COMMENTARY

Launching a Countrywide Attack on Type 2 Diabetes: The UK Experience

Laurie Scudder, DNP, NP; Jonathan Valabhji, MD, MBBS

Disclosures

July 18, 2016

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Diabetes Prevention Across the Pond

Laurie Scudder, DNP, NP: Welcome to a conversation about diabetes prevention programs (DPPs). Today, we are going to be discussing DPPs in the United Kingdom (UK).

The National Health Services (NHS) DPP Healthier You launched in 2016, with a first wave anticipated to cover almost 26 million people—one half of the UK population. We are here today to talk with Professor Jonathan Valabhji. Prof Valabhji is the national clinical director for obesity and diabetes at NHS England and a consultant in diabetology at St Mary's Hospital, Imperial College Healthcare NHS Trust in London. We are going to talk about the program, its key elements, and the implications for primary care.

Can you describe the key elements of your nationwide DPP, the first in the world? What are the key elements that make this effort successful when other interventions have been less successful? Can you describe some of the evidence base that supports widespread implementation of your program?

Jonathan Valabhji, MD, MBBS: We have commissioned an evidence review to get the ball rolling as to what the real-world translational interventions look like, based on the original randomized controlled trials, the largest of which took place in the United States.[1] A number of real-world translations have taken place in various countries, so we assessed that evidence.

We created a service specification that was based on our Expert Reference Group's interpretation of the systematic review and meta-analysis of real-world translations that we commissioned. It focuses on behavioral change to address weight loss, improve nutrition, and increase exercise—all fairly standard DPP goals. The evidence was strongest for group-based face-to-face encounters over at least a 9-month period with at least 13 face-to-face interventions, each of 1-2 hours' duration, so that the total contact time we are estimating should be at least 16 hours.

No One-Size-Fits-All Approach

Dr Scudder: Are the group sessions conducted weekly, and are they supplemented by any nongroup activity? Do you incorporate phone support, smartphone apps, or wearable fitness devices?

Dr Valabhji: We undertook a national procurement program. We went out with the service specification. We invited organizations to tender, and we appointed four different providers, each with the capacity to provide a national footprint—an intervention anywhere in the country, so we have four different DPP providers on what we are calling a "framework." Each of the interventions is slightly different, based on the parameters that I have outlined. Some are a little frontloaded, with a more intense initial phase followed by a maintenance phase, but there are variations on the theme based on the service specification. We do not have a one-size-fits-all approach for the entire country.

In England, there are approximately 200 different local health economies. Some have grouped together into larger units, and we invited expressions of interest from local health economies who wished to be part of the first wave of rollout of the national program.

We had a huge amount of interest—about three quarters of all local health economies expressed an interest in taking part in the first wave. We went through a process of selection based on the infrastructure that was already in place for identification of people in the high-risk category who are the targets for this intervention. We are looking at people who have what we call "nondiabetic hyperglycemia." The United States uses the term "prediabetes," albeit using wider HbA1c inclusion criteria than we do in the UK.

Local health economies that already had a reasonable infrastructure for identification and referral pathways were chosen preferentially. We started with 27 local health economies. We have a series of waves, in which each of those health economies chooses one of the four DPP providers on the national framework, so they can choose the program provider that best suits the local population needs, which vary across the UK. We have rural areas; urban areas; areas with a preponderance of people of South Asian origin, who we know are at much higher risk for type 2 diabetes; and areas with a preponderance of African and Caribbean populations, who are also at higher risk. Each of the local health economies can choose the program provider that they feel best suits their local population needs.

We have had what we are calling "mini-competitions" for the first eight local health economies. They have already selected their DPP providers from the framework, but over the course of the year, all 27 of the first-wave local health economies will have selected their providers. We are expecting the first referrals to be taken up by providers this month, and we are aiming for somewhere in the region of 20,000 interventions to be provided in the first year. We know that that will only touch a small proportion of the at-risk population, but this is the first phase of national rollout.

The 27 health economies that we are starting with will geographically cover about 50% of the country's population during this first phase. At steady state, we are expecting to be providing approximately 100,000 interventions annually once we have reached all areas of England.

Role of the General Practitioner

Dr Scudder: Can you describe how these programs will integrate with the primary care services already being provided to some of these patients? How will primary care physicians be involved in monitoring these patients?

Dr Valabhji: Let me give you a little background. We wanted to address three strategic issues with the program. The first, which is very similar to the issue in the United States, is that we have a rising prevalence of people who are overweight and obese (around two thirds of the adult population in England), and that is driving the higher prevalence of type 2 diabetes. The cost of diabetes is huge for our health service. We have an NHS that is free at the point of delivery for all our population, but demands are increasing, and one of the areas of increasing demand is diabetes. Around 10% of our spending on health in the country is directed towards the cost of diabetes services; the majority of that is spent on dealing with the complications of diabetes. So we are very realistic about the lead-in time to returns on investments in terms of our prevention efforts.

So the first strategy is to address this burgeoning health problem of type 2 diabetes. The evidence base from the original randomized controlled trials strongly suggests that we can prevent or delay this in those at high risk, and that is what we are aiming to do.

