Screening: the treatment
The UK example
Whole population screening for diabetes does not take place in the UK. The National Screening Committee (NSC) has assessed the evidence for screening the whole population diabetes and concluded that it does not meet the necessary criteria. An updated technology appraisal (to that first published in 2007) was published in August 2013 to examine screening for type 2 diabetes. This report examined evidence published between 2009 and 2012 and concluded that the case for whole population screening is less strong now than it was in 2007. The conclusion was based largely on the lack of any benefit in terms of a reduction in cardiovascular outcomes for those with screen detected diabetes. The report was however, supportive of a risk assessment for identifying those at increased risk of diabetes so that preventative measures could be put in place to reduce the number of people developing type 2 diabetes.
In its Public Health guidance the National Institute for Health and Clinical Excellence (NICE) supports these conclusions and recommends localities put in place an integrated package of measures that can promote health and prevent the development of type 2 diabetes along with other conditions (cardiovascular disease and some cancers). NICE acknowledges that whilst lifestyle interventions can reduce risk in individuals the greatest benefit will be seen by interventions aimed at modifying behaviour in whole communities and populations.
Targeted risk assessment
Although whole population screening is not recommended in the UK, both the NSC and NICE support targeted risk assessment. In 2009 the UK Government launched the vascular risk screening programme. The aim of the programme was to identify those people most at risk of developing heart disease, stroke, diabetes, kidney disease and some forms of dementia and to offer personalised preventative advice.
The programme is now called the NHS Health Check and is offered to all adults in England between the ages of 40 and 74 who have not already been diagnosed with one of these conditions once every five years. Initially the checks were the responsibility of NHS primary care trusts but in April 2013 responsibility passed to local authorities. Local authorities are mandated to provide the checks as part of the 2013 Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations.
It has been estimated that the checks will prevent 4000 cases of diabetes per year and diagnose 20,000 new cases of diabetes per year.
As yet there is little evidence of the benefit of NHS Health checks, although it may be too early to detect this. It is not clear how many cases of diabetes have been diagnosed using the NHS Health Checks although there is some evidence there has not been a great change in the prevalence of diabetes in practices using the health checks. In one area of England 349 (1.2%) of the patients receiving a health check were diagnosed with type 2 diabetes.
Ensuring Health Improvement
In order to achieve such benefits uptake of health checks needs to be high. Data are collected to determine how well the programme is taken up in each locality and how accessible it is for the local population.
The Public Health Outcomes Framework (PHOF) sets out the desired outcomes for public health in England. A set of indicators are used to understand progress year on year in each local authority area.
Indicator number 2.22i is defined as the percentage of eligible population aged 40-74 offered an NHS Health Check in the year and indicator number 2.22ii is the percentage of eligible population aged 40-74 offered an NHS Health Check who received an NHS Health Check. These data can be used for benchmarking and rewarding performance.
NICE has produced guidance to support the identification and management of individuals at increased risk of developing type 2 diabetes. It has produced an algorithm based on a two-step approach to identifying those most at risk. In step one a validated risk assessment tool is used to identify those at greatest risk and step two involved undertaking a blood test either measurement of HbA1c or fasting blood glucose. Such an algorithm can be used by local authorities to determine the order in which individuals are invited to attend for health checks starting with those at greatest risk.
At risk individuals
NICE advises offering brief lifestyle advice to those identified as being at low (those who have a low or intermediate risk score) or moderate (a high risk score, but with a fasting plasma glucose less than 5.5 mmol/l or HbA1c of less than 42 mmol/mol [6.0%]) risk of type 2 diabetes and signposting to local behavioural change services (for example weight management or smoking cessation).
Individuals identified as being at high risk of developing type 2 diabetes (a high risk score and fasting plasma glucose of 5.5–6.9 mmol/l or HbA1c of 42–47 mmol/mol [6.0–6.4%]) should be referred to a local evidence-based, quality-assured intensive lifestyle-change programme.
Individuals with newly diagnosed diabetes
If an individual is found to have a fasting plasma glucose of, 7.0 mmol/l or above, or HbA1c of 48 mmol/mol [6.5%] or above, but no symptoms of type 2 diabetes a second confirmatory blood test should be undertaken. If diabetes is not confirmed then the individual should be managed as per the recommendations for those at moderate risk. If diabetes is confirmed then the individual should be managed according to NICE guidance on the management of type 2 diabetes. Best practice guidance for Health Checks sets this out as the provision of:
- information about diabetes, and an offer of structured education
- individualised nutritional advice
- an annual review, that includes measurements of BMI, waist, HbA1c, blood pressure, cholesterol and triglycerides, smoking status, retinopathy, peripheral pulses, microalbuminuria and eGFR
- agreement of target HbA1c and the appropriate treatment and support to achieve it
- contact details for patient groups such as Diabetes UK, and a copy of its leaflet “What diabetes care to expect”
- Management of blood pressure, blood lipids, anti-thrombotic therapy, kidney damage, eye screening, neuropathic pain and other neuropathic complications according to NICE clinical guideline 66 The management of type 2 diabetes
Every newly diagnosed individual should also be entered onto their general practitioner’s practice diabetes register.
