A decade in diabetes specialist services, 2000 to 2011, in England: the views of consultant diabetologists and diabetes specialist nurses amidst persistent healthcare delivery change.

AIMS: To assess the impact of continual major National Health Service reorganization on commissioning, organizational and delivery arrangements for secondary care diabetes services. To explore how consultant diabetologists and diabetes specialist nurses perceive the issues facing diabetes specialist services in 2011 and how these have changed in the preceding decade. METHODS: We used a longitudinal case study approach that combined quantitative and qualitative methods. Five locations in England were purposively selected to represent the wider diabetes specialist community, and seven semi-structured interviews were conducted. Interviews were recorded, transcribed verbatim and analysed using Framework analysis. Findings were compared with and contrasted to results from national quantitative surveys of diabetes specialist services undertaken in 2000 and 2006. RESULTS: Clinicians viewed positively the expertise and commitment of multidisciplinary teams and their ability to adapt to new situations. Negative perceptions persisted throughout the decade, relating to the continual change that threatens to dismantle relationships and services which had taken many years to establish. Lack of resources, inadequate manpower planning and poor access to psychological support for people with diabetes remained constant themes from 2000 to 2011. CONCLUSIONS: A willingness to innovate and work differently to improve services was identified; however, clinicians must be supported through organizational changes to ensure people with diabetes receive high-quality care. The disruptive nature of organizational change was a recurrent theme throughout the decade. Periods of stability must exist within commissioning to allow relationships, which are key to integration, to be maintained and permit service improvements to develop.

Experience of the introduction of routine antibody testing in primary care and of running a trial for latent autoimmune diabetes in adults (LADA).

This brief report discusses the introduction of routine Glutamic Acid Decarboxylase Antibody (GADA) testing in primary care for newly diagnosed diabetes. GADA testing is well used and the majority of people found to be positive are initiated on insulin rapidly and progress to require a basal bolus regime.

Effect of population screening for type 2 diabetes on mortality: long-term follow-up of the Ely cohort.

AIMS/HYPOTHESIS: The aim of this study was to assess the impact of invitation to screening for type 2 diabetes and related cardiovascular risk factors on population mortality. METHODS: This was a parallel-group population-based cohort study including all men and women aged 40-65 years, free of known diabetes, registered with a single practice in Ely, UK (n = 4,936). In 1990-1992, approximately one-third (n = 1,705) were randomly selected to receive an invitation to screening for diabetes (with an OGTT) and related cardiovascular risk factors. In the remaining two-thirds of the population, 1,705 individuals were randomly selected for invitation to screening in 2000-2003 and 1,526 were not invited at any point during the follow-up period. All individuals were flagged for mortality until January 2008. RESULTS: There were 345 deaths between 1990 and 1999 (median 10 years follow-up). Compared with those not invited, individuals who were invited to the 1990-1992 screening round had a non-significant 21% lower all-cause mortality (HR 0.79 [95% CI 0.63-1.00], p = 0.05) after adjustment for age, sex and deprivation. There were 291 deaths between 2000 and 2008 (median 8 years follow-up), with no significant difference in mortality between invited and non-invited participants in 2000-2003. Compared with the non-invited group, participants who attended for screening at any time point had a significantly lower mortality and those who did not attend had a significantly higher mortality. CONCLUSIONS/INTERPRETATION: Invitation to screening was associated with a non-significant reduction in mortality in the Ely cohort between 1990 and 1999, but this was not replicated in the period 2000-2008. This study contributes to the evidence concerning the potential benefits of population screening for diabetes and related cardiovascular risk factors.

Secular trends in established and novel cardiovascular risk factors in Welsh 12-13 year olds: a comparison between 2002 and 2007.

BACKGROUND: This study examines CVD risk factors trends in Welsh adolescents between 2002 and 2007. PARTICIPANTS AND METHODS: CVD risk factor data was examined from two cross-sectional studies. The first study (73 participants; aged 12.9 ± 0.3 years) was completed in 2002. The second study (90 participants; aged 12.9 ± 0.4 years) was conducted in 2007. Measurements included body mass index (BMI), waist circumference (WC), total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, fibrinogen (Fg) and high-sensitivity C-reactive protein (hs-CRP). RESULTS: In boys, mean BMI and WC were lower in 2007, although not significantly (p ≥ 0.05). In 2007, there were improvements in mean lipid, Fg and hs-CRP concentrations in both sexes (p < 0.05). In 2002, 42.8% of boys and 34.2% of girls were overweight or obese; in 2007, this was 23.7% and 28.9% for boys and girls, respectively. More adolescents in 2002 exceeded the recommended levels for lipids, Fg and hs-CRP. CONCLUSION: This is the only study to examine CVD risk factor trends in Welsh adolescents. Although overweight continues to be widespread in 12-13 year olds, this study did not identify significant mean changes in overweight and obesity between 2002 and 2007. Overall, the data presented a positive trend in lipid profile and inflammatory factors.

