DIABETICMedicine DOI: 10.1111/dme.12697
Invited Editorial How does current diabetes care compare with landmark clinical studies? Diabet. Med. 32, 841–842 (2015) Current guidelines for the management of diabetes have been shaped by a number of landmark studies that identified the influence of blood glucose levels, blood pressure and statin medication in reducing the risk of macro- and microvascular complications [1,2]; however, it is well known that there are differences between the results of trials in carefully selected trial populations, who receive treatment according to an unvarying, often resource-intensive protocol and that which is achievable in the ‘real world’, where all people with diabetes receive usual care informed by guidelines. The National Diabetes Audit (NDA) [3] measures the achievement of treatment targets in the majority of people with diabetes in England and Wales. Different approaches to data presentation make direct comparisons between current care, as measured by the NDA, and research studies difficult; however, by selecting people in the NDA with similar characteristics to those recruited for the trials and analysing their data in a similar way to that used by the trials, it is possible to get an insight into the achievements of contemporary diabetes care programmes. Between 1983 and 1989, people aged 13–39 years with Type 1 diabetes of 1–15 years’ duration were enrolled in the Diabetes Control and Complications Trial (DCCT). The findings of this trial and its follow-on observational study, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, confirmed the relationship between blood glucose levels and risk of microvascular disease (chronic kidney disease and retinopathy) [4]. After a mean follow-up of 6.5 years, people allocated to conventional treatment (managing blood glucose levels to prevent symptoms) had a mean HbA1c concentration of 76 mmol/mol (9.1%), whilst those in the intensive treatment group (aiming for an HbA1c concentration in the normal range) had a mean HbA1c concentration of 56 mmol/mol (7.3%) [5]. A broadly similar cohort of 40 807 people with Type 1 diabetes aged 13–39 years, who had been diagnosed for 1–15 years, was drawn from the 2012/2013 NDA dataset. This cohort had a mean HbA1c concentration of 72 mmol/mol (8.7%), roughly similar to the patients in the DCCT receiving conventional treatment. Furthermore, over the past 4 years within the whole NDA there has been no change in the low percentage of people with Type 1 diabetes achieving an HbA1c target of ≤ 58 mmol/mol (7.5%); similarly, in the DCCT intervention group the percentages remain low (28.7% in 2009/2010,
ª 2015 The Authors. Diabetic Medicine ª 2015 Diabetes UK
Cover Image: Digital illustration of autoimmunity © Ingram Publishing. See article of the month “Latent autoimmune diabetes of the adult; current knowledge and uncertainty” by Laugesen et al. (page 843).
28.1% in 2010/2011, 27.0% in 2011/2012, 27.3% in 2012/ 2013) [6]. The UK Prospective Diabetes Study (UKPDS) was established to explore the role of hyperglycaemia on macro- and microvascular complications in people with Type 2 diabetes. It recruited people aged 25–65 years old with newly diagnosed Type 2 diabetes between 1977 and 1991 [7]. The UKPDS showed that more intensive management of blood glucose reduced the future risk of micro- and macrovascular complications in people with Type 2 diabetes. It also highlighted the important role of managing high blood pressure and cholesterol in this group of people. After 10 years’ follow-up, the mean HbA1c in the intensive management group was 53 mmol/mol (7.0%) compared with 63 mmol/mol (7.9%) in the conventional treatment group [8]. A similar cohort of 534 602 people with Type 2 diabetes aged 25–65 years, who had been diagnosed for ≤10 years was drawn from the 2012/2013 NDA dataset. They had a mean HbA1c of 57 mmol/mol (7.4%), i.e. closer to the intensive treatment group in the UKPDS. This NDA cohort also had mean systolic blood pressure of 131.3 mmHg, and mean diastolic blood pressure of 77.7 mmHg with mean total cholesterol of 4.5 mmol/l. For Type 2 diabetes the NDA continues to show slight improvements in the percentage of people achieving a blood pressure of ≤ 140/80 mmHg (61.4% in 2010/2011, 68.7% in 2012/ 2013) but the proportion meeting National Institute for Health and Care Excellence targets for HbA1c (68.4% ≤58 mmol/mol in 2012/2013) and total cholesterol (76.8% < 5 mmol/l in 2012/2013) has remained stable.
