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Kershaw KA, Storer B, Braund T, Chakouch C, Coleshill M, Haffar S, Harvey S, Newby J, Sicouri G, Murphy M. The prevalence of anxiety in adult endocrinology outpatients: A systematic review and meta-analysis. Psychoneuroendocrinology 2023; 158:106357. [PMID: 37776733 DOI: 10.1016/j.psyneuen.2023.106357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Anxiety disorders and anxiety symptoms are common mental disorders in the medically unwell and have significant impacts on patients' quality of life and engagement with psychiatric and medical services. Several systematic reviews have examined the prevalence of anxiety in specific endocrinology settings with estimates varying significantly from study to study. No meta-analysis has examined anxiety rates across the endocrinology outpatient setting. The aim of this meta-analysis is to provide endocrinologists with a precise estimate of the prevalence of anxiety - and impacting factors - in their outpatient clinics. METHOD PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched to identify studies that assessed anxiety prevalence in endocrinology outpatients published up to 23 January 2023. This was part of a larger systematic review search of anxiety prevalence in common medical outpatient clinics. Data characteristics were extracted independently by two investigators. Studies of patients 16 years and older and representative of the clinic were included. The point prevalence of anxiety or anxiety symptoms was measured using validated self-report questionnaires or structured interviews. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Pooled estimates were analysed under the random-effects model and subgroup analyses on relevant variables were conducted under a mixed-effects model. Heterogeneity was assessed using the I2 statistic. RESULTS Fifty-nine studies with a total of 25,176 participants across 37 countries were included in this study. The overall pooled prevalence of anxiety or anxiety symptoms was 25·1% (95%CI 21·4-29·2; 6372/25,176; n = 59). Subgroup analyses revealed no difference in prevalence between outpatients with diabetes mellitus compared to other grouped endocrine disorders. Generalized Anxiety Disorder (GAD) was the most frequent clinical diagnosis 11·7% (95%CI 8·1-16·7; I2=87·93%; 443/4604; n = 17), while panic disorder was significantly higher in the non-diabetes group 9·5% (95%CI 5·9-14·9; I2=57·28%; 56/588; n = 8), compared to the diabetes group 5·2% (95%CI 3·7-7·3; I2=32·18%; 184/3669; n = 6). Estimates of prevalence were higher when assessed with a self-report scale 32·4% (95%CI 25·6-40·0; I2=96·06%; 1565/4675; n = 21) compared to diagnostic interview 17·6% (95%CI 12·2-24·7; I2=94·39%; 636/5168; n = 21). Outpatients in developing countries had higher rates of anxiety than those in developed countries. Female diabetes patients reported higher rates of anxiety compared to males. CONCLUSION Our study provides evidence that anxiety occurs frequently amongst endocrinology outpatients and at a higher rate than is estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective management strategies be developed to support endocrinologists in identifying and treating these conditions in their outpatient clinics.
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Affiliation(s)
| | - Ben Storer
- The Black Dog Institute, Sydney, Australia
| | - Taylor Braund
- The Black Dog Institute, Sydney, Australia; School of Psychiatry, University of New South Wales, Sydney, Australia
| | | | | | - Sam Haffar
- The Black Dog Institute, Sydney, Australia
| | - Samuel Harvey
- The Black Dog Institute, Sydney, Australia; School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Jill Newby
- The Black Dog Institute, Sydney, Australia; School of Psychology, University of New South Wales, Sydney, Australia
| | - Gemma Sicouri
- The Black Dog Institute, Sydney, Australia; School of Psychology, University of New South Wales, Sydney, Australia
| | - Michael Murphy
- The Black Dog Institute, Sydney, Australia; School of Psychiatry, University of New South Wales, Sydney, Australia
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Konnyu KJ, Yogasingam S, Lépine J, Sullivan K, Alabousi M, Edwards A, Hillmer M, Karunananthan S, Lavis JN, Linklater S, Manns BJ, Moher D, Mortazhejri S, Nazarali S, Paprica PA, Ramsay T, Ryan PM, Sargious P, Shojania KG, Straus SE, Tonelli M, Tricco A, Vachon B, Yu CH, Zahradnik M, Trikalinos TA, Grimshaw JM, Ivers N. Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes. Cochrane Database Syst Rev 2023; 5:CD014513. [PMID: 37254718 PMCID: PMC10233616 DOI: 10.1002/14651858.cd014513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors. Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted. Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three. Combinations of the three most effective QI strategies were estimated to lead to the below effects: - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%; - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg; - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.
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Affiliation(s)
- Kristin J Konnyu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sharlini Yogasingam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Johanie Lépine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katrina Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Sathya Karunananthan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - John N Lavis
- McMaster Health Forum, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Braden J Manns
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sameh Mortazhejri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Peter Sargious
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Kaveh G Shojania
- University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Marcello Tonelli
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Andrea Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
- Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Occupational Therapy Program, University of Montreal, Montreal, Canada
| | - Catherine Hy Yu
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Michael Zahradnik
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
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Sharma S, Gillespie P, Hobbins A, Dinneen SF. Estimating the cost of type 1 diabetes in Ireland. Diabet Med 2022; 39:e14779. [PMID: 34958713 DOI: 10.1111/dme.14779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Type 1 diabetes is a chronic disease, which given its existing and projected prevalence, is likely to pose a significant economic burden, both in terms of directs costs to the healthcare system and indirect costs to society. We aimed to estimate the economic burden of type 1 diabetes in Ireland, which at present, is unknown. METHODS A cost of illness study was undertaken to estimate the cost of type 1 diabetes in Ireland for 2018. Data for prevalence, morbidity, mortality, healthcare resource use, absenteeism, and unit costs were obtained from national, and where necessary, international sources. Direct healthcare costs were estimated for primary care, outpatient, emergency and inpatient care, for associated complications, structured education programmes, insulin and related care. Additionally, indirect costs from lost earnings due to premature death and employee absenteeism were estimated. RESULTS Type 1 diabetes was estimated to cost €129 million in Ireland in 2018, with direct healthcare costs accounting for €81.5 million or 63% and indirect costs for €47.5 million or 37% of the total. On average, this amounted to €3994 per patient in direct healthcare costs and €2326 per patient in indirect costs. CONCLUSION Type 1 diabetes is a leading public health problem. Our study is the first to assess the economic burden of type 1 diabetes in Ireland, and our results should be informative to policymakers tasked with prioritising healthcare and research funding resource allocation.
