1. Newbury Pre Diabetes Project A real-world implementation of QDiabetes in a CCG Area Tim Walter Newbury and District CCG

2.  Raise awareness generally  Lifestyle intervention for those at risk  Early identification of those at risk of, or already with DM2 without a diagnosis Aims of the PreDM Project

3.  My Journey  Newbury Pre-Diabetes Project  Phase 1 Lifestyle Intervention - Surgeries  Phase 2 County Show experience  Phase 3 Targeted screening  As an example to copy/change as you wish  Resources www.predm.co.ukwww.predm.co.uk What to expect from today

4. Trends at Falkland Surgery  2000 Type 1 DM = 44 Type 2 DM = 150 (194)  2005 Type 1 DM = 56 Type 2 DM = 250 (306)  2008 Type 1 DM = 66 Type 2 DM = 369 (435)  2012 Type 1 DM = 73 Type 2 DM = 399 (472)  12/11/2013 Total 498  The massive increase in DM is predominantly in the Type 2 group  About 3.5% of population

5. Summary of historic care  1990’s – minimise impact (Symptoms and meds)  2000’s – move to targets and “maximize dose” and identify missed diagnosis  2010’s – earlier diagnosis (seeking borderline results) of pts with IGT, single Random BS readings etc

7.  Inaugural joint 2012-13 winners  Funded by QResearch ( in a joint partnership between Emis, Emis NUG and University of Nottingham)  Prof. Aziz Sheikh of Primary Care Research & Development at the University of Edinburgh – Smoking Cessation  Myself – Pre-Diabetes Project  Plus John Robson and Kambiz Boomla QInnovation

8. Nice Guidance Recent National Institute for Health and Clinical Excellence (NICE) guidance has recommended: Identifying people at risk of developing type 2 diabetes, using a validated risk assessment score and a blood test (fasting blood glucose or HbA1c) to confirm high risk. Providing those at high risk with an intensive lifestyle-change programme to prevent or delay the onset of type 2 diabetes.

9.  Recommendation 3 Developing a local strategy  Recommendation 6 Conveying messages to the local population  Recommendation 8 Promoting a healthy diet: local action  Recommendation 10 Promoting physical activity: local action Nice PH35 Preventing type 2 diabetes: population and community-level interventions

10.  reduce their weight by more than 5%  keep their fat intake below 30% of energy intake  keep their saturated-fat intake below 10% of energy intake  eat 15 g/1000 kcal of fibre or more  are physically active for at least 4 hours per week. Finnish Diabetes Prevention Study

11.  QDiabetes Tool  Concept of Pre-Diabetes  Early intervention reduces risk by up to 60% (Finnish Study and DPP in USA)  Lifestyle interventions (E4H) work in the short term  Project looks to combine these to assess practical issues and costs Components of the project

12.  113,000 - mixed clinical system CCG  Surgery Process, 1 st cohort EmisWEB  Instructions to practices to run the bulk QDiabetes module  Identify patients with > 30% 10yr risk  Invitation to have bloods and join E4H Group  Currently ending 2 nd Cohort phase, LV and INPS  Starting SystmOne and last EmisWEB practice Newbury PreDM Project

13.  50 patients invited per practice (8 surgeries) (30-80% risk calculations)  400 in first 2 cohorts  18% uptake  Of those having bloods 14% at diagnostic levels, more with marginal results  E4H – Average 3kg Weight loss, = 110Kg total in 1st cohort  Up to 15Kg loss  1kg =16% risk reduction in DM Surgery Phase 1 st and 2 nd Cohort Results

14.  Admin charge 150  E4H staff cost 400  Accommodation 400  Total cost therefore 1000 per practice  Approx benefit – 1DM, average 3kg weight loss per participant, raising profile etc Surgery Phase - Costs per practice

