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Is education the key to good diabetes management?

Colin Kenny

Education, education, education” was the famous mantra with which Tony Blair set out his agenda for office after his party’s election in 1997. Perhaps he inspired the founding committee members of the PCDS, because from its inception, education of healthcare professionals has been at the forefront of the Society’s drive to improve the care of people with diabetes. 

This aim has been fulfilled in the intervening years through the pages of this journal, its series of CPD modules, and by the many symposia and workshops hosted by the Society. Recently, an online platform for educational material has been launched. Diabetesonthenet.com is a unique website, designed to benefit healthcare professionals (HCPs) with an interest in diabetes and it aspires to become a key educational resource for HCPs seeking to help their patients by enhancing their knowledge and skills in diabetes care.

Patient education
A significant amount of research time has been devoted to the subject of patient education for people with diabetes, and Marian Carey reviews these data on page 154. Intuitively, we feel that well-informed people with diabetes could be empowered to take control of their condition and should be able to make informed decisions about diet, lifestyle and medical therapy, and engage with their HCPs in a meaningful way, ultimately resulting in improved control and life expectancy. Unfortunately, when the science of patient education is analysed, it is much harder to demonstrate that it has delivered hard outcomes in terms of HbA1c level and cardiovascular risk factor reduction, which remain resistant to most well-thought-out education interventions. 

The investigators in the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) programme have just published 3-year follow-up data (Khunti et al, 2012). This trial was based in primary care settings but unfortunately, in keeping with their reported 1-year data (Davies et al, 2008), there was no difference in biomedical or lifestyle outcomes at 3 years, although some illness beliefs demonstrated improvements. This was a well-conducted trial with good scientific underpinnings for the education interventions, delivered in groups and carefully controlled.

These results for group education in the DESMOND study align with other studies that used one-to-one motivational interviewing in diabetes but found no benefit over group education (Rosenbek Minet et al, 2011). A Canadian analysis also concluded that there was no significant difference in the clinical effectiveness between group education and one-to-one education in the management of type 2 diabetes (Canadian Agency for Drugs and Technologies in Health, 2011). The Expert Patient Education Versus Routine Treatment (X-PERT) programme reported significant improvements in HbA1c level at 14 months in a population with established type 2 diabetes, although long-term results have not yet been reported (Deakin et al, 2006). It is interesting to note that Dose Adjustment For Normal Eating (DAFNE) training for people with type 1 diabetes, also delivered in a group setting, has shown a significant improvement in outcomes (Shearer et al, 2004).

Those of us who believe in the benefit of patient education and are regularly referring individuals for educational sessions in localities where they are available are faced with a dilemma. Are these referrals evidence-based and worthwhile? It would appear that few of these educational interventions can promise hard outcomes in terms of important Quality and Outcomes Framework (QOF)-related biochemical markers, although X-PERT may be better than some. Softer outcomes are unfortunately intangible, although many people report increased confidence in everyday management of their diabetes and report enjoying talking to other individuals and comparing strategies in group teaching settings. 

Recently, NICE guidance has made “structured education to every person and/or their carer at and around the time of diagnosis” a central component of care (NICE, 2011), although this is not yet part of QOF. Given the resource implications of such education courses, providers will be looking at these interventions carefully, particularly as the population of people with newly diagnosed diabetes rises. We may have to accept that education delivers softer outcomes that may empower people with diabetes to adhere to their treatment regimen and indirectly influence HbA1c results – a strategy that sits alongside delivering the hard biomedical outcomes that are fundamental to contemporary general practice care.

Healthcare professional education
Last year, a multiprofessional group examined the status of HCPs’ education in diabetes (Walsh et al, 2011) and agreed that to meet the challenge of providing high-quality diabetes care, enhanced levels of knowledge and skills were needed. The group examined the availability of education for those within contemporary healthcare systems who may directly or indirectly encounter people with diabetes. They were particularly interested to see if these facilitated the key competencies needed in diabetes care. By using targeted searches the group identified the core content of any course of study as: glucose metabolism and physiological response; epidemiology; diabetes management; diabetes emergencies; living with diabetes; the context of care delivery; and research and innovation.