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Affiliation(s)
- Shikha Sharma
- Health Economics & Policy Analysis Centre, National University of Ireland, Galway, Ireland
| | - Paddy Gillespie
- Health Economics & Policy Analysis Centre, National University of Ireland, Galway, Ireland
- CURAM, Science Foundation Ireland (SFI) Research Centre for Medical Devices, National University of Ireland, Galway, Ireland
| | - Anna Hobbins
- Health Economics & Policy Analysis Centre, National University of Ireland, Galway, Ireland
- CURAM, Science Foundation Ireland (SFI) Research Centre for Medical Devices, National University of Ireland, Galway, Ireland
| | - Sean F Dinneen
- School of Medicine, National University of Ireland, Galway and Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
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dos Santos Mamed M, Gastaldi G. COVID: The Missing Trigger to Start a Remote FIT Course. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:834082. [PMID: 36992774 PMCID: PMC10012057 DOI: 10.3389/fcdhc.2022.834082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022]
Abstract
Type 1 diabetes management is a highly demanding task that largely falls on people with diabetes, their family, and their peers. Diabetes self-management education and support aim at increasing knowledge, skills, and confidence to take appropriate diabetes management decisions. The current evidence shows that efficient diabetes self-management relies on person-centered interventions and a team of pluri-disciplinary educators with expertise in diabetes care and education. The irruption of the COVID-19 pandemic has increased diabetes burden and the need to offer remote diabetes self-management education services. The present article offers a perspective about expectations and quality issues related to the implementation of a remote version of the FIT course, a validated structured diabetes management educational program.
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Affiliation(s)
| | - Giacomo Gastaldi
- Department of Medicine, Diabetology Unit, Geneva University Hospital, Geneva, Switzerland
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5
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Davidson P, LaManna J, Davis J, Ojeda MM, Hyer S, Dickinson JK, Todd A, Hammons TM, Mohammed Fahim S, McDaniel CC, McKee CA, Clements JN, Yehl K, Litchman ML, Blanchette JE, Kavookjian J. The Effects of Diabetes Self-Management Education on Quality of Life for Persons With Type 1 Diabetes: A Systematic Review of Randomized Controlled Trials. Sci Diabetes Self Manag Care 2022; 48:111-135. [PMID: 35030970 PMCID: PMC9069895 DOI: 10.1177/26350106211070266] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE It is well documented that chronic conditions, such as diabetes, impact quality of life (QoL). QoL assessment is essential when developing and evaluating diabetes self-management education support interventions. The aim of this systematic review was to evaluate the evidence and gaps in the research and the impact of diabetes self-management education (DSME) on QoL outcomes in persons with type 1 diabetes mellitus (T1DM). METHODS A systematic review of English language studies published between January 1, 2007, and March 31, 2020, was conducted using a modified Cochrane review method. Studies were included if they were randomized controlled trials (RCTs), participants had T1DM with or without caregivers, a DSME intervention alone or a component(s) of the ADCES7™ Self-Care Behaviors was described, and QoL was a primary or secondary outcome. A 3-tiered review process was utilized for selecting articles. Retained articles were assessed for risk of bias. RESULTS Nineteen articles, reporting on 17 RCTs, met inclusion criteria, of which 7 studies reported QoL as the primary outcome and 10 as a secondary outcome. Seven studies detected significant impact of DMSE on QoL outcomes in either the participants or family caregivers, which varied in participant populations, selection of QoL tools (generic vs diabetes-specific), intervention type, intervention length, and type of interventionist. CONCLUSION DSME has the potential to influence QoL outcomes in people with T1DM. Research using more standardized methods are needed to delineate impact on a broader range of factors that influence QoL for those living with T1DM across the life span and their caregivers.
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Affiliation(s)
| | | | - Jean Davis
- University of Central Florida, College of Nursing, Orlando, Florida
| | - Maria M Ojeda
- Walden University, College of Nursing, Minneapolis, Minnesota
| | - Suzanne Hyer
- University of Central Florida, College of Nursing, Orlando, Florida
| | | | - Andrew Todd
- University of Central Florida, College of Nursing, Orlando, Florida
| | | | | | - Cassidi C McDaniel
- Auburn University Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Cynthia A McKee
- West Chester University of Pennsylvania, West Chester, Pennsylvania
| | | | - Kirsten Yehl
- Association of Diabetes Care & Education Specialists, Chicago, Illinois
| | | | | | - Jan Kavookjian
- Auburn University Harrison School of Pharmacy, Auburn University, Auburn, Alabama
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Holmes-Truscott E, Cooke DD, Hendrieckx C, Coates EJ, Heller SR, Speight J. A comparison of the acceptability and psychometric properties of scales assessing the impact of type 1 diabetes on quality of life-Results of 'YourSAY: Quality of Life'. Diabet Med 2021; 38:e14524. [PMID: 33445223 DOI: 10.1111/dme.14524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 01/19/2023]
Abstract
AIMS To compare the acceptability, reliability and validity of five contemporary diabetes-specific quality of life (QoL) scales among adults with type 1 diabetes in the United Kingdom and Australia. METHODS Adults with type 1 diabetes (UK = 1139, Australia = 439) completed a cross-sectional, online survey including ADDQoL-19, DCP, DIDP, DSQOLS and Diabetes QoL-Q, presented in randomised order. After completing each scale, participants rated it for clarity, relevance, ease of completion, length and comprehensiveness. We examined scale acceptability (scale completion and user ratings), response patterns, structure (exploratory and confirmatory factor analyses) and validity (convergent, concurrent, divergent and known groups). To assess cross-country reproducibility, analyses conducted on the UK dataset were replicated in the Australian dataset. RESULTS Findings were largely consistent between countries. All scales were acceptable to participants: ≥90% completing all items, and ≥80% positive user ratings, except for DSQOLS' length. Scale structure was not supported for the DCP. Overall, in terms of acceptability and psychometric evaluation, the DIDP was the strongest performing scale while the ADDQoL-19 and Diabetes QoL-Q scales also performed well. CONCLUSIONS These findings suggest that the recently developed brief (7 items), neutrally worded DIDP scale is acceptable to adults with type 1 diabetes and has the strongest psychometric performance. However, questionnaire selection should always be considered in the context of the research aims, study design and population, as well as the wider published evidence regarding both the development and responsiveness of the scales.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Vic., Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Vic., Australia
