X-PERT structured education programmes improve control in diabetes

The NHS reforms endorse the strapline “no decision about me, without me” and call for quality, innovation, productivity and prevention (Department of Health [DH], 2010). These reforms are an opportunity for healthcare organisations to improve the quality of services they deliver and, in doing so, improve the health and well-being of the nation. NHS efficiency savings have been proposed, aiming for a £15–20 billion saving between 2011 and 2014, and it is anticipated that these savings can only be achieved through quality improvements and advances in innovation (Nicholson, 2009).

The estimated prevalence of diabetes (diagnosed and undiagnosed) in people aged 16 and over in England is 7.4% (Association of Public Health Observatories, 2010). The prevalence of diabetes has now reached 3.75 million in the UK, with 2.9 million people being aware that they have the condition (Diabetes UK, 2012), adding to stress on the healthcare budget at a time of financial stringency.

Diabetes is a costly condition, taking up 10% of the NHS budget, and a significant part of this cost is attributable to inpatient care and treating diabetes-related conditions (DH, 2012). Intensifying glycaemic control has been shown to reduce the onset of diabetes-related complications, but there is emerging evidence that achieving target blood glucose levels through prescribed diabetes medication may cause unwanted side effects or complications (Skyler et al, 2009). Although prescription costs for type 2 diabetes have increased by 89% between 1997 and 2007, glycaemic control (HbA_1c) has only improved by 0.1 percentage points, from 8.8% (73 mmol/mol) to 8.7% (72 mmol/mol; Currie et al, 2010).

The clinical and cost-effectiveness of structured education to improve diabetes self-management has been established (Norris et al, 2001; Deakin et al, 2005; Jacobs-van Der Bruggen et al, 2009). NICE (2008a) guidance states that all people at risk of, and diagnosed with, diabetes should have an opportunity to attend a structured patient education programme with annual follow-up. Up to 90% of people will access structured education if offered as an integral part of diabetes treatment and management (NICE, 2008b). The NICE quality standard defines personalised advice on nutrition and physical activity and structured education as specific quality statements (NICE, 2011). In England, 85% of primary care trusts (PCTs) report that they have contracts to provide structured education for people with newly diagnosed type 2 diabetes, and 76% report that these programmes are NICE compliant; however, only 66% of PCTs review whether all people newly diagnosed are offered structured education, and 48% of specialist providers report that they do not have the capacity to meet demand (Innove, 2012).

X-PERT Health’s structured education programmes have been shown to improve clinical, lifestyle and psychosocial outcomes in people with newly diagnosed and existing diabetes (Deakin et al, 2006). Additionally, they have been  demonstrated to be a cost-effective strategy in the treatment and management of diabetes (Deakin, 2011a), costing as little as £15 per participant (Deakin, 2011b). The X-PERT Prevention of Diabetes (X-POD) programme was launched at the Diabetes UK Annual Professional Conference in March 2012 to meet the needs of those at risk of developing the condition.

What is X-PERT education?
X-PERT structured education programmes are delivered over 6 weeks by healthcare professionals who have trained as educators. The programmes are designed to increase participants’ knowledge, skills and confidence to make informed decisions and self-manage their condition.

The X-PERT philosophy is supported by: discovery learning (Bruner, 1961); problem-based learning (Barrows, 1996); facilitative learning (Rogers, 1959); experiential learning (Kolb, 1984); the principles of adult learning (Brookfield, 2001); group education (Deakin et al, 2005); the patient-centred approach (Lacroix and Assal, 2003); and the empowerment model (Anderson and Funnell, 2000).

The X-PERT programmes include X-PERT Diabetes, X-PERT Insulin and X-POD. These structured education programmes deliver a range of topics to help people understand:

• Health and disease.
• Tablets and insulin.
• Food, nutrients and digestion.
• What health results mean.
• The benefit of physical activity.
• Weight management.
• The impact of blood glucose, blood pressure and blood cholesterol levels on long-term health.
• Self-management of diabetes.
• Special considerations regarding travel, insurance, driving and work.

