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Art, Music and Drama Therapists
Dietitians
Physiotherapists
Orthoptists
Prosthetists and Orthotists
Occupational Therapists
Podiatrists
Paramedics
Radiographers
Speech and Language Therapists
Allied Health Professions
Diabetes toolkit
Maximising allied health professionals contribution to the
delivery of high quality and cost effective patient care.
A guiDe fOR heALThcARe cOMMiSSiOneRS
preventionassessment
treatmentrehabilitation
re-ablementlong-term gain
how AhPs improve patient care and save the nhS money > Click
to enter toolkit
This toolkit is one of a series of toolkits developed by NHS
London on behalf of the Strategic AHP Leads Group (SAHPLE)
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Home Diabetes toolkit 2
Opening narrative
In line with NHS Diabetes stated aim Allied Health Professions
(AHPs) are proactively supporting initiatives and service redesign
which is evidenced based and addresses the QIPP (Quality,
Innovation, Productivity and Prevention) challenge.
The Strategic Health Authority Allied Health Profession Leads
(SAHPLE) commissioned a project to identify clinical pathways where
AHPs make a significant difference in the clinical outcomes for a
group of vulnerable patients including those with diabetes.
AHPs include a number of professions who work both in
uniprofessional teams and often show their strengths in diabetes
care as part of a Multidisciplinary Team (MDT), for example as part
of a coordinated foot protection team as highlighted in the
redesign in Salford:
See the success stories on the NHS Diabetes website >
Key outcomes
Amputation rates have fallen by two thirds.
Number of foot ulcers has reduced by 300 over four years.
Estimated savings of over 1m over four years.
This success story is one of a number highlighted by NHS
Diabetes.
The key AHP professions in diabetes include:
Dietitians Dietetic treatment aims to optimise glycaemic
control, improve HbA1c, reduce hypoglycaemia, improve lipid
profiles and reduce hypertension.
Occupational therapists Optimise function and independent
living. Provide functional and vocational advice. Facilitate return
to employment and leisure activities, and maintain independence
improving quality of life.
Orthoptists Provide assessment of vision, visual fields and eye
movements. Diagnosis of low vision or visual field loss will aid
prevention of falls.
Orthotists Provide orthoses to complement podiatry treatment to
enable mobilisation. Orthoses include shoes to accommodate
dressings, insoles to reduce plantar pressures and offloading
devices to aid wound healing.
Physiotherapists Provide specialist assessment, treatment and
advice on improving levels of physical activity, prescription and
monitoring of individualised exercise programmes. This helps
optimise blood glucose levels in those with diabetes and can help
prevent/delay the onset of type 2 diabetes. Physiotherapists also
have a role to play in the assessment and rehabilitation of
complications and comorbidities associated with diabetes.
Podiatrists By detecting and managing the long-term
complications of the diabetic foot the podiatrist reduces the risk
of disability and foot complications which can have costly and
devastating consequences for people with diabetes.
Radiographers Provide expert imaging and interpretation to
identify disease progression / complications (such as arthropathy/
osteomyelitis/renal/ visual complications).
Paramedics Patients often present via the 999 system with acute
or emergency problems which involve peripheral neurovascular issues
either directly or indirectly. Paramedics are able to recognise
such complaints and/or co morbidities early on and refer to the
most appropriate pathway, either emergency or through alternative
specialist pathways.
Introduction >
For further information please contact:
Lesley Johnson SHA Allied Health Professions Lead NHS London
Southside 105 Victoria Street London SW1E 6QT
[email protected]
This toolkit has been endorsed by:
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prevention>assessment>
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re-ablement>long-term gain>
Home Diabetes toolkit 3
introduction
What does this toolkit do for you?
This toolkit has been developed by a range of clinicians working
in diabetes care. The information has been provided by a national
collaboration of clinicians in conjunction with their professional
bodies and is based on available research evidence.
The work has been reviewed by a range of specialists including
Dr. Rowan Hillson, the National Clinical Lead for Diabetes. The
toolkit has been endorsed by the Professional Bodies.
This toolkit provides information on the following:
Which interventions most positively benefit patient care
What range of interventions over time will reap the most
benefits during illness and lead to independence
How do the interventions match to the Outcomes Framework
Which interventions are able to save money to the system
How is the functional ability of patients enabled by using
Allied Health Professionals (AHPs).
Audience
This information is aimed at those involved in commissioning or
developing diabetes care.
