Introduction To The Alphabet Strategy And Evidence Based Medicine.

Introduction To The Introduction To The Alphabet Strategy And Alphabet Strategy And

Evidence Based MedicineEvidence Based Medicine

Introduction To The Introduction To The Alphabet Strategy And Alphabet Strategy And

Evidence Based MedicineEvidence Based Medicine

UK prevalence of diabetes UK prevalence of diabetes mellitusmellitusUK prevalence of diabetes UK prevalence of diabetes mellitusmellitus

• UK prevalence of diabetes mellitus = 3.54%.UK prevalence of diabetes mellitus = 3.54%.

• 2.2 million people in the UK have diabetes :2.2 million people in the UK have diabetes :

• 1.9 million ( 87%) have type 2 diabetes.1.9 million ( 87%) have type 2 diabetes.

• 300,000 (13%) have type 1 diabetes.300,000 (13%) have type 1 diabetes.

• There may be as many as one million There may be as many as one million undiagnosed cases of type 2 diabetes.undiagnosed cases of type 2 diabetes.

• UK prevalence of diabetes mellitus = 3.54%.UK prevalence of diabetes mellitus = 3.54%.

• 2.2 million people in the UK have diabetes :2.2 million people in the UK have diabetes :

• 1.9 million ( 87%) have type 2 diabetes.1.9 million ( 87%) have type 2 diabetes.

• 300,000 (13%) have type 1 diabetes.300,000 (13%) have type 1 diabetes.

• There may be as many as one million There may be as many as one million undiagnosed cases of type 2 diabetes.undiagnosed cases of type 2 diabetes.

Diabetes UK, 2006

Diabetes Atlas second edition, IDF 2003

< 2%

2% - 5%

5% - 8%

8% - 11%

11% - 14%

14% - 17%

17% - 20%

>20

Global prevalence of diabetes 2003Global prevalence of diabetes 2003

Chronic complications of Chronic complications of diabetesdiabetesChronic complications of Chronic complications of diabetesdiabetes

RetinopathyRetinopathyMost common cause of Most common cause of

blindness in people of blindness in people of working ageworking age

RetinopathyRetinopathyMost 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 long-men with long-standing diabetesstanding diabetes

Coronary and Coronary and cerebrovascular cerebrovascular

DiseaseDisease2–4 fold increased risk 2–4 fold increased risk

of coronary heart of coronary heart disease and stroke, 75% disease and stroke, 75%

have hypertensionhave hypertension

Foot ProblemsFoot Problems15% of people with 15% of people with diabetes develop diabetes develop

foot ulcers; 5–15% of foot ulcers; 5–15% of people with diabetic people with diabetic

foot ulcers need foot ulcers need amputationsamputations

The Audit Commission. Testing Times. A Review of Diabetes Services in England and Wales, 2000.

Life expectancy and Life expectancy and diabetesdiabetesLife expectancy and Life expectancy and diabetesdiabetes

40

45

50

55

60

65

70

75

80

85

15-19 20-29 30-39 40-49 50-59 60-70

Lif

e e

xpe

cta

nc

y (

yrs

)

Diabetics

NonDiabetics

Age at diagnosis (yrs)

Goodkin G. Journal of Occupational Medicine 1975;17(11): 716–721.

Donnelly R, et al. British Medical Journal 2000; 320: 1062–1066.

Asian

European

Men Women

Age groups

20–39 40–59 60–79 20–39 40–59 60–79

30%

25%

20%

15%

10%

5%

0%

Diabetes in the UK Indo - Asian Diabetes in the UK Indo - Asian communitycommunityDiabetes in the UK Indo - Asian Diabetes in the UK Indo - Asian communitycommunity

Cost of diabetes to the NHSCost of diabetes to the NHSCost of diabetes to the NHSCost of diabetes to the NHS

NHS spend on diabetes is :NHS spend on diabetes is :

• 5% of the total budget, or5% of the total budget, or

• £10 million per day.£10 million per day.

This is predicted to increase to 10% This is predicted to increase to 10% of the total budget by 2011.of the total budget by 2011.

NHS spend on diabetes is :NHS spend on diabetes is :

• 5% of the total budget, or5% of the total budget, or

• £10 million per day.£10 million per day.

This is predicted to increase to 10% This is predicted to increase to 10% of the total budget by 2011.of the total budget by 2011.

