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

• 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

Need for an early and intensive approach to type 2 diabetes management

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

Individualised HbA1c goals

New global guidelines

Tighter HbA1c goals

EVOLVING PRACTICE

Treating to target vs. stepwise

•Comprehensive•Standard•Minimal

Tailoring to health systems

Stepwise approach: delays control and leaves patients at risk of complications

OAD = oral anti-diabetic1Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.

2Stratton IM et al. BMJ 2000; 321:405–412.

Duration of diabetes

Hb

A1c

(%

)1

7

6

9

8

10

Diet andexercise

OADmonotherapy

OAD combination

OAD +basal insulin

OAD monotherapy

uptitration

OAD + multiple daily

insulin injections

Mean

Complications2

Early, intensive intervention: reach glycaemic goals and reduce the risk of complications

OAD = oral anti-diabetic1Adapted from Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.

2Stratton IM et al. BMJ 2000; 321:405–412.

Duration of diabetes

Hb

A1c

(%

)1

7

6

9

8

10

Complications2

Diet andexercise

OAD monotherapy

OAD combination

OAD uptitration

OAD + basal insulin

OAD + multipledaily insulin

injections

Mean

The Global Partnership recommendations:

*Or fasting/preprandial plasma glucose < 110 mg/dl (6.0 mmol/l) where assessment of HbA1c is not possible

• Aim for good glycaemic control = HbA1c < 6.5%*

< 6.5%< 6.5%• 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

• Monitor HbA1c every 3 monthsin addition to regular glucose self-monitoring

Del Prato S et al. Int J Clin Pract 2005; 59:1345–1355.

Paradigm for early combination treatment

If HbA1c > 6.5%*at 3 months

Initiate combination therapy† in parallel with diet/exercise

If HbA1c 9% at diagnosis

Initiate combination therapy† or insulin

in parallel with diet/exercise

0 1 2 3 4 5 6

If HbA1c < 9% at diagnosis

Initiate monotherapy in parallel with diet/exercise

Months from diagnosis

Treat to goal of

HbA1c < 6.5%* by 6 months

*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%

HbA1c 7–8%

36%32%

32%

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 morefrequent HbA1c testing…

…in the majority (~80%) of their patients…

… but, HbA1c is only asupplementary test

• On follow-up, some clinics had not maintained changes and hadreverted to old habits

Consistent, co-ordinated and complementary programme of activities needed to produce effective and enduring changes

% of doctors

0 10010 20 30 40 50 60 70 80 90

Role of guidelines in encouraging early, intensive intervention

Adapted from: Wood D et al. Eur Heart J 1998; 19:1434 1503. NCEP Expert Panel. JAMA 2001; 285:24862497. Erhardt L et al. Vascular Disease Prevention 2004; 1:167174.

Objectives

Simplify management, improve quality of care

Summarise scientific consensus

Provide best advice available

Define patients at risk, set goals for prevention/therapy

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 HbA1c as close to

the non-diabetic range as possible, minimum < 7%”. §ALAD 2007: unpublished.

Hb

A1c

6.0%

6.5%

7.0%

7.5%

1999 2000 2001 2003 2004 2005 2006 2007

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

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

Increasedlegal liability

Poor compliance; reluctance to take

life-long medication

Healthcare Systems Doctors Patients

Adapted from Erhardt L et al. Vascular Disease Prevention 2004; 1:167174 Cabana MD et al. JAMA 1999; 282:14581465.

Barriers to physician uptake

Adapted from Cabana MD et al. JAMA 1999; 282:14581465.

“I didn’t know there were guidelines”

“I haven’t read the

guidelines”

“It’s all good in theory, but

practice is different”

“I know what’s best

for my patients”

“My patients are happy

with their care as it is”

“It takes time – time I

haven’t got”

Knowledge Improved outcomes

Attitudes Behaviour

“My patients are better

controlled now”

“I’m more confident I’m

doing the best for my patients”

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 CDA-verified materials

• Available online, with downloadable slides

Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl 2):S1152.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

*Based on International Diabetes Federation Western Pacific Region guidelines and involving: initial educational symposiumand 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 onguidelines*

No education onguidelines

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

General Practitioner Implementation in Asia of Normoglycaemic Targets. http://www.clinicaltrial.gov/ct/show/NCT00499824?order=4

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; 66:96102.

Improving Diabetes Education, Access to care, and Living

Project IDEAL: Overcoming barriers to guideline implementation

*Blood pressure < 140 mmHg systolic and < 90 mmHg diastolic; †LDL-c < 100 mg/dL

HbA1c tested

HbA1c 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 (%)

0 10010 20 30 40 50 60 70 80 90Follow-up (2001)

Bell RA et al. NC Med J 2005; 66:96102.

The benefits of themultidisciplinary 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

DieticianDietician

Diabetes specialist

nurse

Diabetes specialist

nursePatientPatient

PhysicianPhysician

PodiatristPodiatrist

National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes. www.ndep.nih.gov/resources/health.htm.

The multidisciplinary team: additional members

Pharmacist

Diabetologist/endocrinologist

Other specialists

DieticianDietician

Diabetes specialist

nurse

Diabetes specialist

nursePatientPatient

PhysicianPhysician

PodiatristPodiatrist

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

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

Multidisciplinaryteam

Control

Cha

nge

in H

bA1

c fr

om b

ase

line

(%)

HbA1cHbA1c

30

25

20

15

10

5

0

Hos

pita

lisat

ions

/10

00

per

son-

mon

ths

HospitalisationHospitalisation

Multidisciplinaryteam

Control

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

Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.

0

20,000

40,000

60,000

80,000

100,000

120,000

Baseline 12 months

Cos

t of

pha

rmac

othe

rapy

/yea

r (U

S$)

Costs↓ 62%

Key steps for improving clinical practice

Disease management programmes can improve management of chronic disorders, includingtype 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