Summary

Uncontrolled diabetes is the main reason surgical operations are postponed. Surgery is delayed for considerable periods, often without optimisation services in place, placing strain on primary and secondary care services. Patients often end up on increasing numbers of medications without underlying issues being addressed. This new intervention combined specialist dietetic support with new technologies to allow patients to optimise their diabetes with feedback loops to the hospital teams, reducing workload and leading to better surgical outcomes and longer-term health.

Innovation

The diabetes optimisation pathway prior to this project was ineffective, often involving escalation in diabetes medications over months and multiple primary care appointments. Patients often returned for a repeat pre-assessment (PAC) review without sufficient reduction in their HbA1c for surgery to proceed. In May 2023 diabetes dietitians devised a one-year pilot service for patients in the most deprived areas across the North ICP area (Newcastle, Northumbria and Gateshead NHS Trusts) to improve the optimisation pathway and clinical outcomes. It ran between June 2023 and June 2024 and was integrated into the pre-assessment processes for two large NHS Trusts. Eligible patients with HbA1c over 69mmol/mol were referred directly to the service. This Waiting Well Diabetes programme comprised diabetes education alongside funded flash glucose monitoring. Service users were supported to interpret sensor data and make changes to achieve the NCPOC perioperative glycaemic targets. Once optimised, results were sent to the surgical team to advise readiness for surgery. Service users were supported until their surgery date and followed up afterwards before discharge. Pre-identified outcomes included numbers of referrals, patient uptake, numbers optimised and having had surgery, time to optimisation, and change in HbA1c, medication use, and Diabetes Distress.

Equality, Diversity and Variation

This intervention was commissioned for adults with any type of diabetes meeting the following criteria: listed for non-emergency elective surgery; HbA1c ≥ 69mmol/mol; primarily Index of Multiple Deprivation (IMD) decile 1 or 2 (most deprived). Interviews with 10 people who met these criteria informed the service design. Interviewees expressed a preference for glucose sensor technology. Support for those not proficient with smartphones/apps was also needed. To address potential financial barriers, sensors and other patient resources were costed into service provision. During the initial optimisation period, patients were provided with two glucose sensors and a Carbs & Cals book. Another sensor was provided two weeks prior to surgery, enabling all patients to access the technology for a defined period and find out what factors impacted their blood glucose levels. A5X devices were supplied to those without smartphones and more basic readers for those without home wi-fi access or who did not use mobile apps. Flexible delivery included weekly clinics at NHS sites in the target areas, home visits and telephone follow-up support. A structured, six-week group programme held in community venues facilitated peer support and more time-efficient programme delivery. Referrals to a local hub for support or onward referral for wider psychosocial factors were available. Two people living with type 1 diabetes and dyslexia were supported with carbohydrate counting education using visual resources.

Results

During the first year, 149 referrals were received, of which 137 were eligible (92%). Five people declined to participate. Complete data is available for 57 of the 58 patients who had planned surgery by end of June 2024. Average age at referral was 61±11.4 years, 58% male, 91% White British. Regarding types of diabetes, eight (14%) were type 1, 47 (82%) were type 2 and two (4%) were type 3c. A total of 42 (74%) were on insulin at referral. In terms of deprivation, 65% were from IMD deciles 1 and 2. The median (IQR) duration of dietetic support provided was 8(6) weeks, with 81% having one-to-one appointments. For this intervention, optimisation is defined as achieving HbA1c less than 69mmol/mol as per Perioperative Society guidelines. As HbA1c takes three months to reflect improved glucose levels, sensor GMI (estimated HbA1c) was used for end-of-intervention values, based on two weeks of data with sensor use ≥70% to provide a validated HbA1c estimate. Mean ± sd HbA1c at referral was 89±19 mmol/mol (median [IQR]: 84[19]mmol/mol); mean GMI (end of intervention) was 58±11mmol/mol (median [IQR]: 56[11]mmol/mol); mean HbA1c reduction (referral to end of intervention): 32±19mmol/mol (median[IQR] reduction: 29[18]mmol/mol). A total of 95% of patients (54/57) achieved optimisation. Although three did not reach optimisation before their surgery, they achieved clinically significant HbA1c reductions (120 down to 76mmol/mol, 88 to 75mmol/mol and 154 to 123mmol/mol, respectively). No adverse events or increase in hypoglycaemia were observed. To maximise outcomes with a limited period of sensor use, education around dietary impact on glycaemia and guidance around portions was provided prior to first sensor application. Individualised dietary counselling was provided. To achieve the improvements in glycaemia outlined, non-insulin medication changes were required for patients with Type 2 diabetes. Of 42 patients on insulin, the net change in TDD was a reduction of 388 units/day (141,629 units/year), saving 472 insulin Flexpens.

User Feedback

Feedback was positive, with constructive criticism actively encouraged and acted upon.

Dissemination and Sustainability

Waiting Well Diabetes is an ICP-wide service based in Newcastle Hospitals Trust (NUTH). It is a collaboration between NECS (North East Commissioning Support), NUTH and Northumbria NHS Trusts, with Gateshead joining soon. The initiative links with specialist diabetes teams and GP practices, and refers on to community teams for holistic patient support. The project is part of an NENC ICS-wide Waiting Well pilot across the North-East region, with inequalities funding that has been extended for another year. It has been shortlisted as a finalist in the Trust’s Celebrating Excellence Awards 2024. The initiative has been shared at meetings and outcomes published in a peer-reviewed journal. The business case for permanency proposes making the service available to all patients with diabetes awaiting surgery. Funding is approved for a 0.6wte Band 3 Dietetic Support worker to support the total 1.5wte diabetes dietitians delivering the service. The Band 8a dietitian has received approval for supplementary prescribing to reduce waiting time/additional HCP appointments. An online version of the programme is planned.