#GPGeneral The Alphabet Strategy for Diabetes Care: A Patient-Centred, Multi-Professional Evidence-based Approach Vinod Patel BSc (Hons) MD MRCGP FRCP DRCOG Principal Clinical Teaching Fellow Warwick Medical School, University of Warwick Consultant Physician, Endocrinology and Diabetes George Eliot Hospital NHS Trust, Nuneaton

#GPGeneral Meet our Generic Patient! Albert Ramsinghhamidowski! 56-year-old Taxi driver, married, family history of diabetes. Type 2 diabetes, 8 years’ duration, putting on weight, occasionally sweaty. Better with chocolate! Brother, aged 62, recently had a heart attack. Taking: Metformin 500 mg x 3 per day Gliclazide 80 mg x 2 per day Simvastatin 40mg Ramipril 1.25mg x 1 per day BP: 142/84, T-Chol 4.9 mmol/l, LDL 2.7 HbA1c 70mmol/mol = 8.5% What does best practice look like? Is this always achievable? Practical Tips for over-coming barriers

#GPGeneral Diabetes is a major health problem in the UK: Over 3.0 million people diagnosed 1 Approx 4.9% of UK adult population 1 T2D accounts for 85-95% of all cases 1 The total number of people with diabetes in the UK could increase to >5.5 million by Diabetes – a UK health challenge References last accessed December 2012: 1. IDF Atlas Diabetes UK. By million 2013 >3.0 million 3

#GPGeneral Calculated from QoF Prevalence and NDA Data by GEH Team (2012). Prevalence = record of specific complication over a defined time period (one year). Complication n PeopleDiabetes % No Diabetes % Risk ↑ DKA Angina MI Cardiac Failure Stroke ESRD Retinopathy Rx Minor Amputn Major Amputn UK Diabetes Complications: Based on 2.9 million people (2012)

#GPGeneral Reducing Complications Can we reduces these outcomes? Cardiovascular Death… by 56% All death … by 46% CABG … 50% Stroke : non-fatal … by 85% Amputations … by 50% Revascularisation for PVD … 50% End Stage Renal failure by … by 83% Retinopathy Commonest cause of blindness < 65 Nephropathy 30% of all new renal replacement therapy Macrovascular CVD disease 2–4 fold increased risk of CHD and Stroke, 75% have hypertension Foot problems Commonest cause of amputation Diabetes Care : The Complications

#GPGeneral Healthcare Delivery and Education Evidence Base Care Planning HCP & Patient Education

#GPGeneral A Patient-Centred, Multi-Professional,Evidence-based Approach Diabetes Care “Checklist” A Patient-Centred, Multi-Professional,Evidence-based Approach Advice:Advice: –Diet and weight control, Physical activity, not smoking Blood Pressure:Blood Pressure: –aim ≤ 130/80 Cholesterol:Cholesterol: –TC ≤ 4.0, LDL ≤ 2.0, HDL ≥ 1.0 Diabetes Control:Diabetes Control: –HbA1c% 48 (6.5%) Eyes:Eyes: –check yearly at least Feet:Feet: –check yearly at least Guardian Drugs:Guardian Drugs: –?Aspirin 75mg –?ACE inhibitors, ARBs JD Lee & V Patel 2012

#GPGeneral Each year smoking causes the greatest number of preventable deaths References: 1. ASH Factsheet, Smoking Statistics: illness & death, June 2011 ( NB area represents valuehttp:// Obesity: 34,000 Smoking: 81,400 Alcohol: 8,724 Suicide: 5,377 Murder: 648 HIV: 529 Traffic: 2,946

Blood Pressure UKPDS 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% % Reduction in risk -24 Significant -34 Significant -21 Non significant -44 Significant -56 Significant -37 Significant -35 Significant Deaths reduced by 32%

Primary prevention diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy) NB NICE Guidelines Advise 20mg od now Atorvastatin 10mg Placebo 2838 patients Placebo Cholesterol Atorvastatin 10mg versus Placebo

21 (1.5%) 24 (1.7%) 51 (3.6%) 83 (5.8%) Atorva* 48% (11- 69) 39 (2.8%) Stroke 31% ( ) 34 (2.4%) Coronary revascularisation 36% (9- 55) 77 (5.5%) Acute coronary events 37% (17- 52) p= (9.0%) Primary endpoint** Hazard Ratio Risk Reduction (CI)Placebo*Event * N (% randomised) Favours Atorvastatin Favours Placebo **Fatal MI,Other acute CHD death, non fatal MI, Unstable angina, CABG, Fatal stroke, non fatal stroke CARDS study: Treatment effects

