The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)

An objective and validated index of nausea and vomiting such as the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C] Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A] There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (Appendix III). [Grade A] There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B] Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B] Because of the risk of extrapyramidal effects metoclopramide should be used as second-line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C] Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP] Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C] Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in Appendix III. [GPP] Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D] All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C].

The experience of blood glucose monitoring in people with type 2 diabetes mellitus (T2DM)

BACKGROUND

Finger prick blood glucose (BG) monitoring remains a mainstay of management in people with type 2 diabetes (T2DM) who take sulphonylurea (SU) drugs or insulin. We recently examined patient experience of BG monitoring in people with type 1 diabetes (T1DM). There has not been any recent comprehensive assessment of the performance of BG monitoring strips or the patient experience of BG strips in people with T2DM in the UK.

METHODS

An online self-reported questionnaire containing 44 questions, prepared following consultation with clinicians and patients, was circulated to people with T2DM. 186 responders provided completed responses (25.5% return rate). Fixed responses were coded numerically (eg not confident = 0 fairly confident = 1).

RESULTS

Of responders, 84% were treated with insulin in addition to other agents. 75% reported having had an HbA1c check in the previous 6 months. For those with reported HbA1c ≥ 65 mmol/mol, a majority of people (70%) were concerned or really concerned about the shorter term consequences of running a high HbA1c This contrasted with those who did not know their recent HbA1c, of whom only 33% were concerned/really concerned and those with HbA1c <65 mmol/mol of whom 35% were concerned. Regarding BG monitoring/insulin adjustment, only 25% of responders reported having sufficient information with 13% believing that the accuracy and precision of their BG metre was being independently checked. Only 9% recalled discussing BG metre accuracy when their latest metre was provided and only 7% were aware of the International Standardisation Organisation (ISO) standards for BG metres. 77% did not recall discussing BG metre performance with a healthcare professional.

CONCLUSION

The group surveyed comprised engaged people with T2DM but even within this group there was significant variation in (a) awareness of shorter term risks, (b) confidence in their ability to implement appropriate insulin dosage (c) awareness of the limitations of BG monitoring technology. There is clearly an area where changes in education/support would benefit many.

Mortality Rate Associated with Diabetes: Outcomes From a General Practice Level Analysis in England Using the Royal College of General Practitioners (RCGP) Database Indicate Stability Over a 15 Year Period

INTRODUCTION

Total population mortality rates have been falling and life expectancy increasing for more than 30 years. Diabetes remains a significant risk factor for premature death. Here we used the Oxford Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) practices to determine diabetes-related vs non-diabetes-related mortality rates.

METHODS

RCGP RSC data were provided on annual patient numbers and deaths, at practice level, for those with and without diabetes across four age groups (< 50, 50-64, 65-79, ≥ 80 years) over 15 years. Investment in diabetes control, as measured by the cost of primary care medication, was also taken from GP prescribing data.

RESULTS

We included 527 general practices. Over the period 2004-2019, there was no significant change in life years lost, which varied between 4.6 and 5.1 years over this period. The proportion of all diabetes deaths by age band was significantly higher in the 65-79 years age group for men and women with diabetes than for their non-diabetic counterparts. For the year 2019, 26.6% of deaths were of people with diabetes. Of this 26.6%, 18.5% would be expected from age group and non-diabetes status, while the other 8.1% would not have been expected-pro rata to nation, this approximates to approximately 40,000 excess deaths in people with diabetes vs the general population.

CONCLUSION

There remains a wide variation in mortality rate of people with diabetes between general practices in UK. The mortality rate and life years lost for people with diabetes vs non-diabetes individuals have remained stable in recent years, while mortality rates for the general population have fallen. Investment in diabetes management at a local and national level is enabling us to hold the ground regarding the life-shortening consequences of having diabetes as increasing numbers of people develop T2DM at a younger age.

Completion of annual diabetes care processes and mortality: A cohort study using the National Diabetes Audit for England and Wales

AIM

To conduct an analysis to assess whether the completion of recommended diabetes care processes (glycated haemoglobin [HbA1c], creatinine, cholesterol, blood pressure, body mass index [BMI], smoking habit, urinary albumin, retinal and foot examinations) at least annually is associated with mortality.

MATERIALS AND METHODS

A cohort from the National Diabetes Audit of England and Wales comprising 179 105 people with type 1 and 1 397 790 people with type 2 diabetes, aged 17 to 99 years on January 1, 2009, diagnosed before January 1, 2009 and alive on April 1, 2013 was followed to December 31, 2019. Cox proportional hazards models adjusting for demographic characteristics, smoking, HbA1c, blood pressure, serum cholesterol, BMI, duration of diagnosis, estimated glomerular filtration rate, prior myocardial infarction, stroke, heart failure, respiratory disease and cancer, were used to investigate whether care processes recorded January 1, 2009 to March 31, 2010 were associated with subsequent mortality.

