PRACTICE INSIGHTS

National Survey of Pharmacist Certified Diabetes

Educators
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 certified

diabetes educators (CDEs) and information about their training, professional
affiliations, and types of diabetes education services that they provide. We
also queried these pharmacists about clinical activities, reimbursement,
impact of certification, and intent to pursue CDE recertification. A list of
pharmacists who were CDEs as of August 31, 2000, was obtained from the
National Certification Board for Diabetes Educators. We then sent a six-page
anonymous survey to 415 pharmacist CDEs; 233 surveys (56.1%) were
returned. Of these respondents, 140 are women and 93 are men, with a mean
age of 41.5 years. Most reside in Southern or Western states. Average time
since pharmacist licensure was 17 years, and average time as a CDE was 5
years. Most had completed postgraduate training, including residencies
and/or fellowships; 52.8% had faculty appointments; 46.7% stated they were
billing for their services; and 45.9% were obtaining reimbursement. Most
pharmacists (84.4%) stated that they intended to pursue CDE recertification.
Providing details about pharmacist CDEs and their clinical activities may
motivate other pharmacists to pursue this credential. Pharmacists are often
the most accessible of all health care providers, and earning the CDE
credential may be an important contribution to diabetes care and education.
(Pharmacotherapy 2002:22(12):1579–1593)

