Structured diabetes education has made little difference to patient outcomes Dr David Cavan Bournemouth Diabetes and Endocrine Centre

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 HbA1cHypoDKAPAID National (DAFNE) –Aberdeen 8.6 to 8.5% (ns) ↓ ↓ –Nottingham 8.6 to 8.3% –Irelandno change ↓ –National 8.7 to 8.5% ↓ ↓ Local –Bournemouth8.7 to 8.4% ↓ ↓ 21 to 15 –Wirral8.9 to 8.7% ↓ 27 to 16 –Edinburgh8.9 to 8.3% –Eastbourne8.7 to 8.4%27 to 11 –DEN 5 centres*8.7 to 8.4% ↓ ↓ 29 to 18 Source: Diabetes UK and EASD abstracts (*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 % –Weight reduction 2-3kg –48% reduced diabetes medications –Deakin, Diab Med (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 Desmond control – 6 hours ‘ad hoc’ education Desmond trial – 6 hours education Focus – 5 hours ‘local’ education

Type 2 education at diagnosis 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 % 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