The document discusses the Three Dimensions of Care for Diabetes (3DFD) program, which addresses diabetes management for individuals with psychological and social needs, highlighting the significant economic burden of diabetes on the NHS. It presents findings from research showing how integrated mental and physical healthcare can improve outcomes, such as glycaemic control and psychological health, although costs for patients may rise. The document also outlines the importance of collaborative care models and offers insights on future funding for integrated services.

1. Three Dimensions of Care for Diabetes
(3DFD) – diabetes management for people
with psychological/social needs
Dr Carol Gayle, Consultant Diabetologist
Dr Anne Doherty, Consultant Liaison Psychiatrist
27th January 2016

2. The cost of diabetes to the NHS
1/10th of NHS budget/yr: ~ £10 billion
£1 million per hour
Amputations from diabetic foot disease most
common reason for amputation
Inpatient admissions twice as long

3. Depression is associated with all stages of
diabetes
odds ratio
1.37-1.60
Pre-diabetes: Mezuk Diabetes Care 2008; Kan Diabetes Care 2012
Diabetes: Anderson et al Diabetes Care 2001
Glycaemic control: Lustman et al Diabetes Care 2000
Complications: de Groot et al Psychosom Med 2001
Mortality: Ismail et al Diabetes Care 2007; Winkley Diabetologia 2011
odds ratio
2.1
effect size
0.17
odds ratio
3.1
hazards
ratio
2.0-5.0
pre-diabetes diabetes suboptimal
glycaemic control
complications mortality
3

4. Depressive disorder and mortality in people with
their first diabetic foot ulcer (n=253).65.7.75.8.85.9.951
3 6 9 12 15 18
Observation time (months)
Major depressive disorder
Minor depressive disorder
No/minimal depression
Ismail et al DiabetesCare 2007
Adjusted hazard ratio 3.23 (1.39 to 7.5)
Adjusted hazard ratio 2.73 (1.38 to 5.40)
Cumulativesurvival
4
0

5. Other psychiatric conditions
Anxiety disorders - 14% anxiety disorder (Grigsby 2002)
Psychosis 7.3% vs 5.2% (Nuevo 2011, de Hert 2006)
Eating disorder – 6-10% x2 general population (Young 2013)
Cognitive impairment - x2 decline (Rouch 2012)

6. 2013 estimated prevalence of diabetes
by local authority
2030 estimate of diabetes, assuming obesity
continues to rise at the current rate
Contains Ordnance Survey data
© Crown copyright and database right 2013Source: Diabetes Prevalence Model for local authorities in England

7. Social problems

8. Standards

9. Psychologica
l care
Diabetes
care
Social care
But services don’t reflect this…
Diabetes
care
Psychologica
l care
Social care

10. But services don’t reflect this…
Diabetes
care
Psychologica
l care
Social care
Secondary
Community/
Intermediate
Primary

11. Teamcare
• RCT of 214 participants with
poorly controlled diabetes +/-
coronary heart disease, and
coexisting depression
• Intervention: a medically
supervised nurse, working with
each patient's primary care
physician, provided guideline-
based, collaborative care
management, with the goal of
controlling risk factors
• Reduction in HbA1c of 0.6%
• Katon 2010
ADaPT
• RCT of 344 participants with
T1DM
• Motivational interviewing +/-
Cognitive behaviour therapy v
usual care
• Reduction in HbA1c
• 0.5% MET + CBT v usual care
(p = 0.008)
• 0.2% MET v usual care
• 0.3% MET + CBT v MET
• Greater reduction in HbA1c
associated with higher HbA1c,
and younger age at baseline
• Ismail 2010

12. Complex care models
• Most research in diabetes
• Meta-analysis (Atlantis 2014) found 7 RCTs, and concluded
that collaborative or integrated care significantly improved
depression and glycaemic control in individuals with
diabetes and depression.
– However the overall weighted mean difference was small, and
the authors noted that most of these studies were conducted in
the US and may not be generalizable to other healthcare
settings.
• Clustered RCT (Coventry 2015)
– modest improvement in depressive symptoms at 4 months
– did not examine glycaemic control or physical health
outcomes, and it