Diabetes UK, 2004

NICENICE

GMS ContractGMS Contract

National National Service Service FrameworkFramework

GuidelinesGuidelines

Evidence Evidence basebase

Increasing Increasing prevalenceprevalence

User User expectationsexpectations

LipidsLipids

Blood Blood pressurepressure

LifestyleLifestyle

Feet

GlycaemiaGlycaemia Eyes

Patient Patient orientedoriented

Multi -Multi -disciplinarydisciplinary

AuditAudit

Evidence-based medicineEvidence-based medicineEvidence-based medicineEvidence-based medicine

“ “ The integration of best research The integration of best research evidence with clinical expertise and evidence with clinical expertise and patient values . ”patient values . ”

“ “ The integration of best research The integration of best research evidence with clinical expertise and evidence with clinical expertise and patient values . ”patient values . ”

Sackett DL et al (2000) Evidence Based Medicine

Best research evidenceBest research evidence

Clinical expertiseClinical expertise Patient valuesPatient values

Best research evidenceBest research evidence

Clinical expertiseClinical expertise Patient valuesPatient values

… … within available resourceswithin available resources

William of Ockham William of Ockham (1285-1349)(1285-1349)

“ “ Entia non sunt Entia non sunt multiplicanda praeter multiplicanda praeter necessitatem necessitatem ”

“ “ Entities are not to be Entities are not to be multiplied beyond multiplied beyond necessity ”necessity ”

KK

II

SS

SS

KKeepeep

IItt

SSimple ,imple ,

SStupidtupid

“ “ Excellence requires that Excellence requires that important, simple things are important, simple things are done right all the time . ”done right all the time . ”

National Service Framework for National Service Framework for Coronary Heart DiseaseCoronary Heart Disease

The Alphabet StrategyThe Alphabet StrategyThe Alphabet StrategyThe Alphabet Strategy

• AAdvicedvice

• BBlood pressurelood pressure

• CCholesterolholesterol

• DDiabetes controliabetes control

• EEye examinationye examination

• FFeet examinationeet examination

• GGuardian drugsuardian drugs

• HHeart risk scoreeart risk score

• AAdvicedvice

• BBlood pressurelood pressure

• CCholesterolholesterol

• DDiabetes controliabetes control

• EEye examinationye examination

• FFeet examinationeet examination

• GGuardian drugsuardian drugs

• HHeart risk scoreeart risk score


• AAdvicedvice Smoking , diet , exerciseSmoking , diet , exercise

• BBlood pressure lood pressure << 140/80 140/80

• CCholesterol holesterol TC ≤ 4 , LDL : HDL ≤ 2TC ≤ 4 , LDL : HDL ≤ 2

• DDiabetes control iabetes control HbA1c ≤ 7%HbA1c ≤ 7%

• EEye examination ye examination Annual examinationAnnual examination

• FFeet examination eet examination Annual examinationAnnual examination

• GGuardian drugs uardian drugs Aspirin, ACEI, statins &CAspirin, ACEI, statins &C

• HHeart risk score eart risk score UKPDS, FraminghamUKPDS, Framingham









Patel V, Morrissey JPatel V, Morrissey JThe Alphabet StrategyThe Alphabet StrategyBritish Journal of Diabetes &British Journal of Diabetes &Vascular Disease, 2002: 2: 1: 58-59Vascular Disease, 2002: 2: 1: 58-59

Patel V, Morrissey JPatel V, Morrissey JThe Alphabet StrategyThe Alphabet StrategyBritish Journal of Diabetes &British Journal of Diabetes &Vascular Disease, 2002: 2: 1: 58-59Vascular Disease, 2002: 2: 1: 58-59

A is for ...A is for ...A is for ...A is for ...

ADVICEADVICE

ADVICEADVICE

AdviceAdviceAdviceAdvice• Adherence to diet and medicationAdherence to diet and medication

• Smoking cessation, exercise, weight reductionSmoking cessation, exercise, weight reduction

• Ensure diabetes education and advise Diabetes UK Ensure diabetes education and advise Diabetes UK membershipmembership

• Stress role of the dietician, podiatrist and diabetes Stress role of the dietician, podiatrist and diabetes care nursescare nurses

• Regular follow-up with comprehensive Annual Review Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non-complications will be persistent Diabetes Clinic non-attendersattenders

• Lifestyle targets: weight reduction > 5% if obese , fat Lifestyle targets: weight reduction > 5% if obese , fat intake < 30% of energy intake , saturated fat < 10% of intake < 30% of energy intake , saturated fat < 10% of energy intake , fibre > 15g per 1000 calories, exercise energy intake , fibre > 15g per 1000 calories, exercise for four hours / week.for four hours / week.

