Professional Documents
Culture Documents
Where to start?
The Cure
The Cause
Metabolic control
Acute complications (hypoglycaemia, DKA)
Glycaemic variability
Chronic microvascular complications
Quality of life
Mental health
Diabetes distress
Family distress
Cognitive outcomes
Costs of care
Patient satisfaction
Patient empowerment
Discrimination
Does
Knowledge
Evidence
Practice?
1900
1920
1940
1960
1980
2000
1993- DCCT
2020
Mean
HbA1C
Source of data
21 centres
2269 patients
11-18
8.2%
18 centres
1133 patients
<11
32 centres
3353 patients
10-16
8.3%
AdDIT, 2012
Marcovecchio et al Diabetes Care
2014; 37:805-813
14 centres
358 patients
219 centres
5960 patients
8.0%
8-25
8.0%
(mean of
individual
median)
SWEET, 2012
8.5%
Mean HbA1C
Source of data
US (2010-2012)
8.2%
8.2%
8.7%
8.4%
8.5%
US (2012-2013)
1-5
6-12
13-19
1-19
8-25
England (2010-2011)
<25
8.9%
Wales (2010-2011)
<25
8.9%
Denmark (2006)
<18
8.2%
Scotland (2002-2004)
1-15
9.2%
DIABAUD3
Germany/Austria (2009)
<20
8.1%
DPV
France (1998-2007)
5-19
8.2-8.4%
Slovenia (2012)
<22
7.8% (median)
BB: 13->52%
BD/TID: 50->25%
Pump: <1->13%
BD Premix: 33->7%
What do we know?
Funding environments
Subsidized (government/health insurance) insulin?
20/20
20/20
20/20
10/20
Questions:
What are the general barriers to achieving an HbA1C < 7.5%?
What are the specific medical barriers to achieving an HbA1C < 7.5%?
If you could change one thing in your diabetes care team or
practices to improve metabolic outcomes what would it be?
100
90
80
70
60
50
40
30
20
10
0
Characteristics of
medical care
Immutable characteristics
Modifiable characteristics
Cross-sectional, multicentre,
international study n = 2062 (11-18 yrs)
Single parent family HbA1C +0.4%
Ethnic minority HbA1C +0.5%
Poor parental well-being HbA1C +0.3%
Adolescents and parents working together
as an effective team
Stronger
determinant than ...
Hoey Pediatr Diabetes 2009; 10:9-14
Not enough access to diabetes allied health staff (diabetes nurse educators, dietitians etc)
Not enough access to doctors
Demographic and family issues over which the diabetes team have no control
250
200
150
100
50
0
Care delivery
Technology
High SMC
Mod SMC
Low SMC
9
8.5
Passive
Non-Adherent
8
%
7.5
* p <0.001
7
6.5
6
Pre-CSII
3-6 months
12-18 months
What do we do?
- Tasks of self care
- Care delivery
- Technology
Patients in the tight-control group took three to five insulin injections a day or used
a pump with the goal of keeping their blood sugar as close to 6 percent as possible.
They tested their blood four to seven times a day and once a week checked it at 3
A.M. Perhaps most importantly, they worked closely with nurses, dieticians and doctors
who called them on the phone one or more times a week.
Christopher Sabin, 27, who works for Civic Forum Association, a not-for-profit
organization in Manhattan, was a patient in the tight control group at Albert Einstein
Hospital. "The team was the strongest part of the program," he said. "They are really
there to help us through the tough times."
Per 100
patients
Sweden
per 100
patients
RCH per
100
patients
Nurse practitioners
0.08
Nurse managers
0.12
0.06
Administration assistants
0.31
0.06
Doctors
0.48
0.14
0.67
1.0
0.37
Dieticians
0.19
0.5
0.22
Psychologists
0.08
0.2
0.0
Social workers
0.13
0.3
0.09
Exercise physiologists
0.0
Podiatrists
0.003
0.0
Care delivery
Scottish Study Group for the Care of the Young with Diabetes
1997-8 compared to 2002-4, children aged < 15 years
Yes
Slovenian National Registry Data
Dovc et al Diabet Technol Therap 2014; 16:33-40
No
Danish National Registry Data
Nordly et al Diabet Med 2005; 22:1566-73
Svennson et al, Pediatr Diab 2009; 10:461-7
Technology
Hovorka, Cambridge
AP@home consortium
*Collaborating centres
Buckingham,
Stanford
Phillip, Tel Aviv
DREAM
*Collaborating centres
******
* *
Weinzimmer, Yale
PID
**
*
Rabasa-Lhoret, Montral
*Collaborating centres
** **
Medtronic, Northridge
PLGM/PILGRIM
* Collaborating centres
*
*
Damiano, Boston
BPGCS
Kovatchev, Virginia
DiAs- Diabetes Assistant
*Collaborating centres
ISPAD 2014
ISPAD 2024
Population
Mean HbA1C
Source of data
US (2010-2012)
8.2%
8.2%
8.7%
8.4%
8.5%
US (2012-2013)
1-5
6-12
13-19
1-19
8-25
England (2010-2011)
<25
8.9%
Wales (2010-2011)
<25
8.9%
Denmark (2006)
<18
8.2%
Scotland (2002-2004)
1-15
9.2%
DIABAUD3
Germany/Austria (2009)
<20
8.1%
DPV
France (1998-2007)
5-19
8.2-8.4%
Slovenia (2012)
<22
7.8% (median)
12
10
8
6
4
2
0
More usual Psychological Re-design
clinical care
input
initial
(time, visits,
education
staff etc)
(targets etc)
Intensify
insulin
therapy