| | - Debbie D Cooke
- School of Health Sciences, University of Surrey, Guildford, UK
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Vic., Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Vic., Australia
| | - Elizabeth J Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Simon R Heller
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Vic., Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Vic., Australia
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McKnight JA, Ochs A, Mair C, McKnight O, Wright R, Gibb FW, Cunningham SG, Strachan M, Ritchie S, McGurnaghan SJ, Colhoun HM. The effect of DAFNE education, continuous subcutaneous insulin infusion, or both in a population with type 1 diabetes in Scotland. Diabet Med 2020; 37:1016-1022. [PMID: 31872473 DOI: 10.1111/dme.14223] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2019] [Indexed: 11/29/2022]
Abstract
AIM To investigate the effect of DAFNE and continuous subcutaneous insulin infusion in clinical practice. METHODS Within NHS Lothian, continuous subcutaneous insulin infusion started in 2004 and DAFNE education began in 2006. We extracted anonymized data from the national database for all those aged > 18 years with type 1 diabetes having a Dose Adjustment For Normal Eating course or continuous subcutaneous insulin infusion start date (n = 4617). RESULTS In total, 956 persons received DAFNE education, and 505 had received an insulin pump, 208 of whom had DAFNE education followed by insulin pump. Mean (SD) HbA1c before DAFNE education was 68 (15) mmol/mol (8.4% [1.4%]) and 66 (13) mmol/mol (8.2% [1.2%]) before continuous subcutaneous insulin infusion. In the year following DAFNE education, the mean fall in within-person HbA1c was 3.8 mmol/mol (95% CI 4.0 to 3.4; 0.3% [0.4% to 0.3%]). Those with the poorest control (HbA1c ≥ 85 mmol/mol [9.9%]) experienced the largest decline (15.7 mmol/mol [1.4%]). Those in the lowest HbA1c band at initiation (< 53 mmol/mmol [7.0%]) experienced a rise. In the year following continuous subcutaneous insulin infusion initiation there was a mean fall in within-person HbA1c of 6.6 mmol/mol (6.8 to 6.4; 0.6% [0.6% to 0.6%]). In those with the poorest control (HbA1c ≥ 85 mmol/mol [9.9%]), the mean fall in HbA1c was 22.2 mmol/mol (23 to 21; 2.0% [2.1% to 1.9%]). Continuous subcutaneous insulin infusion effectiveness was not different with or without DAFNE education. The effects of both interventions were sustained over 5 years. CONCLUSIONS Both DAFNE education and insulin pump therapy had the greatest effect on HbA1c in those with higher baseline values. There was little difference to attained HbA1c when Dose Adjustment For Normal Eating education was introduced before insulin pump therapy.
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Affiliation(s)
- J A McKnight
- Edinburgh Centre for Diabetes and Endocrinology, Metabolic Unit, Western General Hospital, Edinburgh, UK
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - A Ochs
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - C Mair
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - O McKnight
- Forth Valley Royal Hospital, NHS Forth Valley, Scotland
| | - R Wright
- Department of Diabetes, St John's Hospital, Livingston, UK
| | - F W Gibb
- Edinburgh Centre for Diabetes and Endocrinology, New Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S G Cunningham
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - M Strachan
- Edinburgh Centre for Diabetes and Endocrinology, Metabolic Unit, Western General Hospital, Edinburgh, UK
| | - S Ritchie
- Edinburgh Centre for Diabetes and Endocrinology, Metabolic Unit, Western General Hospital, Edinburgh, UK
| | - S J McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - H M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
- Department of Public Health, NHS Fife, Kirkcaldy, UK
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West S, Ramis MA, Burgess L, Kynoch K. Effectiveness of multidisciplinary led self-management interventions on glycaemic control in people with type 1 diabetes: a systematic review protocol. JBI Evid Synth 2020; 18:2373-2379. [DOI: 10.11124/jbisrir-d-19-00283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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9
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Heller SR, Gianfrancesco C, Taylor C, Elliott J. What are the characteristics of the best type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective? Diabet Med 2020; 37:545-554. [PMID: 32034796 DOI: 10.1111/dme.14268] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2020] [Indexed: 12/17/2022]
Abstract
The last 20 years have witnessed a marked change in approaches to the management of type 1 diabetes in the UK. This is exemplified by National Institute of Health and Care Excellence (NICE) guidance which acknowledges that reaching and maintaining target glucose depends on people with type 1 diabetes effectively implementing flexible intensive insulin therapy. The guidance emphasizes that successful self-management requires the acquisition of complex skills and is best achieved by participation in high-quality structured education. Controlled trials and other research have shown that programmes teaching self-management can lower glucose levels while reducing hypoglycaemia, improve psychological outcomes and are highly cost-effective. An important principle of successful programmes is therapeutic education in which learning becomes a partnership between the professional and the person with diabetes who learns to fit diabetes into his/her everyday life. Other recommended elements of programmes include a written curriculum, group teaching by a professional multidisciplinary team and quality assurance. Yet many participants struggle post-course to implement and maintain skills, and overall HbA1c levels, particularly in the UK, remain far from target. Recent studies have identified the barriers to sustained effective self-management and concluded that even high-quality programmes generally lack critical components. These include incorporating evidence from behaviour change research, exploiting the promise of new technologies in reducing the burden of self-management, and providing structured professional support once people have completed the training. Studies are currently underway to evaluate structured training courses which have added these elements and examine whether they can lower glucose to levels closer to target without impairing quality of life.
