Lean in Primary Care:

Redesigning the Diabetes ProcessThe Alphabet Strategy Approach

Vinod Patel* and John Morrissey**

*Reader in Clinical SkillsUniversity of Warwick Medical School

*Lead for Diabetes CareGeorge Eliot Hospital NHS Trust, Nuneaton

Amitha Gopinath: Project Manager

On behalf

George Eliot Hospital NHS Trust Diabetes Care Team

Diabetes is a Significant Global Healthcare Problem

Hogan P, et al. Diabetes Care. 2003;26:917-932.King H, et al. Diabetes Care. 1998;21:1414-1431.

250 million currently

20% of population in Middle-East,

USA, India over 40 years

Diabetes Care: The ComplicationsDiabetes Care: The ComplicationsRetinopathyRetinopathy

Most 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 longmen with long--standing diabetesstanding diabetes

Macrovascular disease Macrovascular disease 22––4 fold increased risk 4 fold increased risk of coronary heart disease of coronary heart disease

and stroke, 75% have and stroke, 75% have hypertensionhypertension

Foot problemsFoot problemsCommonest cause of nonCommonest cause of non--

traumatic amputationtraumatic amputation

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

U.K. economic costsU.K. economic costsU.K. economic costs

Year 2000 projected NHS Year 2000 projected NHS diabetes expenditure ( 9% ) :diabetes expenditure ( 9% ) : £4,878,000,000£4,878,000,000

Equivalent to:Equivalent to:per week £93,807,692 per day £13,401,098 per hour £ 558,379 per minute £ 9,306per second £ 155

50% of Costs are due to premature complications50% of Costs are due to premature complications

Diabetes UK. May 2000.Diabetes UK. May 2000.

Diabetes Care: the evidence baseDiabetes Care: the evidence baseUKPDS

RENAAL

IRMA

HOPE

DCCT

EDIC

WOSCOPS4S

HPS

ASCOT-LLA

LIPID

STENO-2

CARDS TNT

EUCLIDEUCLID

DPP

Diabetes Care: Components of CareDiabetes Care: Components of CareBP control

Cholesterol profile modification

Multi-disciplinary

Eye screening

Statins

Weight loss

Regular exercise

Dietary modification

Foot screening

ACE inhibitors

AII receptor blockers

Smoking cessation

Patient orientated

Aspirin

Diabetes UK AuditDiabetes UK Audit

Foot Examination55.1% only

Range 4-95%

Foot Examination55.1% only

Range 4-95%

HbA1c%70.1%

Range 17-99%

HbA1c%70.1%

Range 17-99%

Malcolm Roxburgh. Diabetes UK Multi-Centre Audit 2000.

Blood Pressure71.1%

Range 33-100%

Blood Pressure71.1%

Range 33-100%

Eye examination56.5% only

Range 16-100%

0

10

20

30

40

50

60

70

80

90

100

%

Site

Proportion of Patients with Foot Record in YearAve 55.1%

Feet Examined % 4.332 8.894 22.94 23.06 24.75 29.31 34.16 34.39 34.61 34.83 35.87 38.99 39.86 40.18 41.77 43.61 51.91 52.42 55.72 58.94 58.94 64.51 65.76 68.14 70.7 72.26 74.05 74.3 75.09 77.16 79.35 87.8 91.7 95.3 96.67

Site 28

Sit e 17

Sit e 9Sit e 14

Si te 27

Sit e 29

Si te 18

Sit e 19

Si te 32

Si te 3Sit e 20

Sit e 8Sit e 22

Si te 21

Sit e 15

Si te 35

Si te 1 Sit e 7Site 13

Sit e 26

Si te 38

Site 2Si te 10

Sit e 11

Si te 34

Site 36

Sit e 5Si te 37

Site 6 Sit e 4Sit e 33

Si te 16

Site 24

Sit e 30

Site 12

0

10

20

30

40

50

60

70

80

90

100

%

Site

Proportion of Patients with Eyes ExaminedAve 56.5%

Eyes Examined % 16.56 21.74 27.77 31.6 31.97 32.62 42.6 42.83 45.08 45.41 45.71 46.6 46.6 49.17 54.75 55.38 55.98 57.42 57.84 58.93 60.92 61.22 62.99 63.96 68.06 68.66 72.79 73.9 76.64 81.56 81.84 82.11 89.89 90.6 94.74 98.69 100

