1. 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

2. 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.

3. 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
Treating to target vs. stepwise
Individualised HbA1c goals

4. OAD monotherapy uptitration OAD + multiple daily insulin injections
Stepwise approach: delays control and leaves patients at risk of complications
OAD monotherapy uptitration
OAD + multiple daily insulin injections
Diet and
exercise
OAD
monotherapy
OAD
combination
OAD + basal insulin 10
Complications2 9
Mean
HbA1c (%)1 8 7 6
Duration of diabetes
OAD = oral anti-diabetic
1Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345– Stratton IM et al. BMJ 2000; 321:405–412.

5. OAD + multiple daily insulin injections
Early, intensive intervention: reach glycaemic goals and reduce the risk of complications
Diet and
exercise 10
OAD
monotherapy 9
OAD + multiple daily insulin injections
OAD
combination
OAD
uptitration
OAD + basal insulin
HbA1c (%)1 8
Complications2
Mean 7 6
Duration of diabetes
OAD = oral anti-diabetic
1Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345– Stratton IM et al. BMJ 2000; 321:405–412.

6. The Global Partnership recommendations:
Aim for good glycaemic control = HbA1c < 6.5%*
< 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
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.

7. Paradigm for early combination treatment
If HbA1c  9% at diagnosis
Initiate combination therapy† or insulin in parallel with diet/exercise
Treat to goal of HbA1c < 6.5%* by 6 months
If HbA1c < 9% at diagnosis
Initiate monotherapy in parallel with diet/exercise
If HbA1c > 6.5%* at 3 months
Initiate combination therapy† in parallel with diet/exercise 1 2 3 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.

8. Encouraging early treatment to glycaemic goal
Happy 7 campaign, Korea
Case Study

9. 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%
Case Study

10. 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
Case Study

11. 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 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
Case Study

12. 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  NCEP Expert Panel. JAMA 2001; 285:24862497. Erhardt L et al. Vascular Disease Prevention 2004; 1:167174.

13. Guidelines and the drive for tighter glycaemic control
7.5%
ALAD 2000
CDA* ADA 2003
ADA 2004†
ADA/ EASD‡
7.0%
IDF Global IDF Western Pacific
HbA1c
AACE Roadmap
ALAD 2007§
6.5%
Global Partnership
CDA*
ADA 2004†
6.0%
1999
2000
2001
2003
2004
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.

14. 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

15. 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.

16. Barriers to physician uptake
Knowledge
Attitudes
Behaviour
Improved outcomes
“It’s all good in theory, but practice is different”
“My patients are happy with their care as it is”
“My patients are better controlled now”
“I didn’t know there were guidelines”
“I haven’t read the guidelines”
“I know what’s best for my patients”
“It takes time – time I haven’t got”
“I’m more confident I’m doing the best for my patients”
Adapted from Cabana MD et al. JAMA 1999; 282:14581465.

17. Improving implementation of treatment guidelines
Canadian Diabetes Association guidelines, The GIANT Study & Project Ideal
Case Study

18. 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 CDA-verified materials
Available online, with downloadable slides
Case Study
Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl 2):S1152. Canadian Diabetes Association E-guidelines.

19. 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
Secondary outcomes: FPG, blood pressure, adverse events, healthcare use, treatment escalation
Study due to complete
by end 2008
*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
Case Study
General Practitioner Implementation in Asia of Normoglycaemic Targets.

20. Improving Diabetes Education, Access to care, and Living
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
Case Study
Bell RA et al. NC Med J 2005; 66:96102.

21. Project IDEAL: Overcoming barriers to guideline implementation
Baseline (1998)
Patients (%)
Follow-up (2001) 10 20 30 40 50 60 70 80 90
100
HbA1c tested
< 8.0%
HbA1c control:
< 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
Case Study
Bell RA et al. NC Med J 2005; 66:96102.

22. The benefits of the multidisciplinary approach

23. Key function of the multidisciplinary team
To provide:
Continuous, accessible and consistent care focused on the needs of individuals with type 2 diabetes

24. 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.

25. The multidisciplinary team: core members
Physician
Diabetes specialist nurse
Patient
Dietician
Podiatrist
National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.

26. The multidisciplinary team: additional members
Other specialists
Physician
Diabetes specialist nurse
Patient
Diabetologist/ endocrinologist
Dietician
Podiatrist
Pharmacist
National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.

27. Benefits of the multidisciplinary approach
Kaiser Permanente & PEDNID LA studies
Case Study

28. Improvements in patient care: Kaiser Permanente Medical Care Program, California
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
–0.2
HbA1c
–0.4
Change in HbA1c from baseline (%)
–0.6
–0.8
–1.0
–1.2
–1.4
Control
Multidisciplinary team 30 25
Hospitalisation 20 
Hospitalisations/ 1000 person-months 15 10  5
Multidisciplinary team
Control
Sadur CN et al. Diabetes Care 1999; 22:2011–2017
Copyright © 1999 American Diabetes Association
Adapted with permission from The American Diabetes Association
Case Study

29. Cost of pharmacotherapy/year (US$)
Improved cost-effectiveness: Co-operative Latin American implementation study (PEDNID LA)
Educational model designed/adapted to local conditions by multidisciplinary team in 10 Latin American countries (n = 446)
Four weekly teaching units plus reinforcement session at 6 months
Family members and spouses encouraged to attend
Significant improvements in FPG, HbA1c, body weight, blood pressure, cholesterol, triglycerides
Reduction in pharmacotherapy → 62% decrease in treatment costs
120,000
Costs ↓ 62%
100,000
80,000
Cost of pharmacotherapy/year (US$)
60,000 
40,000
20,000 
Baseline
12 months
Case Study
Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.

30. 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    