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Affiliation(s)
- S R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - C Gianfrancesco
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - C Taylor
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - J Elliott
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
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10
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Kuniss N, Müller U, Kloos C, Jörgens V, Kramer G. Diabetes-related distress is reduced in people with type 1, but not type 2 diabetes after participating in a diabetes treatment and teaching programme. DIABETES & METABOLISM 2019; 45:310-312. [DOI: 10.1016/j.diabet.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 11/14/2017] [Accepted: 11/26/2017] [Indexed: 11/29/2022]
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11
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Groat D, Soni H, Grando MA, Thompson B, Kaufman D, Cook CB. Design and Testing of a Smartphone Application for Real-Time Self-Tracking Diabetes Self-Management Behaviors. Appl Clin Inform 2018; 9:440-449. [PMID: 29925098 DOI: 10.1055/s-0038-1660438] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Type 1 diabetes (T1D) care requires multiple daily self-management behaviors (SMBs). Preliminary studies on SMBs rely mainly on self-reported survey and interview data. There is little information on adult T1D SMBs, along with corresponding compensation techniques (CTs), gathered in real-time. OBJECTIVE The article aims to use a patient-centered approach to design iDECIDE, a smartphone application that gathers daily diabetes SMBs and CTs related to meal and alcohol intake and exercise in real-time, and contrast patients' actual behaviors against those self-reported with the app. METHODS Two usability studies were used to improve iDECIDE's functionality. These were followed by a 30-day pilot test of the redesigned app. A survey designed to capture diabetes SMBs and CTs was administered prior to the 30-day pilot test. Survey results were compared against iDECIDE logs. RESULTS Usability studies revealed that participants desired advanced features for self-tracking meals and alcohol intake. Thirteen participants recorded over 1,200 CTs for carbohydrates during the 30-day study. Participants also recorded 76 alcohol and 166 exercise CTs. Comparisons of survey responses and iDECIDE logs showed mean% (standard deviation) concordance of 77% (25) for SMBs related to meals, where concordance of 100% indicates a perfect match. There was low concordance of 35% (35) and 46% (41) for alcohol and exercise events, respectively. CONCLUSION The high variability found in SMBs and CTs highlights the need for real-time diabetes self-tracking mechanisms to better understand SMBs and CTs. Future work will use the developed app to collect SMBs and CTs and identify patient-specific diabetes adherence barriers that could be addressed with individualized education interventions.
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Affiliation(s)
- Danielle Groat
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States.,Department of Biomedical Informatics, Arizona State University, Scottsdale, Arizona, United States
| | - Hiral Soni
- Department of Biomedical Informatics, Arizona State University, Scottsdale, Arizona, United States
| | - Maria Adela Grando
- Department of Biomedical Informatics, Arizona State University, Scottsdale, Arizona, United States
| | - Bithika Thompson
- Division of Endocrinology, Mayo Clinic Arizona, Scottsdale, Arizona, United States
| | - David Kaufman
- Department of Biomedical Informatics, Arizona State University, Scottsdale, Arizona, United States
| | - Curtiss B Cook
- Department of Biomedical Informatics, Arizona State University, Scottsdale, Arizona, United States.,Division of Endocrinology, Mayo Clinic Arizona, Scottsdale, Arizona, United States
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12
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Heller S, White D, Lee E, Lawton J, Pollard D, Waugh N, Amiel S, Barnard K, Beckwith A, Brennan A, Campbell M, Cooper C, Dimairo M, Dixon S, Elliott J, Evans M, Green F, Hackney G, Hammond P, Hallowell N, Jaap A, Kennon B, Kirkham J, Lindsay R, Mansell P, Papaioannou D, Rankin D, Royle P, Smithson WH, Taylor C. A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial. Health Technol Assess 2018; 21:1-278. [PMID: 28440211 DOI: 10.3310/hta21200] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy. DESIGN Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI. SETTING Eight secondary care diabetes centres in the UK. PARTICIPANTS Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps. INTERVENTIONS Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm® VeoTM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK). MAIN OUTCOME MEASURES Primary outcome - change in glycated haemoglobin (HbA1c) at 2 years in participants whose baseline HbA1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA1c ≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months - moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness. RESULTS We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA1c of ≥ 7.5%. HbA1c and severe hypoglycaemia improved in both groups. The drop in HbA1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA1c change at 2 years, at which the baseline HbA1c was ≥ 7.5%, was -0.24% [95% confidence interval (CI) -0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of -0.36% (95% CI -0.64% to -0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews. LIMITATION Blinding of pump therapy was not possible, although an objective primary outcome was used. CONCLUSION Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM. RESEARCH PRIORITY To understand why few patients achieve a HbA1c of < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries. TRIAL REGISTRATION Current Controlled Trials ISRCTN61215213. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - David White
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Ellen Lee
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Katharine Barnard
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anita Beckwith
- King's College Hospital NHS Foundation Trust, London, UK
| | - Alan Brennan
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - Mark Evans
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Wolfson Diabetes Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fiona Green
- Dumfries Royal Infirmary NHS Trust, Dumfries, UK
| | - Gemma Hackney
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Peter Hammond
- Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Nina Hallowell
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Jaap
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Brian Kennon
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Jackie Kirkham
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter Mansell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Diana Papaioannou
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Pamela Royle
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - W Henry Smithson
- Department of General Practice, University College Cork, Cork, Ireland
| | - Carolin Taylor
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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13
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Raymakers AJN, Gillespie P, O'Hara MC, Griffin MD, Dinneen SF. Factors influencing health-related quality of life in patients with Type 1 diabetes. Health Qual Life Outcomes 2018; 16:27. [PMID: 29394942 PMCID: PMC5797407 DOI: 10.1186/s12955-018-0848-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022] Open
Abstract
Aims Generic, preference-based measures of health-related quality of life (HRQoL) are a common input to the economic evaluation of new health technologies. As such, it is important to explore what characteristics of patients with Type 1 diabetes might impact scores on such measures. Methods This study utilizes baseline data from a cluster-randomized trial that recruited patients with Type 1 diabetes at six centers across Ireland. Health-related quality of life was assessed using the three-level EuroQol EQ-5D (EQ-5D) measure. Patients’ responses to individual dimensions of the EQ-5D were explored. To see which patient factors influenced EQ-5D scores, multivariate regression analysis was conducted with EQ-5D scores as the outcome variable. Results Data was available for 437 Type 1 diabetes patients. The median age of these patients was 40 (IQR: 31-49) years and 53.8% were female. Overall, patients reported a high HRQoL based on EQ-5D scores (0.87 (SD: 0.19). Fifty-four percent of patients reported a perfect HRQoL. For those that reported problems, the most common dimension was the anxiety/depression dimension of the EQ-5D (29.6%). In the multivariate regression analysis, self-reported mental illness (− 0.22 (95% CI: -0.34, − 0.10)) and being unemployed (− 0.07 (95% CI: -0.13, − 0.02)) were negatively associated with EQ-5D scores (p < 0.05). The influence of self-reported mental illness was persistent in sensitivity analyses. Conclusions The study results indicate that patients with Type 1 diabetes report a high HRQoL based on responses to the EQ-5D. However, there are a substantial number of Type 1 diabetes patients that report problems in the anxiety/depression dimension, which may provide avenues to improve patients’ HRQoL. Trial registration Current Controlled Trials ISRCTN79759174. Electronic supplementary material The online version of this article (10.1186/s12955-018-0848-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A J N Raymakers
- CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland. .,Health Economics and Policy Analysis Centre, National University of Ireland Galway, Galway, Ireland.