GADA testing: the current state of knowledge.

This review considers the current knowledge and practice of GADA testing people with diabetes in Europe and the UK. Important issues are raised, including interpretation of the results and the clinical relevance of the GADA titre. Recommendations are made towards standardising GADA testing, using World Health Organization units.

Intervention, recruitment and evaluation challenges in the Bangladeshi community: experience from a peer lead educational course.

BACKGROUND: The incidence of Type 2 diabetes is increasing worldwide and diabetes is four times more common among ethnic minority groups than among the general Caucasian population. This study reflects on the specific issues of engaging people and evaluating interventions through written questionnaires within older ethnic minority groups. METHODS: The original protocol set out to evaluate an adapted version of the X-PERT patient program http://www.xpert-diabetes.org.uk/ using questionnaires and interviews. RESULTS: Questionnaires, even verbally completed, were unsuccessful and difficult to administer as participants found the questionnaire structure and design difficult to follow and did not perceive any benefit to completing the questionnaires. The benefits of attending the course were also poorly understood by participants and in many cases people participated in coming to the course as a favour to the researcher. Engaging participants required word of mouth and the involvement of active members of the community. CONCLUSION: Peer led courses and their evaluation in older ethnic minority communities needs a very different approach for that in younger Caucasian patients. A structured approached to evaluation (favoured by western educational system) is inappropriate. Engaging participants is difficult and the employment of local well known people is essential.

Inflammatory factors, physical activity, and physical fitness in young people.

Cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality in developed countries. Over the past decade there has been much focus on the role of inflammation in the pathogenesis of atherosclerosis; to this end, there is increasing research on inflammatory factors such as C-reactive protein (CRP), interleukin-6 (IL-6), and fibrinogen (Fg). There is compelling evidence that physical activity (PA) and physical fitness (PF) protect against chronic disease. More recently, research has shown that exercise reduces CRP, IL-6, and Fg concentration in adults, and that this is often independent of adiposity. Although there are some data to suggest that this is similarly true for young people, there is inconsistency in the literature. The following review aims to illustrate what is known about the effects of PA and PF on inflammatory factors in young people aged 5-18 years.

Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation.

AIMS: The aim of this study was to evaluate an innovative approach to the provision of primary care-based diabetes services in Bradford, UK. The service model differs from others in comprising 19 clinics which offer a specialist service, intermediate between primary and secondary care, to all patients within the Bradford area. METHODS: The study included: analysis of referral, attendance and register data; questionnaires to general practitioners (GPs) and specialist clinic providers; qualitative interviews with clinic and other professional staff and patients; and an economic analysis. RESULTS: The 19 clinics adopt a range of organizational models. In the first 3 1/2 years, 2415 patients were referred. There was a significant reduction in out-patient attendances at hospital, but also a significant increase in overall patient attendances. Specialist clinic patients differed from hospital patients in being older and having had diabetes for longer since diagnosis. Ten of the 14 clinics run by practising GPs attracted more referrals from within their practices than from outside. GPs and patients across the city believed the clinics were valuable, the main benefits being geographical accessibility, availability of specialists in a community setting, short waiting times for first appointments at most clinics, and continuity of staff. Their reservations included a lack of strategic planning in the location of clinics, long waiting times at some clinics, and poor communication at some clinics with referring GPs. The cost of the primary care clinics is similar to hospital clinics. CONCLUSIONS: This model of specialist primary care services offers an opportunity to develop diabetes services that are convenient to patients, popular with practitioners, and increase capacity. However, the shortcomings as well as the advantages of the model need to be addressed if it is to be implemented elsewhere or for other patient groups.

Diabetes UK funded surveys of the structural provision of primary care diabetes services in the UK.

AIM: To describe diabetes service provision in primary care in the UK. METHODS: Postal questionnaires were sent to all UK primary care organizations (PCOs), and to a sample of general practices in England and all practices in Wales and Scotland. The data collection period ended on 30 April 2001. RESULTS: Seventy-nine per cent of the PCOs and 40% of the practices provided usable information. There is evidence that respondents were not significantly biased in relation to their interest in diabetes care. Diabetes was included as a Health Improvement Programme (or equivalent) priority by 62% of PCOs and had been identified as a clinical governance priority by 27%. Sixty-five per cent had information about the ethnic composition of their general population, 57% had an estimate of the number of people with diabetes. Sixty-nine per cent had a local diabetes register but this was said to cover the entire local population in only 64% of these. At least one audit of diabetes care had been carried out (in the previous 5 years) in 75% and, in 76%, clinical guidelines on diabetes care were made available to practices. In the practices, 80% had a designated lead person for diabetes. Seventy-three per cent had at least one general practitioner with a special interest and 87% at least one nurse. Seventy-two per cent of practices ran specific diabetes clinics and 51% had a screening policy. Eighty-six per cent considered that they had adequate systems in place for the delivery of diabetes care. However, only 6% were able to offer a dedicated diabetes telephone help or advice line and only 9% an evening out of hours clinic. Regular practice meetings were held to discuss diabetes in 35%, whereas 39% had a formal shared care protocol. Fourteen per cent held regular joint meetings with the hospital-based team and in 38% there was membership of Diabetes UK for at least one partner or the practice itself. A third (34%) of responding practices were unsure whether a Local Diabetes Services Advisory Group or equivalent existed in their area. Geographical differences in service provision were identified with, for example, practices in London having fewer components in place that were specifically related to the provision of diabetes care. Single-handed practices, wherever they were situated, had in place fewer staff and facilities specifically for diabetes care.

