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by Vinod Patel of George Eliot Hospital NHS Trust shown at the 3rd Lean Healthcare Forum 2006 ran by the Lean Enterprise Academy
Citation preview
Lean in Primary Care:
Redesigning the Diabetes ProcessThe Alphabet Strategy Approach
Vinod Patel* and John Morrissey**
*Reader in Clinical SkillsUniversity of Warwick Medical School
*Lead for Diabetes CareGeorge Eliot Hospital NHS Trust, Nuneaton
Amitha Gopinath: Project Manager
On behalf
George Eliot Hospital NHS Trust Diabetes Care Team
Diabetes is a Significant Global Healthcare Problem
Hogan P, et al. Diabetes Care. 2003;26:917-932.King H, et al. Diabetes Care. 1998;21:1414-1431.
250 million currently
20% of population in Middle-East,
USA, India over 40 years
Diabetes Care: The ComplicationsDiabetes Care: The ComplicationsRetinopathyRetinopathy
Most common cause of Most common cause of blindness in people of blindness in people of
working ageworking age
NephropathyNephropathy16% of all new patients 16% of all new patients
needing renal replacement needing renal replacement therapytherapy
Erectile dysfunctionErectile dysfunctionMay affect up to 50% of May affect up to 50% of
men with longmen with long--standing diabetesstanding diabetes
Macrovascular disease Macrovascular disease 22––4 fold increased risk 4 fold increased risk of coronary heart disease of coronary heart disease
and stroke, 75% have and stroke, 75% have hypertensionhypertension
Foot problemsFoot problemsCommonest cause of nonCommonest cause of non--
traumatic amputationtraumatic amputation
The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.
U.K. economic costsU.K. economic costsU.K. economic costs
Year 2000 projected NHS Year 2000 projected NHS diabetes expenditure ( 9% ) :diabetes expenditure ( 9% ) : £4,878,000,000£4,878,000,000
Equivalent to:Equivalent to:per week £93,807,692 per day £13,401,098 per hour £ 558,379 per minute £ 9,306per second £ 155
50% of Costs are due to premature complications50% of Costs are due to premature complications
Diabetes UK. May 2000.Diabetes UK. May 2000.
Diabetes Care: the evidence baseDiabetes Care: the evidence baseUKPDS
RENAAL
IRMA
HOPE
DCCT
EDIC
WOSCOPS4S
HPS
ASCOT-LLA
LIPID
STENO-2
CARDS TNT
EUCLIDEUCLID
DPP
Diabetes Care: Components of CareDiabetes Care: Components of CareBP control
Cholesterol profile modification
Multi-disciplinary
Eye screening
Statins
Weight loss
Regular exercise
Dietary modification
Foot screening
ACE inhibitors
AII receptor blockers
Smoking cessation
Patient orientated
Aspirin
Diabetes UK AuditDiabetes UK Audit
Foot Examination55.1% only
Range 4-95%
Foot Examination55.1% only
Range 4-95%
HbA1c%70.1%
Range 17-99%
HbA1c%70.1%
Range 17-99%
Malcolm Roxburgh. Diabetes UK Multi-Centre Audit 2000.
