Fifty years of diabetes management in primary care
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
REVIEW
Fifty years of diabetes management in
primary care
MIKE KIRBY
Abstract
T
he incidence of diabetes has increased
exponentially over the last 50 years, meaning that
the management of diabetes solely by specialist
healthcare professionals is no longer feasible. Since the
1970s, primary and community healthcare professionals
have increasingly treated patients with diabetes.
Advances in diabetes equipment and new treatments
have further enabled patients to be treated more
conveniently and this has enhanced their quality of life.
There has also been an evolution in health service
strategies for diabetes – notably growing
acknowledgement of the benefits of intensive
treatment for patients with type 2, as well as type 1
diabetes, and the now well-recognised importance of
effective shared care programmes between primary and
secondary healthcare professionals. Thus, the Mike Kirby
organisation and delivery of care for patients with
diabetes has improved dramatically since 1952.
Key words: shared care, primary care, diabetes, history. better informed and are less likely to accept advice unquestion-
ingly from healthcare professionals.
Introduction Hence, diabetes care has evolved and new concepts have
Fifty years ago patients with diabetes were mostly treated in hos- been introduced. These include intensive therapy for patients
pitals by specialists, but the sharp rise in the prevalence of type 2 with type 2 diabetes, as well as for those with type 1 diabetes. It
diabetes means that this is no longer practical. Since the 1970s is also appreciated now that diabetes is a cardiovascular disease
increasing numbers of primary and community healthcare pro- and that a holistic approach to treating patients, including exer-
fessionals in the UK have assumed responsibility for the routine cise and life-style changes, is essential to improving patients’ out-
review, monitoring and management of patients with diabetes. comes and well-being. This approach calls for the close involve-
There are other reasons for the increased role of primary ment of primary care professionals and, therefore, the idea of
healthcare professionals in the shared care of contemporary dia- shared care for patients between primary and secondary health-
betes management. New treatments and advances in monitor- care has gained renewed importance over recent years.
ing and delivery devices have allowed more effective and flexible
management strategies. Healthcare professionals are also Therapeutic advances
increasingly aware of the importance of a patient’s quality of life, Oral agents
and so attention has become focused on disease management In the 1950s, sulphonylureas were the only oral antidiabetic
that is more suited to patients’ lifestyles. Additionally, patients agents available for routine clinical use. They were associated with
today expect to be actively involved in their treatment, are often hypoglycaemia and weight gain, and the American University
Group Diabetes Program (1970) suggested that sulphonylureas
might aggravate cardiovascular complications. Biguanides entered
Correspondence to: Dr Mike Kirby routine use in the early 1960s, and while they did not cause hypo-
Director of Hertfordshire Primary Care Research Network (HeartNet), glycaemia or weight gain, the link with lactic acidosis and with-
The Surgery, Nevells Road, Letchworth, Hertfordshire, SG6 4TS, UK.
drawal of phenformin in the late 1970s restricted their use until
Tel: +44 (0)1462 683051; Fax: +44 (0)1462 485650
E-mail: kirbym@globalnet.co.uk the revival of metformin in the 1980s and 90s.
Br J Diabetes Vasc Dis 2002;2:457–61 In the 1990s, the alpha-glucosidase inhibitor acarbose, the
metiglinides and the glitazones were introduced. Use of
VOLUME 2 ISSUE 6 . NOVEMBER/DECEMBER 2002 457
Downloaded from dvd.sagepub.com by guest on May 9, 2015REVIEW
Figure 1. Modern self-monitoring of blood glucose (SMBG) meter Figure 2. Historical glass syringe
Permission from Science Photo Library
(UKPDS) with type 2 diabetes showed the benefits of tight gly-
caemic control, using early and intensive therapy, with ‘near-nor-
mal’ glycaemic targets.3,4 Although patients receiving intensive
Permission from Science Photo Library therapy developed significantly fewer diabetic complications
than patients treated conventionally, both studies noted that
intensive therapy caused significantly more treatment-related
adverse events, particularly hypoglycaemia and weight gain.
acarbose was limited by gastrointestinal intolerance: metiglinides These side effects have limited the success of intensive therapy,
have been viewed as little more than short-acting sulphonylureas although short- and long-acting insulin analogues have gone
although there are subtle mechanistic differences; and glitazones some way to addressing these concerns.