The toolkit will provide an interactive method of ensuring that
patient care is meeting quality standards and providing essential
elements of the QIPP agenda
If you are looking to re-design or provide diabetes services
this information will assist you meet the needs of your local
population:
Contents
1. List of interventions by Allied Health Profession
2. A pathway graphic highlighting where each profession
significantly contributes to value-for-money high quality care
3. QIPP (Quality, Innovation, Productivity and Prevention) key
facts
4. Matching interventions to the Outcomes Framework
5. Research evidence
6. Case studies
7. General information
We hope you find it valuable. Art, Music and Drama Therapists
Dietitians
Physiotherapists
Orthoptists
Prosthetists and Orthotists
Occupational Therapists
Podiatrists
Paramedics
Radiographers Speech and Language Therapists
Rehabilitation Re-ablement Long-term gainPrevention Assessment
Treatment
patient journey
Key AHP InTeRvenTIOn POInTs In THe DIAbeTes PATHWAy
Click on one of the intervention stages below to find out more
about AHPs input
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Presenting condition Health risk Referral to Risk mitigated
Outcome Framework domain
(download)
Cost saved
Obesity Development of Type 2 Diabetes
Dietitians and physiotherapists provide expert support and
guidance on lifestyle change to reduce weight and improve health.
Occupational therapists also provide lifestyle redesign for
obesity.
Prevention of diabetes 1,2 Diabetes UK: obese people are up to
80 times more likely to develop Type 2 diabetes than those who
maintain a healthy weight Diabetes UK website >
Patient initially diagnosed with diabetes
Dietary, physical activity and lifestyle information for
glycaemia control
Dietitians and physiotherapists aim to optimise glycaemic
control, improve HbA1c, reduce hypoglycaemia, improve lipid
profiles and reduce hypertension
Escalation to insulin dependency and deterioration in diabetic
control (NICE guidelines)
1,2 DAFne study: Diabetes education and self management for
ongoing and newly diagnosed (DESMOND) NHS Diabetes website >
Infection and ulceration of feet potentially leading to
amputation
Podiatrists and physiotherapists are involved if initial foot
assessment reveals evidence of neuropathy, absent pulses or foot
deformity
Foot ulceration and potential amputation
2,5 Of the 70 amputations performed per week, 80% potentially
preventable Right Care report >
Peripheral Vascular Disease (PVD) Ulceration, Suspected Foot
Emergency, Charcot Foot
Infection and ulceration of feet potentially leading to
amputation
Podiatrists, radiographers, physiotherapists and orthotists who
form part of the Foot Protection Team
Potential amputation, major foot deformity and long tem
morbidity
2,5 Comprehensive multi-disciplinary foot care programmes have
been shown to increase quality of care and reduce amputation rates
by 3686% View details >
For every 1 spent in Orthotics the NHS saves 4 Download Orthotic
service in the UK report >
View Diabetes Footcare Activity Profile >
Visual deficits Diabetic eye disease is the most common form of
visual loss in the working age population
Orthoptists provide specialist assessment of vision, visual
fields and eye movements
Low vision assessment and management (visual rehabilitation) can
help the patient remain independent and in some cases remain in the
workforce
2,5 Reduce the risk of sight loss amongst people with diabetes
through prompt identification and effective treatment NHS Diabetes
website >
Risk of falls In the UK each year there are estimated 233,000
fractures primarily due to osteoporosis combined with a fall
(fragility fracture)
Orthoptists, occupational therapists, physiotherapists,
podiatrists and paramedics provide coordinated falls prevention
service. Radiographers undertake DXA scans and monitor bone
health.
Visual impairment identified: Home assessment and provision of
equipment and techniques to avoid risk of falling
3,5 Falls cause significant morbidity and mortality particularly
in older people, and also have marked psychological effects on the
individual
Right Care report> Visual loss and falls: a review >
Home Diabetes toolkit 4
commissioning principles: which AhPs do you need?
Click this link to find out how AHPs save the nHs money, and the
evidence and case studies that support claims about the benefit of
their interventions.
Commissioners may not presently know how to maximise the use of
a range of AHPs to add to patient benefit and the QIPP agenda. This
toolkit illustrates the logic and clinical argument around onward
referral to multi-disciplinary AHP teams and outlines appropriate
use of AHP professions so that patient quality is enhanced and
independence wherever possible is gained.
AHPs are not optional but integral to the necessary treatment of
patients. There are clinical and financial risks in patients not
receiving AHP input.This toolkit aims to show what the appropriate
response is to a presenting condition and how a range of AHPs work
together to reach the outcomes aspired to in the National Outcomes
Framework.