Blood Pressure71.1%
Range 33-100%
Blood Pressure71.1%
Range 33-100%
Eye examination56.5% only
Range 16-100%
0
10
20
30
40
50
60
70
80
90
100
%
Site
Proportion of Patients with Foot Record in YearAve 55.1%
Feet Examined % 4.332 8.894 22.94 23.06 24.75 29.31 34.16 34.39 34.61 34.83 35.87 38.99 39.86 40.18 41.77 43.61 51.91 52.42 55.72 58.94 58.94 64.51 65.76 68.14 70.7 72.26 74.05 74.3 75.09 77.16 79.35 87.8 91.7 95.3 96.67
Site 28
Sit e 17
Sit e 9Sit e 14
Si te 27
Sit e 29
Si te 18
Sit e 19
Si te 32
Si te 3Sit e 20
Sit e 8Sit e 22
Si te 21
Sit e 15
Si te 35
Si te 1 Sit e 7Site 13
Sit e 26
Si te 38
Site 2Si te 10
Sit e 11
Si te 34
Site 36
Sit e 5Si te 37
Site 6 Sit e 4Sit e 33
Si te 16
Site 24
Sit e 30
Site 12
0
10
20
30
40
50
60
70
80
90
100
%
Site
Proportion of Patients with Eyes ExaminedAve 56.5%
Eyes Examined % 16.56 21.74 27.77 31.6 31.97 32.62 42.6 42.83 45.08 45.41 45.71 46.6 46.6 49.17 54.75 55.38 55.98 57.42 57.84 58.93 60.92 61.22 62.99 63.96 68.06 68.66 72.79 73.9 76.64 81.56 81.84 82.11 89.89 90.6 94.74 98.69 100
Si te 9
Si te 14
Site 32
Sit e 29
Si te 8
Si te 36
Site 31
Sit e 15
Sit e 7
Si te 27
Si te 2
Site 26
Sit e 38
Sit e 20
Si te 17
Site 22
Sit e 34
Sit e 21
Sit e 3
Site 10
Sit e 19
Sit e 13
Sit e 37
Si te 1
Site 35
Sit e 5
Sit e 11
Si te 33
Si te 4
Site 6
Sit e 24
Sit e 16
Si te 28
Si te 30
Site 12
Sit e 18
Si te 23
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
%
Site
Proportion of Patients with DBP RecordAve 71.1%
DBP Examined % 32.85 36.38 38.03 45.27 47.83 48.18 49.68 51.24 58.01 58.17 60.92 61.65 64.68 68.50 72.49 74.48 74.81 78.87 79.92 79.92 80.68 81.21 83.84 83.99 85.24 86.34 87.91 88.76 89.17 90.13 90.83 94.48 94.51 96.19 96.40 97.44 97.68
Site 18 Site 29 Site 32 Si te 20 Site 14 Site 25 Si te 1 Si te 19 Site 3 Site 36 Site 27 Si te 15 Site 22 Site 31 Site 17 Site 9 Site 5 Site 21 Site 26 Site 38 Si te 13 Site 7 Site 6 Site 35 Si te 37 Si te 12 Site 8 Site 10 Site 28 Si te 33 Site 4Site 11
Site 24 Site 2 Si te 34 Site 30 Site 16
0
10
20
30
40
50
60
70
80
90
100
%
Site
Proportion of patients with HbA1 c measuredAve 70.1%
Series1 16.6 22.8 26.2 36 39.7 41.3 44.7 48.6 56.6 60.9 62.5 63.9 64.2 65.9 75.3 77.5 79.7 80.7 85.9 86.6 87 88.7 89.7 91.1 91.5 94.4 94.7 95.8 97.7 98.9
Site 16
Site 21
Site 7
Site 18
Site 20
Site 32
Site 15
Site 29
Site 8
Site 36
Site 22
Site 3
Site 19
Site 26
Site 2
Site 17
Site 33
Site 11
Site 28
Site 37
Site 14
Site 34
Site 4
Site 6
Site 24
Site 13
Site 12
Site 5
Site 1
Site 35
Aims:Aims:“Set national standards and ... “Set national standards and ... define service models for ... the define service models for ... the prevention ... identification and prevention ... identification and ... management ... of diabetes ... management ... of diabetes and its major complicationsand its major complications.”
Standard 4:Standard 4:“All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes.”
Department of Health 2003Department of Health 2003
Diabetes Care:
How should/could we be doing diabetes care
What are the 10 most important aspects of effective diabetes care
How can these be put in ? place
Diabetes Care:The Alphabet Strategy Approach
•Background
•Alphabet Strategy
•Multi-factorial Intervention
•Implementation in Secondary Care
•User Empowerment
•UK Primary Care
•Global Application
•i-DREAM
A simple effective approach?
““Excellence requires Excellence requires that important, simple that important, simple things are done right things are done right all the time.”all the time.”
