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EDITORIAL
The Annual Review: Here to Stay One of the aims of the 1989 St Vincent declaration on diabetes care and research in Europe was to reduce the incidence of long-term complications of diabetes.’ It was proposed that effective measures should be implemented for the prevention of these costly complications and a number of 5-year targets were set: new cases of blindness and end-stage renal failure secondary to diabetes should be reduced by a third; gangrene and amputations should be reduced by half. The British Diabetic Association (BDAI subsequently published a document What Diabetic Care to Expect, which is available to any interested person.* This lists the procedures that should be followed at the annual medical review of all diabetic patients. The main part of this review concerns screening for longterm complications, and urinalysis for protein, blood pressure measurement, examination of the legs and feet for neuropathy and vascular disease and fundal examination with dilated pupils should all be carried out at least annually.* In addition to complication screening, assessment of glycaemic control, injection sites, and general well-being are all important components of the review, which has proved to be an efficient and popular approach to diabetes management. It is clear that if the 5-year St Vincent targets are to be achieved (only 2 years now remain), then widespread implementation of the annual review is essential. The recent Budapest meeting reviewed progress in Europe and elsewhere in the 3 years since St Vincentr3 and proposed guidelines for the implementation of the main St Vincent declaration. Professor Keen pointed out at the Budapest meeting that St Vincent was only the beginning, and that the charter should make people realize that the goals can be r e a ~ h e d :the ~ Budapest meeting marked the end of the beginning. He also pointed out that in Europe much remains to be done: there is still much avoidable blindness and there are too many amputations. One of the requirements of the annual review, that of retinopathy screening, was recently tested in a legal case.s A diabetic patient with severe visual impairment cliamed that the clinic doctors had failed to monitor her eyes adequately. Her eminent medical advisers stated that with appropriate and timely treatment, there would have been a 70 % chance of saving her sight. All the
0742-3071/92/1008874l1$05.50 & Sons, Ltd.
0 1992 by John Wiley
advisers were adamant that annual screening of the eyes was essential. This case was settled before trial for f225 000. The BDA i s currently performing an audit of complications screening by sending questionnaires to a large sample of diabetic patients. By this method the impact of the St Vincent declaration and the degree of implementation of a comprehensive annual review screen of diabetic patients will be assessed. The results of this large survey will not be known for some time. In the meantime, surely we must redouble our efforts to ensure that adequate complication screening is offered to all diabetic patients. T ~ Fplace of the examination is unimportant: it could be the diabetes centre, the mini clinic or the traditional clinic. The content of the review is pivotal. In the area of foot screening, for example, many patients have reported ’my feet are fine’ only for the doctor to find a small plantar ulcer on foot inspection.6 Can we honestly expect our high-risk patients to remove their shoes and socks and inspect their feet daily if we fail to do so when they attend the clinic for an occasional review? It remains for all those involved in diabetes care to screen their patients on a regular basis because the St Vincent targets are attainable. The sword of Damocles in the form of legal action might hang over those who ignore such advice.
Andrew J.M. Boulton Manchester, UK
References 1. Diabetes care and research in Eurape: the St Vincent declaration. Diabetic Med 1990; 7: 360. 2. British Diabetic Association, What Diabetic Care to Expecf, London: BDA, 1990, 3 . Krans HMJ,Tarnas C.The Budapest meeting: implementlng
the St Vincent declaratlon, IDF Bulletin 1992; 37: 5-6, 4. Keen H. The St Vincent declaration: historical perspectivesl IDF Bulletln 1992; 37; 7, 5 , Brahams D. Medicine and the law: eye monitoring in diabetes, Lancet 1992; 339: 863464. 6. Sussman KE, Reiber G , Albert SF. The diabetic foot problem-a failed system of health care? Diab Re6 Clin Pract 1992; 17: 1-8.
887 DIABETIC MEDICINE, 1992; 9 : 687
EDITORIAL
The Annual Review: Here to Stay One of the aims of the 1989 St Vincent declaration on diabetes care and research in Europe was to reduce the incidence of long-term complications of diabetes.’ It was proposed that effective measures should be implemented for the prevention of these costly complications and a number of 5-year targets were set: new cases of blindness and end-stage renal failure secondary to diabetes should be reduced by a third; gangrene and amputations should be reduced by half. The British Diabetic Association (BDAI subsequently published a document What Diabetic Care to Expect, which is available to any interested person.* This lists the procedures that should be followed at the annual medical review of all diabetic patients. The main part of this review concerns screening for longterm complications, and urinalysis for protein, blood pressure measurement, examination of the legs and feet for neuropathy and vascular disease and fundal examination with dilated pupils should all be carried out at least annually.* In addition to complication screening, assessment of glycaemic control, injection sites, and general well-being are all important components of the review, which has proved to be an efficient and popular approach to diabetes management. It is clear that if the 5-year St Vincent targets are to be achieved (only 2 years now remain), then widespread implementation of the annual review is essential. The recent Budapest meeting reviewed progress in Europe and elsewhere in the 3 years since St Vincentr3 and proposed guidelines for the implementation of the main St Vincent declaration. Professor Keen pointed out at the Budapest meeting that St Vincent was only the beginning, and that the charter should make people realize that the goals can be r e a ~ h e d :the ~ Budapest meeting marked the end of the beginning. He also pointed out that in Europe much remains to be done: there is still much avoidable blindness and there are too many amputations. One of the requirements of the annual review, that of retinopathy screening, was recently tested in a legal case.s A diabetic patient with severe visual impairment cliamed that the clinic doctors had failed to monitor her eyes adequately. Her eminent medical advisers stated that with appropriate and timely treatment, there would have been a 70 % chance of saving her sight. All the
0742-3071/92/1008874l1$05.50 & Sons, Ltd.
0 1992 by John Wiley
advisers were adamant that annual screening of the eyes was essential. This case was settled before trial for f225 000. The BDA i s currently performing an audit of complications screening by sending questionnaires to a large sample of diabetic patients. By this method the impact of the St Vincent declaration and the degree of implementation of a comprehensive annual review screen of diabetic patients will be assessed. The results of this large survey will not be known for some time. In the meantime, surely we must redouble our efforts to ensure that adequate complication screening is offered to all diabetic patients. T ~ Fplace of the examination is unimportant: it could be the diabetes centre, the mini clinic or the traditional clinic. The content of the review is pivotal. In the area of foot screening, for example, many patients have reported ’my feet are fine’ only for the doctor to find a small plantar ulcer on foot inspection.6 Can we honestly expect our high-risk patients to remove their shoes and socks and inspect their feet daily if we fail to do so when they attend the clinic for an occasional review? It remains for all those involved in diabetes care to screen their patients on a regular basis because the St Vincent targets are attainable. The sword of Damocles in the form of legal action might hang over those who ignore such advice.
Andrew J.M. Boulton Manchester, UK
References 1. Diabetes care and research in Eurape: the St Vincent declaration. Diabetic Med 1990; 7: 360. 2. British Diabetic Association, What Diabetic Care to Expecf, London: BDA, 1990, 3 . Krans HMJ,Tarnas C.The Budapest meeting: implementlng
the St Vincent declaratlon, IDF Bulletin 1992; 37: 5-6, 4. Keen H. The St Vincent declaration: historical perspectivesl IDF Bulletln 1992; 37; 7, 5 , Brahams D. Medicine and the law: eye monitoring in diabetes, Lancet 1992; 339: 863464. 6. Sussman KE, Reiber G , Albert SF. The diabetic foot problem-a failed system of health care? Diab Re6 Clin Pract 1992; 17: 1-8.
887 DIABETIC MEDICINE, 1992; 9 : 687
