Dr Kevin Fernando discusses the updated NICE quality standard on diabetes in adults: education about diabetes can motivate patients and enable self-management
Read this article to learn more about:
- the importance of risk assessment in patients who might develop diabetes and lifestyle changes to prevent diabetes
- structured education programmes for people with diabetes, which can enable them to self-manage their condition
- the impact of foot and limb complications for people with diabetes and the role of healthcare professionals in assessing risk.
Diabetes UK has recently published its report on the State of the nation 2016 (England): time to take control of diabetes, which collates evidence from recent national diabetes audits, encompassing care processes, treatment targets, in-patient care, pregnancy, and foot care.1 This report warns explicitly that diabetes is the fastest-growing medical threat facing our nation, and is of prime public health importance. The report also highlights that there are over 3 million people living with diabetes in England, and around 5 million people are at high risk of developing type 2 diabetes mellitus (type 2 diabetes).1
Allied to this, the recently published NHS Digital report on Prescribing for diabetes in England 2005/06–2015/16 informs us that drugs used in diabetes (British National Formulary section 6.1) now make up 10.6% of total primary care net ingredient costs and 4.6% of all prescription items.2
Management of diabetes
The management of diabetes has become progressively complex and time-consuming, with increasing multimorbidity and polypharmacy. Coupled to this, there has been an explosion in new classes of diabetes medications, with many more in the pipeline, which makes it very challenging to match individual treatment to an individual patient. Patient education still has a pivotal role in the management of diabetes, in order to facilitate the important and necessary lifestyle changes required for self-management.
Appropriate management of diabetes can have a significant impact on both quality of life and longevity, by reducing, or even preventing the potentially devastating and costly microvascular and macrovascular complications of the disease; life expectancy is reduced by up to 15 years in those living with diabetes,3 and cardiovascular disease is responsible for around 50% of deaths in type 2 diabetes.4 Diabetes care accounts for around 10% of NHS expenditure.5
The need for a quality standard for diabetes in adults
The care of people with diabetes varies considerably across the UK; the Committee of Public Accounts (a select committee of the British House of Commons) concluded a report in January 2016 on the management of adult diabetes services in the NHS. It found: 'unacceptable variations in the take up of education programmes, delivery of recommended care processes, achievement of treatment standards, and in outcomes for diabetes patients'.6 This disparity in care leads to a 'postcode lottery' in the provision of quality care for people with diabetes.
NICE quality standard
NICE originally published its Quality Standard (QS6) for Diabetes in adults3 in March 2011. It comprised a set of specific and measurable statements, developed from the best available evidence, which addressed clinical effectiveness, patient safety, and patient experience in adults living with diabetes. NICE quality standards help healthcare and social care practitioners to focus on evidence-based, priority areas of care and can inform patients what to expect from their care providers. Furthermore, these quality standards guide NHS trusts and commissioners in assessing the standards of care they provide, and redressing the variation seen in diabetes care throughout the UK.
In August 2016, NICE QS6 was updated to take into account new evidence,3 and also the recently published suite of NICE diabetes guidelines, including NICE Guideline (NG) 17 on Type 1 diabetes in adults: diagnosis and management (August 2015),7 NICE NG28 on Type 2 diabetes in adults: management (December 2015),8 and NICE NG19 on Diabetic foot problems: prevention and management (August 2015).9 NICE QS6 was earmarked for update after an annual review of all NICE quality standards during 2014, which identified significant changes in several areas of improvement for diabetes in adults.
The quality statements
Of the 13 statements in the original version of NICE QS6, many were no longer considered national priorities for improvement, but were thought to perhaps still have a role at a local level. NICE updated five statements and added two, resulting in a total of seven statements in the updated QS6. These statements are listed in Table 1(see below).
|1||Adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme. [new 2016]|
|2||Adults with type 2 diabetes are offered a structured education programme at diagnosis. [2011, updated 2016]|
|3||Adults with type 1 diabetes are offered a structured education programme 6–12 months after diagnosis. [2011, updated 2016]|
|4||Adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy. [new 2016]|
|5||Adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service. [2011, updated 2016]|
|6||Adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment. [2011,updated 2016]|
|7||Adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes. [2011, updated 2016]|
|National Institute for Health and Care Excellence (2011, updated 2016). Diabetes in adults. NICE Quality Standard 6.
NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken.
The updated quality standard is expected to contribute to improvements in the following outcomes:3
- incidence of type 2 diabetes
- control of blood glucose levels
- cardiovascular risk
- incidence of complications
- rates of ulceration, infection, complications, and amputation of feet and lower limbs
- hospital admissions and readmissions
- quality of life
- life expectancy.
Preventing type 2 diabetes—statement 1
A recently published study suggested that more than one-third of adults in England are at high risk of type 2 diabetes and this prevalence has tripled over the past 8 years.10 This was a cross-sectional study and therefore it was not possible to identify how many of these people progressed to type 2 diabetes. Furthermore, the lower American Diabetes Association (ADA) criteria were used to define risk of type 2 diabetes, which will have contributed to this high prevalence figure.
Nevertheless, there is overwhelming evidence from international large-scale diabetes prevention studies11,12 that lifestyle changes can delay or prevent type 2 diabetes and its complications. This forms the basis of the recently launched NHS Diabetes Prevention Programme13—a collaboration between NHS England, Public Health England, and Diabetes UK. In August 2015, Public Health England published a systematic review demonstrating that programmes similar to the NHS Diabetes Prevention Programme can be successful in preventing 26% of people at high risk of type 2 diabetes progressing to overt type 2 diabetes.14
Healthcare practitioners (HCPs) undertaking diabetes risk assessments should ensure that they use a validated risk assessment tool such as QDiabetes-2015®15, as endorsed in NICE Public Health Guideline 38 Type 2 diabetes: prevention in people at high risk16). Adults at high risk of type 2 diabetes should be offered a referral to an intensive lifestyle-change programme.
Structured education programmes for adults with diabetes—statements 2 and 3
Structured education programmes can help adults with diabetes improve their knowledge, and also motivate and empower them to take control of their condition and self-manage it effectively. This will result in a significant impact on quality of life. Some example programmes are:
- for type 2 diabetes:
- for type 1 diabetes:
Specifically, adults with type 1 diabetes need to acquire a large range of new skills and knowledge, such as how to manage their insulin therapy, and they will benefit from more intensive structured education once they have adjusted to their new diagnosis.
Good evidence now exists for the benefits of structured education, which demonstrates clinical effectiveness and cost-effectiveness;17 however, access to structured education is disparate throughout the UK, partly as a result of financial restrictions limiting availability in many areas. These statements encourage an increase in the provision of such programmes, and subsequent patient attendance. Commissioners and service providers should prioritise spending on structured education.
HbA1c goals, medications, and care planning—statements 4 and 7
Currently, primary care practices perform annual reviews for adults with diabetes to monitor for complications, and then manage these complications appropriately. These quality statements support high-quality, patient-based diabetes care, drawing on the latest evidence, including the recently published NICE NG28 Type 2 diabetes in adults: management (December 2015)8 and NICE NG17 Type 1 diabetes in adults: diagnosis and management (August 2015).7
Quality statement 4 encourages first intensification of treatment to dual therapy at an HbA1c level of 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment, aiming for an HbA1c target of 53 mmol/mol (7.0%). NICE QS6 suggests that practitioners consider dual therapy with:3
- metformin and a dipeptidyl peptidase (DPP)-4 inhibitor or
- metformin and pioglitazone or
- metformin and a sulfonylurea.
If metformin is not tolerated or is contraindicated, practitioners should consider dual therapy with:
- a DPP-4 inhibitor and pioglitazone or
- a DPP-4 inhibitor and a sulfonylurea or
- pioglitazone and a sulfonylurea.
Some patients with type 2 diabetes may benefit from combination therapy with medications including sodium-glucose cotransporter 2 (SGLT-2) inhibitors,3 and NICE Technology Appraisal (TA) 315,18 TA288,19 and TA33620 cover this.
