Prevention of disease – education makes a difference in the community

Prevention of disease – education makes a difference in thecommunity

I was asked recently to give two public

lectures on ‘‘How to keep a healthy

heart’’. The first was at the Royal

Institute in the centre of London and

the second was part of an impressive

initiative of educational lectures from

a Croydon, South London, Family

Practice. The attendances, over 350

and 200 men and women respectively,

identified the interest of the public in

learning about their health and

suggested to me that we as a profession

are not using our communication skills

in the most appropriate way.

We all know the major keys to

preventing coronary disease but are we

delivering the messages in a format and

to a listening audience in a way that

maximises prevention? If we leave it to

journalists and the tabloid press we

encourage alternative non-evidence

based medicine. Every other patient

seems to be taking a cocktail of pre-

parations such as selenium, zinc, vita-

min complexes and so on but few have

had their blood pressure checked or

know of the importance of adhering to

proven therapies when coronary disease

has been identified (aspirin, statins, ACE

inhibitors, betablockers or appropriate

alternatives). Those who have their lipids

checked know its ‘‘OK’’ but most are

unaware of the targets, the importance

of the numbers and the difference

between LDL-cholesterol and HDL-

cholesterol. True a small number are

very well informed – turn left on a boe-

ing 747 and a small select group are to be

found in first class whereas the majority

are in economy and it’s the majority we

need to reach.

Reaching out to a lay audience who

has turned up to hear the lecture

(which must be interactive, focused,

free of jargon and followed by many

questions) does limit the delivery to

an interested and motivated group. It

is however better than leaving it entirely

to the media who though well inten-

tioned and able to deliver effective mes-

sages are driven by topical issues and

not necessarily the basics. I am not

being critical, as I firmly believe the

media has a very important role, but

realistic, as stories sell papers and

make for good radio and television.

When I agreed to give the lectures I

realised I had to re-write all my slides

(thank goodness for PowerPoint) and

make the message clear using everyday

language and illustrations. It is also

important to challenge the audience –

when I asked how much money a pack

a day smoker is likely to spend in a

lifetime the gasps were universal as the

next slide showed £35,000. Few of the

audience knew of the substantial tax

revenues from smoking, which far

outweigh the health care costs, and the

life shortening of 10–15 years. When I

stopped the talk at 30 minutes it was to

point out that since I had started 3 peo-

ple in the UK had died as a consequence

of smoking but the message that each

year 17,000 UK children are hospitalised

due to smoking related chest complaints

was the most powerful – innocence being

a victim of adult choice.

I like to talk using analogies as I feel

this conveys the message in an under-

standable language. In the UK every six

weeks the deaths from hypertension are

equivalent to one jumbo jet crashing –

if that number of planes fell from the

sky governments would act far more

vigorously than they do about preven-

tative health care. Private health care is

no better as it does not cover preven-

tion or monitoring but is only too will-

ing to allow treatment for a stroke or

myocardial infarct – quite absurd.

Rather than ‘preaching to the con-

verted’ we need local hospitals / primary

care doctors and nurses to pro-actively

venture into the community with edu-

cational road shows. Waiting for the

public to come to us will deliver infor-

mation to those motivated but we will

miss out the majority. We need to be

the pinnacle of an educational pyramid

disseminating information as widely as

possible. We will give of our time with-

out financial reward but the reward in

my case of encouraging a healthy heart

and making it clear how everyone can

benefit provided me with the satisfac-

tion of providing health care advice

where it mattered and when it mattered.

Road shows can be on any medical

subject where a clear message is needed –

heart disease, cancer, blood pressure,

lung disease and so on. From education

comes prevention – we can make a

difference and we must.

Graham Jackson

Editor

Diabetes in the new General Medical Services contract: targets andadherence to metformin therapy

The new General Medical Services

(GMS) contract implemented on 1

April 2004 dramatically changed fund-

ing for General Practitioner (GP) prac-

tices and has far-reaching implications

for the management of certain key dis-

eases (1). This was described in the

BMJ (2003; 326: 47–48) as ‘a mighty

leap that vaults over anything being

ª 2005 Blackwell Publishing Ltd Int J Clin Pract, March 2005, 59, 3, 263–267

EDITORIAL do i : 1 0 . 1 1 11 / j . 1 3 68 - 5 031 . 2 0 05 . 0 0 511 . x

attempted in the USA’, and there are

clear benefits for patients.

