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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence Jun Wu a,∗ , Mary Lynn Davis-Ajami b , Virginia Noxon c , Zhiqiang Kevin Lu c a
Department of Pharmaceutical & Administrative Sciences, Presbyterian College School of Pharmacy, 307 N. Broad Street, Clinton, SC 29325, USA b Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, USA c Department of Clinical Pharmacy & Outcomes Sciences, University of South Carolina, Columbia, USA
a r t i c l e
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a b s t r a c t
Article history:
Aims: To determine predictors associated with the diabetes self-management education and
Received 22 April 2016
training (DSME) venue and its impact on oral antidiabetic (OAD) medication adherence.
Received in revised form
Methods: The Medical Expenditure Panel Survey household component (MEPS-HC) data
22 September 2016
(2010–2012) identified adults with diabetes prescribed OAD medication(s) who completed
Accepted 16 October 2016
a supplemental Diabetes Care Survey (DCS). Based on the DCS responses to questions about
Available online xxx
the number and type of DSME venue(s), two groups were created: (1) multiple venues (a physician or health professional plus internet and/or group classes) vs (2) single venue
Keywords:
(physician or health professional only). The medication possession ratio (MPR) measured
Diabetes self-management
medication adherence, with 0.80 the cut-point defining adherent. Logistic regression exam-
education and training
ined factors associated with the DSME venue and its effect on OAD medication adherence.
Oral antidiabetic medication
Results: Of the 2119 respondents, 41.6% received DSME from multiple venues. Age (<65 years),
Medication adherence
education-level (college or higher), high-income, and diet modification were significantly
Diabetes
more likely associated with receiving DSME from multiple venues. In single vs multiple venues, medication adherence was suboptimal (mean MPR 0.66 vs 0.64, p = 0.245), and venue showed no influence on adherence (OR: 0.92, 95% CI, 0.73–1.16). Conclusion: Sociodemographic characteristics influence where adults with diabetes receive DSME. Adding different DSME venues may not address suboptimal OAD medication adherence. © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Diabetes affects 29.1 million individuals or 9.3% of the US population, with another 86 million classified as prediabetes
∗
[1]. Each year the number of new diabetes cases increases. As a chronic disease, diabetes requires daily self-care management involving an array of self-care behaviors, lifestyle interventions, and medication management to optimize blood glucose levels, and prevent disease progression [2]. Medication adherence along with dietary and activity recommendations significantly impact health outcomes [3–5]. Interdisciplinary diabetes self-management education and support (DSME) is
Corresponding author. Fax: +1 864 938 3909. E-mail address:
[email protected] (J. Wu). http://dx.doi.org/10.1016/j.pcd.2016.10.005 1751-9918/© 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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central to improving glycemic control, medication adherence and health outcomes [6,7]. The National Standards for Diabetes Self-Management Education and Support emphasize individualized patient-centered educational approaches that are accessible, professionally coordinated, evidence based, and supportive of the disease management and monitoring processes over time [2]. Individuals with diabetes receive DSME from various formal and informal sources, including one-on-one discussions, structured group classes, online courses, or self-directed internet searches [8–10]. Physicians and certified diabetes educators are the most common primary source of DSME. Professionally coordinated DSME covers core topics in the Standards including: disease process and treatment options; lifestyle factors; safe medication use management; preventing, detecting and treating acute and chronic complications; personal strategies for psychological well-being; and strategies to promote health and behavior change [2]. However, access to medical appointments, appointment time constraints, short appointments, and work flow and throughput demands, limit the time available for DSME [11,12]. Licensed health care providers’ attitudes and knowledge about diabetes and their individual communication skills and ability to foster good patient-provider relationships also impact DSME outcomes including medication adherence [13–15]. Additionally, the patient’s ability to absorb and retain information during short appointments leaves gaps in DSME. Individuals with diabetes when faced with chronic complex self-directed care might explore other sources to augment their formal DSME. Self-directed DSME gives individuals flexibility in choosing DSME venues that suit their schedules, learning styles, educational levels, language, or socioeconomic means. However, few research studies assessed the use patterns of DSME venue and how the number or type of DSME venue impact specific diabetes care outcomes, such as diabetes medication adherence in a nationally representative sample of adults with diabetes. Understanding how to receive DSME and their impact on diabetes care outcomes could help DSME educators tailor educational strategies based on patient characteristics to deliver more effective educational programs. The objectives of this study are to: (1) determine demographic and socioeconomic factors associated with the likelihood of receiving DSME from multiple venues (talking to or phoning any physician or health professional, plus reading about diabetes self-management on the internet and/or group classes) vs single venue (talking to a physician or health professional only) and (2) examine the effect of DSME venue on oral antidiabetic (OAD) medication adherence in a large generalizable sample of the US adult population with diabetes.