Si te 9

Si te 14

Site 32

Sit e 29

Si te 8

Si te 36

Site 31

Sit e 15

Sit e 7

Si te 27

Si te 2

Site 26

Sit e 38

Sit e 20

Si te 17

Site 22

Sit e 34

Sit e 21

Sit e 3

Site 10

Sit e 19

Sit e 13

Sit e 37

Si te 1

Site 35

Sit e 5

Sit e 11

Si te 33

Si te 4

Site 6

Sit e 24

Sit e 16

Si te 28

Si te 30

Site 12

Sit e 18

Si te 23

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

%

Site

Proportion of Patients with DBP RecordAve 71.1%

DBP Examined % 32.85 36.38 38.03 45.27 47.83 48.18 49.68 51.24 58.01 58.17 60.92 61.65 64.68 68.50 72.49 74.48 74.81 78.87 79.92 79.92 80.68 81.21 83.84 83.99 85.24 86.34 87.91 88.76 89.17 90.13 90.83 94.48 94.51 96.19 96.40 97.44 97.68

Site 18 Site 29 Site 32 Si te 20 Site 14 Site 25 Si te 1 Si te 19 Site 3 Site 36 Site 27 Si te 15 Site 22 Site 31 Site 17 Site 9 Site 5 Site 21 Site 26 Site 38 Si te 13 Site 7 Site 6 Site 35 Si te 37 Si te 12 Site 8 Site 10 Site 28 Si te 33 Site 4Site 11

Site 24 Site 2 Si te 34 Site 30 Site 16

0

10

20

30

40

50

60

70

80

90

100

%

Site

Proportion of patients with HbA1 c measuredAve 70.1%

Series1 16.6 22.8 26.2 36 39.7 41.3 44.7 48.6 56.6 60.9 62.5 63.9 64.2 65.9 75.3 77.5 79.7 80.7 85.9 86.6 87 88.7 89.7 91.1 91.5 94.4 94.7 95.8 97.7 98.9

Site 16

Site 21

Site 7

Site 18

Site 20

Site 32

Site 15

Site 29

Site 8

Site 36

Site 22

Site 3

Site 19

Site 26

Site 2

Site 17

Site 33

Site 11

Site 28

Site 37

Site 14

Site 34

Site 4

Site 6

Site 24

Site 13

Site 12

Site 5

Site 1

Site 35

Aims:Aims:“Set national standards and ... “Set national standards and ... define service models for ... the define service models for ... the prevention ... identification and prevention ... identification and ... management ... of diabetes ... management ... of diabetes and its major complicationsand its major complications.”

Standard 4:Standard 4:“All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes.”

Department of Health 2003Department of Health 2003

Diabetes Care:

How should/could we be doing diabetes care

What are the 10 most important aspects of effective diabetes care

How can these be put in ? place

Diabetes Care:The Alphabet Strategy Approach

•Background

•Alphabet Strategy

•Multi-factorial Intervention

•Implementation in Secondary Care

•User Empowerment

•UK Primary Care

•Global Application

•i-DREAM

A simple effective approach?

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

National Service Framework National Service Framework for Coronary Heart Diseasefor Coronary Heart Disease

Patel V, Morrissey J.The Alphabet Strategy.British Journal of Diabetes &Vascular Disease. 2002.;2:1:58-59

Patel V, Morrissey J.The Alphabet Strategy.British Journal of Diabetes &Vascular Disease. 2002.;2:1:58-59

Alphabet StrategyAlphabet Strategy•• Advice: Advice:

–– exercise, diet, not smoking, exercise, diet, not smoking, regular testing & clinicsregular testing & clinics

•• Blood Pressure: Blood Pressure: –– aim less than 140/80aim less than 140/80

•• Cholesterol: Cholesterol: Creatinine CareCreatinine Care–– less than 4less than 4