| | - P Gillespie
- CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Health Economics and Policy Analysis Centre, National University of Ireland Galway, Galway, Ireland
| | - M C O'Hara
- Research and Development, Health Services Executive, Health and Wellbeing Division, Galway, Ireland
| | - M D Griffin
- CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - S F Dinneen
- School of Medicine, Clinical Science Institute, National University of Ireland Galway, Galway, Ireland.,Endocrinology and Diabetes Centre, Galway University Hospital, Galway, Ireland
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14
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Saha S, Riemenschneider H, Müller G, Levin-Zamir D, Van den Broucke S, Schwarz PEH. Comparative analysis of diabetes self-management education programs in the European Union Member States. Prim Care Diabetes 2017; 11:529-537. [PMID: 28663021 DOI: 10.1016/j.pcd.2017.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/19/2017] [Accepted: 05/30/2017] [Indexed: 01/13/2023]
Abstract
Diabetes self-management education (DSME) is generally considered as an integral part of diabetes care. The availability of different types of self-management in the European Union Member States (EUMS) remains uncertain. The aim of this study is to perform a comparative analysis of existing DSME programs (DSMEP) implemented in EUMS. Unpublished data regarding DSME in the EUMS was assessed with Diabetes Literacy Survey using wiki tool (WT) targeting patients and different stakeholders. An additional literature review (LR) was performed in PubMed to identify published studies regarding DSMEP in the EUMS from 2004 to 2014. A total of 102 DSMEP implemented in EUMS were reported in the WT and 154 programs were identified from the LR. Comparative analysis of the data indicated that a majority of programs are aimed at adults and only a minority at children and elderly. Only a small percentage of the programs utilize information technology for teaching and learning, and only one out of five programs pay attention to depression. The identified DSMEP aimed primarily to empower patients through increasing knowledge and changing attitudes and beliefs towards diabetes. This study provides an overview of the present state-of-the-art on diabetes self-management education programs in the 28 EUMS. To increase participation, existing DSMEP should be made more accessible to the patients as well as tailored to specific patient groups.
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Affiliation(s)
- Sarama Saha
- Medical Clinic 3, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Henna Riemenschneider
- Medical Clinic 3, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.
| | - Gabriele Müller
- Center for Evidence-based Healthcare, Medical Faculty, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Diane Levin-Zamir
- Clalit Health Services, University of Haifa School of Public Health, Israel
| | | | - Peter E H Schwarz
- Medical Clinic 3, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
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15
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Hurley L, O'Donnell M, O'Hara MC, Carey ME, Willaing I, Daly H, Dinneen SF. Is diabetes self-management education still the Cinderella of diabetes care? PATIENT EDUCATION AND COUNSELING 2017; 100:1957-1960. [PMID: 28545846 DOI: 10.1016/j.pec.2017.05.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/14/2017] [Indexed: 06/07/2023]
Abstract
This paper reflects on the status of diabetes self-management education (DSME) as a branch of diabetology in Europe and discusses some opportunities for better supporting DSME delivery. DSME (also commonly known as Therapeutic Patient Education) has been evolving as a therapy for diabetes for decades. As a continent, Europe is fortunate to have nurtured many pioneers in DSME, and currently has many experts in the field progressing the knowledge base and striving to improve access to DSME for people with diabetes. While there is a wide variety of DSME programmes being delivered throughout Europe, for most people diabetes education is not truly embedded in routine clinical care, being seen as more of an optional add-on to conventional therapies. In comparison to drugs and devices, DSME lacks investment, and funding for DSME research lags far behind other therapies. The rigour with which forms of DSME are developed and evaluated varies, and there is a lack of European quality standards. To try to address some of these deficiencies, greater pan-European collaboration and leadership is required.
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Affiliation(s)
- Lorna Hurley
- Centre for Diabetes, Endocrinology and Metabolism, University Hospital Galway, Galway, Ireland.
| | - Máire O'Donnell
- Discipline of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Mary Clare O'Hara
- Centre for Diabetes, Endocrinology and Metabolism, University Hospital Galway, Galway, Ireland
| | - Marian E Carey
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ingrid Willaing
- Diabetes Management Research, Steno Diabetes Center, Gentofte, Denmark
| | - Heather Daly
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Seán F Dinneen
- Centre for Diabetes, Endocrinology and Metabolism, University Hospital Galway, Galway, Ireland; Discipline of Medicine, National University of Ireland Galway, Galway, Ireland
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16
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Tang TS, Yusuf FLA, Polonsky WH, Fisher L. Assessing quality of life in diabetes: II - Deconstructing measures into a simple framework. Diabetes Res Clin Pract 2017; 126:286-302. [PMID: 28190527 DOI: 10.1016/j.diabres.2016.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 10/13/2016] [Indexed: 12/19/2022]
Abstract
A growing number of instruments measuring diabetes-specific health-related quality of life (HRQOL) have been identified in previous systematic reviews, the most recent being published in 2008. The purpose of this paper is report on an updated systematic review of diabetes-specific HRQOL measures highlighting the time period 2006-2016; to deconstruct existing diabetes-specific HRQOL measures into a simple framework for evaluating the goodness-of-fit between specific research needs and instrument characteristics; and to present core characteristics of measures not yet reported in other reviews to further facilitate scale selection. Using the databases Medline, Pubmed, CINAHL, OVID Embase, and PsycINFO, we identified 20 diabetes-specific HRQOL measures that met our inclusion criteria. For each measure, we extracted eight core characteristics for our measurement selection framework. These characteristics include target population (type 1 vs. type 2), number and type of HRQOL dimensions measured and scored, type of score and calculation algorithm, sensitivity to change data reported in subsequent studies, number of survey items, approximate time length to complete, number of studies using the instrument in the past 10years, and specific languages instruments is translated. This report provides a way to compare and contrast existing diabetes-specific HRQOL measures to aid in appropriate scale selection and utilization.
