The effect of DAFNE education, continuous subcutaneous insulin infusion, or both in a population with type 1 diabetes in Scotland

Abstract

Aim To investigate the effect of DAFNE and continuous subcutaneous insulin infusion in clinical practice.Methods Within NHS Lothian, continuous subcutaneous insulin infusion started in 2004 and DAFNE education began in 2006. We extracted anonymized data from the national database for all those aged > 18 years with type 1 diabetes having a Dose Adjustment For Normal Eating course or continuous subcutaneous insulin infusion start date (n = 4617). ResultsIn total, 956 persons received DAFNE education, and 505 had received an insulin pump, 208 of whom had DAFNE education followed by insulin pump. Mean (SD) HbA 1c before DAFNE education was 68 (15) mmol/mol (8.4% [1.4%]) and 66 (13) mmol/mol (8.2% [1.2%]) before continuous subcutaneous insulin infusion. In the year following DAFNE education, the mean fall in within-person HbA 1c was 3.8 mmol/mol (95% CI 4.0 to 3.4; 0.3% [0.4% to 0.3%]). Those with the poorest control (HbA 1c ≥ 85 mmol/mol [9.9%]) experienced the largest decline (15.7 mmol/mol [1.4%]). Those in the lowest HbA 1c band at initiation (< 53 mmol/mmol [7.0%]) experienced a rise.In the year following continuous subcutaneous insulin infusion initiation there was a mean fall in within-person HbA 1c of 6.6 mmol/mol (6.8 to 6.4; 0.6% [0.6% to 0.6%]). In those with the poorest control (HbA 1c ≥ 85 mmol/mol [9.9%]), the mean fall in HbA 1c was 22.2 mmol/mol (23 to 21; 2.0% [2.1% to 1.9%]). Continuous subcutaneous insulin infusion effectiveness was not different with or without DAFNE education. The effects of both interventions were sustained over 5 years.Conclusions Both DAFNE education and insulin pump therapy had the greatest effect on HbA 1c in those with higher baseline values. There was little difference to attained HbA 1c when Dose Adjustment For Normal Eating education was introduced before insulin pump therapy.

Socioeconomic deprivation, technology use, C‐peptide, smoking and other predictors of glycaemic control in adults with type 1 diabetes

“…Other factors, such as persistent C‐peptide secretion, 11,12,16 male gender, 17 lower BMI 18,19 and non‐ smoking status, 18 have been reported but their relationship to HbA 1c in type 1 diabetes has not been consistently demonstrated, particularly independently of potential confounders. Participation in DAFNE was not independently associated with meeting glycaemic targets, although our centre has previously demonstrated that completing DAFNE is prospectively associated with substantial improvement in HbA 1c 6 …”

“…We have shown that a range of factors are independently associated with the likelihood of having an HbA 1c below the national target for people with type 1 diabetes. Some factors, such as flash monitoring use, 8,14 CSII use 6,7 and lower socioeconomic deprivation, 15 would be fully expected based on previously published data. Other factors, such as persistent C‐peptide secretion, 11,12,16 male gender, 17 lower BMI 18,19 and non‐ smoking status, 18 have been reported but their relationship to HbA 1c in type 1 diabetes has not been consistently demonstrated, particularly independently of potential confounders.…”

“…Clinician preconceptions, with little supporting evidence, relating to who is likely to derive benefit from CSII, may contribute to the inequitable distribution of CSII use 20 . This is despite evidence that those with the highest baseline HbA 1c derive the greatest benefit from CSII, with respect to HbA 1c lowering, 6 and deprivation is not a significant predictor of response to CSII 21 . Attendance at a DAFNE course was also significantly less likely in those in the most deprived SIMD quintiles, which parallels the experience of other large diabetes centres 9 .…”

“…It is not clear whether recent advances in insulin therapy, widening access to structured education, continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) (or flash monitoring) have substantially transformed this situation. Clear evidence supports the glucose lowering efficacy of structured education programmes, such as ‘Dose Adjustment for Normal Eating’ (DAFNE), 5,6 CSII 6,7 and CGM/flash monitoring 7,8 . Access to these interventions, however, remains limited and skewed towards individuals with lower levels of socioeconomic deprivation 8‐10 .…”

Marked improvements in glycaemic outcomes following insulin pump therapy initiation in people with type 1 diabetes: a nationwide observational study in Scotland

“…CSII therapy initiation in Scotland follows criteria set by the National Institute for Health and Care Excellence (NICE) guidelines [ 6 ], Scottish Government policy and individual National Health Service (NHS) health board budget allocation decisions. A recent study [ 7 ] examined the effect of CSII therapy on HbA 1c among people with type 1 diabetes in the Scottish health board Lothian and found a significant decrease in HbA 1c following CSII initiation, particularly among those with suboptimal glycaemic control. In this paper, we widen the scope of that analysis by focusing on CSII therapy initiation in people with type 1 diabetes throughout Scotland.…”