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Improving clinical practice –
a world of experience
The Global Partnership for Effective Diabetes Management, including
the development of this slide set, is supported by GlaxoSmithKline
Need for an early and intensive approach
to type 2 diabetes management
• At diagnosis of type 2 diabetes:
50% of patients already have complications1
up to 50% of -cell function has
already been lost2
• Current management:
two-thirds of patients do not
achieve target HbA1c3,4
majority require polypharmacy
to meet glycaemic goals over time5
1UKPDS
Group. Diabetologia 1991; 34:877–890. 2Holman RR. Diabetes Res Clin Prac 1998; 40 (Suppl.):S21–S25. 3Saydah SH et al. JAMA 2004; 291:335–342.
4Liebl
A et al. Diabetologia 2002; 45:S23–S28. 5Turner RC et al. JAMA 1999; 281:2005–2012.
Management of diabetes is evolving
7.0
6.5
6.0
Tighter
HbA1c goals
New global
guidelines
EVOLVING PRACTICE
•Comprehensive
•Standard
•Minimal
Tailoring to health
systems
Individualised
HbA1c goals
Treating to target
vs. stepwise
Stepwise approach: delays control and
leaves patients at risk of complications
Diet and
exercise
OAD
monotherapy
OAD
monotherapy
uptitration
OAD
combination
OAD +
basal insulin
OAD +
multiple daily
insulin injections
10
HbA1c (%)1
9
Mean
8
7
6
Duration of diabetes
OAD = oral anti-diabetic
1Adapted
from Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.
2Stratton IM et al. BMJ 2000; 321:405–412.
Early, intensive intervention: reach glycaemic
goals and reduce the risk of complications
10
Diet and
exercise
OAD
monotherapy
HbA1c (%)1
9
8
OAD
combination
OAD
uptitration
OAD +
basal insulin
OAD + multiple
daily insulin
injections
Mean
7
6
Duration of diabetes
OAD = oral anti-diabetic
1Adapted
from Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.
2Stratton IM et al. BMJ 2000; 321:405–412.
The Global Partnership recommendations:
• Aim for good glycaemic
control = HbA1c < 6.5%*
• Monitor HbA1c every 3 months
in addition to regular glucose
self-monitoring
• Treat patients intensively to
achieve target HbA1c < 6.5%*
within 6 months of diagnosis
< 6.5%
• After 3 months, if patients are
not at target HbA1c < 6.5%,*
consider combination therapy
*Or fasting/preprandial plasma glucose < 110 mg/dl (6.0 mmol/l) where assessment of HbA1c is not possible
Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.
Paradigm for early combination treatment
If HbA1c  9%
at diagnosis
Initiate combination
therapy† or insulin
in parallel with
diet/exercise
If HbA1c < 9%
at diagnosis
If HbA1c > 6.5%*
at 3 months
Initiate monotherapy
in parallel with
diet/exercise
Initiate combination
therapy† in parallel
with diet/exercise
0
1
2
3
Treat to goal of
HbA1c < 6.5%*
by 6 months
4
5
6
Months from diagnosis
*Or fasting/preprandial plasma glucose < 110 mg/dl (6.0 mmol/l) where assessment of HbA1c is not possible
†Combination therapy should include agents with complementary mechanisms of action
Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.
Encouraging early treatment to
glycaemic goal
Happy 7 campaign, Korea
Encouraging early, intensive intervention:
Happy 7, Korea
• Initiated in response to poor
understanding of HbA1c and
importance of quickly
achieving glycaemic goals
• Objectives:
– Change doctors’ beliefs and
behaviours towards HbA1c
measurement
– Increase awareness of
HbA1c among patients
Most Korean patients with T2DM
do not have good glycaemic control
HbA1c
> 8%
HbA1c
< 7%
32%
36%
32%
HbA1c
7–8%
Happy 7: The campaign
• ~20,000 patients with type 2
diabetes in 300 clinics
• 2-day programme in each clinic,
including:
– Patient and nurse education
– HbA1c measurement using portable
testing equipment
– BMI, waist size and plasma
glucose
• Detailed report generated for
each clinic
Happy 7: the results
A positive response… but more work to do
Committed to more
frequent HbA1c testing…
…in the majority (~80%) of
their patients…
… but, HbA1c is only a
supplementary test
0
10
20
30
40
50
60
70
80
90
100
% of doctors
• On follow-up, some clinics had not maintained changes and had
reverted to old habits
 Consistent, co-ordinated and complementary programme of activities
needed to produce effective and enduring changes
Role of guidelines in encouraging
early, intensive intervention
Summarise scientific consensus
Provide best advice available
Objectives
Define patients at risk,
set goals for prevention/therapy
Simplify management,
improve quality of care
Adapted from: Wood D et al. Eur Heart J 1998; 19:1434 1503.