Patients with diabetes mellitus present an
enormous challenge to the health care system.
Diabetes is a costly disease in which many
complications may occur, and yet maintaining
appropriate blood glucose control prevents
From the Department of Pharmacy Practice, College of
Pharmacy (Drs. Shane-McWhorter and Oderda) and the
Department of Family and Preventive Medicine, School of
Medicine (Dr. Shane-McWhorter), University of Utah, Salt
Lake City, Utah; the Department of Pharmacy Practice,
Medical University of South Carolina, Charleston, South
Carolina (Dr. Fermo); and the Oregon Health and Science
University, 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, April
22–25, 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.
occurrence and progression of many of these
complications.1–6 New statistics indicate that 17
million people in the United States (or 6.2% of
the population) have diabetes. It has been
diagnosed in 11.1 million Americans. Another
5.9 million are estimated to have diabetes, but as
yet the disease is undiagnosed. 7 There are
800,000 new cases of diabetes diagnosed every
year or 2200/day.8, 9 Diabetes treatment costs
approximately $98 billion/year. 10, 11 Statistics
compiled by the Centers for Disease Control and
Prevention indicate the prevalence of preventive
care practices is suboptimal, and compliance
with national health recommendations is poor.12
This 1997 survey of people with diabetes in 41
states demonstrated that only 61.6% of these
individuals reported receiving a dilated-eye
examination within the previous year, 54.6%
reported receiving a foot examination within the
1580 PHARMACOTHERAPY Volume 22, Number 12, 2002
previous year, 39.6% reported self-monitoring of
blood glucose at least once/day, and 18.4%
reported having their hemoglobin A 1c (A1C)
levels checked in the previous year.12
One of the most important aspects of diabetes
management is patient education so that
individuals with diabetes have the necessary
information to optimize diabetes control; this
may help maintain wellness and prevent
diabetes-related complications. Certified diabetes
educators (CDEs) provide self-management
education with the target goal of maintaining
appropriate blood glucose control and thereby
preventing diabetes-related complications. When
diabetes initially is diagnosed, however, the
provider (often a primary care provider) does not
have the time necessary to provide the patient
with self-management education. Ancillary
health care professionals are key in the continued
support and education of these patients.
However, an adequate number of professionals
with advanced training to whom patients may be
referred is lacking. Pharmacists lack provider
status under Medicare and consequently are often
not recognized by other health care professionals
or by billing services as medical providers. Thus,
patients might not be referred to them for
diabetes education.
To provide quality diabetes care and education,
health care professionals must receive basic
preparation and continuing education in specific
educational strategies and behavioral interven-
tions.13–19 Behavioral and lifestyle modifications
are the keys to successful self-management of
diabetes.20, 21 In one study, four different education
programs produced lowering of A1C and body
mass index, but behavioral programs produced
greater patient satisfaction and greater likelihood
to seek the services of ancillary health care
providers, such as podiatrists.20 In an assessment
of attitudes of dietitians, nurses, and physicians
toward diabetes, diabetes specialists had more
positive attitudes than did nonspecialists and yet
all were in favor of a team approach to care.21
Instructors without specialized training in
diabetes,15, 16, 22–27 behavioral interventions,20, 21,
28–31
teaching and learning skills,17, 32–36 as well as
counseling skills,14, 18 may not focus on patient
behavioral changes and, therefore, may not
improve clinical outcomes. Several reports have
addressed the issue of specialized training in
diabetes to improve clinical outcomes. For
instance, some reports have shown a mismatch in
perceived versus actual diabetes knowledge
among staff nurses 15, 24, 26; those who actually
spend more time in diabetes practice and diabetes
continuing education have higher knowledge
scores and provide more comprehensive exercise
teaching than those who have less training. 16
Those with specialized training in screening and
patient education for diabetic foot ulcers have
helped prevent lower extremity amputations,23, 25
yet because of a lack of provider education in
preventive diabetes foot care, a Medicare benefit
for therapeutic shoes was extremely underused.27
Also, training in behavioral interventions is
important. Besides increased patient satisfaction20
or a more positive attitude,21 educators who had
formal training had a positive association with
greater use of behavioral techniques. 28 In one
report, subjects had improved metabolic control
when they were taught coping skills, a type of
behavioral intervention, from an educator. 29
Another report stated that over half the educators
had received behavioral training to help with
lifestyle modifications. 30 Some behavioral
techniques they cited included goal setting,
behavioral modification, positive reinforcement,
making contracts with patients, and stress
reduction. 30 In another setting, practitioners
stated they found benefit from training they
received in behavioral techniques that included
agenda-setting techniques, motivational inter-
viewing, and assessing readiness for change.31
Instruction in teaching and learning skills also
may have an effect on outcomes. In one study,
nurses questioned the adequacy of their
knowledge of diabetes and how competent they
felt in caring for patients with diabetes. 17
Another report eloquently discussed the scarcity
of techniques to train health care professionals to
provide education so that patients may better
self-manage their diabetes.32 The authors stated
that education must be aligned with patients’
sociocultural characteristics, personal beliefs
regarding diabetes, and ability to cope with the
disease and with the realization that the patient is
the locus of control. 32 Other investigators
mentioned using techniques of adult education
to address a psychosocial variable, such as
attitude, as an important contributor to positive
diabetes management.33 Training of health care
professionals improves patient teaching skills.34
Patient education that produces behavioral
changes requires that health care professionals
have specific training, good communication and
teaching skills, a supportive attitude, a readiness
to listen and negotiate, 35 as well as time and
adequate teaching skills.36
Without training in counseling skills, providers
 SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al
Table 1. Demographics of Respondents by Sex, Age, and Diabetes Status
Characteristic Men
No. (%) of respondents 93 (39.9)
Age (yrs)
Range 31–67
Mean ± SD 45.9 ± 7.48
Diabetes status, no. (%)
Type 1 9 (3.9)
Type 2 3 (1.3)
may not be able to positively affect patient
behavior. In one study, physicians were provided
specialized training and were taught to conduct
dietary risk assessments and provide patient-
centered counseling to change dietary patterns.14
Other types of counseling, including patient
education and adherence promotion skills, are
not always part of dietitians’ training, but
supplemental training may improve these
teaching skills. 15 In summary, health care
professionals require greater knowledge and
utilization of behavioral interventions in patients
with any chronic disease.18, 19, 28, 37, 38
One option for pharmacists to obtain diabetes-
focused postgraduate education is preparation for
the CDE examination. This certification by the
National Certification Board for Diabetes
Educators (NCBDE) is one way that health care
professionals may demonstrate mastery of a
specific body of knowledge. The CDE has
become the accepted credential for diabetes self-
management education,39 which is an interactive,
collaborative, ongoing process involving the
person with diabetes and the educator(s).40 This
process involves assessment of the individual’s
specific education needs, identification of the
individual’s specific diabetes self-management
goals, education and behavioral interventions
directed toward helping the individual achieve
identified self-management goals, and evaluation
of the individual’s attainment of identified self-
management goals.40
Passing an examination administered through
the NCBDE is a requirement to becoming a CDE.
Also, those qualifying for certification must meet
certain professional and/or educational criteria
and demonstrate that they have provided a
certain amount of direct diabetes self-manage-
ment education in the 2–5 years before taking the
examination. 41 The many health care profes-
sionals who are CDEs include nurses, dietitians,
social workers, physicians, physical therapists,
1581
Women Total
140 (60.1) 233 (100)
27–60 27–67
38.4 ± 7.88 41.5 ± 8.56
6 (2.6) 15 (6.5)
5 (2.1) 8 (3.4)
and pharmacists. According to the NCBDE, there
were 415 pharmacists as of August 31, 2000.
The current total number of CDEs is over
12,000.42
We sought to determine several characteristics
of pharmacist CDEs regarding their training,
professional organization memberships, work
activities, work sites, motives for certification, and
impact of certification. We also hoped to elucidate
information about clinical activities, reimburse-
ment, and intent to obtain recertification.
Methods
After obtaining investigational review board
approval, a list of pharmacists who were CDEs as
of August 31, 2000, was obtained from the
NCBDE. A six-page anonymous survey was sent
to all 415 pharmacist CDEs. After 1 month, a
second mailing was sent to nonrespondents.
The survey asked questions about academic
degrees and postgraduate training, professional
and academic affiliations, practice sites, and work
activities. Other questions examined motives for
certification and impact of certification. The
survey also asked questions about pharmaceutical
care services, patient education, physical
assessment provided, billing and reimbursement
for diabetes services, and outcome measures.
The survey queried individuals about intent to
recertify as a CDE and to obtain the new
advanced practice multidisciplinary credential,
the board certified-advanced diabetes management
(BC-ADM) certification. The BC-ADM is the first
advanced practice certification examination in
diabetes care available to a variety of professional
disciplines with advanced degrees; it emphasizes
clinical assessment and disease-state management,
in addition to patient education and counseling.
More information regarding the advanced practice
credential is available from www.aadenet.org or
www.nursingworld.org/ancc.
1582 PHARMACOTHERAPY Volume 22, Number 12, 2002
Table 2. Demographics of Respondents by Degree and Postgraduate Training
No. (%) of Pharmacist CDEs
Degree or Training Men Women Total
Pharmacy
B.S. only 67 (28.7) 65 (27.9) 132 (56.6)
B.S. + post-B.S. Pharm.D. 18 (7.7) 40 (17.2) 58 (24.9)
B.S. + nontraditional Pharm.D. 6 (2.6) 6 (2.6) 12 (5.2)
Entry-level Pharm.D. 2 (0.9) 29 (12.4) 31 (13.3)
Totals 93 (39.9) 140 (60.1) 233 (100)
Additional degrees
Ph.D. 0 0 0
M.S. 3 (8.6) 4 (11.4) 7 (20)
M.P.H. 1 (2.9) 0 1 (2.9)
M.B.A. 2 (5.7) 3 (8.6) 5 (14.3)
Other master’s 0 2 (5.7) 2 (5.7)
Other degrees 8 (22.8) 12 (34.3) 20 (57.1)
Totals 14 (40) 21 (60) 35 (100)
a
Postgraduate training
None 18 (42.9) 24 (57.1) 42 (100)
Pharmacy practice residency 8 (21.1) 30 (78.9) 38 (100)
Specialty residency 9 (24.3) 28 (75.7) 37 (100)
Fellowship 4 (36.4) 7 (63.6) 11 (100)
Certificate program 43 (43.0) 57 (57.0) 100 (100)
Other 7 (46.7) 8 (53.3) 15 (100)
B.S. = bachelor of science; Pharm.D. = doctor of pharmacy; Ph.D. = doctor of philosophy; M.S. = master of
science; M.P.H. = master of public health; M.B.A. = master of business administration.
a
Some individuals completed more than one postgraduate training program.

