diabetes in context - bhcic.co.uk › ... › 03 › 190124-kings-inertia-and-elderly-abridge… ·...

$: Diabetes in context - bhcic.co.uk › ... › 03 › 190124-Kings-Inertia-and-elderly-abridge… · 45–70% increased risk of fall-related fracture in relation to hypoglycaemia in$
1

Tackling clinical inertia in Diabetes in

Primary Care?

David Strain,

Diabetes and Vascular Research Centre

University of Exeter Medical School, UK

2

The financial burden of diabetes

The cost of diabetes to the NHS is over £1.5m an hour

or 10% of the NHS budget for England and Wales

This equates to over £25,000 being spent on diabetes every minute

Cost to treat diabetes-related complications is 3 – 4 fold

the cost of prescribing medications

Annual out-patient costs estimated

between £300 and £370 per patient

Annual in-patient care estimated

between £1,800 and £2,500 per patient

Diabetes.co.uk. Cost of Diabetes [accessed September 2018] https://www.diabetes.co.uk/cost-of-diabetes.html

3

The Cost of Diabetes in the UK

Expenditure Type 1

Diabetes

Type 2

Diabetes

Total Percent

Diabetes

drugs

£0.344 billion £0.712 billion £1.056 billion 7.8%

Non-diabetes

drugs

£0.281 billion £1.810 billion £2.091 billion 15.2%

Inpatient £1.007 billion £8.038 billion £9.045 billion 65.8%

Outpatient (excluding drugs)

£0.170 billion £1.158 billion £1,328 billion 9.7%

Other (including

social service)

£0.230 billion 1.7%

Total £1.802 billion £11.718 billion £13.750 billion 100%

Kanavos, van den Aardweg and Schurer: Diabetes expenditure, burden of disease and management in 5 EU countries, LSE (Jan 2012)

4

Many patients with type 2 diabetes still fail to reach target HbA1c <7%

0

10

20

30

40

50

60

70

80

90

100

HbA1c checked

Met HbA1c target

HbA1c, glycated haemoglobin A1c.

Stone MA, et al. Diabetes Care. 2013;36:2628-38.

Perc

en

t, %

GUIDANCE study 7,597 patients

5

UKPDS

(n=3867)

ADVANCE2

(n=11,140)

ACCORD3

(n=10,251)

VADT4

(n=1791)

Duration of diabetes (years) 0 8 10 11.5

Mean baseline HbA1c (%) 7.1 7.5 8.3 9.4

Mean baseline FPG (mmol/L) 8.0 8.5 9.7 11.4

Mean age (years) 53 66 62 60

Microvascular ± =

Macrovascular = =

Should we treat early?

UKPDS Group. Lancet.1998;352:837–853; ADVANCE Collaborative Group. N Engl J Med. 2008;358:2560–

2572; ACCORD Study Group. N Engl J Med. 2008;358:2545–2559; Duckworth W, et al. N Engl J Med.

2009;360:129–139

Disease progression

6

Convincing our patients to the need for early intervention

When should you start servicing the car?

7

Diabetes picture in the UK

24,000 people with diabetes die prematurely each year because of ineffective

management

80% of costs of diabetes are attributable to management of avoidable

complications

Only 49% of people with diabetes receive all the basic tests

Only 1 in 5 achieved the recommended levels for blood glucose, blood

pressure and cholesterol

Without these simple checks, there is an increased risk of developing

complications

Department of Health: the management of adult diabetes services in the NHS. 17th report of session 2012–13. Available at

https://www.nao.org.uk/wp-content/uploads/2012/05/121321.pdf. Last accessed October 2017.

8

Intensification of glucose-lowering treatment delayed despite OAD

failure

Avoidable glycaemic burden = time remaining on

therapy after exceeding HbA1c target

12.316.5

26.025.9

36.6

51.1

0

10

20

30

40

50

60

Metformin… Sulfonylurea… Combination…

Month

s

7% HbA1c target8% HbA1c target

Met, metformin; OAD, oral antidiabetic drug; SU, sulphonylurea

Brown et al. Diabetes Care 2004;27:1535–40

At insulin initiation, the average patient had:

• 5 years with A1C > 8%

• 10 years with A1C > 7%

9

How do we modify CV risk in T2DM?

