Diabetes care: is it fair enough?

Missed checks, disrupted care and health inequalities have been revealed in a new report looking at the state of diabetes care in England | Diabetes UK

People with diabetes can expect to receive routine diabetes care, which includes a series of checks every year for things such as blood sugar and blood pressure. Receiving all of these checks is shown to reduce the risk of complications such as heart disease, hospitalisation and premature death. In their new report, ‘Diabetes Care: Is it fair enough?’ Diabetes UK reveals that less than half (47%) of people living with diabetes in England received all eight of their required checks in 2021-22, meaning 1.9 million people did not receive the care they need.

Diabetes-related deaths are up by 7,000 a year compared to pre-pandemic levels, an increase that may be linked to the backlog in routine diabetes care caused by the Covid-19 pandemic when services faced huge disruptions.  The report calls for urgent action to address the routine diabetes care backlog and prevent avoidable deaths of people living with diabetes.

Full report: Diabetes Care: Is it fair enough? | Diabetes UK

Press release: Too many people diabetes still not receiving vital care | Diabetes UK

See also: Poor diabetes care may be behind 7,000 excess deaths | BBC News

Diabetes in adults: updated quality standards

National Institute for Health and Care Excellence (NICE)

NICE has updated and replaced the quality standard on diabetes in adults (published March 2011). The quality standard on diabetes in adults is now split into separate quality standards on type 1 diabetes in adults and type 2 diabetes in adults.

Type 1 diabetes in adults. Quality standard [QS208]
This quality standard covers care and treatment for adults (aged 18 and over) with type 1 diabetes. It describes high-quality care in priority areas for improvement. It does not cover diabetes in children and young people, diabetes in pregnancy or other types of diabetes in adults.

Type 2 diabetes in adults. Quality standard [QS209]
This quality standard covers prevention of type 2 diabetes in adults (aged 18 and over) and care and treatment for adults with type 2 diabetes. It describes high-quality care in priority areas for improvement. It does not cover diabetes in children and young people, diabetes in pregnancy and other types of diabetes in adults.

Diabetes Prevention Programme Non-diabetic Hyperglycaemia Report, 2020/21

Obesity and higher levels of HbA1c were associated with greater risks of progression to type 2 diabetes | National Diabetes Audit (NDA) | Healthcare Quality Improvement Partnership

The National Diabetes Audit (NDA) has published its latest Diabetes Prevention Programme report into non-diabetic hyperglycaemia. Based on data from English GP practice systems for the period of January 2020 to March 2021, and data generated by providers of the Diabetes Prevention Programme relating to referrals up to March 2021, it aims to support the delivery of evidence based behavioural interventions that can prevent or delay the onset of type 2 diabetes in adults who have been identified as having non-diabetic hyperglycaemia (NDH).

The report found that 440,260 people were newly diagnosed with NDH, and that new diagnoses continued to be made amongst people of similar demographics to earlier years. Other key findings include:

• 39% of all people with NDH had glycaemic tests and BMI checks (56% in 2019-20)
• Obesity and higher levels of HbA1c were associated with greater risks of progression to type 2 diabetes
• Care process rates dipped overall under COVID-19 pressures – 67% of people with NDH had a glycaemic test, and 46% had body mass index (BMI) monitoring.

However, the report also found noticeable variation in how well people were being monitored across demographic groups, with people who were of black ethnicity, those aged under 40, and people who had been diagnosed with NDH more than 10 years ago being less likely to have had glycaemic tests or BMI checks. People over 65 were most likely to have had care processes completed. As such, it goes on the recommend that GP practices should conduct annual glycaemic tests (HbA1c, or fasting plasma glucose) and BMI checks for people with non-diabetic hyperglycaemia, endeavouring to provide these care processes across all groups.

Full detail: Diabetes Prevention Programme Non-diabetic Hyperglycaemia Report, 2020/21

Related:

• National Diabetes Audit, 2020-21 Report: Care processes and treatment targets
• New reports published – July 2022 | Healthcare Quality Improvement Partnership

Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes

British Journal of General Practice | Vol. 72 (719): e421-e429 | DOI: https://doi.org/10.3399/BJGP.2021.0508

Subgroups of type 2 diabetes (T2DM) have been well characterised in experimental studies. It is unclear, however, whether the same approaches can be used to characterise T2DM subgroups in UK primary care populations and their associations with clinical outcomes. The aim of this study was to derive T2DM subgroups using primary care data from a multi-ethnic population, evaluate associations with glycaemic control, treatment initiation, and vascular outcomes, and to understand how these vary by ethnicity.

