Healthcare professionals' experiences in identifying and supporting mental health problems in adults living with type 1 diabetes mellitus: A qualitative study.

AIMS: To explore perspectives and experiences of healthcare professionals in the identification and support provision of mental health problems in adults living with type 1 diabetes. METHODS: Using a qualitative research design, 15 healthcare professionals working in the United Kingdom were individually interviewed using a semi-structured interview schedule. Data were analysed using reflexive inductive thematic analysis. RESULTS: Four themes were identified relating to barriers: time, knowledge, relationship between services and stigma. Three themes were identified relating to facilitators: education, communication and appropriate tools and services. CONCLUSIONS: This research emphasises the need for educational tools to improve the skills and competency of healthcare professionals in identifying mental health problems in people with type 1 diabetes, highlighting practical and theoretical implications for healthcare improvements and the necessity for additional research to design care pathways that better support this population, in which all healthcare professionals are aware of.

Home monitoring of haemoglobin A1c in diabetes: A systematic review and narrative synthesis on accuracy, reliability and patient acceptability.

AIM: In the UK people with diabetes who do not attend annual review appointments often have higher haemoglobin A1c (HbA1c ) levels. We aim to determine the acceptability of self-collected posted capillary blood samples, and if they produce accurate and reliable HbA1c results. METHODS: We include adult studies comparing capillary blood to venous blood for measuring HbA1c . We exclude methods not suitable for postage. Electronic databases of MEDLINE, Embase, CINAHL, Web of Science, Google Scholar and OpenGrey were searched from inception to September 2021, as well as relevant conference abstracts. Two reviewers performed study selection, data extraction and risk of bias assessment independently. Narrative synthesis was performed. RESULTS: Our search retrieved 3747 records. Following de-duplication and screening 30 articles were included. The mean difference (MD) and limits of agreement (LoA) between capillary and venous HbA1c were smaller and narrower respectively when micro/capillary tubes (micro/cap) were used for capillary blood storage compared to dried blood spots (capDBS) (micro/cap MD range -0.4 to 1.4 mmol/mol vs. capDBS MD range -4.3 to 7.2 mmol/mol, micro/cap LoA width 2.4 to 6 mmol/mol vs. capDBS LoA width 11.7 to 16.8 mmol/mol). After using self-collection kits, 83%-96% of participants reported satisfaction, 87%-99% found it easy and 69%-94% reported they would use it again. CONCLUSION: Microtubes/capillary tubes look promising as a method of self-collecting and posting capillary blood samples for the measurement of HbA1c based on the accuracy and reliability findings presented. DBS samples demonstrated comparatively poorer accuracy. Data on acceptability were limited and further research is needed.

Population stratification in type 2 diabetes mellitus: A systematic review.

AIMS: There is increasing interest in using stratification in type 2 diabetes to target resources, individualise care and improve outcomes. We aim to systematically review and collate literature that has utilised population stratification methods in the study of adults with type 2 diabetes; and to describe and compare stratification methodologies, population characteristics, variables used to stratify and outcome variables. METHODS: The MEDLINE, EMBASE, CINAHL and Cochrane databases were searched from inception to July 2020. Studies included adults with type 2 diabetes using population stratification methods. The review protocol was registered on PROSPERO (ID: CRD42020206604) and conducted in line with PRISMA guidance. Extracted data included study aims; study setting (primary or secondary care); population characteristics; stratification variables and outcomes; and methodological approach to stratification. RESULTS: Across 348 included studies, there were a total of 10,776,009 participants with a mean age of 61.0 years (SD 5.94). 6.7% of studies used data-driven methods and the rest employed expert-driven approaches using pre-defined stratification criteria. The commonest variable used to stratify populations was HbA1c (n = 57, 16.4%); few studies stratified using clinically important non-traditional variables such as health behaviours and beliefs. CONCLUSIONS: Most studies performing population stratification in type 2 diabetes used expert-driven approaches with the aim of predicting outcomes in glycaemic control, mortality and cardiovascular complications. We identified relatively few studies using data-driven approaches, which offer opportunities generate hypotheses beyond current expert knowledge. We describe important research gaps including stratification with regard to disease remission.

