3 Dimensions for Diabetes (3DFD) Khalida Ismail & Carol Gayle 8 th March 2016 King s Fund, London
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1 3 Dimensions for Diabetes (3DFD) Khalida Ismail & Carol Gayle 8 th March 2016 King s Fund, London
2 Rochelle... female, late 20s, single parent son age 4 years & daughter age 18 months type 1 diabetes in second pregnancy HbA1c 108 mmol/mol Undetected severe post partum depression
3 Depression and mortality in people with their first diabetic foot ulcer (n=253) Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. Diabetes Care 2007:30; Winkley K, Sallis H, Kariyawasam D, Leelarathra L, Chalder T, Edmonds M, Stahl D, Ismail K. Diabetologia 2012;155: Funding: Wellcome Trust
4 Diabetes is associated with nearly every psychiatric disorder ICD-10 Chapter F categories General popn/no psych disorder Relative risk reference group Dementia 2.0 Schizophrenia 3.0 Substance use ~? Depression 2.0 Eating disorders Chien et al Compr Psychiatry 2011; Anderson et al Diabetes Care 2000
5 Social problems
6 3DFD: a blank canvas
7 Parallel versus integrated services Diabetes Diabetes Mental Health Social Mental Health Social
8 Active ingredients of 3DFD debt management housing support occupational rehab literacy advocacy Social interventions Diabetes Management medication support biomedical monitoring diabetes education technology complications patient-led MDT meeting increase self efficacy for diabetes HbA1c Patient reported outcomes Patient Liaison mental health services diagnostic assessment risk management psychotropic brief psychological treatments family work
9 3 Dimensions For Diabetes (3DFD) 1,2,3 Social Interventions Diabetes management Primary care Patient Liaison mental health services Specialist care 1 BMJ Best Diabetes Team Award Doherty et al International Journal of Psychiatry in Medicine NHS Regional Innovation Fund London 2010
10 Challenges and Opportunities De novo service Organisational resistance Sustainability Defining the model? Whatever it was-it had to be simple Full integration into diabetes teams, community and hospitals MDT, Education and training luxury service Pathways Improving Access to Psychological Services (IAPT) Commissioners Cross sector steering group with Diabetes Modernisation Initiative Evaluation, business case, dissemination & awards Hospital charities and CCG funding Commissioned service but needs scaling up
11 3DFD characteristics Year 1 Oct n=306 Year 2 Oct n=255 Total Oct n=561 Age, mean (SD) 47 (14.8) 50 (15.1) 48 (14.9) Gender n, (%) Male 121(39.4) 110 (43.3) 231 (41.2) Female 181 (60.6) 144 (56.7) 325 (58.8) Diagnosis n, (%) Type 1 89 (28.9) 60 (23.6) 149 (26.6) Type (71.1) 194 (76.4) 412 (73.4) Ethnic group n, (%) HbA1c mean (SD) Caucasian 76 (24.7) 81 (31.9) 157 (28.0) African/Caribbean 98 (31.9) 88 (34.6) 186 (33.2) Other 133 (43.2) 88 (33.5) 218 (38.8) % (DCCT) 10.7 (1.9) 11.6 (2.1) 11.1 (2.0) mmol/mol (IFCC) 93 (10) 103 (11) 98 (10)
12 3DFD characteristics Year 1 Oct n=306 Year 2 Oct n=255 Total Oct n=561 Age, mean (SD) 47 (14.8) 50 (15.1) 48 (14.9) Gender n, (%) Male 121(39.4) 110 (43.3) 231 (41.2) Female 181 (60.6) 144 (56.7) 325 (58.8) Diagnosis n, (%) Type 1 89 (28.9) 60 (23.6) 149 (26.6) Type (71.1) 194 (76.4) 412 (73.4) Ethnic group n, (%) HbA1c mean (SD) Caucasian 76 (24.7) 81 (31.9) 157 (28.0) African/Caribbean 98 (31.9) 88 (34.6) 186 (33.2) Other 133 (43.2) 88 (33.5) 218 (38.8) % (DCCT) 10.7 (1.9) 11.6 (2.1) 11.1 (2.0) mmol/mol (IFCC) 93 (10) 103 (11) 98 (10)
