There is an urgent need to reorganise the way diabetes care is delivered with a focus at the community level – and the role of data is key – according to a panel of international experts that includes Professor Jonathan Shaw of Monash University, Melbourne.
Their recommendations to governments across the world, published in the Lancet Commission on Diabetes last week, are the culmination of four years of extensive work on data curation, synthesis and modelling.
The specially convened panel of diabetes, epidemiology, public health and clinical care experts came together in 2016 as part of a Lancet Commission series to review new modelling data and propose action plans in a bid to quell the growing global diabetes epidemic.
Now they deliver four recommendations on ‘closing the gap’ in diabetes with respect to prevention, knowledge, care and data.
One of their key conclusions is that change must be embedded at the community level, using non-medical field workers if necessary, to educate, monitor patients and collect data.
The Commission is big on data-based models, with recommendations to implement national linked registers to capture people at risk of developing diabetes.
Other key elements include an emphasis on ‘prevention, early detection, prompt diagnosis, and continuing care with regular monitoring and ongoing evaluation’ as the key elements in reducing the growing burden of diabetes.
In terms of diabetes care, the Commission highlights the best evidence for managing diabetes – reducing HbA1c by 0.9%, systolic blood pressure by 10 mmHg, LDL cholesterol by 1 mmol/L (39 mg/dL), or a combination of all three, to independently reduce the risk for CVD, all-cause death, or both, by 10% to 20%.
But rather than looking to new and expensive drugs and technologies to achieve those goals, the Commission combines the cornerstones of diabetes prevention and care – lifestyle interventions, access to essential diabetes medicines and therapeutics to treat associated risk factors, including statins and RAS inhibitors for instance
It notes that for individuals with impaired glucose tolerance, implementing a structured lifestyle intervention and use of metformin could prevent or delay type 2 diabetes in by 30%-50%, while sustained weight reduction in patients with obesity could induce remission of type 2 diabetes for up to 2 years.
The Commission also highlights the need for technical know-how to improve capacity for data collection, surveillance, and audit.
Its recommendations include national linked diabetes risk-factor registries, improved medical electronic records and software that allows clinicians to integrate diabetes screening and care into maternal, child, and adolescent health programs. This are all essential to achieving the evidence-based – but for many, unrealistic – goals of diabetes management and prevention at a population level.
The potential benefits of investigating in such systems are significant: modelling done by the Commission found that in the ten lower-middle-income countries with the greatest burden of diabetes globally, up to 800 000 premature deaths could be prevented by improving diabetes diagnosis, access to essential medicines and support for management of cardio metabolic risk factors.
The Commission also recommends task shifting – passing knowledge about how to prevent, treat, and manage diabetes long term down the healthcare chain from doctors to people such as community field workers who could be trained to collect data, monitor patients, stratify risk and capture those people falling through the gaps.
In an interview with the limbic, Commission member Professor Jonathan Shaw from Baker Heart and Diabetes Institute, Melbourne, says that while Australia has ‘excellent’ diabetes health services, the system is more fragmented than other models, which he says is ‘not good’ for team-based care.
“We do have it, there are lots of institutions that run team-based care but I think there is a lot that falls between the cracks – I think we can do better at organising care and having better linkages between the relevant healthcare professionals for diabetes.”
He adds that Australia has socially and economically disadvantaged communities that would stand to benefit from the Commission’s recommendations.
“The Indigenous population is a prime example of that where the prevalence of diabetes is massively increased compared to the general population and the risk of complications from diabetes is much higher … that’s where team-based care, using people who are deeply embedded in the community and who are much more familiar with the social requirements of a community … but yet also have familiarity with the issues of healthcare delivery, can work.”
In terms of data collection and surveillance, Professor Shaw says that’s an area where Australia falls furthest.
The ability to access national datasets and linking them is critical to implementing the Commissions’ recommendations but citing ongoing concerns from the public around privacy – which he concedes is important – Professor Shaw says Australia has a long way to go.