Diabetes centres: adapting to change

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  • The evolution of diabetes centres in the UK, with co-location of clinical teams, has resulted in examples ofsuccess in improving clinical efficiency, communicationand patient-centred care.

    The diabetic clinic dinosaur is dying: will diabetic dayunits evolve?1 This was the developing philosophy of the1980s, and the prediction was fulfilled. Without doubtthere were good reasons for dissatisfaction with standards of diabetes care at the time, and problemswith the traditional diabetic [sic] clinic were well recognised: poor clinic structure and standards of education woefully below those desired.2 Although afew pioneering general practitioner cooperative careschemes were in existence at the time, these were verymuch few and far between, with the vast volume of diabetes care still delivered primarily by the hospital specialist medical team and with the emerging involve-ment of diabetes specialist nurses.

    ConceptionIn 1987, under the aegis of the Diabetes EducationStudy Group, a seminal workshop2 was held to discussand debate the concept of diabetes centres. Those of uswho attended were very much aware that an excitingmilestone in diabetes care was being witnessed.Remarkably, but probably not surprisingly, issues identi-fied then are still as relevant today. Diabetes centresalone would not necessarily resolve identified inadequa-cies of care, but they offered the opportunity of betterorganisation, co ordination and integration of districtdiabetes services; a dedicated and recognised environ-ment facilitating multidisciplinary team working and,above all, a platform for education provision that had very recently emerged as so essential to improvingoutcomes in diabetes care.3

    Growth and inevitable changeEvery district was determined to secure a diabetes centre, and some 10 years later a further survey4 by theBritish Diabetic Association (BDA; now Diabetes UK) foundthat, of an initial 132 UK centres reported, there were 96which fulfilled the BDAs definition of a diabetes centre.Rather like Darwinian finches on the Galapagos Islands,many centres had evolved to meet local service needs withinthe constraints of local circumstances. Nonetheless, despitethis degree of heterogeneity, a functional core common toall was evident and diabetes centres were seen very positivelyand very much as a source for good in the overall strategy ofdelivering good diabetes care to the community. For twodecades, diabetes centres were in the ascendancy, undertak-ing increasing clinical activity and expanding other impor-tant related roles such as research.5 However, with time, thelaws of critical mass could not be challenged indefinitelyand there was no way that diabetes centres and hospitalbased diabetes services could continue to provide theentirety of diabetes care; nor was it desirable that they did

    so. The shift of most diabetes management into primarycare and the community reflects a logical and inevitablechange to accommodate the burgeoning demands fromincreasing diabetes prevalence.

    This new world...Where has this left the future role for diabetes centres inthis new world? That was the question raised in a recent further survey by Diabetes UK coordinated by GillianHawthorne (Newcastle), the results of which are publishedwithin this issue of Practical Diabetes International (seepage 290). Interestingly, fewer diabetes centres were identi-fied compared to the 1998 survey4 but, nonetheless, some respondents were still striving to secure a new centre for their locality. Core function of centres remainsfundamental, with most multidisciplinary specialist clinicalservice management taking place within the centres andeducational resource being a much valued facility.

    However, diabetes centres have clearly evolved andmany new initiatives are reported to indicate that adaptations to new ways of working and delivering dia-betes care are being embraced. A dedicated helpline(telephone, e-mail) and one stop shop opportunity areevidently valued by patients. Facility to undertake clinicalresearch is also that much easier within the centre, particularly with the increasing support of the UKDiabetes Research Network portfolio offering involve-ment in a number of diabetes related research studies.

    LocationLocation of diabetes centres within acute trusts has longbeen some source of contention and there is an argumentfor a community base. However, the specialist diabetesteam remains heavily involved in supporting inpatient diabetes care, and we believe the results of NHS Diabetesrecent inpatient diabetes audit will confirm the essentialneed for this to continue. Specialist team support bothhelps minimise the need for hospitalisation and reducesthe length of stay for those admitted with diabetes usuallyas a secondary consideration. Split site working is simplynot efficient and priorities may be compromised. Theconcept of providing diabetes care within a polyclinic setting has caused some uncertainty as to how it wouldfunction and there are concerns about its flexibility andability to cope with demand on a daily basis.

