The impact of nursing staff education on diabetes inpatient glucose management: a pilot cluster randomised controlled trial.

BACKGROUND: An increasing number of patients in hospital have diabetes, with most of them cared for by non-specialist staff. The effect of diabetes education for staff on patient outcomes, as well as the most effective method of staff education is unclear. Therefore, the aim of this study was to compare diabetes outcomes in medical wards where nursing staff were offered one face-to-face (F2F) session followed by access to online education (online), F2F education only, or standard care (control). METHODS: We conducted a pilot cluster randomised controlled trial involving 16-weeks baseline/rollout followed by a 28-week post-intervention period across three medical wards (clusters) in a Sydney Teaching Hospital. The online ward provided an online competency-based diabetes education program and 1-h F2F teaching from a diabetes nurse educator (DNE), the F2F ward provided four separate 1-h teaching sessions by a DNE, with no additional sessions in the control ward. The primary outcome was length of stay (LOS); secondary outcomes included good diabetes days (GDD), hypoglycaemia and medication errors. Poisson and binary logistic regression were used to compare clusters. RESULTS: Staff attendance/completion of ≥ 2 topics was greater with online than F2F education [39/48 (81%) vs 10/33 (30%); p < 0.001]. Among the 827/881 patients, there was no difference in LOS change between online [Median(IQR) 5(2-8) to 4(2-7) days], F2F [7(4-14) to 5(3-13) days] or control wards [5(3-9) to 5(3-7) days]. GDD improved only in the online ward 4.7(2.7-7.0) to 6.0(2.3-7.0) days; p = 0.038. Total patients with hypoglycaemia and appropriately treated hypoglycaemia increased in the online ward. CONCLUSIONS: The inclusion of online education increased diabetes training uptake among nursing staff. GDD and appropriate hypoglycaemia management increased in the online education wards. TRIAL REGISTRATION: Prospectively registered on the Australia New Zealand Clinical Trials Registry (ANZCTR) on 24/05/2017: ACTRN12617000762358 .

Effectiveness of a locality-based integrated diabetes care service on clinical outcomes.

BACKGROUND: Diabetes management often requires close cooperation between primary and specialist services, but a range of challenges in Australia and elsewhere make seamless care difficult. AIMS: To evaluate the effectiveness of a new locality-based integrated diabetes care service for people with Type 2 diabetes in an inner regional area. METHODS: A quasi-experimental evaluation comparing baseline and follow-up clinical data collected from general practices and specialist services participating in an integrated diabetes care programme in an inner-regional area. Patients had at least one specialist service consultation. The primary outcome was glycated haemoglobin (HbA1c). RESULTS: Clinical data were collected for 178 (74.5%) of 239 patients (age ± standard deviation, 65 ± 11 years; 46% female; median (interquartile range) diabetes duration, 19 (11.0-24.0) years) from seven general practices over 33 months (median 18.5 months). There were reductions in HbA1c (0.7 ± 1.6% (8 ± 18 mmol/mol); P < 0.001), systolic blood pressure (5.8 ± 19.5 mmHg; P < 0.001), diastolic blood pressure (2.4 ± 14.3 mmHg; P = 0.04), total cholesterol (0.5 ± 1.3 mmoL/L; P < 0.001), low-density lipoprotein (0.4 ± 0.9 mmoL/L; P < 0.001), body mass index (0.5 ± 1.6 kg/m2 ; P < 0.001) and weight (1.8 ± 4.7 kg; P < 0.001). The proportion without microalbuminuria increased from 48.4% to 59.3% (P = 0.03). CONCLUSIONS: Glycaemia and cardiovascular risk factors can be reduced in patients with long-standing Type 2 diabetes by moving to a locality-based integrated primary-secondary care diabetes care service.

Effectiveness of Diabetes Case Conferencing Program on Diabetes Management.

Aims: Diabetes case conferencing is where an endocrinologist visits a general practitioner (GP) to advise on the care of patients with diabetes. Past case conferencing studies have reported improved diabetes management and clinical outcomes in primary care. This study investigated the effectiveness of a diabetes case conferencing program in South Western Sydney, Australia. Methods: Complex diabetes cases were referred by general practitioners to a visiting endocrinologist for review after obtaining patient consent. The patient was not usually present. After the case discussion, a diabetes management plan was developed jointly by the general practice/specialist team. Clinical data were compared at baseline and each year up to three years (2017-2020) after the consultation using paired t-test. The primary outcome was HbA1c. Results: Clinical data were collected for 645/775 patients (mean age 64 ± 15(SD) years; 351 (54.4%) males from 40/43 general practices; 96.4% had type 2 diabetes; 6.5% were insulin treated, 54.3% non-insulin treated, 31.5% both insulin and non-insulin treated and 3.4% diet only. There were reductions in HbA1c by 1.0 ± 1.7% (11 ± 19 mmol/mol) (p < 0.001), systolic blood pressure 8.2 ± 18.1 mmHg (p < 0.001), diastolic blood pressure 2.7 ± 11.6 mmHg (p < 0.001), total cholesterol 0.2 ± 1.7 mmol/l (p = 0.007), low-density lipoprotein 0.2 ± 1.0 mmol/l (p < 0.001), weight 3.3 ± 10.1 kg (p < 0.001) and body mass index (BMI) 1.3 ± 3.5 kg/m2 (p < 0.001). Conclusions: Glycaemia, weight and cardiovascular risk factors improved following case conferencing consultations in a primary care setting.