National Service Framework National Service Framework for Coronary Heart Diseasefor Coronary Heart Disease
Patel V, Morrissey J.The Alphabet Strategy.British Journal of Diabetes &Vascular Disease. 2002.;2:1:58-59
Patel V, Morrissey J.The Alphabet Strategy.British Journal of Diabetes &Vascular Disease. 2002.;2:1:58-59
Alphabet StrategyAlphabet Strategy•• Advice: Advice:
–– exercise, diet, not smoking, exercise, diet, not smoking, regular testing & clinicsregular testing & clinics
•• Blood Pressure: Blood Pressure: –– aim less than 140/80aim less than 140/80
•• Cholesterol: Cholesterol: Creatinine CareCreatinine Care–– less than 4less than 4
•• Diabetes Control: Diabetes Control: –– HbA1c% 6.5% or less HbA1c% 6.5% or less
•• Eyes: Eyes: –– check yearly at leastcheck yearly at least
•• Feet: Feet: –– check yearly at leastcheck yearly at least
•• Guardian Drugs: Guardian Drugs: –– Aspirin 75mg protects against Aspirin 75mg protects against
heart disease, ACE inhibitors, heart disease, ACE inhibitors, ARBsARBs
AdviceAdvice• Strongly advise adherence to diet and medication• Smoking cessation, exercise, weight reduction• Ensure diabetes education and advise Diabetes UK
membership• Stress role of the dietician, chiropodist and diabetes care
nurses• Regular follow-up with comprehensive Annual Review is
essential. 20% of patients with early severe complications will be persistent non-attenders
• Lifestyle targets: weight reduction >5% if obese, fat intake <30% of energy intake, saturated fat <10% of energy intake, fibre>15g per 1000 calories, exercise for four hours / week.
Lifestyle changes reducing progression to DM
Diabetes Prevention Program Finnish Diabetes Prevention Study
7% weight loss in the obese > 5% weight loss
Avoid excess alcohol Fat intake < 30% of total calories
Diet advice Saturated fat < 10% of total calories
Smoking advice Fibre intake ≥ 15g per 1000 calories intake
150 mins of moderate exercise per week
Exercise > 4 hours per week
Other measures: increased veg/and fruits, less sugar/salt
Blood PressureUKPDS 38: 154/87 versus 144/82
UK Prospective Diabetes Study (UKPDS) Group (38). BMJ 1998;317:703–713
MI
Microvascular endpoint –34%
Heart failure –35%
Stroke –37%
All macrovascular endpoints –44%
Retinal photocoagulation –56%
Any diabetes-related endpoint –24%
0 -10 -20 -30 -40 -50
% Reduction in risk
-24 Significant
-34 Significant
-21 Non significant
-44 Significant
-56 Significant
-37 Significant
-35 Significant
Deaths reduced by 32%
C is for ...C is for ... CHOLESTEROL4S Diabetes Sub-Study:
Major Coronary Events In Patients with Diabetes
Coronary death and non-fatal MICoronary death and non-fatal MI
11 22 33 44 55 660000
2020
4040
6060
8080100100
RiskRiskreductionreduction
55%55%
Diabetic,simvastatinDiabetic,simvastatin ( n=105)( n=105)Diabetic, placebo (n=97)Diabetic, placebo (n=97)
Years since randomisationYears since randomisation
Prop
ortio
n w
ithou
t maj
or
Prop
ortio
n w
ithou
t maj
or
CH
D e
vent
s (%
)C
HD
eve
nts
(%)
CARDSCollaborative Atorvastatin Diabetes Study
Helen Colhoun, John Betteridge, Paul Durrington, Graham Hitman, Andrew Neil, Shona Livingstone, Margaret Thomason, Michael Mackness, Valentine Menys, John Fuller on behalf of the CARDS Investigators
Presented at ADA 2004
Atorvastatin 10mg
Placebo
2838patients
CARDS Design
Placebo
•Primary Prevention Diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy)
CARDS Study: Treatment Effects
21 (1.5%)
24 (1.7%)
51 (3.6%)
83 (5.8%)
Atorva*
48% (11- 69)39 (2.8%)Stroke
31% (-16- 59)34 (2.4%)Coronary revascularisation
36% (9- 55)77 (5.5%)Acute coronary events
37% (17- 52)p=0.001
127 (9.0%)Primary endpoint**
Hazard Ratio Risk Reduction (CI)Placebo*Event
.2 .4 .6 .8 1 1.2**Fatal MI ,Other acute CHD death, non fatal MI, Unstableangina, CABG, Fatal stroke, non fatal stroke
Favours Atorvastatin Favours Placebo* N (% randomised)
Diabetes ControlUKPDS 33: HbA1c% 7.9% versus 7.0%
