laura grant 1, julia lawton 2, david hopkins 3, jackie elliott 4, suzanne lucas 5, marie clark 6,...
TRANSCRIPT
Laura Grant1, Julia Lawton2, David Hopkins3, Jackie Elliott4, Suzanne Lucas5, Marie Clark6, Ian MacLellan7, Mark Davies8, Simon Heller4 & Debbie Cooke9
1Adelphi Values, Manchester 2University of Edinburgh; 3King’s College Hospital, 4University of Sheffield, 5Diabetes Modernisation Initiative, London, 6University College London, 7Ian MacLellan, DAFNE User Action Group (DUAG), 8Belfast City Hospital, 9University of Surrey
Identifying Core Components of Structured Education Courses for
Type 1 Diabetes
Introduction
From multiple fixed doses of insulin to more complex insulin adjustment
Reduced risk of severe hypoglycaemia & improvements in overallHbA1c
Developed in Dusseldorf, Germany
Structured education programmes, DAFNE & BERTIE
Existing measures did not capture the current approach to type 1 diabetes management
Aims
Describe and compare the way structured education courses for type 1 diabetes have evolved in the UK, so that we could
Develop, pilot and validate a questionnaire assessment tool of diabetes-specific self-care behaviours, for adults with type
1 diabetes.
Methods
83 courses on Diabetes Education Network
28 met NICE criteria + 1 from manual internet searching
Reason for exclusion Number of coursesNo reply 3 coursesCourse in development 4 coursesBased directly on DAFNE or BERTIE 6 coursesEducation for both type 1 and type 2 2 coursesCourse too specific e.g. newly diagnosed 2 courses
Not enough information 2 coursesMissing data on QA and audit 2 courses
Educators from 5 courses were interviewed (April-June 2011)
Consensus meeting with 15 key stakeholders
DAFNE, BERTIE, ICE, SELECT & DAISY
Methods
Core Components of Courses
Core Components from Interviews
Carbohydrate counting and insulin dose adjustment
Hypoglycaemia management
Group work
Goal setting
Challenges
Empowerment
Summary of Process
Identified the core components of diabetes structured education
Related these components to self-care behaviours
Develop a questionnaire tool to assess the extent to which people carry out these behaviours
Example Questionnaire Items
Routine BG Monitoring (6 items)- I check my blood glucose when I am physically active e.g. walking, gardening- On average, over the last 2 weeks, how many times have you checked your blood glucose each day?- I carried my blood glucose meter with me
Recording & Reflecting on BG Monitoring (3 items)- I recorded my blood glucose results e.g. in a diary, on a computer- I recorded information that could affect my blood glucose levels e.g. carbohydrate intake, insulin dose, exercise- I looked for trends or patterns in my recorded blood glucose levels and used this to adjust my quick-acting insulin
Example Questionnaire Items
Checking Ketones (2 items)[when ill] I check my ketone levels when my blood glucose is higher than normal
Timing of Quick-Acting Insulin with Meals (2 items)- I took my quick-acting insulin before meals- I took my quick-acting insulin after meals
Adjusting Quick-Acting Insulin to Carbohydrate Intake (2 items)- I adjusted my QA insulin according to the carbohydrate I was eating
- I counted the carbohydrates I ate
I take less insulin than recommended (5 items)
- to try to avoid putting on weight
- because I am fed up with my diabetes
Response Format5-point Likert Scale ‘never’ to ‘always’ for majority of items
611 adults with type 1 from 16 hospitals
N Min Max Mean Std
Dev
HbA1c (mmol/mol) 584 5.4 15.1 8.2 1.4
IFCC 584 35 141 67 15.2
Age 610 18 86 47 14.8
Duration 600 6 mth 73 25 15.5
Total N N %
Attended structured educ 608
Yes 376 62
No 232 38
Gender 610
Male 272 45
Female 338 55
Educational level 609
Below degree level 375 61
Undergraduate degree and higher
234 38
Diabetes complications 611
Yes 296 48
No 395 52
Example Items: How did people respond?
N %
Never 163 26.7
Rarely 65 10.6
Sometimes 48 7.9
Often 63 10.3
Always 266 43.5
Total 605 99.0
Missing 999 6 1.0
Total 611 100.0
I recorded my blood glucose results e.g. in a diary, on a computer
Example Items: How did people respond?
N %
Never 233 38.1Rarely 82 13.4Sometimes 73 11.9Often 82 13.4Always 83 13.6Total 553 90.5
Missing999 7 1.1System 51 8.3Total 58 9.5
Total 611 100.0
[when ill] I check my ketone levels when my blood glucose is higher than normal
Example Items: How did people respond?
Taking less insulin than recommended
• 111 participants (18%) took less insulin than recommended for one or more of the reasons listed:
- To try to avoid putting on weight- Fed up with diabetes- Do not like injecting- Do not like thinking about diabetes
Educ N Mean (sd) Score Range
t df Sig.
Routine BG monitoring
Yes 358 25.9 (4.6) 6-31 3.6 575 .000
No 219 24.4 (4.9)
Recording & reflection
Yes 373 9.4 (4.1) 3-15 3.0 598 .003
No 227 8.4 (3.9)
Monitoring ketones Yes 342 4.6 (2.6) 2-10 3.5 544 .000
No 204 3.8 (2.5)
Checking long-acting dose
Yes 310 3.6 (0.7) 2-10 -3.1 503 .002
No 195 3.8 (0.5)
Comparing behaviours: structured education vs. none
Comparing behaviours: structured education vs. none
No significant differences: Timing of QA with meals, Dose correction, Adjusting QA insulin in specific situations, Rotating injection/infusion sites, Carrying appropriate hypo treatments, Changing BG levels before showing nurse/Dr, Avoiding checking BG when high
Educ N Mean (sd) Score Range
t df Sig.
Routine BG monitoring
Yes 358 25.9 (4.6) 6-31 3.6 575 .000
No 219 24.4 (4.9)
% Chi
Do not always attend diabetes appts
Yes 374 9 n/a 4.6 1 .03
No 231 15
Model B Std. Error
Beta t Sig.
Educational level -.31 .12 -.11 -2.50 .013
Diabetes duration -.01 .00 -.07 -1.45 .147
Insulin pump/MDI .19 .15 .06 1.30 .195
Attended structured education -.00 .13 .00 -.01 .996
Routine BG monitoring -.03 .01 -.09 -1.87 .062
Recording & reflection -.01 .02 -.03 -.68 .499
Monitoring ketones .12 .03 .22 4.92 .000
Timing of QA with meals -.05 .02 -.09 -2.04 .042
Adjusting insulin to carb intake -.09 .04 -.13 -2.62 .009
Insulin omission -.24 .18 -.06 -1.36 .175
Carrying hypo treatments -.20 .16 .06 1.27 .205
Over-treating hypos -.16 .06 -.12 -2.71 .007
Changing BG levels for dr/nurse .69 .24 .13 2.85 .005
Avoiding testing when high .11 .15 .03 .71 .480
Rotating injection/infusion sites -.07 .08 -.04 -.88 .380
Attending clinic appointments .31 .21 .07 1.45 .148
Summary
• Developed questionnaire to measure self-care behaviours in type 1 diabetes that reflect current approaches to management
• Examined differences in self-care behaviours between those who have and haven’t done structured education
• Explained 23% of variance in HbA1c using some of these
behavioural variables. Why only 23%?
Acknowledgments: Thank you to all the participants
and DEN
Funder: NIHR Research for Patient Benefit Programme