Presentation on theme: "Improving clinical practice – a world of experience"— Presentation transcript:
1Improving clinical practice – a world of experience The Global Partnership for Effective Diabetes Management, including the development of this slide set, is supported by GlaxoSmithKline
2Need for an early and intensive approach to type 2 diabetes management At diagnosis of type 2 diabetes:50% of patients already have complications1up to 50% of -cell function hasalready been lost2Current management:two-thirds of patients do notachieve target HbA1c3,4majority require polypharmacyto meet glycaemic goals over time51UKPDS 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.
3Management of diabetes is evolving 7.06.56.0Tighter HbA1c goalsNew global guidelinesEVOLVING PRACTICEComprehensiveStandardMinimalTailoring to health systemsTreating to target vs. stepwiseIndividualised HbA1c goals
4OAD monotherapy uptitration OAD + multiple daily insulin injections Stepwise approach: delays control and leaves patients at risk of complicationsOAD monotherapy uptitrationOAD + multiple daily insulin injectionsDiet andexerciseOADmonotherapyOADcombinationOAD + basal insulin10Complications29MeanHbA1c (%)1876Duration of diabetesOAD = oral anti-diabetic1Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345– Stratton IM et al. BMJ 2000; 321:405–412.
5OAD + multiple daily insulin injections Early, intensive intervention: reach glycaemic goals and reduce the risk of complicationsDiet andexercise10OADmonotherapy9OAD + multiple daily insulin injectionsOADcombinationOADuptitrationOAD + basal insulinHbA1c (%)18Complications2Mean76Duration of diabetesOAD = oral anti-diabetic1Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345– Stratton IM et al. BMJ 2000; 321:405–412.
6The Global Partnership recommendations: Aim for good glycaemic control = HbA1c < 6.5%*< 6.5%Monitor HbA1c every 3 months in addition to regular glucose self-monitoringTreat patients intensively to achieve target HbA1c < 6.5%* within 6 months of diagnosisAfter 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 possibleDel Prato S et al. Int J Clin Pract 2005; 59:1345–1355.
7Paradigm for early combination treatment If HbA1c 9% at diagnosisInitiate combination therapy† or insulin in parallel with diet/exerciseTreat to goal of HbA1c < 6.5%* by 6 monthsIf HbA1c < 9% at diagnosisInitiate monotherapy in parallel with diet/exerciseIf HbA1c > 6.5%* at 3 monthsInitiate combination therapy† in parallel with diet/exercise123456Months 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 actionDel Prato S et al. Int J Clin Pract 2005; 59:1345–1355.
8Encouraging early treatment to glycaemic goal Happy 7 campaign, KoreaCase Study
9Encouraging early, intensive intervention: Happy 7, Korea Initiated in response to poor understanding of HbA1c and importance of quickly achieving glycaemic goalsObjectives:Change doctors’ beliefs and behaviours towards HbA1c measurementIncrease awareness of HbA1c among patientsMost Korean patients with T2DM do not have good glycaemic controlHbA1c > 8%HbA1c < 7%32%36%32%HbA1c 7–8%Case Study
10Happy 7: The campaign~20,000 patients with type 2 diabetes in 300 clinics2-day programme in each clinic, including:Patient and nurse educationHbA1c measurement using portable testing equipmentBMI, waist size and plasma glucoseDetailed report generated for each clinicCase Study
11Happy 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 test102030405060708090100% of doctorsOn 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 changesCase Study
12Role of guidelines in encouraging early, intensive intervention Summarise scientific consensusProvide best advice availableObjectivesDefine patients at risk, set goals for prevention/therapySimplify management, improve quality of careAdapted from: Wood D et al. Eur Heart J 1998; 19:1434 NCEP Expert Panel. JAMA 2001; 285:24862497. Erhardt L et al. Vascular Disease Prevention 2004; 1:167174.
13Guidelines and the drive for tighter glycaemic control 7.5%ALAD 2000CDA* ADA 2003ADA 2004†ADA/ EASD‡7.0%IDF Global IDF Western PacificHbA1cAACE RoadmapALAD 2007§6.5%Global PartnershipCDA*ADA 2004†6.0%19992000200120032004200520062007*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.