Each programme consists of six weekly sessions lasting 2.5 hours; Table 1 outlines an overview of X-PERT Health’s structured education programmes.

The X-PERT programmes have been shown in a randomised controlled trial to improve clinical, lifestyle and psychosocial outcomes in white Caucasian and South Asian people with newly diagnosed and existing diabetes (Deakin et al, 2006). They have also been demonstrated to be a cost-effective strategy in the treatment and management of diabetes; it costs as little as £15 per participant and has the potential to reduce the NHS prescription bill by £367 million per year (Deakin, 2011a).

Structured education audit
Audit standards have been identified from the published randomised controlled trial and national targets (Deakin et al, 2006; NICE, 2008a). The following outcomes are recorded at baseline, 6 months and annually thereafter and entered onto the audit database: attendance, HbA_1c (mmol/mol), body weight (kg), body mass index (kg/m²), waist circumference (cm), blood pressure (systolic and diastolic; mmHg), lipid profile (total, LDL, HDL and triglyceride cholesterol; mmol/L) and prescribed diabetes medication. A medication increase is defined as commencing on, or an increase in oral hypoglycaemic agents (OHAs) or insulin; a medication decrease is defined as a reduction in the type or quantity of OHAs or the number of units of insulin injected. The audit report presents the number of participants for each outcome and the mean value at each time point. 

Educators also enter how many of the sessions were attended. The audit report demonstrates that 95% of participants attended at least one session, and 81% attended four or more sessions. Participant satisfaction is recorded by participants completing an evaluation questionnaire that scores the structured education programme for enjoyment, usefulness, degree of self-management obtained and impact on living with diabetes. The mean satisfaction score for each programme is calculated from the total questionnaire scores and entered onto the database; the mean participant satisfaction score was 95%.

Participant empowerment is assessed at baseline, 6 weeks and annually thereafter by participants completing a validated questionnaire (Anderson et al, 2003). The mean empowerment score is calculated for the group from individual questionnaires and is entered onto the audit database. The audit report provides the mean score for each time point and the percentage change from baseline, which is currently an increase in empowerment of 23% post-education and 26% at 1 year.

There are 57 licensed X-PERT organisations or clusters of organisations, and 40 (70%) have entered audit data. In order to ensure that the national implementation of the X-PERT programme continues to be clinically and cost-effective, continuous audit is conducted. Audit reports can be generated for any time period per programme, per educator, per organisation or for all participants and present the number of participants (n) and the mean values for each outcome. A recent audit of 23 610 people with diabetes further validates the X-PERT approach by demonstrating excellent attendance rates and highly significant results in line with the clinical trial results at 6 months and 1 and 2 years. Table 2 presents the audit results for all centres.

Conclusion
Type 2 diabetes is considered a progressive disease characterised as a triad of insulin resistance, beta-cell dysfunction and impaired hepatic glucose production (Ramlo-Halsted and Edelman, 2000). The benefits of improved glycaemic control in reducing the onset of secondary diabetes complications has been established (Stratton et al, 2000), and it has previously been accepted that people will require increased prescribed diabetes medication over time to obtain target glycaemic control (UK Prospective Diabetes Study [UKPDS] Group, 1998). However, X-PERT Health suggests that the same results can be achieved through lifestyle and self-management; X-PERT Health’s structured education programmes lead to health improvements and a reduced requirement for diabetes medication, which significantly improves individuals’ quality of life and reduces the cost to the NHS. It has always been assumed that diabetes is a progressive condition (UKPDS Group, 1998), but there is now emerging evidence that this assumption is not true; if individuals make significant lifestyle changes, they can indeed halt and even reverse the progression of the condition (Pastors et al, 2002; Coppell et al, 2010; Andrews et al, 2011; Deakin et al, 2011a; Lim et al 2011).