Intensively-treated patients: HbA1C = 7.0% Conventionally-treated patients: HbA1C = 7.9% This 0.9% decrease is associated with reduction in risk for:
Significant
Significant
Borderline significance
Borderline significance
Significant
Significant
--1212
--2525
--1616
--2121
--3434
--2424
0 -10 -20 -30 -40 -50
% Reduction in risk
MI: 16% p=0.052
Retinopathy: -21%
Cataract extraction: -24%
Microvascular endpoint: -25%
Albuminuria at 12 years: -34%
Any diabetes-related endpoint: -12%
E is for Eye Screening
E is for ....Eye screening
• Diabetic Maculopathy: Commonest cause of blindness in UK under 65
• Haemorrhages and/or hard exudates within one disc diameter of the macula, with or without visual loss
• Treatment: clinical risk factors (BP, Glycaemia, cholesterol) and focal laser photocoagulation
F is for ...F is for ...FOOT SCREENINGFOOT SCREENING
Guardian Drugs
Aspirin 75mg od:
JBS 2 (2005) advocates considering aspirin 75mg od against CVD events in:
• Any established atherosclerotic disease• ≥ 50 years, or those younger but have had diabetes for
10 years, or hypertenisve• Retinopathy or nephropathy• Once BP <150/90
Guardian Drugs
• ACE-inhibitors and Angiotensin-II Receptor Antagonists have a special role in preventing diabetes complications (MICRO-HOPE, LIFE)
• ACE-inhibitors and Angiotensin-II Receptor Antagonists have a special role in preventing diabetes
• Statins are guardian drugs
LIFE: New Onset Diabetes by Treatment Group
Study Month0 6 12 18 24 30 36 42 48 54 60 66
0
2
4
6
8
10
Prop
ortio
n of
pat
ient
s, %
AtenololLosartan
Lindholm LH, J Hypertens 2002 (in press)
Doing all this Doing all this polypharmacypolypharmacy wwill ill poisonpoison ourour patientspatients!!
Blood pressure, Cholesterol, Diabetes control, ACE-I, Aspirin!
The StenoThe Steno--2 Study : 2 Study : AA SummarySummary
Steno Diabetes CentreSteno Diabetes Centre
Copenhagen, DenmarkCopenhagen, Denmark
••160 with T2D and microalbuminuria160 with T2D and microalbuminuria
••80 allocated to conventional treatment80 allocated to conventional treatment
••80 allocated to intensive treatment80 allocated to intensive treatment
••Mean age 55.1 yearsMean age 55.1 years
••Mean followMean follow--up 7.8 yearsup 7.8 years
StenoSteno--2 2 TTargetsargetsStenoSteno--2 intensive 2 intensive
cohort %cohort %JBS/AlphabetJBS/Alphabet
GuidelinesGuidelines
AAdvicedvice StandardStandard StandardStandard
BBlood Pressurelood Pressure 130 / 80 130 / 80
Earlier Earlier 140 / 85140 / 85140 / 80140 / 80
Optimal 130/80Optimal 130/80
GMS Audit 145/80GMS Audit 145/80
CCholesterolholesterol 4.54.5 4.04.0GMS Audit 5GMS Audit 5
DDiabetes Control : iabetes Control : HbHbAA11cc%% 6.56.5%% 7.07.0%%GMS Audit 7.5%GMS Audit 7.5%
EEyesyes AnnuallyAnnually AnnuallyAnnually
FFeeteet AnnuallyAnnually AnnuallyAnnually
GGuardians : aspirinuardians : aspirin, , ACEI / ACEI / AIIAAIIA
AllAll MostMost
StatinsStatins mostmost AllAll
Actual contribution of each risk factor in improving cardiovascular risk in Steno-2
• ? Blood Pressure
(down by 12/6 mmHg)
•? Diabetes Control
(HbA1c% down by 1%
•? Cholesterol Treatment
(down by 1.2 mmol/l)
•? Smoking reduction
(down by ? 15% overall)
Steno 2: Event Reduction
53 %
61% 58%
67%
0
10
20
30
40
50
60
70
cardiovasculardisease
nephropathy retinopathy autonomicneuropathy
Nu m
ber o
f eve
nts
StenoSteno--2 : CVD Event Reduction2 : CVD Event Reduction
EventEvent ConventionalConventional IntensiveIntensive
Cardiovascular DeathCardiovascular Death 77 …died earlier!…died earlier! 77
MI : nonMI : non--fatalfatal 1717 55
CABGCABG 1010 55
PCIPCI 55 00
Stroke : nonStroke : non--fatalfatal 2020 33
AmputationsAmputations 1414 77
Revascularisation for PVDRevascularisation for PVD 1212 66
P<0.002P<0.00285 events in 35 85 events in 35
patientspatients
44% overall44% overall
33 events in 19 33 events in 19 patientspatients
24% overall24% overall
Steno-2 : Conclusion
“ A target driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%.”