Results [3.0%], master of science; 5 [2.1%], master of

Demographics, Education, Training, and Work
Experience
Of 415 questionnaires, 233 (56.1%) were
returned. Responses were received from 93 men
(39.9%) and 140 women (60.1%). Mean age of
male pharmacists was 45.9 ± 7.48 years, and that
of female pharmacists was 38.4 ± 7.88 years.
Mean age of all respondents was 41.5 ± 8.56
years. Twenty-three (9.9%) of 232 respondents
who answered the question about diabetes status
stated they had diabetes. Table 1 summarizes the
demographics of respondents by sex, age, and
diabetes status.
Respondents’ education and postgraduate
training is summarized in Table 2. Two hundred
two respondents (86.7%) had a bachelor of
science (B.S.) degree in pharmacy, with 132
(56.6%) having this as their only pharmacy
degree. However, 101 pharmacists (43.4%) had a
doctor of pharmacy (Pharm.D.) degree.
Pharmacists with the Pharm.D. degree included
58 (24.9%) with a post-B.S. degree, 31 (13.3%)
with an entry-level Pharm.D., and 12 (5.2%) with
a nontraditional Pharm.D. degree. No
respondents had a doctor of philosophy (Ph.D.)
degree, and 15 (6.4%) had master’s degrees (7
business administration; 1 [0.4%], master of
public health; and 2 [0.9%], other master’s
degrees). Twenty respondents (8.6%) had other
degrees.
Most of the respondents also had postgraduate
training. Forty-two (18.0%) indicated that they
had no postgraduate training. Thirty-eight
pharmacists (16.3%) completed a pharmacy
practice residency, 37 (15.9%) completed a
specialty residency, and 11 (4.7%) completed
fellowship training. One hundred respondents
(42.9%) completed certificate programs. Several
individuals completed more than one type of
postgraduate training.
Professional experience varied. Pharmacist
licensure ranged from 3–44 years, with a mean
time since licensure of 16.9 ± 8.75 years.
Respondents stated that time since obtaining
CDE certification ranged from less than 1 year to
18 years, with a mean of 4.7 ± 3.77 years. Male
pharmacists had been licensed and certified
(CDE) longer than female pharmacists (Table 3).
Geographic Location of Respondents
The states in which the pharmacist CDEs
practiced were divided into four regions:
Northeast, South, Midwest, and West (Figure 1).
 SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al 1583
Table 3. Pharmacy Work Experience
Parameter Men Women Total
No. of years as licensed pharmacist
Range 4–44 3–39 3–44
Mean ± SD 21.7 ± 8.02 13.8 ± 7.78 16.9 ± 8.75
No. of years as CDE
Range 0–18 1–17 0–18
Mean ± SD 5.2 ± 4.05 4.4 ± 3.55 4.7 ± 3.77
CDE = certified diabetes educator.

More respondents practiced in Southern states, American Society of Health-System Pharmacists

followed by the West, then the Midwest, and the
Northeast (Table 4).
Membership in Professional Organizations and
Professional Recognition
More respondents were members of the
American Association of Diabetes Educators
(AADE) than any other professional organization
(Figure 2). We asked about membership in the
(ASHP), the American Pharmaceutical Association
(APhA), American College of Clinical Pharmacy
(ACCP), and the American Society of Consultant
Pharmacists (ASCP). We also asked about
membership in the American Association of
Colleges of Pharmacy (AACP) since we thought
that many of the pharmacist CDEs also might
teach pharmacy students. Professional affiliations
listed by the respondents as “other” were
primarily state chapters of ASHP and APhA.

West (29.3%) Midwest (18%) Northeast (14.4%)

n=65 (23 M, 42 F) n=40 (13 M, 27 F) n=32 (18 M, 14 F)

ME

South (38.3%)
n=85 (36 M, 49 F)
Figure 1. Geographic location of 222 pharmacists who responded to this question. Puerto Rico (not shown) is included in the
South region. Alaska and Hawaii are included in the West region.
1584 PHARMACOTHERAPY Volume 22, Number 12, 2002
Table 4. Geographic Distribution of Respondents by State
No. of CDEs No. of CDEs No. of CDEs No. of CDEs
Northeast (M, F) South (M, F) Midwest (M, F) West (M, F)
Connecticut 3 (3, 0) Alabama 7 (5, 2) Illinois 16 (5, 11) Alaska 0
Delaware 1 (0, 1) Arkansas 1 (1, 0) Indiana 3 (0, 3) Arizona 1 (1, 0)
Maine 0 District of Columbia 1 (0, 1) Iowa 1 (0, 1) California 17 (6, 11)
Massachusetts 5 (2, 3) Florida 4 (1, 3) Kansas 1 (0, 1) Colorado 5 (1, 4)
New Hampshire 1 (0, 1) Georgia 6 (3, 3) Michigan 3 (1, 2) Hawaii 8 (2, 6)
New Jersey 3 (2, 1) Kentucky 5 (2, 3) Minnesota 2 (1, 1) Idaho 1 (0, 1)
New York 12 (7, 5) Louisiana 0 Missouri 4 (2, 2) Montana 0
Pennsylvania 7 (4, 3) Maryland 6 (3, 3) Nebraska 2 (1, 1) Nevada 3 (1, 2)
Rhode Island 0 Mississippi 1 (1, 0) North Dakota 0 New Mexico 3 (1, 2)
Vermont 0 North Carolina 17 (4, 13) Ohio 5 (1, 4) Oregon 5 (3, 2)
Oklahoma 4 (2, 2) South Dakota 1 (0, 1) Utah 4 (1, 3)
Puerto Rico 1 (0, 1) Wisconsin 2 (2, 0) Washington 17 (7, 10)
South Carolina 2 (0, 2) Wyoming 1 (0, 1)
Tennessee 8 (5, 3)
Texas 9 (3, 6)
Virginia 10 (5, 5)
West Virginia 3 (1, 2)
Total CDEs
for region 32 (18, 14) 85 (36, 49) 40 (13, 27) 65 (23, 42)
Percentage
(n=222) 14.4 38.3 18.0 29.3
Regional
population
(millions)a 54.4 103.3 64.4 63.2
No. of CDEs/
100,000 5.9 8.3 6.2 10.3
CDEs = certified diabetes educators.
a
From the 2000 U.S. Census Bureau. Available from http://factfinder.census.gov/servlet/GCTTable?_ts=40311773953. Accessed May 24, 2002.