•• Diabetes Control: Diabetes Control: –– HbA1c% 6.5% or less HbA1c% 6.5% or less

•• Eyes: Eyes: –– check yearly at leastcheck yearly at least

•• Feet: Feet: –– check yearly at leastcheck yearly at least

•• Guardian Drugs: Guardian Drugs: –– Aspirin 75mg protects against Aspirin 75mg protects against

heart disease, ACE inhibitors, heart disease, ACE inhibitors, ARBsARBs

AdviceAdvice• Strongly advise adherence to diet and medication• Smoking cessation, exercise, weight reduction• Ensure diabetes education and advise Diabetes UK

membership• Stress role of the dietician, chiropodist and diabetes care

nurses• Regular follow-up with comprehensive Annual Review is

essential. 20% of patients with early severe complications will be persistent non-attenders

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

Lifestyle changes reducing progression to DM

Diabetes Prevention Program Finnish Diabetes Prevention Study

7% weight loss in the obese > 5% weight loss

Avoid excess alcohol Fat intake < 30% of total calories

Diet advice Saturated fat < 10% of total calories

Smoking advice Fibre intake ≥ 15g per 1000 calories intake

150 mins of moderate exercise per week

Exercise > 4 hours per week

Other measures: increased veg/and fruits, less sugar/salt

Blood PressureUKPDS 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 Significant

-34 Significant

-21 Non significant

-44 Significant

-56 Significant

-37 Significant

-35 Significant

Deaths reduced by 32%

C is for ...C is for ... CHOLESTEROL4S Diabetes Sub-Study:

Major Coronary Events In Patients with Diabetes

Coronary death and non-fatal MICoronary death and non-fatal MI

11 22 33 44 55 660000

2020

4040

6060

8080100100

RiskRiskreductionreduction

55%55%

Diabetic,simvastatinDiabetic,simvastatin ( n=105)( n=105)Diabetic, placebo (n=97)Diabetic, placebo (n=97)

Years since randomisationYears since randomisation

Prop

ortio

n w

ithou

t maj

or

Prop

ortio

n w

ithou

t maj

or

CH

D e

vent

s (%

)C

HD

eve

nts

(%)

CARDSCollaborative Atorvastatin Diabetes Study

Helen Colhoun, John Betteridge, Paul Durrington, Graham Hitman, Andrew Neil, Shona Livingstone, Margaret Thomason, Michael Mackness, Valentine Menys, John Fuller on behalf of the CARDS Investigators

Presented at ADA 2004

Atorvastatin 10mg

Placebo

2838patients

CARDS Design

Placebo

•Primary Prevention Diabetes patients with one other risk factor (hypertension, smoker, micro-albuminuria, retinopathy)

CARDS Study: Treatment Effects

21 (1.5%)

24 (1.7%)

51 (3.6%)

83 (5.8%)

Atorva*

48% (11- 69)39 (2.8%)Stroke

31% (-16- 59)34 (2.4%)Coronary revascularisation

36% (9- 55)77 (5.5%)Acute coronary events

37% (17- 52)p=0.001

127 (9.0%)Primary endpoint**

Hazard Ratio Risk Reduction (CI)Placebo*Event

.2 .4 .6 .8 1 1.2**Fatal MI ,Other acute CHD death, non fatal MI, Unstableangina, CABG, Fatal stroke, non fatal stroke

Favours Atorvastatin Favours Placebo* N (% randomised)

Diabetes ControlUKPDS 33: HbA1c% 7.9% versus 7.0%

Intensively-treated patients: HbA1C = 7.0% Conventionally-treated patients: HbA1C = 7.9% This 0.9% decrease is associated with reduction in risk for:

Significant

Significant

Borderline significance

Borderline significance

Significant

Significant

--1212

--2525

--1616

--2121

--3434

--2424

0 -10 -20 -30 -40 -50

% Reduction in risk

MI: 16% p=0.052

Retinopathy: -21%

Cataract extraction: -24%

Microvascular endpoint: -25%

Albuminuria at 12 years: -34%

Any diabetes-related endpoint: -12%

E is for Eye Screening

E is for ....Eye screening

• Diabetic Maculopathy: Commonest cause of blindness in UK under 65

• Haemorrhages and/or hard exudates within one disc diameter of the macula, with or without visual loss