14For guidelines to work, they need to be implemented Guidelines are designed to improve the care of patientsIt takes a lot of time and effort to develop good management guidelinesDespite this, guidelines are often not followed in routine clinical practiceThe barriers to guideline implementation must be understood and addressed if patient care is to improve
15Common barriers to implementing guidelines Healthcare SystemsDoctorsPatientsOrganisational constraintsLack of awareness, familiarity and agreementLack of awareness and understandingLack of reimbursementLow motivation and/or outcome expectancyLimited access to careInadequate staffing resource and specialist supportInability to reconcile guidelines with patient preferencesPoor compliance; reluctance to takelife-long medicationIncreased legal liabilityInsufficient time and/or resourceLack of adherence to lifestyle modificationsAdapted from Erhardt L et al. Vascular Disease Prevention 2004; 1:167174 Cabana MD et al. JAMA 1999; 282:14581465.
16Barriers to physician uptake KnowledgeAttitudesBehaviourImproved 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; 282:14581465.
17Improving implementation of treatment guidelines Canadian Diabetes Association guidelines, The GIANT Study & Project IdealCase Study
18Development and communication of guidelines: Canadian Diabetes Association 2003 Advocated early and intensive managementMulti-disciplinary team approachPlans for dissemination integral to developmentPractical tool: cross-referencing, clinical tools, linksFed into government initiativesPartners in Progress: work with industry to disseminate CDA-verified materialsAvailable online, with downloadable slidesCase StudyCanadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl 2):S1152. Canadian Diabetes Association E-guidelines.
19Does following guidelines impact patient care? The GIANT study General practitioner Implementation in Asia of Normoglycaemic Targets100 family doctorsRandomisationEducation on guidelines*No education on guidelinesFour subjects with T2DM for each doctorPrimary outcome: HbA1c change at 6 monthsSecondary outcomes: FPG, blood pressure, adverse events, healthcare use, treatment escalationStudy due to completeby 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 informationCase StudyGeneral Practitioner Implementation in Asia of Normoglycaemic Targets.
20Improving Diabetes Education, Access to care, and Living Project IDEALImproving Diabetes Education, Access to care, and LivingCommunity-based initiative among low-income residents of North Carolina, USAAssessed the impact of 14 programmes designed to improve adherence to guidelines and quality of careProgrammes included:New education/care programmes at existing healthcare facilitiesMobile screening, education and healthcare unitsAdvice in community pharmacies/physicians’ officesDiabetes educator/nurse practitioner visits to residential facilitiesCase StudyBell RA et al. NC Med J 2005; 66:96102.
21Project IDEAL: Overcoming barriers to guideline implementation Baseline (1998)Patients (%)Follow-up (2001)102030405060708090100HbA1c tested< 8.0%HbA1c control:< 7.0%Blood pressure testedBlood pressure control*Lipids testedLDL-c control†Nephropathy assessedDilated eye examComplete foot exam*Blood pressure < 140 mmHg systolic and < 90 mmHg diastolic; †LDL-c < 100 mg/dLCase StudyBell RA et al. NC Med J 2005; 66:96102.
23Key function of the multidisciplinary team To provide:Continuous, accessible and consistent care focused on the needs of individuals with type 2 diabetes
24Additional functions of a multidisciplinary team Provide input at diagnosis of condition and continually thereafter to:agree standards of carediscuss rational therapeutic suggestionsmonitor guideline adherence and short-term outcomesavoid early complications or provide timely intervention to decrease diabetes-related complicationsEnable long-term patientself-managementCodispoti C et al. J Okla State Med Assoc 2004; 97:201–204.
25The multidisciplinary team: core members PhysicianDiabetes specialist nursePatientDieticianPodiatristNational Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.
26The multidisciplinary team: additional members Other specialistsPhysicianDiabetes specialist nursePatientDiabetologist/ endocrinologistDieticianPodiatristPharmacistNational Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.
27Benefits of the multidisciplinary approach Kaiser Permanente & PEDNID LA studiesCase Study
29Cost of pharmacotherapy/year (US$) Improved cost-effectiveness: Co-operative Latin American implementation study (PEDNID LA)Educational model designed/adapted to local conditions by multidisciplinary team in 10 Latin American countries (n = 446)Four weekly teaching units plus reinforcement session at 6 monthsFamily members and spouses encouraged to attendSignificant improvements in FPG, HbA1c, body weight, blood pressure, cholesterol, triglyceridesReduction in pharmacotherapy → 62% decrease in treatment costs120,000Costs ↓ 62%100,00080,000Cost of pharmacotherapy/year (US$)60,00040,00020,000Baseline12 monthsCase StudyGagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.
30Key steps for improving clinical practice Disease management programmes can improve management of chronic disorders, including type 2 diabetesAchieve glycaemic goals as quickly as possible using early, intensive interventionTailor education about the importance of achieving glycaemic goals to the target audienceMake recommendations practical and engage all relevant partiesUse co-ordinated and complementary campaigns to build long-term improvements in care