Fifty years of management in primary care MIKE KIRBY Abstract The incidence of has increased exponentially over the last 50 years, meaning that the management of solely by specialist healthcare professionals is no longer feasible. Since the 1970s, primary and community healthcare professionals have increasingly treated patients with. Advances in equipment and new treatments have further enabled patients to be treated more conveniently and this has enhanced their quality of life. There has also been an evolution in health service strategies for notably growing acknowledgement of the benefits of intensive treatment for patients with type 2, as well as type 1, and the now well-recognised importance of effective shared care programmes between primary and secondary healthcare professionals. Thus, the organisation and delivery of care for patients with has improved dramatically since 1952. Key words: shared care, primary care,, history. Introduction Fifty years ago patients with were mostly treated in hospitals by specialists, but the sharp rise in the prevalence of type 2 means that this is no longer practical. Since the 1970s increasing numbers of primary and community healthcare professionals in the UK have assumed responsibility for the routine review, monitoring and management of patients with. There are other reasons for the increased role of primary healthcare professionals in the shared care of contemporary management. New treatments and advances in monitoring and delivery devices have allowed more effective and flexible management strategies. Healthcare professionals are also increasingly aware of the importance of a patient s quality of life, and so attention has become focused on disease management that is more suited to patients lifestyles. Additionally, patients today expect to be actively involved in their treatment, are often Correspondence to: Dr Mike Kirby Director of Hertfordshire Primary Care Research Network (HeartNet), The Surgery, Nevells Road, Letchworth, Hertfordshire, SG6 4TS, UK. Tel: +44 (0)1462 683051; Fax: +44 (0)1462 485650 E-mail: kirbym@globalnet.co.uk Br J Diabetes Vasc Dis 2002;2:457 61 Mike Kirby better informed and are less likely to accept advice unquestioningly from healthcare professionals. Hence, care has evolved and new concepts have been introduced. These include intensive therapy for patients with type 2, as well as for those with type 1. It is also appreciated now that is a cardiovascular disease and that a holistic approach to treating patients, including exercise and life-style changes, is essential to improving patients outcomes and well-being. This approach calls for the close involvement of primary care professionals and, therefore, the idea of shared care for patients between primary and secondary healthcare has gained renewed importance over recent years. Therapeutic advances Oral agents In the 1950s, sulphonylureas were the only oral antidiabetic agents for routine clinical use. They were associated with hypoglycaemia and weight gain, and the American University Group Diabetes Program (1970) suggested that sulphonylureas might aggravate cardiovascular complications. Biguanides entered routine use in the early 1960s, and while they did not cause hypoglycaemia or weight gain, the link with lactic acidosis and withdrawal of phenformin in the late 1970s restricted their use until the revival of metformin in the 1980s and 90s. In the 1990s, the alpha-glucosidase inhibitor acarbose, the metiglinides and the glitazones were introduced. Use of VOLUME 2 ISSUE 6. NOVEMBER/DECEMBER 2002 457
Figure 1. Modern self-monitoring of blood glucose (SMBG) meter Figure 2. Historical glass syringe Permission from Science Photo Library Permission from Science Photo Library acarbose was limited by gastrointestinal intolerance: metiglinides have been viewed as little more than short-acting sulphonylureas although there are subtle mechanistic differences; and glitazones are expensive, cause weight gain and fluid retention and are only as second-line agents. 1 However, these drugs offer a useful choice and should be used sooner rather than later. Insulin therapy Fifty years ago insulin therapy consisted of regular insulin and either neutral protamine Hagedorn (NPH) or the (then) recently Lente class of insulins. 2 All were derived from animals and NPH, Lente and Ultralente were chemically modified to be longer-acting than regular (soluble) insulin. Unfortunately injection regimens with these insulins do not reproduce the daily profile of endogenous insulin. In an attempt to match the physiological insulin profile commercially- mixtures of insulins were produced with different durations of action, and latterly short-acting and longacting insulin analogues have appeared. Other notable advances in insulin therapy, include the production of ultra-pure, monocomponent insulin in 1973, and the manufacture of human insulin in the 1980s using recombinant DNA technology. This allowed the mass production of human insulin and insulin analogues, and resulted in the near disappearance of porcine and bovine insulins. Intensive therapy for patients with type 1 and 2 The Diabetes Control and Complications Trial (DCCT) with type 1 and the United Kingdom Prospective Diabetes Study (UKPDS) with type 2 showed the benefits of tight glycaemic control, using early and intensive therapy, with near-normal glycaemic targets. 