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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,

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Presentation on theme: "Improving clinical practice – a world of experience The Global Partnership for Effective Diabetes Management, including the development of this slide set,"— Presentation transcript:

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 At diagnosis of type 2 diabetes: 50% of patients already have complications 1 up to 50% of -cell function has already been lost 2 Current management: two-thirds of patients do not achieve target HbA 1c 3,4 majority require polypharmacy to meet glycaemic goals over time 5 Need for an early and intensive approach to type 2 diabetes management 1 UKPDS Group. Diabetologia 1991; 34:877– Holman RR. Diabetes Res Clin Prac 1998; 40 (Suppl.):S21–S25. 3 Saydah SH et al. JAMA 2004; 291:335– Liebl A et al. Diabetologia 2002; 45:S23–S28. 5 Turner RC et al. JAMA 1999; 281:2005–2012.

3 Management of diabetes is evolving Individualised HbA 1c goals New global guidelines Tighter HbA 1c goals EVOLVING PRACTICE Treating to target vs. stepwise Comprehensive Standard Minimal Tailoring to health systems

4 Stepwise approach: delays control and leaves patients at risk of complications OAD = oral anti-diabetic 1 Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345– Stratton IM et al. BMJ 2000; 321:405–412. Duration of diabetes HbA1c (%) Diet and exercise OAD monotherapy OAD combination OAD + basal insulin OAD monotherapy uptitration OAD + multiple daily insulin injections Mean Complications 2

5 Early, intensive intervention: reach glycaemic goals and reduce the risk of complications OAD = oral anti-diabetic 1 Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345– Stratton IM et al. BMJ 2000; 321:405–412. Duration of diabetes HbA1c (%) Complications 2 Diet and exercise OAD monotherapy OAD combination OAD uptitration OAD + basal insulin OAD + multiple daily insulin injections Mean

6 The Global Partnership recommendations: *Or fasting/preprandial plasma glucose < 110 mg/dl (6.0 mmol/l) where assessment of HbA 1c is not possible Aim for good glycaemic control = HbA 1c < 6.5%* < 6.5% Treat patients intensively to achieve target HbA 1c < 6.5%* within 6 months of diagnosis After 3 months, if patients are not at target HbA 1c < 6.5%,* consider combination therapy Monitor HbA 1c every 3 months in addition to regular glucose self-monitoring Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.

7 Paradigm for early combination treatment If HbA 1c > 6.5%* at 3 months Initiate combination therapy in parallel with diet/exercise If HbA 1c 9% at diagnosis Initiate combination therapy or insulin in parallel with diet/exercise If HbA 1c < 9% at diagnosis Initiate monotherapy in parallel with diet/exercise Months from diagnosis Treat to goal of HbA 1c < 6.5%* by 6 months *Or fasting/preprandial plasma glucose < 110 mg/dl (6.0 mmol/l) where assessment of HbA 1c 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

9 Encouraging early, intensive intervention: Happy 7, Korea Initiated in response to poor understanding of HbA 1c and importance of quickly achieving glycaemic goals Objectives: –Change doctors beliefs and behaviours towards HbA 1c measurement –Increase awareness of HbA 1c among patients Most Korean patients with T2DM do not have good glycaemic control HbA 1c > 8% HbA 1c < 7% HbA 1c 7–8% 36% 32%

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 –HbA 1c measurement using portable testing equipment –BMI, waist size and plasma glucose Detailed report generated for each clinic

11 Happy 7: the results A positive response… but more work to do Committed to more frequent HbA 1c testing… …in the majority (~80%) of their patients… … but, HbA 1c is only a supplementary test 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 % of doctors

12 Role of guidelines in encouraging early, intensive intervention Adapted from: Wood D et al. Eur Heart J 1998; 19: NCEP Expert Panel. JAMA 2001; 285: Erhardt L et al. Vascular Disease Prevention 2004; 1: Objectives Simplify management, improve quality of care Summarise scientific consensus Provide best advice available Define patients at risk, set goals for prevention/therapy

13 ADA 2004 IDF Global IDF Western Pacific ALAD 2000 CDA* ADA 2003 AACE Roadmap Global Partnership ALAD 2007 § CDA* ADA 2004 ADA/ EASD Guidelines and the drive for tighter glycaemic control *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 HbA 1c as close to the non-diabetic range as possible, minimum < 7%. § ALAD 2007: unpublished. HbA 1c 6.0% 6.5% 7.0% 7.5%

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 Lack of reimbursement Inability to reconcile guidelines with patient preferences Lack of adherence to lifestyle modifications Organisational constraints Inadequate staffing resource and specialist support Lack of awareness, familiarity and agreement Low motivation and/or outcome expectancy Lack of awareness and understanding Limited access to care Insufficient time and/or resource Increased legal liability Poor compliance; reluctance to take life-long medication Healthcare SystemsDoctorsPatients Adapted from Erhardt L et al. Vascular Disease Prevention 2004; 1: Cabana MD et al. JAMA 1999; 282:

16 Barriers to physician uptake Adapted from Cabana MD et al. JAMA 1999; 282: I didnt know there were guidelines I havent read the guidelines Its all good in theory, but practice is different I know whats best for my patients My patients are happy with their care as it is It takes time – time I havent got Knowledge Improved outcomes AttitudesBehaviour My patients are better controlled now Im more confident Im doing the best for my patients

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

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 Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl 2):S Canadian Diabetes Association E-guidelines.

19 Does following guidelines impact patient care? The GIANT study G eneral practitioner I mplementation in A sia of N ormoglycaemic T argets 100 family doctors *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 Randomisation Education on guidelines* No education on guidelines Four subjects with T2DM for each doctor Primary outcome: HbA 1c change at 6 months Secondary outcomes: FPG, blood pressure, adverse events, healthcare use, treatment escalation Study due to complete by end 2008 General Practitioner Implementation in Asia of Normoglycaemic Targets.

20 Project IDEAL 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: Improving Diabetes Education, Access to care, and Living

21 Project IDEAL: Overcoming barriers to guideline implementation *Blood pressure < 140 mmHg systolic and < 90 mmHg diastolic; LDL-c < 100 mg/dL HbA 1c tested HbA 1c control: < 8.0% < 7.0% Lipids tested LDL-c control Nephropathy assessed Dilated eye exam Blood pressure tested Blood pressure control* Complete foot exam Baseline (1998) Patients (%) Follow-up (2001) Bell RA et al. NC Med J 2005; 66:

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 Dietician Diabetes specialist nurse Patient Physician Podiatrist National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.

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

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

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 Sadur CN et al. Diabetes Care 1999; 22:2011–2017 Copyright © 1999 American Diabetes Association Adapted with permission from The American Diabetes Association –1.4 –1.2 –1.0 –0.8 –0.6 –0.4 –0.2 0 Multidisciplinary team Control Change in HbA 1c from baseline (%) HbA 1c Hospitalisations/ 1000 person-months Hospitalisation Multidisciplinary team Control

29 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, HbA 1c, body weight, blood pressure, cholesterol, triglycerides Reduction in pharmacotherapy 62% decrease in treatment costs Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001– ,000 40,000 60,000 80, , ,000 Baseline12 months Cost of pharmacotherapy/year (US$) Costs 62%

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


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