Under the new scheme, practice

income is generated through four main

areas:

1 A global sum pays for essential and

additional services that a practice pro-

vides.

2 Payment for enhanced services is

available for the provision of specialised

or innovative services and for a higher

standard of essential or additional ser-

vices.

3 Separate funding for premises and

information technology is provided.

4 Rewards for the quality of patient

care are offered in the quality and out-

come framework.

Whereas the previous contract

emphasised high volume, the new con-

tract includes more provision for qual-

ity of care of the quality and outcome

framework. The structure consists of

several domains (clinical, organisational,

additional services and patient experi-

ences) under which various aspects of

performance are judged by reference

to key indicators. Points are awarded

for meeting targets, and funding is

allocated according to the number of

points attained. Additional points and

funding are available to reward a

breadth of achievement across each of

the domains. Currently, each point

obtained (for an average practice)

amounts to £75, which is equivalent

to £78,750 per year, if the maximum

1050 points are scored. This figure is

set to rise to £120 per point (£126,000

maximum) for the period 2005–2006.

Of the 10 clinical areas within the

quality and outcome framework out-

lined in the contract, treatment of dia-

betes holds a substantial (18%) share of

the 550 total clinical points available to

a practice. Tight control over blood

glucose levels in patients with type 2

diabetes is important for delaying the

onset and reducing the risk of diabetes-

related microvascular complications

(2). For this reason, high priority has

been placed on glycaemic control as a

target in the new GMS contract. The

clinical indicator for which a large pro-

portion of the diabetes points are

awarded is the HbA1c level; there are

16 points available for 50% of patients

with HbA1c� 7.4% (DM6), and 11

points available for 85% of patients

with HbA1c� 10% (DM7). These tar-

gets will be difficult to achieve with

many current patients failing to meet

these goals. The increasing prevalence

of type 2 disease due to obesity and lack

of exercise will increase substantially the

workload in primary care.

However, the ongoing work in dia-

betes research and recent advances in

treatment and disease management

should go some way to making these

targets achievable. The recommended

management of blood glucose levels in

type 2 diabetes is set out in Guideline

G of the National Clinical Guidelines

(NICE) (3). In these guidelines, met-

formin is recommended as the first-line

glucose-lowering therapy in overweight

patients (those with a body mass index

over 25 kg/m2) who have inadequately

controlled glycaemic levels; it is pro-

posed as an option either as a first-line

treatment or as part of a combination

therapy, for patients who are not over-

weight.

Metformin has been used in the

treatment of diabetes for over 30 years

and has been shown to be a safe and

effective medication (4–6). However,

the lack of reliable clinical trials for

older medications necessitated a more

recent review of metformin therapy. As

such, several studies were conducted in

the mid-1990s and these provide the

comprehensive evidence base on which

the NICE guidelines stand (7–9). In

addition to these studies, a major trial

was undertaken in the UK by the UK

Prospective Diabetes Study (UKPDS)

group (10) to investigate the effect of

metformin in overweight patients with

type 2 diabetes.

In the UKPDS study, 753 overweight

patients (>120% ideal body weight)

with raised fasting plasma glucose

(6.1–15mmol/l) but no hyperglycaemic

symptoms after 3 months initial diet

were randomised to either conventional

treatment with diet alone (n5 411) or

treatment with metformin (n5 342)

to control blood glucose. Glycated

haemoglobin levels were measured as

an assessment of hyperglycaemia, and

the outcome of treatment was measured

by diabetes-related clinical endpoints,

diabetes-related death and all-cause

mortality. A secondary analysis com-

pared the 342 metformin-treated patients

with patients treated with sulphonylurea

[chlorpropamide (n5 265) or glibencla-

mide (n5 277)] or insulin (n5 409).

The study found that metformin

therapy was associated with risk reduc-

tions over conventional diet treatment

of 32% for any diabetes-related end-

point, 42% for diabetes-related death

and 36% all-cause mortality. Glycae-

mic control in the metformin-treated

patients was improved, with median

HbA1c levels of 7.4% for patients

receiving metformin compared with

8% for patients on diet treatment

alone. In the secondary analysis, met-

formin was found to be more effective

than chlorpropamide, glibenclamide

and insulin at reducing diabetes-related

clinical endpoints. Because the mode of

action is directed at insulin sensitivity

rather than insulin secretion, there were

less hypoglycaemic episodes reported

by patients receiving metformin than

those by receiving the sulphonylureas

or insulin. Unlike the other drugs,

metformin did not lead to any weight

gain, a significant advantage considering

these patients are already overweight.

