Abstract
Objective:
Diabetes-related care makes up approximately 24% of outpatient clinic visits. Therefore, confidence and understanding of diabetes management is necessary for family medicine residents.
Methods:
We developed a combined lecture and simulation lab curriculum utilizing a registered nurse and pharmacist to deliver education to 20 family medicine learners. Pre and post surveys of the educational material were completed in 2 sections including one gauging medical knowledge and a second part gauging level of comfort.
Results:
Of the learners who participated, fourteen completed the pre-post surveys. Most (53%) respondents improved their scores, while 20% scored the same 27% scored worse. The overall average score increased 57% to 70% and improvement was statistically significant (P < .05). All learners improved confidence by at least 1 point.
Conclusion:
An interprofessional team utilizing a lecture curriculum focusing on providing education on effective prescribing, medication safety profiles, and resource availability, showed improvement in confidence but mixed knowledge benefit. Further modifications to the curriculum may yield further educational gains.
Introduction
Diabetes is an increasingly prevalent disease that is the eighth leading cause of death in the United States and has yearly medical costs estimated at greater than $400 billlion.1,2 Diabetes-related care composes 24% of outpatient visits. 3 Of the 37.3 million people with diabetes, at least 90% of them have type 2 diabetes. 1 Although medication treatment of diabetes has existed since 1921, early treatment options were limited. 4 Recently, promising drugs have been developed that expand treatment options and promote individualized treatment, but also increase provider decision burden. Given the burden of diabetes for patients and the US health care system, knowledge of diabetes treatment is necessary for providers. To achieve this, education for healthcare professionals is essential in ensuring safe treatment of this patient population. Previous research supports interventions to improve diabetes related care. For example, in a physician group that participated in a simulation and case-based curriculum, safer treatment decisions and improved glycemic control in their patients with diabetes were observed after training. 5
Beyond adopting simulation and case-based styled education, interprofessional teaching provides an additional level of interaction. Interprofessional education integrates familiarizing the individual with the roles of different members of the team around the shared mission of restoring or maintaining the health, safety, and wellbeing of the patient. Among health professional students, interprofessional education and team-based approaches also improved development of collaboration skills. 6
This study aims to evaluate education sessions provided to medical learners at a midwestern rural family medicine clinic. The diabetes training curriculum integrated the use of interprofessional education, simulation, and patient cases with the objective of increasing familiarity of diabetes medication management among medical learners. We looked first at knowledge gains and secondarily at improvement in confidence.
Methods
An interprofessional team in a rural family medicine outpatient clinic made up of physician, registered nurse, pharmacist, and pharmacy resident hosted a diabetes education session for 20 medical learners (see Supplemental File for specific roles). The curriculum consisted of a lecture-style component covering the topics of continuous glucose monitors (CGM), diabetes medications (GLP-1 agonists, SGLT2 inhibitors, and insulin), safety related to the use of these medications, and resources to provide patients with easier access to the medications which spanned about 60 min. A simulation lab was integrated into the presentation to give learners the opportunity to interact with 2 brands of CGM (Dexcom G6 or Freestyle Libre generation 2 or 3), self-monitoring blood glucose (SMBG) devices, and GLP-1 agonist injection devices which spanned about 60 min. This material was formatted to assist learners in best practice prescribing and how to deliver proper counseling to patients starting or continuing these medications. Patient case scenarios were utilized throughout to assist the educational material.
The effectiveness of this session was measured through the administration and analysis of identical pre and post surveys (Table 1). Pre surveys were completed immediately before the didactic education and post surveys were completed immediately after. Fifteen minutes was allotted for completion for both the pre and post surveys. Participants were able to self-select an alias to connect the surveys in an identifiable manner yet keep anonymity and are included in the online Supplemental Files. The first part of the survey consisted of a knowledge assessment, containing 7 questions styled with both multiple choice and “select all that apply.” This section gauged knowledge pertaining to CGM duration, common medication adverse effects for GLP-1 agonists and SGLT2 inhibitors, hypoglycemia treatment, and the pharmacokinetics of different types of insulin. The second part of the survey included 5 questions measuring comfort levels of treating patients with diabetes in various scenarios with a Likert scale ranging from 1 (“very low”) to 5 (“very high”). The scores for overall confidence were calculated by adding up the number associated with each question. Analysis was completed at socscistatistics.com using T-test calculator for 2 dependent means. Participation was voluntary and the Mayo Clinic IRB determined it to be exempt from review.
