Emerging standards for diabetes care from a city-wide primary care audit

An estimation of the long-term clinical and economic benefits of insulin lispro in Type 1 diabetes in the UK

AIMS

To determine the long-term health economic benefits associated with lispro vs. regular human insulin (RHI) in UK Type 1 diabetic (T1DM) patients using the previously published and validated CORE Diabetes Model.

METHODS

A literature review designed to capture clinical benefits associated with lispro and T1DM cohort characteristics specific to UK was undertaken. Clinical benefits were derived from a Cochrane meta-analysis. The estimated difference (weighted mean) in glycated haemoglobin (HbA(1c)) was -0.1% (95% confidence interval -0.2 to 0.0%) for lispro vs. RHI. Severe hypoglycaemia rates for lispro and RHI were 21.8 and 46.1 events per 100 patient years, respectively. Costs and disutilities were accounted for severe hypoglycaemia rates. All costs were accounted in 2007 poundUK from a National Health Service (NHS) perspective. Future costs and clinical benefits were discounted at 3.5% annually.

RESULTS

In the base-case analysis, lispro was projected to be dominant compared with RHI. Lispro was associated with improvements in quality-adjusted life expectancy (QALE) of approximately 0.10 quality-adjusted life years (QALYs) vs. RHI (7.60 vs. 7.50 QALYs). Lifetime direct medical costs per patient were lower with lispro treatment, pound70 576 vs. pound72 529. Severe hypoglycaemia rates were the key driver in terms of differences in QALE and lifetime costs. Sensitivity analyses with assumptions around time horizon, discounting rates and benefits in terms of glycaemic control or hypoglycaemic event rates revealed that lispro remained dominant.

CONCLUSIONS

Our findings suggest that lispro is likely to improve QALE, reduce frequency of diabetes-related complications and lifetime medical costs compared with RHI.

Estimating the long-term cost-effectiveness of exenatide in the United States: an adjunctive treatment for type 2 diabetes mellitus

OBJECTIVES

This analysis provides an early estimate of the cost-effectiveness of adjunctive exenatide in treating type 2 diabetes mellitus in the United States. Data from pivotal phase III 30-week clinical trials and 52 weeks of their subsequent open-label extension studies (i.e., 82 weeks total) were used to project the effects of 30 years of adjunctive exenatide treatment.

METHODS

This analysis utilized a published and validated Markov model incorporating Monte Carlo simulation with tracker variables to estimate the clinical and cost outcomes of adding exenatide to a background of metformin and/or sulfonylurea treatment, with the effects of 30 years of adjunctive exenatide treatment (projected from data from 82 weeks of exenatide treatment) compared with no additional treatment beyond metformin and/or a sulfonylurea. Sensitivity analyses were performed on key clinical assumptions, discount rates, and shorter time horizons.

RESULTS

The base-case scenario (30 years of exenatide) yielded an incremental cost-effectiveness ratio (ICER) of $35,571. We found that shortening the time horizons and removing the lipid effects of exenatide had the greatest negative impact on ICERs when performing sensitivity analysis.

CONCLUSIONS

Our analysis demonstrated that exenatide used for 20 or 30 years compared with no additional treatment beyond metformin and/or a sulfonylurea is cost-effective in the adjunctive treatment of type 2 diabetes with an ICER less than $50,000 per life-year gained. Sensitivity analyses suggest that, in addition to sustained reduction in HbA(1c), the added clinical effects of improved lipid values, systolic blood pressure, and reduced body mass index all positively contributed to the cost-effectiveness of exenatide.

Insulin therapy in type 2 diabetes patients failing oral agents: cost-effectiveness of biphasic insulin aspart 70/30 vs. insulin glargine in the US

OBJECTIVES

To project the long-term clinical and economic outcomes of treatment with biphasic insulin aspart 30 (BIAsp 70/30, 30% soluble and 70% protaminated insulin aspart) vs. insulin glargine in insulin-naïve type 2 diabetes patients failing to achieve glycemic control with oral antidiabetic agents alone (OADs).