Table 5. Faculty Status, Appointment Rank, Academic 100

Track at Colleges of Pharmacy

90
Educational No. (%) of
Appointments Pharmacist CDEs
80
Faculty status 123 (52.8)
Appointment rank 70
Volunteer faculty 10 (8.1)
Percentage of Respondents

Instructor 2 (1.6) 60
Clinical adjunct faculty 55 (44.7)
Assistant professor 27 (22.0) 50
Associate professor 18 (14.7)
Professor 4 (3.2) 40
Other 7 (5.7)
Total 123 (100) 30

Academic track
Adjunct 36 (31.3) 20

Clinical 62 (53.9)
Tenure 9 (7.8) 10

Other 8 (7.0)
Total 115 (100) 0
AADE ASHP APhA ACCP ASCP AACP Other
CDEs = certified diabetes educators. n=151 n=88 n=79 n=56 n=23 n=20 n=84

Figure 2. Professional affiliations of the 233 respondents.

Many pharmacists had proven expertise in
other areas as well as diabetes. Thirty
pharmacists (12.9%) obtained board certification
in pharmacotherapy, one in psychiatry, and one
AADE = American Association of Diabetes Educators; ASHP
= American Society of Health-System Pharmacists; APhA =
American Pharmaceutical Association; ACCP = American
College of Clinical Pharmacy; ASCP = American Society of
Consultant Pharmacists; AACP = American Association of
Colleges of Pharmacy; Other = state chapters of ASHP and
APhA.
 SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al 1585
Table 6. Percentage of Time Spent in Work Activities
No. (%) of Pharmacist CDEs
Clinical Drug Scholarly
% of Time Activity Teaching Administrative Distribution Activity Research Other
1–25 66 (36.3) 118(77.6) 85 (70.9) 28 (24.8) 44 (97.7) 40 (95.2) 8 (61.5)
26–50 54 (29.7) 23 (15.2) 22 (18.3) 30 (26.5) 1 (2.3) 2 (4.8) 2 (15.4)
51–75 29 (16) 7 (4.6) 7 (5.8) 25 (22.2) 0 0 1 (7.7)
76–100 33 (18) 4 (2.6) 6 (5.0) 30 (26.5) 0 0 2 (15.4)
Totals 182 (100) 152 (100) 120 (100) 113 (100) 45 (100) 42 (100) 13 (100)
CDEs = certified diabetes educators.

Table 7. Reasons for Pursuing the CDE Credential
No. (%) of
Reason Pharmacist CDEs (n=233)
Professional development 208 (89.3)
Personal satisfaction 204 (87.6)
Enhance reimbursement 79 (33.9)
Promotion 22 (9.4)
Salary increase 10 (4.3)
Job requirement 7 (3.0)
Other 25 (10.7)
CDEs = certified diabetes educators.
in nutrition support. Furthermore, several also
had obtained recognition from different
professional organizations. Six pharmacists had
achieved fellowship status in ACCP, five in ASHP,
four in ASCP, and three in APhA.
Educational Appointments at Colleges of
Pharmacy
A total of 123 (52.8%) respondents had college
of pharmacy faculty appointments. Most
respondents were clinical adjunct faculty,
whereas others had various faculty appointments.
Faculty status, rank, and academic track are
listed in Table 5 for respondents who answered
these questions.
Position Description
Of 216 responses, 167 pharmacists (77.3%)
indicated their position as full time, and 49
(22.7%) stated their position as part time.
Responses varied for the percentage of time
devoted to diabetes care: 127 (61.1%) of 208
respondents indicated 1–25% of their time was
devoted to diabetes care activities; 46 (22.1%),
26–50% of their time; 15 (7.2%), 51–75% of their
time; and 20 (9.6%), 76–100% of their time.
Pharmacists were asked the percentage of time
they devoted to different work activities,
including clinical activities, teaching,
administrative, drug distribution, scholarly
endeavors, research, or other types of work
(Table 6). A significant difference was noted
between those with a B.S. only and those with a
Pharm.D., with the latter spending more time in
clinical activities, research, and scholarly
activities (p<0.001, p=0.002, and p=0.002,
respectively).
Practice Sites of Pharmacist CDEs
Two hundred thirty pharmacists responded to
the questions regarding primary practice sites.
The survey revealed that most respondents (100
pharmacists [54.5%]) practiced in ambulatory
care clinics, consisting of family medicine,
internal medicine, diabetes specialty, and other
clinics (including Veterans Affairs [VA] clinics).
Other primary practice work sites included
independent pharmacies (45 pharmacists
[19.6%]), retail pharmacies (36 [15.6%]), and
acute care hospitals (31 [13.5%]). Seven
pharmacists (3%) stated they were self-employed,
six (2.6%) worked for industry, three (1.3%)
worked in long-term care facilities, and two
(0.9%) worked in home health care.
One hundred eighty-four pharmacists
answered the question regarding the most
applicable setting of their primary practice site.
Thirty-four (18.5%) stated they worked in an
academic center, 21 (11.4%) in a private
physician practice, 20 (10.9%) in managed care,
18 (9.8%) in a VA clinic, four (2.2%) in Indian
health service, and 87 (47.2%) at other sites.
Reasons for Pursuing CDE Certification
When asked to select reasons for pursuing
certification, options included enhanced
potential for reimbursement (for diabetes
education), increased salary, job promotion, job
requirement, personal satisfaction, professional
1586 PHARMACOTHERAPY Volume 22, Number 12, 2002
Table 8. Impact of CDE Certification
No. (%) of Pharmacist CDEs (n=233)
Parameter Improved No Change Unknown
Respect from peers 205 (88.0) 24 (10.3) 2 (0.9)
Personal confidence 201 (86.3) 29 (12.4) 0
Clinical skills 199 (85.4) 32 (13.7) 0
Job satisfaction 180 (77.3) 48 (20.6) 0
Patient satisfaction 175 (75.1) 44 (18.9) 8 (3.4)
Respect from patients 169 (72.5) 52 (22.3) 8 (3.4)
Other 3 (1.3) 0 0
CDE = certified diabetes educator.

