Structured education for people with type 2 diabetes

Abstract

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).¹ A good example of such a programme for patients with type 1 diabetes is the DAFNE (dose adjustment for normal eating) programme,² which has been endorsed by National Institute for Health and Clinical Excellence (NICE) guidance.³

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.⁴ 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.⁵

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 Council’s framework for complex interventions.⁶ 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,⁷ 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.⁸ The national service framework for diabetes emphasises self management as an important part of diabetes care.⁹ 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.¹⁰ A good example of how to provide this ongoing support comes from the Turin group,⁷ which is evaluating the implementation of supported group care in centres across Italy.¹¹ 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.