CV, cardiovascular; T2DM, type 2 diabetes mellitus1. Rydén L et al. Eur Heart J 2013;34:3035–3087; 2. Fox CS et al. Diabetes Care 2015;38:1777–1803; 3. Piepoli MF et al. Eur Heart J 2016;37:2315–2381

Lifestyle modification1–3Platelet inhibition1–3

Blood-pressure control1–3

Multifactorial

Approach

Management of dyslipidaemia1–3

Glycaemic control1–3

10

Using digital technology to tackle clinical inertia

11

What is Eclipse

12

1. Protection of Vulnerable Diabetes Patients.

2. Personalised Care for Diabetes.

3. Validated Improvements in Patient Safety

4. Reduced Workload for GPs

5. Reduced Costs for the CCG

6. Reduced burden on Secondary Care

7. Enhanced Education

8. Patient facing portal to empower patients in their own self care

What it delivers

13

Using ECLIPSE to tackle clinical inertia

People who are overdue screening identified

14


High Risk Patients electronically identified

Looking at

flux of

endpoint

data helps

identify

patients

earlier.

15


Stratification of patients by overall cost (not just medication costs)

Top 20 most expensive

patients in practice of 550

people with diabetes

A&E, Accident & Emergency department; APC, admitted patient care; F, female; M, male; OP, Out Patient attendance

Data used by permission of Caldicott Guardian, Litcham surgery

18−65 years

66−75 years

76−85 years

>85 years

<18 years

16

Using ECLIPSE to tackle clinical inertia: Implementation of Actions

17

Using the database in the UK

9% less admissions

17% less out patient appointments

8% less A&E Admissions

10% less Emergency Admissions

We have the potential to identify

predictors and contributory elements

An internal audit compared practices that regularly use ECLIPSE vs. those

who have installed the system but rarely use it

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Saving money

Improving quality of life costs money

No medication saves lives

• They just delay death

Only ways to save money are

• Spend less time in hospital

• Spend more time at work (paying tax)

• Dying!

19

Engaged care translates to reduced patient costs through better outcomes

Year ending 2012/13 2013/14 2014/15

Prescription costs* +11.2% +5.7% -16.6%

Unplanned admission

costs-52% -88% -57.7%

Referral costs -86.1% -72% N/A **

Total cost per 1000

patients-0.7% -5.2% -19.7%

* includes all prescriptions for co-morbidities in addition to diabetes related

treatment costs

** No referrals to specialists were recorded in this year.

Strain WD EASD P1698 2016

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Summary

Early intensification of therapy reduces progression of diabetes

An individualized approach is required based on the predominant features of the disease.

For those with Pre-existing heart failure SGLT-2i may have an advantage

For those with proven atherosclerotic disease GLP-1-RA may be of use

For all, the most important consideration in choosing the drugs that the people will take…

21

Diabetes in the elderly

David Strain,

Diabetes and Vascular Research Centre

University of Exeter Medical School, UK

22

Prevalence of hypoglycaemia more frequent in older adults

Retrospective data suggests

12.8% of patients aged over 70 years

vs. 10.1% aged 60–69 years

vs. 9% aged under 60 years

Prospective data however…

39% of elderly patients treated with SU-treated

64% treated with insulin for >5 years

36% expenditure increase in patients experiencing hypoglycaemia2

45–70% increased risk of fall-related fracture in relation to hypoglycaemia in people >65 years2

1. McCoy RG et al. Diabetes Care 2012;35:1897–901; 2. Johnston SS et al. Diabet Obes Metab 2012;14:634–43

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Longevity

• Will they benefit from treatment?

• Cholesterol (statin) therapy takes months(years) to give benefit

• Stopping smoking takes minutes to benefit physiology, but QALY benefit…?

• Glycaemic control alone take years (decades) to improve outcomes

1. Heart Protection Study Collaborative Group. Lancet 2011;378:2013–20; 2. UKPDS 33. Lancet 1998;352:837–53; 3. Holman et al. N Engl J Med 2008;359:1577–89; 4. Bain et al. J R Soc Med 1992;85:80–2.QALY=quality-adjusted life year

24

Individualising treatment for older adults in a clinical trial

At baseline, an individualised 24−week HbA1c target was defined by the investigator for

each of the 278 older adults

• Mean age 74.8 SD (4.12), range 70−97 years

Target was based on clinical judgment, taking into account:

