While the COVID-19 pandemic has highlighted a number of pre-existing challenges in delivering diabetes care in the NHS, some of the innovative approaches taken to continue patient management during the pandemic need to be retained to improve ongoing care, say UK experts.
The research was presented during the Diabetes UK Professional Conference: Online Series on October 27, in a session dedicated to the remodelling of diabetes services during the COVID-19 pandemic.
Nicola Milne, a community diabetes specialist nurse with Manchester University NHS Foundation Trust said that, prior to the COVID-19 pandemic, diabetes care “very much focused on face-to-face consultations”, with the majority “really rigid” 30- to 40-minute appointments every 3 to 6 months.
“But was that working? We knew we were starting to face a number of challenges,” she said.
These included increasing numbers of patients, the increasing complexity of diabetes care, poor uptake of structured diabetes education, and the need for access to advances in technology.
Alongside, there were challenges around healthcare service capacity, as well as with workforce recruitment and retainment, with Milne saying that a recent survey found there was a 10% vacancy rate for diabetes specialist nurses.
Variation in Care
The arrival of the COVID-19 pandemic only served to heighten these challenges.
Initial guidance issued on 23 March – around the time of the UK-wide lockdown – recommended that inpatient diabetes services should continue and may need to be increased to a 7-day service.
However, secondary care services, including diabetes foot, and pregnancy and diabetes services, were to be kept to a safe minimum, while group-based face-to-face contact was to be avoided.
Nicola Milne said that a survey by Diabetes UK in August revealed there was consequently “considerable variation” in diabetes inpatient care during the first peak of the pandemic.
Some trusts were able to adapt to the circumstances and provide a proactive, flexible service that relied on increased use of technology and maximised the number of days worked, while others saw their care comprised, particularly when their diabetes teams were disbanded and redeployed.
The result for Milne’s community service was that it had a 55% reduction in capacity due to staff shortages, but was required to perform an additional 580 type 2 diabetes reviews as a result of early hospital discharge, admission avoidance, and a reduction in outpatient services.
However, data from a study published in The Lancet showed that a disproportionate number of diabetes patients died from COVID-19 infection, and that both type 1 and type 2 diabetes were significant independent predictors of COVID-19 mortality.
Nicola Milne said that this underlined how frontline diabetes services need an effective ‘back line’ of community and outpatient services and remote consultations.
Moreover, there is a “need” for patient triage and risk stratification to ration overstretched and restricted services.
“This is really uncomfortable for us as healthcare professionals because we always want to give 100% to 100% of the people we’re caring for,” she said, “but we have got to accept that we are going to have to risk stratify because we’re not going to be able to do everything for everybody.”
A number of triage and risk stratification tools were consequently published during the pandemic or are in development that take into account not just HbA1c levels but also blood pressure, cholesterol levels, and renal function.
“But one thing that’s really important in all of this is to ensure that we don’t miss our vulnerable groups,” Milne added. “It’s easy to get our IT systems to, say, show me everybody with an HbA1c over 86%, or show me everybody with an eGFR under 30. But it’s more difficult for it to identify some of our vulnerable groups.”
These include deprived individuals and those with mental health problems, as well as people from certain ethnic groups who may have issues accessing services.
In response, Milne noted that “one thing that’s going to be really important, because we can’t have all those really busy waiting areas now of people waiting to see specialist clinicians in secondary care, is we’re going to have to work more closely in collaboration and use more integrated diabetes care”.
This means working across disciplines and specialties, and focusing on reducing cardiovascular and renal risk factors, as well as support for self-monitoring, flexible review intervals, and online education.
This, she said, will have to be conducted against the backdrop of a 70% reduction in the number of people diagnosed with type 2 diabetes over the last 5 months compared with usual numbers.
“That’s over 40,000 missing new diagnoses of type 2 diabetes,” Milne said, “and we need to be mindful of that when we return back to our normal services.”
She closed her presentation by saying that, moving forwards, there will be a blend of face-to-face consultations and digital innovations.
“We need to take with us what’s been working” during the pandemic, “and I think that will help with some of the issues that we’ve previously been having” in delivering care.
“It’s important we do as much as we can to empower ourselves and the people that we’re caring for and we must remember that as a team, together everybody achieves more,” Milne added.
Professor Partha Kar, associate national clinical director for diabetes for NHS England and a consultant in diabetes medicine at Portsmouth Hospitals NHS Trust, chaired the session.
In the second presentation, Dr Deborah Wake, clinical reader at the Centre for Medical Informatics, Usher Institute, University of Edinburgh, took up the thread about the use of digital services during the COVID-19 pandemic.
She said that there are three main areas where such technologies showed their potential: remote patient support and education; at home screening and testing; and patient triage and risk stratification.
Wake discussed a number of tools for patient triage in addition to those presented by Milne, but said that the issue with all of them is that the triage documents are “being deployed in a very manual way”.
In other words, clinicians are “looking up patient records one by one, making a decision on that patient record and then moving on, and that’s not an efficient, timely, way to do it”.
Dr Wake noted that “most of us are now operating in environments where at least the GP practice systems collect this data routinely, and we should therefore be able to automate a system and a process that allows triage to be delivered much more efficiently and effectively across large areas”.
To those ends, she and her colleagues have been examining how to deploy automated triage and risk prediction, which “can be through simple rules or it can be through more sophisticated machine learning predictive analytics”.
The latter may allow clinicians to predict across large populations the risk of complications such as hypoglycaemia, diabetic ketoacidosis, kidney disease, retinopathy, stroke, heart disease, amputation, hospitalisation, and death.
“Within each of these settings we can actually pin down who are the high risk patients or the medium risk or the low risk patients…and create a list, which then can go into, an automatic email alert or can be used by an administrator to recall patients,” Dr Wake said.
These tools can also be used to predict drug responses, and support patients through social tools, and promote sub-typing with diabetes.
However, Dr Wake emphasised that “there needs to be a real drive from the top in terms of policies and leadership around this”.
“I think triage is incredibly important but at the moment it is not being delivered in an efficient, effective way, and I think through the use of digital and data we can be doing that much better.”
No funding declared.
Nicola Milne declares funding relating to educational sessions, and conference and advisory board attendance from: BD, Boehringer Ingelheim, BMS/AstraZeneca, Eli Lilly, Janssen, MSD, Takeda, Novo Nordisk, Sanofi, Napp, Abbott and Ascensia, MyLan, Roche.
Dr Wake is co-founder and shareholder of MyWay digital health.
Diabetes UK Professional Conference: Online Series: Abstract: The who, what, where and when of diabetes care during the COVID-19 pandemic. Presented October 27.
Diabetes UK Professional Conference: Online Series: Abstract: Contribution of digital services. Presented October 27.