P R A C T I C E I N S I G H T S
National Survey of Pharmacist Certified DiabetesEducators
Laura Shane-McWhorter, Pharm.D., FASCP, Joli D. Fermo, Pharm.D., Nanette C. Bultemeier, Pharm.D., and Gary M. Oderda, Pharm.D., M.P.H.
We sought to determine the demographics of pharmacists who were certifieddiabetes educators (CDEs) and information about their training, professionalaffiliations, and types of diabetes education services that they provide. Wealso queried these pharmacists about clinical activities, reimbursement,impact of certification, and intent to pursue CDE recertification. A list ofpharmacists who were CDEs as of August 31, 2000, was obtained from theNational Certification Board for Diabetes Educators. We then sent a six-pageanonymous survey to 415 pharmacist CDEs; 233 surveys (56.1%) werereturned. Of these respondents, 140 are women and 93 are men, with a meanage of 41.5 years. Most reside in Southern or Western states. Average timesince pharmacist licensure was 17 years, and average time as a CDE was 5years. Most had completed postgraduate training, including residenciesand/or fellowships; 52.8% had faculty appointments; 46.7% stated they werebilling for their services; and 45.9% were obtaining reimbursement. Mostpharmacists (84.4%) stated that they intended to pursue CDE recertification.Providing details about pharmacist CDEs and their clinical activities maymotivate other pharmacists to pursue this credential. Pharmacists are oftenthe most accessible of all health care providers, and earning the CDEcredential may be an important contribution to diabetes care and education.(Pharmacotherapy 2002:22(12):15791593)
Patients with diabetes mellitus present anenormous challenge to the health care system.Diabetes is a costly disease in which manycomplications may occur, and yet maintainingappropriate blood glucose control prevents
occurrence and progression of many of thesecomplications.16 New statistics indicate that 17million people in the United States (or 6.2% ofthe population) have diabetes. It has beendiagnosed in 11.1 million Americans. Another5.9 million are estimated to have diabetes, but asyet the disease is undiagnosed.7 There are800,000 new cases of diabetes diagnosed everyyear or 2200/day.8, 9 Diabetes treatment costsapproximately $98 billion/year.10, 11 Statisticscompiled by the Centers for Disease Control andPrevention indicate the prevalence of preventivecare practices is suboptimal, and compliancewith national health recommendations is poor.12
This 1997 survey of people with diabetes in 41states demonstrated that only 61.6% of theseindividuals reported receiving a dilated-eyeexamination within the previous year, 54.6%reported receiving a foot examination within the
From the Department of Pharmacy Practice, College ofPharmacy (Drs. Shane-McWhorter and Oderda) and theDepartment of Family and Preventive Medicine, School ofMedicine (Dr. Shane-McWhorter), University of Utah, SaltLake City, Utah; the Department of Pharmacy Practice,Medical University of South Carolina, Charleston, SouthCarolina (Dr. Fermo); and the Oregon Health and ScienceUniversity, Portland, Oregon (Dr. Bultemeier).
Supported in part by Parke-Davis, Somerville, New Jersey.Presented as a poster at the American College of Clinical
Pharmacy 2001 Spring Practice and Research Forum, April2225, 2001, Salt Lake City, Utah.
Address reprint requests to Laura Shane-McWhorter,Pharm.D., University of Utah College of Pharmacy,Department of Pharmacy Practice, 30 South 2000 E #260,Salt Lake City, UT 84112.
PHARMACOTHERAPY Volume 22, Number 12, 2002
previous year, 39.6% reported self-monitoring ofblood glucose at least once/day, and 18.4%reported having their hemoglobin A1c (A1C)levels checked in the previous year.12
One of the most important aspects of diabetesmanagement is patient education so thatindividuals with diabetes have the necessaryinformation to optimize diabetes control; thismay help maintain wellness and preventdiabetes-related complications. Certified diabeteseducators (CDEs) provide self-managementeducation with the target goal of maintainingappropriate blood glucose control and therebypreventing diabetes-related complications. Whendiabetes initially is diagnosed, however, theprovider (often a primary care provider) does nothave the time necessary to provide the patientwith self-management education. Ancillaryhealth care professionals are key in the continuedsupport and education of these patients.However, an adequate number of professionalswith advanced training to whom patients may bereferred is lacking. Pharmacists lack providerstatus under Medicare and consequently are oftennot recognized by other health care professionalsor by billing services as medical providers. Thus,patients might not be referred to them fordiabetes education.