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Affiliation(s)
| | | | - William H Polonsky
- Behavioral Diabetes Institute, San Diego, CA, USA; University of California, San Diego, CA, USA
| | - Lawrence Fisher
- University of California, San Francisco, San Francisco, CA, USA
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17
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James ML, Green L, Amiel SA, Choudhary P. Evaluation of the Effect of Carbohydrate Intake on Postprandial Glucose in Patients With Type 1 Diabetes Treated With Insulin Pumps. J Diabetes Sci Technol 2016; 10:1287-1293. [PMID: 27137456 PMCID: PMC5094321 DOI: 10.1177/1932296816646797] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND It has been suggested that dietary freedom in functional insulin therapy may be detrimental to glycemic control in type 1 diabetes. This study evaluates the effect of carbohydrate intake on glycemic control and postprandial blood glucose concentrations. METHODS Insulin pump data from 148 adults with type 1 diabetes, trained in functional insulin therapy, using pumps for ≥6 months, with ≥2 weeks of consecutive downloaded data, ≥80% use of a bolus calculator, ≥3 capillary blood glucose tests/day, and a concurrent HbA1C, were analyzed. More detailed periprandial data (pre- and postmeal glucose, carbohydrate intake, insulin bolus) were collected from a subset of 105 downloads (3495 meals). RESULTS Mean (± SD) age of contributors was 43 ± 13 years, HbA1C 7.84% ± 0.93 (62.19 mmol/mol); daily carbohydrate intake 166 ± 71 g. HbA1C reduced with increased meals/day (r = -.370, P < .0005) and increased with mean carbohydrate content/meal (r = .198, P = .043). However, total daily carbohydrate intake had a weak but significant negative association with HbA1C (r = -.181, P = .027). There was no association between standard deviation of carbohydrate intake and HbA1C (r = .021, P = .802) or between meal carbohydrate content and postprandial change in blood glucose (r = -.004, P = .939) for meals with early postprandial (1-3 hours; n = 390) readings. There was a weak positive correlation (r = .184, P = .008) between meal carbohydrate content and late (4-7 hours; n = 390) postprandial readings. DISCUSSION With appropriate training, patients using insulin pumps can accommodate a flexible diet with variable carbohydrate intake, without detriment to glycemic control. However, large carbohydrate meals may contribute to poorer outcomes, through impact on late postprandial glycemia.
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Affiliation(s)
- Mariel L James
- King's College London, Weston Education Centre, London, UK
| | - Louisa Green
- King's College Hospital, Denmark Hill, London, UK
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18
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Ehrmann D, Bergis-Jurgan N, Haak T, Kulzer B, Hermanns N. Comparison of the Efficacy of a Diabetes Education Programme for Type 1 Diabetes (PRIMAS) in a Randomised Controlled Trial Setting and the Effectiveness in a Routine Care Setting: Results of a Comparative Effectiveness Study. PLoS One 2016; 11:e0147581. [PMID: 26799064 PMCID: PMC4723092 DOI: 10.1371/journal.pone.0147581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/04/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The effectiveness of an intervention in clinical practice is often reduced compared to the efficacy demonstrated in a randomised controlled trial (RCT). In this comparative effectiveness study, the RCT-proven efficacy of a diabetes education programme for type 1 diabetic patients (PRIMAS) was compared to the effectiveness observed in an implementation trial (IT) under routine care conditions. METHODS 75 patients with type 1 diabetes received PRIMAS through an RCT, whereas 179 patients were observed in an implementation trial. Baseline characteristics and treatment outcomes at the 6-month follow-up (improvement of HbA1c, hypoglycaemia problems, and diabetes-related distress) were compared. RESULTS At baseline, the type 1 diabetic patients in the RCT had a significant longer diabetes duration (18.7 ± 12.3 vs. 13.8 ± 12.7 yrs., p = .005), lower self-efficacy scores (21.9 ± 4.7 vs. 23.7 ± 6.1, p = .02) and a greater number of diabetes complications (0.8 ± 1.3 vs. 0.4 ± 0.9, p = .02). After 6 months, PRIMAS achieved comparable effects under RCT and implementation trial conditions, as demonstrated by improvement in HbA1c (-0.36% ± 1.1 vs. -0.37 ± 1.2; Δ -0.01, 95% CI -0.33 to 0.31) and hypoglycaemia unawareness (-0.5 ± 1.4 vs. -0.3 ± 1.4; Δ 0.18, 95% CI -0.21 to 0.57). The likelihood of clinical improvement did not depend on the trial setting (RCT vs. IT: OR 1.18, 95% CI 0.60 to 2.33). The participants with worse glycaemic control (OR 1.40, 95% CI 1.02 to 1.92), hypoglycaemia problems (OR 2.13, 95% CI 1.53 to 2.97) or elevated diabetes distress (OR 1.40, 95% CI 1.03 to 1.89) had a better chance of clinical improvement. CONCLUSIONS The effectiveness of PRIMAS under routine care conditions was comparable to the efficacy demonstrated in the RCT. Clinical improvement was independent of the setting in which PRIMAS was evaluated. The PRIMAS education programme for type 1 diabetes can be delivered under conditions of routine care without a loss of effectiveness, compared to its original evaluation in an RCT.