3,4 Although patients receiving intensive therapy significantly fewer diabetic complications than patients treated conventionally, both studies noted that intensive therapy caused significantly more treatment-related adverse events, particularly hypoglycaemia and weight gain. These side effects have limited the success of intensive therapy, although short- and long-acting insulin analogues have gone some way to addressing these concerns. Advances in monitoring and insulin delivery devices Blood glucose monitoring In the 1950s patients with had to visit their hospital to obtain accurate blood glucose tests. Urine glucose testing was possible at home, using the Benedict s test, but this was inaccurate and only gave positive results with very high glucose concentrations. Self monitoring of blood glucose (SMBG) meters first became in the UK in the 1970s. The early meters required a significant amount of blood. However, more advanced machines with easy-to-use strips and requiring little blood were soon (figure 1). In the 1980s and 1990s computerised SMBG meters were introduced. SMBG has empowered patients, helping them to take a more active part in their management and lead more normal lives. In the clinic, monitoring of glycaemic control has been greatly facilitated since the 1980s with the use of glycated haemoglobin (HbA 1 and HbA 1C ). Insulin delivery systems One drawback of insulin therapy is the need for injections. However, delivery systems have improved significantly over the last 50 years. In the 1950s syringes were made of glass and required rigorous and time-consuming cleaning between injections (figure 2). The needles themselves were large and made injections painful. Injection guns were as early as 1955. These were the size of revolvers and patients pulled triggers to insert the needle and inject the insulin. In the 1980s dis- 458 THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
Figure 3. Insulin pens Figure 4. Timeline of evolution in therapies and equipment for management Evolution of management Sulphonylureas first used in UK Lente class of insulins introduced Metformin in UK Monocomponent insulin Insulin Recombinant metiglinides and glitazones glargine human insulin produced 2nd generation in the UK sulphonylureas Glimepiride - 3rd generation Insulin aspart sulphonylurea and lispro Three new classes of OHAs introduced: α-glucosidase inhibitors, 1950 1960 1970 1980 1990 2000 Source: OptiPen range 2002 posable plastic syringes became in the UK. Insulin pens were in the 1980s, but were not included on the NHS prescription list until 2000 (figure 3). Not all insulins are yet in pen cartridges, and cartridges are not suitable for patients taking more than one form of insulin. Syringes despite being less convenient remain commonplace. Continuous subcutaneous insulin infusion (CSII) using insulin pumps are unlikely to be used by most patients because they are expensive and require a significant amount of patient education and motivation to monitor glucose concentrations consistently. 5 Injection guns First shared care scheme tried Table 1. Standard 1 SMBG meters introduced in the UK Disposable plastic syringes Computerised SMBG devices Changes to GP contracts for chronic disease management Selected National Service Framework Standards DCCT UKPDS NSF for Diabetes CSII pumps Some insulin pens included on NHS prescription list strategies to reduce the risk of developing type 2 and to reduce the inequalities in the risk of developing type 2 NO mediated anti-aggregation Progression in health service strategies The development of new treatment options and advances in monitoring and delivery equipment were important factors in the evolution of management (figure 4). The growing incidence and burden of type 2 has also contributed to change and has led to the recent development of a National Service Framework (NSF) for to outline expected standards for management. The NSF standards (table 1) were published late last year and their implementation is scheduled to commence by April 2003. Preventing and minimising the complications Programmes to prevent are essential. This demands a holistic approach to management through education initiatives that aim to change the lifestyles of at-risk patients. Diabetes is now recognised as a cardiovascular disease, with a focus being on weight reduction, improving diet and increasing physical activity. Indeed, even modest lifestyle changes can help to delay or prevent type 2. 