The PolyThe Poly--pillpillConcept:Concept:
“The Polypill Concept proposes treating BP, LDL-cholesterol, homocysteineand platelet dysfunction by administration of three antihypertensive agents, a statin, folic acid and aspirin will reduce cardiovascular disease by more than 80%”
AspostatinoprilolazideAspostatinoprilolazide FolateFolate !!
The Diabetes The Diabetes PolypillPolypill??
StatinAspirinMetformin ThiazideACE-I or ARB
Indo-linguistically: “equality” ie in terms of reducing morbidity and mortality esp. CVD
BMJ
Polypill Paper
Does the Alphabet Strategy Does the Alphabet Strategy deliver these targets? deliver these targets?
Aims
1. To evaluate clinical change and cardiovascular risk reduction achieved, using the Alphabet strategy as a template for audit in diabetes care.
2. To evaluate the usefulness of the UKPDS and Framingham cardiac risk function in clinical audit.
Advice
18.3
15.5
14
15
16
17
18
19
% patients
T0 Tfu
Smoking status
Smokers
p=NS
n=400
Blood Pressure
145.8
82.0
140.5*
76.5**
020406080
100120140160
Blood pressure
mmHg
T0 Tfu
SystolicDiastolic
*SBP p<0.001
**DBP p<0.001
n=400
Cholesterol
5.8
1.05
4.9*
1.26**
0.01.02.03.04.05.06.0
Serum cholesterol
mmol/l
T0 Tfu
Total cholesterolHDL cholesterol
*TC p<0.001
**HDL p<0.001
n=400
Diabetes Control
7.98.1
6
6.5
7
7.5
8
8.5
HbA1c %
T0 Tfu
p<0.001
n=400
Eye Examination
86.5
97.5
80
85
90
95
100
% patients examined
T0 Tfu
Examined
p<0.001
n=400
Foot Examination
69.8
83.5
60
65
70
75
80
85
% patients examined
T0 Tfu
Examined
p<0.05
n=400
Heart Disease Risk Score
UKPDS: T0 vs. Tfu p=NS Tadj vs. Tfu p<0.001
UKPDS 10 year absolute CHD risk
23.9
31.2
23.7
05
101520253035
Absolute 10 year risk %
T0 Tadj Tfu
n=315
Public Health & Prevention
Primary
Experts
Secondary care
Tertiary
Secondary
Primary Interface
………...Diagnosis……….General treatment……… Review
….… Screening…… Healthy eating…… Exercise……Weight care
Palliative …………………….…………………… Renal replacement ………………….. Amputation…………………. Rehabilitation………………… PCI / CABG……………….. Advanced eye surgery
……………… DKA…………….. Infections…………..... CVD…………... CVD Risk…………... Insulin start………….. Screening eyes………….Screening feet………….Screening renal…….…...Complex cases
Diabetes Chronic Disease Management
Single Team
Patients views on the Alphabet strategy
• Brilliant – shows you were you are!
• Very useful
• Motivational
• Helps you focus on your conditions
• Keep things in proportion
• Provides additional information
• Gives you an idea of what to aim for
• Enlightening
• Helpful
• Gives better understanding
GEDI Knights!George Eliot Diabetes Information Sticks
Amitha GopinathKelly BroganTerry Franklin
Retinal cameraappeal
Patient Survey
• 96.7% understood the strategy. ‘Diabetes control’ and ‘Advice’ posters gave the most powerful information.