• Treatment: clinical risk factors (BP, Glycaemia, cholesterol) and focal laser photocoagulation

F is for ...F is for ...FOOT SCREENINGFOOT SCREENING

Guardian Drugs

Aspirin 75mg od:

JBS 2 (2005) advocates considering aspirin 75mg od against CVD events in:

• Any established atherosclerotic disease• ≥ 50 years, or those younger but have had diabetes for

10 years, or hypertenisve• Retinopathy or nephropathy• Once BP <150/90

Guardian Drugs

• ACE-inhibitors and Angiotensin-II Receptor Antagonists have a special role in preventing diabetes complications (MICRO-HOPE, LIFE)

• ACE-inhibitors and Angiotensin-II Receptor Antagonists have a special role in preventing diabetes

• Statins are guardian drugs

LIFE: New Onset Diabetes by Treatment Group

Study Month0 6 12 18 24 30 36 42 48 54 60 66

0

2

4

6

8

10

Prop

ortio

n of

pat

ient

s, %

AtenololLosartan

Lindholm LH, J Hypertens 2002 (in press)

Doing all this Doing all this polypharmacypolypharmacy wwill ill poisonpoison ourour patientspatients!!

Blood pressure, Cholesterol, Diabetes control, ACE-I, Aspirin!

The StenoThe Steno--2 Study : 2 Study : AA SummarySummary

Steno Diabetes CentreSteno Diabetes Centre

Copenhagen, DenmarkCopenhagen, Denmark

••160 with T2D and microalbuminuria160 with T2D and microalbuminuria

••80 allocated to conventional treatment80 allocated to conventional treatment

••80 allocated to intensive treatment80 allocated to intensive treatment

••Mean age 55.1 yearsMean age 55.1 years

••Mean followMean follow--up 7.8 yearsup 7.8 years

StenoSteno--2 2 TTargetsargetsStenoSteno--2 intensive 2 intensive

cohort %cohort %JBS/AlphabetJBS/Alphabet

GuidelinesGuidelines

AAdvicedvice StandardStandard StandardStandard

BBlood Pressurelood Pressure 130 / 80 130 / 80

Earlier Earlier 140 / 85140 / 85140 / 80140 / 80

Optimal 130/80Optimal 130/80

GMS Audit 145/80GMS Audit 145/80

CCholesterolholesterol 4.54.5 4.04.0GMS Audit 5GMS Audit 5

DDiabetes Control : iabetes Control : HbHbAA11cc%% 6.56.5%% 7.07.0%%GMS Audit 7.5%GMS Audit 7.5%

EEyesyes AnnuallyAnnually AnnuallyAnnually

FFeeteet AnnuallyAnnually AnnuallyAnnually

GGuardians : aspirinuardians : aspirin, , ACEI / ACEI / AIIAAIIA

AllAll MostMost

StatinsStatins mostmost AllAll

Actual contribution of each risk factor in improving cardiovascular risk in Steno-2

• ? Blood Pressure

(down by 12/6 mmHg)

•? Diabetes Control

(HbA1c% down by 1%

•? Cholesterol Treatment

(down by 1.2 mmol/l)

•? Smoking reduction

(down by ? 15% overall)

Steno 2: Event Reduction

53 %

61% 58%

67%

0

10

20

30

40

50

60

70

cardiovasculardisease

nephropathy retinopathy autonomicneuropathy

Nu m

ber o

f eve

nts

StenoSteno--2 : CVD Event Reduction2 : CVD Event Reduction

EventEvent ConventionalConventional IntensiveIntensive

Cardiovascular DeathCardiovascular Death 77 …died earlier!…died earlier! 77

MI : nonMI : non--fatalfatal 1717 55

CABGCABG 1010 55

PCIPCI 55 00

Stroke : nonStroke : non--fatalfatal 2020 33

AmputationsAmputations 1414 77

Revascularisation for PVDRevascularisation for PVD 1212 66

P<0.002P<0.00285 events in 35 85 events in 35

patientspatients

44% overall44% overall

33 events in 19 33 events in 19 patientspatients

24% overall24% overall

Steno-2 : Conclusion

“ A target driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%.”