Table 9. Percentage of Patients Seen by Age Group and Presence of Gestational Diabetes
No. (%) of Pharmacist CDEs
Women with
% of Pts Gestational
Seen Children Adolescents Adults Geriatrics Diabetes
1–20 67 (94.4) 77 (95.1) 10 (4.8) 47 (27.2) 64 (91.4)
21–40 4 (5.6) 3 (3.7) 25 (12.0) 47 (27.2) 3 (4.3)
41–60 0 0 55 (26.3) 34 (19.6) 1 (1.4)
61–80 0 0 51 (24.4) 27 (15.6) 1 (1.4)
81–100 0 1 (1.2) 68 (32.5) 18 (10.4) 1 (1.4)
Totals 71 (100) 81 (100) 209 (100) 173 (100) 70 (100)
CDEs = certified diabetes educators.

development, or other reasons. The two most
commonly cited reasons were professional
development and personal satisfaction (Table 7).
Effect of Obtaining the CDE Credential
For this question, pharmacists were asked to
rate the individual categories as improved, no
change, or unknown impact (Table 8).
Parameters that pharmacists thought improved
the most included respect from peers, personal
confidence, clinical skills, job satisfaction, patient
satisfaction, and respect from patients. Ten
(4.9%) of 202 respondents stated they received a
promotion. Only 40 (20 male and 20 female
respondents) of 221 pharmacists who answered
the salary question stated they received an
increase. Specific salary increases ranged from
1–40% for 15 female pharmacists and 2–50% for
16 male pharmacists who answered this question.
Mean salary increase was 11.9%.
Number of Patients Provided Diabetes Care
When asked how many patients they provide
diabetes care to, the options were fewer than 25,
25–50, 51–100, 101–200, or more than 200
patients. Two hundred fourteen responded to
this question. More respondents (59 pharmacists
[27.6%]) stated they provided care to more than
200 patients. Thirty pharmacists (14%) stated
that they cared for fewer than 25 patients with
diabetes. Thirty-nine (18.2%) cared for 25–50;
46 (21.5%) cared for 51–100 patients; and 40
(18.7%) cared for 101–200 patients.
Patient Demographics by Age, Gestational
Diabetes, and Ethnicity
Many pharmacists stated they did not provide
care for children, adolescents, or women with
gestational diabetes. Most provided diabetes care
to adult and geriatric patients (Table 9). The two
most commonly seen ethnic patient groups were
Caucasian and African-American (Table 10). The
ethnic group “other” comprised mostly Native
Americans and Pacific Islanders.
Clinical Activities
General Pharmaceutical Care Functions
These functions included pharmaceutical care
activities such as dispensing drugs, providing
drug information to other practitioners,
reviewing drug profiles, modifying drug therapy
under protocol, nutritional assessments, or
ordering laboratory tests under protocol.
 SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al 1587
Table 10. Percentage of Patients Seen by Ethnicity
No. (%) of Pharmacist CDEs
% of Pts African-
Seen Caucasian American Hispanic Asian Other
1–20 27 (13.7) 80 (47.4) 98 (73.1) 88 (90.7) 13 (61.9)
21–40 34 (17.3) 38 (22.5) 22 (16.4) 4 (4.1) 3 (14.3)
41–60 50 (25.4) 32 (18.9) 8 (6.0) 3 (3.1) 0
61–80 37 (18.8) 12 (7.1) 4 (3.0) 2 (2.1) 1 (4.8)
81–100 49 (24.8) 7 (4.1) 2 (1.5) 0 4 (19.0)
Totals 197 (100) 169 (100) 134 (100) 97 (100) 21 (100)
CDEs = certified diabetes educators.

Table 11. General Pharmaceutical Care Functions

No. (%) of Pharmacist CDEs
Activity Regularly Occasionally Never Not Currently Totals
Review drug profiles 181 (80.8) 35 (15.6) 6 (2.7) 2 (0.9) 224 (100)
Provide drug information 173 (76.2) 53 (23.3) 0 1 (0.5) 227 (100)
Modify therapy 118 (52.9) 62 (27.8) 22 (9.9) 21 (9.4) 223 (100)
Dispense drugs 104 (47.1) 55 (24.9) 59 (26.7) 3 (1.3) 221 (100)
Order laboratory tests 86 (39.5) 40 (18.3) 65 (29.8) 27 (12.4) 218 (100)
Do nutrition assessment 57 (26.3) 114 (52.5) 38 (17.5) 8 (3.7) 217 (100)
CDEs = certified diabetes educators.

Table 12. Specific Patient Education Activities

No. (%) of Pharmacist CDEs
Activity Regularly Occasionally Never Not Currently Totals
Drug counseling 204 (90.7) 19 (8.4) 0 2 (0.9) 225 (100)
Disease process 184 (81.8) 37 (16.4) 2 (0.9) 2 (0.9) 225 (100)
Meter use 183 (81.7) 35 (15.7) 3 (1.3) 3 (1.3) 224 (100)
Insulin injections 151 (68) 63 (28.4) 4 (1.8) 4 (1.8) 222 (100)
Foot care 144 (66.4) 58 (26.7) 13 (6) 2 (0.9) 217 (100)
Nutrition counseling 109 (50.4) 84 (38.9) 20 (9.3) 3 (1.4) 216 (100)
CDEs = certified diabetes educators.

