Achieving good glycaemic outcomes for young adults with diabetes remained a challenge at the Royal Liverpool University Hospital. Towards the end of 2015, patient engagement was poor with high non-attendance in clinics. Through a process of team briefings and service user feedback, a number of changes were made, including a clinic restructure. Outcomes at the end of 2016 showed a significantly lower non-attendance rate, quadrupled rates of patients achieving HbA1c <53mmol/mol, very positive user satisfaction and financial gains.
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Towards the end of 2015, the immediate challenges faced by the young adult diabetes service at the Royal Liverpool University Hospital were a high clinic ‘did-not-attend’ (DNA) rate (47%), rising admission rates of diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH) in this age group (15% and 6%), and a lack of data analysis to measure specific outcomes of this clinic cohort, as the National Diabetes Audit (NDA) measured outcomes of all people with type 1 (T1D) and type 2 (T2D) diabetes. Using results of local audits and feedback from a subsequent multidisciplinary team (MDT) and patient focus group meeting, the young adult diabetes clinic was redesigned with a vision to have a structured, patient-led, flexible clinic service.
The service redesign included the following:
- A weekly joint-multidisciplinary team (MDT) ‘Young Adult Diabetes Clinic’ with the consultant, diabetes specialist nurse and specialist dietician, lasting at least 30 minutes per patient, with four monthly follow-up appointments. This was different from the individual appointments made earlier
- Development of a clinic pathway, defining the young-adult cohort (19-25 years), services offered, follow-up arrangements and transfer to the >25 years adult clinic under the same consultant
- Flexible drop-in sessions with diabetes specialist nurse and dietician, in between planned clinic appointments, for structured education, self-management advice and carbohydrate-counting revision
- Team information leaflets with contact details (telephone and email) and guide to useful diabetes related online resources. Patients are encouraged to email data, questions and feedback regularly
- Telephonic reminders to patients of the upcoming clinic appointment, in addition to texts already sent, by the clinic clerk and department secretary
- Pre-clinic questionnaire for patients to fill prior to entering the consultation room, highlighting the most important lifestyle and diabetes-related topics to discuss, with an aim to make the consultation more focused.
LIVT1D - Liverpool’s first peer-support group for adults with T1D, was established by people attending the young adult diabetes clinic. The aim was to create a platform for people with type 1 diabetes to be supported, encouraged and empowered by peers, family members and healthcare professionals, outside the clinic set-up. It was established following a focus group meeting of the MDT and 10 people with type 1 diabetes, attending the young adult diabetes clinic, held at the University of Liverpool campus in September 2016. A steering group was formed, which included three patients, a consultant diabetologist and a senior diabetes specialist nurse. In addition, a closed Facebook group and a Twitter handle were created and managed by people attending the young adult clinic, with an aim to reach out to anyone with type 1 diabetes for support and empowerment, while ensuring privacy and highlighting that this was not a substitute to clinical care at the hospital.
Using the information from the clinic database spreadsheet, we analysed demographics and outcomes in a 24-month period, from January 2015 (12 months pre-clinic redesign) to December 2016 (12 months post-clinic redesign). 123 patients in total were identified in the clinic cohort. Diabetes diagnosis of all patients included type 1 diabetes (92%), type 2 diabetes (7%) and MODY (1%), with mean duration of diabetes of 13.7 ± 6.6 years. Majority of these patients (85%) were on a basal-bolus insulin regime. In 2016, 89 patients (versus 76 in 2015) attended the MDT clinic appointments, with the total number of attendances for the year being 192 (v. 129). More significantly, 65% (v. 42%, p=0.001) of patients attended two or more clinic appointments and the DNA rate for the clinic was reduced to 32% (v. 47%, p=0.03). After adjusting for the number of appointments and DNA rate, financial gains made in 2016 were £3,663. Mean HbA1c for the clinic was reduced at 74 ± 22mmol/mol (v. 76 ± 20mmol/mol, p=0.91). 12.3% of patients (v. 2.6%, p=0.03) had an HbA1c at the NICE recommended target of <53mmol/mol and 25% (v. 14%, p=0.17) of patients had an HbA1c <58mmol/mol. Reductions in admission rates for DKA and SH at the Royal Liverpool University Hospital for this patient cohort, in 2016, were seen with 8% (v. 15%, p=0.12) and 2% (v. 4%, p=0.40), respectively. 11 fewer admissions for DKA and SH were recorded in 2016, totalling a financial saving of £9,336.
Sustainability and Spread
The positivity generated by LIVT1D in a short space of time and its speculated impact on clinical outcomes will allow the team to share its experiences with a wider audience through partnerships with neighbouring Trusts, similar peer-support groups and local universities in the North West and nationally. Feedback from this group along with clinical outcomes will be presented as a business case for funding peer support through the local CCG and potential transformational funds.
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