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Home Diabetes toolkit 5
Presenting condition Health risk Referral to Risk mitigated
Outcome Framework domain
(download)
Cost saved
Patient asking for strategies to manage long term condition when
severe
Deterioration of diabetes control with exacerbation of
co-morbidities and loss of independence
Occupational therapists and physiotherapists are able to offer
expert assessment of home environment and strategies to achieve
rehabilitation and reablement goals
Maintenance of independence and avoidance of depression
2,4 The ultimate goals of patient education are to improve to
control of vascular risk factors, and to aid the management of
diabetes-associated complications, if and when they develop, to
improve quality of life.
NHS Diabetes website >
Amputated foot/leg Mobility and activities of daily life
impacted by limb loss. Deterioration of co-morbidities
Prosthetists, physiotherapists, occupational therapists and
podiatrists provide a coordinated team alongside medical and
nursing colleagues to optimise patient rehabilitation
Injury to contralateral limb and prevention of falls, maintain
independence and return to employment. Enhance social
inclusion.
1,2,3 Fall in the number of people who were undergoing repeat
major amputations caused by diabetes
NHS Diabetes website >
For every 1 spent in Orthotics the NHS saves 4
BACPAR website >
commissioning principles: page 2 of 2
Click on one of the professions above to find out how AHPs save
the nHs money, and the evidence and case studies that support
claims about the benefit of their interventions.
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Home
Benefits of AhP input: prevention stage (1 of 2)
AHPs contributions at the prevention stage.
Dietitians provide individualised diet therapy for those with
impaired glucose regulation and metabolic syndrome to reduce risk
of progression to diabetes.
Dietitians also provide support and guidance on lifestyle
changes to help patients reduce weight and improve their health
thus reducing risk of developing diabetes.
Modifying diet and physical activity prevented or delayed type 2
diabetes onset in high risk ethnically diverse population with
IGT.
Dietitians play a crucial role in leading the coordination of
activities at all levels including individual and family
counselling, local initiatives in schools and work places and
government policies to support and facilitate healthier
choices.
In gestational diabetes dietetic led advice on diet and
lifestyle is a high priority following pregnancy to prevent
progression to diabetes.
Thomas B. Bishop J (2007) Manual of dietetic Practice Section
4.
Orthotists
Specialist diabetic orthotists provide accommodating footwear
and insoles to prevent ulcers and amputation. They also offer
regular reviews, where footcare advice is provided, and facilitate
re-referral to the high risk foot clinic if necessary.
The prevention and management of foot problems in type 2
diabetes, NICE guideline, page 18. NICE website >
Studies show that high risk patients without prescribed footwear
will develop ulcers.
Boulton AJ, Clinical Trials report: Therapeutic footwear in
diabetes, CURRENT DIABETES REPORTS. Volume 2, Number 6, 475-476
Key fact In terms of interventions, the cost of targeting high
risk groups at population level to prevent or delay raised glucose
levels is likely to be lower than the cost of one-to-one
interventions to stop people with raised glucose levels progressing
to type 2 diabetes.
NICE Guideline Costing statement: Preventing type 2 diabetes:
population and community interventions May 2011.
65kThe cost on the NHS to heal one ulcer is 3k to 7.5k. Should
this progress to amputation the cost is estimated to escalate to
65k. This is much more than the cost of preventative orthoses.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium: pg 12,13. See
website >
International Diabetes Federation, The diabetic foot:
amputations are preventable, 2005. See website >
Podiatrists
Podiatrists provide structured diabetes education and deal with
all aspects of foot health and lifestyle modifications, such as
smoking cessation, footwear education and falls prevention. They
also provide foot screening an essential part of the prevention
programme for patients with diabetes and foot health advice to all
other health professionals and carers
A guide to the benefits of podiatry to patient care. The Society
of Chiropodists and Podiatrists. 2010 See report >
The prevention and management of foot problems in type 2
diabetes, NICE guideline, page 18.NICE website >
navigate to:
Dietitians
Diabetes toolkit 6
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
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Home
Benefits of AhP input: prevention stage (2 of 2)
Dietitians
Dietitians provide support and guidance on lifestyle changes to
help patients reduce weight and improve their health thus reducing
risk of developing diabetes.
Modifying diet and physical activity prevented or delayed type 2
diabetes onset in high risk ethnically diverse population with
IGT.
The Diabetes Prevention Programme Research Group (2000) The
Diabetes Prevention Programme (DPP): description of the lifestyle
intervention. Diabetes Care 25: 2165-2171
The Diabetes Prevention Programme Research Group (2000)
Reduction in incidence of Type 2 diabetes with lifestyle
intervention or metformin. New Eng J Med 346: 393-403
Wylie-Rosett, J. and Delahanty, L. (2002) an integral role for
the dietitian: implications of the diabetes prevention program J.