2.
Methods
2.1.
Data source
A retrospective cross sectional study covering years 2010–2012 was conducted among the publically available, de-identified, Medical Expenditure Panel Survey (MEPS) full year consolidated household component (MEPS-HC) respondents. MEPS is conducted under the auspices of the Agency for Healthcare
Research and Quality (AHRQ). The MEPS-HC is drawn from a nationally representative subsample of households that participated in the prior year’s National Health Interview Survey [16]. MEPS-HC uses a stratified multistage national probability design allowing researchers to give nationally representative information about the civilian non-institutionalized US population. More specifically, MEPS-HC collects data about demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income and employment. The survey is conducted with an overlapping panel design where each year a new independent panel of participants begins a full year survey. The survey is then divided into 2–3 separate interview rounds in one year. The survey participants in each year by panel are independent. Our study accessed the full year consolidated, medical condition, and prescribed medicines files. The MEPS-HC full year consolidated files were accessed for demographic, socioeconomic, health status and all Diabetes Care Survey (DCS) variables. The MEPS prescribed medicines files were accessed for variables related to OAD prescribed medications used as an inclusion criterion, as well as to calculate the medication adherence measure. The medical condition files were accessed to evaluate the comorbidities.
2.2.
Study population
The study identified MEPS respondents (≥18 years) who were told by a physician or health professional that they had diabetes and who were prescribed one or more OAD medication(s). Eligible respondents were defined as those who participated in the full year survey, completed the DCS, and responded “yes” to the DSME gate question that stated “During the last 12 months, have you learned how to take care of your diabetes?”
2.3.
Receiving DSME from multiple vs single venue
DCS, a priority condition sub-survey of the MEPS, is a part of MEPS-HC and fielded during one of the interview rounds. In the DCS, MEPS surveyors query respondents “During the last 12 months, have you learned how to take care of your diabetes?” Those who answer “yes” to this gate question go on to answer six additional questions regarding where they learned diabetes self-management (1) talking to a doctor/health professional within their primary care practice, (2) talking to a doctor/health professional not in your primary care practice, (3) from a phone call with a health professional, (4) from reading about it on the internet, (5) by taking a group class, and (6) other, specify. For our study, we collapsed the six categories into the following two main categories: (1) multiple venues: defined as a physician or health professional plus one or more additional venue including reading on the internet and/or group class; (2) a single venue: defined as a physician or health professional only. Those who reported internet and/or group class only as DSME venues were excluded from the study due to extremely small sample size (<3%). The qualitative answers for “other” were not included.
Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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2.4.