NCEP Expert Panel. JAMA 2001; 285:24862497. Erhardt L et al. Vascular Disease Prevention 2004; 1:167174.
Guidelines and the drive for tighter
glycaemic control
7.5%
ALAD
2000
CDA*
ADA 2003
ADA
2004†
ADA/
EASD‡
HbA1c
7.0%
IDF Global
IDF Western AACE
Pacific Roadmap
ALAD
2007§
6.5%
Global
Partnership
CDA*
ADA 2004†
2003
2004
6.0%
1999
2000
2001
2005
2006
2007
*CDA: goal  7%, or < 6% in individuals “in whom it can be achieved safely”. †ADA: from 2004 onwards, goal for ‘patients in general’ is < 7%, while goal for
‘individual patients’ is ‘as close to normal (< 6%) as possible without significant hypoglycaemia. ‡ADA/EASD Consensus Statement: “Target HbA1c as close to
the non-diabetic range as possible, minimum < 7%”. §ALAD 2007: unpublished.
For guidelines to work, they need to be
implemented
• Guidelines are designed to improve the
care of patients
• It takes a lot of time and effort to develop
good management guidelines
• Despite this, guidelines are often not followed
in routine clinical practice
• The barriers to guideline implementation must be
understood and addressed if patient care is to
improve
Common barriers to implementing
guidelines
Healthcare Systems
Doctors
Patients
Organisational
constraints
Lack of awareness,
familiarity and
agreement
Lack of awareness
and understanding
Lack of
reimbursement
Low motivation and/or
outcome expectancy
Limited access to care
Inadequate staffing
resource and
specialist support
Inability to reconcile
guidelines with patient
preferences
Poor compliance;
reluctance to take
life-long medication
Increased
legal liability
Insufficient time
and/or resource
Lack of adherence to
lifestyle modifications
Adapted from Erhardt L et al. Vascular Disease Prevention 2004; 1:167174
Cabana MD et al. JAMA 1999; 282:14581465.
Barriers to physician uptake
Knowledge
“I didn’t know
there were
guidelines”
“I haven’t read
the
guidelines”
Attitudes
“It’s all good
in theory, but
practice is
different”
“I know what’s
best for my
patients”
Behaviour
“My patients
are happy
with their care
as it is”
“It takes time
– time I
haven’t got”
Improved
outcomes
“My patients are
better controlled
now”
“I’m more
confident I’m
doing the best
for my patients”
Adapted from Cabana MD et al. JAMA 1999; 282:14581465.
Improving implementation of
treatment guidelines
Canadian Diabetes Association guidelines,
The GIANT Study & Project Ideal
Development and communication of guidelines:
Canadian Diabetes Association 2003
• Advocated early and intensive
management
• Multi-disciplinary team approach
• Plans for dissemination integral
to development
• Practical tool: cross-referencing,
clinical tools, links
• Fed into government initiatives
• Partners in Progress: work with
industry to disseminate CDAverified materials
• Available online, with
downloadable slides
Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl 2):S1152.
Canadian Diabetes Association E-guidelines. http://www.diabetes.ca/cpg2003/
Does following guidelines impact patient care?
The GIANT study
General practitioner
Implementation in
Asia of
Normoglycaemic
Targets
100 family doctors
Randomisation
Education on
guidelines*
No education on
guidelines
Four subjects with T2DM
for each doctor
Primary outcome: HbA1c change at 6 months
Study due to complete
by end 2008
Secondary outcomes:
FPG, blood pressure, adverse events,
healthcare use, treatment escalation
*Based on International Diabetes Federation  Western Pacific Region guidelines and involving: initial educational symposium
and follow-up continuing medical education symposium at 3 months; reminders about guidelines sent to doctors every 3 months;
desktop reminder cards; patient diary cards to prompt discussion/record information
General Practitioner Implementation in Asia of Normoglycaemic Targets. http://www.clinicaltrial.gov/ct/show/NCT00499824?order=4
Project IDEAL
Improving Diabetes Education, Access to care, and Living
• Community-based initiative among low-income residents
of North Carolina, USA
• Assessed the impact of 14 programmes designed to
improve adherence to guidelines and quality of care
• Programmes included:
–
–
–
–
New education/care programmes at existing healthcare facilities
Mobile screening, education and healthcare units
Advice in community pharmacies/physicians’ offices
Diabetes educator/nurse practitioner visits to residential facilities
Bell RA et al. NC Med J 2005; 66:96102.
