Learning to manage: Diabetes self-management education dissemination and effectiveness among vulnerable populations in the United States

The management of type 2 diabetes in the United States is a population health priority. Approximately 1 in 10 adults in the United States have diabetes and a significant majority have inadequately controlled blood glucose, blood pressure, and cholesterol. Previous research shows that many adults with diabetes lack the knowledge, skills, behaviors, and support to properly manage their condition. Diabetes self-management education has become an important part of diabetes care guidelines as a way to improve the self-management of adults with diabetes in order to lead to improve patient health and reduce inappropriate health care use and medical costs. Despite this, it is unclear who is actually receiving diabetes self-management education in the US, overall and by mode of delivery and diabetes educator type, and whether education is associated with improved population health. Therefore, the objective of this dissertation research is to investigate the distribution of diabetes self-management education, patient sociodemographic factors that influence the receipt of that education, and its contribution toward diabetes outcomes, medical expenditures, and healthcare use in US adults. We achieved this research objective by completing three specific research aims. We used nationally representative data from the Medical Expenditure Panel Survey and the National Health and Nutrition Examination Survey. We found that although a substantial majority of individuals received some form of diabetes self-management education, receiving diabetes education was associated with race/ethnicity and income (Aim 1), and varied by mode of education delivery. Individuals who received diabetes self-management education were less likely to have glycemic control but were more likely to receive antiglycemic treatment (Aim 2). Receiving diabetes self-management education was associated with greater diabetes-related ambulatory and prescription use, depending on the mode of education delivery (Aim 3). Our findings highlight some strengths of the current state of diabetes management occurring in usual care, including the widespread delivery of some form of diabetes education and its association with greater ambulatory and prescription use. However, we also found evidence of the need for more effective diabetes education delivery systems in usual care in order to improve patient self-care behaviors and reduce inpatient and emergency room use.