The National Institute for Health and Care Excellence recommends that people with type 2 diabetes should have access to structured diabetes education. The programmes must be evidence-based, have specific learning objectives, a structured curriculum and be delivered by trained educators.
The below case study evaluates the outcomes and the impact of the EMPOWER T2n structured diabetes education programme, designed by Spirit Health Group, for people with newly diagnosed type 2 diabetes. EMPOWER T2n has been externally validated against the criteria from the National Institute for Health and Care Excellence for structured diabetes education.
A study recently published in the British Journal of Healthcare Management, collected data from 443 participants with type 2 diabetes from four Clinical Commissioning Groups who accessed the EMPOWER T2n SDE between 2015 – 2018. The results of this study demonstrate that EMPOWER T2n is associated with improvements in participants’ clinical parameters, as well as providing cost savings over a 3-year time period.
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Spirit Healthcare, Empowering Patients with Type 2 Diabetes
The National Institute for Health and Care Excellence recommends that people with type 2 diabetes should have access to structured diabetes education (SDE), with SDE able to deliver improved glycaemic control and help to prevent diabetes-related complications[i]. However, the extent and duration of the benefits may vary according to factors such as the support methods, providers and duration of the programme[ii]. This case study evaluates the outcomes and the impact of the EMPOWER T2n structured diabetes education programme.
Introduction
People with type 2 diabetes have a higher risk of adverse health outcomes than the general population, which has substantial resource implications[iii]. In the UK, expenditure on diabetes in 2010–2011 was 10% of all NHS costs, which was broadly comparable to the estimated global costs of diabetes care (11%)[iv].
The UK population is ageing, with the number of people older than 85 years expected to increase by 16.1% between 2009 and 2019[v]. 2015 Statistics from Public Health England cite a rise in obesity, both of which are risk factors for type 2 diabetes.
The management of diabetes complications accounts for around 80% of the overall costs of diabetes healthcare[vi]. Reducing the rate of type 2 diabetes complications would reduce its human and financial costs. This not only includes improving blood glucose control, but also blood pressure, lipids, and rates of smoking, all of which can reduce the long-term complications of diabetes[vii].
In the UK, the National Institute for Health and Care Excellence’s (NICE) 2016 quality statement recommended that people with type 2 diabetes should receive structured diabetes education at the time of diagnosis and that this programme must be evidence-based, have specific learning objectives, a structured curriculum and be delivered by trained educators.
Empower SDE
EMPOWER T2n was designed specifically for people with newly diagnosed type 2 diabetes. It consists of a structured curriculum delivered to 10–12 participants in a single session lasting 3–4 hours. The lesson plan encourages active and practical involvement of participants, along with the use of problem-solving models, aids identification, and planning of individualised strategies and interventions to facilitate diabetes self-management. Participants set goals, and clinical and biometric data are captured at 6 and 12-to-14 months. EMPOWER T2n has been externally validated against the criteria from the National Institute for Health and Care Excellence for structured diabetes education and is also certified according to the Quality Institute for Self-Management Education and Training (QISMET) Diabetes Self-Management Education quality standard.
EMPOWER is a fully managed programme that enables a high level of consistency and responsiveness. The entire process is managed end-to-end and employs dedicated educators and administrators, who are able to offer support and expertise to patients. The programme achieves results through:
- Making courses available when people are more likely to be available; including at weekends and evenings.
- Making courses available in a range of languages to suit the patient population who will be attending.
- Making courses available to suit people with special learning needs, including one to one sessions, and by providing a sign language interpreter for people with hearing difficulties.
- Making courses available in locations where people are more likely to seek and/or be able to access them. For example, community centres and faith centres.
- Ensuring that the access team is specialised in just that: getting people to attend.
- Using dedicated, specialist staff to deliver structured diabetes education (SDE) and deliver it consistently to the same standard every time.
- Extending SDE to an online diabetes education service for patients who prefer to receive it digitally, and extending the service to enable patients to self-refer.