The PolyThe Poly--pillpillConcept:Concept:

“The Polypill Concept proposes treating BP, LDL-cholesterol, homocysteineand platelet dysfunction by administration of three antihypertensive agents, a statin, folic acid and aspirin will reduce cardiovascular disease by more than 80%”

AspostatinoprilolazideAspostatinoprilolazide FolateFolate !!

The Diabetes The Diabetes PolypillPolypill??

StatinAspirinMetformin ThiazideACE-I or ARB

Indo-linguistically: “equality” ie in terms of reducing morbidity and mortality esp. CVD

BMJ

Polypill Paper

Does the Alphabet Strategy Does the Alphabet Strategy deliver these targets? deliver these targets?

Aims

1. To evaluate clinical change and cardiovascular risk reduction achieved, using the Alphabet strategy as a template for audit in diabetes care.

2. To evaluate the usefulness of the UKPDS and Framingham cardiac risk function in clinical audit.

Advice

18.3

15.5

14

15

16

17

18

19

% patients

T0 Tfu

Smoking status

Smokers

p=NS

n=400

Blood Pressure

145.8

82.0

140.5*

76.5**

020406080

100120140160

Blood pressure

mmHg

T0 Tfu

SystolicDiastolic

*SBP p<0.001

**DBP p<0.001

n=400

Cholesterol

5.8

1.05

4.9*

1.26**

0.01.02.03.04.05.06.0

Serum cholesterol

mmol/l

T0 Tfu

Total cholesterolHDL cholesterol

*TC p<0.001

**HDL p<0.001

n=400

Diabetes Control

7.98.1

6

6.5

7

7.5

8

8.5

HbA1c %

T0 Tfu

p<0.001

n=400

Eye Examination

86.5

97.5

80

85

90

95

100

% patients examined

T0 Tfu

Examined

p<0.001

n=400

Foot Examination

69.8

83.5

60

65

70

75

80

85

% patients examined

T0 Tfu

Examined

p<0.05

n=400

Heart Disease Risk Score

UKPDS: T0 vs. Tfu p=NS Tadj vs. Tfu p<0.001

UKPDS 10 year absolute CHD risk

23.9

31.2

23.7

05

101520253035

Absolute 10 year risk %

T0 Tadj Tfu

n=315

Public Health & Prevention

Primary

Experts

Secondary care

Tertiary

Secondary

Primary Interface

………...Diagnosis……….General treatment……… Review

….… Screening…… Healthy eating…… Exercise……Weight care

Palliative …………………….…………………… Renal replacement ………………….. Amputation…………………. Rehabilitation………………… PCI / CABG……………….. Advanced eye surgery

……………… DKA…………….. Infections…………..... CVD…………... CVD Risk…………... Insulin start………….. Screening eyes………….Screening feet………….Screening renal…….…...Complex cases

Diabetes Chronic Disease Management

Single Team

Patients views on the Alphabet strategy

• Brilliant – shows you were you are!

• Very useful

• Motivational

• Helps you focus on your conditions

• Keep things in proportion

• Provides additional information

• Gives you an idea of what to aim for

• Enlightening

• Helpful

• Gives better understanding

GEDI Knights!George Eliot Diabetes Information Sticks

Amitha GopinathKelly BroganTerry Franklin

Retinal cameraappeal

Patient Survey

• 96.7% understood the strategy. ‘Diabetes control’ and ‘Advice’ posters gave the most powerful information.

• 36.7% found the ‘Guardian Drugs’ poster the hardest

• 36% stated their diabetes control; required most attention.

• 100 % of patients stated they understood the importance of BP and diabetes control.

• A mean score of 8.9/10 was given for usefulness and 90% found the experience enjoyable.

Benefits to patients • Educational tools help patients understand the main

components of care in a clear and logical manner

• The handheld records allows patients to know their BP, cholesterol etc and to track changes.

