INTERNATIONAL RESEARCH & OPINION

Diabetes news from the 35th Annual Meeting of the EASD Brussels, Belgium September-October 1999

The results of a number of studies investigating ways to improve the management of type 2 diabetes mellitus were presented at the 1999 Congress of the European Association for the Study of Diabetes [Brussels, Belgium; September-October 1999].

Staged Diabetes Management improves outcomes ...

Concerns about associated costs and quality of care in patients with diabetes have led to the development of diabetes management programmes such as 'Staged Diabetes Management' (SDM). *

Developed jointly by Becton Dickinson and the International Diabetes Center, US, SDM involves a comprehensive set of practice guidelines and algorithms for healthcare providers, as well as information packages for the patient and community use. The SDM approach comprises comanagement by a primary-care-physician-centred healthcare-provider team. Patients are involved in establishing their own treatment goals and timelines.

Investigators from the Ochsner Clinic in New Orleans, US, have found that SDM is an effective tool for improving glycaemic control, quality of life (QOL) and resource use among patients with type 2 diabetes in the managed-care setting. I

... in managed-care environment The investigators reported that, among 203 patients

with type 2 diabetes, 77% of those randomised to the SDM programme experienced an improvement in their glycosylated haemoglobin (HbAle) levels, compared with 53% of those randomised to standard care.

The mean HbAle reduction was significantly greater in the SDM group, and more patients in the SDM group achieved an HbA le level of < 8% (70 vs 53%, respectively). Furthermore, global QOL scores** at 6 and 12 months had improved in the SDM group, compared with baseline, but had deteriorated in the control group.

Patients who participated in the SDM programme also used considerably fewer healthcare resources than patients who received standard care. The number of clinic visits was significantly lower in the SDM group than in the control group (554 vs 578 per 100 patient-months, respectively), as was the number of outpatient visits (5.8 vs 8.5) and the number of hospital admissions (1.7 vs 4.8).

Patients in the SDM group received case manage­ment according to SDM algorithms from diabetes nurse educators supervised by endocrinologists. It was estimated that nurses spent an average of 4.28 hours/patient/week doing case management, but that this time would decrease as the patient became better informed and the nurse became more proficient with the SDM programme.

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... and primaty-care setting

In another study presented at the conference, the daily use of SDM treatment algorit.~ms at 11 primary~ care practices in Germany improved glycaemic control among younger patients and reduced the occurrence of severe hypoglycaemia among elderly patients.2

An improvement in patient satisfaction with therapy and QOL after 3 months' implementation of the algorithms also occurred.

Of note, type 2 diabetes treatment goals determined by the German SDM treatment algorithms vary according to patient age. These goals are 'normo­glycaemic control' for patients aged < 65 years, and 'no hyper- or hypoglycaemic symptoms' for those aged> 65 years.

The researchers found that, among 370 patients with diabetes (310 of whom had type 2 disease), 196 who were randomised to SDM showed a greater improvement in their HbAle levels than 174 who received standard care; the difference was particularly great for patients aged < 65 years. Among patients aged> 65 years, fewer in the SDM group experienced severe hypoglycaemic events (0.06 vs 0.16 patients/ year).

According to the results of the Bradley question­naire, patient satisfaction with therapy and QOL were better at 3 months than at baseline in the SDM group, whereas both outcomes had deteriorated among patients in the standard-care group. Likewise, the rate of blood glucose self-monitoring in the SDM group increased by > 2-fold during the study period, whereas that in the standard-care group remained fairly static.

Guidelines effective in the long term?

In a poster presented at the conference, a group of Dutch researchers examined the long-term effective­ness of implementing a primary-care intervention strategy aimed at improving glycaemic control among patients with type 2 diabetes.3

The intervention comprised practice guidelines for the management of type 2 diabetes, postgraduate medical education, consultation of experts, peer review, structured registration of care, and evaluation and feedback of quality of care.

The proportion of patients in the intervention group (n = 384) with an HbAle ievei S 7.5% increased from 57% at baseline to 74% at 1.5 years, fell to 66% by 2.5 years, and rose again to 70% after 3.5 years.

In contrast, in a control group of patients (n = 84) who did not receive the intervention, the proportion with an HbAle level:5 7.5% fell from 88% at baseline to 50% at 3.5 years. However, after 3.5 years the intervention strategy did not appear to provide a positive improvement in cardiovascular risk factors.

PhannacoEconomics & Outcomes News 20 Nov 1999 No. 239

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10 INTERNATIONAL RESEARCH & OPINION

Empower patients, says WHOIIDF The St. Vincent Declaration states that the goal

of improving health and avoiding complications in patients with diabetes can only be achieved with active patient participation. The results of two surveys presented at the conference indeed suggest that involving individuals in the management of their disease could improve quality of care. t

A mail survey was conducted by the WHOIIDFi Patient Empowerment Workshop and Smith Kline Beecham, involving> 450 patients with diabetes.4

The results indicated that approximately 75% of patients perceive that their diabetes is under control and are not concerned about the complications of the disease. However, this perception is contrary to existing evidence indicating that diabetes is often insufficiently controlled and that serious complications frequently develop.

The researchers believe that greater educational efforts are required to make people aware of the complications and seriousness of diabetes. They suggest that through patient empowerment, individuals may become more involved in their own care resulting in improved outcomes.

The second survey, also conducted by the WHOIIDF Empowerment Workshop and SmithKline Beecham, revealed that most patients want their healthcare professionals to involve them in decisions regarding management of their disease.5 91 % of insulin users and 78% of patients treated with oral antihyperglycaemics felt they should be involved in the decision-making process. The majority of patients felt capable of making their own treatment choices. Quality of care would improve if more patients and physicians openly discussed treatment options, concluded the researchers. * see PhannacoEconomics & Outcomes News 130: 8, 20 Sep 1997;800458783 ** assessed using a questionnaire developed at the Harvard School of Public Health, US t Both studies were supported by a grant from SmithKline Beecham Phannaceuticals, with additional funding provided by Abbott Laboratories, Bayer AG, Eli Lilly and Company, LifeScan, Inc., and Novo Nordisk. :t World Health Organization/lntemational Diabetes Federation 1. Blonde L, et aI. Staged diabetes management: improvements in health status and patient self-management skills among patients in a managed care setting. Diabetologia 42 (Supp\. 1): 252 (plus poster). Aug 1999 2. Klinge A, et aI. Staged diabetes management(Rm): implementation in Gennany. Diabetologia 42 (Supp\. 1): 252 (Plus poster), Aug 1999 3. Renders eM, et aI. Long-tenn effectiveness of a quality system on glycaemic control and cardi(}-vascular risk profile for patients with type 2 diabetes in general practice. Diabetologia 42 (Supp\. I): 253 (plus poster), Aug 1999 4. Baksi AK, et aI. How concerned are people about their diabetes? Diabetologia 42 (Supp\. 1): 258 (Plus poster), Aug 1999 5. Gormley DA, et aI. Do people with diabetes desire a role in diabetes treatment decisions? Diabetologia 42 (Supp\. I): 258 (Plus poster), Aug 1999 800763'"

PhannacoEconomics & Outcomes News 20 Nov 1999 No. 239 1173-5503199/0239-000101$01.00° Adla'nternatlona' Limited 1999. All right. r_rved