841
Invited Editorial N. Holman et al.
DIABETICMedicine
These comparisons suggest that, over the past 15 years, considerable progress has been made in the management of Type 2 diabetes but not of Type 1 diabetes. The treatment outcomes achieved by people with Type 2 diabetes across England and Wales for HbA1c, blood pressure and cholesterol are only slightly higher than those achieved by people in the intensive management group of the UKPDS. By contrast the mean HbA1c of 72 mmol/l (8.7%) among people with Type 1 diabetes is still firmly in the high risk range and not changing. We believe that improvements will require new approaches to care and are especially urgent for Type 1 diabetes. N. Holman1,2, R. Gadsby3, L. Dunn4, C. Sylvester4 and B. Young1,5 1 National Cardiovascular Intelligence Network, Public Health England, York, 2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, 3 Warwick Medical School, University of Warwick, Warwick, 4Clinical Audit, Health and Social Care Information Centre, Leeds, UK and 5Salford Royal Foundation Trust, Salford, UK
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References 1 National Institute for Health and Care Excellence (NICE). Type 1 guideline in adults CG 15. London: NICE, 2004. 2 National Institute for Health and Care Excellence (NICE). Type 2 guideline CG 87. London: NICE, 2009. 3 Health and Social Care Information Centre. National Diabetes Audit Available at: http://www.hscic.gov.uk/nda. Last accessed 7 January 2015. 4 The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group Retinopathy and nephropathy in patients with Type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 2000; 342: 381–389. 5 The Diabetes Control and Complications Trial. The effect of intensive treatment of diabetes on the development and progression of long term complications of insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977–986. 6 NDA Care processes and treatment targets report 2012/13. 7 UK Prospective Diabetes Study Group. UK Prospective Diabetes Study (UKPDS). VIII. Study design, progress and performance Diabetelogia 1991; 34: 877–890. 8 UK Prospective Diabetes Study Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837–853.
ª 2015 The Authors. Diabetic Medicine ª 2015 Diabetes UK
Invited Editorial How does current diabetes care compare with landmark clinical studies? Diabet. Med. 32, 841–842 (2015) Current guidelines for the management of diabetes have been shaped by a number of landmark studies that identified the influence of blood glucose levels, blood pressure and statin medication in reducing the risk of macro- and microvascular complications [1,2]; however, it is well known that there are differences between the results of trials in carefully selected trial populations, who receive treatment according to an unvarying, often resource-intensive protocol and that which is achievable in the ‘real world’, where all people with diabetes receive usual care informed by guidelines. The National Diabetes Audit (NDA) [3] measures the achievement of treatment targets in the majority of people with diabetes in England and Wales. Different approaches to data presentation make direct comparisons between current care, as measured by the NDA, and research studies difficult; however, by selecting people in the NDA with similar characteristics to those recruited for the trials and analysing their data in a similar way to that used by the trials, it is possible to get an insight into the achievements of contemporary diabetes care programmes. Between 1983 and 1989, people aged 13–39 years with Type 1 diabetes of 1–15 years’ duration were enrolled in the Diabetes Control and Complications Trial (DCCT). The findings of this trial and its follow-on observational study, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, confirmed the relationship between blood glucose levels and risk of microvascular disease (chronic kidney disease and retinopathy) [4]. After a mean follow-up of 6.5 years, people allocated to conventional treatment (managing blood glucose levels to prevent symptoms) had a mean HbA1c concentration of 76 mmol/mol (9.1%), whilst those in the intensive treatment group (aiming for an HbA1c concentration in the normal range) had a mean HbA1c concentration of 56 mmol/mol (7.3%) [5]. A broadly similar cohort of 40 807 people with Type 1 diabetes aged 13–39 years, who had been diagnosed for 1–15 years, was drawn from the 2012/2013 NDA dataset. This cohort had a mean HbA1c concentration of 72 mmol/mol (8.7%), roughly similar to the patients in the DCCT receiving conventional treatment. Furthermore, over the past 4 years within the whole NDA there has been no change in the low percentage of people with Type 1 diabetes achieving an HbA1c target of ≤ 58 mmol/mol (7.5%); similarly, in the DCCT intervention group the percentages remain low (28.7% in 2009/2010,
ª 2015 The Authors. Diabetic Medicine ª 2015 Diabetes UK
Cover Image: Digital illustration of autoimmunity © Ingram Publishing. See article of the month “Latent autoimmune diabetes of the adult; current knowledge and uncertainty” by Laugesen et al. (page 843).