EMPOWER’s approach to patient recruitment is to use specialist contact handlers who have been employed and trained to encourage people to attend.
Gill Peck, EMPOWER Clinical Lead at Spirit Healthcare comments: “Our aim is to give patients the knowledge and confidence they need to manage their condition at home. Where it has been delivered, patients have given great feedback about the course. It’s a friendly, relaxed atmosphere and has helped patients make positive changes to their lifestyle.”
Published Clinical Data
A study recently published in the British Journal of Healthcare Management collected data, subsequently aggregated and anonymised, from 443 consenting participants with type 2 diabetes from four Clinical Commissioning Groups (Leicester City; East Lancashire; East Leicestershire and Rutland; West Leicestershire) who accessed the EMPOWER T2n SDE between April 2015 and March 2018. These were also the first four Clinical Commissioning Groups to adopt the EMPOWER T2n structure.
For each participant, relevant clinical (baseline) parameters were recorded before their access to EMPOWER T2n then, if possible, at 6 and 14 months via their general practice. These clinical parameters were body weight, blood glucose levels, glycated haemoglobin levels, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol and smoking status.
For each participant, paired clinical data (excluding bodyweight) from baseline and 6 months were used to model the risk of cardiovascular events and related costs. Paired data were entered into the UK Prospective Diabetes Study Risk Engine (University of Oxford, Diabetes Trials Unit), which was validated by Kothari and Stevens et al (2002)[viii].
Risk estimates for coronary heart disease and stroke were calculated over a 3-year time frame for each subgroup based on ethnicity, gender and smoking status at baseline and 6-months, and subsequently aggregated.
The risks and costs of microvascular complications were estimated using participants’ baseline and 6-month glycated haemoglobin levels, modelled using data from a study by Baxter et al (2016)[ix], and based on an assumption that any beneficial effects observed at 14-months were maintained at these levels.
Finally, the change in medicine use from baseline was based on actual data at 14-months after the EMPOWER T2n programme, submitted by participants’ general practices, and the expected increase in medicine use over time thereafter.
Outcomes
The study data revealed that mean changes in body weight from baseline to 6 and 14-months were -1.9 kg and -2.1 kg respectively, as well as statistically significant reductions in glycated haemoglobin and total cholesterol compared to the baseline at 6 months, both of which were maintained at 14 months. In addition, there were statistically significant changes for systolic blood pressure and the proportion of patients who were smokers (at 6-months only) and high-density lipoprotein-cholesterol (at 14-months only).
Data from the 443 participants with paired data for at least one clinical parameter were entered into the UK Prospective Diabetes Study Risk Engine. Modelled changes in the rates of cardiovascular events in the base case over a 3-year time frame were −0.97% for coronary heart disease events and −0.03% for stroke.
At baseline, 44.5% of participants were taking medicines for glycaemia (including 4.4% who were taking two medicines) and 55.5% were treatment naïve. At 14-months, 63.1% of participants were medicine-free and the remaining 36.9% were taking one type of medicine. There were no participants on more than one medicine at 14-months.
Taking into account the modelled reduction in cardiovascular, microvascular and prescribing costs the overall gross savings over the 3-year timeframe were £191.25 per patient. Based on retrospective billing data from the participating Clinical Commissioning Groups, the mean cost per attendee of the EMPOWER T2n programme was £96.17.
Patient Impact
In addition to the clinical data, feedback from patients attending EMPOWER T2n is highly positive[x]. Across the different CCGs where EMPOWER is delivered, an average 99.2% of respondents (1500) would recommend the course to friends and family, based on the NHS approved Friends & Family Test score. Of the change goals that participants set for themselves on completion of the course, approximately 73% are in relation to food and 20% exercise. People also rate the programme very positively, with mean scores for the programme, materials and educators consistently scoring more than 9 out of 10.
Ashit, an EMPOWER T2n participant from Leicester, Leicestershire and Rutland, commented:
“The course has been a real plus to my diabetes. After five years of living with diabetes, this is the first time I have had good knowledge of how to live appropriately with diabetes. Don’t let diabetes control you.”