6 The complications of have severe economic consequences, as well as majorly impacting on the lives of patients. The type 2 Diabetes Accounting for a Major Resource Demand In Society (T2ARDIS) study found that hospitalisation of patients with -associated complications accounts for approximately 41% of overall expenditure, compared with only 2% on Standard 2 Standard 3 Standard 4, 5 & 6 Standard 7 strategies to identify people who do not know they have All patients with will receive a service that encourages partnership in decision-making, supports them in managing their and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process All patients with will receive high-quality care, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of. All children will be supported to optimise their physical, psychological, intellectual, educational and social development. All young people with will experience a smooth transition of care from paediatric services to adult services, whether hospital- or community-based agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained healthcare professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence VOLUME 2 ISSUE 6. NOVEMBER/DECEMBER 2002 459
drug therapy. The same study found that early intervention with intensive treatment strategies (as proposed by the UKPDS and DCCT) could cut the cost of by reducing the risk of complications and, therefore, hospitalisation. 7 To reduce the risk of complications of, the recently-published NICE guidelines for the management of type 2 recommended that: Each patient should be set an HbA 1C target of between 6.5% and 7.5%. Weight loss and increased physical activity should be encouraged in those who are overweight or obese. Healthcare professionals should work with individuals to develop beneficial lifestyle changes in combination with ongoing patient education. A combination of clinical and community-based programmes is needed to implement these health service strategies. Moreover, a collaborative team approach to managing, involving a broad range of healthcare professionals, is essential for these strategies to be put into practice successfully. This will include primary care in the community by GPs and by practice and community nurses who will monitor and review patients, secondary care by diabetologists and specialist nurses, as well as frontline emergency staff. The importance of shared care The high incidence of has necessitated a shift in the traditional relationship of specialist physician/patient relationship. GPs and practice nurses now play a pivotal role in care. The scale of the problem was underlined by a UK study examining the epidemiology of type 2 in the community, which found that of 1,122 individuals, 4.5% had previously undiagnosed and 16.7% had impaired glucose tolerance. 8 Shared care has been defined as "the joint participation of hospital consultants and GPs in the planned delivery of care for patients with a chronic condition". 9 However, this definition needs widening for as input from a broader range of healthcare professionals is required (figure 5). 10 The idea of shared care is not new. It was tried as early as 1953, when health visitors provided a link between hospital clinics and general practices, but the concept has subsequently evolved. General practice-based mini-clinics for started to appear in the early 1970s, but it was changes to the UK GP contract in 1990 and the institution of payment for chronic disease management in primary care in 1993 that really brought about the switch in focus. Today, over 90% of GPs claim fees for care. The aims for shared care programmes for should include early diagnosis, the identification and management of risk factors and diabetic complications, advice on diet, effective blood glucose control, prompt and appropriate referral for specialist advice and the continued education and motivation of patients. 10 The advantages of such initiatives are that they allow the flexible treatment of patients in familiar surroundings and provide a complete treatment approach rather than simply setting glycaemic targets. Potential disadvantages are that no single professional takes Figure 5. Algorithm of shared care schemes in the UK Optometrist Chiropodist Dietician Patient groups (e.g. DUK) Hospital centre Diabetes specialist nurse PATIENT GP and PCT District register Diabetologist and team (Figure 3.1 in Shared care for. Gatling, Hill and Kirby) Ophthalmologist and other specialists full responsibility and those in primary care are generally less accustomed to performing routine follow-up than those in outpatient settings. Additionally, primary care centres may lack the appropriate personnel, and staff may lack the expertise/specialist education to give optimal care. Several studies have investigated the efficacy of shared care for. 11-13 These concluded