Structured diabetes education has made little difference to patient outcomes

1. Structured diabetes education has made little difference to patient outcomes Dr David Cavan Bournemouth Diabetes and Endocrine Centre David.Cavan@rbch.nhs.uk

2. 2001 2001 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002951

3. 2005Structured education: Key Criteria to fulfil NICE requirements • Patient centred philosophy • Structured, written curriculum • Trained educators • Quality assurance • Audit

4. NICE Diabetes Quality Standard 1: People with diabetes and/or their carers receive a structured education programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education

5. 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

6. Local vs national? Change from baseline to one year HbA1c 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)

7. 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

8. Type 2 diabetes X-Pert DESMOND local programmes

9. 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

10. 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

11. Type 2 education at diagnosis Desmond control – 6 hours ‘ad hoc’ education Focus – 5 hours ‘local’ education Desmond trial – 6 hours education

12. Type 2 education at diagnosis UKPDS – 3 dietitian visits Desmond control – 6 hours ‘ad hoc’ education Focus – 5 hours ‘local’ education Desmond trial – 6 hours education

13. 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

14. 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%

15. 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

16. Impact of structured education? National Diabetes Audit 2011 Attended structured education: • 1.55% newly diagnosed type 1 • 3.57% newly diagnosed type 2

17. 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

18. Conclusion • Structured diabetes education has made little difference to patient outcomes