• 36.7% found the ‘Guardian Drugs’ poster the hardest
• 36% stated their diabetes control; required most attention.
• 100 % of patients stated they understood the importance of BP and diabetes control.
• A mean score of 8.9/10 was given for usefulness and 90% found the experience enjoyable.
Benefits to patients • Educational tools help patients understand the main
components of care in a clear and logical manner
• The handheld records allows patients to know their BP, cholesterol etc and to track changes.
• Clinical audit demonstrates that patients have a higher standard of care than before and higher than average.
• We have demonstrated a potential reduction in CHD by 25% ( cardiac risk score reduced from 31.2% to 23.7%)
Public Health & Prevention
Primary
Experts
Secondary care
Tertiary
Secondary
Primary Interface
………...Diagnosis……….General treatment……… Review
….… Screening…… Healthy eating…… Exercise……Weight care
Palliative …………………….…………………… Renal replacement ………………….. Amputation…………………. Rehabilitation………………… PCI / CABG……………….. Advanced eye surgery
……………… DKA…………….. Infections…………..... CVD…………... CVD Risk…………... Insulin start………….. Screening eyes………….Screening feet………….Screening renal…….…...Complex cases
Diabetes Chronic Disease Management
Single Team
Patient Groups
Expert Patients
Benefits to staff
• This strategy has resulted in closer team working of all members of the Diabetes Care team, effectively towards a very high standard of care.
• This includes practice nurse, general practitioners, hospital doctors, nurses, pharmacists, podiatrists and dieticians. The materials have been produced by the whole team.
• The team feels empowered in the fact that a very high standard of care is being delivered.
• Recruitment to our unit is excellent with most staffs members involved in dissemination of the strategy.
0
20Po
ints
( to
tal =
66
)
RegisterBMI Record
Smoking record
Smoking cessation
Flu jabBP recordBP = < 145 / 85
TC recordTC = < 5Ma recordCr recordA1c recordA1c = < 10A1c = < 7.4Eyes record
FP recordPN recordMa Rx
All practices : points by parameter 2004
Points shortPoints won
0
20Po
ints
( to
tal =
94
)
RegisterBMI Record
Smoking record
Smoking cessation
Flu jabBP recordBP = < 145 / 85
TC recordTC = < 5Ma recordCr recordA1c recordA1c = < 10A1c = < 7.4Eyes record
FP recordPN recordMa Rx
All practices : points by parameter 2005
Points shortPoints won
“Degree” in Diabetes Care: 2004
Overall ScoresOverall ScoresPracticePractice
20042004 20052005
R1R1 8787
R2R2 7878
R3R3 7676
R4R4 7676
R5R5 7575
R6R6 7474
R7R7 7171
R8R8 6969
R9R9 6060
R10R10 4141
R11R11 4141
R12R12 2020
0 0 -- 6464Class 3Class 3
65 65 –– 7474Class 2 LowerClass 2 Lower
75 75 –– 8484Class 2 UpperClass 2 Upper
85 85 –– 9999Class 1Class 1
Degree in Diabetes Care: 2005
Overall ScoresOverall ScoresPracticePractice
20042004 20052005
R1R1 8787 92*92*
R2R2 7878 97**97**
92*92*
8989
98**98**
95**95**
95**95**
95**95**
93*93*
92*92*
7878
91*91*
R3R3 7676
R4R4 7676
R5R5 7575
R6R6 7474
R7R7 7171
R8R8 6969
R9R9 6060
R10R10 4141
R11R11 4141
R12R12 2020
0 0 -- 6464Class 3Class 3
65 65 –– 7474Class 2 LowerClass 2 Lower
75 75 –– 8484Class 2 UpperClass 2 Upper
85 85 –– 9999Class 1Class 1
UK Median 84
Global Alphabet Strategy Implementation Audit
GAIA Project
Methods• Medical students from the University of
Warwick collected data in Alphabet Strategyformat during their electives around the world.
• We analysed data on 4545 patients from 50 centres, in 31 countries, in all continents bar Antarctica. The results were organised into quintiles (Q1-Q5) according to GMS2 points.