RESULTS

Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes, respectively. Completion of five or fewer, compared to eight, care processes (retinal screening not included as data were not reliable) had a mortality hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.28-1.46) in people with type 1 and 1.32 (95% CI 1.30-1.35) in people with type 2 diabetes. The HR was higher for respiratory disease deaths and lower in South Asian ethnic groups.

CONCLUSIONS

People with diabetes who have fewer routine care processes have higher mortality. Further research is required into whether different approaches to care might improve outcomes for this high-risk group.

A patient-clinician James Lind Alliance partnership to identify research priorities for hyperemesis gravidarum

OBJECTIVE

There are many uncertainties surrounding the aetiology, treatment and sequelae of hyperemesis gravidarum (HG). Prioritising research questions could reduce research waste, helping researchers and funders direct attention to those questions which most urgently need addressing. The HG priority setting partnership (PSP) was established to identify and rank the top 25 priority research questions important to both patients and clinicians.

METHODS

Following the James Lind Alliance (JLA) methodology, an HG PSP steering group was established. Stakeholders representing patients, carers and multidisciplinary professionals completed an online survey to gather uncertainties. Eligible uncertainties related to HG. Uncertainties on nausea and vomiting of pregnancy and those on complementary treatments were not eligible. Questions were verified against the evidence. Two rounds of prioritisation included an online ranking survey and a 1-hour consensus workshop.

RESULTS

1009 participants (938 patients/carers, 118 professionals with overlap between categories) submitted 2899 questions. Questions originated from participants in 26 different countries, and people from 32 countries took part in the first prioritisation stage. 66 unique questions emerged, which were evidence checked according to the agreed protocol. 65 true uncertainties were narrowed via an online ranking survey to 26 unranked uncertainties. The consensus workshop was attended by 19 international patients and clinicians who reached consensus on the top 10 questions for international researchers to address. More patients than professionals took part in the surveys but were equally distributed during the consensus workshop. Participants from low-income and middle-income countries noted that the priorities may be different in their settings.

CONCLUSIONS

By following the JLA method, a prioritised list of uncertainties relevant to both HG patients and their clinicians has been identified which can inform the international HG research agenda, funders and policy-makers. While it is possible to conduct an international PSP, results from developed countries may not be as relevant in low-income and middle-income countries.

The onset of nausea and vomiting of pregnancy: a prospective cohort study

BACKGROUND

Nausea and vomiting are experienced by most women during pregnancy. The onset is usually related to Last Menstrual Period (LMP) the date of which is often unreliable. This study describes the time to onset of nausea and vomiting symptoms from date of ovulation and compares this to date of last menstrual period METHODS: Prospective cohort of women seeking to become pregnant, recruited from 12 May 2014 to 25 November 2016, in the United Kingdom. Daily diaries of nausea and vomiting were kept by 256 women who were trying to conceive. The main outcome measure is the number of days from last menstrual period (LMP) or luteinising hormone surge until onset of nausea or vomiting.

RESULTS

Almost all women (88%) had Human Chorionic Gonadotrophin rise within 8 to 10 days of ovulation; the equivalent interval from LMP was 20 to 30 days. Many (67%) women experience symptoms within 11 to 20 days of ovulation.

CONCLUSIONS

Onset of nausea and vomiting occurs earlier than previously reported and there is a narrow window for onset of symptoms. This indicates that its etiology is associated with a specific developmental stage at the foetal-maternal interface.

TRIAL REGISTRATION

NCT01577147 . Date of registration 13 April 2012.

Applying Parkes Grid Method to Evaluate Impact of Variation in Blood Glucose Monitoring (BGM) Strip Accuracy Performance in Type 1 Diabetes Highlights the Potential for Amplification of Imprecision With Less Accurate BGM Strips

BACKGROUND

The National Health Service spends £170 million on blood glucose monitoring (BGM) strips each year and there are pressures to use cheaper less accurate strips. Technology is also being used to increase test frequency with less focus on accuracy.Previous modeling/real-world data analysis highlighted that actual blood glucose variability can be more than twice blood glucose meter reported variability (BGMV). We applied those results to the Parkes error grid to highlight potential clinical impact.

METHOD

BGMV is defined as the percent of deviation from reference that contains 95% of results. Four categories were modeled: laboratory (<5%), high accuracy strips (<10%), ISO 2013 (<15%), and ISO 2003 (<20%) (includes some strips still used).The Parkes error grid model with its associated category of risk including "alter clinical decision" and "affect clinical outcomes" was used, with the profile of frequency of expected results fitted into each BGM accuracy category.