Survey Questions.
Results
Fourteen of the twenty participating learners completed the pre-post surveys in an identifiable manner. The remaining learners either did not complete the surveys using the same identifying alias or did not complete both portions of both surveys. Of the 14 who correctly completed the pre-post surveys, there was 1 fourth year medical student, 4 in their first post-graduate year (PGY1), 4 in their second post-graduate year (PGY2), and 5 in their third post-graduate year (PGY3). 15 learners successfully completed Part 1 of the survey which revealed that over half of learners had improvement in responses. Improvement was evaluated based on the percentage of questions answered correctly. Most (53%) respondents improved their score by at least 1 question, 20% had their scores remain the same, and 27% received a worse score on their post-education survey than their pre-education survey. The overall average score among learners for the pre-education survey was 57% and was 70% for the post-education survey. Statistical analysis of post-test knowledge questions was significantly significant (P < .05).
Of the 13 learners who completed Part 2 of the survey, 100% had improvement in confidence by at least 1 point. In the post-education surveys, there were 2 questions that had higher numbers of incorrect responses. The question that the learners had the biggest challenge with—asking about the resources needed to initiate a CGM—resulted in 87% of individuals answering incorrectly (Figure 1). The second highest incorrect question, with 53% of learners answering incorrectly addressed the most common adverse effect of SGLT2 inhibitors. Lastly, 47% of learners could not correctly identify the steps in treating hypoglycemia, the “Rule of 15.” Figure 2 shows pre-post confidence ratings.
Results from pre-post survey Part 1.
Results from pre-post survey Part 2.
Discussion
The pre-education session surveyed showed an average score of 57%. This demonstrates an overall knowledge gap of diabetes treatment among medical learners. Previous research of collaboration between pharmacists and physicians in the treatment of diabetes can have the benefit of improving diabetes outcomes for the patient and minimizing the cost of healthcare resources used. 7 Although our results showed a higher average score of 70% in the post-education surveys, 27% of learners receiving a worse score, suggesting the need for improvement in the delivery of content during the education session. Implementing small changes to how the education is delivered and how the survey is formatted and administered could be effective in improving the retention and evaluation of knowledge among learners.
Education Delivery
The 3 most missed questions were related to CGM initiation (Q1), diabetes medication side effects (Q4), and counseling points for safe use of diabetes medications (Q6). There was another question, Q5, related to this topic that also did not show improvement. These topics are important because of their influences on medication accessibility to patients and safe medication use. In the first part of the survey, there were 2 questions addressing adverse effects in diabetes medications. For question 3, related to the GLP-1 agonist medication class, 87% of individuals answered correctly going into the training session. This number increased to 100% after completing the training. This may be because this class of medication has become a first line agent per the most current American Diabetes Association (ADA) in the treatment of type 2 diabetes. 8 Learners struggled more with the second question in this category, Q4, relating to SGLT2 inhibitors. For this question, only 53% of learners came in with previous knowledge of this concept, and 46% answered correctly at the completion of the training. SGLT2 inhibitors have not been first line diabetes therapy until very recent guidelines and residents may have less experience prescribing and counseling this medication.
Adjustments to the didactic teaching of the curriculum could also be tailored to improve the knowledge of learners going through the program. Providing explicit information regarding medication safety profiles as well as an effective way to deliver this content to patients could benefit both the provider and patient in their collaboration of improving a patient’s diabetes outcomes. Increasing the familiarity of medical learners with pharmacological diabetes management may help improve their prescribing confidence. When looking at learner confidence before and after completing training, the lowest level of improvement was for Q10, addressing adjustments in the medication regimens of sick patients. Improving this efficiency and confidence can be achieved by emphasizing this information during the didactic portion of the education session. The understanding of these concepts can be assessed by giving the learner patient cases that contain specific events related to medication safety and adherence issues the patient may be having due to adverse effects.