TNT Study: Secondary Prevention Secondary Prevention: Reduction in CVD events by 25% (Diabetes or Metabolic Syndrome). Atorvastatin 10mg Atorvastatin 80mg DM and CHD patients

#GPGeneral Diabetes Control: UKPDS: 1% decrease in HbA 1c is associated with a reduction in complications by…. Stratton IM, et al. BMJ 2000; 321: 405–12. 43% 37% 21% 14% 12% HbA 1C 1% * p< ** p=0.035 Stroke** Microvascular complications e.g. kidney disease and blindness * Amputation or fatal peripheral blood vessel disease* Deaths related to diabetes* Heart attack*

#GPGeneral 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

#GPGeneral F is for... FOOT SCREENING

#GPGeneral 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 may have a special role in preventing diabetes Statins are guardian drugs Guardian drugs

Days of Follow-up Kaplan-Meier Rates ramiprilPlacebo RRR = 33% ( ) p= HOPE : stroke rate - ramipril vs placebo in Diabetes Patients

#GPGeneral Doing all this polypharmacy will poison Albert Ramsinghhamidowski! Blood pressure, Cholesterol, Diabetes control, ACE-I, Aspirin!

Steno Diabetes Centre Copenhagen, Denmark 160 with T2D and microalbuminuria 80 allocated to conventional treatment 80 allocated to intensive treatment Mean age 55.1 years Mean follow-up 7.8 years The Steno-2 Study : A summary

IntensiveConventional Advice Standard Blood Pressure 131 / 73146/78 Cholesterol TC 3.5 mmol/l LDL 1.8 mmol/l 5mmol/l Diabetes Control : HbA1c% 7.9%9% Eyes Annually Feet Annually Guardians : aspirin, ACEI / AIIA All on ACE-I Statins 85%22% Intensive Steno-2 targets achieved- same as NICE Targets NEJM 2008 Conventional Steno-2 targets achieved- same as QoF Targets

Steno-2 : CVD event reduction EventConventionalIntensive Cardiovascular Death7 …died earlier!7 MI : non-fatal175 CABG105 PCI50 Stroke : non-fatal203 Amputations147 Revascularisation for PVD126 P< events in 35 patients 44% overall 33 events in 19 patients 24% overall

Steno-2 : CVD deaths at 13 years EventConventional Mortality 30% Intensive Mortality 50% Cardiovascular Deaths P<0.05 Reduced by 57%! Cholesterol was 3.8 mmol/l at 13.3 years

Steno-2 : 13 years follow up dataEvent Reduction in Intensive Group All Deaths 46% Cardiovascular Deaths 57% Cardiovascular events 59% End Stage Renal Failure 1 versus 6 patients Retinal Laser Rx 55% P<0.05

Alphabet strategy consultation Introduction Hello! How are you? How can I help you today? Introduction Hello! How are you? How can I help you today? Patient: Dizzy turns, loss of energy, Patient: Dizzy turns, loss of energy, HCP: OK lets talk about that first. I will then go through your ABC care plan with you HCP: OK lets talk about that first. I will then go through your ABC care plan with you Advice: Weight 112 kgm, BMI 31, smokes 20, exercise little Advice: Weight 112 kgm, BMI 31, smokes 20, exercise little Blood pressure: 154/92, rechecked 146/86 Blood pressure: 154/92, rechecked 146/86 Cholesterol : 6.4 mmol/l, LDL 4.2 mmol/l, HDL 0.8 mmol/l, creatinine 132 umol/l Cholesterol : 6.4 mmol/l, LDL 4.2 mmol/l, HDL 0.8 mmol/l, creatinine 132 umol/l Diabetes control: HbA1c% 8.3%, metformin 500mg tds, Diabetes control: HbA1c% 8.3%, metformin 500mg tds, Eye examination : no retinopathy Eye examination : no retinopathy Feet examination : no problems Feet examination : no problems Guardian drugs : ? Guardian drugs : ? Problem List: 1. Hypoglycaemia 2. Smokes Problem List: 1. Hypoglycaemia 2. Smokes 3. BP too high 4. Cholesterol too high 3. BP too high 4. Cholesterol too high Plan: 1. ? ‘gliptin Plan: 1. ? ‘gliptin 2. Encourage smoking cessation 2. Encourage smoking cessation 3. Start ? diuretic 3. Start ? diuretic 4. ? Review lipid ? Change to Atorvastatin, ? Concordance 4. ? Review lipid ? Change to Atorvastatin, ? Concordance Follow up: 3 months with HbA1c%, lipid profile, U&Es

#GPGeneral Patient Education

Diabetes Care Planning Remember! Our patient spend 3 hours a year with HCP in Diabetes And the other 8763 hours looking after themselves!