RESULTS

Applying to single readings, almost all strip accuracy ranges derived in a controlled setting fell within the category: clinically accurate/no effect on outcomes areas.However modeling the possible blood glucose distribution in more detail, 30.6% of longer term results of the strips with current ISO accuracy would fall into the "alter clinical action" category. For previous ISO strips, this rose to 44.1%, and for the latest higher accuracy strips, this fell to 12.8%.

CONCLUSION

There is a minimum standard of accuracy needed to ensure that clinical outcomes are not put at risk. This study highlights the potential for amplification of imprecision with less accurate BGM strips.

People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement

BACKGROUND

The self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing.

METHODS

An on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained.

RESULTS

59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol. Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG. 72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter's performance. The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient's concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient's concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c.

CONCLUSION

Many people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.

The treatment rate of erectile dysfunction (ED) in younger men with type 2 diabetes is up to four times higher than the equivalent non-diabetes population

INTRODUCTION

Erectile dysfunction (ED) is common in older age and in diabetes mellitus (DM). Phosphodiesterase type 5-inhibitors (PDE5-is) are the first-line for ED. We investigated how the type of diabetes and age of males affect the PDE5-i use in the primary care setting.

METHODS

From 2018 to 2019, the general practice level quantity of all PDE5-i agents was taken from the general practice (GP) Prescribing Dataset in England. The variation in outcomes across practices was examined across one year, and for the same practice against the previous year.

RESULTS

We included 5761 larger practices supporting 25.8 million men of whom 4.2 million ≥65 years old. Of these, 1.4 million had T2DM, with 0.8 million of these >65. About 137 000 people had T1DM. About 28.8 million tablets of PDE5-i were prescribed within the 12 months (2018-2019) period in 3.7 million prescriptions (7.7 tablets/prescription), at total costs of £15.8 million (£0.55/tablet). The NHS ED limit of one tablet/user/wk suggests that 540 000 males are being prescribed a PDE5-i at a cost of £29/y each. With approximately 30 000 GPs practising, this is equivalent to one GP providing 2.5 prescriptions/wk to overall 18 males. There was a 3x variation between the highest decile of practices (2.6 tablets/male/y) and lowest decile (0.96 tablets/male/y). The statistical model captured 14% of this variation and showed that T1DM males were the largest users, while men age <65 with T2DM were being prescribed four times as much as non-DM. Those T2DM >65 were prescribed 80% of the non-DM amount.

CONCLUSION

There is a wide variation in the use of PDE5-is. With only 14% variance capture, other factors including wide variation in patient awareness, prescribing rules of local health providers, and recognition of the importance of male sexual health by GP prescribers might have a significant impact.

Influences on the use of antidepressants in primary care: All England general practice-level analysis of demographic, practice-level and prescriber factors

INTRODUCTION

General practice (GP) antidepressants (ADs) prescribing in England has almost doubled in the past decade: how does location, GP characteristics, and prescribing selection influence antidepressant prescribing rate (ADPR) and growth.

METHODS

Stepwise multivariate regression analysis was applied to national public relevant data for each general practice to establish associations between these factors and ADPR. The regression coefficient was applied to the actual change in the number of different ADs and costs/dose to extrapolate the impact of these on growth.

RESULTS

In 2017-2018, 2.1 billion doses of antidepressant were prescribed into a population of 52 million people in 6,146 larger practices. In the model, location demographics accounted for 62% of the variation in ADPR: including practice size and health raised this to 71%, and local prescribing behaviour to 80%. Practices using more different drugs and lower-cost/dose had higher ADPR. Extrapolation showed that 40% of growth in ADPR could be attributed to the historic changes in these factors.

CONCLUSIONS

While practice location factors do impact on AD prescription rates, local long-term physical health condition prevalence and prescribing behaviours are almost as important. We hope that our findings can provide insights that are helpful to local clinical behaviour and medicines management.

Cost of hospital treatment of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) compared to the non-diabetes population: a detailed economic evaluation

OBJECTIVES

Other than age, diabetes is the largest contributor to overall healthcare costs and reduced life expectancy in Europe. This paper aims to more exactly quantify the net impact of diabetes on different aspects of healthcare provision in hospitals in England, building on previous work that looked at the determinants of outcome in type 1 diabetes (T1DM) and type 2 diabetes (T2DM).

SETTING

NHS Digital Hospital Episode Statistics (HES) in England was combined with the National Diabetes Audit (NDA) to provide the total number in practice of people with T1DM/T2DM.

OUTCOME MEASURES

We compared differences between T1DM/T2DM and non-diabetes individuals in relation to hospital activity and associated cost.