that good organisational structures for primary care clinics is essential, and it is important that GPs and practice nurses feel supported, and that care is truly shared between primary and secondary care, not simply shifted. A meta-analysis of the effectiveness of care in general practice found that well-organised practices, with computerised central recall and prompts for GPs and patients, achieved standards of care that were similar to or better than hospital care. The authors noted, however, that unstructured primary care is associated with poorer glycaemic control and greater mortality than hospital care. 11 A recent study found that 80% of practices now feel adequately supported and that most have good organisational practices. However, the same study found that more work needs to be done to ensure seamless care across the primary secondary care interface, and suggested the establishment of shared treatment protocols. 12 Similar findings and suggestions were reported by Greenhalgh in her systematic review of shared care programmes, finding them effective only if the system includes a register for patient monitoring, protected time for care, a practice nurse with some experience, a written protocol agreed with the local consultant diabetologist and a system for auditing standards of care. 13 Conclusions The increasing incidence of means that its effective management has become a priority for healthcare professionals and has led to most people with now being treated in general practice rather than hospital outpatient clinics. Advances in equipment and treatments over the last 50 years 460 THE BRITISH JOURNAL OF DIABETES AND VASCULAR DISEASE
Key messages Over the last 50 years the increasing prevalence of has necessitated a switch in focus from secondary to primary care disease management New therapeutic agents and advances in monitoring and delivery systems have also allowed this evolution in management The benefits of early and intensive therapy for patients with type 1 and type 2 are increasingly recognised Diabetes is now appreciated as a cardiovascular disease, as is the importance of risk factor management, especially blood pressure control and lipid management The benefits of a collaborative team approach and sharing of care for patients with between primary and secondary care is widely acknowledged Shared treatment protocols, good organisational structures and auditing are essential to ensure seamless care across the primary secondary care interface have also contributed to this evolution in management and the application of new concepts. These include the increasing recognition of the benefits of intensive therapy for patients with type 2, as well as those with type 1 disease. Additionally, the importance of shared care for is now recognised, as is the need for organisational structures that ensure these programmes are implemented and managed effectively. Diabetes management has changed markedly since 1952 and the next 50 years also promises to see innovative treatments, strategies, and perhaps a cure, for. Editor s note Mike Kirby epitomises the new face of primary care commitment to shared care management. His career has enveloped a wealth of experience within hospital and general practice, enabling a clear perspective on the evolution of current organisational structures for care. References 1. Gale E. Lessons from the glitazones: a story of drug development. Lancet 2001;357:1870-5. 2. Owens DR, Zinman B, Bolli GB. Insulins today and beyond. Lancet 2001;358:739-46. 3. UK Prospective Diabetes Study (UKPDS) Group 33. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2. Lancet 1998;352:837-53. 4. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of on the development and progression of long-term complications in insulin-dependent mellitus. N Engl J Med 1993;329:977-86. 5. Rosenstock J. Insulin therapy: Optimising control in type 1 and type 2. Clin Cornerstone 2001;4:50-64. 6. Narayan KM, Bowman BA, Engelgau ME. Prevention of type 2. BMJ 2001;323:63-4. 7. Type 2 Diabetes Accounting for a Major Resource Demand In Society. Diabetes UK. 2000. Ref Type: Electronic Citation. 8. Williams DRR, Wareham NJ, Wareham NJ et al. Undiagnosed glucose intolerance in the community: the Isle of Ely project. Diabet Med 1995;12:30-5. 9. Hickman M, Drummond N, Grimshaw J. The operation of shared care for chronic disease. Health Bull 1994;52:118-26. 10. Gatling W, Hill R, Kirby M. The shared care concept. Shared care for. Oxford: Isis Medical Media Ltd, 1999:29-36. 11. Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials. BMJ 1998;317:390-6. 12. Pierce M, Agarwal G, Ridout D. A survey of care in general practice in England and Wales. Br J Gen Pract 2000;50:542-5. 13. Greenhalgh PM. Shared care for. A systematic review. 67,1-35. 1994. The Royal College of General Practitioners. Ref Type: Report. VOLUME 2 ISSUE 6. NOVEMBER/DECEMBER 2002 461