Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with Type 1 diabetes

To determine the impact of structured education promoting flexible intensive insulin therapy on rates of diabetic ketoacidosis, and the costs associated with emergency treatment for severe hypoglycaemia and ketoacidosis in adults with Type 1 diabetes.

Care of people with diabetes : a manual of nursing practice

Contents: Diagnosing and classifying diabetes -- Assessment and nursing diagnosis -- Monitoring diabetes mellitus -- Nutritional aspects of caring for people with diabetes -- Medication commonly used in diabetes management -- Hypoglycaemia -- Hyperglycaemia, diabetic ketoacidosis (DKA), hyperosmolar coma and lactic acidosis -- Long term complications of diabetes -- Management during surgical and investigative procedures -- Special situations and unusual conditions related to diabetes -- Diabetes and sexual health -- Diabetes in the older person -- Diabetes in children and adolescents -- Women, pregnancy, and gestational diabetes -- Psychological and quality of life issues related to having diabetes -- Diabetes education -- Discharge planning -- Community and primary care nursing and home-based care -- Complementary therapies and diabetes -- Managing diabetes in the emergency situations.

The ADKnowl: identifying knowledge deficits in diabetes care

Aims To present the ADKnowl measure of diabetes-related knowledge and evaluate its use in identifying the nature and extent of patient and health professional knowledge deficits.

Method The ADKnowl was used in a large-scale study of 789 patients (451 treated with insulin and 338 treated with tablets and/or diet) attending for annual review at one of two hospital out-patient diabetes clinics

Results Knowledge deficits were apparent in the patients. For example, 57% did not recognize the inaccuracy of the statement `fresh fruit can be eaten freely with little effect on blood glucose levels'. Seventy-five percent of patients did not know that it is advisable to trim toenails to the shape of the toe. Knowledge deficits were identified for many other areas of diabetes management, e.g. prevention of hypoglycaemia, avoidance of ketoacidosis. Sixteen health professionals at the clinics answered the same items. Contrary to recommendations, 25% of health professionals thought that fresh fruit could be eaten freely. Seventy-five percent of health professionals did not know the current recommendations for trimming toenails. As expected, HbA1c did correlate with scores from two specific items, while HbA1c did not correlate with summed ADKnowl score.

Conclusions Patient knowledge deficits were identified. Some specific knowledge deficits among health professionals may be the cause of some patient knowledge deficits. The ADKnowl is a useful tool in assessing both patient and health professional knowledge deficits and is available for use in a context of continuing evaluation.

Pilot Study of clinician attitudes to insulin pump therapy: international differences and the need for a greater understanding of the patient perspective

OBJECTIVES: To identify and survey health care professionals (HCPs) attitudes to insulin pump therapy (CSII).

METHODS: Eight specialists were interviewed to explore the attitudes and beliefs about CSII. Responses were analysed thematically and used to inform the design of a new 22-item questionnaire: the Attitudes to Pump Therapy (APT) Survey. The APT was pilottested among 95 HCPs (54% male; 75.5% diabetologists/DSNs, 13.8% general practitioners) at the International Diabetes Federation (IDF) conference, 2006. Results were analysed using non-parametric statistics with bonferroni correction.

RESULTS: Analyses of interview data identified 9 themes: biomedical, perceived control of care/diabetes, technology, quality of life, financial resources, training, education & support, suitability, and evidence-base. Items were designed to reflect these themes with responses scored on a 5-point Likert scale (strongly agree—strongly disagree). No statistically significant differences
were found by gender, HCP speciality, country (and continent) of origin or proportion of patients using CSII. Most notable differences were found in relation to gross domestic product (GDP) and the potential for pump therapy to achieve tight blood glucose control (lower GDP = more agreement: p = 0.001), and result in diabetic ketoacidosis (DKA) (lower GDP = less agreement: p < 0.005). Ranked mean scores showed a split between biomedical/clinical items (N = 11) and items concerned with patient experience (N = 11). Attitudes about biomedical/clinical issues were generally clear (i.e. for 7/11 items, the mean score was “agree”) but less decisive about patient experience (i.e. for 8/11 items, the mean score was “neither agree nor disagree”).

CONCLUSION: Few subgroup differences existed, but those that did may be explained by lack of access to treatment (directly corresponding to GDP). Clinicians’ were generally clear in their attitudes regarding biomedical aspects but less so regarding patient experience. Research focusing on patient-reported outcomes is likely to offer clinicians a greater understanding of the patients’ perspective of insulin pump therapy.

Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: the OzDAFNE program

AIMS: To evaluate structured type 1 diabetes education delivered in routine practice throughout Australia.

METHODS: Participants attended a five-day training program in insulin dose adjustment and carbohydrate counting between April 2007 and February 2012. Using an uncontrolled before-and-after study design, we investigated: HbA1c (% and mmol/mol); severe hypoglycaemia; diabetes ketoacidosis (DKA) requiring hospitalisation, and diabetes-related distress (Problem Areas in Diabetes scale; PAID), weight (kg); body mass index. Data were collected pre-training and 6-18 months post-training. Change in outcome scores were examined overall as well as between groups stratified by baseline HbA1c quartiles. Data are mean±SD or % (n).

RESULTS: 506 participants had data eligible for analysis. From baseline to follow-up, significant reductions were observed in the proportion of participants reporting at least one severe hypoglycaemic event (24.7% (n=123) vs 12.1% (n=59), p<0.001); and severe diabetes-related distress (29.3% (n=145) vs 12.6% (n=60), p<0.001). DKA requiring hospitalisation in the past year reduced from 4.1% (n=20) to 1.2% (n=6). For those with above target baseline HbA1c there was a small, statistically significant improvement (n=418, 8.4±1.1% (69±12mmol/mol) to 8.2±1.1% (66±12mmol/mol). HbA1c improvement was clinically significant among those in the highest baseline quartile (n=122, 9.7±1.1% (82±11mmol/mol) to 9.0±1.2% (75±13mmol/mol), p<0.001).

CONCLUSIONS: The proportion of participants reporting severe hypoglycaemia, DKA and severe diabetes-related distress was at least halved, and HbA1c reduced by 0.7% (7mmol/mol) among those with highest baseline levels. Structured type 1 diabetes education delivered in routine practice offers clinically important benefits for those with greatest clinical need.