RESULTS

The study captured 90% of hospital activity and £36 billion/year of hospital spend. The NDA Register showed that out of a total reported population of 58 million, 2.9 million (6.5%) had T2DM and 240 000 (0.6%) had T1DM. Bed-day analysis showed 17% of beds are occupied by T2DM and 3% by T1DM. The overall cost of hospital care for people with diabetes is £5.5 billion/year. Once the normally expected costs including the older age of T2DM hospital attenders are allowed for this fell to £3.0 billion/year or 8% of the total captured secondary care costs. This equates to £560/non-diabetes person compared with £3280/person with T1DM and £1686/person with T2DM. For people with diabetes, the net excess impact on non-elective/emergency work is £1.2 billion with additional estimated diabetes-related accident & emergency attendances at 440 000 costing the NHS £70 million/year. T1DM individuals required five times more secondary care support than non-diabetes individuals. T2DM individuals, even allowing for the age, require twice as much support as non-diabetes individuals.

CONCLUSIONS

This analysis shows that additional cost of provision of hospital services due to their diabetes comorbidities is £3 billion above that for non-diabetes, and that within this, T1DM has three times as much cost impact as T2DM. We suggest that supporting patients in diabetes management may significantly reduce hospital activity.

Antidepressant Prescribing in England: Patterns and Costs

Objective

The number of prescriptions for antidepressants (ADs) in England and Wales has almost doubled in the past decade. The objective of this article is to describe the current prescribing rates of different antidepressants by general practice (GP) practice.

Methods

We collated the prescribing behavior in each GP practice in the year April 1, 2017, to March 31, 2018. The monthly GP practice prescribing data reports for medication prescribing for each British National Formulary code and practice, as well as the prescriptions, quantity, and costs were examined in relation to prescribing practice.

Results

The data showed that 2.1 billion doses of antidepressant were prescribed to a total population of 52 million people. That equates to 11% of individuals taking ≥ 1 antidepressants on any day. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed class of ADs, with sertraline the most prescribed SSRI. The other most prescribed ADs were citalopram, fluoxetine, and mirtazapine. Some older agents, such as trimipramine and doxepin, are prescribed at a very high tariff.

Conclusions

Broadly, the findings are in keeping with National Institute for Health and Care Excellence guidance in that the bulk of prescriptions were for SSRIs. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications as supported by the evidence base.

General practice (GP) level analysis shows that patients' own perceptions of support within primary care as reported in the GP patient survey (GPPS) are as important as medication and services in improving glycaemic control

BACKGROUND

The way that GP practices organize their services impacts as much on glycaemia in type 2 diabetes as does prescribing.

AIM

Our aim was to evaluate the link between patients' own perception of support within primary care and the % patients at each GP practice at target glycaemic control (TGC) and at high glycaemic risk (HGR).

DESIGN AND SETTING

Utilisation of National Diabetes Audit (NDA) available data combined with the General practitioner patient survey (GPPS).

METHOD

The NDA 2016_17 published data on numbers of type 2 patients, levels of local diabetes services and the target glycaemic control (TGC) % and high glycaemic risk (HGR) % achieved. The GPPS 2017 published % "No" responses from long term condition (LTC) patients to the question "In the last 6 months, had you enough support from local services or organisations to help manage LTCs?". Multivariate regression was used on the set of indicators capturing patients' demographics and services provided.

RESULTS

6498 practices were included (with more than 2.5 million T2DM patients) and median values with band limits that included 95% practices for % "No" response to the question above was 12% (2%-30%), for TGC 67% (54%-78%) and for HGR 6% (2%-13%). The model accounted for 25% TGC variance and 26% HGR variance. The standardised β values shown as (TGC/HGR) (+=more people; -=less people) for older age (+0.24/-0.25), sulphonylurea use (-0.21/+0.14), greater social disadvantage (-0.09/+0.21), GPPS Support %No (-0.08/+0.12), %Completion 8 checks (+0.09/-0.12) and metformin use (+0.11/-0.05).

CONCLUSION

The relation between the person with diabetes and clinician in primary care is shown to be quantitatively potentially as important in influencing glycaemic outcome as the services provided and medication prescribed. We suggest that all of us in who work in the health care system can bear this in mind in our everyday work.

Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes

OBJECTIVE

Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement.

METHOD

From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers.

RESULTS

Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000.

CONCLUSIONS

GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.

Real-world practice level data analysis confirms link between variability within Blood Glucose Monitoring Strip (BGMS) and glycosylated haemoglobin (HbA1c) in Type 1 Diabetes

AIMS/HYPOTHESIS

Our aim was to quantify the impact of Blood Glucose Monitoring Strips variability (BGMSV) at GP practice level on the variability of reported glycated haemoglobin (HbA1cV) levels.

METHODS

Overall GP Practice BGMSV and HbA1cV were calculated from the quantity of main types of BGMS being prescribed combined with the published accuracy, as % results within ±% bands from reference value for the selected strip type. The regression coefficient between the BGMSV and HbA1cV was calculated. To allow for the aggregation of estimated three tests/day over 13 weeks (ie, 300 samples) of actual Blood Glucose (BG) values up to the HbA1c, we multiplied HbA1cV coefficient by √300 to estimate an empirical value for impact of BGMSV on BGV.

