Summary
Individuals with Early Onset Type 2 Diabetes (EOT2D) represent a high-risk group often underserved by health systems. Using electronic medical record data, a risk stratification tool was developed to triage people with EOT2D into specialist clinics (high-risk and preconception clinics). General practices were incentivised to refer within a streamlined electronic referral system and additional support was provided to high-prevalence practices. Within 15 months, 485 appointments had occurred within preconception clinics; 148 appointments within high-risk clinics. The high-risk clinic was associated with -2.0% reduction in HbA1c and -1.3mmol/L in triglycerides at six months, while patient feedback showed high satisfaction.
Innovation/Novel approach to an existing problem
EOT2D is defined as the diagnosis of Type 2 diabetes below 40 years. In Leicester, Leicestershire and Rutland (LLR), a service pathway was developed for this group, aligned with T2Day funding. Pathway development comprised: a literature search to identify important considerations when designing the service; a regional pathway for management of people with EOT2D; a search of electronic medical records (EMRs) to assess the feasibility of the pathway. EMR searches were conducted across the ICB to understand the burden of vascular risk factors associated with EOT2D and achievement of care process targets. Some individuals identified had a higher risk of complications and were likely to require more resource-intensive intervention. A total of 2,772 adults (35% women) and 40 children with EOT2D were identified. The need for a specialist clinic was reaffirmed, with at least 299 (10.8%) people meeting HbA1c criteria. Additionally, 468 (48.2%) women were at high risk of pregnancy-related complications, establishing the need for a bespoke pre-pregnancy clinic. Since February 2024, the Leicester Diabetes Centre (LDC) pathway has been identifying and supporting people living with EOT2D. Practices were provided with pre-made EMR searches to easily identify patients eligible for the specialist clinics. LDC supported 30 general practices with the highest prevalence of EOT2D to search for eligible patients. The team contacted the individual about the service and referred if consent was given. Eden designed an online training package for healthcare professionals to run in parallel.
Equality, Diversity and Variation
EOT2D is more common in people from ethnic minorities and those living in the most socioeconomically deprived areas. Leicester has a higher-than-average prevalence of type 2 diabetes (9.0% vs 6.2% nationally) and has high levels of deprivation (32nd most deprived out of 317 local authorities). Additionally, Leicester’s diverse population includes a high proportion of ethnic minorities, with 43% identifying as Asian and 41% born outside of the UK. EMRs were used to analyse ethnic variance and levels of deprivation and identified that most patients seen within the high-risk clinic were of South Asian ethnicity (60.8%). Index of Multiple Deprivation data highlighted that 75.17% of patients supported in clinic are in the most deprived areas. Also, 37 of the 136 patients supported are non-English speaking (27.2%). The use of translation services to support appointments has been key. Staff developed a personalised way to communicate about appointments, and added a local language line service for appointments.
Impact to Patient Care
Since March 2024, there has been continued effort to find and support high-risk patients living with EOT2D. The most recent data collection highlighted 833 individuals eligible for the high-risk clinic. Outreach support searches have been conducted within 18/30 most prevalent practices to date. For these, EMR practice unit access was provided to the Diabetes Specialist Nurse (DSN) outreach professionals based in LDC to enable them to conduct the searches. Of the eligible individuals, 164 (19.7%) were identified. Consent was gained from 154 (18.5%) who were referred to the high-risk EOT2D clinic. This highlights not only the importance of the pathway and intervention, but also of the Eden EOT2D online training programme, which had over 120 local primary healthcare professionals registered by the end of March 2025. The service has made a substantial positive impact on diabetes care. Some clinic patients have already established micro and macrovascular complications, so support for them is vital. The clinic focuses on shared decision making and initiating medications with robust evidence of cardiovascular protection. Locally available psychological support referral pathways have also been used in the clinics. Early morning, afternoon and early evening consultations are offered (face to face, telephone, video call). In 2023, there were 100 appointments to clinically manage preconception for local women living with diabetes. Approximately 50% were living with T2D. In 2024, with T2Day funds, capacity was increased, providing approximately 485 appointments, an increase of 385%. This included around 30 women with EOT2D referred from GP practices, and two-to-three patients per month referred through midwives.
Results
Data analysis was completed on patients (n=111) who had their first appointment in 2024. It highlights a significant reduction at six months in HbA1c (P<0.001) of 2.03%, triglycerides (P=0.019) of -1.3mmol/L, and body mass index (P=0.188) with a reduction of 0.5 kg/m2. The results showed no change in blood pressure or cholesterol, but the mean result was within the recommended target range. Data collection at six months does not show the true potential impact for these patients. Providing regular, enhanced support via a a multidisciplinary team beyond established primary care support is likely to have contributed to the positive results. There were 136 patients who had appointments in the EOT2D clinic as of April 2025, 23 of whom did not attend (DNA) (16.9%). One of the potential reasons why the DNA rate was not higher is because of the flexible and accommodating approach to supporting patients, and offering translation support. For pregnancy and preconception, there has been a 385% increase in the number of appointments for women living with diabetes.
User Feedback
A patient feedback questionnaire was developed with LDC. To date, 23 patients have completed it, using a Likert scale from 1-5 (1= very poor, 5= excellent). The overall quality of care received within the service scored a mean average of 4.6. ‘Has the service helped you to manage your diabetes better?’ scored a mean average score of 4.5. ‘Did the way we arranged your appointment work well for you?’ scored a mean average of 4.3. Positive feedback was received from relevant stakeholders and healthcare professionals.
