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Self-managing diabetes the X-PERT way

Trudi Deakin
BSc AdDip PGCE PhD RD
Clinical Champion
East Lancashire Diabetes Network
Research Dietician
Burnley, Pendle and Rossendale PCT
E:trudi.deakin@nhs.net

Diabetes is a self-management condition. However, healthcare delivery is often based on acute models of care where health professionals are the "experts" and inform the patient of the correct treatment for optimal care. The patient is viewed as a recipient and performer of regimens to be accepted and obeyed.
Diabetes education is often delivered one-to-one in an unstructured fashion. Follow-up can be infrequent due to increased prevalence and limited resources. Many people with diabetes are finding the current delivery of service inadequate and have difficulty putting theory into practice.
The diabetes X-PERT Programme was designed in conjunction with patients and the local branch of Diabetes UK. It is a six-week group education programme based on the theories of patient empowerment and patient activation. The programme has been evaluated by means of a randomised controlled trial involving 314 participants. Ten programmes have been delivered at community venues within Burnley, Pendle and Rossendale, East Lancashire. Three of these programmes have been specific for Urdu-speaking, South Asian participants. The control group received routine treatment and individual appointments from the GP, practice nurse and dietitian.
Each X-PERT session uses visual aids to explore health issues related to diabetes, and each participant receives a copy of their own health results combined with an explanation. All sessions are based on patient activation, discovery learning and empowerment. There are six weekly sessions, each lasting two-and-a-half hours. The educational content is illustrated in Box 1.

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The X-PERT Programme aims to increase knowledge, skills and confidence so that individuals are able to make informed decisions regarding their diabetes  self-management. The final 30 minutes of each session involves people obtaining their own health results and discussing what they are and what they mean to them. Sessions also address psychosocial aspects, barriers to change and goal-setting. Participants are encouraged to set goals based on a five-step empowerment model developed by Anderson and Funnell at the Michigan Diabetes Research and Training Centre, USA.
In the randomised controlled trial 16 participants were invited onto each programme and approximately one-third of the participants attended with a carer. Attendance rates were excellent: 95% of participants attended the programme, and 82% attended at least four sessions. Participant evaluation was also excellent.
Biomedical (glycated haemoglobin, blood pressure, lipid profile, BMI and waist circumference), lifestyle (self-management skills, physical activity levels and nutritional intake) and psychosocial (quality of life, treatment satisfaction and empowerment score) outcomes were collected from the "expert patients" and controls at baseline, four months and 14 months.
Highly significant statistical differences were found in favour of the X-PERT Programme for biomedical, lifestyle and psychosocial outcomes.(1,2) The participants assigned to the X-PERT Programme had significantly improved diabetes control, a reduced requirement for diabetes medication, clinically important reductions to blood pressure, and a 3cm reduction in waist circumference. They had improved diabetes self-management skills, increased physical activity levels and were enjoying a healthier diet. Quality of life improved through freedom to eat and drink and enjoyment of food. Self-empowerment scores significantly improved, as did treatment satisfaction.
There have been several unplanned outcomes from participants attending the X-PERT Programme. In addition to the improvement in patients' health and wellbeing, many have become peer educators; others have set up local support groups; and some are sitting on healthcare organisations and delivery committees. Several of the expert patients formed the "Patient empowerment and education subgroup" for the Local Diabetes Services Implementation Group (LDSIG), which submitted a report based on the patients' perspectives of local diabetes services. The report was well received, and several of these recommendations are to be implemented. The Programme has won four national awards:

  • Diabetes UK 2003 Diabetes Education Award (2003).
  • National Obesity Forum Weight Management in Diabetes Care Award (2003).
  • Health Service Journal Patient-Centred Care Award (2004).
  • The Secretary of State's Excellence in Healthcare Management Award (2004).

The following have been professionally developed and are available for purchase: a curriculum to include a scripted manual of the six-week programme; an evaluation and quality assurance programme; a CD-Rom of patient handouts; a set of educational visual aids, including a magnetic display board and four interactive magnetic posters, a magnetic board game, the "Fat Attack" DVD/video, patient-centred models and a carbohydrate awareness quiz. The Diabetes National Service Framework (NSF)(3) and the NICE technology appraisal of patient-education models for diabetes(4) make it clear that all PCTs will need to commit to offering structured education programmes to people with type 2 diabetes from the point of diagnosis. Now that tools are in place to provide patients with learning resources, the NICE guidance on patient education will be reinstated from January 2006. Key criteria that a structured education programme should meet to fulfil the NICE requirements have been developed by a working party of users and providers sponsored jointly by Diabetes UK and the Department of Health.(5) The X-PERT Programme meets those criteria and is featured in the Improving Diabetes Services - the NSF Two Years On publication.(6) A local pragmatic approach to allow all people with type 2 diabetes to benefit from structured education is to train primary care staff, such as practice nurses, to deliver the X-PERT Programme. The "Train the trainers" course is now available.
For more information, please contact Trudi Deakin at Burnley, Pendle and Rossendale PCT at trudi.deakin@nhs.net

References

  1. Deakin TA. Expert patient education versus routine treatment (X-PERT). PhD thesis. University of Leeds: Nuffield Institute for Health; 2004.
  2. Deakin TA, Cade JE, Williams DDR, et al. Empowered patients: better diabetes control, greater freedom to eat, no weight gain! Diabetologia 2003;46(S2):A90.
  3. Department of Health. National Service Framework for diabetes: delivery strategy. London: DH; 2002.
  4. National Institute for Clinical Excellence. Guidance on the use of patient-education models for diabetes. Technology Appraisal 60. London: NICE; 2003.
  5. Department of Health and Diabetes UK. Structured patient education in diabetes: report from the Patient Education Working Group. London:DH; 2005. Available from URL: http://www.dh.gov.uk/asset Root/04/11/31/97/ 04113197.pdf
  6. Department of Health. Improving diabetes services - the NSF two years on. London: DH; 2005.