RESULTS

Four thousand five hundred and twenty-four practice years with 159 700 T1DM patient years where accuracy data were available for more than 80% of strips prescribed were included, with overall BGMSV 6.5% and HbA1c mean of 66.9 mmol/mol (8.3%) with variability of 13 mmol/mol equal to 19% of the mean. At a GP practice level, BGMSV and HbA1cV as % of mean HbA1c (in other words, the spread of HbA1c) were closely related with a regression coefficient of 0.176, P < 0.001. Thus, greater variability in the BGMS at a GP practice level resulted in a greater spread of HbA1C readings in T1DM patients. Applying this factor for BGMS to the national ISO accepted standard where 95% results must be ≤±15% from reference, revealed that for BG, 95% results would be ≤±45% from the reference value. Thus, the variation in BG is three times that of the BGMS. For a patient with BG target @10 mmol/L using the worst performing ISO standard strips, on 1/20 occasions (average 1/week) actual blood glucose value could be >±4.5 mmol/L from target, compared with the best performing BGMS with BG >±2.2 mmol/L from reference on 1/20 occasions.

CONCLUSION

Use of more variable/less accurate BGMS is associated both theoretically and in practice with a larger variability in measured BG and HbA1c, with implications for patient confidence in their day-to-day monitoring experience.

Sodium-glucose co-transporter-2 inhibitors, the latest residents on the block: Impact on glycaemic control at a general practice level in England

AIMS

To determine, using published general practice-level data, how differences in Type 2 diabetes mellitus (T2DM) prescribing patterns relate to glycaemic target achievement levels.

METHODS

Multiple linear regression modelling was used to link practice characteristics and defined daily dose (DDD) of different classes of medication in 2015/2016 and changes between that year and the year 2014/2015 in medication to proportion of patients achieving target glycaemic control (glycated haemoglobin A1c [HbA1c] ≤58 mmol/mol [7.5%]) and proportion of patients at high glycaemic risk (HbA1c >86 mmol/mol [10.0%]) for practices in the National Diabetes Audit with >100 people with T2DM on their register.

RESULTS

Overall, HbA1c outcomes were not different between the years studied. Although, in percentage terms, most practices increased their use of sodium-glucose co-transporter-2 (SGLT2) inhibitors (96%), dipeptidyl peptidase-4 (DPP-4) inhibitors (76%) and glucagon-like peptide 1 (GLP-1) analogues (53%), there was wide variation in the use of older and newer therapies. For example, 12% of practices used >200% of the national average for some newer agents. In cross-sectional analysis, greater prescribing of metformin and analogue insulin were associated with a higher proportion of patients achieving HbA1c ≤58 mmol/mol; the use of SGLT2 inhibitors and metformin was associated with a reduced proportion of patients with HbA1c >86 mol/mol; otherwise associations for sulphonylureas, GLP-1 analogues, SGLT2 inhibitors and DPP-4 inhibitors were neutral or negative. In year-on-year analysis there was ongoing deterioration in glycaemic control, which was offset to some extent by increased use of SGLT2 inhibitors and GLP-1 analogues, which were associated with a greater proportion of patients achieving HbA1c levels ≤58 mmol/mol and a smaller proportion of patients with HbA1c levels >86 mmol/mol. SGLT2 inhibitor prescribing was associated with significantly greater improvements than those found for GLP-1 analogues.

CONCLUSION

Greater use of newer agents was associated with improvement in glycaemic outcomes but was not sufficient to compensate for the prevailing decline. This may reflect wide variability in the prescribing of newer agents. We found that SGLT inhibitors may be superior to other oral agents in relation to HbA1c outcome. Serious consideration should be given to their use.

Failing to meet the needs of generations of care home residents with diabetes: a review of the literature and a call for action

In residential care homes and aged-care facilities globally, between one in three and one in four residents may have diabetes, an often complex highly co-morbid illness that leads to frailty, dependency, disability and reduced life expectancy. Residents with diabetes also have a high risk of hypoglycaemia, avoidable hospital admissions, and represent one of the most difficult challenges to health professionals and care staff in optimizing their diabetes and medical care. This detailed review examines the literature relating to care home diabetes over the last 25 years to assess what has been achieved in characterizing residents with diabetes, and what we know about the various but limited intervention studies that have been carried out internationally. The guidance and guidelines that have been published to assist clinicians in planning effective and safe care for this rather vulnerable group of people with diabetes are also reviewed. The review presents the first diagrammatic representation of a likely physiological cascade depicting the mainly irreversible functional decline a resident with diabetes might experience, provides modern principles of care for each resident with diabetes, and identifies what priority recommendations are required to be implemented if diabetes care is to improve. The review concludes that action is required since diabetes care still remains fragmented, sub-optimal, and in need of investment, otherwise care home residents with diabetes will continue to have their needs unfulfilled.