Project IDEAL: Overcoming barriers
to guideline implementation
Baseline (1998)
Follow-up (2001)
Patients (%)
0
10
20
30
40
50
60
70
80
90
100
HbA1c tested
HbA1c control:
< 8.0%
< 7.0%
Blood pressure tested
Blood pressure control*
Lipids tested
LDL-c control†
Nephropathy assessed
Dilated eye exam
Complete foot exam
*Blood pressure < 140 mmHg systolic and < 90 mmHg diastolic; †LDL-c < 100 mg/dL
Bell RA et al. NC Med J 2005; 66:96102.
The benefits of the
multidisciplinary approach
Key function of the multidisciplinary team
To provide:
Continuous, accessible and
consistent care focused on
the needs of individuals with
type 2 diabetes
Additional functions of a multidisciplinary team
• Provide input at diagnosis of condition and
continually thereafter to:
–
–
–
–
agree standards of care
discuss rational therapeutic suggestions
monitor guideline adherence and short-term outcomes
avoid early complications or provide timely
intervention to decrease diabetes-related
complications
• Enable long-term patient
self-management
Codispoti C et al. J Okla State Med Assoc 2004; 97:201–204.
The multidisciplinary team:
core members
Physician
Patient
Dietician
Diabetes
specialist
nurse
Podiatrist
National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes. www.ndep.nih.gov/resources/health.htm.
The multidisciplinary team:
additional members
Physician
Patient
Diabetes
specialist
nurse
Other
specialists
Diabetologist/
endocrinologist
Dietician
Podiatrist
Pharmacist
National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes. www.ndep.nih.gov/resources/health.htm.
Benefits of the
multidisciplinary approach
Kaiser Permanente & PEDNID LA studies
Individuals with poorly controlled
diabetes randomised to outpatient
care from:
– multidisciplinary nurse led team
(diabetes nurse educator,
psychologist, nutritionist and
pharmacist) (n=97)
– or primary care physician (n=88)
•
After 6 months, multidisciplinary
team approach associated with:
significant improvements in
 glycaemic control
significant reductions in
 hospital admissions and
outpatient visits
Hospitalisations/
1000 person-months
•
Change in HbA1c
from baseline (%)
Improvements in patient care: Kaiser
Permanente Medical Care Program, California
0
–0.2
–0.4
–0.6
–0.8
–1.0
–1.2
–1.4
HbA1c
Control
Multidisciplinary
team
30
25
Hospitalisation
20
15
10
5
0
Control
Multidisciplinary
team
Sadur CN et al. Diabetes Care 1999; 22:2011–2017
Copyright © 1999 American Diabetes Association
Adapted with permission from The American Diabetes Association
Improved cost-effectiveness: Co-operative Latin
American implementation study (PEDNID LA)
•
•
Educational model
designed/adapted to local conditions
by multidisciplinary team in 10 Latin
American countries (n = 446)
Four weekly teaching units plus
reinforcement session at 6 months
Family members and spouses
encouraged to attend
improvements in
 Significant
FPG, HbA1c, body weight,
blood pressure, cholesterol,
triglycerides
in pharmacotherapy
 Reduction
→ 62% decrease in treatment
costs
120,000
Cost of pharmacotherapy/year (US$)
•
Costs
↓ 62%
100,000
80,000
60,000
40,000
20,000
0
Baseline
12 months
Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.
Key steps for improving clinical practice
 Disease management programmes can improve
management of chronic disorders, including
type 2 diabetes
 Achieve glycaemic goals as quickly as possible
using early, intensive intervention
 Tailor education about the importance of achieving
glycaemic goals to the target audience
 Make recommendations practical and engage all
relevant parties
 Use co-ordinated and complementary campaigns to
build long-term improvements in care
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