This innovative pilot project delivers a targeted approach to prevention of type 2 diabetes in Wales using the criteria of HbA1c, hypertension, obesity, age >45 years, followed by a brief intervention utilising unregistered practice-based staff trained by registered dietitians in a Nutrition Skills for Life course. An all-Wales diabetes prevention pathway was developed to enable scalability of this initial primary care cluster work. Evaluation showed this to be an effective model, with 62% of participants going from pre-diabetes to normal glycaemia. The health economic review predicted the cost per QALY gained to be -£5,300.
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This was a real-world cohort intervention with participants acting as their own control. It was a new service evaluation intervention on utilising trained support workers and not a clinical trial. The pilot cluster in Afan Valley serves a population of 50,566 patients in an urban, semi-rural environment. A total of 49% of this cluster is in a most deprived area, with a further 32% in the next most deprived area. The pilot project and rollout phase inclusion criteria were: HbA1c of 42-47mmol/mol in the last 12 months; aged between 40 and75 years, plus a BMI>30kg/m2. Lifestyle intervention was offered to all patients, regardless of HbA1c results (during the rollout phase patients were excluded if HbA1c >47mmol). HbA1c was repeated approximately 6-12 months later. All Health Care Support Workers (HCSWs)/facilitators undertook the following training prior to delivering consultations: Agored Cymru accredited Level 2 Nutrition Skills for Life (3 days) delivered by the local Community Dietetics Department (part of the larger ‘Nutrition Skills For Life’ course), providing the competencies required to promote healthy eating messages; a half-day facilitator training for Pre-Diabetes Consultation. A dietitian provided the HCSW with regular support, including access to computer systems, review of the usage of the telephone script, feedback on areas that worked well and aspects to consider for future delivery, as well as verbal and written feedback prior to the next booked consultations, and quality assurance.
A total of 1,238 people had HbA1c measured at baseline and one year after intervention. Intervention was given to all people regardless of HbA1c concentration at baseline. The mean (±SD) HbA1c fell from 42.0 (5.7) to 39.4 (5.9) mmol/mol, p<0.0001. The mean time between the baseline and one-year HbA1c samples was 460 (±145) days. Out of the 1,238 patients, 751 (61%) remained in the same category after one year, while 487 (39%) had a different glucose tolerance status. Of the 487 who had changes in their glucose tolerance status, 437 (35%) improved and 50 (4%) deteriorated. A McNemar-Bowker Chi Square test showed that there was a significant difference after one year in the proportions of people with normal glucose tolerance, prediabetes and diabetes (χ2 = 308.93, df =3, p<0.0001).
Compared with baseline, at one year following the intervention there were significantly more patients with normal glucose tolerance than pre-diabetes (30%, 95% CI: 26%, 33%). There were also more with normal glucose tolerance than diabetes (20%, 95% CI: 7%, 34%) and more pre-diabetes than diabetes (12%, 95% CI: 7%, 17%). In those patients who had pre-diabetes (HbA1c 42-47 mmol/mol) (n=615) the mean (±SD) HbA1c fell from 43.8 (1.5) to 40.7 (3.0) mmol/mol, p<0.0001 a decrease of 3.12 mmol/mol. The mean time between the baseline and one-year HbA1c samples was 479 (±134) days. In the rollout phase results, mean uptake of the intervention across all four clusters was 79%. Analysis of change in HbA1c is currently ongoing. Out of 61 patients who received lifestyle intervention in November 2019 across the four clusters, four surgeries were selected to evaluate outcomes of the intervention. A total of 36 (59%) of patients re-attended for repeat HbA1c in March 2020. A total of three (5%) patients declined the repeat HbA1c as they wanted to make further changes to their diet/lifestyle first. For 22 (36%) patients the HbA1c results could not be reviewed owing to the curtailment of service caused by COVID-19. Out of the 36 patients with HbA1c measured at six months, 18 (50%) had a reduction. Of these, 12 were no longer in the prediabetes range, six (17%) stayed the same and 12 (33%) deteriorated.
Sustainability and Spread
The prevention pathway has received approval from the All Wales Diabetes Implementation Group (AWDIG) and has been shared with the Welsh Government for consideration in future clinical planning. It has been identified as a priority in Healthy Weight Healthy Wales (Welsh Government, 2019). The model is sustainable and scalable as it utilises trained support workers within primary care clusters, rather than relying overly on healthcare professionals. By supporting self-management and reducing levels of diabetes and prediabetes it will reduce demands on the NHS in the longer term. The Welsh Government is committed to prudent and value-based health care. The implementation of the All Wales pre-diabetes pathway is an ideal opportunity to undertake a programme of targeted data collection as each cluster implements it. Most of the data are collected routinely on GPs’ software hosting the electronic patient record and it would not be onerous to formalise the capture of the important outcome variables. Following the results of the pilot project, it has been included in the National Integrated Medium-Term Plan (IMTP) across health boards in Wales. Engagement meetings have been undertaken within Swansea Bay University Health Board. A business case is under development to support implementation across all eight clusters and inclusion in cluster development plans. Support for wider rollout and evaluation has been received from Directors of Public Health Wales and the programme has been endorsed by AWDIG. Discussions for roll out as part of national clinical plan for Wales have been suspended due to COVID 19. A pathway has been agreed on an All Wales basis and is being discussed at health board level for inclusion in IMTP. Prior to COVID-19, work was planned in three of the seven health-boards. The plan in the longer term is to develop central All Wales evaluation.
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