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Laura Grant 1, Julia Lawton 2, David Hopkins 3, Jackie Elliott 4, Suzanne Lucas 5, Marie Clark 6, Ian MacLellan 7, Mark Davies 8, Simon Heller 4 & Debbie Cooke 9 1 Adelphi Values, Manchester 2 University of Edinburgh; 3 King’s College Hospital, 4 University of Sheffield, 5 Diabetes Modernisation Initiative, London, 6 University College London, 7 Ian MacLellan, DAFNE User Action Group (DUAG), 8 Belfast City Hospital, 9 University of Surrey Identifying Core Components of Structured Education Courses for Type 1 Diabetes
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Introduction From multiple fixed doses of insulin to more complex insulin adjustment Reduced risk of severe hypoglycaemia & improvements in overall HbA1c Developed in Dusseldorf, Germany Structured education programmes, DAFNE & BERTIE Existing measures did not capture the current approach to type 1 diabetes management
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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.
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Methods 83 courses on Diabetes Education Network 28 met NICE criteria + 1 from manual internet searching Reason for exclusionNumber of courses No reply3 courses Course in development4 courses Based directly on DAFNE or BERTIE6 courses Education for both type 1 and type 22 courses Course too specific e.g. newly diagnosed2 courses Not enough information2 courses Missing data on QA and audit2 courses
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Educators from 5 courses were interviewed (April-June 2011) Consensus meeting with 15 key stakeholders DAFNE, BERTIE, ICE, SELECT & DAISY Methods
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Core Components of Courses Core Components from Interviews Carbohydrate counting and insulin dose adjustment Hypoglycaemia management Group work Goal setting Challenges Empowerment
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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
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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
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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 Format 5-point Likert Scale ‘never’ to ‘always’ for majority of items
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611 adults with type 1 from 16 hospitals NMinMaxMean Std Dev HbA1c (mmol/mol)5845.415.18.21.4 IFCC584351416715.2 Age61018864714.8 Duration6006 mth732515.5
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Total NN% Attended structured educ608 Yes37662 No23238 Gender610 Male27245 Female33855 Educational level609 Below degree level37561 Undergraduate degree and higher 23438 Diabetes complications611 Yes29648 No39552
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Example Items: How did people respond? N% Never16326.7 Rarely6510.6 Sometimes487.9 Often6310.3 Always26643.5 Total60599.0 Missing99961.0 Total611100.0 I recorded my blood glucose results e.g. in a diary, on a computer
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Example Items: How did people respond? N % Never23338.1 Rarely8213.4 Sometimes7311.9 Often8213.4 Always8313.6 Total55390.5 Missing 99971.1 System518.3 Total589.5 Total611100.0 [when ill] I check my ketone levels when my blood glucose is higher than normal
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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
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EducNMean (sd)Score Range tdfSig. Routine BG monitoring Yes35825.9 (4.6)6-313.6575.000 No21924.4 (4.9) Recording & reflection Yes3739.4 (4.1)3-153.0598.003 No2278.4 (3.9) Monitoring ketonesYes3424.6 (2.6)2-103.5544.000 No2043.8 (2.5) Checking long-acting dose Yes3103.6 (0.7)2-10-3.1503.002 No1953.8 (0.5) Comparing behaviours: structured education vs. none
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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 EducNMean (sd)Score Range tdfSig. Routine BG monitoring Yes35825.9 (4.6)6-313.6575.000 No21924.4 (4.9) %Chi Do not always attend diabetes appts Yes3749n/a4.61.03 No23115
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ModelBStd. Error BetatSig. Educational level-.31.12-.11-2.50.013 Diabetes duration-.01.00-.07-1.45.147 Insulin pump/MDI.19.15.061.30.195 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.12.03.224.92.000 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-.20.16.061.27.205 Over-treating hypos-.16.06-.12-2.71.007 Changing BG levels for dr/nurse.69.24.132.85.005 Avoiding testing when high.11.15.03.71.480 Rotating injection/infusion sites-.07.08-.04-.88.380 Attending clinic appointments.31.21.071.45.148
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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%?
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d.cooke@surrey.ac.uk Laura.grant@adelphivalues.com Acknowledgments: Thank you to all the participants and DEN Funder: NIHR Research for Patient Benefit Programme
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