28.1% in 2010/2011, 27.0% in 2011/2012, 27.3% in 2012/ 2013) [6]. The UK Prospective Diabetes Study (UKPDS) was established to explore the role of hyperglycaemia on macro- and microvascular complications in people with Type 2 diabetes. It recruited people aged 25–65 years old with newly diagnosed Type 2 diabetes between 1977 and 1991 [7]. The UKPDS showed that more intensive management of blood glucose reduced the future risk of micro- and macrovascular complications in people with Type 2 diabetes. It also highlighted the important role of managing high blood pressure and cholesterol in this group of people. After 10 years’ follow-up, the mean HbA1c in the intensive management group was 53 mmol/mol (7.0%) compared with 63 mmol/mol (7.9%) in the conventional treatment group [8]. A similar cohort of 534 602 people with Type 2 diabetes aged 25–65 years, who had been diagnosed for ≤10 years was drawn from the 2012/2013 NDA dataset. They had a mean HbA1c of 57 mmol/mol (7.4%), i.e. closer to the intensive treatment group in the UKPDS. This NDA cohort also had mean systolic blood pressure of 131.3 mmHg, and mean diastolic blood pressure of 77.7 mmHg with mean total cholesterol of 4.5 mmol/l. For Type 2 diabetes the NDA continues to show slight improvements in the percentage of people achieving a blood pressure of ≤ 140/80 mmHg (61.4% in 2010/2011, 68.7% in 2012/ 2013) but the proportion meeting National Institute for Health and Care Excellence targets for HbA1c (68.4% ≤58 mmol/mol in 2012/2013) and total cholesterol (76.8% < 5 mmol/l in 2012/2013) has remained stable.
841
Invited Editorial N. Holman et al.
DIABETICMedicine
These comparisons suggest that, over the past 15 years, considerable progress has been made in the management of Type 2 diabetes but not of Type 1 diabetes. The treatment outcomes achieved by people with Type 2 diabetes across England and Wales for HbA1c, blood pressure and cholesterol are only slightly higher than those achieved by people in the intensive management group of the UKPDS. By contrast the mean HbA1c of 72 mmol/l (8.7%) among people with Type 1 diabetes is still firmly in the high risk range and not changing. We believe that improvements will require new approaches to care and are especially urgent for Type 1 diabetes. N. Holman1,2, R. Gadsby3, L. Dunn4, C. Sylvester4 and B. Young1,5 1 National Cardiovascular Intelligence Network, Public Health England, York, 2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, 3 Warwick Medical School, University of Warwick, Warwick, 4Clinical Audit, Health and Social Care Information Centre, Leeds, UK and 5Salford Royal Foundation Trust, Salford, UK
842
References 1 National Institute for Health and Care Excellence (NICE). Type 1 guideline in adults CG 15. London: NICE, 2004. 2 National Institute for Health and Care Excellence (NICE). Type 2 guideline CG 87. London: NICE, 2009. 3 Health and Social Care Information Centre. National Diabetes Audit Available at: http://www.hscic.gov.uk/nda. Last accessed 7 January 2015. 4 The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group Retinopathy and nephropathy in patients with Type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 2000; 342: 381–389. 5 The Diabetes Control and Complications Trial. The effect of intensive treatment of diabetes on the development and progression of long term complications of insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977–986. 6 NDA Care processes and treatment targets report 2012/13. 7 UK Prospective Diabetes Study Group. UK Prospective Diabetes Study (UKPDS). VIII. Study design, progress and performance Diabetelogia 1991; 34: 877–890. 8 UK Prospective Diabetes Study Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837–853.
ª 2015 The Authors. Diabetic Medicine ª 2015 Diabetes UK