The WISDOM self-management intervention: A cost-effectiveness analysis to support the transformation of type 2 diabetes care in England.

OBJECTIVES: To assess the cost-effectiveness of the WISDOM self-management intervention for type 2 diabetes compared with care as usual. DESIGN: We performed a difference-in-differences analysis to estimate differences in risk factors for diabetes complications between people in the WISDOM group (n = 25, 276) and a control group (n = 15, 272) using GP records. A decision analytic model was then used to extrapolate differences in risk factors into costs and outcomes in the long term. SETTING: Participating GP practices in West Hampshire and Southampton, UK. PARTICIPANTS: All people diagnosed with type 2 diabetes between January 1990 and March 2020 (n = 40,548). OUTCOMES: Diabetes-related complications, quality-adjusted life years (QALYs) and costs to the English National Health Service at 5 years and lifetime. INTERVENTIONS: The WISDOM intervention included risk stratification, self-management education programme to professionals and people with type 2 diabetes, and monitoring of key treatment targets. RESULTS: WISDOM was associated with less atrial fibrillation [p = 0.001], albuminuria [p = 0.002] and blood pressure [p = 0.098]. Among all people in the intervention group, WISDOM led to 51 [95%CI: 25; 76] QALYs gained and saved £278,036 [95%CI: -631,900; 176,392] in the first 5 years after its implementation compared with care as usual. During those people' lifetime, WISDOM led to 253 [95%CI: 75; 404] QALYs gained and cost saving of £126,380 [95%CI: -1,466,008; 1,339,628]. The gains in QALYs were a result of reduced diabetes-related complications through improved management of the associated risk factors. CONCLUSIONS: The WISDOM risk-stratification and education intervention for type 2 diabetes appear to be cost-effective compared to usual care by reducing diabetes complications.

Liraglutide and the management of overweight and obesity in people with severe mental illness: qualitative sub-study.

BACKGROUND: People with severe mental illness are two to three times more likely to be overweight or have obesity than the general population and this is associated with significant morbidity and premature mortality. Liraglutide 3 mg is a once daily injectable GLP-1 receptor agonist that is licensed for the treatment of obesity in the general population and has the potential to be used in people with severe mental illness. AIMS: To record the expectations and experiences of people with schizophrenia, schizoaffective disorders or first episode psychosis taking daily liraglutide 3 mg injections in a clinical trial for the treatment of obesity. To seek the views of healthcare professionals about the feasibility of delivering the intervention in routine care. METHODS: Qualitative interviews were undertaken with a purposive sub-sample of people with schizophrenia, schizoaffective disorders or first episode psychosis with overweight or obesity who were treated with a daily injection of liraglutide 3 mg in a double-blinded, randomised controlled pilot study evaluating the use of liraglutide for the treatment of obesity. Interviews were also conducted with healthcare professionals. RESULTS: Seventeen patient participants were interviewed. Sixteen took part in the baseline interview, eight completed both baseline and follow-up interviews, and one took part in follow-up interview only. Mean interview duration was thirteen minutes (range 5-37 min). Despite reservations by some participants about the injections before the study, most of those who completed the trial reported no challenges in the timing of or administering the injections. Key themes included despondency regarding prior medication associated weight gain, quality of life impact of weight loss, practical aspects of participation including materials received and clinic attendance. Healthcare professionals reported challenges with recruitment, however, overall it was a positive experience for them and for participants. CONCLUSION: Liraglutide appears to be an acceptable therapy for obesity in this population with limited side effects. The quality of life benefits realised by several intervention participants reinforce the biomedical benefits of achieved weight loss.

Introduction to the development of complex interventions.

Healthcare interventions are complex, but have the potential to deliver more efficient, cost-effective care and improved health outcomes. Careful attention must be paid to their early planning and development to minimise research waste or interventions that fail to deliver what they set out to achieve. The Medical Research Council provides guidance to help intervention developers, encouraging an explicit and iterative approach. This article describes the Medical Research Council's guidance and introduces two frequently used tools that further support the process of intervention design.