Route to improving Type 1 diabetes mellitus glycaemic outcomes: real-world evidence taken from the National Diabetes Audit

AIM

To use general practice-level data for England, available through the National Diabetes Audit, and primary care prescribing data to identify prescription treatment factors associated with variations in achieved glucose control (HbA_1c ).

METHODS

General practice-level National Diabetes Audit data on Type 1 diabetes, including details of population characteristics, services, proportion of people achieving target glycaemic control [HbA_1c ≤58 mmol/mol (7.5%)] and proportion of people at high glycaemic risk [HbA_1c >86 mmol/ml (10%)], were linked to 2013-2016 primary care diabetes prescribing data on insulin types and blood glucose monitoring for all people with diabetes.

RESULTS

A wide variation was found between the 10^th percentile and the 90^th percentile of general practices in both target glycaemic control (15.6% to 44.8%, respectively) and high glycaemic risk (4.8% to 28.6%, respectively). Our analysis suggests that, given the extrapolated total of 280 000 people with Type 1 diabetes in the UK, there may be the potential to increase the number of those within target glycaemic control from 80 000 to 101 000; 53% of this increase (11 000 people) would result from service improvements and 47% (10 000 people) from medication and technology changes. The same improvements would also provide the opportunity to reduce the number of people at high glycaemic risk from 42 000 to 26 500. A key factor associated with practice-level target HbA_1c achievement would be greater use of insulin pumps for up to an additional 56 000 people.

CONCLUSION

If the HbA_1c achievement rates in service provision, medication and use of technology currently seen in practices in the 90^th percentile were to be matched with regard to HbA_1c achievement rates in all general practices, glycaemic control might be improved for 36 500 people, with all the attendant health benefits.

Improvements in clinical diabetes care in the first year of the new General Medical Services contract in the UK

The prevalence of diabetes and the cost of providing services will increase dramatically over the next ten years. There is a wide consensus that the way forward is for primary care to provide more care to higher clinical standards. The new General Medical Services contract (GMS2) offers incentives to achieve diabetes management targets. We compared the performances of health centres in North Warwickshire in the pre-contract year 2004 and post-contract in 2005. The audit tool comprised the GMS2 quality indicators in Alphabet Strategy format. There were statistically significant improvements in performance against almost all the quality indicators. We conclude with some reservations that GMS2 has considerably improved the quality of diabetes care in our locality.

Attitudes, access and anguish: a qualitative interview study of staff and patients' experiences of diabetic retinopathy screening

OBJECTIVE

To examine the experiences of patients, health professionals and screeners; their interactions with and understandings of diabetic retinopathy screening (DRS); and how these influence uptake.

DESIGN

Purposive, qualitative design using multiperspectival, semistructured interviews and thematic analysis.

SETTING

Three UK Screening Programme regions with different service-delivery modes, minority ethnic and deprivation levels across rural, urban and inner-city areas, in general practitioner practices and patients' homes.

PARTICIPANTS

62 including 38 patients (22 regular-screening attenders, 16 non-regular attenders) and 24 professionals (15 primary care professionals and 9 screeners).

RESULTS

Antecedents to attendance included knowledge about diabetic retinopathy and screening; antecedents to non-attendance included psychological, pragmatic and social factors. Confusion between photographs taken at routine eye tests and DRS photographs was identified. The differing regional invitation methods and screening locations were discussed, with convenience and transport safety being over-riding considerations for patients. Some patients mentioned significant pain and visual disturbance from mydriasis drops as a deterrent to attendance.

CONCLUSIONS

In this, the first study to consider multiperspectival experiential accounts, we identified that proactive coordination of care involving patients, primary care and screening programmes, prior to, during and after screening is required. Multiple factors, prior to, during and after screening, are involved in the attendance and non-attendance for DRS. Further research is needed to establish whether patient self-management educational interventions and the pharmacological reformulation of shorter acting mydriasis drops, may improve uptake of DRS. This might, in turn, reduce preventable vision loss and its associated costs to individuals and their families, and to health and social care providers, reducing current inequalities.

Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care

The Mini-Cog was shown to be a brief, acceptable and practical cognitive screen for older people with diabetes when administered by a primary care nurse. It could be integrated easily into the annual diabetes review and help to identify those who may benefit from extra help with their management.

Percutaneous endoscopic gastrostomy (PEG) feeding in elderly people with diabetes resident in nursing homes

AIM

To investigate the level of percutaneous endoscopic gastrostomy (PEG) feeding in elderly people with diabetes resident in Nursing homes in one area of the U.K., to describe their degree of disability, co-morbidities and to estimate medication costs of these residents.