In total, 31 931 adults with T2DM were included: 47% South Asian (n = 14 884), 26% white (n = 8154), 20% black (n = 6423). Two previously described subgroups were replicated, ‘mild age-related diabetes’ (MARD) and ‘mild obesity-related diabetes’ (MOD), and a third was characterised ‘severe hyperglycaemic diabetes’ (SHD). Compared with MARD, SHD had the poorest long-term glycaemic control, fastest initiation of antidiabetic treatment (hazard ratio [HR] 2.02, 95% confidence interval [CI] = 1.76 to 2.32), and highest risk of microvascular complications (HR 1.38, 95% CI = 1.28 to 1.49). MOD had the highest risk of macrovascular complications (HR 1.50, 95% CI = 1.23 to 1.82). Subgroup differences in treatment initiation were most pronounced for the white group, and vascular complications for the black group.

Conclusion: Clinically useful T2DM subgroups, identified at diagnosis, can be generated in routine real-world multi-ethnic populations, and may offer a pragmatic means to develop stratified primary care pathways and improve healthcare resource allocation.

Full paper: Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes: a UK real-world data study using the East London Database

Diabetes guidance: NICE updates

National Institute for Health and Care Excellence | updated 31st March

Type 1 diabetes in adults: diagnosis and management
This guideline covers care and treatment for adults (aged 18 and over) with type 1 diabetes. It includes advice on diagnosis, education and support, blood glucose management, cardiovascular risk, and identifying and managing long-term complications.

In March 2022, NICE reviewed the evidence and updated the recommendations on diagnosis and continuous glucose monitoring (CGM), replacing existing recommendations on diagnosis and CGM.

Type 2 diabetes in adults: management
This guideline covers care and management for adults (aged 18 and over) with type 2 diabetes. It focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications.

In March 2022, NICE reviewed the evidence and made new recommendations on continuous glucose monitoring (CGM).

Diabetes (type 1 and type 2) in children and young people: diagnosis and management
This guideline covers the diagnosis and management of type 1 and type 2 diabetes in children and young people aged under 18. The guideline recommends how to support children and young people and their families and carers to maintain tight control of blood glucose to reduce the long-term risks associated with diabetes.

In March 2022, NICE reviewed the evidence and updated the recommendations on continuous glucose monitoring (CGM), replacing existing recommendations on CGM.

Lifestyle advice for hypertension or diabetes: trend analysis from 2002 to 2017 in England

British Journal of General Practice | Vol. 72, Issue 717 | DOI: https://doi.org/10.3399/BJGP.2021.0493

Guidelines recommend that GPs give patients lifestyle advice to manage hypertension and diabetes. Increasing evidence shows that this is an effective and practical treatment for these conditions, but it is unclear whether GPs offer this support. the aim of this research was to investigate trends in the percentage of patients with hypertension/diabetes receiving lifestyle advice versus medication.

The study showed only a minority of patients with diabetes or hypertension report receiving lifestyle advice or have this recorded in their medical records. Interventions beyond guidelines are needed to increase the delivery of behavioural interventions to treat these conditions.

Full detail: Lifestyle advice for hypertension or diabetes: trend analysis from 2002 to 2017 in England

Effects of Diet versus Gastric Bypass on Metabolic Function in Diabetes

BACKGROUND

Some studies have suggested that in people with type 2 diabetes, Roux-en-Y gastric bypass has therapeutic effects on metabolic function that are independent of weight loss.

METHODS

We evaluated metabolic regulators of glucose homeostasis before and after matched (approximately 18%) weight loss induced by gastric bypass (surgery group) or diet alone (diet group) in 22 patients with obesity and diabetes. The primary outcome was the change in hepatic insulin sensitivity, assessed by infusion of insulin at low rates (stages 1 and 2 of a 3-stage hyperinsulinemic euglycemic pancreatic clamp). Secondary outcomes were changes in muscle insulin sensitivity, beta-cell function, and 24-hour plasma glucose and insulin profiles.

RESULTS

Weight loss was associated with increases in mean suppression of glucose production from baseline, by 7.04 μmol per kilogram of fat-free mass per minute (95% confidence interval [CI], 4.74 to 9.33) in the diet group and by 7.02 μmol per kilogram of fat-free mass per minute (95% CI, 3.21 to 10.84) in the surgery group during clamp stage 1, and by 5.39 (95% CI, 2.44 to 8.34) and 5.37 (95% CI, 2.41 to 8.33) μmol per kilogram of fat-free mass per minute in the two groups, respectively, during clamp stage 2; there were no significant differences between the groups. Weight loss was associated with increased insulin-stimulated glucose disposal, from 30.5±15.9 to 61.6±13.0 μmol per kilogram of fat-free mass per minute in the diet group and from 29.4±12.6 to 54.5±10.4 μmol per kilogram of fat-free mass per minute in the surgery group; there was no significant difference between the groups. Weight loss increased beta-cell function (insulin secretion relative to insulin sensitivity) by 1.83 units (95% CI, 1.22 to 2.44) in the diet group and by 1.11 units (95% CI, 0.08 to 2.15) in the surgery group, with no significant difference between the groups, and it decreased the areas under the curve for 24-hour plasma glucose and insulin levels in both groups, with no significant difference between the groups. No major complications occurred in either group.