Despite the positive effects demon-

strated in clinical trials, a significant

number of patients are failing to

achieve good glycaemic control. It is

important to recognise that factors

other than drug efficacy play a role in

determining the success of a treatment

programme; therapy can only be effec-

tive when patients adhere to the pre-

scribed course of treatment.

Patients with type 2 diabetes are

poorly adherent with therapy as evi-


264 EDITORIAL

denced by a study by Donnan et al. (11).

Data on oral anti-diabetic drug usage was

obtained from prescription records in

such a way that patients were unaware

they were being studied, to give a truly

representative view of the extent of

patient adherence in the community.

The study found that only one of three

patients had adequate adherence to oral

anti-diabetic drug treatment. Poor

adherence leads to ineffective therapy

and poor glycaemic control. This pre-

sents a significant barrier for GPs, pre-

venting them from attaining the targets

set by the key indicators in the new GMS

contract. Thus, it is important to address

the issues behind poor adherence.

Non-intentional poor adherence can

be caused by confusion with drug regi-

mens especially because patients with

type 2 diabetes are typically 60 years

plus and receiving multiple medications

with frequent dosing intervals (11–16).

Intentional poor adherence is also a

problem in type 2 diabetes, because

patients can be relatively asymptomatic

without treatment and do not appreciate

the benefits of intervention; oral anti-

hyperglycaemic drugs can cause unplea-

sant side-effects, which also discourages

their use (17–19). Gastrointestinal

symptoms are a well-recognised problem

with metformin which often limits its use

of the durg. There are several angles from

which these issues can be tackled.

Firstly, drug regimens can be simpli-

fied by employing the use of new,

modified forms of well-known oral

anti-hyperglycaemic drugs, which allow

a reduced dosage frequency. One exam-

ple is Glucophage SR, which provides an

extended release metformin formulation

which has similar efficacy to immediate-

release metformin with the advantage

that it can be taken once rather than

twice or three times daily (20). The addi-

tional advantage of this formulation is

that gastro-intestinal side-effects are

reduced, thereby aiding the problem of

intentional poor adherence (21–23).

Secondly, improvements can be

made in patient education and support.

Adherence is likely to be improved if

the patient understands the drug regi-

men, the reasons behind it and the

possibility of side-effects. Involvement

of a multi-disciplinary team (and sub-

sequent improved disease management)

can provide benefits in both the clinical

aspects of the disease, i.e. glycated hae-

moglobin levels, and the psychological

health of the patient (24).

In conclusion, the new GMS con-

tract sets high standards for glycaemic

control in patients with diabetes. Cur-

rent anti-diabetic medications are effec-

tive at improving glycaemic control,

but many patients fail to adhere with

drug regimens. Reasons behind non-

adherence must be tackled in order to

increase the number of patients with

adequately controlled blood glucose

levels and those achieving the targets

set by the new GMS contract.

Professor Mike Kirby

Director of the Hertfordshire

Primary Care Research Network

Herts SG6 4TS, UK

REFERENCES

1 British Medical Association. Investing in

general practice: the new general medical

services contract. London, 2003.

2 UK Prospective Diabetes Study Group

(UKPDS). Intensive blood-glucose con-

trol with sulphonylureas or insulin com-

pared with conventional treatment and

risk of complications in patients with

Type 2 diabetes (UKPDS 33). Lancet

1998; 352: 837–53.

3 National Institute for Clinical Excel-

lence. Managing Type 2 diabetes: mana-

ging blood glucose levels (Guideline G).

London: Department of Health, 2002.

4 Johnson AB, Webster JM, Sum CF

et al. The impact of metformin therapy

on hepatic glucose products and skeletal

muscle glycogen synthase activity in

overweight Type 2 diabetic patients.

Metabolism 1993; 42: 1217–22.

5 DeFronzo RA, Barzilai N, SimonsonDC.

Mechanism of metformin action in obese

and lean non-insulin-dependent diabetic

subjects. J Clin Endocrinol Metab 1991;

73: 1294–301.

