This is the current release of the guideline.

This guideline updates a previous version: American Association of Diabetes Educators (AADE). Guidelines for the practice of diabetes education. Chicago (IL): American Association of Diabetes Educators (AADE); 2009. 39 p.

To increase access to diabetes self-management education and training (DSME/T) and achieve better patient care by:

• Delineating the roles of the multiple levels of diabetes educators
• Suggesting a career path for diabetes educators
• Clarifying the contribution that can be made by individuals who have the knowledge, capability, diversity and language skills needed to address diabetes self-management and support in a variety of settings

Note: It is beyond the scope of these guidelines to address the range of activities that diabetes care practitioners may be educated and authorized to perform based on facility and organizational policies, bylaws, and clinical privileging; state practice acts; and state occupational supervision regulations.

Individuals with type 1 and 2 diabetes

Diabetes self-management education and training, including the following components:

• Assessment
• Goal-setting
• Planning
• Implementation
• Evaluation and follow-up

American Association of Diabetes Educators (AADE) staff systematically conducted literature reviews, seeking high-quality research (e.g., randomized controlled trials, meta-analyses and well-conducted quasi-experimental studies), consensus documents, and published standards of care and practice.

As the next step, the AADE Professional Practice Committee (PPC) recommended published studies and documents that would serve as the foundation for development of the guidelines and recommended to the writing team papers that were widely cited (i.e., in more than 30 published documents) and deemed (based on their expert opinion) to be "embraced" by those who undertake the practice of diabetes self-management education and training (DSME/T) and are substantially influential to the field. These materials were provided to the writing team prior to their initial meeting. The AADE Research Committee advised on how the quality of specific studies and documents would impact the graded rating of the questions.

The evidence used in developing the guidelines included key meta-analyses, evidence-based reviews, clinical trials, cohort studies, epidemiologic studies, position statements, and consensus statements and guidelines (English language only).

The writing group obtained relevant reports through a computerized search of the literature using PubMed and other search engines; reports also were obtained by scanning incoming journals in medical libraries and reviewing references in pertinent review articles, major textbooks, and syllabi from national and international meetings on diabetes subjects using relevant titles and text words (e.g., diabetes self-management, education, training, behavior change). The defined search terms varied only to reflect each of the specific self-care behaviors. An electronic database was created to include full reference information for each report; abstracts for most of the reports were included in the database. In total, 1,621 reports were identified. A review of recent guidelines, position statements, and articles not identified in the universal search also was conducted to obtain additional information that was potentially relevant to the questions. Key reports, whether supportive or not, were included and summarized based on their relevance to the practice questions addressed in the guidelines.

The evidence analysis inclusion criteria included studies conducted and published since 1984, documents relating to the practice of diabetes education published by professional organizations, DSME/T-related published manuscripts, peer-reviewed journals, articles, and relevant guidelines.

Not stated

Criteria for Rating Evidence

Grading of Evidence

The American Association of Diabetes Educators (AADE) Research Committee graded the evidence cited to support the recommendations. This committee provides technical advice regarding matters of research (behavior, clinical, and other) and any other question pertaining to research as requested to support diabetes self-management education and training (DSME/T). The development of the guidelines was driven by the strength of the evidence and revised to accurately reflect the recent science and body of knowledge.

Two members of the Research Committee graded each piece of evidence according to criteria presented in the "Rating Scheme for the Strength of the Evidence" field. Whenever possible, practice recommendations were assigned a letter grade (A-D) based on the level of scientific substantiation. An A grade is the strongest recommendation, indicating that the evidence derives from a methodically robust study, typically a randomized control trial (RCT) or a very high-quality quasi-experimental study. The AADE Research Committee noted that not all RCTs necessarily provide level 1 evidence. Rather, in some instances, RCTs could be level 2 or 3 if they were poorly executed or used inappropriate methodology. A grade of D indicates evidence that is built on consensus.

The following evidence grading process was used:

1. AADE posted all relevant articles to be graded—along with the criteria, score sheet, and guidelines—on a Web-based document sharing system.
2. Two evidence graders from the AADE Research Committee were assigned to each paper. If they agreed on a level of evidence (e.g., level 1), the work was considered done and the agreed-upon grade assigned. If they disagreed, a third grader was invited to grade the evidence and serve as a "tie breaker."
3. Reviewers posted their grades to the score sheet document in the Web-based document sharing system.
4. The grades were provided to the writing team and were included in the reference section of the guidelines.

The guidelines were developed by a volunteer writing group composed of diabetes care professionals with diverse educational backgrounds and various credentials representing all regions of the United States. The American Association of Diabetes Educators (AADE) Professional Practice Committee (PPC) provided oversight for the development and review process. The PPC is a technical committee consisting of 10 volunteers who provide technical advice, review, and input on a variety of issues relating to the practice of diabetes education. The PPC develops official AADE documents that articulate the association's views and mission, reflect current evidence, delineate standards of care, and support the AADE7^™ framework.