• Clinical audit demonstrates that patients have a higher standard of care than before and higher than average.

• We have demonstrated a potential reduction in CHD by 25% ( cardiac risk score reduced from 31.2% to 23.7%)

Public Health & Prevention

Primary

Experts

Secondary care

Tertiary

Secondary

Primary Interface

………...Diagnosis……….General treatment……… Review

….… Screening…… Healthy eating…… Exercise……Weight care

Palliative …………………….…………………… Renal replacement ………………….. Amputation…………………. Rehabilitation………………… PCI / CABG……………….. Advanced eye surgery

……………… DKA…………….. Infections…………..... CVD…………... CVD Risk…………... Insulin start………….. Screening eyes………….Screening feet………….Screening renal…….…...Complex cases

Diabetes Chronic Disease Management

Single Team

Patient Groups

Expert Patients

Benefits to staff

• This strategy has resulted in closer team working of all members of the Diabetes Care team, effectively towards a very high standard of care.

• This includes practice nurse, general practitioners, hospital doctors, nurses, pharmacists, podiatrists and dieticians. The materials have been produced by the whole team.

• The team feels empowered in the fact that a very high standard of care is being delivered.

• Recruitment to our unit is excellent with most staffs members involved in dissemination of the strategy.

0

20Po

ints

( to

tal =

66

)

RegisterBMI Record

Smoking record

Smoking cessation

Flu jabBP recordBP = < 145 / 85

TC recordTC = < 5Ma recordCr recordA1c recordA1c = < 10A1c = < 7.4Eyes record

FP recordPN recordMa Rx

All practices : points by parameter 2004

Points shortPoints won

0

20Po

ints

( to

tal =

94

)

RegisterBMI Record

Smoking record

Smoking cessation

Flu jabBP recordBP = < 145 / 85

TC recordTC = < 5Ma recordCr recordA1c recordA1c = < 10A1c = < 7.4Eyes record

FP recordPN recordMa Rx

All practices : points by parameter 2005

Points shortPoints won

“Degree” in Diabetes Care: 2004

Overall ScoresOverall ScoresPracticePractice

20042004 20052005

R1R1 8787

R2R2 7878

R3R3 7676

R4R4 7676

R5R5 7575

R6R6 7474

R7R7 7171

R8R8 6969

R9R9 6060

R10R10 4141

R11R11 4141

R12R12 2020

0 0 -- 6464Class 3Class 3

65 65 –– 7474Class 2 LowerClass 2 Lower

75 75 –– 8484Class 2 UpperClass 2 Upper

85 85 –– 9999Class 1Class 1

Degree in Diabetes Care: 2005

Overall ScoresOverall ScoresPracticePractice

20042004 20052005

R1R1 8787 92*92*

R2R2 7878 97**97**

92*92*

8989

98**98**

95**95**

95**95**

95**95**

93*93*

92*92*

7878

91*91*

R3R3 7676

R4R4 7676

R5R5 7575

R6R6 7474

R7R7 7171

R8R8 6969

R9R9 6060

R10R10 4141

R11R11 4141

R12R12 2020

0 0 -- 6464Class 3Class 3

65 65 –– 7474Class 2 LowerClass 2 Lower

75 75 –– 8484Class 2 UpperClass 2 Upper

85 85 –– 9999Class 1Class 1

UK Median 84

Global Alphabet Strategy Implementation Audit

GAIA Project

Methods• Medical students from the University of

Warwick collected data in Alphabet Strategyformat during their electives around the world.

• We analysed data on 4545 patients from 50 centres, in 31 countries, in all continents bar Antarctica. The results were organised into quintiles (Q1-Q5) according to GMS2 points.