METHODS

Baseline patient characteristics and treatment effect data from the recent 'INITIATE' clinical trial served as input to a peer-reviewed, validated Markov/Monte-Carlo simulation model. INITIATE demonstrated improvements in HbA1c favouring BIAsp 70/30 vs. glargine (-0.43%; p < 0.005) and greater efficacy in reaching glycaemic targets among patients poorly controlled on OAD therapy. Effects on life expectancy (LE), quality-adjusted life expectancy (QALE), cumulative incidence of diabetes-related complications and direct medical costs (2004 USD) were projected over 35 years. Clinical outcomes and costs were discounted at a rate of 3.0% per annum. Sensitivity analyses were performed.

RESULTS

Improvements in glycaemic control were projected to lead to gains in LE (0.19 +/- 0.24 years) and QALE (0.19 +/- 0.17 years) favouring BIAsp 70/30 vs. glargine. Treatment with BIAsp 70/30 was also associated with reductions in the cumulative incidences of diabetes-related complications, notably in renal and retinal conditions. The incremental cost-effectiveness ratio was $46 533 per quality-adjusted life year gained with BIAsp 70/30 vs. glargine (for patients with baseline HbA1c >/= 8.5%, it was $34 916). Total lifetime costs were compared to efficacy rates in both arms as a ratio, which revealed that the lifetime cost per patient treated successfully to target HbA1c levels of <7.0% and </= 6.5% were $80 523 and $93 242 lower with BIAsp 70/30 than with glargine, respectively.

CONCLUSIONS

Long-term treatment with BIAsp 70/30 was projected to be cost-effective for patients with type 2 diabetes insufficiently controlled on OADs alone compared to glargine. Treatment with BIAsp 70/30 was estimated to represent an appropriate investment of healthcare dollars in the management of type 2 diabetes.

Continuous subcutaneous insulin infusion versus multiple daily injections of insulin: economic comparison in adult and adolescent type 1 diabetes mellitus in Australia

BACKGROUND

Recent meta-analyses in the published medical literature have found improved glycaemic control with continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) of insulin for patients with diabetes mellitus. In Australia, CSII is predominantly used in type 1 diabetes mellitus (T1DM) patient populations. OBJECTIVE/INTERVENTION: To project long-term costs and outcomes of CSII (Novorapid or Humalog) compared with MDI (NPH insulin plus Novorapid or Humalog) in adult and adolescent T1DM patients in Australia.

METHODS

The study was a modelling analysis utilising a lifetime horizon in adult and adolescent specialty care T1DM patient populations from Australia. Published Australian diabetes complication costs (adjusted to Australian dollars [$A], year 2006 values), treatment costs and discount rates of 5.0% per annum were applied to costs and clinical outcomes. A lifetime horizon was taken, considering only direct medical costs and excluding indirect and non-medical costs. The validated CORE diabetes model employs standard Markov/Monte Carlo simulation techniques. It was used to simulate diabetes progression in Australian adult (mean age 43 years, duration of diabetes 17 years, mean glycosylated haemoglobin [HbA(1c)] 8.2%) and adolescent (mean age 17 years, duration of diabetes 6 years, mean HbA(1c) 8.9%) patients with baseline characteristics taken predominantly from Australian National Diabetes Information Audit and Benchmarking (ANDIAB) in Australia. The main outcome measures were incremental costs and effectiveness of CSII compared with MDI in Australian adult and adolescent patients with T1DM.

RESULTS

Mean direct lifetime costs were $A34,642 higher with CSII treatment than with MDI for adult patients and $A41,779 higher for adolescent patients. Treatment with CSII was associated with an improvement in life expectancy of 0.393 years for adults compared with MDI and 0.537 years for adolescents. The corresponding gains in QALYs were 0.467 QALYs and 0.560 QALYs for adults and adolescents, respectively. This produced incremental cost effectiveness ratios (ICERs) of $A88,220 and $A77,851 per life-year gained for CSII compared with MDI for adult and adolescent T1DM patients, respectively, in Australia. These data also produced corresponding ICERs of $A74,147 per QALY and $A74,661/QALY for adult and adolescent T1DM patients, respectively. Sensitivity analyses suggested that our base-case assumptions were mostly robust with improvements in ICERs for reduction in hypoglycaemic events with CSII treatment and worse ICERs for lower HbA(1c) changes associated with CSII treatment compared with MDI.

CONCLUSIONS

Our analysis suggests that CSII is associated with ICERs in the range of $A53,022-259,646 per QALY gained, with most ICERs representing good value for money in Australia under the majority of scenarios explored.

