Primary Care Diabetes

Editorial Board

2010-07-01

Health check—For whom and by whom?

Rhys Williams — 2010-07-01

As we all know, adults aged 40–75 and living in England are now entitled to a free NHS Health Check aimed at detecting, at an early stage, those deemed to be at highest risk of developing hart disease, stroke, (type 2) diabetes and kidney disease.

The perfect diabetes review

Paul Grant — 2010-03-08

Abstract: Background: Diabetes is a chronic multi-system disease that needs specialised annual review that is thorough, efficient and beneficial to the patient's needs.The diabetes review clinic in the UK has varying formats and contents. In the main, the goal should be to review the patient holistically as diabetes can affect every body system. By assessing the patient's glycaemic control and screening for potential complications we run the best chance of limiting the severity of disease progression. There are many differing opinions as to how best it should be performed. Recent research has shown that Diabetologists may be failing their patients in that they are not adequately screening or assessing for diabetic complications, such as erectile dysfunction, as suggested by the national institute for health and clinical excellence (NICE) guidelines.Conclusions: We propose a basic summary of the essential areas which must be included in a diabetes review. However, we understand that this may prove unwieldy and logistically difficult in a busy clinic/practice setting.

Has pay for performance improved the management of diabetes in the United Kingdom?

Riyadh Alshamsan, Christopher Millett, Azeem Majeed, Kamlesh Khunti — 2010-04-05

Abstract: Over the past decade the UK government has introduced a number of major policy initiatives to improve the quality of health care. One such initiative was the introduction of the Quality and Outcomes Framework (QOF), a pay for performance scheme launched in April 2004, which aims to improve the primary care management of common chronic conditions including diabetes. Some evidence suggest that introduction of QOF has been associated with improvements in the quality indicators for diabetes care included in the framework. However, it is difficult to disentangle the impact of QOF from other quality initiatives as few studies adjusted for underlying trends in quality. There is some evidence that QOF may have reduced inequalities in diabetes care between affluent and deprived areas but women and individuals from ethnic minority groups appear to have benefited least from this initiative. Less is known about the impact of QOF on aspects of diabetes care not reflected in the framework, including self-management and continuity of care.

Pakistan National Diabetes Survey: Prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan

2010-02-11

Abstract: Aims: The prevalence of diabetes mellitus and impaired glucose tolerance (IGT) and their relationship to age and obesity were estimated in Punjab, Pakistan by a population-based survey done in 1998.Methods: Oral glucose tolerance tests were performed in a stratified random sample of 1852 adults aged ≥25 years. The diagnosis of diabetes and IGT were made on the basis of WHO criteria.Results: The prevalence of diabetes was 12.14% in males and 9.83% in females. Overall total glucose intolerance (diabetes and IGT) was present in 16.68% males and 19.37% females. Central obesity, hypertension and positive family history were strongly associated with diabetes.Conclusions: These results indicate that the prevalence of glucose intolerance is high in the studied population and comparable with the published data from the other three provinces of Pakistan i.e. Sindh, Baluchistan and North West Frontier Province, studied by the same group.

Insulin initiation in primary care for patients with type 2 diabetes: 3-Year follow-up study

Jeremy Dale, Steven Martin, Roger Gadsby — 2010-04-14

Abstract: Purpose of study: To evaluate the 3-year impact of initiating basal insulin on glycaemic control (HbA1c) and weight gain in patients with poorly controlled type 2 diabetes registered with UK general practices that volunteered to participate in an insulin initiation training programme.Methods: Audit utilising data collected from practice record systems, which included data at baseline, 3, 6 months and subsequent six-monthly intervals post-insulin initiation for up to 10 patients per participating practice.Results: Of 115 eligible practices, 55 (47.8%) contributed data on a total of 516 patients. The mean improvement in HbA1c levels in the first 6 months was 1.4% (range −3.8% to 8.2%, median=1.40%). Thereafter, there was no overall change in HbA1c levels, although the change for individual patients ranged from −4.90% to +7.50%. At 36 months, 141 (41%) patients for whom data were provided had achieved the pre-2006/2007 UK Quality and Outcomes Framework (QOF) target of 7.4% or less, including 98 (29%) who had achieved an HbA1c of 7% or less. Patients who achieved target had a lower HbA1c at baseline (mean 9.1% compared to 9.7%; p<0.001); had a lower weight at 36 months (mean 88.0kg compared to 93.5kg; p=0.05); were more likely to be on basal insulin alone (88, 47.1% compared to 46, 34.6%; p<0.05); and were slightly older (mean 64.5 years compared to 61.7 years; p<0.05).Conclusion: Attending an insulin initiation training programme may successfully prepare primary healthcare professionals to initiate insulin therapy as part of everyday practice for patients with poorly controlled type 2 diabetes. The impact on glycaemic control is maintained over a 3-year period. Although intensification of treatment occurred during this period, the findings suggest scope for further intensification of insulin therapy in order to improve on the glycaemic control achieved during the first 6 months post-insulin initiation.

