LEADERS

Revised recommendations for diabetes diagnosis and

iabetes mellitus has never been an easy classification to D determine. Its heterogeneity and various characteristics have engendered many different attempts at sub-division, none of which have reflected accurately the underlying nature of the disorder. Earlier classification by age of recognised onset1 clearly had anomalies, and was replaced by separation accord- ing to perceived pathogenic mechanisms (IDDM, NIDDM, IGT)2. Yet classification inherently linked to the form of treat- ment inevitably has caused confusion and uncertainty. In response to this debate and to some extent with a feeling of ‘deja vu’ , revised recommendations concerning classification of diabetes have been proposed3 and recently accepted by the American Diabetes Association. It is very likely these will be accepted by the WHO4 later this year. Details of the new classification are given on page 142. Type 1 and 2 diabetes, this time with Arabic rather than Roman numerals, have returned, with additional sub-categories.

At the same time diagnostic biochemical criteria have been reviewed and a new group of impaired glucose homeostasis (impaired fasting glucose or IFG) introduced, based on FPG >6.1 mmoVL (110 mg% or mg/dL) and <7.0 mmol/L (126 mg% or mg/dL). On the understanding that even blood sugars at these lower levels can be associated with considerable ‘silent’ morbidity, the Expert Committee recommends testing for diabetes in all adults over 45 every three years, and more often andor younger if at high risk. By lowering the diagnosis point it is intended that many more will be detected at an early stage, offering the hope that serious complications may be prevented or delayed by similarly earlier intervention.

The tenets of desirable screening characteristics5, namely, that the disorder should be an important health problem, the nature of which is understood, and detectable in pre-clinical phase, are fulfilled and to that extent permit identification of those at potential risk. Hopefully, this detection will result in life-style adjustment but the evidence is that good intentions from health education may prove disappointing6. Additional screening for a further risk group should require an effective treatment to be available and as yet this is largely lacking for the new category of impaired glucose homeostasis. Moreover,

classification a significant number of patients previously classified as having impaired glucose tolerance now fulfil the criteria for diabetes. Although it is recognised that dietary advice and exercise can enhance insulin sensitivity in this gr0up7, no evidence exists to show that these considerations or pharmacological measures to improve glucose homeostasis can prevent or retard the development of vascular disease. Enthusiasm for screening must be set against the ‘Opening Pandora’s Box’ effects when clinical implications are uncertain and consequent patient anxieties unpredictable.

Nonetheless these revised diagnostic criteria will detect a significantly increased number of people susceptible to vascu- lar disease, and will offer the opportunity for individuals identified to modify their life-style and obtain appropriate advice on therapy. Prospective studies of life-style/ti-eatment interventions for this new group are now required: in particular, to examine the relationship between glucose metabolism and atherosclerosis. Meanwhile it would appear prudent to tackle aggressively other risk factors such as dyslipidaemia and hypertension where current evidence clearly supports therapeutic intervention.

Kenneth M Shaw MD FRCP, Michael H Cummings MD MRCP,

Department of Diabetes and Endocrinology, Queen Alexandra Hospital, Portsmouth, UK

References 1. Diabetes Mellitus: Report of a WHO Expert Committee. World Health

2. WHO Expert Committee on Diabetes Mellitus (Second Report). World Health

3. Report of the Expert Committee on the Diagnosis and Classification of Diabetes

4. Alberti KGMM, 1997. (personal communication) 5. Wilson JMG, Jungner G. Principles and practice of screening for disease.

Geneva: WHO, 1968 6. Ebrahim S, Smith GD. Systematic review of randomised controlled trials of

multiple risk factor interventions for preventing coronary heart disease. BMI 1997; 314: 166674

7. Alberti KGMM. The clinical implications of impaired glucose tolerance. Diaber Med 1996; 13: 927-37

8. McDonald IG, Daly J, Jelinek VM, et al. Opening Pandora’s Box: The unpredictability of reassurance by a normal test result. BMJ 19%; 313: 329-32

Oeganisation, Geneva, 1965. Technical Report Series 310

Organisation, Geneva, 1980. Technical Report Series 646

Mellitus. Diabetes Care 1997; 20: 1183-97

Can computers interface between primary and secondary diabetes care?

early eight years have elapsed since the St Vincent N Declaration set as one of its objectives the establishment of “monitoring and control systems using state-of-the-art information technology (IT) for quality assurance of diabetes

health care provision”. Sadly, progress has been slow and one of the main stumbling blocks remains the means for linking diabetes-related health information that is being collected, largely independently, in primary and secondary care IT

Practical Diabetes International August 1997 Vol. 14 No. 5 121

LEADERS Can computers inte~ace between primary and secondary diabetes care?

systems. In this issue Colin Kenny describes the current situation. It is clearly disappointing that in the UK, where over 90% of GP practices are computerised, there has been a relative absence of any co-ordinated planning or standardi- sation of data collection for diabetes, even though a recom- mended UK dataset has been in existence for five years now.