are expensive, cause weight gain and fluid retention and are only
available as second-line agents.1 However, these drugs offer a Advances in monitoring and insulin delivery devices
useful choice and should be used sooner rather than later. Blood glucose monitoring
In the 1950s patients with diabetes had to visit their hospital to
Insulin therapy obtain accurate blood glucose tests. Urine glucose testing was
Fifty years ago insulin therapy consisted of regular insulin and possible at home, using the Benedict’s test, but this was inaccu-
either neutral protamine Hagedorn (NPH) or the (then) recently rate and only gave positive results with very high glucose con-
developed Lente class of insulins.2 All were derived from animals centrations. Self monitoring of blood glucose (SMBG) meters first
and NPH, Lente and Ultralente were chemically modified to be became available in the UK in the 1970s. The early meters
longer-acting than regular (soluble) insulin. Unfortunately injec- required a significant amount of blood. However, more advanced
tion regimens with these insulins do not reproduce the daily pro- machines with ‘easy-to-use’ strips and requiring little blood were
file of endogenous insulin. soon developed (figure 1). In the 1980s and 1990s computerised
In an attempt to match the physiological insulin profile com- SMBG meters were introduced. SMBG has empowered patients,
mercially-available mixtures of insulins were produced with dif- helping them to take a more active part in their management
ferent durations of action, and latterly short-acting and long- and lead more normal lives. In the clinic, monitoring of glycaemic
acting insulin analogues have appeared. control has been greatly facilitated since the 1980s with the use
Other notable advances in insulin therapy, include the pro- of glycated haemoglobin (HbA1 and HbA1C).
duction of ultra-pure, monocomponent insulin in 1973, and the
manufacture of human insulin in the 1980s using recombinant Insulin delivery systems
DNA technology. This allowed the mass production of human One drawback of insulin therapy is the need for injections.
insulin and insulin analogues, and resulted in the near disap- However, delivery systems have improved significantly over the
pearance of porcine and bovine insulins. last 50 years. In the 1950s syringes were made of glass and
required rigorous – and time-consuming – cleaning between
Intensive therapy for patients with type 1 and 2 injections (figure 2). The needles themselves were large and
diabetes made injections painful. Injection ‘guns’ were developed as early
The Diabetes Control and Complications Trial (DCCT) with type 1 as 1955. These were the size of revolvers and patients pulled trig-
diabetes and the United Kingdom Prospective Diabetes Study gers to insert the needle and inject the insulin. In the 1980s dis-
458 THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
Downloaded from dvd.sagepub.com by guest on May 9, 2015REVIEW
Figure 3. Insulin pens Figure 4. Timeline of evolution in therapies and equipment for
diabetes management
Evolution of diabetes management
Three new classes of
Sulphonylureas OHAs introduced:
first used in UK α-glucosidase inhibitors, Insulin
Recombinant metiglinides and glitazones glargine
Metformin human insulin available
available produced 2nd generation in the UK
Lente class in UK sulphonylureas
of insulins Monocomponent available Glimepiride - 3rd
introduced insulin developed generation
Insulin aspart sulphonylurea
and lispro
developed
1950 1960 1970 1980 1990 2000
Source: OptiPen range 2002
Computerised DCCT UKPDS NSF for
SMBG meters SMBG devices Diabetes
Injection guns introduced developed
available in the UK
Changes to CSII pumps
Disposable GP contracts
plastic syringes for chronic Some insulin pens
First shared care developed
scheme tried disease included on NHS
posable plastic syringes became available in the UK. Insulin pens management prescription list
were developed in the 1980s, but were not included on the NHS
prescription list until 2000 (figure 3).
Not all insulins are yet available in pen cartridges, and car-
tridges are not suitable for patients taking more than one form
Table 1. Selected National Service Framework Standards
of insulin. Syringes – despite being less convenient – remain com-
monplace. Continuous subcutaneous insulin infusion (CSII) using
Standard 1 The NHS will develop, implement and monitor
insulin pumps are unlikely to be used by most patients because
strategies to reduce the risk of developing type 2
they are expensive and require a significant amount of patient diabetes and to reduce the inequalities in the risk
education and motivation to monitor glucose concentrations of developing type 2 diabetes NO mediated
consistently.5 anti-aggregation
Standard 2 The NHS will develop, implement and monitor
Progression in health service strategies strategies to identify people who do not know
The development of new treatment options and advances in they have diabetes
monitoring and delivery equipment were important factors in the
evolution of diabetes management (figure 4). The growing inci- Standard 3 All patients with diabetes will receive a service
that encourages partnership in decision-making,
dence and burden of type 2 diabetes has also contributed to
supports them in managing their diabetes and
change and has led to the recent development of a National helps them to adopt and maintain a healthy
Service Framework (NSF) for diabetes to outline expected stan- lifestyle. This will be reflected in an agreed and
dards for diabetes management. The NSF standards (table 1) shared care plan in an appropriate format and
were published late last year and their implementation is sched- language. Where appropriate, parents and carers
should be fully engaged in this process
uled to commence by April 2003.