#GPGeneral Patient Education: Education and Prevention

#GPGeneral Patient Education: Education and Prevention

#GPGeneral Individualised to the Patient

#GPGeneral Patient Education

#GPGeneral Effective communication to other HCP

#GPGeneral National Diabetes Audit Largest diabetes audit in world: England and Wales Approx records, 80% of those with diabetes in England and Wales 8 Care processes (NICE): weight, BP, HbA1c, Urine Albumin Creatinine ratio (UACR), cholesterol, feet screening, smoking status and advice (problems with eye screening data) Obesity: 50% in type 2, 25% in Type : All 9 Care Bundle Processes: 56.4% in type 2, 38.5% in Type : All 9 Care Bundle Processes: 8.1% in type 2, 6.8% in Type 1 Now all 8 care processes: 60.5% (last year 60.6%) HbA1c% ≤ 7.5, Cholesterol, 5 mmol/l, Relevant BP target: National Average: Top 25% 22.3% only. So only 1 in 5 are reaching targets on average

#GPGeneral An educational programme for long term conditions: Climbing all the way up Kirkpatrick’s hierarchy of evaluation of teaching Vinod Patel, L Varadhan, A Gopinath, J D Lee, S Shaikh, D James, P Sear, J Wilson, T Ritchie, P Saravanan, R Nair, J Morrissey George Eliot Diabetes Care Team Nuneaton

#GPGeneral Background Kirkpatrick’s hierarchy of evaluation of teaching can be summarised as the following four levels: 1 Reaction: satisfied, leave happy 2 Learning: knowledge, skills developed, new attitudes 3 Behaviour change: work environment adapts 4 Outcomes: distinct clinical outcomes realised Usually educational programmes still only appear to evaluate at the first level, in clinical practice it is outcomes that we are trying to achieve

#GPGeneral Aim To present a model of LTC Education that evaluates at all 4 Kirkpatrick’s hierarchy of evaluation of teaching Evidence-based Patient-centred Multi-professional Core Concepts: Miller’s Seven and “digital” transfer of learning

#GPGeneral “Digital vs Analogue” learning: A novel perspective Shannon, the father of modern information theory, recognised that the essential problem of information transfer was its truthfulness and completeness (1948). He stated: “the fundamental problem of communication is that of reproducing at one point either exactly or approximately a message selected at another point” Claude Elwood Shannon

#GPGeneral Alphabet Strategy for Diabetes Care A patient-centred, evidence-based strategy based on the most important aspects of diabetes care. Miller’s key educational idea that most people can only remember around 7 concepts (Miller 1956). The Alphabet strategy approach includes: Advice : not smoking, exercise, weight loss Blood pressure : ≥130/80 Cholesterol : ≥ 4 mmol TC Diabetes control : ≥ 7.0 % HbA1c Eye screening : Yearly Feet screening : Yearly Guardian drugs : most patients on ACE:I

#GPGeneral Main results Level 1: Reaction Healthcare professional Education programme This has been delivered over 100 occasions as part of a clinical education programme. Evaluations have been consistently positive. Cyprus, Bahrain, India, China (rest UK and Scotland)

#GPGeneral Main results Level 1: Reaction GAIA Survey 35 diabetes centres in 25 countries 57.5% of 146 healthcare professionals felt they were likely to adopt the strategy. 84.5% felt it was evidence-based and 88.0% practical. Australia Bangladesh Barbados Belize Cuba, Egypt Falklands islands France Ghana Greece India Ireland Jamaica Jersey States Malaysia Mauritius Germany Norway Solomon islands South Africa Spain, St Kitts Tonga USA Western Samoa

#GPGeneral Main results Level 2: Knowledge Skills Attitudes acquired Patient Education Programme Knowledge of diabetes care was evaluated in 100 patients This showed a significant improvement from 61.5 % to 80.0% (p<0.01).