The group concluded that no single body in the UK could accredit existing education courses, or commission courses if gaps were identified. Ideally, any course should be clearly mapped to required competencies. They felt that there should be clear and transparent pathways for all HCPs to undergo education that was relevant to their working lives, but also gave them the appropriate skill-set to enable their contact with people with diabetes to be high quality, productive and safe.

Diabetesonthenet.com
It is against this background of a clear need for HCPs to improve their access to high-quality educational resources that the Society has been among the parties encouraging the development of Diabetesonthenet.com (a new overarching website providing free access to diabetes-specific news, events and journal content from the publishers of this journal). The project has been almost 2 years in development and has received considerable input from the Committee and a variety of other HCPs working in diabetes and beyond. The website offers HCPs access to a unique resource of contemporary diabetes news and research. The PCDS CPD modules are hosted in a CPD Centre, which has incorporated reflection and action planning steps to keep a record of personal development.

This website deserves to be the point of first internet contact for those interested in developing their diabetes knowledge, to give them confidence in consultations and, through this, to achieve key competencies and enhance skills in managing complex problems. 

Conclusion
Those of us who are passionate about both education and high-quality diabetes care are only too aware of the challenges of delivering this successfully across the five nations of the UK and Ireland. HCP education in diabetes remains uncoordinated and lacking in rigorous quality control. Paradoxically, as the “epidemic” of diabetes gathers pace, there has never been a more important time for high-quality diabetes education. We are delighted to welcome Diabetesonthenet.com as an important and developing resource for those of us wanting to enhance our diabetes knowledge, and take our skills to the higher level of competence that our patients and employers expect.

Education, education, education” was the famous mantra with which Tony Blair set out his agenda for office after his party’s election in 1997. Perhaps he inspired the founding committee members of the PCDS, because from its inception, education of healthcare professionals has been at the forefront of the Society’s drive to improve the care of people with diabetes. 

This aim has been fulfilled in the intervening years through the pages of this journal, its series of CPD modules, and by the many symposia and workshops hosted by the Society. Recently, an online platform for educational material has been launched. Diabetesonthenet.com is a unique website, designed to benefit healthcare professionals (HCPs) with an interest in diabetes and it aspires to become a key educational resource for HCPs seeking to help their patients by enhancing their knowledge and skills in diabetes care.

Patient education
A significant amount of research time has been devoted to the subject of patient education for people with diabetes, and Marian Carey reviews these data on page 154. Intuitively, we feel that well-informed people with diabetes could be empowered to take control of their condition and should be able to make informed decisions about diet, lifestyle and medical therapy, and engage with their HCPs in a meaningful way, ultimately resulting in improved control and life expectancy. Unfortunately, when the science of patient education is analysed, it is much harder to demonstrate that it has delivered hard outcomes in terms of HbA1c level and cardiovascular risk factor reduction, which remain resistant to most well-thought-out education interventions. 

The investigators in the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) programme have just published 3-year follow-up data (Khunti et al, 2012). This trial was based in primary care settings but unfortunately, in keeping with their reported 1-year data (Davies et al, 2008), there was no difference in biomedical or lifestyle outcomes at 3 years, although some illness beliefs demonstrated improvements. This was a well-conducted trial with good scientific underpinnings for the education interventions, delivered in groups and carefully controlled.

These results for group education in the DESMOND study align with other studies that used one-to-one motivational interviewing in diabetes but found no benefit over group education (Rosenbek Minet et al, 2011). A Canadian analysis also concluded that there was no significant difference in the clinical effectiveness between group education and one-to-one education in the management of type 2 diabetes (Canadian Agency for Drugs and Technologies in Health, 2011). The Expert Patient Education Versus Routine Treatment (X-PERT) programme reported significant improvements in HbA1c level at 14 months in a population with established type 2 diabetes, although long-term results have not yet been reported (Deakin et al, 2006). It is interesting to note that Dose Adjustment For Normal Eating (DAFNE) training for people with type 1 diabetes, also delivered in a group setting, has shown a significant improvement in outcomes (Shearer et al, 2004).