• Age of the patient

• Baseline HbA1c value

• Frailty status

• Comorbidities

HbA1c, glycated haemoglobin;; SD, standard deviation

In this elderly cohort (70+ years old, mean age 75), the mean individualised HbA1c

targets set by the investigators were around 7.0% for both treatment groups,

0.9% (range –4.4 to –0.1) lower than the mean baseline HbA1c of 7.9%

Strain et al. Lancet 2013;382:409‒16

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Predictors of investigator-defined treatment targets in

the intention-to-treat population

CovariateEffect size per unit change in covariate

p value

Categorical Variables

Age (<75 vs ≥75 years) -0.036 0.5

Frailty status (No vs Yes) 0.169 0.07

Sex (Female vs Male) 0.119 0.025

Continuous Variables

Screening HbA1c (%) 0.536 <0.0001

Duration of diabetes (years) -0.001 0.7600

Target setting = frailty status (No or Yes) + age (<75 or ≥75) + sex + duration of diabetes + screening HbA1c

*For categorical covariates the estimate is the difference between the adjusted means of comparison-reference in the corresponding category.

For continuous covariates the estimate is the change in adjusted means per unit. HbA1c=glycosylated hemoglobin A1c.

25

Strain WD et al. Aging 2017 March

26

Frailty assessment pathway in diabetes

ABPI, ankle-brachial pressure index; GP, general practitioner; IADL, instrumental activities of daily living; PVD, peripheral vascular disease; SPPB, short physical performance battery

Strain WD et al. Diabet Med. 2018;35:838–845

Patient-related symptoms / concernsFalls

Mobility change

Post-hospital decrease in IADL

Weight loss/fatigue

Primary care

Diabetes specialist/geriatrician

Opportunity for referral

Assessment procedures

• Clinical review

• 4m gait speed

• Get Up and Go Test

• Electronic Frailty Index or

similar tool

Confirm or exclude presence

of frailty

Assessment procedures

• Clinical review

• Fried score

• Frail score

• SPPB

• Grip strength

• 4m gait speed

• Diagnosis of sarcopaenia (dexa scan)

• Evaluate and/or exclude peripheral

neuropathy (monofilament or vibration perception)

• Structured history/ABPI with hand-held

Doppler ultrasound for PVD and referral for

further assessment if required

• Comprehensive assessment of

functional status

• Confirmation of frailty diagnosis

• Review of glycaemic goals

• Exclude vascular and

neuropathic causes of mobility

impairment

Initial management plan

Promote positive lifestyle intervention with regular exercise

Nutritional assessment and exclude vitamin D deficiency

Review glucose control and medications according to functional

27

Normal range for TUAG

Age Group Time in Seconds (95% Confidence Interval)

60 – 69 years 8.1 (7.1 – 9.0)

70 – 79 years 9.2 (8.2 – 10.2)

80 – 99 years 11.3 (10.0 – 12.7)

Group Time in Seconds

Community Dwelling Frail Older Adults > 14 associated with high fall risk

Multimorbid patient > 30 predictive of requiring assistive

device for ambulation and being

dependent in ADLs

Values highly predictive of severe frailty

Bohannon RW. Journal of Geriatric Physical Therapy, 2006;29(2):64-8.Shumway-Cook A, Phys Ther. 2000;80:896-903.

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New UK assessment protocol: simplified frailty assessment

Patient type Examples of patient features

Healthy• Few coexisting chronic illnesses

• Cognitive and functional status intact

Complex

or

intermediate

• Multiple coexisting chronic illnesses

• >2 activities of daily living impairments

• Mild-to-moderate cognitive impairment

Very complex

or

in poor health

• Long-term condition

• End-stage chronic illnesses

• Moderate-to-severe cognitive impairment

• >2 activities of daily living dependencies


29

Treatment targets

Patient characteristics Targets Interventions

The fit older adult with diabetes 58 mmol/mol (7.5%)Avoid initiating new agents that may cause hypoglycaemia or

exaggerate weight loss

Moderate-to-severe frailty 64 mmol/mol (8.0%)

DPP-4 inhibitors and longer acting insulins have demonstrated

safety. TZDs may increase risk of heart failure. SGLT-2i may

provide additional benefit in people with heart failure but also

exacerbate symptoms of diabetes

Very severe frailty 70 mmol/mol (8.5%)

DPP-4 inhibitors renally appropriate dose for those only mildly away

from target. Consider long-acting analogue insulins to achieve

target with minimal fluctuation and lower risk of hypoglycaemia.

