structured diabetes education has made little difference to patient outcomes dr david cavan...
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Structured diabetes education has made little difference to
patient outcomes
Dr David Cavan
Bournemouth Diabetes and Endocrine Centre
2001
2001 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002951
2005Structured education: Key Criteria
to fulfil NICE requirements
• Patient centred philosophy
• Structured, written curriculum
• Trained educators
• Quality assurance
• Audit
NICE Diabetes Quality Standard 1:
People with diabetes and/or their carers receive a structurededucation programme that fulfils the nationally agreed criteriafrom the time of diagnosis, with annual review and access toongoing education
Type 1 diabetes
• 90+ centres run DAFNE (1 week course)– Based on Berger 5 day programme
• 90+ centres run local programmes– majority using 4 x weekly format (eg BERTIE)– 20 using other formats (1 to 6 sessions)– Specific programmes for newly diagnosed and for
pump therapy
• paediatric / adolescent programmes
Local vs national? Change from baseline to one yearHbA1c Hypo DKA PAID
• National (DAFNE)– Aberdeen 8.6 to 8.5%(ns) ↓ ↓– Nottingham 8.6 to 8.3%– Ireland no change ↓ – National 8.7 to 8.5% ↓ ↓
• Local– Bournemouth 8.7 to 8.4% ↓ ↓ 21 to 15– Wirral 8.9 to 8.7% ↓ 27 to 16– Edinburgh 8.9 to 8.3%– Eastbourne 8.7 to 8.4% 27 to 11
– DEN 5 centres* 8.7 to 8.4% ↓ ↓ 29 to 18
Source: Diabetes UK and EASD abstracts 2010-2012 (*DEN 2008)
Type 1 programmes: outcomes
• Reduction in hypoglycaemia and DKA
• Improvement in PAID scores
• Weight neutral
• Reduction in HbA1c: 0-0.5%–Less than seen in Germany
Type 2 diabetes
• X-Pert
• DESMOND
• local programmes
X-Pert
• Six 2-hour weekly sessions• New and established type 2 diabetes• RCT:
– HbA1c reduction 0.7% (no change in controls)– 0.5kg weight loss– Less medications
• National audit >20,000 patients – HbA1c reduction 0.5-0.7%– Weight reduction 2-3kg– 48% reduced diabetes medications– Deakin, Diab Med 2012 29(1) 12
DESMOND RCT results• 6 hours (in 1 or 2 sessions) of group education within 12 weeks of
diagnosis• Philosophy of patient empowerment
• At one year:– HbA1c reduced from 8.4 to 6.8% (NS vs control)– Reduced body weight (3 vs 1.9 kg)– Fewer smokers (14 to 11% vs no change)– Reduced 10 year cardiovascular risk (10.9 vs 13.6%)
• At three years:– No difference in any biomedical or lifestyle outcomes– Khunti BMJ 2012: 344:e2333
Type 2 education at diagnosis
6
6.5
7
7.5
8
8.5
9
9.5
Baseline 3-4 months 1 year 2 years 3 years
Focus 2004 DESMOND trial DESMOND control UKPDS
Desmond control – 6 hours ‘ad hoc’ education
Desmond trial – 6 hours education
Focus – 5 hours ‘local’ education
Type 2 education at diagnosis
6
6.5
7
7.5
8
8.5
9
9.5
Baseline 3-4 months 1 year 2 years 3 years
Focus 2004 DESMOND trial DESMOND control UKPDS
Desmond control – 6 hours ‘ad hoc’ education
UKPDS – 3 dietitian visits
Desmond trial – 6 hours education
Focus – 5 hours ‘local’ education
Summary of outcomes
• Type 1 education– Reduction in hypoglycaemia and DKA– Improvement in PAID scores – Small reduction in HbA1c
• Type 2 education– Reduction in HbA1c following diagnosis– As good as 3 dietitian visits in UKPDS
Outcomes that matter
Diabetes UK 2012:Between 2006 and 2010, there has been an increase in unnecessary complications:
• retinopathy increased by 118%• stroke 87%• kidney failure 56%• amputations 26%
Outcomes that matter
National Diabetes Audit 2011
• Mortality 1.6 times higher (type 2) and 2.6 x higher (type1) than general population
• 9 times higher in young women with type 1 diabetes
Impact of structured education?
National Diabetes Audit 2011
Attended structured education:
• 1.55% newly diagnosed type 1
• 3.57% newly diagnosed type 2
Summary
• Type 1 education has improved self-management skills with important benefits to some patients – but HbA1c and hence risk of complications remains high
• Type 2 education at diagnosis is no better than achieved in UKPDS
• The provision and uptake of education is too small to make a difference at national level
• Ongoing education is virtually non-existent
Conclusion
• Structured diabetes education has made little difference to patient outcomes