Medication adherence
OAD medication adherence was measured by the medication possession ratio (MPR), a validated and frequently used method to estimate medication adherence in retrospective database research [17,18]. The MPR is defined as the number of doses dispensed in relation to the dispensing period. The variable from the prescribed medications file representing days supplied for prescribed OAD medications was used to calculate the one year MPRs for all the respondents. A MPR (≥0.80) was defined as adherent [19]. The MPR was calculated using the following formula:
3
All variables of baseline characteristics were included in the logistic regression to identify factors significantly associated with DSME venues. Logistic regression also assessed the effect of DSME venue on OAD adherence by controlling the demographic and health-related covariates that showed differences between the two study groups (multiple vs single groups). Statistical significance was set a priori at p < 0.05. All data analyses and statistical procedures accounted for the MEPS complex survey design by applying the weights for the supplemental DCS survey to produce the national estimates for the study cohort [21]. SAS version 9.4 was employed for all data management and analysis.
MPR = sum of days supplied/365 days
3. 2.5.
Covariates
Demographic and socioeconomic variables included: age, educational attainment, gender, geographical region, income level as a percentage of the US federal poverty line, insurance coverage, and race. Health status variables were derived from the MEPS-HC consolidated files included: body mass index (BMI), perceived health status and comorbidity. Survey respondents are asked to classify their perceived health status on a Likert scale as excellent, very good, good, fair or poor, during every interview round. The widely used and validated Charlson Comorbidity Index (CCI) served as a measure of comorbidity [20].
2.6.
Data analysis
Chi-square tests compared the study cohort’s characteristics between those using multiple vs a single venue. T-tests compared mean MPRs and chi-square tests compared the proportions of subjects with MPR (≥0.80) between the two groups.
Results
A total of 2119 eligible respondents were identified from DCS, approximating 21.6 million US individuals during years 2010–2012. Fig. 1 displays the details about the number and type of DSME venues. A total of 1347 respondents received DSME from a single venue (58.4%, representing 12.6 million US individuals) vs 772 respondents who received DSME from multiple venues (41.6%, representing 8.9 million US individuals). Table 1 describes the characteristics of the study population. Respondents receiving DSME from multiple vs a single venue showed greater proportions from the age group younger than 65 years (70.6% vs 50.8%, p < 0.001), married status (63.4% vs 56.6%, p = 0.008), college or higher education level (21.5% vs 9.9%, p < 0.001), high-income as a percentage of the US poverty level (42.1% vs 26.0%, p < 0.001), private insurance (67.9% vs 51.7%, p < 0.001), and receiving diet treatment (87.1% vs 78.3%, p < 0.001). Table 2 reports the factors predictive of whether a respondent received DSME from multiple vs a single venue. Overall, age, income and education levels, region, and being treated
Fig. 1 – Different venues for how adults with diabetes receive diabetes self-management education and training (n = 2119, weighted n = 21,563,194). Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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Table 1 – Study population characteristics comparing DSME venues (multiple venues vs single venue) for adults prescribed OAD medications from MEPS pooled years 2010–2012. Multiple venuesa , % (SE) (n = 772, weighted n = 8,950,930)