15.  60,000 attendees  21-22 nd September  2 clinicians doing QDiabetes Screening  2 PH Nurses doing HbA1c for those with high scores  3 E4H staff giving advice, BCA and enrolling to E4H Sessions Newbury Show

16. Newbury Show Pre- Diabetes Stand During a quiet spell! Newbury Show Stand

18.  Potential Audience of 60,000  310 Screened via QDiabetes on iPads  111 targeted HbA1c tests done (Approx 1/3 rd )  80 Body Fat/Composition Measurements  30 people signed up for E4H classes  5 New diabetics (up to HbA1c = 64) plus 5 HbA1c 42-47  NB Health Promotion vs Detection Newbury Show - Results

19. Is it financially worthwhile Breast screening 2 million women 15000 diagnoses 96 million pounds 50 pounds per screen 6000 pounds per diagnosis

20. Is it financially worthwhile Cervical cancer 5 million invites 3.5 million tests 200,000 abnormals 4000 cancers prevented 175 million pounds About 1000 pounds per abnormal, and about 40,000 pounds per cancer prevented

21. Is it financially worthwhile ??? Diabetes – Newbury Show 60,000 attendees 310 screened with QDiabetes 111 HbA1c tests 5 New Diabetics Cost per diagnosis 1000 pounds

22.  Trial this weekend at Falkland Surgery  266 pts with Risk > 15% (without recent bloods done)  Half invited to POC Saturday Drop-in Clinic  Half Posted letter and blood test form  IF numbers are maintained we expect 5% diagnostic rate, and 5% borderline rate Phase 3 - Identification

23.  30% predictive risk seems to = 14% current DM  15% predictive risk seems to = 5% current DM  Letter stating numerical risk seems to trigger response in some of them  E4H making significant impact  It is possible to screen surgery populations  It is possible to organize public event Overall results

24.  Raise awareness generally  Radio Berkshire  Newbury Weekly News and Chronicle  Health Service Journal  Pulse  Newbury Show  60,000 visitors Aims of the PreDM Project

25.  Lifestyle intervention for those at risk  E4H invitations  550 patients  100 attendees  Potentially 1/3 tonne weight loss! Aims of the PreDM Project

26.  Early identification of those at risk of, or already with DM2 without a diagnosis  Phase 1 - Potentially 14 New DM  Phase 2 – 5 New DM  Phase 3 -Invitation for screening  One practice 266 patients  11 practices 1500 patients?  Anticipated pickup rate of 5% in those responding  Possibly 30-70 new diagnoses Aims of the PreDM Project

27.  Public Health  Indicated they wish to repeat the Lifestyle intervention with E4H across NDCCG  NDCCG  Anticipate asking them to fund the detection arm of the project across the whole CCG population if Falkland Trial successful The Future

28.  Do you know how many patients have RBS > 11 or FBS > 7 or HbA1c > 47  Have all those patients with RBS > 7 had a recent follow up blood test  Have you reviewed the patients with IGT/IFG recently to see if they have been rechecked (20-50% 10yr conversion) Challenges for you -Practices

29.  EmisWEB  Activate popups that notify you of possible and probable DM  Consider installing QDiabetes Popup Consider - Practices

30.  Incentivize the Practices to do the above  Consider how you are responding to NICE Guidance  Identification of those with DM (offer screening for those at 15% risk)  Prevention of DM (targeted E4H lifestyle interventions)  Apply pressure to Software suppliers to integrate risk scoring software in INPS and SystmOne Challenges - Commissioners

31. www.predm.co.uk Thank-you Tim Walter Resources

35.  No proof of results (not enough power)  No long term data re weight loss etc.  Cost effectiveness  Need to define your terms!  Rural Berkshire 3.5% prevalence  Actual 5% ? (wide confidence margins) Caveats

36.  QInnovation – go for it  Surgery actions – resources online  CCG actions – “template” online  Not trying to produce research evidence of effectiveness but template for whether it is possible  Any Questions  www.predm.co.uk www.predm.co.uk Conclusions