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Treating type 2 diabetes: how are we doing?

Study
Results
Comment

One of the key management tools in any organisation, large or small, is to know how well or badly you are doing. This information is too often lacking in healthcare, or at any rate is difficult to get at. A study from UK general practice [1] indicates that many things are being done better, but without as much impact as one might imagine.

Study

An anonymised primary care database with 142 practices in England and Wales provided the setting, with only the 74 practices with continuous recording over the years 1994 to 2001 being used. Patients had to be within the practice for at least six months in any one year. Records for type 2 diabetics were searched for information about BMI, blood pressure, Hb A1c, and cholesterol.

Results

There were about 500,000 patients in the 74 practices, 480,000 in 1994 and 525,000 in 2001. The number of type 2 diabetics rose from about 8,000 in 1994 to 13,000 in 2001. The prevalence of type 2 diabetes increased almost every year between 1994 and 2001 in both sexes (Figure 1), and at all ages. Overall the increase in prevalence was about 50%.



Figure 1: Prevalence of type 2 diabetes in England and Wales, by sex and year





The proportion treated with diet only fell from 38% in 1994 to 33% in 2001, with small increases in the proportion treated with oral hypoglycaemic drugs only, and insulin. Large changes in the types of oral agents used occurred over the period, with increases in metformin and short-acting sulphonylureas, and a large decrease in use of long-acting sulphonylurea. Other oral agents were used in under 5% of patients.

Monitoring improved significantly (Table 1), with large increases in cholesterol and Hb A1c measurements, and small but significant increases in BMI and blood pressure measures. The proportion of patients achieving current quality targets of treatment was largely disappointing. Apart from cholesterol, where the proportion of patients achieving a target of less than 5 mmol/L rose (Table 1), and small improvements in blood pressure targets achieved, the proportion of type 2 diabetics with BMI below 25 and Hb A1c below 7.5% or 6.5% actually fell.



Table 1: Monitoring indicators and achieving targets



Percentage measured
Indicator
1994
2001
BMI
43
55
Blood pressure
65
82
Glycosylated Hb
34
74
Cholesterol
17
61
Percent targets achieved
BMI <25
27
19
BP <160/100
65
80
BP <140/80
12
21
Glucosylated Hb <7.5%
54
52
Glucosylated Hb <6.5%
29
23
Cholesterol <5 mmol/L
20
46


Comment

Britain is undergoing a real-time, real-world, experiment, in which primary care quality targets have become one of the major driving forces for change. Most targets are based on good evidence, but the changes needed in the system have been uncomfortable, and arguably managed in a way most likely to cause resentment among the front-line troops.

Like any experiment, we have to wait for the results, and the results specific to this experiment will not be easy to discern, given ongoing rapid changes in medicine and healthcare practice. This study provides the background against which the real world experiment might be judged.

It also throws up a paradox. Despite greatly improved recording of health indicators and large changes in treatment patterns, the overall picture was one in which fewer, not more, targets were being met. Now these are post-hoc targets, not instigated until 2002, after data collection was concluded in this study, but it leaves open the question of what was going on. The trends did noty differ either in practices with the highest level of recording or in newly diagnosed diabetics, so neither of these provides a solution.

Perhaps the answer lies in the increasing weight of diabetic patients. It may be that the best of care is limited in what it can achieve in the face of greater obesity, so statins give better control of cholesterol but diabetes treatments cannot keep up. All this was going on before the immense concentration on obesity current in the last year or so. The next instalment will be interesting.

Reference:

  1. S Lusignan et al. Trends in the prevalence and management of diagnosed type 2 diabetes 1994-2001 in England and Wales. BMC Family Practice 2005 6:13 (www.biomedcentral.com/1471-2296/6/13)

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