Association of British Clinical Diabetologists (ABCD): survey of specialist diabetes care services in the UK, 2000. 3. Podiatry services and related foot care issues.

AIM: To examine the provision of, and variations in, podiatry and other services for diabetic foot care in the UK. METHOD: A postal survey of secondary care providers of diabetes services in the UK in 2000. RESULTS: Following two reminders a 77% response rate was achieved. The responses indicated that 97% had a state-registered podiatrist attached to the service, providing three (median) sessions each week for diabetes care, although only 44% had availability at all diabetic clinics, and only 3% had availability at paediatric diabetic services. Podiatry access at all diabetic clinics increased the likelihood of associated preventative as opposed to reactive ('trouble shooting') care (P < 0.05). All individuals with feet at 'high risk' of ulceration had access to 'at least 2 monthly review' in 15% of trusts, and with active foot ulceration at least weekly in 43%. Over 70% used at least one form of equipment to assess peripheral neuropathy, but peripheral blood flow was only formally measured in 13%. Although podiatry input to patient education was common (84%), only 6% had received formal training in education. Guidelines and strategies for management of active foot problems were available in 50-74% of cases. Orthotic input was highly variable, and absent in 15% of responses. Podiatrist fitting and application of foot protective apparatus was only recorded in 22-61% of responses. Access to isotopic and/or MR foot imaging and peripheral angiography and angioplasty was recorded in 75-83% of responses. Separate specialist foot clinics were available in 49%, and where this was the case the use of newer foot ulcer healing applications was higher (P < 0.01). Clear regional differences were apparent in the nature of the service, the use of newer treatments, and in access to an orthotist, a local 'dedicated' foot surgeon or a separate diabetic foot clinic. Of 245 documented bids for service improvements, only 19 related to foot care and only 21% of bids were successful. CONCLUSIONS: Despite an increase in podiatry support to diabetes care over the last 10 years, the level of access and the nature of the services provided is much less than recommended in many advisory documents. The strategy of a co-ordinated 'team' approach to foot care still takes place in less than 50% of centres. There are clear regional differences in diabetes foot care services. Both providers and purchasers of diabetes services may not have given sufficient attention to this area, given the relatively small number of documented bids for service improvements in this area, and the very low success rate of such bids.

Association of British Clinical Diabetologists (ABCD): survey of specialist diabetes care services in the UK, 2000. 4. Dietetic services and nutritional issues.

AIMS: To examine the provision of, and variations in, dietetic services for diabetes in secondary care in the UK. METHOD: A postal survey of all secondary care providers of diabetes services. RESULTS: There was a 77% response rate. A dedicated dietician supported diabetes services in 73% of responses, but only 45% were able to see newly diagnosed patients within 1 month. Only 3% of responses documented that dietetic services provided the recommended minimum 22 h weekly input to diabetes care, and an annual dietetic review was said to be available in 15%. An opportunity for more frequent visits was most likely if there was poor glycaemic control (78% of responses), particularly when services were provided by a dedicated diabetes dietician. Although dieticians frequently provided input to patient education (88%), specific training for this purpose and provision for continuing education of these individuals was less common (14% and 63%, respectively). Nutritional guidelines were available in 74%, but only 31% of responses documented current guidelines on obesity management. Of bids for additional dietetic resources, only 21% had been successful. There was evidence of regional variation in service provision, and no greater provision of dietetic services in areas with a large South Asian population and an expected high prevalence of diabetes. In broad terms, dietetic services for diabetes care had not altered in comparison with a similar survey in 1997. CONCLUSIONS: The level of dietetic support of secondary care diabetes services remains dramatically lower than recommended in advisory documents, and appears to have changed little over the last 3 years. This is compounded by marked regional differences, and was no better in areas with a higher than average prevalence of diabetes. The survey also highlights the need for more co-ordinated and structured education and training of dieticians as well as more consistency in nutritional guidelines.