6 DeFronzo RA, Goodman AM. Efficacy

of metformin in patients with non-

insulin-dependent diabetes mellitus.

The Multicenter Metformin Study

Group. N Engl J Med 1995; 333: 541–9.

7 Johansen K. Efficacy of metformin in

the treatment of NIDDM. Meta-analysis.

Diabetes Care 1999; 22: 33–7.

8 Campbell IW, Howlett HC. Worldwide

experience of metformin as an effective

glucose-lowering agent: a meta-analysis.

Diabetes Metab Rev 1995; 11 (Suppl. 1):

S57–62.

9 Melchior WR, Jaber LA. Metformin: an

antihyperglycemic agent for treatment

of type II diabetes. Ann Pharmacother

1996; 30 (2): 158–64.

10 UK Prospective Diabetes Study

(UKPDS) Group. Effect of intensive

blood glucose control with metformin

on complications in overweight patients

with Type 2 diabetes. Lancet 1998; 352:

854–65.

11 Donnan PT,MacDonald TM,Morris AD.

Adherence to prescribed oral hypo-

glycaemic medication in a population of

patients with Type 2 diabetes: a retro-

spective cohort study. Diabet Med 2002;

19 (6): 448–55.

12 Wallace TM, Matthews DR. Poor gly-

caemic control in Type 2 diabetes: a

conspiracy of disease, suboptimeal

therapy and attitude. QJM 2000; 93:

369–74.

13 Dezii DM, Kawabata H, Tran M.

Effects of once-daily and twice-daily

dosing on adherence with prescribed

glipizide oral therapy for type 2 dia-

betes. South Med J 2002; 95 (1): 68–71.

14 Nicholas WC, Fischer RG, Stevenson RA,

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15 Pullar T, Birtwell AJ, Wiles PG, Hay A,

Feely MP. Use of a pharmacologic indi-

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macol Ther 1988; 44 (5): 540–5.

16 Paes AH, Bakker A, Soe-Agnie CJ. Impact

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Diabetes Care 1997; 20 (10): 1512–7.

17 Grant RW, Devita NG, Singer DE,

Meigs JB. Polypharmacy and medication

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Diabetes Care 2003; 26 (5): 1408–12.


EDITORIAL 265

18 Howlett HC, Bailey CJ. A risk-benefit

assessment of metformin in type 2 dia-

betes mellitus. Drug Saf 1999; 20 (6):

489–503.

19 Dandona P, Fonseca V, Mier A, Beckett

AG. Diarrhea and metformin in a dia-

betic clinic. Diabetes Care 1983; 6 (5):

472–4.

20 Fujioka K, Pans M, Joyal S. Glycemic

control in patients with Type 2 diabetes

mellitus switched from twice-daily

immediate-release metformin to a once-

daily extended-release formulation. Clin

Ther 2003; 25 (2): 515–29.

21 Garber AJ, Duncan TG, Goodman AM,

Mills DJ, Rohlf JL. Efficacy of metformin

in type II diabetes: results of a double-

blind, placebo-controlled, dose–response

trial. Am J Med 1997; 103 (6): 491–7.

22 Fujioka K, Brazg RL, Raz I et al. Efficacy,

dose–response relationship and safety of

once-daily extended-release metformin

(Glucophage�XR) in Type 2 diabetic

patients with inadequate glycaemic con-

trol despite prior treatment with diet and

exercise: results from two double-blind,

placebo-controlled studies. Diabetes Obes

Metab 2004; 7: 28–39.

23 Blonde L, Dailey GE, Jabbour SA,

Reasner CA, Mills DJ. Gastrointestinal

tolerability of extended-release metfor-

min tablets compared to immediate-

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Res Opin 2004; 20 (4): 565–72.

24 Polonsky WH, Earles J, Smith S et al.

Integrating medical management with

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3048–53.

Barriers to optimal intervention and care for people with dementia

Inequalities in dementia care across Europe:

an agenda for change – a supplement

appearing simultaneously with this issue –

presents papers from the Facing Dementia

Forum held last June in Rome, Italy. The

forum brought together 175 experts in

dementia care from 17 countries in Europe

and North America. The expertise was

wide ranging, including physicians,

caregivers, advocates and people with

dementia. The meeting was hosted by

Eisai and Pfizer in conjunction with

Alzheimer’s Disease International, and its

main purpose was to review and discuss the

results from the FacingDementia Survey, a

research initiative underwritten by Eisai

and Pfizer.