• Main components of the study:1)Data collection2)Diabetes care team questionnaire3)Demographics4)Alphabet strategy questionnaire

GAIA: 31 countries

4545 patients, 50 centres

Total GMS2 points per centre Jersey 87.52

France 84.71

Falklands 78.92

Aus 3 76.93

Norway 76.54

Spain 72.44

Aus 4 72.08

Aus 2 68.3

Greece 68.12

India 1 66.79

Barbados 54.46

Jamaica 41.29

India 5 39.59

W Samoa 37.21

Bangladesh 35.71

India 3 33.91

Malaysia 48.31

Ireland 45.69

Q3

USA 66.4

South Africa 59.05

St Kitts 32.75

Q2

Q1

10.16Tonga

12.35Egypt 2

13.35Belize

16.16Egypt 1

17.27India 6

19.66Aus 1

Q5

19.7Ghana 2

25.26Sol Islands

27.11India 2

28.48Cuba

29.2India 4

30.05Mauritius

32.42Ghana 1

Q4

28.48Q4

13.35Q5

37.21Q3

66.4Q2

76.93Q1

Median

N= 34

Likely to adopt Alphabet Strategy in their departments

0102030405060708090

100

perc

enta

ge

Q1 Q2 Q3 Q4 Q5n=35centers, 146 responses

Strategy will improve the outcome of their practice

0102030405060708090

100

Perc

enta

ge

Q1 Q2 Q3 Q4 Q5

n=35centers, 146 responses

Strategy could be applied with their economic background

0102030405060708090

100

Perc

enta

ge

Q1 Q2 Q3 Q4 Q5

n=35centers, 151 responses

Indo-Asian Diabetes Care:The Alphabet Strategy

• Advice: exercise, diet, not smoking, regular clinics

• Blood Pressure: aim less than 140/80

• Cholesterol: TC less than 5, LDL < 3, HDl> 0.9

• Diabetes Control: HbA1c% 7% or less

• Eyes: check yearly at least refer appropriately

• Feet: check yearly at least refer appropriately

• Guardian Drugs: Aspirin 75mg, ACE-I, AT II antagonists, statins

ASIAD ProjectAlphabet Strategy – Indian Application for Diabetes

An European Strategy applied in outpatient setting in Asia

L Varadhan1, V Palanikumaran2, A Gopinath1,

J Morrissey1, V Patel3l NHS 1 George Eliot Hospital NHS Trust

2 Shenbagam Hospital, Madurai, India3 Warwick Medical School, University of Warwick, Coventry, UK

Methods• Few changes made to the Alphabet strategy template to

suit Indian standards: replace HbA1c with fasting and postprandial blood glucose; microalbuminuria with proteinuria

• A prospective audit was done on 100 further patients implementing the Alphabet Strategy

• Documentation of various aspects of diabetes care were compared with 100 case notes randomly selected from the outpatient setting in UK

Alphabet Strategy – UK template

Alphabet Strategy – Indian template

Advice

99 99 100 99 99 100 100 100 94

0

10

20

30

40

50

60

70

80

90

100

BMI recorded Smoking record Cess advice

Before AS India After AS India UK

Blood Pressure & Cholesterol

99 99 100

60

99 100

10

64

97

0

10

20

30

40

50

60

70

80

90

100

BP Recording TC record Lipid profile

Before AS India After AS India UK

Creatinine & Proteinuria

5

49

99

0 03

48

93

56

0

10

20

30

40

50

60

70

80

90

100

Creat Recording Micral record Proteinuria

Before AS India After AS India UK

Diabetes

0 0

100

41

97 100

0

10

20

30

40

50

60

70

80

90

100

HbA1c FPG/PPPG

Before AS India After AS India UK

Eye & Feet Examination

98 100 100 95 100

80

0

10

20

30

40

50

60

70

80

90

100

Eye exam Feet exam

Before AS India After AS India UK

Guardian drugs

6

71 71

7

57

75

5

38

73

2

20

52

0

10

20

30

40

50

60

70

80

Aspirin ACEI/ARB Statin All 3

Before AS India After AS India UK

GMS Score

45

61

76

0

10

20

30

40

50

60

70

80

GMS Score

Before AS India After AS India UK

Conclusion

• The Alphabet strategy of diabetes care is an effective template to ensure that all components of diabetes care are delivered to patients with diabetes.

• The Alphabet strategy of diabetes care has to the potential to be easily adopted to any health care economy

• Comparable standards to diabetes care can be provided using this strategy.

