In 2013 our team published a paper showing outcomes had not improved in our clinic for young people aged 16 to 20 over the previous decade. So we made a number of changes, such as creating an age-specific structured education course and raising the profile of psychology. In doing so we’ve improved engagement with the clinic and its services, have better glycaemic control and results that are now better than the national average for this age group.
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In Sheffield patients transfer to our Young Persons (YP) clinic from the paediatric service at the age of 16, and subsequently transfer to Young Adult clinics for 20-25 year olds thereafter. As part of a research project, data on 96/118 (81%) of the 2011 YP clinic was published, stating that nothing much had changed in the preceding 10 years. It makes for sobering reading, the mean HbA1c in 2011 was 86 + 23 mmol/mol. We decided things must change - however, it was not clear what should change, as nobody else in the UK had published better data in this age group.
Our method included:
- Structured education – WICKED courses / days (from May 2012)
We designed, piloted and refined a course specifically for 16-20 year olds: Working with Insulin, Carbs, Ketones, and Exercise to manage Diabetes. In comparison to the adult DAFNE course or the children’s KICK-OFF course it aims to tackle the issues that specifically concern this age group, eg, exercise, alcohol, parties, sex etc and give them strategies for effective risk management.
- Create a one-stop-shop clinic environment (from Jan 2015)
We created an on-site phlebotomy service and 10 consulting rooms, feeling that our patients needed the opportunity to ‘own’ the new diabetes centre for two afternoons each month. The upheaval was not insignificant but it is now a young person-friendly environment, and attendance rates have improved.
- Appointment of 2nd DSN (from Jan 2015)
0.8 WTE has enabled children under 16 to meet an ‘adult’ DSN prior to admission, as she now attends their transition appointments in the Children’s hospital. This provides an important link when they do transfer their care, and means that even previously poor attenders are more likely to visit and are made to feel welcome by someone they recognise.
- Appointment of an administrator (from Sept 2015) - to update YP database, check care processes completion, produce quarterly reports of outcomes, organise clinic follow-up etc.
- Creation of a ‘five mins for diabetes insulin’ regime (from Oct 2015). We are now practicing more personalised medicine by utilising innovative insulins regimes, eg, Toujeo/Tresiba + Mixed insulin (od or bd), instead of persisting with a bd Mix or basal bolus where this is failing.
- Increased psychology input (from Jan 2016). Extra resource has now been made available by the Trust and for the first time ever we have regular psychology input at each clinic. This allows the psychologist to be introduced to young people, demystifying their role, and increasing uptake of their service.
- Greater use of Freestyle Libres as a diagnostic tool (from Jan 2016). Wearing a Libre for two weeks helps patients see and gain better understanding of the relationship of food and insulin (exercise, alcohol etc).
A consistent improvement in results has been achieved in our YP clinic (93% with type 1 diabetes) since quarter two of 2015. We have achieved a 14 mmol/mol drop in HbA1c. Our results are now better than the national average (for the best comparator available). Secondary outcomes are: improved care process completion, and greater engagement with services. We are performing above average for completion of care processes. The WICKED course has been run in three centres, Sheffield, Harrogate and Leeds. Data from 74 participants, 53.2% female, mean age 18.5, and mean duration of type 1 diabetes of 7.8 years, shows significant improvements. 12-month data is awaited, but at six months there was a statistically significant drop in HbA1c of 4.7 mmol/mol , 87.8 at baseline to 83.1 at 6 months, p=0.037. We have lowered the risks in this vulnerable age group, by better equipping them to self-manage their diabetes. We have increased screening rates for all complications, as well as reducing their long-risk of microvascular complications. The only new investment from our Trust in this clinic since 2011 is 0.05 WTE of Consultant time, the appointment of a 0.8 WTE 2nd DSN (once research funds from WICKED ended), and a part-time administrator, to take over upkeep of the database. We are very grateful for the continued support of Sanofi and Abbott.
Sustainability and Spread
The processes that we have embedded in this service are starting to be used elsewhere. As part of a research project with CLAHRC funding, WICKED has been successfully delivered in Harrogate and Leeds: we hope that the six-month improvement in HbA1c is maintained. Attendees had a significantly lower mean number of HbA1c tests than the rest of the clinic population (1.9 + 0.9 vs 2.4 + 1.2). In the year after WICKED this result switched: WICKED attendees had a significantly higher mean number of HbA1c tests than the rest of the clinic population (4.2 + 1.5 vs 3.0 + 1.1). Secondary outcomes of care process completion have also massively improved, meaning that any problems can be addressed earlier. This will lead to less irreversible microvascular diabetes complications.
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