Good glucose control protects against microvascular and macrovascular disease, and also reduces the osmotic symptoms of diabetes. There is robust evidence21 extolling the benefits of early tight glycaemic control in type 2 diabetes in preventing microvascular complications; however, this came at the expense of increased hypoglycaemia.21 Furthermore, a 'legacy' effect is demonstrated, whereby the benefits of tight glycaemic control in those adults with type 2 diabetes extend beyond a finite period of early intensive treatment; however, HbA1c targets must be individualised to ensure that the benefits of treatment outweigh any harms. There is also evidence from the USA suggesting that in older, high-risk patients with established cardiovascular disease or additional cardiovascular risk factors, too tight glycaemic control can lead to an increase in diabetes complications, particularly hypoglycaemia and macrovascular disease.22
Quality statement 7 recommends that all adults with type 1 diabetes in hospital receive advice from a multidisciplinary team (MDT) with expertise in diabetes. This specialist MDT can help patients with type 1 diabetes understand how best to adapt management of their diabetes when in hospital. Furthermore, in-patients with type 1 diabetes should be supported to continue to self-manage their diabetes, and to administer their own insulin, if they are willing and able and it is safe for them to do so. Input from a specialist MDT team can reduce the length of hospital stay for adults with type 1 diabetes, and improve their experience of hospital admission.
Prevention and management of diabetic foot problems—statements 5 and 6
Quality statements 5 and 6 recommend that those adults with diabetes who are at moderate or high risk of developing a diabetic foot problem should be referred to a foot protection service; those with a limb-threatening or life-threatening diabetic foot problem should be referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service should be informed. These were key priorities for implementation in NG19 Diabetic foot problems: prevention and management (August 2015).9
Foot complications are common in diabetes: 1 in 10 patients with diabetes will experience a diabetic foot ulcer at some point in their lifetime. Diabetes is the commonest cause of non-traumatic limb amputation, and there is a preceding foot ulcer in over 80% of amputations in those with diabetes.9 After a first amputation, patients with diabetes are twice as likely to need a second amputation compared with the general population. Mortality rates are high after diabetic foot ulceration and amputation: up to 70% of people die within 5 years of an amputation, and around 50% die within 5 years of developing a diabetic foot ulcer. Diabetic foot problems impose a significant financial strain on the NHS: an NHS Diabetes report published during 2012 estimated around £650 million is spent on foot ulcers or amputations each year.9
It is important therefore that HCPs (podiatrists, GPs, practice nurses, and district nurses) undertaking foot risk assessments in patients with diabetes, should ensure that those individuals who are at moderate or high risk of developing a diabetic foot problem are referred to the local foot protection service. People with limb-threatening or life-threatening diabetic foot problems should be referred urgently for same-day hospital assessment, and the multidisciplinary foot care service should be informed. All those undertaking foot risk assessments should ensure they have completed relevant training to ensure their competence, such as that commissioned by the Scottish Government, the Foot Risk Awareness and Management Education project (FRAME).
From a primary care perspective, the key priorities for implementation include ensuring prompt referral for structured education for all those newly diagnosed with type 1 and type 2 diabetes. Furthermore, those identified to be at high risk of type 2 diabetes should be offered referral to an intensive programme aimed at making suitable lifestyle changes.
The main barrier here is that access to such structured education and lifestyle programmes is inconsistent throughout the UK therefore limiting availability in many areas. The provision of such services should be a key priority for commissioners and service providers.
Primary care practitioners need to remain vigilant for the potentially debilitating and fatal complications of diabetic foot disease, and refer promptly to local foot protection services if there are any significant concerns. A key challenge here is to ensure that all HCPs in primary care looking after individuals with diabetes are adequately trained to ensure their competence in assessing the risk of diabetic foot disease.
- Diabetes is the fastest growing medical threat facing our nation, and is of prime public health importance
- Appropriate management of diabetes can have a significant impact on both quality and quantity of life; however, the care of those with diabetes varies considerably across the UK
- NICE has updated its quality standard for adults living with diabetes to improve clinical effectiveness, patient safety, and patient experience, as well to improve consistency of diabetes care across the UK
- Large-scale international studies have shown that lifestyle changes can delay or prevent type 2 diabetes and its complications
- Healthcare professionals should use a validated risk assessment tool (such as QDiabetes-2015) to assess an individual's risk of developing diabetes
- Structured education programmes can help adults with diabetes improve their knowledge of the disease, and also motivate and empower them to take control of their condition, and self-manage it effectively, which can have a significant impact on quality of life
- Foot complications are common in diabetes: 1 in 10 people with diabetes will suffer a diabetic foot ulcer at some point in their lifetime, and diabetes is the commonest cause of non-traumatic limb amputation
- All HCPs undertaking foot risk assessments should ensure they have completed relevant training to ensure their competence
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- CCGs should:
- check their performance against NICE QS6 in a baseline assessment and ensure that key elements, like patient education and podiatry services, are effectively commissioned
- prepare to implement the NHS Diabetes Prevention Programme in their areas if they have applied to be part of the second wave (submission deadline was Monday 3 October 2016)
- publish local formulary choices for anti-diabetic medication, and support practices to follow NICE guidance in withdrawing medication when therapeutic goals have not been met, as some therapies are very expensive
- QOF data and information from the National Diabetes Audit can provide detailed analysis of current performance at individual practice level, allowing for targeted support
- Foot care is especially important and effective local care pathways should be in place, ensuring that all people at high or moderate risk of developing diabetic foot problems are referred promptly to podiatry services.