The Swedish National Survey of the Quality and Organization of Diabetes Care in Primary Healthcare—Swed-QOP

Eva Thors Adolfsson, Andreas Rosenblad, Karin Wikblad — 2010-05-03

Abstract: Aim: To describe the quality and organization of diabetes care in primary healthcare in Sweden regarding resources and ways of working.Method: A questionnaire was used to collect data from all 921 primary healthcare centres (PHCCs) in Sweden. Of these, 74.3% (n=684) responded to the questionnaire covering list size of the PHCCs, number of diabetic patients, personnel resources and ways of working.Results: The median list size reported from the PHCCs was 9,000 patients, 294 of whom were diabetic patients. The majority (72%) of PHCCs had diabetes-responsible general practitioners (GPs) and almost all (97%) had diabetes specialist nurses (DSNs) with some degree of postgraduate education in diabetes. The PHCCs reported that they used regional/local diabetes guidelines (93%), were engaged in call-recall diabetic reviews by GP(s) (66%) and DSN(s) (89%), checked that patients had participated in the reviews by GP(s) (69%) and DSN(s) (78%), arranged group education programmes (23%) and reported data to a National Diabetes Register (82%).Conclusions: The presence of diabetes-responsible GP(s) and DSN(s) who use guidelines may contribute to good and equal quality of care. It is, however, necessary to improve the call-recall system and there is an urgent need for all diabetic patients to receive patient education.

A large-scale diabetes prevention program in real-life settings in Qingdao of China (2006–2012)

2010-05-10

Abstract: Aims: Qingdao Diabetes Prevention Program aims to translate the trial experience to real-life settings with goals to: (1) raise the public awareness of diabetes and diabetes risk factors, and promote healthy diet and physical activity; (2) reduce the number of high-risk people developing diabetes through lifestyle counselling; (3) early diagnosis of diabetes; (4) evaluate the effectiveness, cost-effectiveness, feasibility, acceptability and sustainability of the programs.Program design: The project's first phase (2006–2009) was focused on health promotion targeting at the entire population of 1.94 million, and training of professionals; and the second phase (2009–2012) on lifestyle counselling targeting at individuals with a diabetes risk score of ≥14. The effectiveness of the intervention and the cost-effectiveness of the program between the intervention arm (n=8000) and the control arm (n=4000) who are randomly selected from the project targeting and not-targeting areas will be evaluated with the diabetes incidence as the primary outcome.Milestone achieved from 2006 to 2009: 3993 health professionals finished training courses; 724,130 educational booklets were distributed to families and 318,284 high-risk individuals recorded and 130,164 underwent at least one follow-up counselling session.

Obesity and diabetes: the links and common approaches

David Haslam — 2010-05-06

Abstract: The term “diabesity” was famously coined by Sims and colleagues in the 1970s, to highlight the close relationship between type 2 diabetes and obesity. His team demonstrated that young men with no family history of diabetes when overfed for 6 months underwent a BMI increase to 28.0kg/m2 alongside reversible rises in levels of fasting insulin, glucose, and triglycerides, and impaired glucose tolerance. Around 90% of type 2 diabetic patients have a BMI greater than 23.0kg/m2, the risk of diabetes being greatly increased by a family history of diabetes or gestational diabetes, and early weight gain, especially in childhood. Patients with T2DM with co-existing obesity, can potentially be offered sub-optimum treatment at various points in the progression of their illness, unless the Primary healthcare team simultaneously embraces state-of-the-art methods within the fields of both diabetes and obesity. Obese individuals may be victims of inadequate screening, denying the chance of crucial early treatment, they may be left to languish at suboptimal HbA1c, they may be prescribed drugs which induce weight gain, whilst already being obese, vulnerable individuals may be given drugs which induce hypoglycaemia – often guideline and QOF led – and ultimately they may be converted to insulin before preferable alternatives have been explored. There have been many recent advances in both the fields of diabetes and obesity and it is important for clinicians to be aware of and familiar with newer interventions in both areas, as best practice and best outcomes are not achieved in their absence.

Patient-reported outcomes in patients with type 2 diabetes treated with liraglutide or glimepiride, both as add-on to metformin

2010-05-05

Abstract: Patient-reported outcomes for liraglutide or glimepiride on metformin were investigated. Patients’ treatment satisfaction on liraglutide was higher than with metformin alone and comparable with glimepiride+metformin. Patients perceived lower frequency of hypoglycaemia than glimepiride+metformin and lower frequency of hyperglycaemia than metformin. Impact of weight on quality of life did not differ.

Society News 4/2

2010-05-31