Standard 4, 5 & 6 All patients with diabetes will receive high-quality
Preventing diabetes and minimising the care, including support to optimise the control of
complications their blood glucose, blood pressure and other risk
Programmes to prevent diabetes are essential. This demands a factors for developing the complications of
diabetes. All children will be supported to
holistic approach to diabetes management through education optimise their physical, psychological, intellectual,
initiatives that aim to change the lifestyles of at-risk patients. educational and social development. All young
Diabetes is now recognised as a cardiovascular disease, with a people with diabetes will experience a smooth
focus being on weight reduction, improving diet and increasing transition of care from paediatric diabetes services
physical activity. Indeed, even modest lifestyle changes can help to adult diabetes services, whether hospital- or
community-based
to delay or prevent type 2 diabetes.6
The complications of diabetes have severe economic conse- Standard 7 The NHS will develop, implement and monitor
quences, as well as majorly impacting on the lives of patients. agreed protocols for rapid and effective treatment
The type 2 Diabetes Accounting for a Major Resource Demand of diabetic emergencies by appropriately trained
healthcare professionals. Protocols will include
In Society (T2ARDIS) study found that hospitalisation of patients
the management of acute complications and
with diabetes-associated complications accounts for approxi- procedures to minimise the risk of recurrence
mately 41% of overall expenditure, compared with only 2% on
VOLUME 2 ISSUE 6 . NOVEMBER/DECEMBER 2002 459
Downloaded from dvd.sagepub.com by guest on May 9, 2015REVIEW
drug therapy. The same study found that early intervention with Figure 5. Algorithm of shared care schemes in the UK
intensive treatment strategies (as proposed by the UKPDS and
DCCT) could cut the cost of diabetes by reducing the risk of com-
Hospital
plications and, therefore, hospitalisation.7 To reduce the risk of diabetes
centre
complications of diabetes, the recently-published NICE guidelines
for the management of type 2 diabetes recommended that:
Diabetes
● Each patient should be set an HbA1C target of between 6.5% specialist nurse
Dietician
and 7.5%. Diabetologist
and team
● Weight loss and increased physical activity should be encour- Chiropodist
PATIENT
aged in those who are overweight or obese. Optometrist
Ophthalmologist
and other
● Healthcare professionals should work with individuals to specialists
District
develop beneficial lifestyle changes in combination with on- Patient
groups diabetes
(e.g. DUK) register
going patient education.
A combination of clinical and community-based programmes
is needed to implement these health service strategies. GP and
PCT
Moreover, a collaborative team approach to managing diabetes,
involving a broad range of healthcare professionals, is essential (Figure 3.1 in Shared care for diabetes. Gatling, Hill and Kirby)
for these strategies to be put into practice successfully. This will
include primary care in the community by GPs and by practice
and community nurses who will monitor and review patients,
secondary care by diabetologists and diabetes specialist nurses, full responsibility and those in primary care are generally less
as well as frontline emergency staff. accustomed to performing routine follow-up than those in out-
patient settings. Additionally, primary care centres may lack the
The importance of shared care appropriate personnel, and staff may lack the expertise/specialist
The high incidence of diabetes has necessitated a shift in the tra- education to give optimal care.
ditional relationship of specialist physician/patient relationship. Several studies have investigated the efficacy of shared care
GPs and practice nurses now play a pivotal role in diabetes care. for diabetes.11-13 These concluded that good organisational struc-
The scale of the problem was underlined by a UK study examin- tures for primary care clinics is essential, and it is important that
ing the epidemiology of type 2 diabetes in the community, which GPs and practice nurses feel supported, and that care is truly
found that of 1,122 individuals, 4.5% had previously undiag- shared between primary and secondary care, not simply shifted.
nosed diabetes and 16.7% had impaired glucose tolerance.8 A meta-analysis of the effectiveness of diabetes care in general
Shared care has been defined as "the joint participation of practice found that well-organised practices, with computerised
hospital consultants and GPs in the planned delivery of care for central recall and prompts for GPs and patients, achieved stan-
patients with a chronic condition".9 However, this definition dards of care that were similar to or better than hospital care.
