Shanti Vijayaraghavan, Eleanor Barry, Annie Mackela Tamara Hibbert

Pre-diabetes in Newham: definition, identification and management

19 October 2017

Pre-diabetes: a rising concern

• Case finding patients with pre-diabetes in primary care, to ensure correct coding

• 7133 people living diagnosed pre-diabetes; 2017 CEG data – 14,600

• Increase of over 2000 patients identified within one year

• Lack of clarity locally and nationally on how best to deal with this problem

Use routinely held data on general practice computers to estimate the proportion of individuals at high risk of developing diabetes and map these by small geographical area to inform targeted locality-based interventions.

Work Programme 1: Estimate the extent of the problem

12 August 2014: A total of 212,921 (96.3%) aged 25 years and above who are diabetes–free, attending one of the 59 GP practices in Newham were examined by QDiabetesscores:• 38,940 (17.6%) at high risk of developing T2D (risk of 20% or more); men (54.1%),

median age of 52 (IQR 44-60) years, South Asian population (57.0%)• 23,063 subjects QDscore>30% (3144 undiagnosed at high risk)• People in North East 1 cluster have the highest median QDscore

We have a problem with large numbers of people at risk of developing diabetes in 10 years

Work Programme 2: Pre-Diabetes Systematic Review and Meta-analysis

Systematic Review Questions• How do we identify those at most risk of diabetes?• Which test should be used?• How effective are interventions in reducing diabetes risk?

Summary of Findings 1:

• Different tests do not accurately identify each other’s abnormalities

• Each test reflects a different underlying process.

• Different groups have rates of progression.

• HbA1c correctly identifies half of people at high risk of DM

• HbA1c abnormal in twice as many people

• Different populations which behave differently.

• Trials still use OGTT/IGT as gold standard in patient selection.

Summary of Findings 2:

• Lifestyle interventions

• RR reduction 36%.

• Intervention length 6m-6yrs and intensive.

• Surrogate outcomes over used.

• Statistically significant improvements do not equal clinically significant improvements.

• Sustainability of improvements

• Large attrition rates.

• Disconnect between literature at every step

Work Programme 3: co-design an intervention with local stakeholders and patients in identified GP practices

This aimed at addressing:• Engagement in screening• Acceptability and sustainability of an

individualised, goal defined approach to reducing risk for diabetes

• The impact on primary care of delivering this model, including cost-effectiveness

Adult population in Newham

High risk of diabetes (QD score>20%)

Confirmed pre-diabetes

Type 2 DM

GDM + QD>20%

GDM

221,035

38,940

2271

518

8781 predicted 28,911

Stratifying the “at-risk” population

Claremont Clinic Intervention

Pilot launched in January 2016

1. Focus Group feedback - March 2016

• overwhelmed by diagnosis

• most of them were contacted by reception staff and felt information was not given to them appropriately

• couldn’t ask questions when results communicated

• They would have preferred to speak to a health professional

GROUPS NUMBERS

PATIENTS WITH HBA1C 42-47 MMOL/MOL 525

PATIENTS WITH CODES OF PREDIABETES 388

PATIENTS WITH CODES OF IMPAIRED FASTING/GLUCOSE TOLERANCE

148

PATIENTS WITH PAST OR CURRENT CODES OF GDM

91

PATIENTS WITHOUT THE ABOVE, BUT WITH QRISK >20%

136 (amongst them 92 have BMI<20%)

2. Improved coding and stratifying the local population at risk

As part of Primary Prevention EPCS GP practice identifies patients 18 years and over with:• Pre-diabetes register (IGT or IFG or HbA1c 42-

47mMol/Mol or history of gestational diabetes mellitus(GDM)) plus a BMI ≥ 27

And/or• At risk of CVD Q-Risk > 20% plus a BMI ≥ 27

At EPCS Primary Prevention Annual Review if patient consents: • refer to Lifestyle Advisor using Primary

Prevention Referral form via nhs.net address

At Lifestyle Advisor appointment :• Patient assessed to identify needs• Referred to either NCP or NDPP (or patient

declines)

