196 Care network promoting the education of type 2 diabetic patients: short term efficacy and comparison with a hospital service specialised in diabetic care

Background, objectives The diabetes care network ‘Maison du diabete et de la nutrition de Nancy et 54’ (MDN54) is a territorial structure which organises formalised and structured therapeutic patient education (TPE) by a multidisciplinary team for type 2 diabetic patients (T2DM) or obese people, usually not treated by an endocrinologist. The goal of this study was to (1) compare baseline characteristics of the T2DM patients from MDN54 with patients followed in a diabetes university hospital department (CHU), (2) to describe the follow up of those patients during 1 year and (3) to compare the changes of some relevant parameters between the territorial and the hospital structure. Programme: description, implementation, monitoring elements T2DM patients are registered at MDN54 by their general practitioner. The patients take part to TPE programs according to a formalised programme as recommended by the HAS: educational diagnosis, group sessions and/or individual face-to-face meeting with an educator, assessment of self-management, and more educational sessions if needed. The sessions are conducted by a multidisciplinary team including private nurses, dieticians, physiotherapists, psychologists and chiropodist. All the sessions take place outside the hospital, at the head office of the MDN54 or in other quarters or cities (rooms offered by local authorities). The family physician is responsible for the annual diabetes check up according to the french national guidelines. TPE programmes have been adapted to primary care during training courses for general practitioners organised by the CHU team. This annual monitoring includes relevant clinical characteristics (body mass index, blood pressure, diabetes complications: retinopathy, neuropathy, wound risk level for diabetic feet, …) and biological results (HbA1c, LDL-cholesterol, HDL-cholesterol, triglycerides, creatinine9s clearance by MDRD, microproteinuria, etc). The MDN54’s cohort included 486 T2DM patients registered between 2005 and 2008; 243 patients had had a complete initial annual assessment and 100 patients 2 successive annual assessments. CHU9s cohort included 1997 patients and among them 848 T2DP with 2 successive annual assessments on the same period. Seventy-five patients of both populations were matched (CHUap and MDN54ap) using the propensity score on the initial values of several parameters (age, sex, duration of diabetes, BMI, total cholesterol, creatinine9s clearance, retinopathy, renal failure, neuropathy, wound risk, hypertension, peripheral vascular disease, treatment with insulin). Results in terms of clinical impact Initial age (62.8 vs 63.0 years), BMI (31.7 vs 31.3 kg/m 2 ) and HbA1c (7.53 vs 7.49%) of the two cohorts (MDN54 vs CHU) were similar (p=NS). Diabetes9 duration (14.3 vs 9.0 years), rate of retinopathy (28.3 vs 10.4%) and nephropathy (44.9 vs 22.2%) were higher in the CHUs cohort (p Discussion-conclusion The population treated by the diabetes care network MDN54 is in keeping with its preliminary objectives: to manage diabetes when the disease is recent and not very complicated. A formalised therapeutic patient education, initiated by the general practitioners in an organised network appears operational, with the support of diabetologists for expertise and training. First line nearby patients TPE for type 2 diabetes, outside the hospital, appears to be beneficial for metabolic control. This network is really useful for primary diabetes care and education. It facilitates the interprofessionnal cooperation as recommended by the HAS. Contexte, objectifs Le reseau «Maison du diabete et de la nutrition de Nancy et 54» (MDN54) est une structure territoriale qui organise des parcours formalises et structures d’education therapeutique (ETP) multi-professionnelle pour les personnes en surpoids ou diabetiques de type 2 (DT2) habituellement non suivies par un diabetologue. Le but de cette etude est 1) de comparer les caracteristiques initiales des patients DT2 de la MDN54 a celles de patients suivis dans un service hospitalo-universitaire de diabetologie (CHU), 2) de decrire l’evolution des indicateurs clinico-biologiques apres 1 an de suivi a la MDN d9un sous groupe de patients et 3) de comparer les resultats a 1 an entre la structure territoriale et la structure hospitaliere en tenant compte des facteurs confondants. Programme: description, mise en oeuvre, elements de suivi Le reseau MDN54 organise des parcours d9ETP pour des patients DT2 sur demande de leur medecin traitant, selon un schema formalise conforme aux recommandations de la HAS: diagnostic educatif, seances de groupes et entretiens individuels, bilan d9evaluation du parcours, reprise educative si necessaire. Les seances sont assurees par une equipe multiprofessionnelle incluant des infirmiers, des dieteticiens, des kinesitherapeutes, des pododologues, des psychologues, tous liberaux et formes a l9ETP. Elles ont lieu en dehors de l9hopital, dans les locaux de la MDN54 ou dans d9autres quartiers ou villes environnantes (salles mises a disposition par les collectivites locales). Le medecin traitant assure le suivi annuel formalise (formulaire ecrit autoduplique) et indemnise, selon les recommandations de bonnes pratiques et dans le cadre d9une formation continue dispensee par l9equipe hospitalo-universitaire. Au cours du bilan annuel sont releves des parametres cliniques (indice de masse corporelle, pression arterielle, complications du diabete: retinopathie, neuropathie, grade de risque podologique, etc.) et biologiques (HbA1c, LDL-cholesterol, HDL-cholesterol, triglycerides, debit de filtration glomerulaire selon le MDRD (DFG), microproteinurie, etc.). La cohorte MDN54 comporte 486 patients DT2 inclus entre 2005 et 2008, dont 243 ont eu un premier bilan d9inclusion et 100 ont eu 2 bilans annuels successifs exploitables pour l9analyse longitudinale. La cohorte CHU est formee de 1997 patients, dont 848 ont ete revus a un an sur la meme periode. Soixante quinze patients des deux populations ont ete apparies (CHUap et MDN54ap) selon la methode du score de propensite, sur les valeurs initiales de plusieurs variables (âge, sexe, anciennete du diabete, lMC, cholesterol total, DFG, retinopathie, insuffisance renale, neuropathie, risque podologique, HTA, arterite, traitement par l9insuline). Resultats en terme d9impact clinique L’âge (62,8 vs 63,0 ans), l9IMC (31,7 vs 31,3 kg/m 2 ) et l9HbA1c (7,53 vs 7,49%) initiaux des deux cohortes (MDN54 vs CHU) sont similaires dans les 2 populations (NS). L9anciennete du diabete (14,3 vs 9,0 ans), le taux de retinopathie (28,3 vs 10,4%) et de nephropathie (44,9 vs 22,2%) sont plus importants au CHU (p Discussion-conclusion La population DT2 du reseau MDN54 est conforme aux attentes: prise en charge des diabetes recents et peu compliques. L9ETP formalisee de proximite, « copilotee » par le medecin traitant dans un cadre structure, avec l9appui des diabetologues du CHU pour l9expertise et la formation continue, est operationnelle en medecine de ville. Elle est capable d9ameliorer le controle metabolique, au moins au debut de la maladie. Cette structure de premiere ligne fait naturellement partie du parcours de soins. Basee sur la cooperation interprofessionnelle, elle est un element clef de l9articulation ville – hopital.