The writing group met in person two times to review and consider the published evidence, define the purpose of the guidelines, create the construct underlying the roles described herein, and discuss barriers to the adoption of the guidelines.

Practice Questions

As a basis for developing the recommendations set forth in these guidelines, the writing group addressed five clinical questions relevant to the role and importance of diabetes education and training in the self-management of diabetes:

1. Does diabetes self-management education and training improve outcomes?
2. What is the framework for diabetes self-management education and training education?
3. What is the process for implementing diabetes self-management education and training?
4. Who should deliver diabetes self-management education and training to persons with diabetes?
5. What are the unique roles and responsibilities of those who deliver diabetes self-management education and training for self-care?

Grades of Recommendation

The annual direct and indirect costs associated with diabetes and its complications are estimated to be $174 billion.

Large controlled clinical trials have demonstrated that intensive treatment of diabetes can significantly decrease the development and/or progression of the complications of diabetes. Studies differ on intensive management of all risk factors, including lipids, blood pressure, and glycemia, had significant beneficial effects on cardiovascular-related deaths. This intensive therapy also was found to be cost-effective in primary practice settings.

A number of studies have reported findings that strongly support cost reduction as a benefit of diabetes education.

Cost of Implementing the Guidelines

Studies on the economic impact associated with the implementation of guidelines have generally confirmed that standardizing practice results in cost savings. The American Association of Diabetes Educators estimates that the economic implications of implementing these guidelines will be minimal and the benefits in improved patient outcomes are likely to be notable. However, the actual costs (and savings) of guidelines implementation for the practice of diabetes education have not been addressed and will remain unclear until specific analyses of guidelines adoption have been undertaken.

The quality and validity of the draft guidelines document was assessed by six reviewers using the Appraisal of Guidelines for Research & Evaluation (AGREE) instrument, which was modified to accommodate the intent of the guidelines. Reviewers then recommended adoption of the guidelines.

The guidelines have been critiqued and vetted by target users. Reviewers from diverse backgrounds and practice perspectives provided critiques at various points during the development process. The reviewers included individuals who are active in the practice of diabetes education for self-care, as well as representatives from nongovernment organizations, academic centers, consulting firms, and public health groups. The reviewers were asked to use the AGREE instrument, which was modified slightly to better suit the purpose of this review. Comments from the external reviewers were considered by the American Association of Diabetes Educators Professional Practice Committee (AADE PPC), shared with the writing team, and integrated into the final version of the document.

Definitions for the levels of evidence (1-3) and the grades of recommendation (A-D) are provided at the end of the "Major Recommendations" field.

Summary of Recommendations

• All patients with diabetes should have access to diabetes self-management education and training. (A)
• Diabetes self-management education and training should focus primarily on supporting behaviors that promote effective self-management as described in the AADE7^™ Self-Care Behaviors. (B)
• Diabetes self-management education and training should follow a comprehensive 5-step process that includes: assessment, goal-setting, planning, implementation, and evaluation. (C)
• Diabetes self-management education and training should be delivered by individuals who are prepared and competent. (A)
• People who deliver diabetes education and care services should function within the practice level articulated in these guidelines. (D)

Table. General Scope of Diabetes Educational/Clinical Care Activities

*It is recognized that some healthcare professionals who are Level 2 or 3 educators may undertake elements of Diabetes Self-Management Education and Training (DSME/T) that are identified in Level 4, however, these practitioners lack nationally recognized certification in diabetes self-management education.

**Includes but not limited to board certification in advanced management (BC-ADM) and Advanced Practice Nurse

Note: Level 4 and 5 practitioners may supervise those in the lower levels.

Definitions:

Grades of Recommendation

Criteria for Rating Evidence

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

The evidence used in developing the guidelines included key meta-analyses, evidence-based reviews, clinical trials, cohort studies, epidemiologic studies, position statements, and consensus statements and guidelines (English language only).

Improved patient outcomes through successful diabetes self-management

Not stated

The American Association of Diabetes Educators and its officers, directors, employees, agents, and members assume no liability whatsoever for any personal or other injury, loss, or damage that may results from the application of the information contained herein.

Implementation and Criteria for Monitoring the Use of these Guidelines

To be successful in advancing the delivery of Diabetes Self-Management Education and Training (DSME/T), strategies are needed to help ensure effective implementation of the various recommendations set forth in the guidelines. Tools have been developed to support implementation (see the following section), and an ongoing outreach campaign will inform diabetes educators and the broader health care community about the guidelines' availability and intent. American Association of Diabetes Educators (AADE) will track the adoption and use of these guidelines via its bi-annual National Practice Survey and through interface with AADE members.

AADE will monitor the usage of these guidelines and reserves the right to make changes in these guidelines without prior notice. Monitoring criteria include the frequency in which the guidelines are cited in the literature and usage rates of these guidelines among health care practitioners.

Tools to Support Implementation of the Guidelines

An electronic database has been created to monitor behavioral goal setting and implementation of diabetes education by practitioners at the various practice levels. The AADE7^™ system tools, which are available for voluntary use, capture quality indicators based on the AADE7^™ clinical and behavioral outcomes. Reports generated by the system help to track practitioner and patient DSME/T activities and assess the achievement of collaboratively set goals and changes in clinical and behavioral outcomes that result in better health for people with diabetes.

The guidelines are intended to be used in conjunction with the AADE Competencies and Skills for Diabetes Educators, which provide a comprehensive description of the knowledge, skills, and competencies necessary for the delivery of diabetes education and care at various practice levels. In addition, AADE has developed a desk reference for diabetes self-management and collaborated with other groups to develop the National Standards for DSME/T. Electronic and print materials were developed to support the practice of diabetes education such as a monograph on continuous quality improvement and published systematic reviews on each of the healthy behaviors.

Cost of Implementing the Guidelines

Studies on the economic impact associated with the implementation of guidelines have generally confirmed that standardizing practice results in cost savings. AADE estimates that the economic implications of implementing these guidelines will be minimal and the benefits in improved patient outcomes are likely to be notable. However, the actual costs (and savings) of guidelines implementation for the practice of diabetes education have not been addressed and will remain unclear until specific analyses of guidelines adoption have been undertaken.

Addressing Potential Barriers to Implementation of These Guidelines

The AADE recognizes that implementation of the recommendations included in these guidelines may be affected by barriers to the delivery of DSME/T at the patient, practitioner, organizational, or societal level. These barriers may include:

• Lack of public awareness regarding the severity of diabetes and the importance of DSME/T
• Inadequate and/or lack of reimbursement and coverage limitations relevant to DSME/T
• Inadequate and/or lack of staffing and resource allocation within clinical and community settings
• Practice constraints regarding licensure and inconsistencies from state to state
• Institutional resistance to change (e.g., need to adjust staffing, workflow, role delineation, budgets)

A recent claims data analysis supports the use of diabetes education and training as a cost-effective component of quality care for all persons with diabetes. Although it is beyond the scope of this document to address the financial and organizational barriers identified, AADE is actively working with local, state, and federal policy makers to resolve these issues and expand access to DSME/T for all persons with diabetes. Further, AADE has developed education resources and tools to assist DSME/T providers in integrating the AADE7^™ framework into their practices. These resources and tools are available on the AADE website (www.diabeteseducator.org/ProfessionalResources ).

Not applicable: The guideline was not adapted from another source.

American Association of Diabetes Educators

American Association of Diabetes Educators Guidelines Workgroup

Guideline Authors: Chris Parkin, MS; Debbie Hinnen, ARNP, BC-ADM, CDE, FAAN; Virginia Valentine, CNS, BC-ADM, CDE; Donna Rice, MBA, BSN, RN, CDE; Marian Batts-Turner, MSN, RN, CDE; Linda Haas, PHC, RN, CDE; Carole Mensing, RN, MA, CDE; Terry Lumber, RN, CNS, CDE, BC-ADM; Karen Fitzner, PhD; Barbara Stetson, PhD; Karen McKnight, RD, LD; Kris Ernst, BSN, RN, CDE; Terry Compton, MS, APRN, RN, CDE; Joe Nelson, MA, LP; Jane Jeffrie Seley, MPH, MSN, GNP, CDE, BC-ADM; Nancy Letassy, RPH; Dawn Sherr, RD, CDE

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Association of Diabetes Educators (AADE). Guidelines for the practice of diabetes education. Chicago (IL): American Association of Diabetes Educators (AADE); 2009. 39 p.

Electronic copies: Available in Portable Document Format (PDF) from the American Association of Diabetes Educators (AADE) Web site .

The following are available:

• Competencies for diabetes educators. A companion document to the Guidelines for Diabetes Education. Chicago (IL): American Association of Diabetes Educators (AADE); 2009. 24 p. Electronic copies: Available from the American Academy of Diabetes Educators (AADE) Web site .
• The scope of practice, standards of practice, and standards of professional performance for diabetes educators. Chicago (IL): American Association of Diabetes Educators (AADE); 2008 Jun. 18 p. Electronic copies: Available from the AADE Web site .
• Diabetes educators & your practice. Brochure. Chicago (IL): American Association of Diabetes Educators (AADE). 8 p. Electronic copies: Available from the AADE Web site .
• Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, Maryniuk M, Peyrot M, Piette JD, Reader D, Siminerio LM, Weinger K, Weiss MA. National standards for diabetes self-management education. Diabetes Care. 2009 Jan;32 Suppl 1:S87-94. Electronic copies: Available from the AADE Web site .

The following is available:

• Side by side: a partner approach to diabetes self care. Chicago (IL): American Association of Diabetes Educators (AADE); 16 p. Electronic copies: Available in English and Spanish from the American Academy of Diabetes Educators Web site .

Additional patient resources, including handouts, videos, pamphlets, and a patient-focused blog are available from the American Academy of Diabetes Educators Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on December 10, 2009. The information was verified by the guideline developer on December 18, 2009. This NGC summary was updated by ECRI Institute on March 11, 2011.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.