To provide quality diabetes care and education,health care professionals must receive basicpreparation and continuing education in specificeducational strategies and behavioral interven-tions.1319 Behavioral and lifestyle modificationsare the keys to successful self-management ofdiabetes.20, 21 In one study, four different educationprograms produced lowering of A1C and bodymass index, but behavioral programs producedgreater patient satisfaction and greater likelihoodto seek the services of ancillary health careproviders, such as podiatrists.20 In an assessmentof attitudes of dietitians, nurses, and physicianstoward diabetes, diabetes specialists had morepositive attitudes than did nonspecialists and yetall were in favor of a team approach to care.21
Instructors without specialized training indiabetes,15, 16, 2227 behavioral interventions,20, 21,2831 teaching and learning skills,17, 3236 as well ascounseling skills,14, 18 may not focus on patientbehavioral changes and, therefore, may notimprove clinical outcomes. Several reports haveaddressed the issue of specialized training indiabetes to improve clinical outcomes. Forinstance, some reports have shown a mismatch inperceived versus actual diabetes knowledgeamong staff nurses15, 24, 26; those who actually
spend more time in diabetes practice and diabetescontinuing education have higher knowledgescores and provide more comprehensive exerciseteaching than those who have less training.16
Those with specialized training in screening andpatient education for diabetic foot ulcers havehelped prevent lower extremity amputations,23, 25
yet because of a lack of provider education inpreventive diabetes foot care, a Medicare benefitfor therapeutic shoes was extremely underused.27
Also, training in behavioral interventions isimportant. Besides increased patient satisfaction20
or a more positive attitude,21 educators who hadformal training had a positive association withgreater use of behavioral techniques.28 In onereport, subjects had improved metabolic controlwhen they were taught coping skills, a type ofbehavioral intervention, from an educator.29
Another report stated that over half the educatorshad received behavioral training to help withlifestyle modifications.30 Some behavioraltechniques they cited included goal setting,behavioral modification, positive reinforcement,making contracts with patients, and stressreduction.30 In another setting, practitionersstated they found benefit from training theyreceived in behavioral techniques that includedagenda-setting techniques, motivational inter-viewing, and assessing readiness for change.31
Instruction in teaching and learning skills alsomay have an effect on outcomes. In one study,nurses questioned the adequacy of theirknowledge of diabetes and how competent theyfelt in caring for patients with diabetes.17
Another report eloquently discussed the scarcityof techniques to train health care professionals toprovide education so that patients may betterself-manage their diabetes.32 The authors statedthat education must be aligned with patientssociocultural characteristics, personal beliefsregarding diabetes, and ability to cope with thedisease and with the realization that the patient isthe locus of control.32 Other investigatorsmentioned using techniques of adult educationto address a psychosocial variable, such asattitude, as an important contributor to positivediabetes management.33 Training of health careprofessionals improves patient teaching skills.34
Patient education that produces behavioralchanges requires that health care professionalshave specific training, good communication andteaching skills, a supportive attitude, a readinessto listen and negotiate,35 as well as time andadequate teaching skills.36
Without training in counseling skills, providers
SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al
may not be able to positively affect patientbehavior. In one study, physicians were providedspecialized training and were taught to conductdietary risk assessments and provide patient-centered counseling to change dietary patterns.14
Other types of counseling, including patienteducation and adherence promotion skills, arenot always part of dietitians training, butsupplemental training may improve theseteaching skills.15 In summary, health careprofessionals require greater knowledge andutilization of behavioral interventions in patientswith any chronic disease.18, 19, 28, 37, 38
One option for pharmacists to obtain diabetes-focused postgraduate education is preparation forthe CDE examination. This certification by theNational Certification Board for DiabetesEducators (NCBDE) is one way that health careprofessionals may demonstrate mastery of aspecific body of knowledge. The CDE hasbecome the accepted credential for diabetes self-management education,39 which is an interactive,collaborative, ongoing process involving theperson with diabetes and the educator(s).40 Thisprocess involves assessment of the individualsspecific education needs, identification of theindividuals specific diabetes self-managementgoals, education and behavioral interventionsdirected toward helping the individual achieveidentified self-management goals, and evaluationof the individuals attainment of identified self-management goals.40
Passing an examination administered throughthe NCBDE is a requirement to becoming a CDE.Also, those qualifying for certification must meetcertain professional and/or educational criteriaand demonstrate that they have provided acertain amount of direct diabetes self-manage-ment education in the 25 years before taking theexamination.41 The many health care profes-sionals who are CDEs include nurses, dietitians,social workers, physicians, physical therapists,
and pharmacists. According to the NCBDE, therewere 415 pharmacists as of August 31, 2000.The current total number of CDEs is over12,000.42
We sought to determine several characteristicsof pharmacist CDEs regarding their training,professional organization memberships, workactivities, work sites, motives for certification, andimpact of certification. We also hoped to elucidateinformation about clinical activities, reimburse-ment, and intent to obtain recertification.