Single venueb , % (SE) (n = 1,347, weighted n = 12,612,264)
Age category 18–45 46–64 65+
13.9 (1.3) 56.7 (2.3) 29.4 (2.1)
8.8 (1.0) 42.0 (1.8) 49.2 (1.9)
<0.001
Region Northeast Midwest South West
14.7 (1.6) 23.6 (1.6) 42.7 (2.2) 19.0 (1.6)
19.1 (1.4) 23.0 (1.7) 37.2 (1.8) 20.8 (1.5)
0.082
Sex Male Female
51.6 (1.9) 48.4 (1.9)
48.4 (1.7) 51.6 (1.7)
0.220
Race White Black Other
78.1 (1.7) 14.3 (1.3) 7.6 (1.1)
74.9 (1.8) 16.3 (1.5) 8.8 (1.1)
0.274
Marital status Yes No
63.4 (2.0) 36.6 (2.0)
56.6 (1.8) 43.4 (1.8)
0.008
Highest degree High school College or higher No degree/other
38.5 (2.2) 21.5 (1.8) 40.0 (2.2)
40.7 (1.8) 9.9 (1.2) 49.4 (1.9)
<0.001
Poverty linec Poor Low-income Middle-income High-income
14.9 (1.5) 13.2 (1.3) 29.8 (2.0) 42.1 (2.4)
24.9 (1.4) 19.3 (1.3) 29.8 (1.7) 26.0 (1.9)
<0.001
Perceived health status Fair/poor Good Excellent/very good
31.8 (2.0) 39.7 (2.1) 28.5 (2.3)
39.6 (1.6) 36.7 (1.8) 23.6 (1.5)
0.011
Insurance coverage Private Public Uninsured
67.9 (2.3) 23.9 (1.9) 8.2 (1.3)
51.7 (1.8) 41.0 (1.8) 7.3 (0.9)
<0.001
Body mass index Underweight/normal Overweight Obese
8.5 (1.1) 31.0 (2.0) 60.5 (2.1)
13.4 (1.1) 29.5 (1.4) 57.1 (1.7)
0.016
Comorbidity index 0 1 >1
68.5 (2.0) 12.1 (1.5) 19.4 (1.7)
65.4 (1.6) 12.8 (1.2) 21.8 (1.5)
0.473
Insulin use Yes No
23.9 (1.6) 76.1 (1.6)
24.6 (1.6) 75.4 (1.6)
0.739
Treated with diet modification Yes No
87.1 (1.4) 12.9 (1.4)
78.3 (1.2) 21.7 (1.2)
<0.001
Variable
P
DSME: diabetes self-management education and training; MEPS: medical expenditure panel survey; SE: standard error. Received DSME from a physician or health professional plus reading about diabetes self-management on the internet and/or from group classes. b Received DSME from a physician or health professional only. c Poverty line categories: Poor defined as income <100% of US federal poverty line (FPL); low-income defined as 100%–199% of US FPL; middleincome defined as 200%–399% of US FPL; high-income defined as ≥400% of US FPL. a
Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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Table 2 – Associations between potential predictors and receiving DSME through multiple venuesa vs single venueb (n = 2119, weighted n = 21,564,194). Independent variable
Likelihood from multiple venues Odds ratio (95% confidence interval)
P
Age (years) 18–45 46–64 ≥65
1.00 0.74 (0.51, 1.08) 0.35 (0.24, 0.52)
0.118 <0.001
Marital status Yes No
1.00 1.03 (0.82, 1.30)
0.784
Perceived health status Excellent—very good Good Fair-poor
1.00 0.94 (0.69, 1.29) 0.79 (0.59, 1.07)
0.708 0.131
Insurance Private Public Uninsured
1.00 0.81 (0.61, 1.09) 0.96 (0.61, 1.51)
0.163 0.847
Poverty categoryc Poor Low Medium High
1.00 1.16 (0.83, 1.63) 1.37 (0.96, 1.95) 1.99 (1.36, 2.91)
0.394 0.064 0.001
1.32 (0.93, 1.86) 1.57 (1.14, 2.16) 1.31 (0.91, 1.86)
0.118 0.005 0.142
Highest degree High school College or higher Other or no degree
1.00 1.95 (1.34, 2.84) 0.93 (0.73, 1.19)
0.001 0.554
Treated with diet modification No Yes
1.00 1.74 (1.28, 2.36)
0.001
Region Northeast Midwest South West
DSME: diabetes self-management education and training. a Received DSME from a physician or health professional plus reading about diabetes self-management on the internet and/or group classes. b Received DSME from a physician or health professional only. c Poverty line categories Poor = income <100% of US federal poverty line (FPL); low-income = 100%–199% of US FPL; middle-income = 200%–399% of US FPL; high-income ≥ 400% of US FPL.
