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NICE-backed self-care course ‘has little effect on diabetes outcomes’

Educating patients to self-manage their diabetes has little effect long-term on their lifestyle choices or their health outcomes, concludes a major UK study.

The analysis of the first UK national education programme for people with Type 2 diabetes found no difference in HbA1c levels, physical activity or smoking in a group given a full day of advice on self-care of diabetes soon after diagnosis, compared with controls.

 The finding casts doubt over the validity of NICE guidelines that recommend all patients diagnosed with diabetes are given ‘structured education' around the time of diagnosis, and annually thereafter, and prompted one expert to call for a return to traditional GP care.

The advice was partly based on the cost-effectiveness of the DESMOND study at one-year – which had a mean cost of £82 per person – but that is now under scrutiny given the diminishing effect of the programme over time.

The analysis included 824 patients from over 200 general practices that were randomised either to a one-day group education programme looking at lifestyle change and their ‘personal risk factors' or usual GP care.

Three years later HbA1c decreased in both groups, but a change of -1.32 in the intervention group was not significantly different from the -0.81 change in the controls.

The 10-year coronary heart disease risk was also decreased in both groups, but with no significant difference between groups, with a reduction of -7.80% for the intervention compared to -6.49% in the control group.

There were no significant differences in either the proportion of non-smokers, or the level of physical activity between groups.

Study leader Professor Khamlesh Khunti, a GP in Leicester and professor of primary care diabetes and vascular medicine at the University of Leicester, said the study showed some improvement in illness beliefs, but that regular advice was needed rather than a one-off session.

He said:  ‘It demonstrates that these patients need annual advice – a session every year, rather than a one-off programme when they are diagnosed – in order to see continued benefits with regard to lifestyle and biomedical outcomes.'

But Dr Alan Begg, a GP in Montrose and co-editor of the Practical Diabetes journal, queried whether the programme was cost-effective.

He said: ‘Previous research assumed that lifestyle change, such as smoking cessation, could only be maintained if the intervention continues.

‘Will educational programmes be commissioned if there are only "soft" educational outcomes rather than measurable behavioural change or improvements in morbidity and mortality?'

In an editorial on the study, Professor Frank Snoek, professor of medical psychology at the VU University Medical Centre, the Netherlands, said the study showed why GP care was so important.  He said: ‘Perhaps we should focus again on the setting of appropriate targets by professionals who care for patients with diabetes and the patients themselves.'

BMJ 2012, online 26 April

http://www.bmj.com/content/344/bmj.e2333?view=long&pmid=22539172

 

BOX: Change in outcomes

                                                       Intervention group                    control group

HbA1c                                                   -1.32                                                      -0.81

Body weight                                       -1.75                                                      -1.44

LDL-cholesterol                                 -0.92                                                      -0.84

BMJ 2012, online 26 April

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