At risk of diabetes provided option of:• NCP or NDPP

History of GDM referred to:• NDPP

At risk of CVD referred to: • NCP

Exclusion Criteria• Diabetes • Existing Ischaemic Heart Disease (IHD), Angina or

previous Myocardial Infarction (MI)• Unexplained and/or ongoing chest pain• Currently under investigation for cardiac related

conditions• Severe aortic stenosis or regurgitation • Active myocarditis or Pericarditis• Persistent and unexplained tachycardia• Symptoms of heart failure• BP >180/105• Acute or unstable illness • BMI 35-45-clinical discretion is to be applied BMI>45

to be excluded from this service

Newham Community Prescription Pathway

Both NCP & NDPP Providers to send:• attendance and completion

data to Lifestyle Advisors

NCP = Newham Community PrescriptionNDPP = National Diabetes Prevention Programme (Start date tbc)

Referral and attendance information sent by Lifestyle Advisors entered onto patient record via:• Primary Prevention

Template

Lifestyle Advisors email to GP practice:• Referral / declining data • Attendance and completion data

1

2

34

Key:General Practice-Lifestyle AdvisorPhysical activity providers

5

67

Claremont Clinic Intervention - Outputs

• Identification of high- risk groups from Practice register

• Co-designed script and improved clinical contact following testing

• Co-produced pathways for Community Prescription and Healthier You

14

GDM Work Stream – Market Street Health Group

• Review of practice data from 2010-2015:53% of women with a GDM pregnancy will progress to IGT, pre-diabetes or Type 2 diabetes within ten yearsMean follow-up time post-delivery until diagnosis was 3.5 years

• Post-natal pathway modified to include more opportunistic Screening

• Focus group to understand challenges faced by women post-partumUser feedback used to develop the intervention programme

• Joint weekly ( 2 hour) exercise-based programme, peer-supported, “opt out” only, for 6 months in 2 twelve week cycles

The programme

• Seen at the GP surgery.

• Opt out rather than opt in.

• Discussion at their 6 week check so there is a seamless transition from antenatal to postnatal care.

• The women see a GP or Practice nurse involved Diabetes Care.

The programme

• Referred into GDM pilot if they had…• A history of GDM.• A family history of T2DM.• A BMI >30.

• Our initial aim was to recruit 20 women, the numbers became too large so we had to streamline the referrals to those only with a history of GDM.

• Each woman has initial assessment with a motivational interview, needs assessment and baseline measurements.

• Programme delivered by Darshana Lathigra.– Nutritionist and fitness instructor.

The programme

• 45 minutes of physical activity.• 45 minutes of ‘education’-dietary and fitness

advice.• Drop in service that runs over 6 months.• They all have Darshana’s telephone number if

they want to re-engage with the programme.• Different activities/venues depending on the

weather.• First session attended by Dr Philippa Hanson and

myself.

The programme• 37 women with GDM were referred into the

programme.• I spoke to 2 reluctant patients at the initial

referral stage.• DNAs were followed up with a reason

documented.• The attendees have been offered a 6month

review with HbA1c similar to 6month DM review.• At one year post natal the women join the

current Primary Prevention Extended Primary Care Service (EPCS).

The programme

• We have several opportunities to engage with our GDM group.– Mother’s postnatal check (GP).

– Baby’s 6 week check (GP).

– On site Health visitor clinics.

– Baby’s immunisation appointments (Nurse).• When baby is 8, 12 and 16 weeks old.

• Again at 13 months.

• Pre-school boosters at 3 years 4 months.

– Any GP or Nurse appointment

Market Street Health Group Intervention- Output

• Creation of a risk-register for women with high risk of developing diabetes

• More user-friendly, nurse-led post-natal pathways

• Increase in post-natal OGTT from 41% to 72%

• Co-designed local lifestyle intervention programme for women with previous GDM in place

22

The Team

Shanti Vijayaraghavan Jim LawrieShahzada Khan Tamara HibbertPhilippa Hanson Anne Marie-Maher VyasTrisha Greenhalgh Jo LawAnnie Mackela Eleanor BarrySamantha Roberts Graham TomsAndrew Patterson Ciaran Joyce

THANK YOU

24