Diabetes Care: Different Economic Models

1 2 3 4

Professional Personal Adviser

All drugs

Full profile, all drugs

Continuous monitoring

Specialisedservice

Full support. MRI

All drugs

ACE-1, ARB, CCB

All drugs

Home testingHbAc1%

Camera

Vascular service

ACE-I, ARB

General

ACE-I, CCB

Measure, statin

HbA1c%

Trained staff, laser

Trained staff

Statins

Leaflets

Thiazides

Diet

Clinic tests

Clinic ExaminationClinical examination

Aspirin

A

B

C

D

E

F

G

The Alphabet Strategy for Diabetes Care:

• Educational talks for healthcare professionals and patients

• Guidelines: evidence – based, clear, simple to use.

• Educational materials and posters for patients.

• Specific materials for ethnic minority diabetes care.

• Handheld patient record

• Patient self management assessment scorecard ( gold, sliver, bronze “medals”)

• GAIA Project

• Website ( www.abcdiabetescare.org.uk)

VIDYADiabetes CHD Stroke Renal

Advice Advice

Blood PressureCholesterolCreatinineDiabetes controlESCRD CareECG, US, ?CT

Functional management

Guardian Drugs

Blood Pressure

CholesterolCreatinine

Diabetes control

ECG and other Investigation

Functional disability management

Guardian Drugs

Advice

Blood Pressure

CholesterolCreatinine

Diabetes control

ECG / ETT / Echocardiography

Functional status and follow up

Guardian Drugs

Advice

Blood Pressure

CholesterolCreatinineDiabetes control

Eyes

Feet

Guardian Drugs

A

B

C

D

E

F

G

Alphabet Strategy for Diabetes Care• Advice:

– Education, self-management, smoking cessation, diet, physical activity, weight reduction

• Blood Pressure: – Target <130/80– Audit standard <140/90

• Cholesterol: – TC ≤ 4.0 mmol/l, LDL ≤ 2, – Consider HDL ≥ 1 men, HDL ≥ 1.2 women

• Diabetes Control: – Target HbA1c% ≤ 6.5%

• Eyes: – check yearly and refer if needed

• Feet: – check yearly and refer if needed

• Guardian Drugs:– Aspirin 75mg, ACE-I or ARBs, Statins

Alphabet Strategy for Diabetes Care• Advice:

– Education, self-management, smoking cessation, diet, physical activity, weight reduction

• Blood Pressure: – Target <130/80– Audit standard <140/90

• Cholesterol: – TC ≤ 4.0 mmol/l, LDL ≤ 2, – Consider HDL ≥ 1 men, HDL ≥ 1.2 women

• Diabetes Control: – Target HbA1c% ≤ 6.5%

• Eyes: – check yearly and refer if needed

• Feet: – check yearly and refer if needed

• Guardian Drugs:– Aspirin 75mg, ACE-I or ARBs, Statins

Single Team: Patients, Primary, Secondary, Tertiary, Public Health, other stakeholders

Re-iterative, evidence changing, patient focussed

Awards• Diabetes UK 2006: Clinical care poster award: First Prize

• NHS West Midlands Innovation Award 2005 :Innovation in Service Award: First PrizeThis award was given for a clinical decision making programme that integrates best clinical evidence for Diabetes Care. Abstracts of important clinical trials in are present in the novel AT-A-GLANCE format. This is both an educational and clinical management toolwhich has the unique addition of a patient education facility included.

• Health Care Social Awards 2005: Long term condition Award, Midlands and East ,Runner-up.This award will recognise services and innovations that help support patients with long term conditions and improve their quality of life.

Awards• Diabetes UK 2005: Diabetes UK/ Servier Type 2 Diabetes

Research Award: First prize

• British Association of Medical Managers 2004: Medical Management Team of the Year Award: First PrizeThis award was given for the Alphabet Strategy for Diabetes. Themain strength of this project that made it of national interest is the integration of patient-centred evidence-based management strategy for Diabetes care. Moreover the strategy allows most healthcare professionals in diabetes care to work together across the primary/secondary care interface.

• Hospital Doctor Awards Commendation 1999:This award was given for the team effort in setting high standards of clinical care