THE ROLE OF A STRUCUTURED EDUCATION PROGRAMME IN THE MANAGEMENT OF PATIENTS WITH TYPE 2 DIABETES.

Abstract

Background Type 2 diabetes is a chronic disease associated with significant morbidity and mortality. Early treatment intervention and prevention of complications is key to management. It is well recognised that improving glycaemic control reduces the risk of long term complications in addition to managing the acute symptoms at the time of presentation, in patients with type 2 diabetes. Conventionally treatment has centred on pharmacological agents to improve glycaemic control and manage cardiovascular risk. In recent years programmes to educate patients to self-manage have become the focus of interest among health care professionals in the management of type 2 diabetes and are recommended by both SIGN and NICE for newly diagnosed patients with type 2 diabetes. Evidence from these structured education programmes reports improvement in glycaemic control, weight reduction and improvement in illness beliefs in the first year of management. However few self-management programmes have reported longer term effects of the intervention. Nonetheless it has been suggested that education on self-management may play a key role in tackling beliefs about health with a resultant impact on metabolic control, concordance with medication, quality of life and long-term complications. Aims The aim of this study was to evaluate whether the attendance at a structured education programme in our rural setting (DESMOND Diabetes Education and Structured Management for Ongoing and Newly diagnosed Diabetes) could achieve improvement in glycaemic control (HbA1c) and other cardiovascular risk markers (cholesterol, BP and BMI) one year after attending, in line with studies in urban setting. Methods Data included in this study was collected over a three year period in order to have an adequate sample size with which to compare findings. Demographic data including age, sex, weight, age at diagnosis and duration of diabetes was recorded at baseline and 12 months post programme. The cardiovascular risk factors to be analysed included Glycosylated haemoglobin (HbA1c) and random total cholesterol. HbA1C was measured using high performance liquid chromatography (HPLC), (TOSOH G8 Analyse). The cation exchange column separates haemoglobin components by different ionic charge. Cholesterol was measured using an enzymatic method (Abbott architect C800). Blood pressure (BP) was recorded using an electronic sphygmomanometer. BP was measured in the sitting position after 2 mins and 5 min and the average of these reading recorded. Target blood pressure ≤ 140/80 mmHg. BMI was calculated using the following formula: BMI= Weight (kg)/Height (m²). Dependent variables include: HbA1c, blood pressure, BMI and cholesterol. Independent variables include: Age, gender and duration of diabetes. The inclusion criteria included males and females who had a diagnosis of type 2 diabetes within and up to a 12 month period. There was no upper age limit however the lower age limit was 18 years. Only patients who had had their cardiovascular risk markers and BMI measured prior to and 12 months after attending structured education were included. The exclusion criteria included participants who had not had all of their cardiovascular risk factors and BMI recorded at base line and or at the twelve month review date. Also patients who did not complete the 6 hour DESMOND education programme. Ethical approval was sought and approved prior to recruitment for this study from the local health board via International Research Application System (IRAS) as this is currently the system they use. Informed consent from participants was not required as participants opted into the programme following referral by their GP or practice nurse and data collected for the purposes of the study was anonymised and entered into an electronic data base which was password protected. Access to the information on this data base is only available to the health professional that carried out the research. Queen Margaret University ethical approval forms have been completed and attached. Participants in this study were recruited at point of entry into the programme following referral by their G.P or practice nurse and subsequent acceptance and agreement to attend. Currently only those with newly diagnosed diabetes enter this programme. All patients were required and agreed to attend a six hour education programme (DESMOND) either in a full day format or after attending to half days. Results Over the period of the study 397 patients out of 453 invited attended and complete the DESMOND programme. The primary outcome of this intervention was a reduction in HbA1c. The median HbA1c at entry was 55mmols/mol compared to 49mmols/mol at completion (p<0.005). There was an improvement in both Systolic blood pressure (134mmHg vs 132mmHg after 12 months, p=0.021) and Diastolic blood pressure (80mmHg vs 76mmHg after 12 months, p<0.005). There was an improvement in total cholesterol (5mmol/l vs 4mmol/l after 12 months, p=0.001). BMI was also reduced (32kg/m2 vs 31kg/m2 after 12 months, p<0.005). Conclusion. At the end of one year (data collected over a three year period) has demonstrated that our structured programme has an improvement in HbA1c, Cholesterol and BMI as demonstrated in other studies. Therefore this structured education programme in a rural setting can achieve at one year, similar improvements in cardiovascular risk markers demonstrated in urban studies. While there is evidence to suggest improvements these cardiovascular risk markers reduce cardiovascular risk it remains to be demonstrated whether these can be sustained over time and what level of ongoing intervention would be required to achieve these benefits. Further evaluation at 3 years would be recommended.