• Mike Robling, Rachel McNamara, Kristina Bennert, Christopher C Butler, Sue Channon, David Cohen, Elizabeth Crowne, Helen Hambly, Kamila Hawthorne, Kerenza Hood, Mirella Longo, Lesley Lowes, Tim Pickles, Rebecca Playle, Stephen Rollnick, Emma Thomas-Jones, and John W Gregory.
• South East Wales Trials Unit, Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK. roblingmr@cardiff.ac.uk
• BMJ. 2012 Jan 1;344:e2359.

ObjectiveTo evaluate the effectiveness on glycaemic control of a training programme in consultation skills for paediatric diabetes teams.DesignPragmatic cluster randomised controlled trial.Setting26 UK secondary and tertiary care paediatric diabetes services.Participants79 healthcare practitioners (13 teams) trained in the intervention (359 young people with type 1 diabetes aged 4-15 years and their main carers) and 13 teams allocated to the control group (334 children and their main carers).InterventionTalking Diabetes programme, which promotes shared agenda setting and guiding communication style, through flexible menu of consultation strategies to support patient led behaviour change.Main Outcome MeasuresThe primary outcome was glycated haemoglobin (HbA(1c)) level one year after training. Secondary outcomes were clinical measures (hypoglycaemic episodes, body mass index, insulin regimen), general and diabetes specific quality of life, self reported and proxy reported self care and enablement, perceptions of the diabetes team, self reported and carer reported importance of, and confidence in, undertaking diabetes self management measured over one year. Analysis was by intention to treat. An integrated process evaluation included audio recording a sample of 86 routine consultations to assess skills shortly after training (intervention group) and at one year follow-up (intervention and control group). Two key domains of skill assessment were use of the guiding communication style and shared agenda setting.Results660/693 patients (95.2%) provided blood samples at follow-up. Training diabetes care teams had no effect on HbA(1c) levels (intervention effect 0.01, 95% confidence interval -0.02 to 0.04, P=0.5), even after adjusting for age and sex of the participants. At follow-up, trained staff (n=29) were more capable than controls (n=29) in guiding (difference in means 1.14, P<0.001) and agenda setting (difference in proportions 0.45, 95% confidence interval 0.22 to 0.62). Although skills waned over time for the trained practitioners, the reduction was not significant for either guiding (difference in means -0.33, P=0.128) or use of agenda setting (difference in proportions -0.20, -0.42 to 0.05). 390 patients (56%) and 441 carers (64%) completed follow-up questionnaires. Some aspects of diabetes specific quality of life improved in controls: reduced problems with treatment barriers (mean difference -4.6, 95% confidence interval -8.5 to -0.6, P=0.03) and with treatment adherence (-3.1, -6.3 to -0.01, P=0.05). Short term ability to cope with diabetes increased in patients in intervention clinics (10.4, 0.5 to 20.4, P=0.04). Carers in the intervention arm reported greater excitement about clinic visits (1.9, 1.05 to 3.43, P=0.03) and improved continuity of care (0.2, 0.1 to 0.3, P=0.01).ConclusionsImproving glycaemic control in children attending specialist diabetes clinics may not be possible through brief, team-wide training in consultation skills.Trial RegistrationCurrent Controlled Trials ISRCTN61568050.

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