Changing trends in Diabetes in a GP Practice

Tim Walter

BackgroundFalkland Surgery population of 14,500 in

NewburyMarket TownMain practice demographic is of an average

age split but higher than average elderly population c.f. locally (75yrs+)

Some pockets of deprivationHigh level of employment

Trends2000 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)

Therefore the massive increase in DM is predominantly in the Type 2 group

About 3.5% of population

Why diagnose early?

At diagnosis UKPDS showed 39% H/tension24% microalbuminuria24% ECG changes of Ischaemia50% had some sort of complication

“Pre-diabetes”IGT, IFG, Gestational DM, metabolic syndrome etcNow also looking to include a “Risk Assessed” group

Conversion Rates Not clear what conversion rate of risk scored pts might be But IGT carries approx. 50% 10yr conversion rate to DM

Risk reduction In USA up to 58% reduction in progression to DM with

lifestyle intervention (71% in older pts) DPP showed 16% risk reduction per Kg lost

QDiabetes at Falkland SurgeryIn practice we looked at a subgroup of pts age 35+, BMI > 35, excluded other med

problemsChose this population to restrict workloadCalculated score and selected pts with 10yr risk

score of 20% or more (50 pts)i.e. 1 in 5 of these patients predicted to develop

DM in the next 10 yrs

Most will be “normal”, some have IGT, some have DM

Results from Selected GroupAverage Age 60Average HbA1c 4013% pts with HbA1c > 42 (non DM

threshold)16% pts with fasting BS > 5.6QDiabetes scores 20-49.9%Often large variation in QRisk and QDiabetes

scores for an individual eg 8% vs 49%, 10% vs 30% (Ave 15% vs 30%)

ProjectInvitation to participateBaseline blood tests (Renal, Fasting BS,

Cholesterol, HbA1c, LFTs etc)Nurse appt to record details of weight, waist,

smoking etcRandomly allocated to two intervention

groups10 week Eat4Health vs 10 week

Walking4HealthRepeat measurements

InterventionsEat4Health

Established, effective, 10 week group sessions looking at diet, exercise, attitudes to food and diet

Walking4Health1/2hr co-ordinated walking program over same

time period

Repeat monitoringRollout to other local practices if successful

Eat4Health – Waist Circumference

Eat4Health – Weight Loss

Eat4Health - Activity

SummarySmall scale project (approx 25 pts)Workable, practical application of evidence

based toolsTransferrable

IssuesDoes it work, short-term, long-term?Short term costs, longer term benefits if it does

workCosts approx £20 plus bloods, plus admin per pt

Proposed plans for the CCGIdentify at risk groups

Promote the use of QDiabetes across populationsSupport the workload involved across the CCGHowever, useless unless action taken as a result

Intervention for identified patientsEat4HealthWalking4HealthOther surgery based initiatives

References Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes

for 2010 and 2030. Diabetes research and clinical practice 2010;87(1):4-14. Diabetes UK: Diabetes in the UK 2010: Key statistics on diabetes

http://www.diabetes.org.uk/Documents/Reports/Diabetes_in_the_UK_2010.pdf, March 2010.

Holt TA, Stables D, Hippisley-Cox J, O'Hanlon S, Majeed A. Identifying undiagnosed diabetes: cross-sectional survey of 3.6 million patients' electronic records. Br J Gen Pract 2008;58(548):192-6.

Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis. Diabetes Care 1992;15(7):815-9.

Yates T, Davies M, Khunti K. Preventing type 2 diabetes: can we make the evidence work? Postgrad Med J 2009;85(1007):475-80.

Tuomilehto J, Lindstrom J. The major diabetes prevention trials. Curr.Diab.Rep. 2003;3(2):115-22.

Hippisley-Cox J, Coupland C, Robson J, Sheikh A, Brindle P. Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore. BMJ 2009;338:b880.

Qdiabeteshttp://www.bmj.com/content/338/bmj.b880.fu

llQresearch - 11 million ptsIntegrated within Emis25-79yr olds M&FCohort of 2.5 million pts

Other stuff for referenceIgnore slides below

Early DetectionComputer system analyses and flags up patients

with previously raised sugar levels. Work done in University of Warwick, published in BMJ and we have been running this for about 2 years

Random BSs over 11, fasting over 7 without codes to indicate diagnosed already

Looked at 12 patients with potentially missed DM, 9 were subsequently confirmed

Ongoing process as new patients ariseSecond group with random BS over 7

National InitiativesWe need to see co-ordinated education

and actionPublicity on healthy livingLabellingRole models Newspapers/Magazines/AdvertisingPrevention better than cureHowever this costs money now, but won’t

show results for many years