needs widening for diabetes as input from a broader range of The authors noted, however, that unstructured primary care is
healthcare professionals is required (figure 5).10 associated with poorer glycaemic control and greater mortality
The idea of shared care is not new. It was tried as early as than hospital care.11 A recent study found that 80% of practices
1953, when health visitors provided a link between hospital clin- now feel adequately supported and that most have good organ-
ics and general practices, but the concept has subsequently isational practices. However, the same study found that more
evolved. General practice-based mini-clinics for diabetes started work needs to be done to ensure seamless care across the pri-
to appear in the early 1970s, but it was changes to the UK GP mary–secondary care interface, and suggested the establishment
contract in 1990 and the institution of payment for chronic dis- of shared treatment protocols.12 Similar findings and suggestions
ease management in primary care in 1993 that really brought were reported by Greenhalgh in her systematic review of shared
about the switch in focus. Today, over 90% of GPs claim fees for care programmes, finding them effective only if the system
diabetes care. includes a register for patient monitoring, protected time for dia-
The aims for shared care programmes for diabetes should betes care, a practice nurse with some diabetes experience, a
include early diagnosis, the identification and management of written protocol agreed with the local consultant diabetologist
risk factors and diabetic complications, advice on diet, effective and a system for auditing standards of care.13
blood glucose control, prompt and appropriate referral for spe-
cialist advice and the continued education and motivation of Conclusions
patients.10 The advantages of such initiatives are that they allow The increasing incidence of diabetes means that its effective
the flexible treatment of patients in familiar surroundings and management has become a priority for healthcare professionals
provide a complete treatment approach rather than simply set- and has led to most people with diabetes now being treated in
ting glycaemic targets. general practice rather than hospital outpatient clinics. Advances
Potential disadvantages are that no single professional takes in diabetes equipment and treatments over the last 50 years
460 THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
Downloaded from dvd.sagepub.com by guest on May 9, 2015REVIEW
and the next 50 years also promises to see innovative treatments,
strategies, and perhaps a cure, for diabetes.
Key messages
Editor’s note
Mike Kirby epitomises the new face of primary care commitment to
shared care diabetes management. His career has enveloped a wealth of
● Over the last 50 years the increasing prevalence of experience within hospital and general practice, enabling a clear per-
diabetes has necessitated a switch in focus from spective on the evolution of current organisational structures for dia-
secondary to primary care disease management betes care.
● New therapeutic agents and advances in monitoring
and delivery systems have also allowed this evolution in References
1. Gale E. Lessons from the glitazones: a story of drug development. Lancet
diabetes management 2001;357:1870-5.
● The benefits of early and intensive therapy for patients 2. Owens DR, Zinman B, Bolli GB. Insulins today and beyond. Lancet
2001;358:739-46.
with type 1 and type 2 diabetes are increasingly 3. UK Prospective Diabetes Study (UKPDS) Group 33. Intensive blood-glu-
recognised cose control with sulphonylureas or insulin compared with conventional
● Diabetes is now appreciated as a cardiovascular disease, treatment and risk of complications in patients with type 2 diabetes.
Lancet 1998;352:837-53.
as is the importance of risk factor management, 4. Diabetes Control and Complications Trial Research Group. The effect of
especially blood pressure control and lipid management intensive treatment of diabetes on the development and progression of
●
long-term complications in insulin-dependent diabetes mellitus. N Engl J
The benefits of a collaborative team approach and
Med 1993;329:977-86.
sharing of care for patients with diabetes between 5. Rosenstock J. Insulin therapy: Optimising control in type 1 and type 2 dia-
primary and secondary care is widely acknowledged betes. Clin Cornerstone 2001;4:50-64.
6. Narayan KM, Bowman BA, Engelgau ME. Prevention of type 2 diabetes.
● Shared treatment protocols, good organisational BMJ 2001;323:63-4.
structures and auditing are essential to ensure seamless 7. Type 2 Diabetes Accounting for a Major Resource Demand In Society.
care across the primary–secondary care interface Diabetes UK. 2000. Ref Type: Electronic Citation.
8. Williams DRR, Wareham NJ, Wareham NJ et al. Undiagnosed glucose
intolerance in the community: the Isle of Ely diabetes project. Diabet Med
1995;12:30-5.
9. Hickman M, Drummond N, Grimshaw J. The operation of shared care for
have also contributed to this evolution in diabetes management chronic disease. Health Bull 1994;52:118-26.
and the application of new concepts. These include the increas- 10. Gatling W, Hill R, Kirby M. The shared care concept. Shared care for dia-
ing recognition of the benefits of intensive therapy for patients betes. Oxford: Isis Medical Media Ltd, 1999:29-36.
11. Griffin S. Diabetes care in general practice: meta-analysis of randomised
with type 2 diabetes, as well as those with type 1 disease. control trials. BMJ 1998;317:390-6.
Additionally, the importance of shared care for diabetes is now 12. Pierce M, Agarwal G, Ridout D. A survey of diabetes care in general prac-
recognised, as is the need for organisational structures that tice in England and Wales. Br J Gen Pract 2000;50:542-5.
ensure these programmes are implemented and managed effec- 13. Greenhalgh PM. Shared care for diabetes. A systematic review. 67,1-35.
1994. The Royal College of General Practitioners. Ref Type: Report.
tively. Diabetes management has changed markedly since 1952
VOLUME 2 ISSUE 6 . NOVEMBER/DECEMBER 2002 461
Downloaded from dvd.sagepub.com by guest on May 9, 2015You can also read
