Case Study – the South Eastern Health and Social Care Trust
In 2012, Northern Ireland’s Chief Medical Officer, Dr. Michael McBride, identified d-Nav® as an opportunity to fundamentally transform patient care. As such, Dr. McBride initiated an evaluation of the applicability of the d-Nav service as a regional solution to support insulin users in Northern Ireland. The South Eastern Health and Social Care Trust diabetes care team volunteered to conduct the evaluation.
About the South Eastern Trust
The South Eastern Health & Social Care Trust is one of 5 Trusts within Northern Ireland. The Trust is an integrated organization, incorporating acute hospital services, community health and social services and serves a population of approximately 345,000 people with a budget of around £500 million.
The South Eastern Trust (SET) covers the local government districts of Ards, North Down, Down and Lisburn. The main hospital bases are: Ards Community Hospital, Bangor Community Hospital, Downe Hospital, Downshire Hospital, Lagan Valley Hospital and the Ulster Hospital. Community bases are located in many local towns and villages from Moira in the West to Portaferry in the East and from Bangor in the North to Newcastle in the South.
Under the leadership of Dr. Roy Harper, the SET provides secondary diabetes care services to about 3,300 people through its different locations. The majority of these patients, about 2,500 people, have type 2 diabetes. At the SET, nearly 1,800 people with type 2 diabetes use insulin as the primary therapy for their diabetes.
On average, the SET diabetes care team records 42,000 patient encounters per year. Clinical outcome with respect to total cholesterol and blood pressure are excellent, yet average HbA1c is above 8% [DCCT]. The SET is now utilizing the d-Nav service to enhance insulin therapy and improve outcomes for its insulin users.
At present nearly 40% of the SET insulin users are relying on the d-Nav service to enhance their insulin use. An average patient is in his or her late 50s, has been diagnosed with diabetes for about 10 years, and has been an insulin user for about 5 years. Patients are referred with an average baseline HbA1c of 9.4% and 80% of patients have baseline HbA1c > 8%. Within 6-12 months most patients achieve treatment goals and are then able to maintain an average HbA1c of 7% while using d-Nav.
Satisfaction levels are very high with over 96% of patients saying yes to the question: “In relation to the overall use of d‐Nav, are you happy with the support and advice you have received from the Diabetes Team?” This can also explain the very high retention rates of the service, with more than 90% of people with type 2 diabetes that have ever been referred to the service still using it to a great level of success.
Health Economics Impact
Initial evaluation of d-Nav suggests it is significantly cheaper than the standard of care. Savings are introduced in three different areas: elimination of medication waste, improved healthcare resource utilization, and reduced cost of short-term complications like diabetes foot ulcers (DFU).
In many cases, insulin users with HbA1c > 8% are prescribed additional medications, such as DPP-4 inhibitors, SGLT-2 inhibitors, or GLP-1 agonists to improve glycemic control. For most d-Nav subscribers, additional medications can be discontinued as the d-Nav digital insulin enhancement results in optimal glycemic control without the need for concomitant medications.
Diabetes foot ulcers (DFU) are perhaps the most challenging short-term diabetes complication. They are not only extremely expensive but also have a 3-year mortality rate, which is higher than many types of cancer. DFU prevalence rate among Medicare beneficiaries is 12.8% with an additional annual associated cost of over $15,000 per episode. When a patient’s HbA1c is 7% or lower, the average DFU will heal in 31 days. However, if a patient’s HbA1c is 8% or greater the average DFU will heal in 147 days.
The third beneficial effect of d-Nav can be seen through better utilization of secondary care resources. Insulin is generally viewed as a complex specialty medication that requires secondary care support. Many insulin users with type 2 diabetes are referred to the SET to provide support for their insulin use. Transforming Your Care sets out an overarching road map for change in the provision of health and social care services in Northern Ireland. It focuses on reshaping how services are to be structured and delivered in order to make best use of all resources available to us, and in so doing, ensure that services are safe, resilient and sustainable into the future. The d-Nav service allows the SET to enhance primary care services by offering expert insulin support in addition to its secondary care services.
The SET uses a simple protocol to refer patients to the d-Nav service. Eligible patients are adult insulin users, and have HbA1c > 8% yet a target HbA1c < 7.5%. About 70% of the SET insulin users meet that description. Once a patient is referred, a d-Nav specialist nurse contacts the patient and sets them up with d-Nav. The service includes structured follow up and support to verify patients are successful in achieving their treatment goal. The structured follow up also provides a continuum of clinical triaging to alert the SET physicians when further intervention is required.
The HCP Portal allows the SET physicians to log in to the d-Nav service database and view their patient information 24/7. The Portal tracks all contacts made between the patient and the d-Nav nurses as well as lab results and d-Nav downloads.
Within a couple of years, the South Eastern Trust was able to shift nearly 40% of its insulin using patient population to the d-Nav service. Doing so significantly improved clinical outcomes and patient satisfaction levels as well as reduced the total cost of care. The collaboration between the Hygieia team and the SET team has been excellent. The SET physicians utilize Hygieia’s HCP Portal to follow their patients’ progress and increase efficiency. Based on the success of d-Nav at the SET, Hygieia has recently been awarded a tender to provide the d-Nav service as a regional solution in Northern Ireland.