Conclusion
The clinical and economic results of this study demonstrate that EMPOWER T2n is associated with improvements in participants’ clinical parameters at 6 and 14 months. Furthermore, based on modelling of these data, it provides cost savings over a 3-year time period.
NICE recommends that people with type 2 diabetes should receive structured diabetes education at the time of diagnosis. However, the actual number of people who have accessed structured diabetes education in the UK is unclear because of uncertainty regarding the accuracy of the audit data. The reported access of newly diagnosed patients to SDE across NHS England in 2017 was 7.1%[xi]. The report contained a caveat that the 7.1% figure may be an underestimate.
In Scotland, the most recent audit of attendance rates across NHS Boards appeared to show that fewer than 5% of patients had accessed structured diabetes education[xii]. For EMPOWER T2n, the mean access rate over 2 years in the four Clinical Commissioning Groups that provided the data was 55.6%.
If the rates reported in England and Scotland were accurate, increasing access to structured diabetes education to the levels attained by EMPOWER T2n could have delivered an additional saving of over £7.7 million and 366 additional life-years over the same 3-year period in England. In Scotland, these changes may have been proportionally greater if it is assumed that the structured diabetes education programmes accessed by patients delivered the outcomes associated with EMPOWER T2n in this study and at the current comparable level of costs.
In addition, attendee feedback indicates how receptive people with diabetes are to the EMPOWER programme and how the course is helping them better understand and manage their condition.
Given the considerable benefits for patients and the wider health economy, policymakers may wish to consider how they can enhance access to structured diabetes education for people with type 2 diabetes.
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[i] Wong CKH, Wong WCW, Wan EYF et al. Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine. 2016;53(2):412–422. https://doi.org/10.1007/s12020-015-0843-z
[ii] Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926– 943. https://doi.org/10.1016/j.pec.2015.11.003
[iii] Hex N, Bartlett C, Wright D, Taylor M, Varley D. Estimating the current and future costs of type 1 and type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med. 2012;29(7):855–862. https://doi.org/10.1111/j.1464-5491.2012.03698.x
[iv] Weber C. Challenges in funding diabetes care: a health economic perspective. Expert Rev Pharmacoecon Outcomes Res. 2010;10(5):517–524. https://doi.org/10.1586/erp.10.48
[v] Stoye IFS. UK health spending. The Institute for Fiscal Studies; 2017.
[vi] Hex N, Bartlett C, Wright D, Taylor M, Varley D. Estimating the current and future costs of type 1 and type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med. 2012;29(7):855–862. https://doi.org/10.1111/j.1464-5491.2012.03698.x
[vii] Turner RC, Millns H, Neil HAW et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ. 1998;316(7134):823–828. https://doi.org/10.1136/bmj.316.7134.823
[viii] Kothari V, Stevens RJ, Adler AI et al. UKPDS 60: the risk of stroke in type 2 diabetes estimated by the UK Prospective Diabetes Risk Engine. Stroke. 2002;33(7):1776–1781.
[ix] Baxter M, Hudson R, Mahon J et al. Estimating the impact of better management of glycaemic control in adults with type 1 and type 2 diabetes on the number of clinical complications and the associated nancial bene t. Diabet Med. 2016;33(11):1575–1581. https://doi.org/10.1111/dme.13062
[x] EMPOWER feedback analysis. Data on file Spirit healthcare, Dec 2019
[xi] The Healthcare Quality Improvement Partnership (HQIP). National Diabetes Audit, 2016-17 report 1: care processes and treatment targets England and Wales. 2018. https://www.hqip.org.uk/wp-content/ uploads/2018/03/National-Diabetes-Audit-2016-17-Report-1-Care-Processes-and-Treatment-T….pdf (accessed 17 September 2019)
[xii] Scottish Diabetes Survey Monitoring Group. Scottish Diabetes Survey. NHS Scotland; 2016.