Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester, UK.
Centre for Primary Care and Health Services Research, NIHR ARC Greater Manchester, School of Health Sciences, The University of Manchester, Manchester, UK.
BMJ Open Diabetes Res Care. 2020 Dec;8(2). doi: 10.1136/bmjdrc-2020-001835.
Diabetes prevention programs (DPPs) are effective, in a pre-diabetic population, in reducing weight, lowering glycated hemoglobin and slowing the progression to diabetes. Little is known about the relationship between participation in DPPsand participant characteristics or service delivery. We investigated uptake and retention in England's NHS DPP, reporting on variability among patient subgroups, providers, and sites.
This prospective cohort study included 99 473 adults with non-diabetic hyperglycemia referred to the English DPP between 2016 and 2017. The program seeks to change health behaviors by offering at least 16 hours of group education and exercise. Multilevel logistic regression models were used to analyze variation in uptake, retention, and completion.
Uptake among 99 473 adults referred to the program was 56% (55 275). Among 55 275 who started the program, 34% (18 562) achieved the required dose and 22% (12 127) completed the full course. After adjustment for variation in case mix, substantial heterogeneity in uptake and retention was seen across four service providers (uptake OR 1.77 (1.33, 2.34), 4.30 (3.01, 6.15), and 1.45 (1.07, 1.97) compared with the reference provider) and between sites (uptake for typical individuals ranged from 0.32 to 0.78 across the middle 95% of sites, intraclass correlation coefficient (ICC) 0.07). Higher levels of retention and completion were seen where some out-of-hours provision was offered (retention OR 1.32 (1.25, 1.39)).
This study provides the first independent assessment of participation in the English DPP and the first study internationally to examine the impact of DPP service delivery on participation. When implementing a large-scale DPP, heterogeneity in service provision between different providers and sites can result in variable participation beyond that attributable to case mix, with potential consequences for effectiveness and health inequalities. Extending out-of-hours provision may improve participation in prevention programs.
糖尿病预防计划（DPP）在糖尿病前期人群中有效，可降低体重、糖化血红蛋白水平并减缓向糖尿病的进展。然而，对于 DPP 参与度与参与者特征或服务提供之间的关系，我们知之甚少。我们调查了英格兰国民保健署（NHS）DPP 的参与情况，并报告了患者亚组、提供者和站点之间的可变性。
本前瞻性队列研究纳入了 2016 年至 2017 年期间被转诊至英格兰 DPP 的 99473 名非糖尿病高血糖成年人。该计划旨在通过提供至少 16 小时的小组教育和运动来改变健康行为。使用多水平逻辑回归模型分析了参与度、保留率和完成率的变化。
在被转诊至该计划的 99473 名成年人中，有 56%（55275 人）参与了该计划。在开始该计划的 55275 人中，有 34%（18562 人）达到了所需剂量，22%（12127 人）完成了全程。在调整病例组合的变异性后，在四个服务提供者之间（与参考提供者相比，接受率 OR 1.77（1.33，2.34）、4.30（3.01，6.15）和 1.45（1.07，1.97））和站点之间（对于典型个体，在中间 95%的站点中，接受率范围为 0.32 至 0.78，组内相关系数（ICC）为 0.07）存在较大的异质性。在提供一些非工作时间服务的地方，保留率和完成率较高（保留率 OR 1.32（1.25，1.39））。
本研究首次独立评估了英格兰 DPP 的参与情况，也是国际上首次研究 DPP 服务提供对参与度的影响。在实施大规模 DPP 时，不同提供者和站点之间的服务提供存在异质性，可能导致除病例组合之外的参与度存在差异，从而对有效性和健康不平等产生影响。延长非工作时间的服务可能会提高预防计划的参与度。