with diet modification were significant factors associated with the DSME venue. Subjects aged 65 years or older were 65% less likely to receive DSME from multiple venues than those whose age ranged between 18 and 45 years (p < 0.001). Respondents from the high income-level as a percentage of the US poverty line were nearly two times more likely to receive DSME from multiple venues than those from a poor income-level (p = 0.001). Compared to those with a high school degree, the likelihood of receiving DSME from multiple venues increased by 95% in respondents with a college or higher degree (p = 0.001). Those treated with diet modification were 1.74 time more likely to receive DSME from multiple venues (p = 0.001). Interestingly, respondents living in the Midwest were 1.57 times more likely to receive DSME from multiple venues than those in northeastern geographical regions s (p = 0.005). Table 3 reports the effect of DSME on medication adherence. MEPS respondents who received DSME from multiple
vs a single venue showed similar mean OAD MPR (0.66 vs 0.64, p = 0.245). No differences were found in the percentage of respondents with MPRs ≥ 0.80, the cut off defining OAD medication adherence, between the two groups (42.6% vs 40.2%, p = 0.352). As shown in Table 4, after adjusting for demographic and health-related covariates, the DSME venue did not influence the OAD adherence, either (Odds ratio: 0.92, 95% confidence interval: 0.73–1.16).
4.
Discussion
4.1.
Major findings
This US population-based study using the data from supplemental DCS in MEPS examined demographic and socioeconomic factors associated with whether DSME obtained from a physician or health care provider only vs multiple venues (a
Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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Table 3 – OAD medication adherence (multiple venues vs single venue) (n = 2,119, weighted n = 21,564,194). OAD medication adherence
Multiple venuesa (n = 772, weighted n = 8,950,930)
Single venueb (n = 1,347, weighted n = 12,612,264)
MPR, mean (SE) MPR ≥ 0.8, % (SE)
0.66 (0.01) 42.6 (1.6)
0.64 (0.01) 40.2 (2.1)
P 0.245 0.352
DSME: diabetes self-management education and training; MPR: medication possession ratio; OAD: oral antidiabetic; SE: standard error. Received DSME from a physician or health professional plus reading about diabetes self-management on the internet and/or group classes. b Received DSME from a physician or health professional only. a
Table 4 – Effect of receiving DSME through multiple venuesa vs single venueb on adherence to OAD (n = 2,119, weighted n = 21,564,194). Independent variable
Likelihood of adherence Odds ratio (95% confidence interval)
p
Receiving DSME Single venue Multiple venues
1.00 0.92 (0.73, 1.16)
0.470
Age (years) 18–45 46–64 ≥65
1.00 1.11 (0.78, 1.56) 0.74 (0.52, 1.05)
0.566 0.089
Marital status Yes No
1.00 0.98 (0.77, 1.23)
0.837
Perceived health status Excellent—very good Good Fair—poor
1.00 1.13 (0.82, 1.57) 1.08 (0.78, 1.49)
0.460 0.651
Insurance Private Public Uninsured
1.00 1.31 (1.00, 1.73) 1.12 (0.73, 1.70)
0.054 0.610
Poverty categoryc Poor Low Medium High
1.00 0.98 (0.71, 1.36) 0.93 (0.65, 1.32) 0.78 (0.55, 1.10)
0.916 0.664 0.156
Region Northeast Midwest South West
1.00 0.87 (0.64, 1.31) 0.91 (0.75, 1.40) 1.03 (0.59, 1.26)
0.621 0.869 0.448
Highest degree High school College or higher Other or no degree
1.00 0.82 (0.59, 1.14) 0.78 (0.61, 1.00)
0.235 0.045
Treated with diet modification No Yes
1.00 0.87 (0.66, 1.14)
0.313
DSME: diabetes self-management education and training, OAD: oral antidiabetic drug. Received DSME from a physician or health professional plus reading about diabetes self-management on the internet and/or group classes. b Received DSME from a physician or health professional only. c Poverty line categories: Poor = income <100% of US federal poverty line (FPL); low-income = 100%–199% of US FPL; middle-income = 200%–399% of US FPL; high-income ≥ 400% of US FPL. a
physician or health care provider plus internet or group class) and the impact of venue on OAD medication adherence. Age, income, education levels, geographical region, and whether the individual was treated with diet modification were significantly associated with how adults with diabetes received
DSME. The DMSE venue did not significantly impact medication adherence. Mean OAD medication adherence was below the cut-point defining adherent (0.80), suggesting a suboptimal level to achieve good diabetes outcomes.
Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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4.2.
Factors associated with DSME venue
DSME venues could be individualized for demographic and socioeconomic factors identified in this study. MEPS respondents (65 years and older) were more likely to receive DSME from physicians or health professionals only. Older patients may lack awareness about additional DSME resources. Older individuals with writing or literacy difficulties may not use information technology to search for diabetes self-management information. Some elders may be more comfortable turning to well-established trusting relationships with their doctors or health professionals. Close patient provider relationships may facilitate how well the patient understands self-management processes and desirable health outcomes [22–24]. Physicians are more likely to use a patient-centered interaction style when treating those ≥65 years; an approach that improves patient satisfaction with health care [25]. The personal interaction during DSME given from a physician or health professional may meet an older patient’s social and emotional needs, and need for ongoing support and direction [24]. Secondly, younger individuals have greater access to the internet. The US Census Bureau reported internet access as most common in households between 35 and 44 years (81.9%) but the lowest in households over age 55 (61.7%) [26]. The Internet has been an essential resource providing diabetes management [27,28]. Increasingly, group educational programs are promoted via the internet. Third, subjects with lower incomes or those with only high school degrees were less likely to receive DSME from the internet or group classes, compared to those with higher incomes or college degrees. Low income and lack of education or educational opportunity may impact health literacy. Health literacy is associated with maintaining good glycemic control and disease self-management [27–30]. Adequate health literacy would help those with diabetes to navigate additional resources beyond their physician. Moreover, costs associated with group diabetes classes could burden those with lower incomes, particularly for the uninsured. Finally, those treated with diet modification were more likely to receive DSME from multiple venues. Patients may need supplemental information regarding dietary aspects of diabetes care. The Internet and group classes are good resources for patients to learn how to improve daily behavior and activities that are two key components in diabetes care [7,31,32].
4.3. Effect of DSME venue on OAD medication adherence Influencing health outcomes is a major focus for diabetes education. Improving OAD medication adherence with a goal of improving glycemic control often is a major objective for DSME programs. In addition to diet and exercise, medication adherence is central in glycemic control. However, no significant difference between multiple DSME venues vs a single medical provider source was observed for medication adherence. Firstly, OAD medication adherence in our study compares similarly with previously reported OAD medication adherence findings where OAD medication adherence range from 50%–80% [33,34]. Previous research reports equivocal findings for the effect of patient education on medication adherence
7
[35–37]. Our study shows that receiving DSME from multiple venues vs single venue did not significantly affect OAD medication adherence. The suboptimal OAD medication adherence is concerning and less than 50% of all respondents from our study cohort were adherent to their OAD medication regimen. Providing DSME through internet content helps overcome geographic, economic and demographic barriers to health information, expands the reach of diabetes education programs, and helps create a self-directed learning environment. Although, the internet provides a flexible channel for quick access to information targeting the general audience, internet content may not specifically address individual learning needs [8,9,32]. A physician or health professional remains the primary source cable of individualizing complex information related to diabetes medication management [8,9]. Physician or health professional directed DSME can be individualized with specific and accurate information tailored to meet diabetes self-management goals. Although group educational programs traditionally deliver formal DSME, educator skill and strategies taken toward teaching influence the effectiveness of program delivery [10]. The NICE guideline emphasizes patient involvement to support optimal medication adherence outcomes [38]. Patients’ needs and preferences, and good communication between health providers and patients, play an important role in enhancing medication use [38]. Health care providers may introduce additional educational venues such as group classes or internet materials to augment information communicated by the physician or health professional to encourage medication adherence. However, based on the results in this study, additional DSME venues may not significantly influence medication use. One possible reason is that DSME when delivered through the internet or group classes may not adequately address individual learning needs. Providers should view a simple addition of a different DSME venue with caution as a solution to suboptimal medication adherence. Finally, medication adherence is a multidimensional phenomenon associated with socioeconomic, treatment, health condition, health system, and patient-related factors [39]. More studies are needed to examine what educational factors effectively improve medication adherence in patients with diabetes, such as patient and provider factors (e.g., communication), as well as health system factors (e.g., efficiencies to free up time for patient education) [13].
