Introduction To The Alphabet Strategy And Evidence Based Medicine

1. Introduction To The Alphabet Strategy And Evidence Based Medicine

2. UK prevalence of diabetes mellitus • UK prevalence of diabetes mellitus = 3.54%. • 2.2 million people in the UK have diabetes : • 1.9 million ( 87%) have type 2 diabetes. • 300,000 (13%) have type 1 diabetes. • There may be as many as one million undiagnosed cases of type 2 diabetes. Diabetes UK, 2006

3. Global prevalence of diabetes 2003 < 2% 2% - 5% 5% - 8% 8% - 11% 11% - 14% 14% - 17% 17% - 20% >20 Diabetes Atlas second edition, IDF 2003

4. Chronic complications of diabetes • Coronary and cerebrovascular Disease • 2–4 fold increased risk of coronary heart disease and stroke, 75% have hypertension Retinopathy Most common cause of blindness in people of working age Nephropathy 16% of all new patients needing renal replacement therapy Foot Problems 15% of people with diabetes develop foot ulcers; 5–15% of people with diabetic foot ulcers need amputations • Erectile Dysfunction • May affect up to 50% of men with long-standing diabetes The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.

5. Non Diabetics 85 80 75 Diabetics 70 65 Life expectancy (yrs) 60 55 50 45 40 15-19 20-29 30-39 40-49 50-59 60-70 Age at diagnosis (yrs) Life expectancy and diabetes Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721. Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066.

6. 30% 25% 20% 15% 10% 5% 0% Men Women Asian European 20–39 40–59 60–79 20–39 40–59 60–79 Age groups Diabetes in the UK Indo - Asian community

7. Cost of diabetes to the NHS NHS spend on diabetes is : • 5% of the total budget, or • £10 million per day. This is predicted to increase to 10% of the total budget by 2011. Diabetes UK, 2004

8. GMS Contract Evidence base NICE Increasing prevalence National Service Framework User expectations Guidelines

9. Glycaemia Eyes Lipids Patient oriented Blood pressure Multi -disciplinary Lifestyle Feet Audit

13. “ The integration of best research evidence with clinical expertise and patient values . ” Evidence-based medicine Sackett DL et al (2000) Evidence Based Medicine

14. Best research evidence Clinical expertise Patient values

15. Best research evidence Clinical expertise Patient values … within available resources

16. William of Ockham (1285-1349) “ Entia non sunt multiplicanda praeter necessitatem ” “ Entities are not to be multiplied beyond necessity ”

17. K I S S

18. Keep It Simple , Stupid

19. “ Excellence requires that important, simple things are done right all the time . ” National Service Framework for Coronary Heart Disease

20. The Alphabet Strategy • Advice • Blood pressure • Cholesterol • Diabetes control • Eye examination • Feet examination • Guardian drugs • Heart risk score

21. The Alphabet Strategy • Advice Smoking , diet , exercise • Blood pressure < 140/80 • Cholesterol TC ≤ 4 , LDL : HDL ≤ 2 • Diabetes control HbA1c ≤ 7% • Eye examination Annual examination • Feet examination Annual examination • Guardian drugs Aspirin, ACEI, statins &C • Heart risk score UKPDS, Framingham

22. Patel V, Morrissey J The Alphabet Strategy British Journal of Diabetes & Vascular Disease, 2002: 2: 1: 58-59

23. A is for ... ADVICE

24. Advice • Adherence to diet and medication • Smoking cessation, exercise, weight reduction • Ensure diabetes education and advise Diabetes UK membership • Stress role of the dietician, podiatrist and diabetes care nurses • Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic 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.

26. B is for ... BLOOD PRESSURE

27. 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 UKPDS 38 : 154/87 versus 144/82 -21Non significant -34 Significant -35Significant -37Significant -44Significant -56 Significant -24 Significant UK Prospective Diabetes Study (UKPDS) Group (38). BMJ 1998;317:703–713

28. C is for ... CHOLESTEROL

29. CHD prevention trials with statins in diabetes: CHD Endpoints: †HPS = first major vascular event; ††CARE = absolute risk of coronary events; ** CARDS: Acute Coronary Events ‡4S = major CHD events; ‡‡4S reanalysis=major coronary events. Cohorts: *HPS = risk reduction for the entire cohort (nondiabetics and patients with diabetes). Footnote: NS = results not statistically significant. 1. HPS Collaborative Group. Lancet. 2002;360:7-22. 2. Goldberg RB, Mellies MJ, Sacks FM, et al. Circulation. 1998;98:2513-2519. 3. Pyörälä K, Pedersen TR, Kjekshus J, et al. Diabetes Care. 1997;20:614-620. 4. Haffner SM, Alexander CM, Cook TJ, et al. Arch Intern Med. 1999;159:2661-2667. CARDS Study ADA 2004. GREACE Study

30. D is for ... DIABETES CONTROL 

31. Effect on diabetes complications of HbA1c% reduction Reductions in HbA1c and corresponding reductions in microvascular and macrovascular complications described in major studies of persons with T1 DM and T2 DM

32. To summarise . . . • Control blood glucose to prevent microvascular complications. • Lower cholesterol to prevent macrovascularcomplications. • Lower blood pressure to prevent both.

33. E is for ... EYE EXAMINATION

35. F is for ... FEET EXAMINATION

37. G is for ... GUARDIAN DRUGS

39. The Alphabet Strategy • Advice Smoking , diet , exercise • Blood pressure < 140/80 • Cholesterol TC ≤ 4 , LDL : HDL ≤ 2 • Diabetes control HbA1c ≤ 7% • Eye examination Annual examination • Feet examination Annual examination • Guardian drugs Aspirin, ACEI, statins &C • Heart risk score UKPDS, Framingham