Structured diabetes education has made little difference to

patient outcomes

Dr David Cavan

Bournemouth Diabetes and Endocrine Centre

David.Cavan@rbch.nhs.uk

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