• Main components of the study:1)Data collection2)Diabetes care team questionnaire3)Demographics4)Alphabet strategy questionnaire
GAIA: 31 countries
4545 patients, 50 centres
Total GMS2 points per centre Jersey 87.52
France 84.71
Falklands 78.92
Aus 3 76.93
Norway 76.54
Spain 72.44
Aus 4 72.08
Aus 2 68.3
Greece 68.12
India 1 66.79
Barbados 54.46
Jamaica 41.29
India 5 39.59
W Samoa 37.21
Bangladesh 35.71
India 3 33.91
Malaysia 48.31
Ireland 45.69
Q3
USA 66.4
South Africa 59.05
St Kitts 32.75
Q2
Q1
10.16Tonga
12.35Egypt 2
13.35Belize
16.16Egypt 1
17.27India 6
19.66Aus 1
Q5
19.7Ghana 2
25.26Sol Islands
27.11India 2
28.48Cuba
29.2India 4
30.05Mauritius
32.42Ghana 1
Q4
28.48Q4
13.35Q5
37.21Q3
66.4Q2
76.93Q1
Median
N= 34
Likely to adopt Alphabet Strategy in their departments
0102030405060708090
100
perc
enta
ge
Q1 Q2 Q3 Q4 Q5n=35centers, 146 responses
Strategy will improve the outcome of their practice
0102030405060708090
100
Perc
enta
ge
Q1 Q2 Q3 Q4 Q5
n=35centers, 146 responses
Strategy could be applied with their economic background
0102030405060708090
100
Perc
enta
ge
Q1 Q2 Q3 Q4 Q5
n=35centers, 151 responses
Indo-Asian Diabetes Care:The Alphabet Strategy
• Advice: exercise, diet, not smoking, regular clinics
• Blood Pressure: aim less than 140/80
• Cholesterol: TC less than 5, LDL < 3, HDl> 0.9
• Diabetes Control: HbA1c% 7% or less
• Eyes: check yearly at least refer appropriately
• Feet: check yearly at least refer appropriately
• Guardian Drugs: Aspirin 75mg, ACE-I, AT II antagonists, statins
ASIAD ProjectAlphabet Strategy – Indian Application for Diabetes
An European Strategy applied in outpatient setting in Asia
L Varadhan1, V Palanikumaran2, A Gopinath1,
J Morrissey1, V Patel3l NHS 1 George Eliot Hospital NHS Trust
2 Shenbagam Hospital, Madurai, India3 Warwick Medical School, University of Warwick, Coventry, UK
Methods• Few changes made to the Alphabet strategy template to
suit Indian standards: replace HbA1c with fasting and postprandial blood glucose; microalbuminuria with proteinuria
• A prospective audit was done on 100 further patients implementing the Alphabet Strategy
• Documentation of various aspects of diabetes care were compared with 100 case notes randomly selected from the outpatient setting in UK
Alphabet Strategy – UK template
Alphabet Strategy – Indian template
Advice
99 99 100 99 99 100 100 100 94
0
10
20
30
40
50
60
70
80
90
100
BMI recorded Smoking record Cess advice
Before AS India After AS India UK
Blood Pressure & Cholesterol
99 99 100
60
99 100
10
64
97
0
10
20
30
40
50
60
70
80
90
100
BP Recording TC record Lipid profile
Before AS India After AS India UK
Creatinine & Proteinuria
5
49
99
0 03
48
93
56
0
10
20
30
40
50
60
70
80
90
100
Creat Recording Micral record Proteinuria
Before AS India After AS India UK
Diabetes
0 0
100
41
97 100
0
10
20
30
40
50
60
70
80
90
100
HbA1c FPG/PPPG
Before AS India After AS India UK
Eye & Feet Examination
98 100 100 95 100
80
0
10
20
30
40
50
60
70
80
90
100
Eye exam Feet exam
Before AS India After AS India UK
Guardian drugs
6
71 71
7
57
75
5
38
73
2
20
52
0
10
20
30
40
50
60
70
80
Aspirin ACEI/ARB Statin All 3
Before AS India After AS India UK
GMS Score
45
61
76
0
10
20
30
40
50
60
70
80
GMS Score
Before AS India After AS India UK
Conclusion
• The Alphabet strategy of diabetes care is an effective template to ensure that all components of diabetes care are delivered to patients with diabetes.
• The Alphabet strategy of diabetes care has to the potential to be easily adopted to any health care economy
• Comparable standards to diabetes care can be provided using this strategy.
