It takes a team to manage diabetes

New tools provide model for treatment of chronic conditions

From the April ACP Observer, copyright © 2007 by the American College of Physicians.

By Stacey Butterfield

A 50-year-old patient with diabetes first came to the clinic at the University of North Carolina Chapel Hill weighing 202 pounds and with an HbA1C of 9.2. Her diabetes was being treated with oral medications and insulin.

As a participant in a study trial, the patient was given a copy of "Living with Diabetes: An Everyday Guide for You and Your Family," a new guide produced by the ACP Foundation. Together with brief counseling about setting achievable goals and follow-up phone calls to check on progress, the Guide helped her make healthy changes to her lifestyle.

Designed in a magazine format with lots of photos and a conversational style, the guide is an entirely new means of patient education, one developed by providers and patients to give practical everyday ideas about how to live with diabetes and focus on small behavior changes.

Together with a research assistant, the UNC patient used the guide to develop incremental action plans. Several small goals later, she was attending water aerobics three times a week and eating smaller portions of carbohydrates. Five months later, she's off insulin, weighs 189 pounds, has an A1C of 6.1, and credits her success to the "Living with Diabetes" guide.

Written for low-literacy

Her story is not unique, said Jean Krause, CEO of the ACP Foundation. After four months, most patients in a three-state study who tested the guide made similar progress in achieving small goals. The key to the guide's success is focusing on what patients want to know and do, and providing brief counseling on goal setting.

Using photos and quotes from actual patients, the Guide, written in English and Spanish, covers the basics of diet, exercise, blood sugar testing, medication and insulin. The diet section shows culturally typical meals and snacks in proper portion sizes.

The guide has gotten good response from patients of all education levels, but it is especially targeted to patients with low health literacy. Most of the text is written at a fifth grade or below reading level, with nothing above seventh grade.

Free resources available

Officially launched at Internal Medicine 2007, "Living with Diabetes" will be available to order free on the College's Web site or through ACP's customer service department, and sample copies will be mailed out with the April 3 Annals of Internal Medicine distributed to general internists and endocrinologists.

The guide is intended to be used by the patient in conjunction with a coach—a physician, nurse, medical assistant or any other member of the practice. The coach helps the patient set reasonable goals, and follows up with a phone call every few weeks to make sure the patient is sticking to the plan.

This team approach to diabetes care is the hallmark of the College's ongoing three-year Diabetes Initiative, funded by an unrestricted educational grant from Novo Nordisk. Several of the initiative's products will be launched in the near future, including:

The ACP Diabetes Care Guide: A Team-Based Practice Manual and Self-Assessment Program: A product for all members of the practice team including physicians, physician assistants, nurse practitioners, nurses and diabetes educators that offers best evidence and practices for diabetes treatment. The guide facilitates team collaboration among physicians, staff and patients and includes a CD with multiple-choice test questions, which offer up to 15 continuing education credits for physicians, physician assistants, nurses, nurse practitioners, and dietitians. The CD also includes an array of interactive tools for both patients and members of the clinical team, as well as a Patient Registries Tutorial that explains the basics of selecting and using a patient registry. The free guide will be launched at Internal Medicine 2007, where College staff will be recruiting physicians to field test the guide in their own practices.

ACP Diabetes Portal: This Web-based portal will offer tools, resources and research on diabetes care. It includes evidence-based information from a variety of College sources, including PIER, MKSAP, Annals and the diabetes guides. The site has both clinician and patient areas, so providers can use the portal for their own reference as well as patient education. The site is free to access starting in early April.

ACP Diabetes Track: 2005-2007 Since the launch of the Diabetes Initiative in 2005, every Annual Session has included a diabetes-specific track. Recordings of the sessions (including those at Internal Medicine 2007) will soon be out on CD, along with the accompanying PowerPoint presentations. The "ACP Diabetes Track: 2005-2007" CD will be available free through the Diabetes Portal beginning in August.

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