Educate carers and relatives regarding risk of hypoglycaemia

DPP-4, Dipeptidyl peptidase-4; NPH, neutral protamine Hagedorn; SGLT-2i, sodium-glucose co-transporter-2 inhibitor; TZD, thiazolidinedione


30

ADA/EASD 2018 consensus for glucose-lowering medication in T2D

*Proven CVD benefit means it has label indication of reducing CVD events. For GLP-1RA strongest evidence for liraglutide>semaglutide>exenatide extended release. For SGLT-2i evidence modestly stronger for empagliflozin>canagliflozin; †Be aware that SGLT-2i vary by

region and individual agent with regard to indicated level of eGFR for initiation and continued use; ‡Both empagliflozin and canagliflozin have shown reduction in HF and reduction in CKD progression in CVOTs; §Degludec or U100 glargine have demonstrated CVD safety; ¶Low dose may be better tolerated though less well studied for CVD effects; ||Choose later generation SU with lower risk of hypoglycaemia; #Degludec / glargine U300<glargine U100 / detemir<NPH insulin; **Semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide; ††If

no specific comorbidities (i.e. no established CVD, low risk of hypoglycaemia and lower priority to avoid weight gain or no weight-related comorbidities); ‡‡Consider country- and region-specific cost of drugs. In some countries, TZDs relatively more expensive and DPP-4i

relatively cheaper

To avoid clinical inertia reassess and

modify treatment regularly

(3–6 months)

Consider the addition of SU|| OR basal insulin:• Choose later generation SU with lower risk of hypoglycaemia• Consider basal insulin with lower risk of hypoglycaemia#

If HbA1c above target If HbA1c above targetIf HbA1c above target

GLP-1RA

TZD

DPP-4i

OR

OR

SGLT-2i†

DPP-4i

GLP-1RA

OR

OR

SGLT-2i†

TZD

OR

SGLT-2i†

TZD

OR

If HbA1c above target

SGLT-2i† TZDGLP-1RADPP-4i

Compelling need to minimise hypoglycaemia

Continue with addition of other agents as outlined above



DPP-4 inhibitors in elderly patients

have been demonstrated to have a

complication rate comparable with

younger patients

Not particularly potent

Relatively well tolerated

31





relatively cheaper



(3–6 months)



GLP-1RA

TZD

DPP-4i

OR

OR

SGLT-2i†

DPP-4i

GLP-1RA

OR

OR

SGLT-2i†

TZD

OR

SGLT-2i†

TZD

OR







GLP1-RA

May reduce risk of stroke more than

alternative glucose lowering

methods (Semaglutide)

Associated with weight loss

Unknown effect on those with

sarcopaenia

32





relatively cheaper



(3–6 months)



GLP-1RA

TZD

DPP-4i

OR

OR

SGLT-2i†

DPP-4i

GLP-1RA

OR

OR

SGLT-2i†

TZD

OR

SGLT-2i†

TZD

OR







SGLT2-I

May be associated with higher stroke

risk (Empagliflozin)

Reduce hospitalisations and delay

death from heart failure (Empagliflozin

& Canagliflozin)

Associated with weight loss


sarcopaenia

May exacerbate symptoms of

diabetes

33





relatively cheaper



(3–6 months)



GLP-1RA

TZD

DPP-4i

OR

OR

SGLT-2i†

DPP-4i

GLP-1RA

OR

OR

SGLT-2i†

TZD

OR

SGLT-2i†

TZD

OR







TZD

Associated with fluid retention

(c.f. heart failure)

Reduces stroke risk (pioglitazone)

Increased fracture risk

May be associated with bladder

cancer


sarcopaenia

Degludec / glargine U300<glargine U100 / detemir<NPH insulin

34

ADA/EASD 2018 consensus for glucose-lowering medication in T2DTo avoid

clinical inertia reassess and


(3–6 months)



GLP-1RA

TZD

DPP-4i

OR

OR

SGLT-2i†

DPP-4i

GLP-1RA

OR

OR

SGLT-2i†

TZD

OR

SGLT-2i†

TZD

OR







Insulins should be considered in order

In CF low dose insulin protects against

sarcopaenia

?Effect in frailty




relatively cheaper

Degludec / glargine U300<glargine U100 / detemir<NPH insulin

35

De-escalation thresholds

Patient characteristics Threshold Suggested interventions

The fit older adult with diabetes 53 mmol/mol (7.0%)

