Newbury Pre Diabetes Project A real-world implementation of QDiabetes in a CCG Area

Tim Walter

Newbury and District CCG

Raise awareness generally

Lifestyle intervention for those at risk

Early identification of those at risk of, or already with DM2 without a diagnosis

Aims of the PreDM Project

My Journey

Newbury Pre-Diabetes Project

Phase 1 Lifestyle Intervention - Surgeries

Phase 2 County Show experience

Phase 3 Targeted screening

As an example to copy/change as you wish

Resources www.predm.co.uk

What to expect from today

Trends at Falkland Surgery

2000 Type 1 DM = 44 Type 2 DM = 150 (194)

2005 Type 1 DM = 56 Type 2 DM = 250 (306)

2008 Type 1 DM = 66 Type 2 DM = 369 (435)

2012 Type 1 DM = 73 Type 2 DM = 399 (472)

12/11/2013 Total 498

The massive increase in DM is predominantly in the Type 2 group

About 3.5% of population

Summary of historic care

1990’s – minimise impact (Symptoms and meds)

2000’s – move to targets and “maximize dose” and identify missed diagnosis

2010’s – earlier diagnosis (seeking borderline results) of pts with IGT, single Random BS readings etc

Inaugural joint 2012-13 winners

Funded by QResearch ( in a joint partnership between Emis, Emis NUG and University of Nottingham)

Prof. Aziz Sheikh of Primary Care Research & Development at the University of Edinburgh – Smoking Cessation

Myself – Pre-Diabetes Project

Plus John Robson and Kambiz Boomla

QInnovation

Nice Guidance

Recent National Institute for Health and Clinical Excellence (NICE) guidance has recommended:

• Identifying people at risk of developing type 2 diabetes, using a

validated risk assessment score and a blood test (fasting blood glucose or HbA1c) to confirm high risk.

• Providing those at high risk with an intensive lifestyle-change

programme to prevent or delay the onset of type 2 diabetes.

Recommendation 3 Developing a local strategy

Recommendation 6 Conveying messages to the local population

Recommendation 8 Promoting a healthy diet: local action

Recommendation 10 Promoting physical activity: local action

Nice PH35 Preventing type 2 diabetes: population and community-level interventions

reduce their weight by more than 5%

keep their fat intake below 30% of energy intake

keep their saturated-fat intake below 10% of energy intake

eat 15 g/1000 kcal of fibre or more

are physically active for at least 4 hours per week.

Finnish Diabetes Prevention Study

QDiabetes Tool

Concept of Pre-Diabetes

Early intervention reduces risk by up to 60% (Finnish Study and DPP in USA)

Lifestyle interventions (E4H) work in the short term

Project looks to combine these to assess practical issues and costs

Components of the project

113,000 - mixed clinical system CCG

Surgery Process, 1st cohort EmisWEB

Instructions to practices to run the bulk QDiabetes module

Identify patients with > 30% 10yr risk

Invitation to have bloods and join E4H Group

Currently ending 2nd Cohort phase, LV and INPS

Starting SystmOne and last EmisWEB practice

Newbury PreDM Project

50 patients invited per practice (8 surgeries) (30-80% risk calculations)

400 in first 2 cohorts

18% uptake

Of those having bloods 14% at diagnostic levels, more with marginal results

E4H – Average 3kg Weight loss, = 110Kg total in 1st cohort

Up to 15Kg loss

1kg =16% risk reduction in DM

Surgery Phase 1st and 2nd Cohort Results

Admin charge 150

E4H staff cost 400

Accommodation 400

Total cost therefore 1000 per practice

Approx benefit – 1DM, average 3kg weight loss per participant, raising profile etc

Surgery Phase - Costs per practice

60,000 attendees

21-22nd September

2 clinicians doing QDiabetes Screening

2 PH Nurses doing HbA1c for those with high scores

3 E4H staff giving advice, BCA and enrolling to E4H Sessions

Newbury Show

Newbury Show Pre-Diabetes Stand During a quiet spell!

Newbury Show Stand

Potential Audience of 60,000

310 Screened via QDiabetes on iPads

111 targeted HbA1c tests done (Approx 1/3rd)

80 Body Fat/Composition Measurements

30 people signed up for E4H classes

5 New diabetics (up to HbA1c = 64) plus 5 HbA1c 42-47

NB Health Promotion vs Detection

Newbury Show - Results

Is it financially worthwhile Breast screening

2 million women

15000 diagnoses

96 million pounds

50 pounds per screen

6000 pounds per diagnosis

Is it financially worthwhile Cervical cancer

5 million invites

3.5 million tests

200,000 abnormals

4000 cancers prevented

175 million pounds

About 1000 pounds per abnormal, and about 40,000 pounds per cancer prevented

Is it financially worthwhile ??? Diabetes – Newbury Show

60,000 attendees

310 screened with QDiabetes

111 HbA1c tests

5 New Diabetics

Cost per diagnosis 1000 pounds

Trial this weekend at Falkland Surgery

266 pts with Risk > 15% (without recent bloods done)

Half invited to POC Saturday Drop-in Clinic

Half Posted letter and blood test form

IF numbers are maintained we expect 5% diagnostic rate, and 5% borderline rate

Phase 3 - Identification

30% predictive risk seems to = 14% current DM

15% predictive risk seems to = 5% current DM

Letter stating numerical risk seems to trigger response in some of them

E4H making significant impact

It is possible to screen surgery populations

It is possible to organize public event

Overall results

Raise awareness generally

Radio Berkshire

Newbury Weekly News and Chronicle

Health Service Journal

Pulse

Newbury Show

60,000 visitors

Aims of the PreDM Project

Lifestyle intervention for those at risk

E4H invitations

550 patients

100 attendees

Potentially 1/3 tonne weight loss!

Aims of the PreDM Project

Early identification of those at risk of, or already with DM2 without a diagnosis Phase 1 - Potentially 14 New DM

Phase 2 – 5 New DM

Phase 3 -Invitation for screening

One practice 266 patients

11 practices 1500 patients? Anticipated pickup rate of 5% in those responding

Possibly 30-70 new diagnoses

Aims of the PreDM Project

Public Health

Indicated they wish to repeat the Lifestyle intervention with E4H across NDCCG

NDCCG

Anticipate asking them to fund the detection arm of the project across the whole CCG population if Falkland Trial successful

The Future

Do you know how many patients have RBS > 11 or FBS > 7 or HbA1c > 47

Have all those patients with RBS > 7 had a recent follow up blood test

Have you reviewed the patients with IGT/IFG recently to see if they have been rechecked (20-50% 10yr conversion)

Challenges for you -Practices

EmisWEB

Activate popups that notify you of possible and probable DM

Consider installing QDiabetes Popup

Consider - Practices

Incentivize the Practices to do the above

Consider how you are responding to NICE Guidance

Identification of those with DM (offer screening for those at 15% risk)

Prevention of DM (targeted E4H lifestyle interventions)

Apply pressure to Software suppliers to integrate risk scoring software in INPS and SystmOne

Challenges - Commissioners

www.predm.co.uk

Thank-you

Tim Walter

Resources

No proof of results (not enough power)

No long term data re weight loss etc.

Cost effectiveness

Need to define your terms!

Rural Berkshire 3.5% prevalence

Actual 5% ? (wide confidence margins)

Caveats

QInnovation – go for it

Surgery actions – resources online

CCG actions – “template” online

Not trying to produce research evidence of effectiveness but template for whether it is possible

Any Questions

www.predm.co.uk

Conclusions