Pharmacists were asked to classify these activities
as those they performed regularly, occasionally,
never, or not currently but plan to do in the
future (Table 11). The least frequently performed
activities were ordering laboratory tests and
nutritional assessments.
Specific Patient Education Activities
Pharmacists were asked how often they
perform specific patient education activities such
as blood glucose meter use, the diabetes disease
process, drug counseling, insulin administration,
nutrition counseling, and foot care (Table 12).
The most performed activities were drug
counseling and education regarding the diabetes
disease process, followed by blood glucose meter
use. Nutrition counseling was the least performed
activity.
Physical Assessment
More pharmacists conducted blood pressure
monitoring than foot examinations or other types
of physical assessment (Table 13). The phar-
macists were asked how often they performed
these activities. Other types of physical assess-
ment regularly performed included primarily
skin change, cardiovascular, or neurologic
assessment.
Point-of-Care Testing
These questions included how often the
pharmacists performed glucose, A1C, fructosamine,
1588 PHARMACOTHERAPY Volume 22, Number 12, 2002
Table 13. Physical Assessment Performed by Respondents
No. (%) of Pharmacist CDEs
Activity Regularly Occasionally Never Not Currently Totals
Blood pressure
measurement 92 (50.8) 72 (39.8) 6 (3.3) 11 (6.1) 181 (100)
Foot examinations 74 (41.6) 66 (37.1) 23 (12.9) 15 (8.4) 178 (100)
Other 10 (66.7) 5 (33.3) 0 0 15 (100)
CDEs = certified diabetes educators.

Table 14. Point- of-Care Testing

No. (%) of Pharmacist CDEs
Test Regularly Occasionally Never Not Currently Totals
Glucose 100 (68) 38 (25.9) 1 (0.7) 8 (5.4) 147 (100)
Hemoglobin A1c 50 (39.1) 21 (16.4) 35 (27.3) 22 (17.2) 128 (100)
Cholesterol 48 (38.4) 29 (23.2) 28 (22.4) 20 (16) 125 (100)
Fructosamine 18 (16.5) 22 (20.2) 56 (51.4) 13 (11.9) 109 (100)
Other 12 (80) 3 (20) 0 0 15 (100)
CDEs = certified diabetes educators.

Table 15. Recommendations or Referrals

No. (%) of Pharmacist CDEs
Recommendation Regularly Occasionally Never Not Currently Totals
Drug therapy change 132 (64.7) 64 (31.3) 4 (2) 4 (2) 204 (100)
Laboratory tests 119 (58.9) 62 (30.7) 17 (8.4) 4 (2) 202 (100)
Referrals 104 (51.5) 78 (38.6) 17 (8.4) 3 (1.5) 202 (100)
CDEs = certified diabetes educators.

