Introduction To The Alphabet Strategy And Evidence Based Medicine

1
Introduction To The Alphabet Strategy And
Evidence Based Medicine
2
UK prevalence of diabetes mellitus

• UK prevalence of diabetes mellitus 3.54.
• 2.2 million people in the UK have diabetes
• 1.9 million ( 87) have type 2 diabetes.
• 300,000 (13) have type 1 diabetes.
• There may be as many as one million undiagnosed
  cases of type 2 diabetes.

Diabetes UK, 2006
3

Global prevalence of diabetes 2003
lt 2 2 - 5 5 - 8 8 - 11 11 - 14 14 -
17 17 - 20 gt20
Diabetes Atlas second edition, IDF 2003
4
Chronic complications of diabetes

• Coronary and cerebrovascular Disease
• 24 fold increased risk of coronary heart
  disease and stroke, 75 have hypertension

• Retinopathy
• Most common cause of blindness in people of
  working age

Nephropathy 16 of all new patients needing
renal replacement therapy
Foot Problems 15 of people with diabetes
develop foot ulcers 515 of people with
diabetic foot ulcers need amputations

• Erectile Dysfunction
• May affect up to 50 of men with long-standing
  diabetes

The Audit Commission. Testing Times. A Review of
Diabetes Services in England and Wales, 2000.
5
Life expectancy and diabetes
Goodkin G. Journal of Occupational Medicine
197517(11) 716721. Donnelly R, et al. British
Medical Journal 2000 320 10621066.
6
Diabetes in the UK Indo - Asian community
7
Cost of diabetes to the NHS

• NHS spend on diabetes is
• 5 of the total budget, or
• 10 million per day.
• This is predicted to increase to 10 of the total
  budget by 2011.

Diabetes UK, 2004
8
GMS Contract
Evidence base
NICE
Increasing prevalence
National Service Framework
User expectations
Guidelines
9
Glycaemia
Eyes
Lipids
Patient oriented
Blood pressure
Multi -disciplinary
Lifestyle
Feet
Audit
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13

• Evidence-based medicine

The integration of best research evidence with
clinical expertise and patient values .
Sackett DL et al (2000) Evidence Based Medicine
14
Best research evidence
Clinical expertise
Patient values
15
Best research evidence
Clinical expertise
Patient values
within available resources
16
William of Ockham (1285-1349)
Entia non sunt multiplicanda praeter
necessitatem
Entities are not to be multiplied beyond
necessity
17
K I S S
18
Keep It Simple , Stupid
19
Excellence requires that important, simple
things are done right all the time . National
Service Framework for Coronary Heart Disease
20
The Alphabet Strategy

• Advice
• Blood pressure
• Cholesterol
• Diabetes control
• Eye examination
• Feet examination
• Guardian drugs

21
The Alphabet Strategy

• Advice Smoking , diet , exercise
• Blood pressure lt 140/80
• Cholesterol
• TC 200mg/dl , LDL 130mg/dl,
• HDL gt 50mg/dl (F) gt40 mg/dl (M), TGs lt150mg/dl
• Diabetes control HbA1c 7 (IFCC 5.3)
• Eye examination Annual examination
• Feet examination Annual examination
• Guardian drugs Aspirin, ACEI, ARB, statins

22
The Alphabet Strategy

• Advice
• Blood pressure
• Cholesterol
• Diabetes control
• Eye examination
• Feet examination
• Guardian drugs
• Heart risk score

23
The Alphabet Strategy

• Advice Smoking , diet , exercise
• Blood pressure lt 140/80
• Cholesterol TC 4 , LDL HDL 2
• Diabetes control HbA1c 7
• Eye examination Annual examination
• Feet examination Annual examination
• Guardian drugs Aspirin, ACEI, statins C
• Heart risk score UKPDS, Framingham

24
Patel V, Morrissey J The Alphabet
Strategy British Journal of Diabetes Vascular
Disease, 2002 2 1 58-59
25
A is for ...

• ADVICE
•  

26
Advice

• Adherence to diet and medication
• Smoking cessation, exercise, weight reduction
• Ensure diabetes education and advise Diabetes UK
  membership
• Stress role of the dietician, podiatrist and
  diabetes care nurses
• Regular follow-up with comprehensive Annual
  Review is essential. 20 of patients with early
  severe complications will be persistent Diabetes
  Clinic non-attenders
• Lifestyle targets weight reduction gt 5 if obese
  , fat intake lt 30 of energy intake , saturated
  fat lt 10 of energy intake , fibre gt 15g per 1000
  calories, exercise for four hours / week.

27
(No Transcript)
28
B is for ...

• BLOOD PRESSURE
•  

29
UKPDS 38 154/87 versus 144/82
-21 Non significant
-34 Significant
-35 Significant
-37 Significant
-44 Significant
-56 Significant
-24 Significant
UK Prospective Diabetes Study (UKPDS) Group (38).
BMJ 1998317703713
30
C is for ...

• CHOLESTEROL
•  

31
CHD prevention trials with statins in diabetes
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.
20023607-22. 2. Goldberg RB, Mellies MJ, Sacks
FM, et al. Circulation. 1998982513-2519. 3.
Pyörälä K, Pedersen TR, Kjekshus J, et al.
Diabetes Care. 199720614-620. 4. Haffner SM,
Alexander CM, Cook TJ, et al. Arch Intern Med.
19991592661-2667. CARDS Study ADA 2004. GREACE
Study
32
D is for ...

• DIABETES CONTROL 

33
Effect on diabetes complications of HbA1c
reduction
Reductions in HbA1c and corresponding reductions
in microvascular and macrovascular complications
described in major studies of persons with T1 DM
and T2 DM
34
To summarise . . .

• Control blood glucose to prevent
  microvascular complications.
• Lower cholesterol to prevent macrovascular
  complications.
• Lower blood pressure to prevent both.

35
E is for ...

• EYE EXAMINATION

36
(No Transcript)
37
F is for ...

• FEET EXAMINATION

38
(No Transcript)
39
G is for ...

• GUARDIAN DRUGS

40
(No Transcript)
41
The Alphabet Strategy

• Advice Smoking , diet , exercise
• Blood pressure lt 140/80
• Cholesterol TC 4 , LDL HDL 2
• Diabetes control HbA1c 7
• Eye examination Annual examination
• Feet examination Annual examination
• Guardian drugs Aspirin, ACEI, statins C
• Heart risk score UKPDS, Framingham

42

• Thank you for listening !