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Affiliation(s)
- Dominic Ehrmann
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- Otto-Friedrich-University of Bamberg, Department of Clinical Psychology and Psychotherapy, Bamberg, Germany
| | - Nikola Bergis-Jurgan
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann Hammer-Str. 24, 97980, Bad Mergentheim, Germany
| | - Thomas Haak
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- Diabetes Centre Mergentheim, Diabetes Clinic, Theodor-Klotzbuecher-Str. 12, 97980, Bad Mergentheim, Germany
| | - Bernhard Kulzer
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- Diabetes Centre Mergentheim, Diabetes Clinic, Theodor-Klotzbuecher-Str. 12, 97980, Bad Mergentheim, Germany
- Otto-Friedrich-University of Bamberg, Department of Clinical Psychology and Psychotherapy, Bamberg, Germany
| | - Norbert Hermanns
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- Diabetes Centre Mergentheim, Diabetes Clinic, Theodor-Klotzbuecher-Str. 12, 97980, Bad Mergentheim, Germany
- Otto-Friedrich-University of Bamberg, Department of Clinical Psychology and Psychotherapy, Bamberg, Germany
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19
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Yong YM, Shin KM, Lee KM, Cho JY, Ko SH, Yoon MH, Kim TW, Jeong JH, Park YM, Ko SH, Ahn YB. Intensive individualized reinforcement education is important for the prevention of hypoglycemia in patients with type 2 diabetes. Diabetes Metab J 2015; 39:154-63. [PMID: 25922810 PMCID: PMC4411547 DOI: 10.4093/dmj.2015.39.2.154] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/29/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We investigated whether an intensive individualized reinforcement education program could influence the prevention of hypoglycemic events in patients with type 2 diabetes. METHODS From March 2013 to September 2013, patients aged 35 to 75 years with type 2 diabetes who had not previously participated in diabetes education, and treated with insulin or a sulfonylurea-containing regimen were included in the study. After structured group education, the patients assigned to the intensive individualized education group (IT) were requested to visit for reinforcement. All subjects in the IT were encouraged to self-manage dose adjustments. Participants in both groups (control group [CG, group education only; n=22] and IT [n=24]) attended follow-up visits at 2, 8, 12, and 24 weeks. At each visit, all patients were asked whether they had experienced hypoglycemia. RESULTS The total study population consisted of 20 men (43.5%; mean age and diabetic duration of 55.9±11.0 and 5.1±7.3 years, respectively). At 24 weeks, there were no significant differences in hemoglobin A1c values between the CG and IT. The total number of hypoglycemic events per patient was 5.26±6.5 in the CG and 2.58±2.3 times in the IT (P=0.004). Adherence to lifestyle modification including frequency of exercise, self-monitoring of blood glucose, or dietary habit was not significantly different between the groups. However, adherence to hypoglycemia management, especially the dose adjustment of medication, was significantly higher in the IT compared with the CG. CONCLUSION Compared with the structured group education, additional IT resulted in additional benefits in terms of avoidance of hypoglycemia and treating hypoglycemia in patients with type 2 diabetes.
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Affiliation(s)
- Yun-Mi Yong
- Diabetes Care Team, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Kyung-Mi Shin
- Diabetes Care Team, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Kang-Min Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jae-Young Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Sun-Hye Ko
- Diabetes Care Team, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Min-Hyang Yoon
- Diabetes Care Team, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Tae-Won Kim
- Department of Psychiatry, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Yong-Moon Park
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Seung-Hyun Ko
- Diabetes Care Team, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Yu-Bae Ahn
- Diabetes Care Team, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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20
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Elliott J, Rankin D, Jacques RM, Lawton J, Emery CJ, Campbell MJ, Dixon S, Heller SR. A cluster randomized controlled non-inferiority trial of 5-day Dose Adjustment for Normal Eating (DAFNE) training delivered over 1 week versus 5-day DAFNE training delivered over 5 weeks: the DAFNE 5 × 1-day trial. Diabet Med 2015; 32:391-8. [PMID: 25363466 DOI: 10.1111/dme.12621] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/04/2014] [Accepted: 10/28/2014] [Indexed: 12/24/2022]
Abstract
AIMS To compare, in a randomized controlled non-inferiority trial, the outcomes of the traditional format for Dose Adjustment for Normal Eating structured education courses; that is, one delivered over 5 consecutive days (1-week course) with a variant of this format delivered 1 day a week for 5 consecutive weeks (5-week course). METHODS Adults with Type 1 diabetes, from seven UK Dose Adjustment For Normal Eating training centres, were individually randomized, stratified by centre, to receive either a 1-week or 5-week course. A qualitative study was embedded within the trial to explore patients' experiences. RESULTS In total, 213 patients were randomized and 160 completed the study procedures. In the per-protocol analysis, the difference in HbA1c levels (95% CI) between the arms at 6 months was 0.4 mmol/mol (-2.4, 3.1) or 0.03% (-0.22, 0.28) and -0.9 mmol/mol (-3.9, 2.2) or -0.08% (-0.36, 0.20) at 12 months. All confidence limits were within the non-inferiority margin of ± 5.5 mmol/mol (0.5%) for HbA1c %. For those patients with a baseline HbA1c of ≥ 58 mmol/mol (≥ 7.5%) the mean change (95% CI) in HbA1c was -2.2 mmol/mol (-4.0, -0.4) or -0.20% (-0.37, -0.04) at 6 months (P = 0.016), and -2.0 mmol/mol (-4.1, 0.04) or -0.18% (-0.37 to 0.004) at 12 months (P = 0.055). Episodes of severe hypoglycaemia were decreased by 82% [relative risk 0.18 (95% CI 0.03-0.936); P = 0.042], psychosocial outcomes improved significantly, and the difference between arms was not significant. Qualitative interviews showed that patients overwhelmingly favoured the format of course that they attended. CONCLUSIONS In summary, 5-week and 1-week Dose Adjustment for Normal Eating courses are equivalent in terms of biomedical and psychosocial outcomes, and we were persuaded that both course formats should be made available in routine care.
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Affiliation(s)
- J Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
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21
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Heller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J, Emery C, Baird W, Basarir H, Beveridge S, Bond R, Campbell M, Chater T, Choudhary P, Clark M, de Zoysa N, Dixon S, Gianfrancesco C, Hopkins D, Jacques R, Kruger J, Moore S, Oliver L, Peasgood T, Rankin D, Roberts S, Rogers H, Taylor C, Thokala P, Thompson G, Ward C. Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BackgroundMany adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.AimWith evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.FindingsWe confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.ConclusionsWe propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.Trial registrationClinicalTrials.gov NCT01069393.FundingThe NIHR Programme Grants for Applied Research programme.
