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Why Welsh practices hope to stop seeing diabetics
Generic healthy eating campaigns run through the dark days straight after Christmas doubtless have some benefit – but mostly on those inclined to think about their health regardless.
GP Mark Goodwin and his colleagues across a cluster of practices in Port Talbot face high levels of deprivation and obesity. Provided with funding by the health board to test out a new approach to improve the health of their population, the cluster accepted Goodwin’s suggestion to focus on the prevention of diabetes.
“We have high levels of deprivation and we remembered doing some work with prediabetic patients and those at risk of becoming prediabetic about 12 years ago so we agreed to relaunch that.”
With the support of their software provider, the practices identified patients who had ever recorded an abnormal blood sugar level (GTT Hba1c or fasted glucose).
“The two groups together accounted for around 12% of the cluster population – and 16% of my patients.”
With high levels of obesity, including all those with a BMI above 30 in the programme, which is a common risk factor for developing prediabetes, nearly a third of the population would have been covered Goodwin explains – hence the more conservative parameters.
“Over 18 months we called in about 6,000 patients for fresh Hba1c testing. Around 95% agreed to retake the test and 70% returned for a face-to-face consultation with a staff member about healthy eating. Two employees from each practice attended a three day food course recognised by the Welsh government. They offered focused and motivational discussions, with literature, exercise referral and video educational links. Subsequent blood tests showing similar results across the cluster suggest that staff were delivering similar messages across all practices.”
Many patients returned annually over the three year project agreeing to have ongoing annual face-to-face sessions and blood tests.
Goodwin said most patients were eager to take part if the potential benefits were explained clearly.
“We also had good staff building relationships – the people delivering the clinics would usually ring or write the letters and book the follow-ups. That develops rapport and trust with the patient.”
After the first year, the three year programme was rolled out to three other clusters with a total population of 170,000. A team at Swansea University diabetes research unit is now evaluating the results.
Goodwin has done his own analysis and is optimistic about the findings.
“I looked at 1000 patients from my cluster of eight practices who had at least one face-to-face session and two blood tests, one before the first lifestyle and one at least a year after the lifestyle. In 70% of the patients who had the face-to-face consultation their Hba1c had improved, 25% had got worse and 5% stayed the same.
The mean Hba1c has fallen almost 2mmol.
Nearly 40% of those diagnosed as prediabetic returned to normal glycaemia.
“We had seen a 0.4% drop in prevalence of diabetes in my practice from 8.2 to 7.8% in three years. That is not massive but it means 5% fewer diabetics – that’s 11 people. Patients arriving in the practice already diabetic or moving away with diabetes are identical over this time frame so the drop is a result of fewer patients becoming diabetic than die from diabetes and other ailments.
However, with some of Goodwin’s patients continuing to have an Hba1c score over 41, since October he has started prescribing metformin to them. He hopes that the next round of blood test results will show many of those now have scores below 41. If so, the number of his patients with prediabetes will have fallen by around 75%, half through lifestyle advice and half through metformin.
Extending the training, the annual lifestyle and blood testing to those similarly at risk across Wales would cost under £3m, Goodwin suggests – some public health advertising campaigns cost more.
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