Evaluate long-acting sulphonylurea and insulin therapy that may

cause hypoglycaemia. Consider appropriate dosage in setting of

renal function

Moderate-to-severe frailty 58 mmol/mol (7.5%)

Discontinue any sulphonylurea if HbA1c below threshold. Avoid

TZDs due to risk of heart failure. Cautious use of insulin and

metformin mindful of renal function

Very severe frailty 64 mmol/mol (8.0%)

Withdraw sulphonylureas and short-acting insulins due to risk of

hypoglycaemia. Review suitability of NPH insulin – consider

analogues with lower risk of hypoglycaemia. Therapies that

promote weight loss may exacerbate sarcopaenia

NPH, neutral protamine Hagedorn; TZD, thiazolidinedione


36

NICE quality standards. October 2018

3

Table 1: New indicators added to the NICE indicator menu NICE ID Indicator wording Evidence base Rationale

Diabetes

NM157 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months.

NICE NG17 recommendations 1.6.6 and 1.6.7


The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to enable patients with little comorbidity to benefit from tighter glycaemic control whilst aiming to encourage the personalisation of care for people with moderate or severe frailty.

NM158 The percentage of patients with diabetes with moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months.

NICE NG17 recommendation 1.6.7


The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to reduce complications and improve quality of life for people with moderate or severe frailty.

NM159 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less.


NICE NG28 recommendations 1.4.3, 1.4.5 and 1.4.6

This indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. A focus on people without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit.

NM142 The percentage of patients with type 1 diabetes who are aged over 40 years currently treated with a statin.

NICE CG181 recommendation 1.3.24

This indicator aims to reduce cardiovascular risk and prevent future cardiovascular events.

NM160 The percentage of patients aged 25–84 years, with a diagnosis of type 2 diabetes, without moderate or severe frailty, not currently treated with a statin, who have had a consultation for a cardiovascular risk assessment using a risk assessment tool

NICE CG181 recommendation 1.1.8.

NICE QS100 statement 1.

A focus on CVD risk assessment in people with diabetes without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets through individualised, patient-centred care.

Recognises Frailty as a priority for assessment and different treatments


https://www.nice.org.uk/Media/Default/Standards-and-indicators/indicators-general-practice.pdf (accessed 26/10/18)

https://www.nice.org.uk/Media/Default/Standards-and-indicators/indicators-general-practice.pdf

37



3

Table 1: New indicators added to the NICE indicator menu NICE ID Indicator wording Evidence base Rationale

Diabetes

NM157 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months.



The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to enable patients with little comorbidity to benefit from tighter glycaemic control whilst aiming to encourage the personalisation of care for people with moderate or severe frailty.

NM158 The percentage of patients with diabetes with moderate or severe frailty, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months.



The indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. It aims to reduce complications and improve quality of life for people with moderate or severe frailty.

NM159 The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less.


NICE NG28 recommendations 1.4.3, 1.4.5 and 1.4.6

This indicator allows for an individualised management approach that adjusts care according to an individual’s frailty status. A focus on people without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets in people with the greatest capacity to benefit.

NM142 The percentage of patients with type 1 diabetes who are aged over 40 years currently treated with a statin.

NICE CG181 recommendation 1.3.24

This indicator aims to reduce cardiovascular risk and prevent future cardiovascular events.

NM160 The percentage of patients aged 25–84 years, with a diagnosis of type 2 diabetes, without moderate or severe frailty, not currently treated with a statin, who have had a consultation for a cardiovascular risk assessment using a risk assessment tool

NICE CG181 recommendation 1.1.8.

NICE QS100 statement 1.

A focus on CVD risk assessment in people with diabetes without moderate or severe frailty aims to reduce under-treatment and support better control of biomedical targets through individualised, patient-centred care.

38

Take Home messages

● Managing elderly patients is complicated by

– Multiple Co-morbidities,

– Increased risk from the complications of treatment

– Reduced life expectancy, therefore reduced return

● Treatment should focus on reducing risk of side effects and improving symptoms

39

Thank you for your attention

diabetes in context - bhcic.co.uk › ... › 03 › 190124-kings-inertia-and-elderly-abridge… ·...

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