Cost-utility analysis in a UK setting of self-monitoring of blood glucose in patients with type 2 diabetes

BACKGROUND

Self-monitoring of blood glucose (SMBG) in type 2 diabetes patients has been shown in meta-analyses of randomized trials to improve HbA(1c) by approximately 0.4% when compared to no SMBG. However, the cost of testing supplies is high, improvements in health utility due to improved glycaemic control may be possible and cost-effectiveness has not been evaluated.

METHODS

A peer-reviewed validated model projected improvements in lifetime quality-adjusted life years (QALYs), long-term costs and cost-effectiveness of SMBG versus no SMBG. Markov/Monte Carlo modelling simulated the progression of complications (cardiovascular, neuropathy, renal and eye disease). Transition probabilities and HbA(1c)-dependent adjustments came from the United Kingdom Prospective Diabetes Study (UKPDS) and other major studies. Effects of SMBG on HbA(1c) came from clinical studies, meta-analyses and population studies, but can only be considered 'moderate' levels of evidence. Costs of complications were retrieved from published sources. Direct costs of diabetes complications and SMBG were projected over patient lifetimes from a UK National Health Service perspective. Outcomes were discounted at 3.5% annually. Extensive sensitivity analyses were performed.

RESULTS

Depending on the type of diabetes treatment (diet and exercise/oral medications/insulin), improvements in glycaemic control with SMBG improved discounted QALYs anywhere from 0.165 to 0.255 years, with increased total costs of 1013 pounds sterlings- 2564 pounds sterlings/patient, giving incremental cost-effectiveness ratios of 4508 pounds sterlings: 15,515 pounds sterlings/QALY gained, well within current UK willingness-to-pay limits. Results were robust under a wide range of plausible assumptions.

CONCLUSIONS

Based on the moderate level of clinical evidence available to date, improvements in glycaemic control with interventions, including SMBG, can improve patient outcomes, with acceptable cost-effectiveness ratios in the UK setting.

Health-economic comparison of continuous subcutaneous insulin infusion with multiple daily injection for the treatment of Type 1 diabetes in the UK

OBJECTIVES

The aim of this study was to project the long-term costs and outcomes of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) in patients with Type 1 diabetes in the UK.

METHODS

The CORE Diabetes Model is a peer-reviewed, validated model which employs standard Markov/Monte Carlo simulation techniques to describe the long-term incidence and progression of diabetes-related complications. It was used to simulate disease progression in a cohort of patients with baseline characteristics taken from published UK studies (mean age 26 years, duration of diabetes 12 years, mean HbA1c 8.68%). Direct costs for 2003 were calculated from a third-party payer perspective. Discount rates of 3.0% per annum were applied to costs and clinical outcomes.

RESULTS

Treatment with CSII was associated with an improvement in mean quality adjusted life expectancy (QALE) of 0.76 +/- 0.19 years compared with MDI (12.03 +/- 0.15 vs. 11.27 +/- 0.14 years). Mean direct lifetime costs were pounds 19,407 +/- 1727 higher with CSII treatment compared with MDI (pounds 80,511 +/- 1257 vs. pounds 61,104 +/- 1249). This produced an incremental cost-effectiveness ratio (ICER) of pounds 25,648 per quality-adjusted life year (QALY) gained with CSII vs. MDI. The results were most sensitive to variation in hypoglycaemia rates and altering improvements in HbA1c associated with CSII therapy compared with MDI.

CONCLUSIONS

Improvements in glycaemic control associated with CSII over MDI led to improved QALE owing to reduced incidence of diabetes-related complications. CSII was associated with an ICER of pounds 25,648 per QALY gained vs. MDI, representing good value for money by current standards in the UK.

Cost-effectiveness of detemir-based basal/bolus therapy versus NPH-based basal/bolus therapy for type 1 diabetes in a UK setting: an economic analysis based on meta-analysis results of four clinical trials

BACKGROUND

A meta-analysis of results from four clinical trials in type 1 diabetes patients showed that insulin detemir (IDet)-based basal/bolus treatment of type 1 diabetes led to improved HbA1c (0.15%-points lower), reduced risk of major hypoglycaemic events (by 2%) and reduction in body mass index (BMI) (0.26 kg/m2) compared to protamine Hagedorn human (NPH) insulin-based basal/bolus therapy in type 1 patients.