Effectiveness of Integrated Diabetes Care Interventions Involving Diabetes Specialists Working in Primary and Community Care Settings: A Systematic Review and Meta-Analysis.

Introduction: Evidence that integrated diabetes care interventions can substantially improve clinical outcomes is mixed. However, previous systematic reviews have not focussed on clinical effectiveness where the endocrinologist was actively involved in guiding diabetes management. Methods: We searched EMBASE, COCHRANE, MEDLINE, SCOPUS, CINAHL, Google Scholar databases and grey literature published in English language up to 25 January 2021. Reviewed articles included Randomised Controlled Trials (RCTs) and pre-post studies testing the effectiveness on clinical outcomes after ≥6 months intervention in non-pregnant adults (age ≥ 18 years) with type 1 or type 2 diabetes mellitus. Two reviewers independently extracted data and completed a risk of bias assessment. Appropriate meta-analyses for each outcome from RCTs and pre-post studies were performed. Heterogeneity was assessed using the I2 statistic and Cochran's Q and publication bias assessed using Doi plots. Studies were not pooled to estimate the cost-effectiveness as the cost outcomes were not comparable across trials/studies. Results: We reviewed 4 RCTs and 12 pre-post studies. The integrated care model of diabetes specialists working with primary care health professionals had a positive impact on HbA1c in both RCTs and pre-post studies and on systolic blood pressure, diastolic blood pressure, total cholesterol and weight in pre-post studies. In the RCTs, interventions reduced HbA1c (-0.10% [-0.15 to -0.05]) (-1.1 mmol/mol [-1.6 to -0.5]), versus control. Pre-post studies demonstrated improvements in HbA1c (-0.77% [-1.12 to -0.42]) (-8.4 mmol/mol [-12.2 to -4.6]), systolic blood pressure (-3.30 mmHg [-5.16 to -1.44]), diastolic blood pressure (-3.61 mmHg [-4.82 to -2.39]), total cholesterol (-0.33 mmol/L [-0.52 to -0.14]) and weight (-2.53 kg [-3.86 to -1.19]). In a pre-post study with no control group only 4% patients experienced hypoglycaemia after one year of intervention compared to baseline. Conclusions: Integrated interventions with an active endocrinologist involvement can result in modest improvements in HbA1c, blood pressure and weight management. Although the improvements per clinical outcome are modest, there is possible net improvements at a holistic level.

Effects of lifestyle interventions on weight amongst Pasifika communities: A systematic review and meta-analysis.

Background: Pasifika populations experience high incidence and prevalence of obesity and T2DM. However, no international review of lifestyle intervention studies amongst Pasifika communities exists. This study seeks to identify the effect and translatability of lifestyle strategies on weight amongst Pasifika populations. Methods: Lifestyle studies involving ≥90% adult Pasifika participants measuring weight change were eligible for inclusion. Database searching was carried out up to December 2021. Databases searched were MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCOhost) and ProQuest Central. Risk of bias was assessed using RoB2 (RCTs) and the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool. Meta-analysis and meta-regression used a bivariate random-effects model. Strategies were coded against pre-identified components of the newly proposed Cultural and Sustainability Assessment of Intervention (CSAI) framework. Findings: Twenty-three studies (n = 4258 participants) met inclusion and exclusion criteria. Thirty-two lifestyle strategies targeting weight loss (WL) and 7 targeting weight maintenance (WM) were extracted. Meta-analysis estimates small but significant effect of -0.26 standard deviations (95% CI -0.51 to -0.02), with RCTs demonstrating a non-significant effect of -0.23 standard deviations (95% CI -0.49 to 0.035). Culturally relevant strategies included community and peer support facilitators and team-based activities. The CSAI identified 14 out of 23 studies with low cultural competency and sustainability scores (<60%). Interpretation: Qualitative and quantitative analysis show tailored lifestyle interventions has had an estimated small but beneficial effect on WL amongst Pasifika communities. Potential for tailored interventions design to incorporate psychosocial and behavioural considerations. The CSAI has the potential for systematically identifying cultural and sustainability components of efficacy in interventions. Funding: This review was funded under Western Sydney University's Postgraduate Research Scholarship.

Challenges to Introducing Integrated Diabetes Care to an Inner-Regional Area in South Western Sydney, Australia.

INTRODUCTION: Diabetes care often requires collaboration between general practitioners, allied health professionals, nurses, and/or medical specialists. This study aimed to describe the establishment of an integrated diabetes prevention and care approach in an area with limited access to primary and secondary care, and the challenges faced in its initial development. DESCRIPTION: A qualitative research approach to identify challenges was taken. Data included meeting minutes, observational data and reports involving local clinical and non-clinical stakeholders from June 2016- December 2018 and were thematically analysed. DISCUSSION: Key challenges were low patient attendance in general practice, healthcare professional time, low participation at health promotion activities/peer support groups and diabetes education reflecting a low priority among people with and at risk of diabetes. Coordination between services remained a challenge. CONCLUSION: This study highlights the need to integrate new diabetes services with existing health activities in the community and the importance of allowing flexibility and regular contact with local healthcare professional and community to encourage their involvement. Regular meetings with the funders, internal and external stakeholders are key for sustainability and to adapt programmes to the local situation. Further work is needed to identify and implement strategies to overcome these challenges.