QS=quality standard; QOF=quality and outcomes framework
- Diabetes UK. State of the nation 2016 (England): time to take control of diabetes. Available at: www.diabetes.org.uk/About_us/What-we-say/Statistics/State-of-the-Nation-2016-Time-to-take-control-of-diabetes/
- NHS Digital. Prescribing for diabetes, England—2005/06 to 2015/16. Available at: digital.nhs.uk/catalogue/PUB21158
- NICE. Diabetes in adults. NICE Quality Standard QS6.NICE 2016. Available at: www.nice.org.uk/qs6
- An Y, Zhang P, Wang J et al. Cardiovascular and all-cause mortality over a 23-year period among Chinese with newly diagnosed diabetes in the Da Qing IGT and diabetes study. Diabetes care 2015; 38 (7): 1365-1371.
- Hex N, Bartlett C, Wright D et al. Estimating the current and future costs of type 1 and type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med 2012; 29: 855–862.
- Public Accounts Committee. Management of adult diabetes services in the NHS: progress review. January 2016. Available at: www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/inquiries/parliament-2015/management-adult-diabetes-services-in-nhs-progress-review-15-16/
- NICE. Type 1 diabetes in adults: diagnosis and management. NICE Guideline 17. NICE, 2015. Available at: www.nice.org.uk/ng17
- NICE. Type 2 diabetes in adults: management. NICE Guideline 28. NICE, 2015. Available at: www.nice.org.uk/guidance/ng28
- NICE. Diabetic foot problems: prevention and management. NICE Guideline 19. NICE, 2015. Available at: www.nice.org.uk/ng19
- Mainous III A, Tanner R, Baker R et al. Prevalence of prediabetes in England from 2003 to 2011: population-based, crosssectional study. BMJ Open 2014; 4 (6): e005002
- Lindström J, Peltonen M, Eriksson J et al. Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia 2013; 56 (2): 284–293.
- Guanwei L, Zhang P, Wang J et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes Endocrinol 2014; 2 (6): 474–480.
- NHS Diabetes Prevention Programme(NHS DPP).www.england.nhs.uk/ourwork/qualclin-lead/diabetes-prevention/ (accessed 19 September 2016)
- Public Health England. A systematic review and meta-analysis assessing the effectiveness of pragmatic lifestyle interventions for the preventionof type 2 diabetes mellitus in routine practice. Available at: www.gov.uk/government/publications/diabetes-prevention-programmes-evidence-review
- ClinRisk. QDiabetes®-2015 risk calculator. ClinRisk, 2015. Available at: www.qdscore.org (accessed 4 October 201).
- NICE. Type 2 diabetes: prevention in people at high risk. NICE Public Health Guideline 38. NICE, 2012. Available at: www.nice.org.uk/ph38
- Carey M, Khunti K, Davies M. Structured education in diabetes: a review of the evidence. Diabetes & Primary Care 2012; 14 (3): 154–162.
- NICE. Canagliflozin in combination therapy for treating type 2 diabetes. NICE Technology Appraisal 315. NICE 2014. Available at: www.nice.org.uk/ta315
- NICE. Dapagliflozin in combination therapy for treating type 2 diabetes. NICE Technology Appraisal 288. NICE 2013. Available at: www.nice.org.uk/ta288
- NICE. Empagliflozin in combination therapy for treating type 2 diabetes. NICE Technology Appraisal 336. NICE 2015. Available at:www.nice.org.uk/ta336
- UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352 (9131): 837–853. (Erratum in: Lancet 1999; 354 (9178): 602.)
- The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358 (24): 2545–2559. G