The use of liraglutide 3.0 mg daily in the management of overweight and obesity in people with schizophrenia, schizoaffective disorder and first episode psychosis: Results of a pilot randomized, double-blind, placebo-controlled trial.

AIM: To investigate the feasibility and acceptability of using liraglutide 3.0 mg daily in the management of overweight and obesity in people with schizophrenia, schizoaffective disorder and first episode psychosis. MATERIALS AND METHODS: A double-blind, randomized, placebo-controlled pilot trial took place in mental health centres and primary care within Southern Health NHS Foundation Trust. The participants were adults with schizophrenia, schizoaffective or first-episode psychosis prescribed antipsychotic medication who were overweight or obese. The intervention was once-daily subcutaneous liraglutide or placebo, titrated to 3.0 mg daily, for 6 months. The primary outcomes were recruitment, consent, retention and adherence. The secondary exploratory outcomes were weight, HbA1c and Brief Psychiatric Rating Scale. RESULTS: Seven hundred and ninety-nine individuals were screened for eligibility. The most common reasons for exclusion were ineligibility (44%) and inability to make contact (28%). The acceptance rate, as a proportion of all eligible participants, was 12.2%. The most commonly stated reason why eligible candidates declined to participate related to the study-specific medication and protocol (n = 50). Forty-seven participants were randomized, with 79% completing the trial. Participants in the liraglutide arm lost a mean 5.7 ± 7.9 kg compared with no significant weight change in the placebo group (treatment difference -6.0 kg, p = .015). Body mass index, waist circumference and HbA1c were reduced in the intervention group. CONCLUSIONS: This study supports the need for a larger randomized controlled trial to evaluate the use of liraglutide (maximum dose 3.0 mg daily) in the management of obesity in people with severe mental illness.

Completion of annual diabetes care processes and mortality: A cohort study using the National Diabetes Audit for England and Wales.

AIM: To conduct an analysis to assess whether the completion of recommended diabetes care processes (glycated haemoglobin [HbA1c], creatinine, cholesterol, blood pressure, body mass index [BMI], smoking habit, urinary albumin, retinal and foot examinations) at least annually is associated with mortality. MATERIALS AND METHODS: A cohort from the National Diabetes Audit of England and Wales comprising 179 105 people with type 1 and 1 397 790 people with type 2 diabetes, aged 17 to 99 years on January 1, 2009, diagnosed before January 1, 2009 and alive on April 1, 2013 was followed to December 31, 2019. Cox proportional hazards models adjusting for demographic characteristics, smoking, HbA1c, blood pressure, serum cholesterol, BMI, duration of diagnosis, estimated glomerular filtration rate, prior myocardial infarction, stroke, heart failure, respiratory disease and cancer, were used to investigate whether care processes recorded January 1, 2009 to March 31, 2010 were associated with subsequent mortality. RESULTS: Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes, respectively. Completion of five or fewer, compared to eight, care processes (retinal screening not included as data were not reliable) had a mortality hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.28-1.46) in people with type 1 and 1.32 (95% CI 1.30-1.35) in people with type 2 diabetes. The HR was higher for respiratory disease deaths and lower in South Asian ethnic groups. CONCLUSIONS: People with diabetes who have fewer routine care processes have higher mortality. Further research is required into whether different approaches to care might improve outcomes for this high-risk group.

The role of community pharmacists and their position in the delivery of diabetes care: an update for medical professionals.

Pharmacists are the third largest group of healthcare professionals worldwide, but are underused in the delivery of diabetes care. The aim of this narrative was to describe how integration of community pharmacy services into existing healthcare models may improve diabetes care. Relevant literature exploring pharmacy-led interventions for diabetes were identified from a search of Medline, Embase and Cinahl online databases. This review highlights that community pharmacists are accessible, experts in medicine management, trusted by the public and able to achieve financial savings. They are poorly integrated into existing healthcare models, and commissioning arrangements can be poorly perceived by the public and those working in primary care. Community pharmacy interventions in type 2 diabetes have similar, if not greater effects compared to those delivered by other healthcare professionals. It was concluded that community pharmacy interventions in diabetes are feasible, acceptable and deliver improved health outcomes. Future work should build public recognition of pharmacists and improve communication between them and other healthcare professionals.