METHODS

The data was collected from a retrospective case notes review of the 75 people with known diabetes who were resident in the 11 Nursing homes in the Coventry Teaching PCT in early 2010.

RESULTS

14 residents (19% of the total sample) had PEG feeds in situ and one (1.3%) had a nasogastric feeding tube in situ. The 14 residents were taking a total of 80 daily medications, a mean of 5.7 daily medications per resident (range 3-10). The total medication costs for the regular medications for these 14 residents was 2410 euros per month giving a mean of 172 euros/month (range 14-935 euros per month). All of the 14 were recorded as being bedbound, having no speech and being doubly incontinent.

CONCLUSION

All 14 residents being PEG fed have severe levels of disability. Cerebro vascular accident and dementia are the main recorded co-morbidities. The most expensive monthly medication costs were for special order liquid medications, many for cardio vascular disease prevention, which may be considered as inappropriate in such severely disabled residents.

Diabetes in care homes: a cluster randomised controlled trial of resident education

Introduction

Residents of care homes with diabetes are a vulnerable group, lacking comprehensive assessment, monitoring, and specialist access. This study aimed to determine whether a short-term patient centred intervention strategy might benefit people with diabetes living in residential care homes.

Methods

Residents with diabetes were recruited and randomised (by care home) to intervention (25 homes: 57 residents) or control (26 homes: 45 residents). The intervention consisted of a medical review and individualised resident educational programme. The control group received usual care. Measures of glycaemic control (fasting glucose and HbA1c), quality of life, functional ability, cognition, mood, and diabetes knowledge were collected at baseline and after 6 months.

Results

After 6 months the intervention group, compared with control, had better quality of life, mood and diabetes knowledge and a slight increase in HbA1c from a mean value of 6.84 % (1.54) to 7.49 % (1.82). Reports of hypoglycaemia were less at the end of the study in both groups.

Conclusions

The intervention improved patient-centred outcomes, with a small effect on glycaemic control. More research needs to be performed with care home residents to develop the evidence base for appropriate interventions in this neglected group of patients.

Pregnancy nausea and vomiting--the role of the midwife

Seventy five-80 per cent of pregnant women get some degree of nausea and vomiting of pregnancy (NVP) and it becomes severe in about 30 per cent of women with symptoms. Calling it 'morning sickness' is both inaccurate and damaging as it can be seen to trivialise the condition. Severe NVP can cause depression, feelings of inadequacy, loss of time at work, admission to hospital and termination of pregnancy. It is important for midwives to treat women with NVP with understanding and empathy, and for midwives to be able to assess women with NVP and refer for admission those developing hyperemesis gravidarm.

Setting research priorities for Type 1 diabetes

AIMS

Research priorities are often set by academic researchers or the pharmaceutical industry. The interests of patients, carers and clinicians may therefore be overlooked and research questions that matter may be neglected. The aims of this study were to collect uncertainties about the treatment of Type 1 diabetes from patients, carers and health professionals, and to collate and prioritize these uncertainties to develop a top 10 list of research priorities, using a structured priority-setting partnership of patients, carers, health professionals and diabetes organizations, as described by the James Lind Alliance.

METHODS

A partnership of interested organizations was set up, and from this a steering committee of 10 individuals was formed. An online and paper survey was used to identify uncertainties. These were collated, and the steering group carried out an interim priority-setting exercise with partner organizations. This group of uncertainties was then voted on to give a smaller list that went forward to the final priority-setting workshop. At this meeting, a final list of the top 10 research priorities was agreed.

RESULTS

An initial 1141 uncertainties were described. These were reduced to 88 indicative questions, 47 of which went out for voting. Twenty-four were then taken forward to a final priority-setting workshop. This workshop resulted in a list of top 10 research priorities in Type 1 diabetes.

CONCLUSION

We have shown that it is possible using the James Lind Alliance process to develop an agreed top 10 list of research priorities for Type 1 diabetes from health professionals, patients and carers.

Prescribed medicines for elderly frail people with diabetes resident in nursing homes-issues of polypharmacy and medication costs

AIMS

To describe the numbers and costs of medications prescribed to people living with diabetes resident in nursing homes in one primary care trust in the UK.

METHODS

A retrospective case notes review of 75 people with known diabetes who were resident in the 11 nursing homes in the Coventry teaching primary care trust.

RESULTS

Sixty-three residents (84%) were being prescribed four or more medications. Forty-four residents (59%) were prescribed anti-platelet drugs for prevention of cardiovascular disease, including aspirin, clopidogrel and dipyridamole, and 31 residents (41%) were on statin therapy. Eighteen (24%) residents had a monthly medication cost that was above £101 per month. On detailed review, these were largely residents who were being prescribed special order liquid preparations, usually for secondary cardiovascular disease prevention.

