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
2005
Structured 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 structured
education programme that fulfils the nationally agreed criteria
from the time of diagnosis, with annual review and access to
ongoing 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 year
HbA1c
Hypo
DKA
PAID
•
•
National (DAFNE)
↓
↓
8.7 to 8.5%
↓
↓
↓
– Bournemouth
8.7 to 8.4%
↓
–
–
–
–
8.9 to 8.7%
8.9 to 8.3%
8.7 to 8.4%
8.7 to 8.4%
– Aberdeen
– Nottingham
– Ireland
8.6 to 8.5%(ns)
8.6 to 8.3%
no change
– National
Local
Wirral
Edinburgh
Eastbourne
DEN 5 centres*
Source: Diabetes UK and EASD abstracts 2010-2012 (*DEN 2008)
↓
↓
↓
↓
21 to 15
27 to 16
27 to 11
29 to 18
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
9.5
9
Desmond control –
6 hours ‘ad hoc’ education
8.5
8
7.5
7
6.5
Focus
– 5 hours ‘local’
education
Desmond trial –
6 hours education
6
Baseline
Focus 2004
3-4 months
1 year
DESMOND trial
2 years
DESMOND control
3 years
UKPDS
Type 2 education at diagnosis
9.5
UKPDS –
3 dietitian visits
9
Desmond control –
6 hours ‘ad hoc’ education
8.5
8
7.5
7
6.5
Focus
– 5 hours ‘local’
education
Desmond trial –
6 hours education
6
Baseline
Focus 2004
3-4 months
1 year
DESMOND trial
2 years
DESMOND control
3 years
UKPDS
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
stroke
kidney failure
amputations
increased by 118%
87%
56%
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 selfmanagement 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