4.4.
Limitations
Our results should be interpreted in light of some limitations. First, although MEPS provides nationally representative estimates of the non-institutionalized US population, the observational research design using this secondary data source limits the findings. The findings cannot suggest causality, and should be interpreted in light of the DSME literature, diabetes practice guidelines, and individualized patient outcomes. Secondly, MEPS data provides a cross-sectional snapshot over a short time span. Long-term effects about how the venue for DSME affected medication adherence could not be assessed. Third, MEPS DCS does not provide information about educational materials, patient provider interactions, and patient satisfaction with their DSME. The study could not
Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005
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determine if patients searched diabetes information online with guidance from providers; if the online health information met the patients’ complex needs; or the amount of content devoted to medication adherence. Fourth, medication adherence was measured by the MPR using pharmacy records in the MEPS prescribed medicine files limiting our ability to determine if respondents took their prescribed medications. Finally, MEPS does not provide laboratory data therefore limiting our ability to assess glucose control.
the likelihood of whether adults with diabetes treated with OAD medication(s) received DSME from one professional source or multiple venues (a physician or health professional plus internet and/or group classes). The number or type of DSME venues did not impact OAD medication adherence. Caution is advised in just relying on different sources of DSME venues to address suboptimal OAD medication adherence.
Conflicts of interest 4.5.
Practice implications The authors state that they have no conflict of interest.
Despite these limitations, our study identified important practice issues for health professionals and policy makers. Medication adherence was suboptimal in this population and was not significantly associated with DSME venue(s). It remains concerning to see suboptimal medication adherence to OAD medications in a nationally representative sample of adults with diabetes prescribed OAD medications. Further research is needed to substantiate our findings in the clinical setting to determine whether the number and type of educational venue(s) improve OAD mediation adherence thresholds. Collateral research could focus on other educational and patient factors in relation to the number and type of DSME venue(s) to help determine what measures significantly impact OAD medication adherence. Due to the multi-faceted nature of diabetes self-management, a multipronged and integrated approach is needed to enhance self-care among patients with diabetes to achieve improved outcomes [3]. Although the internet and other sources greatly expand the venues for delivering DSME, internet based educational content as experienced by those answering DCS questions in MEPS, may not have addressed medication adherence, or the individual conducting the internet search may not have sought out content related to medication adherence. Future research could provide content analysis, and insight about the individual’s choice of internet content, and its relationship to medication adherence. These could be further explored to improve the impact of internet offerings on medication adherence. Physicians and health professionals often serve as a primary resource for information about disease management and DSME. Physicians and health professionals are well positioned to fully integrate practice findings (e.g., individual laboratory and diagnostic results), and the patient’s condition (e.g., presence of comorbidities, disease severity), with the educational content delivered, and address behavioral, psychosocial, and emotional issues that may impact medication adherence. Yet among our sample of adults who received DSME from a single physician or health care provider source, medication adherence was suboptimal, and a solo physician or health care professional DSME venue was not significantly associated with medication adherence. More research is needed to elicit factors that help those in practice integrate their provider perspective with the educational needs of the patient to improve adherence outcomes.
4.6.
Conclusion
In summary, among adults answering the supplemental DCS in MEPS, demographic and socioeconomic factors influenced
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Please cite this article in press as: J. Wu, et al., Venue of receiving diabetes self-management education and training and its impact on oral diabetic medication adherence, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.10.005