Staged diabetes management: a systematic evidence-based approach to the prevention and treatment of diabetes and its co-morbidities

Abstract

The rising incidence and prevalence of diabetes with its concomitant complications have become a global concern. The necessity for a comprehensive model targeting primary, secondary and tertiary prevention as well as all levels of care has become apparent. Staged Diabetes Management (SDM) was developed over a decade ago, anticipating the need to address diabetes in a systematic evidence-based manner so that new therapies and research findings could be rapidly translated into clinical practice.1, 2 SDM was founded on the principle that a detailed understanding of the natural history of diabetes and the underlying defects responsible for hyperglycaemia and its associated complications should form the basis of sound clinical decision-making. It relies on clinical pathways to guide the clinician through the detection, treatment and follow-up of each type of diabetes and associated macrovascular and microvascular complications. Unique to SDM is that each pathway is customized for utilization in collaboration with local physicians and allied health professionals. Thus far clinicians in 22 countries, using 11 translated versions of SDM, have participated in this process. Taking into account regional differences in medical practice, resource allocation, availability of pharmacologic agents and access to care, these regional versions of SDM have led to a reduction in variation in practice, improved screening and detection, tightened glycemic control and increased surveillance for complications. In use for more than five years in many sites, it has resulted in improved management of hypertension and dyslipidemia. Additionally, it has resulted in a significant decrease in the rate of such complications as foot ulcers and lower extremity amputation. It has been noted that diabetes contributes disproportionately to the cost of medical services throughout the world. In the United States, one-seventh of all medical care costs are consumed by less than 5% of the population with diabetes. A similar pattern has been noted throughout Latin America, Europe and in most of Asia. One way of reducing the financial burden is to find cost-effective approaches to prevention, detection and treatment of diabetes and its complications. The SDM model directly addresses this issue by seeking to optimize the limited resources available for diabetes care, prioritizing treatment, reducing medical error and expanding the role of allied health professionals. As SDM moves into the 21st century, its mission has expanded to encompass the principles of primary and secondary prevention. With the recent identification of an increasing number of novel disease susceptibility genes for type 2 diabetes, the substantial evidence related to the contribution of diet and lifestyle to the onset of disease, and a more complete understanding of the natural history and pathophysiology of all types of diabetes, the possibility of identifying with greater sensitivity and specificity individuals at high risk for diabetes may soon be realized. More important is the introduction of non-hypoglycaemic insulin sensitizing agents and the renewed emphasis on lifestyle changes as viable therapeutic interventions for the prevention of type 2 diabetes and perhaps gestational diabetes. These developments will not dampen the current emphasis on identifying those with undiagnosed disease. Rather, the goal is to accomplish this more systematically and at an earlier point in the natural history of diabetes, in order to prevent or slow the progression of complications. Nor does this portend a reduction in the utilization of resources devoted to the treatment of complications. With an increased understanding of the pathophysiology of cardiovascular, renal, neurological and retinal complications: there is a need to translate what we know into practical clinical processes that will assure the person with diabetes an opportunity to enjoy the highest possible quality of life. Thus, the goal of SDM is to develop and implement new approaches to the continuum of diabetes care. This takes into account an integrated strategy for the prevention, early detection and improved treatment of all forms of diabetes and associated complications. To achieve this goal, the results of research on complex interrelated genetic and environmental risk factors may one day be integrated into the SDM protocols. Simultaneously, efforts to slow the progression of complications have to continue. On 11–12 November 2000, 70 delegates who have worked with SDM, from Australia, Brazil, Canada, Japan, Mexico, Poland, Singapore, Pakistan, Taiwan and the United States, attended a two-day symposium. Held in Puebla, Mexico, following the International Diabetes Federation Congress, the symposium was sponsored by the International Diabetes Center (IDC), a World Health Organization Collaborating Center in Diabetes. The purpose of the symposium was to share recent international experience in the implementation of SDM and to discuss a range of new initiatives pioneered by the developers of SDM at the IDC. Chairperson: Richard Bergenstal (USA) Donnell Etzwiler (USA) Roger Mazze (USA) Boniface J Lin (Taiwan) The importance of tight glycemic control in all forms of diabetes has been well documented.3-6 As early as 1967, the International Diabetes Center demonstrated that tight glycemic control was a critical component in the management of type 1 diabetes and that a multidisciplinary approach would be necessary to meet this goal. As a participant in the Diabetes Control and Complications Trial (DCCT), the IDC was able to demonstrate that an evidence-based multidisciplinary approach could achieve near normal glycemia in individuals with type 1 diabetes. During the course of this landmark study it became clear that an evidence-based systematic approach to clinical decision-making was needed if the findings of the DCCT to be in clinical The of SDM by the manner in clinical at the type of the of and the for and These factors associated with in at of findings that clinical decision-making on such from as the by therapies and complex on for insulin in type 1 diabetes, of use in type 2 diabetes and of insulin in gestational diabetes. the of these In an to one possible of at the to by with to each with the and these it was possible to in to that would guide therapeutic in gestational diabetes, the to to insulin and to insulin as well as as a of the of glycemic control needed to the risk of This approach was to clinical decision-making for with type 1 or type 2 diabetes at the IDC. it was possible to the critical that to improved glycemic reduction in and increased to These the The treatment the basis for a new approach to clinical decision-making. 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