Quality and Outcomes Framework
The quality and outcomes framework is a voluntary annual reward and incentive programme for all general practices in England. For clinical care there are 96 indicators across 22 clinical areas. Diabetes has the most indicators for any single disease. The importance of behaviour modification as the cornerstone of diabetes care is highlighted in the quality and outcomes framework with referral to structured education being one of the indicators as shown below .
|DM014||The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register||New indicator||11||40–90%|
The international perspective
Australia and New Zealand
In 2010 the governments of Australia and New Zealand published a horizon scanning technology prioritising summary concerning targeted screening for cardiovascular risk for all adults between 40-74 years. This report examined the UK vascular screening programme and concluded that such a programme in Australia and New Zealand would identify most of the population at risk of developing CVD with the potential for saving lives and for down-stream financial gains. However, the report also noted that a more targeted approach (based on an initial risk assessment) could identify almost as many at-risk individuals but at a reduced cost. The report recommended undertaking a full economic analysis prior to embarking on such a programme.
The Indian government has a National Diabetes Control Programme. This programme which began as a pilot in 1987, aims to prevent diabetes through the identification of those at greatest risk and to diagnose and treat early those who develop the disease. The impact of this programme has not been evaluated but it has been demonstrated that even amongst those at greatest risk of developing diabetes almost one in four people has not even heard of diabetes.
In Mexico a national programme for adult and elderly health integrates efforts for diabetes prevention, education and control at the federal Ministry of Health. Primary health clinics have been launched to focus on the treatment of obesity, diabetes mellitus, dyslipidemias and high-blood pressure. In addition a National Council for the Prevention and Control of Chronic Diseases has been formed and a nation-wide communication programme using radio and television advertising launched called “Five Steps for Your Health” (“Cinco pasos por tu salud”). This programme targets five healthy behaviours: consume water (instead of soft drinks or other caloric beverages), increase physical activity, increase consumption of fruits and vegetables, and regular weight checks.
The burden of diabetes in Sub-Saharan Africa like the rest of the world is increasing and the challenges in early identification and management of the condition immense. In order to begin to tackle these difficulties the International Diabetes Federation together with the World Health Organisation and the African Union have published a “Diabetes Declaration and Strategy for Africa” . This document calls on governments, stakeholders and partners to work together towards diabetes prevention, improved quality of life, and reduced morbidity and premature mortality.
^ Health Technology Assessment volume 17 issue 35 August 2013 Screening for type 2 diabetes: a short report for the National Screening Committee NR Waugh, D Shyangdan, S Taylor-Phillips, G Suri and B Hall
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^ National Service Frameworks and Strategies http://www.nhs.uk/nhsengland/NSF/pages/Diabetes.aspx (accessed February 2014)
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^ Diabetes UK, and a copy of its leaflet What diabetes care to expect https://www.diabetes.org.uk/OnlineShop/New-to-Diabetes/Whatdiabetes-care-to-expect/ (accessed February 2014)
^ NICE menu of indicators http://www.nice.org.uk/aboutnice/qof/indicators.jsp (accessed February 2014)
^ Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35(6):1364-1379. doi:10.2337/dc12-0413. Erratum in: Diabetes Care. 2013;36(2):490
^ Australian Government Department of Health and Ageing, Australia and New Zealand Horizon Scanning Network, targeted screening for cardiovascular risk for all adults between 40-74 years, 2010, available at: http://www.horizonscanning.gov.au/internet/horizon/publishing.nsf/Content/C8A5BA60BD01A93ECA257757000A2015/$File/PS%20Targeted%20screening%20for%20Cardiovascular_risk.pdf (accessed February 2014)
^ Verma R et al., National programme on prevention and control of diabetes in India: Need to focus Australas Med J. 2012; 5(6): 310–315.
^ Barquera S et al., Diabetes in Mexico: cost and management of diabetes and its complications and challenges for health policy. Globalization and Health 2013, 9:3
^ Azevedo M and Alla S. Diabetes in Sub-Saharan Africa: Kenya, Mali, Mozambique, Nigeria, South Africa and Zambia. Int J Diabetes Dev Ctries. 2008; 28(4): 101–108.
^ Diabetes Declaration and Strategy for Africa, 2006, available at: http://www.idf.org/webdata/docs/Diabetes%20Declaration%20&%20Strategy%20for%20Africa_full.pdf (accessed February 2014)