Design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence @diabetesrc @ALPSlimb

Important work from the Devon NHS trust, UK.

Service user and community clinician design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence

Significance of this study
What is already known about this subject? ► Quality outcome framework, education and multi- disciplinary secondary care have improved services for diabetes in England. However, access to services remains difficult for many patients. What are the new findings? ► Codesign of integrated diabetes care by service us- ers has been shown to: –  Improve access to education and dietary advice with improvement in weight and hemoglobin A1c. –  Reduce major and minor lower extremity ampu- tation incidence sustained for 3 years. –  Achieve improved outcomes with a partly virtual service. How might these results change the focus of research or clinical practice? ► This study provides a model to enhance access to diabetes care and reduce foot complications. The virtual clinic aspects of the service can safely reduce direct contact between patient and clinician now ad- visable to reduce risk of COVID-19.

Service user and community clinician design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence

Introduction Design of an integrated diabetes service based on needs of service users (persons living with diabetes) and community clinicians in a semirural low- income health district of the UK.

Research design and methods One hundred and eighty-five service users engaged through public meetings, questionnaires and focus groups. General practice staff contributed views through workshops and questionnaires. Analysis of feedback indicated service user needs for better access to education, dietary advice and foot care. General practice staff endorsed these views and requested regular access to secondary care in the community. Seven hundred persons registered with diabetes attended eight well-being events in the community. From 2017 virtual practice multidisciplinary patient reviews, virtual referral of foot cases and non- face-to-face helplines were developed. A National Health Service (NHS) approved ‘App’ and web-based personalized education support for those recently diagnosed with diabetes was introduced.

Results Engagement in education for those recently diagnosed with diabetes increased from 5% to 71%. Weight and hemoglobin A1c (HbA1c) levels before and 6 months after starting the program were 99.4±25 and 95.5±24.2 kg and 59.3±16 and 54.8±12.9 mmol/mol, respectively, p=0.00003 and 0.003. Of those engaging at well-being events, 44 had missed regular follow-up. One hundred and seventy-five cases were reviewed virtually with practice staff by the secondary care team avoiding referral to the hospital diabetic clinic. One hundred and seventy-six referrals were made to the virtual multidisciplinary diabetic foot team clinic. Major amputation incidence declined from 13 to 3 major procedures/10 000 per annum and minor amputation from 26 to 18/10 000. Percentage bed day occupancy by persons with diabetes fell significantly in the district general hospital.

Conclusions Integrated community-based diabetes care delivery has been achieved with partially virtual reviews. Patient education, secondary care in the community, access to dietetic advice and foot care outcomes have all improved.

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