Outcome measures have been defined as data that describe a patient's health status. Patient health outcomes have been measured for years, and their use has been increasing as researchers are beginning to see these outcomes as the best way to improve the performance of
TABLE 7 Predictors of Successful Management Duration of the intervention
Regular reinforcement. Proven more effective than one-time or short-term education (not limited to diabetes) Not just unusual or novel, but personalized, repeated contact using every feasible delivery system providing healthcare. Donebedian defines outcomes as "A measurable product and is the changed state or condition of an individual as a consequence of health care over time" (41). An outcome is a change that occurs as a result of some intervention—it is not a single point in time. The chronic care model (3) also supports the need for identification of essential elements to show improvement in outcomes of service delivery. The need to examine these outcomes in healthcare and diabetes care has been reinforced by mandates from Healthcare Financing Administration (HCFA—now renamed CMS, Centers for Medicaid and Medicare Services), Agency for Health Care Policy and Research (AHCPR), and accrediting bodies, such as the JCAHO, National Council on Quality Assurance (NCQA), and the American Diabetes Association Education and Provider Recognition programs.
Healthcare outcomes cross the healthcare continuum. They include educational, behavioral, clinical and long-term health status outcomes. Several outcome measurement instruments exist for assessing patient behavior, functional status, and QOL, for example: SF-36, PAID, and the Diabetes-Self-Management Assessment Report tool (D-SMART) (42-45) Other outcomes that are important to different customers are cost outcomes, such as cost effectiveness (ratio of costs of a program or process to the effects).
Evaluation is critical to the future of DSME programs. The effectiveness of interventions must be documented in order to have a better understanding of which interventions are the most appropriate for a specific population. Diabetes education has long been held by many to be the cornerstone of effective diabetes care. Yet in 1997, when diabetes educators were asked by HCFA to provide specific evidence of what the attributes of effective education were, diabetes educators could give little specificity. In 1999, at the AADE Research Summit, the question was asked: "Is diabetes education effective and what methods are the best?" The answer is: it depends on the following factors, what treatment, for what population, delivered by whom, under what set of conditions, for what outcome, and how did it come about (46)? Outcome measures associated with diabetes education programs include clinical (medical), educational (learning and behavioral), and psychosocial (QOL, coping, efficacy, etc.) (52). Through an extensive review of the literature and a process of expert consensus, the AADE Outcomes Task Force determined that health related behaviors are the unique and measurable outcomes of effective diabetes education (51,56). As the profession of diabetes education has evolved, it has begun to shift focus from 'Did we deliver the right content' to 'Did we achieve the desired patient outcomes?' Research in diabetes education has not yet provided specificity in characteristics of 'best practice' in diabetes education. More detail is required about what steps in the process of diabetes education are important, including variables such as characteristics about the providers, population, delivery methodologies, and healthcare environment. The process of assessing patient characteristics and determining what interventions are associated with the best outcomes is called clinical practice improvement (CPI) (57). CPI is in many ways complementary to the CQI process as well as RCT, as it creates a permanent feedback loop aimed at all clinicians involved in the process of care delivery. It provides them with data about their daily practice, and the information necessary to understand and modify their interventions. The CPI framework is the basis for the AADE National Diabetes Education Outcomes System (NDEOS), which resulted from the work of the AADE Outcomes Task Force. Based on expert consensus, a comprehensive review of the literature, and a customer analysis of the AADE membership, the Outcomes Team determined that health-related behavior changes are the unique and measurable outcomes of diabetes education (44). These behavior changes (which are compatible with the 10 DSME categories listed above) can be categorized in the following outcome areas:
■ Physical activity (exercise)
■ Medication administration
■ Monitoring of blood glucose
■ Problem solving for blood glucose: highs, lows, and sick days
■ Risk-reduction activities
■ Psychosocial adaptation
Finding a definition of DSME that conveys your message in a clear and articulate way is important to the marketing of your program. One definition that has been used widely is the following; "Diabetes self-management education (including medical nutrition therapy) is an interactive, collaborative, ongoing process involving the person with diabetes and the educator. It is a four-step process:
■ Assess individual's education needs
■ Identify individual's specific diabetes self-management goals
■ Educate individual to achieve identified self-management goals
■ Evaluate attainment of goals (51).
Utilizing this information assists the diabetes education coordinator in developing and implementing a quality educational product. As the product expands, other educator roles may be identified and become appropriate.
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