Diabetes Care: Different Economic Models
1 2 3 4
Professional Personal Adviser
All drugs
Full profile, all drugs
Continuous monitoring
Specialisedservice
Full support. MRI
All drugs
ACE-1, ARB, CCB
All drugs
Home testingHbAc1%
Camera
Vascular service
ACE-I, ARB
General
ACE-I, CCB
Measure, statin
HbA1c%
Trained staff, laser
Trained staff
Statins
Leaflets
Thiazides
Diet
Clinic tests
Clinic ExaminationClinical examination
Aspirin
A
B
C
D
E
F
G
The Alphabet Strategy for Diabetes Care:
• Educational talks for healthcare professionals and patients
• Guidelines: evidence – based, clear, simple to use.
• Educational materials and posters for patients.
• Specific materials for ethnic minority diabetes care.
• Handheld patient record
• Patient self management assessment scorecard ( gold, sliver, bronze “medals”)
• GAIA Project
• Website ( www.abcdiabetescare.org.uk)
VIDYADiabetes CHD Stroke Renal
Advice Advice
Blood PressureCholesterolCreatinineDiabetes controlESCRD CareECG, US, ?CT
Functional management
Guardian Drugs
Blood Pressure
CholesterolCreatinine
Diabetes control
ECG and other Investigation
Functional disability management
Guardian Drugs
Advice
Blood Pressure
CholesterolCreatinine
Diabetes control
ECG / ETT / Echocardiography
Functional status and follow up
Guardian Drugs
Advice
Blood Pressure
CholesterolCreatinineDiabetes control
Eyes
Feet
Guardian Drugs
A
B
C
D
E
F
G
Alphabet Strategy for Diabetes Care• Advice:
– Education, self-management, smoking cessation, diet, physical activity, weight reduction
• Blood Pressure: – Target <130/80– Audit standard <140/90
• Cholesterol: – TC ≤ 4.0 mmol/l, LDL ≤ 2, – Consider HDL ≥ 1 men, HDL ≥ 1.2 women
• Diabetes Control: – Target HbA1c% ≤ 6.5%
• Eyes: – check yearly and refer if needed
• Feet: – check yearly and refer if needed
• Guardian Drugs:– Aspirin 75mg, ACE-I or ARBs, Statins
Alphabet Strategy for Diabetes Care• Advice:
– Education, self-management, smoking cessation, diet, physical activity, weight reduction
• Blood Pressure: – Target <130/80– Audit standard <140/90
• Cholesterol: – TC ≤ 4.0 mmol/l, LDL ≤ 2, – Consider HDL ≥ 1 men, HDL ≥ 1.2 women
• Diabetes Control: – Target HbA1c% ≤ 6.5%
• Eyes: – check yearly and refer if needed
• Feet: – check yearly and refer if needed
• Guardian Drugs:– Aspirin 75mg, ACE-I or ARBs, Statins
Single Team: Patients, Primary, Secondary, Tertiary, Public Health, other stakeholders
Re-iterative, evidence changing, patient focussed
Awards• Diabetes UK 2006: Clinical care poster award: First Prize
• NHS West Midlands Innovation Award 2005 :Innovation in Service Award: First PrizeThis award was given for a clinical decision making programme that integrates best clinical evidence for Diabetes Care. Abstracts of important clinical trials in are present in the novel AT-A-GLANCE format. This is both an educational and clinical management toolwhich has the unique addition of a patient education facility included.
• Health Care Social Awards 2005: Long term condition Award, Midlands and East ,Runner-up.This award will recognise services and innovations that help support patients with long term conditions and improve their quality of life.
Awards• Diabetes UK 2005: Diabetes UK/ Servier Type 2 Diabetes
Research Award: First prize
• British Association of Medical Managers 2004: Medical Management Team of the Year Award: First PrizeThis award was given for the Alphabet Strategy for Diabetes. Themain strength of this project that made it of national interest is the integration of patient-centred evidence-based management strategy for Diabetes care. Moreover the strategy allows most healthcare professionals in diabetes care to work together across the primary/secondary care interface.
• Hospital Doctor Awards Commendation 1999:This award was given for the team effort in setting high standards of clinical care