Learners also struggled with identifying the proper way for patients to treat hypoglycemic events. At the completion of the training, only 53% of learners could correctly identify the steps of the “Rule of 15,” a phrase coined for the patient checking their blood sugar, consuming 15 g of carbohydrates, waiting 15 min, and checking their blood sugar again when they experience a hypoglycemic event. This is an important concept for patients to understand with potential serious repercussions. In the primary care clinic setting, hypoglycemia events have been reported in as high as 62% of patients. 9 Providing patients with knowledge of how to know the signs of hypoglycemia and treat it appropriately is crucial in enhancing patient safety.
Despite our findings, there are areas of the current training model that we would recommend retaining. The simulation lab for diabetes testing supplies, including CGM and SMBG monitors, gave the learners an opportunity to practice correct application and use techniques of the instruments provided. At the conclusion of training, they had the opportunity to wear the device for the duration of either 14 days for the Freestyle Libre or 10 days for the Dexcom, the full duration of the use of both sensors. This exercise facilitated firsthand learning to provide learners experience using CGM with the hope that it will enhance their ability to counsel patients on the proper insertion and usage of the instruments.
Survey Content and Administration
The inconsistency with identifying aliases and failure to complete all portions of both surveys resulted in a smaller sample size than anticipated. This can be addressed by giving adequate time to complete the survey and administering the survey on paper to reduce user error. Standardizing the creation of a unique participant code could improve survey validity. Questions that were most incorrect were asked in a “select all that apply” style (Q1, Q5, Q6). Of those who answered the question incorrectly, the majority were partly correct. Looking at Q1, of the 87% of learners who missed this question in the post-education survey responses, 27% missed it due to their incorrect inclusion of “prior authorization review” being necessary in the initiation of a CGM. Depending on the structure of the clinic, many physicians do not have direct contact with the billing. Learners responding to Q6 also struggled with the format of “select all that apply”. Forty-seven percent of respondents missed this question in the post-education survey. Of the responses marked incorrect, all submitted answers were partially correct. Changing the format to multiple choice would limit the variability of responses.
In addition to changing the format of the survey, expanding the survey to ask more questions related to the training will be helpful in assessing the gaps in knowledge that learners have, what they are able to learn in the training session and what areas of the training can be made clearer in the future.
Another way to expand the scope of this study would be to measure the retained knowledge. Administering a follow up survey at the 1- and 6-month mark would help us gauge the impact of training on the learner in how they integrate it into their practice and interactions with patients.
Limitations
Limitations included time constraints for those completing the survey after the educational session. Due to the reported lack of adequate time to take the survey, answers may have been inaccurate. Mis-matched alias limited the number of answers and the ability to perform statistical analysis on individual questions, which constrains proper assessment of the survey. Additionally, the sample size itself was small considering the high rate of incomplete surveys and 25% of the participants being unable to appropriately submit both the pre- and post-surveys. This study was completed at one institution which limits generalizability. Finally, the study questions are not validated, and the post survey was completed immediately after session limiting conclusions on long-term impact.
Conclusion
The prevalence and health risks of diabetes make education training extremely important in promoting care quality. However, there is little data in guiding diabetes education and though our curriculum showed some improvement it had limitations. Nonetheless, it potentially serves as a basis for future studies to see if further gains could be made in this high priority health condition.
Supplemental Material
sj-docx-1-jpc-10.1177_21501319241276801 – Supplemental material for Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents
Supplemental material, sj-docx-1-jpc-10.1177_21501319241276801 for Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents by Amanda Davis, Katherine Davis, Elise Moore, Britanee Samuelson, Lauren Stonerock and Nathaniel E. Miller in Journal of Primary Care & Community Health
Supplemental Material
sj-docx-2-jpc-10.1177_21501319241276801 – Supplemental material for Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents
Supplemental material, sj-docx-2-jpc-10.1177_21501319241276801 for Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents by Amanda Davis, Katherine Davis, Elise Moore, Britanee Samuelson, Lauren Stonerock and Nathaniel E. Miller in Journal of Primary Care & Community Health
Supplemental Material
sj-xlsx-3-jpc-10.1177_21501319241276801 – Supplemental material for Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents
Supplemental material, sj-xlsx-3-jpc-10.1177_21501319241276801 for Evaluation of Interprofessional Delivery of Diabetes Medication Management Training Among Family Medicine Residents by Amanda Davis, Katherine Davis, Elise Moore, Britanee Samuelson, Lauren Stonerock and Nathaniel E. Miller in Journal of Primary Care & Community Health
Footnotes
Acknowledgements
None.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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