The second issue is that our NHS is a reactive, rather than proactive, service, largely because of the expectations of our population, and the fact that health professionals like to please their populations. If I have a problem, I want to book a 10-minute appointment with my general practitioner and walk out with a solution—ideally, a solution written on a prescription. To achieve sustainability in the years ahead, we feel very strongly that we need to swing the emphasis more towards a proactive approach, involving disease prevention.

The first question was where we start to gain buy-in both from our healthcare professionals and from the population at large in terms of the prevention agenda. The type 2 DPPs that have been successful in clinical trials have shown results within a 3-year timeframe. If we were to choose, for example, coronary heart disease as our first preventive effort, we would have to wait a decade or two before we could show that our program was successful.

Therefore, as our first foray into a national prevention agenda, we are starting with a type 2 DPP. A call for specific evaluations of the program has gone out from our National Institute for Health Research, so that we can aim to prove to our population and our healthcare professionals that the NHS can do prevention and that our DPP can do what is written on the tin.

How Are Participants Identified?

Dr Valabhji: The third element of our strategy is that in 2009, we began rollout of a national policy for a cardiovascular health check for all persons between the ages of 40 and 75 years, called the NHS Health Check. That health check assesses lipid profiles, cardiovascular risk, obesity, smoking status, and blood pressure—but also as part of that assessment, there is a diabetes filter, initially based on a questionnaire. Those who are deemed high risk by their questionnaire scores would then have a blood test (HbA1c or fasting glucose) to categorize normality, nondiabetic hyperglycemia, or undiagnosed type 2 diabetes.

Since 2009, we have therefore been identifying swathes of the population that have nondiabetic hypoglycemia. In most of the country, however, there has not been access to a DPP, so there has been no way to empower those people to beneficially modify their higher risk. Before now, we have not had a comprehensive DPP for those identified to already be at high risk; this program will now fill that gap.

We have worked, during the pilot phase (which was the last financial year) at developing seven demonstrator sites. We picked a portfolio of areas across England representing various settings—rural, urban, and areas with high proportions of people of South Asian or African and Caribbean origin—to see how we should apply our intervention practically on the ground. A lot of that work involved interfacing with primary care.

We had expected that a large proportion of referrals into the DPP would be coming from this NHS Health Checks, but in fact, well over 50% of people had already been identified in primary care through routine clinical practice as being in the high-risk category. General practitioners had assessed them for diabetes for various reasons, including a strong family history. We have modeled quite closely how many referrals we might expect from general practitioners.

A lot of other work needs to be done in general practice and in hospital environments, and we have capacity issues across the system. We have placed a significant emphasis on not making additional work for those working in primary care. Our program is designed to have minimal impact on the workload of primary care, so the appointed DPP program providers will do much of the work. They will provide the intervention; do the assessment of weights; and measure the impact on blood test parameters, such as HbA1c. They will examine the personal experience of participants and collect data on attendance. We ask our primary care physicians to contact patients who have already been identified as having nondiabetic hyperglycemia, explain the program, and refer them to one of the programs administered by their chosen provider. We are hoping that the impact on the workload in primary care will therefore be low.

Keeping Patients on the Wagon

Dr Scudder: Can you describe what will happen when the intervention ends? How will the program prevent people from slipping back into high-risk behaviors? At that point, what will be the role of your primary care system?

Dr Valabhji: Much of our learning is iterative. We will be learning more from the demonstrator sites. The first wave of the national rollout will inform subsequent waves. The providers will be assessing participant weight and HbA1c level at program completion.

We have a national system of data collection for people who already have a diagnosis of diabetes—what we call the National Diabetes Audit. Every year, data are extracted from general practice data systems for all patients with a coded diagnosis of diabetes. These data are combined with data extracts from hospital systems and from the Office of National Statistics. As the national clinical director, each year I receive a report (which is published) that tells me, for example, how many people have diabetes, how many have entered a hemodialysis program, and how many have died, and the average glucose levels across the population.

One of our intentions, which we are piloting this year, is to expand that data extraction to include patients with a coded diagnosis of nondiabetic hyperglycemia or the middle category of glucose tolerance, so that we can assess the effect of the program on the subsequent evolution of those patients to type 2 diabetes and the development of diabetes complications, or a lack of progression to type 2 diabetes, which is what we are hoping to achieve. We hope to have very rich data in the longer term about the effectiveness of the program.

We have not been prescriptive in terms of how frequently someone should be referred to the program. The four different DPP providers on the national framework have varying models for contact with individuals who have been through the program, so some maintain contact for a period of time to support maintenance of behavioral changes. Ultimately, however, some people will fall off the end of the program, and it will then be the call of general practitioners to decide if and when to refer them back to the program, depending on their follow-up weights and HbA1c values.

Dr Scudder: It sounds like a terrific program, and we look forward to watching the implementation. I hope that you will join us again in the future and describe the impact of the nationwide rollout. Thank you very much for sharing your time and your expertise with us.

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