#GPGeneral 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

#GPGeneral Main results Level 2: Knowledge Skills Attitudes acquired i-DREAM Programme (interactive Diabetes Research Evidence Application in Management) This programme showed a significant improvement in clinical management, application of evidence-base research and correct prescribing scores (69% before, 98% afterwards (p<0.001)) in 15 clinicians on 10 case studies.

#GPGeneral Main results Level 3: Changes in professional practice Diabetes In-patient Care Evaluation Data was collected on quality of care before and after implementing this strategy. There was significant improvement in 9 of the 10 main parameters of care. DICE Project - Sticker

#GPGeneral Main results Level 3: Changes in professional practice ASIAD Study In India within 4 months there significant improvement in the 100 patients studied (p<0.01). Main changes were: improvement in cholesterol profile (60% to 90%), statin use (5% to 38%), aspirin use (6% to 71%), proteinuria assessment (48% to 93%). Guardian Drugs Before Alphabet Strategy India After Alphabet Strategy India UK Data

#GPGeneral Main results Level 4: Patient outcomes POEM Clinical Audit (Practice Of Evidence-based Medicine) Clinical audit showed over 5 years BP, Lipid profile, diabetes control, eye and feet screening improved. With a significant improvement in CVD score (31.2% to 23.7%) National Diabetes Audit 2013 Admission for Diabetes Complication 2.0% versus 8% national Third best for 8 basic parameters recorded in notes UKPDS: T0 vs. Tfu p=NS Tadj vs. Tfu p< Absolute 10 year risk % T0TadjTfu UKPDS 10 year absolute CHD risk

Diabetes Matrix An Integrated Approach to Prevention, Care and Commissioning LevelTarget Group 1: Community Prevention Entire Local Population 2: Pre-Diabetic Screening At risk groups within the local population 3: Early Diagnosis Pre-diabetic population, Known impaired glucose tolerance, newly diagnosed DM 4: Forging Foundations Newly diagnosed: excellent care from start focus on lifestyle, experience, outcomes, concordance, preventing complications 5: Rolling Review 5A: Well controlled with few risk factors to manage. Achieving high quality care parameters 5B: Complicated, higher risk or psychological or social issues affecting engagement with high quality care 6: Early Escalation Uncontrolled clinical and social factors at high risk of complications, admission or morbidity. eg hypertension, poor concordance, poor glycaemic control 7: Curbing Complications 7A: Patients with known complications/conditions: eg pregnancy, concurrent illness, planned surgery 7B: Patients with unpredictable complications: reaction s to medications, polypharmacy 8: Avoidable Admissions Hypoglycaemia, DKA, Foot ulceration and infection, 9: Unavoidable Admissions Patients with advanced disease and complications: acute coronary syndromes, stroke, amputation, nephropathy, neuropathy 10: Rationalised Long Term Care Patients with co-morbidities not amenable to treatment: end-stage renal disease, review of medications, end-of-life care

#GPGeneral A Patient-Centred, Multi-Professional,Evidence-based Approach Diabetes Care “Checklist” A Patient-Centred, Multi-Professional,Evidence-based Approach Advice:Advice: –Diet and weight control, Physical activity, not smoking Blood Pressure:Blood Pressure: –aim ≤ 130/80 Cholesterol:Cholesterol: –TC ≤ 4.0, LDL ≤ 2.0, HDL ≥ 1.0 Diabetes Control:Diabetes Control: –HbA1c% 48 (6.5%) Eyes:Eyes: –check yearly at least Feet:Feet: –check yearly at least Guardian Drugs:Guardian Drugs: –?Aspirin 75mg –?ACE inhibitors, ARBs JD Lee & V Patel 2012

#GPGeneral

Conclusion This strategy has helped deliver high quality patient education and reduction in cardiovascular risk factors, catering for all 4 levels of Kirkpatrick’s Hierarchy for evaluating an education programme. Such a programme may be applied to other chronic disease states with similar beneficial effects.

#GPGeneral Conclusion Management of LTC present a major current and future challenge in Healthcare Programmes of education have to integrate evidence-base, patient education and care planning and healthcare professional education The basic construct of the Alphabet Strategy lends itself to effective implementation by patients and HCP It evaluates at all 4 of Kirkpatrick’s levels of learning