cholesterol, and other tests (Table 14). Other
tests included prothrombin time or international
normalized ratio, renal testing or test for
microalbuminuria, and body fat analysis.
Recommendations or Referrals
Pharmacists were asked if they recommended
laboratory tests, drug therapy changes, or
referrals to other specialty providers. Most
pharmacists made these recommendations on a
regular basis (Table 15).
Reimbursement
Of 227 responses regarding reimbursement,
106 pharmacists (46.7%) billed for diabetes
services, 112 (49.3%) did not bill, and 9 (4.0%)
did not know. The 112 pharmacists who did not
bill worked in all settings, consisting of 57 in
ambulatory care clinics, 24 in acute care
hospitals, 8 in independent pharmacies, 17 in
retail pharmacies, 3 in industry, 2 in long-term
care facilities, and 1 in a home health care facility.
Only 58 pharmacists answered the question
about amount charged/hour, which ranged from
$25–150/hour with a mean of $68.49. Twelve
gave information about rate charged/visit (range
$15–60, mean $56.25). Seven pharmacists
provided information about other types of
billing, and these rates ranged from $10–250
(mean $75.71).
Of 218 responses, 100 pharmacists (45.9%)
indicated reimbursement was received, 89
(40.8%) stated reimbursement was not received,
and 29 (13.3%) did not know. Of the 100
pharmacists who received reimbursement, 39
stated their institution was reimbursed, 34 stated
their employer was reimbursed, 21 stated they
received the reimbursement individually, and 6
did not know.
Fifty-seven pharmacists provided reimburse-
ment information on percentage received of
amount billed. Specific percentages ranged from
25–100%. Three stated they received 25–49%, 13
 SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al
received 50–79%, and 41 received 80–100% of
amount billed.
System for Measuring Outcomes
Of 226 responses to this question, 129
pharmacists (57.1%) stated they had a system in
place for measuring outcomes, 84 (37.1%) had
no system, and 13 (5.8%) did not know.
Outcomes measurements included tracking
specific clinical parameters such as A1C, lipids,
and blood pressure; frequency of self-monitoring
of blood glucose levels; testing before and after
diabetes education; behavioral outcomes; patient
satisfaction surveys; chart reviews and drug
administration evaluations; hospitalizations or
emergency department visits; and missed
workdays. Several respondents indicated they
used spreadsheets or computer databases for
tracking outcomes.
Future Credentialing and Recommendation to
Other Pharmacists
Of 231 responses, 195 pharmacists (84.4%)
stated they planned to pursue recertification as a
CDE. However, 30 (13%) were unsure, and 6
(2.6%) stated they were not planning to pursue
CDE recertification. When asked if they
recommended CDE credentialing to other
pharmacists interested in providing diabetes care,
209 (90.5%) of 231 stated yes, 16 (6.9%) were
unsure, and 6 (2.6%) stated no.
When queried about BC-ADM credentialing,
47 (20.5%) of 230 respondents stated they would
apply to obtain this credential, 70 (30.4%) stated
they would not, and 113 (49.1%) stated they
were unsure.
Discussion
Pharmacists have been involved in diabetes
care and education for many years. Several
reports of pharmacists providing diabetes patient
care and monitoring have been published, with
some reports including community pharmacies
as the site of diabetes education.43–46 In these
studies, pharmacists have looked at baseline and
follow-up blood glucose values, as well as
adherence to diabetes drugs, 43 monitoring of
adverse drug-related events, evaluation of patient
understanding of diabetes, and quality-of-life
evaluations.44 Clinical parameters such as A1C,
blood pressure, and lipids also have been
tracked.45 Monetary savings were reported in the
Asheville, North Carolina, project in which
1589
community pharmacists saved the city more than
$900/patient/year on diabetes care. 46 In VA
clinics, pharmacist-based diabetes programs in
which insulin was started and adjusted also
reported cost savings, as well as improved
glycemic parameters.47 Other studies conducted
in pharmacist-based programs in a university-
based outpatient clinic 48 and a primary care
clinic49 showed improved clinical parameters in
both studies and 99% adherence to American
Diabetes Association standards as well as lower
A1C versus regular physician care in the latter
study. Even in an indigent care clinic,
pharmacist-managed patients with diabetes had a
significantly greater decline in A1C from baseline
than that of patients in a general clinic.50 Many
of these published reports involved pharmacists
who are CDEs.
The results of a recent study in Canada
indicate that pharmacists agree they should be
part of the diabetes management team and
should be required to have specialized training to
provide diabetes care.51 In a recent survey in
Arizona, however, pharmacists’ attitudes toward
diabetes indicated that they believe diabetes is a
treatable disease, but they do not frequently
provide diabetes education. 52 The authors
speculated a reason for not providing education
is that pharmacists may believe they have
insufficient training to educate patients. The
authors also acknowledged that more diabetes
education through community pharmacists is
needed.
Extensive information about pharmacist CDEs
is not readily available. Providing details about
these individuals and their clinical activities may
motivate other pharmacists to pursue the CDE
credential. Because pharmacists are often the
most accessible of all health care providers,
obtaining the credential may be an important
contribution to diabetes care and education.
People with diabetes see their pharmacists 7
times more often than they see their primary care
physician.53 An encouraging factor is that there
are over 400 pharmacists with this training.
These individuals are uniquely positioned to
mentor other pharmacists to become CDEs and
increase the number of readily accessible
pharmacist educators to patients with diabetes.
Our survey indicated that the mean age of the
pharmacists was 41.5 years and 56.6% have a B.S.
degree only, whereas 43.4% have a Pharm.D.
Overall, pharmacists had been licensed for an
average of 17 years and had been a CDE for an
average of 5 years, although there were some
1590 PHARMACOTHERAPY Volume 22, Number 12, 2002
differences between the sexes. For instance,
more than half the CDE pharmacists are women
(60.1%) who are a few years younger than the
male pharmacists (38 vs 46 yrs) and had been
licensed pharmacists for a shorter time (14 vs 22
yrs). However, they had been CDEs for only a
slightly shorter time (4.4 vs 5.2 yrs).
Respondents practice mostly in Southern and
Western states. The states with the largest
number of CDE respondents were Washington,
California, North Carolina, New York, and
Virginia. However, many states had no CDEs,
including Alaska, Rhode Island, Maine, Vermont,
Montana, North Dakota, and Louisiana, a state
with a large number of individuals with diabetes.
Also, many states had only one CDE, including
Arkansas, Arizona, Delaware, Iowa, Idaho,
Kansas, Mississippi, New Hampshire, South
Dakota, Wyoming, Puerto Rico, and District of
Columbia. This should be a call to action for
pharmacists to increase the number of CDEs in
these states. The ratio of pharmacist CDEs to
patient population is only 0.6–1 pharmacist
CDEs:million people.
Respondents reported membership in several
professional organizations. A large percentage
(65%) were members of AADE, which is an
important organization for CDEs. Pharmacists
should maintain an active presence in this
organization, so they can network with other
CDEs from different disciplines and seek
continuing education opportunities. The three
other major organizations to which respondents
had memberships were ASHP, APhA, and ACCP,
although a few also belong to ASCP and AACP.
Respondents included several individuals who
have pursued many opportunities to increase
their learning and training. Most had completed
postgraduate training, including residency or
fellowship training, and several had completed
more than one type of postgraduate training.
Specifically, of the 38 individuals who had
completed a pharmacy practice residency, 12 also
completed a specialty residency, 7 also completed
a certificate program, one also did a fellowship,
and another person also completed another type
of postgraduate program.
Over half the respondents had faculty
appointments at colleges of pharmacy. This
group may help to inculcate an interest in
pharmacists in training to also become CDEs. As
shown by the geographic distribution of
respondents, many areas do not have pharmacist
CDEs, and these may be particularly important
areas to target.
Most respondents practiced in ambulatory care
clinics and independent or retail pharmacies.
This is also an important finding because these
pharmacists are highly visible and readily
available to promote patient education. However,
for the number of pharmacists in inpatient
settings, this may provide an opportunity to refer
