Patient-initiated versus scheduled type 1 diabetes clinics: Randomised controlled trial

This randomised controlled trial conducted in South West Jutland, Denmark, evaluated a new model of type 1 diabetes outpatient management in which patients had no scheduled clinics but could book them on demand and choose whether the visit would be with a diabetes nurse, physician or dietitian. Participants had unlimited access and a guarantee to see a nurse within 1 week and an endocrinologist within 2 weeks of the request.

HbA_1c was measured prior to each visit, as well as cholesterol and kidney function tests if these had not been measured for more than 9 months. Eye screening continued as per routine care. Participants received reminders if they went 6 months without a visit or HbA_1c test and were chased every 3 months thereafter if they were still not seen. Those who did not respond or could not be contacted were removed from the trial.

A total of 848 people were screened for eligibility (no cognitive condition that could compromise safety or judgment on the need to attend clinics; no progressive retinopathy or current foot ulcer; a 30 mmol/mol or 40 mmol/mol increase in HbA_1c in the last 3 months and 6 months, respectively; and no planned or current pregnancy). Of these, 597 were eligible and 357 agreed to participate. They were randomised 1:1 to the intervention group or to routine care (typically one scheduled clinic per year with an endocrinologist; one or two with a diabetes nurse; and dietetic clinics when appropriate).

The primary outcome was patient-reported satisfaction (5-point Likert scale on a multi-item questionnaire), with secondary clinical outcomes determined by review of participants’ health records. Over the 2-year trial, 25 people in the intervention group and 10 in the control group left the trial (withdrawal of consent, pregnancy or lack of response to clinic reminders).

Overall satisfaction with both the intervention and routine outpatient care was very high (4.59 vs 4.48), with no difference between the two. Nonetheless, there were small but significant differences between the groups in certain aspects of care, with the intervention group deriving more benefit from consultations and having fewer unnecessary visits and greater accessibility than the control group. There were no significant differences in HbA_1c, blood pressure, cholesterol or diabetes complication outcomes between the groups.

The mean number of outpatient visits over the 2 years was lower in the intervention group (4.4 vs 6.3), while the number of telephone contacts was higher (3.1 vs 2.5). Thus, use of overall staff resources was lower.

The authors conclude that patient-initiated visits instead of prescheduled visits were associated with unchanged or increased patient-reported satisfaction, with no changes in clinical outcomes. They could also free up healthcare resources for patients with more complex clinical needs.

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