    Key areas and integrationThe evolution of diabetes centres, supported by evidencederived from this recent survey, has forged an understand-ing of what a diabetes centre offers in three key areas: (i)multidisciplinary clinical care with unique specialist clinics(e.g. insulin pump clinics and an array of diagnostic tech-nologies), (ii) clinically based diabetes research, and (iii) patientand diabetes health care professional education at a local and, in some centres, at a national level. A fully integrated service is fundamental. Appropriate and facilitated accessto specialist diabetes nurses, dietitians, digital retinal

    LEADER

    Pract Diab Int September 2010 Vol. 27 No. 7 Copyright 2010 John Wiley & Sons 269

    Diabetes centres: adapting to change

  • LEADER

    screening and podiatrists can be provided, as well as clinical care pathways to dedicated diabetes vascular,orthopaedic, cardiological, microbiological and psychiatricteams, all supported by the extended subspecialty role ofconsultant diabetologists, and all members of the diabetesmultidisciplinary team.

    The centre concept is achieved to advantage by co-locating the multi-professional team, thus integrating several aspects of clinical service: Inpatient care, where asignificant proportion of patients requiring admission,both elective and emergency, will have diabetes, and ofwhich up to 50% will be newly diagnosed. These patientsrequire very close joint management of their diabeteseither during acute illness or in advance of surgical procedures; Outpatient activity with daily specialist clinicsrequiring multidisciplinary team input; Emergency referralsand urgent drop-in being managed on an ambulatory basisthereby often avoiding need for admission; Diabeteshotline with emergencies assessed by the team on thesame day, while routine referrals are triaged to the rele-vant subspecialty clinic; and, finally, Frontline technologyand teaching ensuring that the latest excellence of service innovation is embraced and disseminated.

    Evolution with new ways of workingDiabetes is the fastest growing chronic disease of ourmodern age. In parallel to the rise in numbers of patients with diabetes, is the awareness of the complex-ities of managing the condition and the explosion of newtherapies. Diabetes centres have been at the forefront ofclinical care over the past two decades. Adapting tochange is a continuing reality within the NHS. There isnow a pressing demand that diabetes centres be no excep-tion to this. However, unlike the dinosaur image of theold traditional diabetes clinics, we believe diabetes centresin the modern diabetes service world, with the emphasison community management, still have an important role to offer; they are indeed evolving with new ways ofintegrated working.

    Professor Ken Shaw, MA, MD, FRCP, Editor-in-Chief, Practical Diabetes InternationalDr Michael Feher, MD, FRCP, Consultant in Diabetesand Clinical Pharmacology, Chelsea and WestminsterHospital, London, UK

    Conflict of interest statementThe authors are consultant diabetologists who work, in part,within a multi-professional diabetes centre.

    References1. Ling P, et al. The diabetic clinic dinosaur is dying: will diabetic day

    units evolve? Diabet Med 1985; 2: 1635.2. Day JL, Spathis M. District Diabetes Centres in the United Kingdom.

    A report on a workshop held by the Diabetes Education StudyGroup on behalf of the British Diabetic Association. Diabet Med 1988;5: 37280.

    3. Baksi AK, et al. (eds). Diabetes Education. John Wiley & Sons, 1984.4. Hall M, et al. Diabetes centres in the UK: results of a survey of UK dia-

    betes centres. British Diabetic Association, 1998.5. Tomlinson S. Should diabetes centres have a research/education

    function? The experience of the Manchester Diabetes Centre.Pract Diabetes 1991; 8: 1836.

    270 Pract Diab Int September 2010 Vol. 27 No. 7

    EZETROL (ezetimibe)ABRIDGED PRESCRIBING INFORMATIONRefer to Summary of Product Characteristics (SPC) before PrescribingAdverse events should be reported.Reporting forms and information can be found at www. yellowcard.gov.uk.Adverse events should also be reported to MSD-SP Ltd (01992-467272).

    PRESENTATION 10 mg Tablet containing 10 mgof ezetimibe.

    USES As adjunctive therapy to diet in:

    Primary hypercholesterolaemia: For co-administrationwith an HMG-CoA reductase inhibitor (statin) for patients with primary (heterozygous familial and non-familial) hypercholesterolaemia not appropriately controlled with a statin alone. Monotherapy: For usein patients with primary (heterozygous familial and non-familial) hypercholesterolaemia in whom a statin is considered inappropriate or is not tolerated. Homozygous Familial Hypercholesterolaemia (HoFH):For co-administration with a statin, for use in patients with HoFH. Patients may also receive adjunctive treatments (e.g. LDL apheresis). Homozygous sitosterolaemia(phytosterolaemia): For use in patients with homozygous familial sitosterolaemia.

    A benecial effect of Ezetrol on cardiovascular morb-idity and mortality has not yet been demonstrated.