After obtaining investigational review boardapproval, a list of pharmacists who were CDEs asof August 31, 2000, was obtained from theNCBDE. A six-page anonymous survey was sentto all 415 pharmacist CDEs. After 1 month, asecond mailing was sent to nonrespondents.
The survey asked questions about academicdegrees and postgraduate training, professionaland academic affiliations, practice sites, and workactivities. Other questions examined motives forcertification and impact of certification. Thesurvey also asked questions about pharmaceuticalcare services, patient education, physicalassessment provided, billing and reimbursementfor diabetes services, and outcome measures.The survey queried individuals about intent torecertify as a CDE and to obtain the newadvanced practice multidisciplinary credential,the board certified-advanced diabetes management(BC-ADM) certification. The BC-ADM is the firstadvanced practice certification examination indiabetes care available to a variety of professionaldisciplines with advanced degrees; it emphasizesclinical assessment and disease-state management,in addition to patient education and counseling.More information regarding the advanced practicecredential is available from www.aadenet.org orwww.nursingworld.org/ancc.
Table 1. Demographics of Respondents by Sex, Age, and Diabetes Status
Characteristic Men Women TotalNo. (%) of respondents 93 (39.9) 140 (60.1) 233 (100)
Age (yrs)Range 3167 2760 2767Mean SD 45.9 7.48 38.4 7.88 41.5 8.56
Diabetes status, no. (%)Type 1 9 (3.9) 6 (2.6) 15 (6.5)Type 2 3 (1.3) 5 (2.1) 8 (3.4)
PHARMACOTHERAPY Volume 22, Number 12, 2002
Demographics, Education, Training, and WorkExperience
Of 415 questionnaires, 233 (56.1%) werereturned. Responses were received from 93 men(39.9%) and 140 women (60.1%). Mean age ofmale pharmacists was 45.9 7.48 years, and thatof female pharmacists was 38.4 7.88 years.Mean age of all respondents was 41.5 8.56years. Twenty-three (9.9%) of 232 respondentswho answered the question about diabetes statusstated they had diabetes. Table 1 summarizes thedemographics of respondents by sex, age, anddiabetes status.
Respondents education and postgraduatetraining is summarized in Table 2. Two hundredtwo respondents (86.7%) had a bachelor ofscience (B.S.) degree in pharmacy, with 132(56.6%) having this as their only pharmacydegree. However, 101 pharmacists (43.4%) had adoctor of pharmacy (Pharm.D.) degree.Pharmacists with the Pharm.D. degree included58 (24.9%) with a post-B.S. degree, 31 (13.3%)with an entry-level Pharm.D., and 12 (5.2%) witha nontraditional Pharm.D. degree. Norespondents had a doctor of philosophy (Ph.D.)degree, and 15 (6.4%) had masters degrees (7
[3.0%], master of science; 5 [2.1%], master ofbusiness administration; 1 [0.4%], master ofpublic health; and 2 [0.9%], other mastersdegrees). Twenty respondents (8.6%) had otherdegrees.
Most of the respondents also had postgraduatetraining. Forty-two (18.0%) indicated that theyhad no postgraduate training. Thirty-eightpharmacists (16.3%) completed a pharmacypractice residency, 37 (15.9%) completed aspecialty residency, and 11 (4.7%) completedfellowship training. One hundred respondents(42.9%) completed certificate programs. Severalindividuals completed more than one type ofpostgraduate training.
Professional experience varied. Pharmacistlicensure ranged from 344 years, with a meantime since licensure of 16.9 8.75 years.Respondents stated that time since obtainingCDE certification ranged from less than 1 year to18 years, with a mean of 4.7 3.77 years. Malepharmacists had been licensed and certified(CDE) longer than female pharmacists (Table 3).
Geographic Location of Respondents
The states in which the pharmacist CDEspracticed were divided into four regions:Northeast, South, Midwest, and West (Figure 1).
Table 2. Demographics of Respondents by Degree...