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Affiliation(s)
- Simon Heller
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Debbie Cooke
- Division of Psychology, University College London, London, UK
| | - Peter Mansell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Brennan
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jonathan Boote
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Centre for Research into Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Celia Emery
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Wendy Baird
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hasan Basarir
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Beveridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rod Bond
- School of Psychology, University of Sussex, Brighton, UK
| | - Mike Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Timothy Chater
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Marie Clark
- Division of Psychology, University College London, London, UK
| | | | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jen Kruger
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Moore
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Lindsay Oliver
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Tessa Peasgood
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Sue Roberts
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | | | - Carolin Taylor
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gill Thompson
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Candice Ward
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Gillespie P, O'Shea E, O'Hara MC, Dinneen SF. Cost effectiveness of group follow-up after structured education for type 1 diabetes: a cluster randomised controlled trial. Trials 2014; 15:227. [PMID: 24927851 PMCID: PMC4070096 DOI: 10.1186/1745-6215-15-227] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 05/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background This study examines the cost effectiveness of group follow-up after participation in the Dose Adjustment for Normal Eating (DAFNE) structured education programme for type 1 diabetes. Methods Economic evaluation conducted alongside a cluster randomised controlled trial involving 437 adults with type 1 diabetes in Ireland. Group follow-up involved two group education ‘booster’ sessions post-DAFNE. Individual follow-up involved two standard one-to-one hospital clinic visits. Incremental costs, quality-adjusted life years (QALYs) gained and cost effectiveness were estimated at 18 months. Uncertainty was explored using sensitivity analysis and by estimating cost effectiveness acceptability curves. Results Group follow-up was associated with a mean reduction in QALYs gained of 0.04 per patient (P value, 0.052; 95% CI, −0.08 to 0.01, intra-class correlation (ICC), 0.033) and a mean reduction in total healthcare costs of €772 (P value, 0.020; 95% CI, −1,415 to −128: ICC, 0.016) per patient. At alternative threshold values of €5,000, €15,000, €25,000, €35,000, and €45,000, the probability of group follow-up being cost effective was estimated to be 1.000, 0.762, 0.204, 0.078, and 0.033 respectively. Conclusions The results do not support implementation of group follow-up as the sole means of follow-up post-DAFNE. Given the reported cost savings, future studies should explore the cost effectiveness of alternative models of group care for diabetes. Trial registration Current Controlled Trials ISRCTN79759174 (assigned: 9 February 2007).
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Affiliation(s)
- Paddy Gillespie
- School of Business and Economics, J,E, Cairnes Building, NUI Galway, Galway, Ireland.
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Snow R, Sandall J, Humphrey C. Use of clinical targets in diabetes patient education: qualitative analysis of the expectations and impact of a structured self-management programme in Type 1 diabetes. Diabet Med 2014; 31:733-8. [PMID: 24495236 DOI: 10.1111/dme.12401] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/15/2013] [Accepted: 01/28/2014] [Indexed: 01/12/2023]
Abstract
AIMS To explore the impact of education and target-setting on the life stories of patients with diabetes up to 10 years after they had participated in the Dose Adjustment for Normal Eating programme (DAFNE). METHODS Qualitative, semi-structured interviews were conducted before and after DAFNE courses to elicit narrative accounts from participants at three UK education centres. Observations of courses also took place. Data were gathered from 21 participants over 32 interviews and 146 h of observations, and analysed using a narrative approach. RESULTS Findings suggest that patient education can create positive transformations in the lives of people with diabetes in ways that are not fully captured by simple quality-of-life scores. However, a review of evidence from other studies shows that DAFNE-recommended blood glucose results are in fact out of reach of even these most motivated and well-informed patients. This information was not shared with DAFNE attendees, who were expected to aim for near-normal HbA1c levels. After the course, participants sometimes perceived themselves as failing in their efforts, even when they had better than average blood glucose results. CONCLUSIONS Specific and measurable low HbA1c targets may be desirable for reducing the risk of complications in diabetes, but they are not attainable or realistic even for most DAFNE graduates. It is suggested that setting goals without information about how achievable they really are could be counterproductive in terms of supporting and maintaining patient self-efficacy long-term.
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Affiliation(s)
- R Snow
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
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Hwee J, Cauch-Dudek K, Victor JC, Ng R, Shah BR. Diabetes education through group classes leads to better care and outcomes than individual counselling in adults: a population-based cohort study. Canadian Journal of Public Health 2014; 105:e192-7. [PMID: 25165838 DOI: 10.17269/cjph.105.4309] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 05/23/2014] [Accepted: 03/22/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Self-management education, supported by multidisciplinary health care teams, is essential for optimal diabetes management. We sought to determine whether acute diabetes complications or quality of care differed for patients in routine clinical care when their self-management education was delivered through group diabetes education classes versus individual counselling. METHODS With the use of population-level administrative and primary data, all diabetic patients in Ontario who attended a self-management education program in 2006 were identified and grouped according to whether they attended group classes (n=12,234), individual counselling (n=55,761) or a mixture of both (n=9,829). Acute complications and quality of care in the following year were compared among groups. RESULTS Compared with those attending individual counselling, patients who attended group classes were less likely to have emergency department visits for hypo/hyperglycemia (odds ratio 0.54, 95% confidence interval [CI]: 0.42-0.68), hypo/hyperglycemia hospitalizations (OR 0.49, CI: 0.32-0.75) or foot ulcers/cellulitis (OR 0.64, CI: 0.50-0.81). They were more likely to have adequate HbA1c testing (OR 1.10, CI: 1.05-1.15) and lipid testing (OR 1.25, CI: 1.19-1.32), and were more likely to receive statins (OR 1.22, CI: 1.07-1.39). CONCLUSION Group self-management education was associated with fewer acute complications and some improvements in processes of care. Group sessions can offer care to more patients with reduced human resource requirements. With increased pressure to find efficiencies in health care delivery, group diabetes education may provide an opportunity to deliver less resource-intensive care that simultaneously improves patient care.
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Abstract
The Dose Adjustment for Normal Eating (DAFNE) programme of intensive insulin therapy for type 1 diabetes provides a structured educational intervention to improve glycemic control, reduce hypoglycemia and improve quality of life. Enhancement of self-management skills is a key element of DAFNE and patients acquire detailed skills in insulin dose adjustment. Following DAFNE training, patients report improved confidence in their ability to manage their own insulin dosing, but generally still seek and require the assistance of health professionals when making substantial changes to their insulin regimens. Some DAFNE trained patients may be able to assist their peers in aspects of diabetes management within a group environment, but widespread introduction of the expert patient/peer educator role in the self-management of type 1 diabetes, in particular related to insulin dose management, would require formal and detailed evaluation, preferably in randomized controlled clinical trials, before being introduced into routine clinical practice.
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Affiliation(s)
- Harold David McIntyre
- Department of Medicine, Mater Clinical School, The University of Queensland and Mater Health Services, South Brisbane, Australia
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