Table 1 details our assumptions and definitions. Table 2 lists self-care tasks. We asked the CDEs to consider a typical patient with type 2 diabetes in a stable phase of care, taking oral hypoglycemic agents, and self-testing blood glucose once daily. They reached consensus on the average time required by this patient for each task, in minutes per day, including preparation and cleanup time. Discussion of other patient types and of circumstances that would change estimated times were encouraged by the moderator.
TABLE 1
Diabetes self care: Assumptions about patients, and definitions of tasks
| Patient characteristics | The CDEs were asked to consider a typical patient with type 2 diabetes, in a stable phase of care, on oral hypoglycemic agents and self-testing blood glucose once daily. These estimates are shown in Table 2. Type 2 diabetes accounts for 90–95% of diabetes in the U.S.25 |
| To provide a basis for considering the variability of time requirements (see text), they also made estimates for other types of patients, ranging from those whose diabetes is controlled by diet alone to elderly patients with multiple chronic conditions. | |
| Task definitions | Time, in minutes per day, represents extra tasks required by diabetes self-care, or extra time for usual tasks. All estimates include time for preparation and cleanup. |
| Taking oral medications (2 min/episode of medication taken) includes time to organize pills for the day or week. All patients are assumed to take aspirin. | |
| Problem solving includes time to make decisions about changes in medication or diet in response to blood sugar values and symptoms, and time for general tasks such as remembering to carry medications, snacks, etc. | |
| Shopping time is the additional time required to read nutrition labels for carbohydrate counting and to make extra trips for perishable fresh produce. Transportation time for extra trips is included. | |
| Exercise includes time to change clothes, shoes, etc. Since most adults do not exercise (see text) the full time required for exercise is included. | |
| Support groups include internet groups, family support, reading groups, supportive group settings, formal diabetes support groups, and church. | |
| Scheduling appointments does not include the time required by the appointments themselves. |
TABLE 2
Estimated time required for recommended care*
| Task | Minutes/day |
|---|---|
| ADA recommendations | |
| Home glucose monitoring | 3 |
| Record keeping | 5 |
| Taking oral medication | 4 |
| Foot care | 10 |
| Oral hygiene, flossing | 1 |
| Problem solving | 12 |
| Meal planning | 10 |
| Shopping | 17 |
| Preparing meals | 30 |
| Exercise | 30 |
| ADA SUBTOTAL | 122 |
| Other desirable self-care | |
| Monitoring blood pressure | 3 |
| Stress management | 10 |
| Support group | 2 |
| Administrative tasks | |
| Phoning educators, doctors | 1 |
| Scheduling appointments | 1 |
| Insurance dealings | 2 |
| Obtaining supplies | 2 |
| TOTAL TIME | 143 |
| *Estimates for patients with stable diabetes who are taking oral agents and self-monitoring blood glucose once | |
Results
Table 2 presents estimated times for a stable patient with type 2 diabetes on oral hypoglycemic agents. The ADA’s recommendations would take this patient 122 minutes per day, more than 2 hours; other tasks bring the total to 143 minutes per day. The first 4 elements, which are unique to diabetes, take only 22 minutes per day. Activities related to exercise or diet, recommended for many chronic conditions, account for most of the time.
The CDEs estimated that patients with newly diagnosed diabetes would take 25% to 30% longer for all tasks. Older and more infirm patients (eg, persons with neurological disorders/stroke, neuropathy, visual impairments, or depression) could require twice as long for most tasks and might also need the help of a caregiver. They might not be able to carry out some tasks, such as exercise. Patients taking insulin need only a few more minutes per day.
Discussion
Estimates by CDEs suggest that recommended diabetes self-care requires more than 2 hours daily. For infirm patients or those with newly diagnosed disease, even more time is required, and some tasks involve the help (and time) of caregivers. These estimates raise an important issue: the care physicians commonly recommend may be too time-consuming for many patients.
In one study, persons with diabetes reported spending a median of 48 minutes daily on self-care tasks.18 Only a few spent no time, but a third to a half skipped specific elements of self-care completely. When asked “What is the biggest obstacle for you in effectively managing your diabetes?” more than a fifth answered “not enough time.”
When patients choose which tasks to undertake, their choices may not optimize health. Although little evidence is currently available to help clinicians and patients prioritize self-care tasks, some tasks are surely more important for certain patients than others. Younger, more mobile patients may benefit more from exercise education than wheelchair-bound patients with advanced disease. Foot care is more important for patients with sensory neuropathy than for those with normal sensation. In the absence of evidence, physicians’ clinical experience can be an important guide to maximizing the benefits of self-care time.
The principles in Crossing the Quality Chasm suggest ways to develop care interactions and guidelines that deal with these realities while keeping the goal of better health front and center.