patients for follow-up with pharmacists in
outpatient settings.
Major reasons for credentialing were personal
satisfaction or professional development,
although enhanced reimbursement also was
cited. Impact of certification included improved
clinical skills, job satisfaction, patient satisfaction
and respect, as well as improved personal
confidence and respect from peers.
More pharmacists stated they provided
diabetes care to more than 200 patients who were
primarily adult or geriatric patients and were
Caucasian or African-American. Few pharmacists
were involved with children, adolescents, and
women with gestational diabetes. The most
frequently provided pharmaceutical care
functions included reviewing drug profiles,
providing drug information to other practi-
tioners, and modifying drug therapy. Education
activities most commonly provided included
drug counseling, blood glucose meter education,
and information about the diabetes disease
process, insulin administration, and foot care.
Physical assessments most frequently performed
included blood pressure monitoring and foot
examinations. Most commonly provided point-
of-care tests were for glucose, cholesterol, and
A1C. Common recommendations were made for
drug therapy changes and obtaining laboratory
tests. A total of 47% of the pharmacists stated
they billed for diabetes services, and 46% stated
that reimbursement was received. Over half of
the pharmacists stated they had a system in place
for measuring outcomes.
Many pharmacists were not doing assessments
or providing information in areas that are crucial
to effective behavioral change in diabetes
education. Specifically, 17.5% stated they did not
perform nutritional assessments and 38.9% only
occasionally provided nutrition counseling.
However, respondents were not afforded an
opportunity to state the reason. The reason for
the large number not providing this type of
education may be that they may work as part of a
multidisciplinary team in which nutritionists
provide this information. Furthermore, survey
responses were not received from many
individuals, and these persons may be providing
 SURVEY OF PHARMACIST CERTIFIED DIABETES EDUCATORS Shane-McWhorter et al
this education. Thus, it is difficult to state that
these activities are typical of all pharmacist
CDEs. Nevertheless, a CDE should be able to
assess a patient’s nutritional status. An important
message is that if these pharmacists were not
providing nutrition education because they lack
appropriate training, these skills may be
enhanced.14 Furthermore, 16.4% stated they only
occasionally and 0.9% never discussed the
disease process of diabetes. Only 26.7%
occasionally and 6% never discussed foot care.
Again, these issues are important, particularly
foot care since studies have shown that
addressing this as an education point may
prevent lower extremity amputation.23, 25, 27 One
possible explanation for not adequately
addressing this issue was if podiatrists were part
of the multidisciplinary team.
There are many challenges for pharmacists in
the management of patients with diabetes,
including obtaining appropriate training,
gathering data that support improved clinical
outcomes, and securing provider recognition by
Medicare, which would allow reimbursement.
Options for pharmacists to provide diabetes
education include preparation for the CDE
examination, the BC-ADM examination, and
certificate training programs. Most pharmacists
surveyed stated that they planned to pursue CDE
recertification. Approximately 20% of the
pharmacists stated they intended to apply for the
new advanced credential, BC-ADM.
The BC-ADM is a multidisciplinary credential,
developed by the AADE and the American
Nurses Credentialing Center, in collaboration
with the American Diabetes Association, the
American Dietetic Association, and the APhA.54
This is the first advanced practice certification in
diabetes care emphasizing clinical assessment
and disease-state management. A separate
certification examination is offered for registered
nurses, registered dietitians, and pharmacists.
The new certification differs from the CDE in
that it focuses on advanced management issues
and an advanced degree is required before one
may sit for the examination. The BC-ADM
examination was offered for the first time in
2001. Of the 164 health professionals who were
awarded this credential, 126 were registered
nurses and nurse practitioners, 32 were
registered dietitians, and 6 were pharmacists.
Certificate programs are an additional option
for pharmacists to obtain diabetes training.
These are programs offered by colleges of
pharmacy, state and national pharmacy
1591
organizations, and the pharmaceutical industry.
The programs are intended to upgrade clinical
skills and knowledge of practicing pharmacists
who are interested in expanding their practice to
include patients with diabetes.
There are several limitations of this survey.
Choices provided in the survey for clinical
activities may not reflect all activities performed
by pharmacist CDEs. Recall bias may have
occurred on certain questions, such as the age
and ethnicity of patients or the types of activities
performed. Another example of recall bias may
have occurred when respondents were asked how
long they had been a CDE. One individual
answered 18 years and another 17 years, yet the
first CDE examination was given in 1986. 42
Respondents who did not bill for their services
were not given an opportunity to explain why
they did not seek reimbursement. The survey
did not query whether anyone worked in
indigent or free clinics. In the questions on
point-of-care testing, the survey did not
distinguish whether the pharmacists themselves
were doing the testing, reviewing the data, or
both. The survey did not provide sufficient
discrete choices for measuring outcomes.
Respondents were not provided an opportunity
to state why they would or would not pursue
CDE recertification and why they would or
would not recommend CDE credentialing to
other pharmacists.
Strengths of the survey include the number of
respondents and the variety of questions the
respondents answered. Another strength is
calling attention to the large number of
pharmacists who are CDEs, as well as to their
professional affiliations. This may establish
mentoring opportunities for other pharmacists
through membership in different professional
organizations. Describing the education and
postgraduate training also emphasizes the
characteristics of individuals who are highly
motivated, and perhaps this is what is required to
overcome the many difficult obstacles in
becoming a CDE. Nevertheless, these individuals
have shown it is possible to overcome the
obstacles. Delineating where these pharmacists
are located is another strength, since this may
help increase their referral base and promote
patients’ access to diabetes care. Calling
attention to the variety of clinical activities may
help enhance awareness of the pharmacist as a
provider of diabetes education. Another strength
was calling attention to the large number that are
billing and obtaining reimbursement for diabetes
1592 PHARMACOTHERAPY Volume 22, Number 12, 2002
services and emphasizing that almost half have
systems in place for measuring outcomes.
Although recent articles have provided some
information on economic evaluation of
pharmacist involvement in diabetes care,46, 47, 55–57
more studies are needed that assess the long-term
economic impact of pharmacist-provided
diabetes care. More studies than those available
on patients’ knowledge of self-care58 or those that
assess patients’ knowledge about their drugs59 or
impact of pharmacists on patients’ knowledge
and compliance with drugs 60 are needed.
Another necessary study is one comparing
patient outcomes when care is provided by
pharmacist CDEs versus non-CDE pharmacist
educators. Our survey indicated that pharmacists
are providing little or no care to Hispanics, Asian
Americans, children, adolescents, and women
with gestational diabetes. Further study is
needed to assess pharmacist care in these target
populations. Other potential studies are those
that address the impact of patients’ satisfaction
with pharmacist care or pharmacist impact on
patients’ quality of life.
Conclusions
Many pharmacists CDEs in the United States
provide care to patients with diabetes. Most have
extensive postgraduate training and belong to a
variety of professional organizations, and over
half have faculty appointments at colleges of
pharmacy. Most of these pharmacists are
practicing in outpatient settings and are not only
providing numerous clinical services, but also
have systems in place for tracking outcomes, and
are billing and obtaining reimbursement for these
activities. It is hoped that by providing details
about these pharmacist CDEs, other pharmacists
will be motivated to pursue this credential.
Acknowledgment
The authors thank Mr. Richard H. Shane for his
valuable advice and technical assistance in the
preparation of this manuscript.
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