• Adherence to diet and medicationAdherence to diet and medication

• Smoking cessation, exercise, weight reductionSmoking cessation, exercise, weight reduction

• Ensure diabetes education and advise Diabetes UK Ensure diabetes education and advise Diabetes UK membershipmembership

• Stress role of the dietician, podiatrist and diabetes Stress role of the dietician, podiatrist and diabetes care nursescare nurses

• Regular follow-up with comprehensive Annual Review Regular follow-up with comprehensive Annual Review is essential. 20% of patients with early severe is essential. 20% of patients with early severe complications will be persistent Diabetes Clinic non-complications will be persistent Diabetes Clinic non-attendersattenders

• Lifestyle targets: weight reduction > 5% if obese , fat Lifestyle targets: weight reduction > 5% if obese , fat intake < 30% of energy intake , saturated fat < 10% of intake < 30% of energy intake , saturated fat < 10% of energy intake , fibre > 15g per 1000 calories, exercise energy intake , fibre > 15g per 1000 calories, exercise for four hours / week.for four hours / week.

B is for ...B is for ...B is for ...B is for ...

BLOOD PRESSUREBLOOD PRESSURE

BLOOD PRESSUREBLOOD PRESSURE

UKPDS 38 : 154/87 versus 144/82UKPDS 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 -24 SignificantSignificant


-21 Non significant

-44-44 SignificantSignificant




C is for ...C is for ...C is for ...C is for ...

CHOLESTEROLCHOLESTEROL

CHOLESTEROLCHOLESTEROL

CHD prevention trials with CHD prevention trials with statins in diabetesstatins in diabetes: : CHD prevention trials with CHD prevention trials with statins in diabetesstatins in diabetes: :

Study Drug Number of

patients

CHD risk redn

Nondiabetics

CHD risk redn

Diabetes

Primary Prevention

CARDS

HPS1 †

Atorvastatin 10mg

Simvastatin 40mg

2838

2912 25%*

37%**

26-33%

Secondary Prevention

CARE2 †† Pravastatin 586 23% 25%

4S3‡

GREACE

Simvastatin

Atorvastatin 24mg

202

313

32% 55%

59%

4S reanalysis4 ‡‡ Simvastatin 483 32% 42%

HPS1 Simvastatin 3051 24%* 12% NS

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

D is for ...D is for ...D is for ...D is for ...

DIABETES DIABETES CONTROL CONTROL

DIABETES DIABETES CONTROL CONTROL

Study name DCCT UKPDS Kumamoto Steno-2

HbA1c 2% 0.9% 2% 1.0%

Retinopathy 63% 17-21% 69% 58%

Nephropathy 54 24-33% 70% 61%

Autonomic neuropathy

60% _ _ 63%

CVD 41% 16% _ 53%

Reductions in HbA1c and corresponding reductions in microvascular and macrovascular complications described in major studies of persons with T1 DM and T2 DM

Effect on diabetes complications Effect on diabetes complications of HbA1c% reductionof HbA1c% reduction

To summarise . . . To summarise . . . To summarise . . . To summarise . . .

• Control blood glucose to prevent Control blood glucose to prevent microvascularmicrovascular complications. complications.

• Lower cholesterol to prevent Lower cholesterol to prevent macrovascularmacrovascular complications.complications.

• Lower blood pressure to prevent Lower blood pressure to prevent bothboth..

E is for ...E is for ...E is for ...E is for ...

EYE EXAMINATIONEYE EXAMINATIONEYE EXAMINATIONEYE EXAMINATION

F is for ...F is for ...F is for ...F is for ...

FEET FEET EXAMINATIONEXAMINATION

FEET FEET EXAMINATIONEXAMINATION

G is for ...G is for ...G is for ...G is for ...

GUARDIAN GUARDIAN DRUGSDRUGS

GUARDIAN GUARDIAN DRUGSDRUGS

Introduction To The Alphabet Strategy And Evidence Based Medicine.

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