METHODS

A published, validated, peer-reviewed Markov simulation model (the CORE Diabetes Model) projected short-term results obtained from the fixed-effects (weighted average) meta-analysis to long-term incidence of complications, improvements in quality-adjusted life years (QALY), long-term costs and the cost-effectiveness for IDet combinations versus NPH combinations in type 1 diabetes patients. Probabilities of complications and HbA1c-dependent adjustments were derived from the DCCT and other studies. Costs of treating complications in the UK were retrieved from published sources. Total direct costs (complications + treatment costs) for each arm were projected over patient lifetimes from a UK National Heath Service perspective. Both costs and clinical outcomes were discounted at 3.5% annually.

RESULTS

Improved glycaemic control, decreased hypoglycaemic events and BMI with IDet-based basal/bolus therapy led to fewer diabetes-related complications, an increase in quality-adjusted life expectancy of 0.09 years, increased total lifetime costs/patient of 1707 pounds sterling and an incremental cost-effectiveness ratio of 19,285 pounds sterling per QALY gained. Results were stable under a wide range of reasonable assumptions.

CONCLUSIONS

Short-term improvements seen with IDet combinations versus NPH combinations led to decreased complications, improvements in QALYs and reductions in complication costs, which partially offset the additional costs of detemir, leading to a cost-effectiveness ratio which fell within a range considered to represent excellent value for money (< 35,000 pounds sterling/QALY gained).

Sustainability and effectiveness of comprehensive diabetes care to a district population

AIMS

To evaluate whether diabetes care in a district population can be sustained over time and intensive management of multiple risk factors can be achieved against a background of rising prevalence of known diabetes and shift of responsibility towards primary care.

METHODS

Assessment of process and outcome measures achieved by a comprehensive diabetes service. Routine data were collected from patients registered with diabetes in a district population by repeated cross-sectional survey in 1991 (n = 2284 patients) and 2001 (n = 5809 patients).

RESULTS

Between 1991 and 2001 the recording of body mass index (76.8 vs. 71.3%, P = 0.01) and HbA(1c) measurement (92.2 vs. 86.4%, P < 0.001) decreased, whereas recording of smoking status (72.4 vs. 82%, P < 0.001), cholesterol level (54.7 vs. 82.5%, P < 0.001) and eye screening result (86.1 vs. 91.3%, P < 0.001) improved. Surviving patients with Type 2 diabetes had significant improvements in systolic blood pressure, diastolic blood pressure and cholesterol, significant deterioration in HbA(1c) and creatinine, and no change in body mass index. Changes in blood pressure and HbA(1c) over time were similar to those reported in the UKPDS.

CONCLUSIONS

The delivery of processes and outcomes of care to a district population can be sustained at a high level over a 10-year period within a comprehensive diabetes service. We would suggest that a multifaceted complex intervention is required to achieve these results.

European comparison of costs and quality in the prevention of secondary complications in Type 2 diabetes mellitus (2000-2001)

AIMS

To compare the out-patient costs and process quality of preventing secondary complications in patients with Type 2 diabetes mellitus in France, Germany, Italy, The Netherlands, Sweden, Switzerland, and the UK.

METHODS

A total of 188 European physician practices assessed annual services for one hypothetical average patient (cost evaluation) and 178 practices reported retrospective data on one or two real patients (quality evaluation) in 2000/2001. In countries with a detailed fee-for-service schedule (Germany, Italy, and Switzerland) reimbursement fees were used to approximate costs. These fee-for-service schedules were also used to develop index (average) fees for all countries, in order to measure resource utilization. The following process quality indicators were evaluated: control of HbA1c; control of lipids; urine test for (micro)albuminuria; control of blood pressure; foot examination; neurological examination; eye examination; and patient education. For each country an average quality rating was calculated by weighting the response to each quality indicator with the level of scientific evidence.

RESULTS

Average quality ratings ranged from 0.40 in The Netherlands to 0.62 in the UK (0 = lowest rating; 1 = highest rating). Total annual costs for secondary prevention were higher in Switzerland than in Germany and Italy (EUR475, EUR381, and EUR283, respectively). Resource utilization was highest in Germany and lowest in the UK.

CONCLUSIONS

The overall quality of preventive services documented was found to be poor in the seven European countries studied. The UK rated as both the most effective and the most efficient country in providing secondary prevention in Type 2 diabetes.