    DOSAGE AND ADMINISTRATION For oral administration.Put patients on an appropriate lipid-lowering diet and continue during treatment. Recommended dose is one Ezetrol 10 mg tablet daily, administered at any time of the day, with or without food. When added to a statin, either, continue with the indicated usual initial dose of that particular statin or the already established higher statin dose. Consult the statin dosage instructions. Co-administration with bile acidsequestrants: Dosing should occur either *2 hours before or *4 hours after administration of a bile acid sequestrant.Use in paediatric patients: Initiation of treatment mustbe performed under review of a specialist. Adolescents *10 years no dosage adjustment required. The clinical experience in paediatric and adolescent patients (aged 10 17 years old) is limited. When administered with simvastatin, consult the dosage instructions for simvastatin, in adolescents. Children 9) liver dysfunction.

    CONTRA-INDICATIONS Hypersensitivity to any comp-onent. When co-administered with a statin, refer to the statin SPC. Ezetrol co-administered with a statin during pregnancy and lactation. Ezetrol co-administered with a statin in patients with active liver disease or unexplained persistent elevations in serum transaminases.

    PRECAUTIONS Liver enzymes: When co-administered with a statin, perform liver function tests at initiation of therapy and according to the statin SPC. Skeletalmuscle: In post-marketing experience with Ezetrol, myopathy and rhabdomyolysis have been reported. Most patients who developed rhabdomyolysis were taking a statin concomitantly with Ezetrol. However, rhabdomyolysis has been reported very rarely with Ezetrol monotherapy and very rarely with the addition of Ezetrol to other agents known to be associated with increased risk of rhabdomyolysis. If myopathy is suspected based on muscle symptoms or is conrmed by a creatine phosphokinase (CPK) level >10 times the ULN, immediately discontinue Ezetrol, any statin, and any of these other agents. Advise all patients starting therapy with Ezetrol of the risk of myopathy and to report promptly any unexplained muscle pain, tenderness or weakness Hepaticinsufciency: Not recommended in patients with moderate or severe hepatic insufciency due to the unknown effects of the increased exposure to Ezetrol. Fibrates: The safety and efcacy of co-administration have not been established. There is a possible risk of cholelithiasis and gall-bladder disease in patients receiving fenobrate and Ezetrol. If suspected, conduct gall-bladder investigations and discontinue co-administration. Ciclosporin: Exercise caution when initiating Ezetrol in patients taking ciclosporin and monitor ciclosporin concentrations. Warfarin, another coumarin anticoagulant or uindione: Monitor the International Normalised Ratio (INR) if taken together with Ezetrol. Excipient: Ezetrol tabletscontain lactose: do not use in patients with rare hereditary problems of galactose intolerance, Lapp lactase deciency or glucose-galactose malabsorption. Efcacy and safety of Ezetrol co-administered with simvastatin in patients 10 to 17 years of age with heterozygous familial hypercholesterolemia have been evaluated. There was generally no detectable effect on growth or sexual maturation in the adolescent boys or girls, or any effect on menstrual cycle length in girls. However, the effects of ezetimibe for a treatment period >33 weeks on growth and sexual maturation have not been studied, (See section 4.2. and 4.8.). The long-

    term efcacy of Ezetrol in patients below 17 years of age to reduce morbidity and mortality in adulthood has not been studied. Interactions (studies have only been performed in adults): Colestyramine: Concomitant colestyramine administration decreased the mean AUC of total Ezetrol approximately 55%. The incremental low density lipoprotein cholesterol (LDL-C) reduction due to adding Ezetrol to colestyramine may be lessened by this interaction. Statins: No clinically signicant pharmacokinetic interactions were seen upon co- administration with atorvastatin, simvastatin, pravastatin, lovastatin, uvastatin, or rosuvastatin. Pregnancy andlactation: Ezetrol co-administered with a statin is contra-indicated during pregnancy and lactation, refer to the SPC for that particular statin. Pregnancy: Ezetrol should be given to pregnant women only if clearly necessary. No clinical data are available on the use of Ezetrol during pregnancy. Lactation: Ezetrol is contra-indicated. Driving and using machines: Dizziness has been reported.

    SIDE EFFECTS Refer to SPC for complete information on side effects

    Clinical studies In clinical studies where Ezetrol was administered alone or with a statin, adverse reactions were usually mild and transient. The overall incidence of side effects reported with Ezetrol was similar between Ezetrol and placebo. Similarly, the discontinuation rate due to adverse experiences was comparable between Ezetrol and placebo.The following common (*1/100,