13 3DFD characteristics Year 1 Oct n=306 Year 2 Oct n=255 Total Oct n=561 Age, mean (SD) 47 (14.8) 50 (15.1) 48 (14.9) Gender n, (%) Male 121(39.4) 110 (43.3) 231 (41.2) Female 181 (60.6) 144 (56.7) 325 (58.8) Diagnosis n, (%) Type 1 89 (28.9) 60 (23.6) 149 (26.6) Type (71.1) 194 (76.4) 412 (73.4) Ethnic group n, (%) HbA1c mean (SD) Caucasian 76 (24.7) 81 (31.9) 157 (28.0) African/Caribbean 98 (31.9) 88 (34.6) 186 (33.2) Other 133 (43.2) 88 (33.5) 218 (38.8) % (DCCT) 10.7 (1.9) 11.6 (2.1) 11.1 (2.0) mmol/mol (IFCC) 93 (10) 103 (11) 98 (10)
14 3DFD characteristics Year 1 Oct n=306 Year 2 Oct n=255 Total Oct n=561 Age, mean (SD) 47 (14.8) 50 (15.1) 48 (14.9) Gender n, (%) Male 121(39.4) 110 (43.3) 231 (41.2) Female 181 (60.6) 144 (56.7) 325 (58.8) Diagnosis n, (%) Type 1 89 (28.9) 60 (23.6) 149 (26.6) Type (71.1) 194 (76.4) 412 (73.4) Ethnic group n, (%) HbA1c mean (SD) Caucasian 76 (24.7) 81 (31.9) 157 (28.0) African/Caribbean 98 (31.9) 88 (34.6) 186 (33.2) Other 133 (43.2) 88 (33.5) 218 (38.8) % (DCCT) 10.7 (1.9) 11.6 (2.1) 11.1 (2.0) mmol/mol (IFCC) 93 (10) 103 (11) 98 (10)
15 3DFD outcomes HbA1c Pre 3DFD Post 3DFD Change score p-value Mean (SD) DCCT % (n=185) Mean (SD) IFCC HbA1c mmol/mol (n=185) 11.3 (2.1) 10.0 (2.0) 1.5 (1.6) < (23) 83 (22) 16 (17) <0.001 HbA1c, mmol/mol 100 Improvement in 98 HbA1c, mmol/mol 95 Improvement in HbA1c, mmol/mol Baseline 6 months 1 year 2 years Glicazide Gliptin Dapagliflozin Lamb/Swk DICT (n=472) Agents producing improved Timeglycaemic control Maintenance of HbA1c 3DFD (n=185)
16 Psychiatric morbidity Psychiatric diagnosis: new, known or relapse N Nil Known diagnosis New diagnosis New relapse Psychiatric Diagnosis
17 Social Needs
18 Social Needs
19 Support worker assisting patient with type 2 diabetes with her housing situation
20 Quantitative outcomes Pre 3DFD Post 3DFD Change score p-value Mean HbA1c, mmol/mol (SD)** 102 (22) 84 (22) -18 (17) <0.001 Mean Patient Health Questionnaire-9 depression score (SD)** Mean General Anxiety Scale-7 score (SD)** 8.8 (6.5) 6.4 (5.8) -2.4 (2.2) (5.3) 4.9 (5.3) -4.0 (3.5) <0.001 Mean Diabetes Distress Scale (SD)** 47.3 (17.1) 36.0 (15.4) (19.1) 0.01 Mean Outcomes Star score (SD)** 55.9 (11.5) 61.6 (14.9) +5.7 (9.1) ** Service for first 6-12 months (n=198)
21 Main 3DFD outcomes - economic Pre 3DFD Post 3DFD Change score p-value No of admissions to A&E/previous year (n=119) No of bed days/previous year (n=119) No of recurrent admissions (days)/previous year (n=119) < (73) 4 (14) -6 (-59) 0.012
22 Cost-benefit analysis Costs 94k/borough/year 0.5WTE Consultant liaison psychiatrist Community outreach worker Admin support and infrastructure Savings 127k/borough/year (-on-year) Short term: reduction in unscheduled care Long term: reduction in developing diabetes complications 3DFD net saving 33K/100 patients/borough/year recurrent 35% return on investment per year
23 Patient testimonial My name is Rochelle, I am a single parent with two children. I had difficulties controlling my diabetes. I became very depressed. 3DFD has managed to help me to overcome my fears of dealing with diabetes. I now use my insulins better... Rochelle:(T1DM) HbA1c 15.2 to 8.7%
24 Quality in Care Awards 2011 BMJ Awards 2014 Diabetes Team of the Year Mary McKinnon Lecture DUK 2015 NHS Innovation Challenge Prize 2015
25 Cross sector integration Health inequalities Translation of research 3DFD Cost effective Dissemination Oxford Surrey Hillingdon Edinburgh Parsonage M, Fossey M, Tutty C. Liaison Psychiatry in the Modern NHS. Centre for mental Health, London. 2012, p35.
26 The Future Scaling up Identifying low vs high risk groups Other long term physical conditions Across the mental health trust Health Foundation Scaling Up Bid 2016 Shortlisted to final round Results next week Watch this space
27 Regional Fund Innovation
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