Estimation of the prevalence of diagnosed diabetes from primary care and secondary care source data: comparison of record linkage with capture-recapture analysis

STUDY OBJECTIVE

To compare multiple source linkage and capture-recapture analysis in determining the current age and gender specific prevalence of type 1 and type 2 diabetes in a UK white population. To assess whole population trends in diabetes prevalence and treatment by comparison with previous studies.

DESIGN

Data were obtained from hospital sources and all 74 general practices in the study population. Analyses were carried out both by record linkage and by use of a two source capture-recapture model to correct for incomplete ascertainment.

SETTING

County of Clwyd, North Wales: total population 418,200.

MAIN RESULTS

By record linkage the age adjusted prevalence of all diabetes was 2.04 (95% confidence intervals 2.00 to 2.09)%. Using the capture-recapture method it was 2.29 (2.24 to 2.33)%. From capture-recapture data the age adjusted prevalence of type 1 diabetes was 0.40 (0.37 to 0.43)% in men and 0.28 (0.25 to 0.30)% in women; the prevalence of type 2 was 2.03 (1.97 to 2.09)% in men and 1.67 (1.62 to 1.72)% in women. These figures represent an increase compared with previous surveys. The age specific prevalence of type 2 diabetes was greater in men in a ratio of approximately 1.5:1 and there were more patients treated by diet alone.

CONCLUSIONS

Record linkage using multiple sources underestimates the prevalence of diabetes compared with capture-recapture estimates. The results suggest the prevalence of known diabetes in the UK has approximately doubled in less than 20 years. There is an increasing preponderance of male patients and of patients treated currently with diet alone.

Effectiveness of changes in the delivery of diabetes care in a rural community

Diabetes has a significant impact upon health in rural Maori communities. A diabetes club was established to support self-care and improve diabetes management in a rural community in Northland, New Zealand. A structured approach to care and an associated audit were also introduced. Patient involvement and ownership of the condition were considered important issues. Monitoring of care processes increased by 79%. The first year of audit was associated with a reduction in mean fructosamine from 369 +/- 85 micromol L-1 to 321 +/- 65 micromol L-1 and this was sustained for a further 3 years. The number of people using insulin increased from 15 to 22%. The audit process facilitated the implementation of changes in the delivery of care. We conclude that the data indicate that the enthusiastic delivery of care in general practice, with a devolution of power to the patient, linked to an audit service can result in improved management among patients with Type 2 diabetes.

Who looks after people with diabetes: primary or secondary care?

Because the prevalence of type 2 diabetes has increased greatly over the past decade, UK general practitioners have been encouraged to develop services for people with diabetes and to offer structured diabetes care. The resultant shift from secondary care can place considerable demands on primary health care teams. Data were obtained from 108 practices in two English health districts followed up in primary and secondary care. Nearly two-thirds of the people with diabetes were being followed up only in general practice, the remainder in hospital or both. The proportion managed in primary care varied from 5.6% to 94.6%. The settings where diabetes care was most likely to be offered were training practices, practices with good nursing support, practices with a high prevalence of diabetes, and practices in which a high proportion of diabetic patients were controlled by diet or hypoglycaemic agents. Tight control of glycaemia and blood pressure is now seen as important in diabetes, and is best achieved in general practice. This survey revealed large variations in delivery of general-practice diabetes care that need to be addressed by better organization and funding.

Quality of care of patients with diabetes: collation of data from multi-practice audits of diabetes in primary care

BACKGROUND

GPs are now playing a greater role in the care of patients with diabetes. The challenges described in the Saint Vincent Joint Task Force Report include achievement of a reduction in long-term complications by collecting key clinical information and systematically organizing care of patients with diabetes. The number of practices conducting audit and the number of primary care audit groups conducting multi-practice audits of diabetes have increased since the introduction of audit in 1991.

OBJECTIVES

We aimed to determine the feasibility of collating data from multi-practice audits of diabetes in primary care and to describe the pattern of care for diabetes patients in primary care.

METHODS

A confidential postal questionnaire was sent to all medical audit advisory groups that had completed a multi-practice audit of diabetic care. The main outcome measures studied were prevalence and treatment of known diabetes and annual compliance with key process measures.

