Structured education for people with type 2 diabetes
Sean F Dinneen
senior lecturer in medicine
1 Department of Medicine, Clinical Science Institute, National University
of Ireland Galway, Galway, Ireland
seandinneen@nuigalwayie
A step towards a more patient centred approach to delivery of care
Effective self management is the cornerstone of good care for people with
diabetes High quality structured education that prepares people for a
lifetime with the condition is a key enabler of self management The term
structured education programme was defined by a patient education working
group in 2005 box A good example of such a programme for patients with
type 1 diabetes is the DAFNE dose adjustment for normal eating programme,
which has been endorsed by National Institute for Health and Clinical
Excellence NICE guidance
Key criteria of a structured education programme
A clear underlying philosophy on which the programme is based
A structured written curriculum
Trained educators familiar with the programme and its delivery
A quality assurance system applied to the structure, process, content,
and delivery of the programme
A process of audit of programme outcomes
including biomedical,
psychosocial, and patient experience
High quality trials of structured education for people with type 2
diabetes in the United Kingdom have been lacking, but two new programmes
have recently been reported The first, X-PERT, showed that structured
education improved biomedical and psychosocial outcomes for patients with
established type 2 diabetes compared with one to one care from a dietitian
The second, the DESMOND diabetes education for ongoing and newly
diagnosed randomised controlled trial, which accompanies this editorial,
studied people with newly diagnosed type 2 diabetes
The DESMOND collaborative is an alliance of clinicians, educators,
academics, and people with diabetes The education programme has been
carefully constructed and evaluated using the Medical Research Councils
framework for complex interventions It has a sound theoretical basis and
involves six hours of group education delivered by trained educators The
trial was undertaken in practices across the UK, so its findings are
generalisable The results show that the DESMOND intervention improved
weight loss, rates of smoking cessation, beliefs about illness, and self
reported
depression However main outcomes of glycated haemoglobin HbA1c
and quality of life did not differ significantly between groups Why did
the programme not have a greater effect?
A dramatic improvement in metabolic control is often seen in the period
after diagnosis of diabetes, so that any effect of a structured education
programme on glycaemic control may have been masked Also, control
practices were given extra funding so that an equivalent amount of time
could be spent with participants in these practices as in intervention
practices Although methodologically sound, this may have contributed to
the lack of difference in HbA1c
The DESMOND intervention encourages participants to set personal goals in
managing their diabetes Because HbA1c was improving anyway, DESMOND
participants may have chosen goals other than glycaemic control, such as
weight loss and smoking cessation Quality of life may not have improved
because this outcome can take a long time to change, or because of the
psychometric properties of the instrument used The personal benefit that
participants derive from a patient centred approach like DESMOND may be
better captured by qualitative research
So how do these
results translate to clinical practice? General
practitioners in the UK have recently been offered financial incentives to
meet certain targets associated with good diabetes care These targets were
not only met but often exceeded The national service framework for
diabetes emphasises self management as an important part of diabetes care
Standard 3 states that patients will receive a service which encourages
partnership in decision-making, supports them in managing their diabetes
and helps them to adopt and maintain a healthy lifestyle
The recent emphasis on structured education within the National Health
Service and the availability of programmes like DAFNE, DESMOND, and X-PERT
should enable this standard to be achieved However, one of the barriers to
success is demonstrated by the DESMOND trial For self management to be
most effective, all patients who could potentially benefit need to be
referred for training The trial showed a major difference in baseline
HbA1c between people in intervention practices and control practices The
authors suggest that, in intervention practices, patients with the highest
HbA1c concentrations were more likely to be referred for DESMOND training
If
this is a reflection of what happens in clinical practice, then a large
proportion of patients with lower HbA1c concentrations who could still
benefit would be excluded
As well as offering education to as many patients as possible, another
challenge is to maintain the patient centred emphasis beyond the initial
delivery of the education programme This requires input from all
healthcare professionals and not just those delivering education The
importance of diabetes self-management support has recently been
acknowledged by the American Diabetes Association A good example of how to
provide this ongoing support comes from the Turin group, which is
evaluating the implementation of supported group care in centres across
Italy Healthcare professionals need to appreciate that structured
education represents one element of a patient centred approach to diabetes
care and not just another box to tick at the time of annual review
Competing interests: None declared
Provenance and peer review: Commissioned; not peer reviewed
1 Department of Health and Diabetes UK Structured patient education in
diabetes: report from the patient education working group 2005
wwwdhgovuk/en/Publicationsandstatistics/Publications/PublicationsPoli
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2 DAFNE Study Group Training in flexible intensive insulin management to
enable dietary freedom in people with type 1 diabetes: dose adjustment
for normal eating DAFNE randomised controlled trial BMJ 2002;325:746-
51
3 National Institute for Health and Clinical Excellence Guidance on the
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Source:carolinashealthcare.org