If there are to be interfaces between primary and secon- dary care systems it is very important that there is clarity of purpose for such links and that there are meaningful benefits for both the patient and the clinicians involved. For clinicians and also patients, perhaps the most important immediate benefit is the capacity to interchange clinical information for the purpose of sharing the care of a patient. Such links can enable immediate communication of management change and may avoid much duplication of effort. They may also permit more efficient organisation of diabetes care in a locality - and therein lies one of the benefits of creating a district diabetes register from this process. However, there must not be confusion between what constitutes a clinical management system and what constitutes a diabetes register. Since dia- betes registers already exist in many general practices as part of the chronic disease management programme as well as in many hospital diabetes services, linking these to create district diabetes registers offers an important means of enhancing the quality and delivery of care. However, the register functionality should flow from this process, not be separate from it.

Quality assurance, both within a district and perhaps also in a wider setting, can then be developed, although the opera- tional issues of implementing such a programme are not always easy and will vary between localities. Benchmarking, at a district or higher level, of agreed measures of process and outcome of care, can be an important tool for the improve- ment of diabetes healthcare provision. Cross-sectional data may be used for needs assessment and the planning and purchasing of diabetes care by commissioning authorities. Such aggregated information, if gathered longitudinally, may also be useful for understanding the effect of interventions on the true outcomes of diabetes. There are, however, important concerns over data ownership and how anonymity is best preserved in diabetes registers. It should not be possible to link data held in this way to an individual, and the means of best achieving this are still under much discussion. There are thus no proposals in the UK for a National Diabetes Register containing patient identities, although these are in existence in other European countries.

The largest barrier to linking information systems and exchanging data electronically between primary and secon- dary care for the purposes enumerated above is the diversity of software and operating systems in both sectors. Although, technically speaking, it is not all that difficult to enable one system to talk to another, when there are more than ten or twelve major systems it becomes prohibitive. The National Health Service (NHS)-wide network may solve this in time through IT systems exchanging messages of predefined

structure and content - ED1 (Electronic Data Interchange) messaging. However, the process of developing and approv- ing these messages is slow and complex and to date they are very limited in number. Certainly, in the UK there are none relating to specific conditions like diabetes that would enable the sharing of clinical information in the ways outlined above. There are also significant security issues surrounding such messaging, and the process of encryption is still under debate. Miquest may offer a partial solution, at least for quality assurance and epidemiological initiatives. This software, which has been developed by the NHS and can reside on the clinician’s computer system, can extract specific data about patients for export and aggregation. This offers great potential if it becomes widely implemented.

Other technologies have been proposed. The Internet offers a very real and simple solution for sharing common databases or software. However, the opportunity to access personal or clinical data over the Internet poses serious security and confidentiality risks that will need to be satisfactorily resolved before this could ever be considered a safe proposition. Alter- natively, there are smartcards which can communicate clinical information electronically and look rather like a credit-card which is carried by the patient. There have been pilots of such systems in the UK and there is currently a wider implemen- tation of such a system in Europe. This system has particular attractions, as the most up-to-date information is always with the patient wherever he may be, even if he is in another part of the country. However, the cost of investment in the hard- ware to operate such a system is considerable and it remains to be seen whether it will ever become a practical reality.

The range of different solutions for linking primary and secondary care data through diabetes registers is in itself a testament to its difficulty. There are no ideal solutions to the problem and there are many important issues around con- fidentiality, patient consent and security that must be resolved. However, important lessons can be learnt now from the implementation and use of existing systems. We cannot afford to wait for the perfect system to arrive. This could be some years in the future and one cannot forget that the NHS does not have a good track record for implementing major IT solutions. Incremental progress is often much more suc- cessful.

Thus, local solutions should be the immediate priority. Technology will progress and become more readily available, so it is very likely that the methodologies will converge in time. Ultimately, one must remember that the purpose of linking data and developing registers is for the patient and the improvement in the quality of diabetes care. If we make it too difficult at this point in time, there is a serious danger that we will ‘throw the baby out with the bath water’

Nick Vaughn MA MD FRCP Consultant Diabetologist, Brighton, UK

Chairman, BDA Diabetes Information Management and Audit Group

122 Practical Diabetes International August 1997 Vol. 14 No. 5