CONCLUSIONS

In this study involving patients with obesity and type 2 diabetes, the metabolic benefits of gastric bypass surgery and diet were similar and were apparently related to weight loss itself, with no evident clinically important effects independent of weight loss. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT02207777. opens in new tab.)

Reference: N Engl J Med 2020; 383:721-732

Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India

Question  Among patients with diabetes and depression in India, does a 12-month collaborative care intervention that includes nonphysician care coordinators, decision support functions in electronic health records, and specialist case reviews improve depressive symptoms and measures of cardiometabolic health more than usual care at 24 months?

Findings  In this randomized clinical trial that included 404 patients at urban clinics in India with poorly controlled diabetes and depression, patients in the collaborative care intervention group, compared with the usual care group, were significantly more likely to achieve the composite outcome of at least a 50% reduction in the 20-item Symptom Checklist Depression Scale score and at least 1 of the following: reduction of at least 0.5 percentage points in hemoglobin A_1c, reduction of at least 5 mm Hg in systolic blood pressure, or reduction of at least 10 mg/dL in low-density lipoprotein cholesterol at 24 months (71.6% vs 54.7%).

Meaning  Among patients with diabetes and depressive symptoms in urban India, a multicomponent collaborative care intervention resulted in statistically significantly greater improvements in a composite measure of depressive symptoms and cardiometabolic indices compared with usual care.

Reference: JAMA. 2020;324(7):651-662.

Covid-19: diabetes clinicians set up social media account to help alleviate patients’ fears

BMJ (2020). Covid-19: diabetes clinicians set up social media account to help alleviate patients’ fears. 368.m1262  doi: https://doi.org/10.1136/bmj.m1262  

A news piece in the BMJ explains how a group of diabetes doctors and other clinicians has set up a social media account to help alleviate patients’ fears around covid-19 and provide them with “a secure base” of information. The Twitter account uses the handle @_diabetes101

BMJ Covid-19: diabetes clinicians set up social media account to help alleviate patients’ fears

Ticagrelor in Patients with Stable Coronary Disease and Diabetes

BACKGROUND

Patients with stable coronary artery disease and diabetes mellitus who have not had a myocardial infarction or stroke are at high risk for cardiovascular events. Whether adding ticagrelor to aspirin improves outcomes in this population is unclear.

METHODS

In this randomized, double-blind trial, we assigned patients who were 50 years of age or older and who had stable coronary artery disease and type 2 diabetes mellitus to receive either ticagrelor plus aspirin or placebo plus aspirin. Patients with previous myocardial infarction or stroke were excluded. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major bleeding as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria.

RESULTS

A total of 19,220 patients underwent randomization. The median follow-up was 39.9 months. Permanent treatment discontinuation was more frequent with ticagrelor than placebo (34.5% vs. 25.4%). The incidence of ischemic cardiovascular events (the primary efficacy outcome) was lower in the ticagrelor group than in the placebo group (7.7% vs. 8.5%; hazard ratio, 0.90; 95% confidence interval [CI], 0.81 to 0.99; P=0.04), whereas the incidence of TIMI major bleeding was higher (2.2% vs. 1.0%; hazard ratio, 2.32; 95% CI, 1.82 to 2.94; P<0.001), as was the incidence of intracranial hemorrhage (0.7% vs. 0.5%; hazard ratio, 1.71; 95% CI, 1.18 to 2.48; P=0.005). There was no significant difference in the incidence of fatal bleeding (0.2% vs. 0.1%; hazard ratio, 1.90; 95% CI, 0.87 to 4.15; P=0.11). The incidence of an exploratory composite outcome of irreversible harm (death from any cause, myocardial infarction, stroke, fatal bleeding, or intracranial hemorrhage) was similar in the ticagrelor group and the placebo group (10.1% vs. 10.8%; hazard ratio, 0.93; 95% CI, 0.86 to 1.02).

CONCLUSIONS

In patients with stable coronary artery disease and diabetes without a history of myocardial infarction or stroke, those who received ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. (Funded by AstraZeneca; THEMIS ClinicalTrials.gov number, NCT01991795. opens in new tab.)

Reference N Engl J Med 2019; 381:1309-1320