This survey was undertaken to assess

the awareness of and behaviour

surrounding Alzheimer’s disease (AD)

and dementia among all key stakeholders

from six European countries: France,

Italy, Germany, Poland, Spain and the

United Kingdom. This unique study –

one of the largest research surveys yet

done on dementia – involved more

than 2500 persons, including caregivers,

members of the general population,

physicians, persons with AD and

influencers of health care policy.

Although some readers may have

reservations about a survey sponsored

by industry and the fact that such a

wide-ranging sampling will inevitably

have methodological flaws, its con-

clusions are important to everyone

working to improve the lot of people

with dementia and their families.

The survey does show some differences

among the six countries, and these may

indicate regional variations within Europe

and also reflect the nature of the survey

itself and the population sampled in each

country. It is the overall message,

however, that is most important.

Three main barriers to optimal inter-

vention and care were identified. Firstly,

despite being a public health issue,

dementia is not a health care priority.

Investment by governments in treatment

and provision of resources to help affected

people has been inadequate. Interestingly,

the general public was somewhat less con-

cerned than physicians and caregivers

about government indifference. This is

perhaps not surprising, when approxi-

mately one-third of Europeans in the sur-

vey felt that AD is serious but does not

really affect many people. They expect

that cancer and coronary disease are

more likely to affect them and their

families. Personal experience with AD

dramatically increases the level of concern.

Clearly, there is a need to educate

governments and private citizens about

the increasing numbers of people with

dementia and the significant cost involved.

For example, the direct cost of AD exceeds

the cost of heart disease, cancer and stroke

combined for elderly patients in the

United Kingdom. In contrast to this,

research spending forAD is approximately

10% of the budget for heart disease and

only 3% of that spent on cancer.

The second barrier is the mistaken

belief that nothing can be done about

dementia. We need to communicate a

much more positive image of dementia,

including the value of both drug and

non-drug treatment and the clear

importance of obtaining a diagnosis.

The major obstacle to developing

more effective treatments for dementia

is that society does not value its older

citizens. We must work to change these

attitudes. We must also emphasise that

dementia is not just a disease of older

people. Dementia affecting people of

working age may also have a devastating

impact. Dementia at whatever age has a

profound impact on the whole family –

siblings, children, grandchildren and

even parents.

The final barrier is the difficulty of

recognising early dementia and the fact

that people often confuse its symptoms

with those of so-called normal ageing.

This inevitably reflects the difficulty of

making an accurate early diagnosis in

the absence of specific diagnostic

markers. There is a clear role for

scientific advances here. On the other

hand, delays in recognising early

dementia often reflect the need to

better educate both the public and


266 EDITORIAL

professionals about the early signs and

symptoms of dementia, emphasising

that a significant memory loss is never

a normal part of the ageing process.

Another factor that often delays diag-

nosis is denial – refusal to entertain the

idea that a loved one may have AD.

This should improve, however, as people

become more aware that treatments are

available to improve the situation.

Four of the supplement articles reflect

movingly on the impact of dementia on

caregivers and patients. Trying to under-

stand what the individual person with

dementia is experiencing is important.

Caregivers and health care professionals

who work with these patients must never

forget that even in severe dementia, some

points of contact are possible. Establishing

good communication with patients and

involving them in pleasurable activities

can greatly enhance their quality of life.

Delegates at the forum presented their

Agenda for Change. It is up to all of us

working in the field of dementia to take on

this agenda to raise awareness of the full

societal, health and economic impact of

dementia and ensure that dementia

becomes a greater priority for governments.

We must communicate a more positive

image of dementia, including the value of

intervention and the availability of support.

Finally, there is a need for a widespread

programme of education that involves the

general public, health care professionals and

patients and their families. Whilst more

effective treatments are needed, there is

still a lot that we can offer our patients

and their families with drug and non-drug

treatment as well as support and advice.

Professor RW Jones, Director

Research Institute for the Care of

the Elderly St Martin’s Hospital

Bath BA2 SRP, UK


EDITORIAL 267

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Prevention of disease – education makes a difference in the community