RESULTS

Data could be collated for 17 of the 25 audit groups that supplied data representing information from 495 practices with 38 288 diabetic patients. Seven audit groups supplied data from a population denominator comprising 1475512 patients giving a prevalence of 1.46% (range 1.1-1.7%), 50.7% (range 32.5-69.0%) were managed by general practice only, 19.1% (7.6-39.7%) by hospital care only and 30.2% (11.0-49.5%) by shared care. Annual mean compliance for process measures showed wide variations: glycated haemoglobin or fructosamine checked for 72.5% (range 25.3-89.3%), fundi checked for 67.5% (57.8-86.6%), urine checked for 65.8% (27.5-80.0%), blood pressure checked for 87.6% (76.9-96.5%), smoking checked for 71.45 (21.9-86.0%), feet checked for 67.7% (40.0-90.8%) and BMI checked for 52.5% (26.4-68.2%).

CONCLUSION

This study shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.

Impact of diabetic retinopathy screening on a British district population: case detection and blindness prevention in an evidence-based model

OBJECTIVES

To quantify case detection and blindness prevention attainable through screening for diabetic retinopathy in a district population.

DESIGN

Literature review including a pooled estimate of screening test sensitivity, and quantitative modelling, including sensitivity analyses.

SETTING AND PATIENTS

The diabetic population of a typical district health authority or health board.

MAIN RESULTS

Evidence suggests that in a British general practice based diabetic population, prevalence of retinopathy requiring treatment would be between 1% and 6%; annual incidence of blindness among diabetics with retinopathy requiring treatment would be between 6% and 9%; sensitivity of screening tests in detecting retinopathy requiring treatment would be between 50% and 88%; and treatment could prevent 77% of expected cases of blindness. Of those screened, about 4% would be correctly detected as requiring treatment during an initial screening round, but this yield could decrease to about 1% in subsequent annual screening rounds. Of those treated, about 6% would be prevented from going blind within a year of treatment and 34% within 10 years of treatment.

CONCLUSIONS

Screening and early treatment of diabetic retinopathy can prevent substantial disability. The effectiveness and efficiency of screening could be enhanced by improving the performance of current tests or increasing use of mydriatic retinal photography, and by increasing uptake, particularly among diabetics at greatest risk.

Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study

In primary care it is difficult to treat the growing number of non-insulin-dependent diabetic (NIDDM) patients according to (inter)national guidelines. A prospective, controlled cohort study was designed to assess the intermediate term (2 years) effect of structured NIDDM care in general practice with and without 'diabetes service' support on glycaemic control, cardiovascular risk factors, general well-being and treatment satisfaction. The 'diabetes service', supervised by a diabetologist, included a patient registration system, consultation facilities of a dietitian and diabetes nurse educator, and protocolized blood glucose lowering therapy advice which included home blood glucose monitoring and insulin therapy. In the study group (SG; 22 general practices), 350 known NIDDM patients over 40 years of age (206 women; mean age 65.3 +/- SD 11.9; diabetes duration 5.9 +/- 5.4 years) were followed for 2 years. The control group (CG; 6 general practices) consisted of 68 patients (28 women; age 64.6 +/- 10.3; diabetes duration 6.3 +/- 6.4 years). Mean HbA1c (reference 4.3-6.1%) fell from 7.4 to 7.0% in SG and rose from 7.4 to 7.6% in CG during follow-up (p = 0.004). The percentage of patients with poor control (HbA1c > 8.5%) shifted from 21.4 to 11.7% in SG, but from 23.5 to 27.9% in CG (p = 0.008). Good control (HbA1c < 7.0%) was achieved in 54.3% (SG; at entry 43.4%) and 44.1% (CG; at entry 54.4%) (p = 0.013). Insulin therapy was started in 29.7% (SG) and 8.8% (CG) of the patients (p = 0.000) with low risk of severe hypoglycaemia (0.019/patient year). Mean levels of total and HDL-cholesterol (SG), triglycerides (SG) and diastolic blood pressure (SG + CG) and the percentage of smokers (SG) declined significantly, but the prevalence of these risk factors remained high. General well-being (SG) did not change during intensified therapy. Treatment satisfaction (SG) tended to improve. Implementation of structured care, including education and therapeutic advice, results in sustained good glycaemic control in the majority of NIDDM patients in primary care, with low risk of hypoglycaemia. Lowering cardiovascular risk requires more than reporting results and referral to guidelines.

Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London

OBJECTIVE

To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices.

DESIGN

Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions.

SUBJECTS

24 inner city, non-training general practices.

SETTING

East London.

MAIN OUTCOME MEASURES

Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts."

RESULTS

In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma.

CONCLUSIONS

Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement.