Low attendance at structured education for people with newly diagnosed type 2 diabetes: General practice characteristics and individual patient factors predict uptake
Introduction
Diabetes self-management education (DSME) for people with newly diagnosed Type 2 diabetes (T2DM) is the cornerstone of diabetes self-care [1], [2]. The United Kingdom’s (UK) landmark multi-centre trial of 824 participants randomised to Diabetes Education for Ongoing and Newly Diagnosed (DESMOND), a one day group course compared to attention control demonstrated improvements in weight, lipids and psychological variables but not glycaemic control 12 months later [3], although the benefits had reduced by 3 years [4]. This is in contrast to a recent systematic review and meta-analysis of 21 randomised controlled trials (RCT) (total n = 2833) of group based DSME which concluded that HbA1c was significantly reduced by an average of 5 mmol/mol at 6 and 12 months compared with the control group [5]. There is also now a significant evidence base to suggest that group DSME programmes can deliver improvement in cardiovascular risk, self-efficacy and diabetes knowledge [5], [6], [7], [8]. Findings such as these are embedded in the UK National Institute for Health and Clinical Excellence (NICE)[9], International Diabetes Federation Global Guideline for T2DM [1] and the United States (US) National Standards for Diabetes Education [2]. In the UK, DSME, usually termed structured diabetes education to meet pre-specified NICE criteria, is usually available at no cost for people with newly diagnosed T2DM but the UK National Diabetes Audit suggests attendance rates vary between 0 and 48% [10]. In Canada and the US attendance rates have been reported to be 30–35% [11], [12].
Reasons for low attendance at group DSME are understudied. Well known barriers to optimal diabetes self-care include psychological and social factors [13] and low levels of health literacy may discourage attendance or prevent those affected from benefitting from this mode of self-management support [14], [15], [16], [17]. Qualitative research of patient barriers to attending structured education programmes have identified: lack of information regarding DSME from health professionals, not perceiving the benefit of attendance, difficulties in access, and shame and stigma of diabetes [18]. Poor uptake is also associated with being older, lower socio-economic status, ethnicity, male gender and diabetes duration >3 years [11], [12], [19], [20]. Characteristics of general practices (primary care centres) are known to influence outcomes, in the UK general practices achieving diabetes targets for HbA1c are associated with lower risk of diabetic retinopathy [21]. Practice characteristics influencing patient attendance at education have not been studied. In the UK, area level deprivation is associated with overall quality of care by general practices [22] but perhaps less so in inner-city settings [23]. The aims of this study were to determine the rate of attendance at structured education amongst people with newly diagnosed T2DM and use multi-level modelling to determine which individual and general practice factors are independently associated with attendance at structured diabetes education.
Section snippets
Design, setting and sampling frame
The UK South London Diabetes Study (SOUL-D) is a prospective urban cohort of people with newly diagnosed T2DM recruited from primary care and followed up for 2 years. Potential participants resident in the UK south London boroughs of Lambeth, Southwark and Lewisham were identified by their General Practitioner. Ninety-six of the 138 primary care centres participated. The methods have been described previously [24].
Case definition
Eligible adults had a recent diagnosis (≤6 months) of T2DM, diagnosed according
Results
Ninety six GP practices out of 138 agreed to participate from which we recruited 1790 eligible participants to SOUL-D (see Fig. 1 and Table 1). GP practices that participated in SOUL-D were more likely to have more doctors (5.42 SD 2.90 vs. 3.71 SD 2.39, p = <0.0001), larger list sizes (10,073 SD 4962 vs. 5822 SD 3376, p = <0.0001), but there was no difference in deprivation (IMD rank 7750 SD 4562 vs 8254 SD 4489, p = 0.61) than those that did not participate. Of participants with eligible data (n =
Discussion
This study investigated the association between individual and general practice level covariates and attendance at structured diabetes education for T2DM. The main findings were that the attendance rate was very low with only a fifth attending. Those who did not attend were a high risk group for diabetes complications: men, people with poorer glycaemic control within 6 months of diagnosis of T2DM, and smokers. At the general practice level, practices with more patients achieving HbA1c ≤ 59
Conclusion
In our population-based prospective cohort of 1790 patients with a new diagnosis of type 2 diabetes recruited from a multi-ethnic inner-city primary care setting, only 365/1626 (22.4%) attended structured education. There were independent associations between female gender, non-smoking status and better glycaemic control and attendance at structured education. There were also independent associations between performance of general practices on diabetes clinical outcomes and attendance at
Practice implications
Clinical implications are that 80% of people with newly diagnosed diabetes within an urban setting of the UK with high rates of deprivation are not getting adequate self-management support. Furthermore, there is an identifiable subgroup of patients at high risk of developing diabetes complications, namely males, cigarette smokers and people with poorer glycaemic control. Better organised general practices with regard to the achievement of diabetes glycaemic control targets are more likely to
Conflicts of interest
None.
Ethical approval
Ethical approval was granted by the King’s College Hospital Research Ethics Committee London UK (reference 08/H0808/1) and by Lambeth, Southwark, and Lewisham Primary Care Trusts London UK (reference RDLSLB 410) and all participants gave informed consent.
Funding
This paper presents independent research funded by the UK's National Institute for Health Research (NIHR) under its Individual Award Programme (Grant Reference Number PDF-2011-04-078) and its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0606-1142). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Informed consent and patient details
I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
Statement of contribution
KW devised the study, conducted data collection, statistical analysis, produced the first draft of the manuscript and is the guarantor for the study. KW affirms the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
DS, conducted statistical analysis, contributed to the study design and contributed to the draft of the manuscript.
Acknowledgements
We would like to thank the patients who volunteered to participate in this study. We would also like to thank our research team, past and present: J. Schonbeck, J. Valka, N. Iles, S. Brooks, J. Hunt, K. Twist, R. Stopford, G. Knight, L. Marwood, A. Barlow, L. East, B. Jackson, E. Britneff and A. Bayley. We also thank: the staff of the participating general practices in Lambeth, Southwark and
Lewisham, especially M. Ashworth, C. Gostling and T. Evans; the Primary Care Research Network (PCRN-GL)
References (43)
- et al.
Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial
Patient Educ. Couns.
(2012) - et al.
Predictors and effectiveness of diabetes self-management education in clinical practice
Patient Educ. Couns.
(2009) - IDF. Global guideline for type 2 diabetes. International Diabetes Federation;...
- et al.
National standards for diabetes self-management education
Diabetes Care
(2008) - et al.
Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial
Br. Med. J.
(2008) - et al.
Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care
Br. Med. J.
(2012) - et al.
Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis
BMC Health Serv. Res.
(2012) - et al.
Does patient education facilitate diabetic patients’ possibilities to reach national treatment targets? A national survey in Swedish primary healthcare
Scand. J. Prim. Health Care
(2009) - et al.
Structured patient education: the Diabetes X-PERT Programme makes a difference
Diabet. Med.
(2006) - NICE. Type 2 Diabetes - newer agents (partial update of CG66) (CG87)....
Frequency and determinants of diabetes patient education among adults in the U.S. population
Diabetes Care
Discordance in perceptions of barriers to diabetes care between patients and primary care and secondary care
Diabetes Care
Association of health literacy with diabetes outcomes
J. Am. Med. Assoc.
The relationship between literacy and glycemic control in a diabetes disease-management program
Diabetes Educ.
Low literacy a problem in diabetes education
Diabet. Med.
The influence of literacy on patient-reported experiences of diabetes self-management support
Nurs. Res.
Patient explanations for non-attendance at structured diabetes education sessions for newly diagnosed Type 2 diabetes: a qualitative study
Diabet. Med.
Disparities in attendance at diabetes self-management education programs after diagnosis in Ontario, Canada: a cohort study
BMC Public Health
Diabetes education program use and patient-perceived barriers to attendance
Fam. Med.
Family practices' achievement of diabetes quality of care targets and risk of screen-detected diabetic retinopathy
PLoS One
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