CONCLUSION

Polypharmacy, defined as taking four or more drugs per day per resident, is highly prevalent within this population of care home residents with diabetes. A high proportion of residents are prescribed drugs for cardiovascular disease prevention, which may be entirely inappropriate in this population with limited life expectancy. Regular medication review of care home residents with diabetes should be undertaken as it has the potential to reduce costs, minimize adverse drug reactions and increase health gain.

People living with diabetes resident in nursing homes--assessing levels of disability and nursing needs

AIMS

To describe the degree of disability and nursing need of people living with diabetes resident in nursing homes in one Primary Care Trust in the UK.

METHODS

A retrospective case notes review of 75 people with known diabetes who were resident in the 11 nursing homes in Coventry Teaching Primary Care Trust.

RESULTS

Very significant levels of disability and nursing need were documented in areas of continence, feeding, mobility and communication. Each individual had a mean of four co-morbidities (range 1-8), excluding diabetes. Using the definition of terminal illness based on a negative answer to the question 'would I be surprised if my patient were to die in the next 12 months' it is likely that the majority of individuals described in this study would be classified as being terminally ill.

CONCLUSION

Using four practical clinical measures, this study has shown very significant levels of disability and nursing care need in this population of mainly elderly people resident in nursing homes in Coventry. In addition, it has demonstrated that a large proportion of nursing home residents with diabetes can be considered to be in the terminal phase of life, a period where many other factors interplay in how care should be delivered and what outcomes are appropriate. In fact, residents in this category may well be candidates for a considered withdrawal of treatments, but not of care.

Medical information about diabetes--how to keep up to date

Diabet. Med. 27, 1335-1340 (2010) ABSTRACT: There is a vast amount of new medical information published on diabetes each year; the number of systematic reviews on diabetes is also increasing rapidly. It is therefore difficult for clinicians keep up to date with the new evidence. It is suggested that reading the full National Institute for Clinical Excellence (NICE) guidelines on diabetes will bring you up to date with information as at the date of the evidence cut-off, which is usually approximately 1 year before publication. Also regularly visiting 'NHS Evidence--diabetes', an online resource that offers a foraging service, surveying the literature and alerting clinicians to all the new important and useful information, enables the busy clinician to manage information overload and help keep up to date.

The future use of liraglutide: implications of the LEAD-2 study for treatment guidelines in type 2 diabetes

The effective identification and management of type 2 diabetes (T2D) in primary care is a healthcare priority. New antidiabetic agents, including glucagon-like peptide (GLP)-1 receptor agonists, may help overcome drawbacks with current treatments. These new agents have been reviewed in the updated National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of T2D. Liraglutide, a GLP-1 receptor agonist, was licensed for use in patients with T2D after the development of the NICE guidelines. Data from Phase III trials evaluating liraglutide are presented here in the context of the role of GLP-1 receptor agonists in NICE guidelines.

Insulin initiation in primary care for patients with type 2 diabetes: 3-year follow-up study

PURPOSE OF STUDY

To evaluate the 3-year impact of initiating basal insulin on glycaemic control (HbA1c) and weight gain in patients with poorly controlled type 2 diabetes registered with UK general practices that volunteered to participate in an insulin initiation training programme.

METHODS

Audit utilising data collected from practice record systems, which included data at baseline, 3, 6 months and subsequent six-monthly intervals post-insulin initiation for up to 10 patients per participating practice.

RESULTS

Of 115 eligible practices, 55 (47.8%) contributed data on a total of 516 patients. The mean improvement in HbA1c levels in the first 6 months was 1.4% (range -3.8% to 8.2%, median=1.40%). Thereafter, there was no overall change in HbA1c levels, although the change for individual patients ranged from -4.90% to +7.50%. At 36 months, 141 (41%) patients for whom data were provided had achieved the pre-2006/2007 UK Quality and Outcomes Framework (QOF) target of 7.4% or less, including 98 (29%) who had achieved an HbA1c of 7% or less. Patients who achieved target had a lower HbA1c at baseline (mean 9.1% compared to 9.7%; p<0.001); had a lower weight at 36 months (mean 88.0kg compared to 93.5kg; p=0.05); were more likely to be on basal insulin alone (88, 47.1% compared to 46, 34.6%; p<0.05); and were slightly older (mean 64.5 years compared to 61.7 years; p<0.05).

CONCLUSION

Attending an insulin initiation training programme may successfully prepare primary healthcare professionals to initiate insulin therapy as part of everyday practice for patients with poorly controlled type 2 diabetes. The impact on glycaemic control is maintained over a 3-year period. Although intensification of treatment occurred during this period, the findings suggest scope for further intensification of insulin therapy in order to improve on the glycaemic control achieved during the first 6 months post-insulin initiation.