This study was performed to investigate the rate of compliance with education prescription and to analyze the effect of diabetes education. To assess the education compliance rate, we divided the enrolled subjects into two groups. The first group included patients who finished their education as ordered and the other included patients who refused to undergo the education session even though their physician prescribed DSME. To investigate the effect of completing diabetes education, we compared two patient groups after education prescription, with an adjustment for diabetes duration.
The effectiveness and importance of diabetes education has been evaluated several times in Korea [10
] and worldwide [11
] and the results of a metaanalysis have already shown that education has beneficial effects in terms of improving glycemic control, weight, and lipid profiles [12
]. Therefore, diabetes education has been regarded as a key component of diabetes management for a long time [2
], and its importance has been growing. As a result, authorities have suggested that there should be national standards for DSME [13
]. Moreover, it has been reported that the education of patients with a shorter duration of diabetes resulted in a better long-term clinical outcome and cost-effectiveness in the United Kingdom [5
] and higher adherence to self-care activities and better glycemic control in Korea [6
]. On the other hand, diabetes education has not been evaluated recently, especially with a focus on compliance with an education prescription in clinical practice.
In 2009, there were more than 2,000 patients who were ordered to get DSME in our center. Among the patients who were prescribed to receive education, the proportion of patients who received education was 64.0%. Interestingly, the proportion of patients who received education was lower in megalopolis locations. Although we could not assess the reasons why about 36.0% of the patients refused to undergo diabetes education in this study, we can assume that it was caused by a lack of comprehension about the importance of DSME or due to economic problems of the patients [14
], because education is not covered by national health insurance in Korea. There have been two descriptive studies in Korea which have mentions about the percent of the patients who had ever had the opportunity to get diabetes education among the whole diabetic patients. In those studies, it was reported that only 26.2% or 39.4% of the patients with diabetes had attended diabetes education classes [8
]. In those two reports, it was unclear whether diabetes education had been recommended to the subjects who had not received an education. In our study 36.0% of the patients refused to attend a class of DSME even though their treating physician prescribed and recommended the education. These findings suggest that a low DSME education rate in the Korean diabetic population might be explained partially by the patients' refusal to get the education. Moreover, we found that educated subjects tended to revisit the clinic regularly and showed better adherence to the evaluation plan. The percentage of regular clinic visits in the compliant group was 38.5%, while it was only 24.8% in the non-compliant group (P
<0.001). Therefore, treating physicians should encourage their patients to undergo DSME.
Between the compliant and non-compliant group, there was a significant difference in the duration of diabetes. To adjust for the effect of diabetes duration, we divided the subjects according to the duration of diabetes. This adjustment revealed that compliance with the education prescription in patients with diabetes for more than 1 year failed to show a significant improvement in hemoglobin A1c compared with patients who ignored the education prescription. The results of the present study correspond well with those of an earlier report from the U.K. The Prospective Diabetes Study (UKPDS) suggested that glycemic control rates among individuals with diabetes decreases with disease duration [15
Our study had some limitations. It was a retrospective non-randomized study, so there are several confounding factors for which we cannot adjust. Client education can enhance medication compliance, but medication compliance cannot be assessed in this study, so better glycemic control was caused by better medication compliance in the educated group. Moreover, the patients who did not undergo the education might have a tendency to ignore other recommendations from their doctor; therefore those tendencies might enhance the positive effect of completing the education. Another problem is that we failed to show the efficacy of either intensive education or follow-up education. It has been reported that the type of education can cause differences in diabetes control [16
]. This discrepancy should be reevaluated in a larger study. Finally, the results of this study are limited to a single center experience.
In this study we found a number of patients refused to receive the DSME in spite of the education being prescribed by their physician. The refusal rate was higher in the patients with longstanding diabetes and urban residence. However, there should be further investigation into the factors affecting the patients' compliance such as academic educational status, socioeconomic status, and cost of education. We also found that earlier education is more effective in real clinical practice. After DSME prescription, educated subjects were more likely to have a change in hemoglobin A1c compared to the subjects who refused to get the education. Since the duration of diabetes was significantly shorter in subjects who followed their physicians' order to get the education, a tendency of hemoglobin A1c decrement was reanalyzed with an adjustment for the duration of diabetes. These beneficial effects on hemoglobin A1c decrement after education persisted after adjusting for the duration of diabetes mellitus. In our study, education in patients with diabetes for more than 1 year failed to make a significant improvement in hemoglobin A1c compared with the patients who ignored the education prescription. Therefore, our data support the importance of implementing early DSME for patients with diabetes. To make patients complete the education, physicians should make an effort to encourage patients to finish the education session. In addition, we need to investigate the reason for education refusal and focus more on reducing the rate of non-compliance with education prescriptions in clinical practice.