13. STEP 1: All known and suspected presentations of
depression
STEP 2: Persistent subthreshold depressive symptoms;
mild to moderate depression
STEP 3: Persistent subthreshold depressive
symptoms or mild to moderate depression with
inadequate response to initial interventions;
moderate and severe depression
STEP 4: Severe and complex1
depression; risk to life; severe self-
neglect
Low-intensity psychosocial interventions, psychological
interventions, medication and referral for further
assessment and interventions
Medication, high-intensity psychological interventions,
combined treatments, collaborative care2, and referral
for further assessment and interventions
Medication, high-intensity psychological
interventions, electroconvulsive therapy, crisis
service, combined treatments,
multiprofessional and inpatient care
Focus of the
intervention
Nature of the
intervention
Assessment, support, psycho-education, active monitoring and
referral for further assessment and interventions
NICE stepped-care model

14. • debt management
• housing support
• occupational rehabilitation
• literacy
• advocacy
• medication support
• biomedical monitoring
• diabetes education
• technology
• complications
• increased self efficacy
towards diabetes
• patient reported outcomes
• patient led case meetings
• diagnostic assessment
• risk management
• psychotropic medications
• brief psychological
treatments
The model
Psychiatry/
Psychology
Diabetes
Social
interventions
Patient

15. Mental Health
Diabetes &
physical
health
Social
interventions
Patient

16. 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%

17. Quality in Care Awards
2011
BMJ Awards 2014
DiabetesTeam of theYear
Mary McKinnon Lecture
DUK 2015
NHS Innovation
Challenge Prize 2015

18. Impact & Dissemination
Other Services
Hillingdon, Oxford
Hull, NHS Lothian,
CNWL
Service commissioned by Lambeth and Southwark CCGs from 2014

19. Timelines
Phase I
• Sept2010
• March2011
Phase II
• Oct2012
• Sept2013
Service
• Sept2013
• present

20. Methods
Time 1
Time 2
Control3DFD
Lambeth &
Southwark
Lambeth &
Southwark
Lewisham
Lewisham
Inclusion criteria
HbA1c >= 75mmol/mol
Mental or social problem
Resident in borough

21. Methods
Time 1
Time 2
Control3DFD
Lambeth &
Southwark
Lambeth &
Southwark
Lewisham
Lewisham

22. Methods
Time 1
Time 2
Control3DFD
Lambeth &
Southwark
Lambeth &
Southwark
Lewisham
Lewisham

23. Inclusion Criteria
• 3DFD
– HbA1c >=
75mmol/mol
– Mental health or
social problems
– Resident L/S
• Control
– HbA1c >=
75mmol/mol
– Mental health or
social problems
– Resident Lewisham

24. Measures
Main outcome measures HbA1c
Cost
Baseline demographics Age, gender, ethnicity, education,
employment
Baseline clinical T1/T2, insulin, duration, complications
Physical health measures BMI, BP, Cholesterol,ACR
Psychological measures Depression PHQ-9
Anxiety GAD-7
Diabetes distress scale
Social measures Outcome/Recovery star
SF12

25. Demographics: age
46.95 57.24
0
10
20
30
40
50
60
70
3DFD (n= 275) Control (n=292)
mean age
mean age
p<0.001

26. Demographics: gender
40%
60%
3DFD
n=275
Male
Female 52%
48%
Control
n=292
Male
Female
p=0.001

27. Demographics: ethnicity
35%
51%
7%
6%
1%
3DFD
n=231
White
Black
Asian
Mixed
Other
46%
36%
6%
12%
0%
Control
n=292
White
Black
Asian
Mixed
Other
p=0.002

28. Clinical characteristics: diabetesT1/T2
32%
68%
3DFD
n=275
T1DM
T2DM
8%
92%
Control
n=281
T1DM
T2DM
p<0.001

29. Duration of diabetes
11.47 9.33
0
2
4
6
8
10
12
14
3DFD (n=206) Control (n=273)
Mean duration of diagnosis (years)
years
p=0.005

30. Clinical characteristics : on insulin
77%
23%
3DFD
n=238
on insulin
not on
insulin
42%
58%
Control
n=287
on insulin
not on
insulin
p<0.001

31. % with complications at baseline
0
10
20
30
40
50
60
70
80
90
100
3DFD (n=193) Control (n=264)
Total Complications
Macro
Micro
p=ns

32. HbA1c at baseline (mmol/mol)
113 92
0
20
40
60
80
100
120
3DFD (n=268) Control (n=288)
HbA1c
HbA1c
p<0.001

33. HbA1c at 1 year (mmol/mol)
99 9282 86
0
20
40
60
80
100
120
3DFD (n=202) Control (n=274)
baseline
1 year
p<0.001p<0.001

34. 16.2 6
0
2
4
6
8
10
12
14
16
18
3DFD (n=202) Control (n=274)
Reduction HbA1c
change (mmol/mol)
Decrease in HbA1c

35. Cholesterol at 1 year
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
5
5.1
5.2
3DFD (n=101) Control (n=268)
baseline
1 year
P=0.02 P=0.54

36. MeanACR at 1 year
0
2
4
6
8
10
12
14
16
3DFD (n=75) Control (n=224)
baseline
1 year
P=0.56 p<0.001

37. BMI at 1 year
30.6
30.7
30.8
30.9
31
31.1
31.2
31.3
31.4
31.5
31.6
31.7
3DFD (n=121) Control (n=247)
baseline
1 year
P=0.4 P=0.5

38. Unmet need
0
20
40
60
80
100
120
Nil Known
diagnosis
New
diagnosis
New relapse
N
Psychiatric Diagnosis
Psychiatric diagnosis: new, known or relapse

39. Depression (PHQ-9)
0
2
4
6
8
10
12
baseline year 1
mean score, n=77
mean score
P<0.001

40. Anxiety (GAD-7)
0
2
4
6
8
10
baseline 1 year
mean score, n=77
mean score
P<0.001

41. Diabetes specific distress (DDS)
40
42
44
46
48
50
52
baseline 1 year
mean score, n=77
mean score
p=0.005

42. Social functioning
(Recovery/Outcome Star)

43. Social functioning
(Recovery/Outcome Star)
50
51
52
53
54
55
56
57
58
Baseline 1 year
mean score, n=76
mean score
p<0.001

44. 0
200
400
600
800
1000
1200
3DFD Control
Year before (£,000)
Year after (£,000)
Cost of 3DFD and Intervention group:
baseline and follow up

45. 0
5
10
15
20
25
30
35
40
45
50
3DFD Control
% increase in cost
% change
Proportion increase per group

46. Multivariate analysis
B p Confidence Interval
Age 26.003 0.23 -16.551 - 68.557
Gender 1.349 0.625 -4.072 - 6.770
Ethnicity -1260.744 0.009 -2199.929 - -321.559
Baseline Costs 0.356 <0.001 0.305 - 0.407
Change in HbA1c (mmol/mol) -14.157 0.046 -28.071 - -0.242
Type of diabetes -1825.054 0.038 -3551.480 - -98.629
Intervention or control group 785.316 0.179 -362.007 - 1932.639

47. Multivariate analysis
Type 1 diabetes Type 2 diabetes
B p Confidence Interval B p Confidence Interval
Age -46.781 0.473 -176.400 - 82.837 37.056 0.1 -7.188 - 81.301
Gender -1226.996 0.458 -4513.166 - 2059.174 1.502 0.565 -3.632 - 6.636
Ethnicity -1231.235 0.374 -3980.141 - 1517.671 -1421.943 0.004 -2399.155 - -444.732
Baseline Costs 0.656 <0.001 0.463 - 0.849 0.318 <0.001 0.268 - 0.369
Change in HbA1c (mmol/mol) -10.332 0.316 -30.777- 10.113 -20.619 0.089 -44.391 - 3.153
Intervention or control group 1500.399 0.491 -2834.036 - 5834.834 603.162 0.302 -545.528 – 1751.852

48. Reduction in HbA1c
0
2
4
6
8
10
12
14
16
18
3DFD Control Usual
care
Glicazide Gliptin SGLT2
HbA1c (mmol/mol)
HbA1c (mmol/mol)

49. HbA1c at 2years
n=60
98
87
82 82
70
75
80
85
90
95
100
Baseline 6 months 1 year 2 years
HbA1c,mmol/mol
Time
Maintenance of HbA1c

50. Implications
• Integrated mental and physical healthcare is
effective in improving outcomes: glycaemic
control, psychological health, social
functioning
• Costs for patients rise, but the proportion by
which they rise may be reduced by integrated
care

51. Additional Areas
• “reverse model” – diabetes care integrated
with CMHT for SMI (PODS study)
• Model cost of avoidance of complications
based on UKPDS and health economics
• What will be the models of funding for the
future for integrated services?

52. Regional
Innovation
Fund