officers were interviewed for their points of views about NEP. Finally, drug users using the NEP and those residents in compulsory detoxification centres were surveyed about using NEP services. RESULT: The NEP offered services during normal working hours and used peer educators to do additional exchanging that involved secondary exchangers in the community. Needle turnover ranged from 70.1% to over 100%. Most attendees (82.3%) knew about the service through friends, but only 7.3% of local IDU were using the services. Peer educators could get almost all the needles they needed, but secondary exchangers could only get approximately two-thirds of their required needles. NEP attendees were more frequent injectors and had a higher education than non-attendees. Needle turnover was higher when peer educators had a higher wage and when local police were supportive of the programme. CONCLUSION: NEP are improving in terms of needle turnover and attendance. Greater cooperation from police, higher wages for peer educators, and wider awareness of the programmes among IDU are needed to increase coverage.

National survey of cancer educators: salary and budget.

The National Cancer Institute's Cancer Patient Education Network (CPEN) is composed of cancer education leaders from National Cancer Institute (NCI)-designated comprehensive and clinical cancer centers throughout the United States. Despite this commonality, the role and responsibilities of CPEN members vary across institutions. In an effort to further understand the commonalities and variances among the membership, the authors undertook a research project addressing salary and budget issues across NCI-designated cancer centers. The purpose of this study was to benchmark salaries and budgets of cancer educators at NCI-designated cancer centers; provide information to support a competitive salary range based on benchmarking with peers responsible for cancer patient education; and glean information on CPEN membership, roles, education levels, and job functions. This article highlights lessons learned and offers suggestions for using this information in a broader capacity for other cancer patient educators and patient educators in general.