Those of us who believe in the benefit of patient education and are regularly referring individuals for educational sessions in localities where they are available are faced with a dilemma. Are these referrals evidence-based and worthwhile? It would appear that few of these educational interventions can promise hard outcomes in terms of important Quality and Outcomes Framework (QOF)-related biochemical markers, although X-PERT may be better than some. Softer outcomes are unfortunately intangible, although many people report increased confidence in everyday management of their diabetes and report enjoying talking to other individuals and comparing strategies in group teaching settings. 

Recently, NICE guidance has made “structured education to every person and/or their carer at and around the time of diagnosis” a central component of care (NICE, 2011), although this is not yet part of QOF. Given the resource implications of such education courses, providers will be looking at these interventions carefully, particularly as the population of people with newly diagnosed diabetes rises. We may have to accept that education delivers softer outcomes that may empower people with diabetes to adhere to their treatment regimen and indirectly influence HbA1c results – a strategy that sits alongside delivering the hard biomedical outcomes that are fundamental to contemporary general practice care.

Healthcare professional education
Last year, a multiprofessional group examined the status of HCPs’ education in diabetes (Walsh et al, 2011) and agreed that to meet the challenge of providing high-quality diabetes care, enhanced levels of knowledge and skills were needed. The group examined the availability of education for those within contemporary healthcare systems who may directly or indirectly encounter people with diabetes. They were particularly interested to see if these facilitated the key competencies needed in diabetes care. By using targeted searches the group identified the core content of any course of study as: glucose metabolism and physiological response; epidemiology; diabetes management; diabetes emergencies; living with diabetes; the context of care delivery; and research and innovation.

The group concluded that no single body in the UK could accredit existing education courses, or commission courses if gaps were identified. Ideally, any course should be clearly mapped to required competencies. They felt that there should be clear and transparent pathways for all HCPs to undergo education that was relevant to their working lives, but also gave them the appropriate skill-set to enable their contact with people with diabetes to be high quality, productive and safe.

Diabetesonthenet.com
It is against this background of a clear need for HCPs to improve their access to high-quality educational resources that the Society has been among the parties encouraging the development of Diabetesonthenet.com (a new overarching website providing free access to diabetes-specific news, events and journal content from the publishers of this journal). The project has been almost 2 years in development and has received considerable input from the Committee and a variety of other HCPs working in diabetes and beyond. The website offers HCPs access to a unique resource of contemporary diabetes news and research. The PCDS CPD modules are hosted in a CPD Centre, which has incorporated reflection and action planning steps to keep a record of personal development.

This website deserves to be the point of first internet contact for those interested in developing their diabetes knowledge, to give them confidence in consultations and, through this, to achieve key competencies and enhance skills in managing complex problems. 

Conclusion
Those of us who are passionate about both education and high-quality diabetes care are only too aware of the challenges of delivering this successfully across the five nations of the UK and Ireland. HCP education in diabetes remains uncoordinated and lacking in rigorous quality control. Paradoxically, as the “epidemic” of diabetes gathers pace, there has never been a more important time for high-quality diabetes education. We are delighted to welcome Diabetesonthenet.com as an important and developing resource for those of us wanting to enhance our diabetes knowledge, and take our skills to the higher level of competence that our patients and employers expect.

REFERENCES:

Canadian Agency for Drugs and Technologies in Health (2011) Education Classes for Diabetes Management: A Review of the Comparative Clinical and Cost-Effectiveness. Canadian Agency for Drugs and Technologies in Health, Ottawa. Available at: http://bit.ly/KuamP8 (accessed 18.05.12)
Davies MJ, Heller S, Skinner TC et al (2008) BMJ 336: 491–5
Deakin TA, Cade JE, Williams R, Greenwood DC (2006) Diabet Med 23: 944–54
Khunti K, Gray LJ, Skinner T et al (2012) BMJ 344: e2333
NICE (2011) Diabetes in Adults Quality Standard. NICE, London. Available at: http://bit.ly/supP8P (accessed 18.05.12)
Rosenbek Minet LK, Wagner L, Lønvig EM et al (2011) Diabetologia 54: 1620–9
Shearer A, Bagust A, Sanderson D (2004) Diabet Med 21: 460–7
Walsh N, George S, Priest L et al (2011) Diabet Med 28: 1501–7

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