Am. Diet Assoc 102: 1065-1068
Key fact Diabetes UK says obese people are up to 80 times more
likely to develop Type 2 diabetes than those who maintain a healthy
weight.
AHPs contribution at the prevention stage. navigate to:
Diabetes toolkit 7
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
Physiotherapists
Physiotherapists promote the health and well being of
individuals and the general public emphasising the importance of
physical activity and exercise. The benefits of exercise in the
prevention of type 2 diabetes are well described. Physiotherapists
help to optimise blood glucose control with exercise/physical
activity to help with prevention/delay of type 2 diabetes.
Physiotherapists utilising their expertise in exercise therapy
and physical activity, can provide advice, education and tailored
exercise programmes for those individuals identified as being at
risk of developing type 2 diabetes.
Deshpande AD et al (2008) Physical Activity and Diabetes:
Opportunities for Prevention Through Policy Physical Therapy.
38(11):pp 1425-1435
Peter, R.et al (2011) Effects of Lifestyle Advice in People
Newly Diagnosed with Type 2 Diabetes, Diabetes & Primary Care
13(5)pp: 276283.
Physical activity can help prevent and manage over 20 conditions
and diseases, promote mental wellbeing and help people to manage
their weight. Even relatively small increases in physical activity
are associated with some protection against chronic disease and an
improved quality of life.
Chief Medical Officers of England S, Wales, and Northern
Ireland. Start Active, Stay Active: A report on physical activity
from the four home countries Chief Medical Officers. London; 2011.
See website >
Stamatakis E, Hamer M, Dunstan DW et al. (2011) Screen based
entertainment time, all-cause mortality, and cardiovascular events.
Population based study with ongoing mortality and hospital events
follow-up. Journal American College Cardiology 57 pp: 292-299
As experts in functional ability and with a thorough knowledge
of the pathophysiology of inactivity, physiotherapists have the
skills and knowledge to improve physical activity levels across
their client demographic.
Chartered Society of Physiotherapy, Physical Activity: Evidence
Briefing (2012) See website >
Key fact Physical activity has been shown to improve glycaemic
control to levels comparable to pharmaceutical intervention.
Yates, T., Khunti, K., Davies, M., (2011) Physical Activity:
Efficacy and Application in the Management of Type 2 Diabetes,
Diabetes & Primary Care 13(5)pp: 311-316
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Dietitians
Dietitians at Northumbria have implemented a pre insulin
assessment process which is now part of the local stepped approach
in the glycaemic management of people with type 2 diabetes. A local
audit of this dietetically led intervention demonstrated that only
half of those referred for insulin therapy actually required this
after the pre insulin assessment. And for those who commenced
insulin there were lower levels of weight gain than expected.
Oliver L.E (2009) Diabetes UK Annual Professional Conference
Poster Presentations. Outcomes for people with Type 2 diabetes on
maximum tolerated oral therapy who have pre-insulin assessment with
a dietitian.
Home
Benefits of AhP input: assessment / diagnosis stage
AHPs contributions at the assessment/diagnosis stage.
Podiatrists
Podiatrists perform full assessments and evaluation of skin,
soft tissue, musculoskeletal, vascular and neurological conditions
in the foot and lower limb. They identify risk factors for lower
limb amputation and develop care plans to prevent deterioration.
National guidelines are in place for the management of the foot in
diabetes.
N West Podiatry Services Guidelines for the Prevention and
Management of foot problems for people with Diabetes 2008, FDUK See
NHS Evidence website >
navigate to:
Orthoptists
Orthoptists provide assessment of vision, visual fields and eye
movements. Diagnosis of low vision or visual field loss helps
prevent falls while diagnosis of cranial nerve palsy, often linked
to microvascular pathology, prompts diabetes detection.
See pubmed.gov website >
Radiographers
Radiographers provide expert imaging and interpretation to
identify disease progression/complications (such as
arthropathy/osteomyelitis/renal/ visual complications).
Management of Diabetes, Scottish Intercollegiate Guidelines
Network - SIGN, 2010
Radiographic Advanced Practitioners can also refer patients with
suspected Charcots foot for further imaging (such as CT) and
orthopaedic opinion.
Paramedics
Paramedics are trained in all aspects of pre-hospital emergency
care ranging from acute problems such as cardiac arrest to urgent
problems such as minor illness and injury. On arrival at an
accident they assess the patients condition, start any necessary
treatment and refer as appropriate. They assess diabetes patients
and can highlight frequent problems via a range of pathways.
Download report >
Orthotists
During reviews, specialist diabetic orthotists will be able to
identify possible new episodes, such as Charcot changes, and
re-refer to a specialist clinic or AHP.
In orthotic-only clinics patients are assessed and provided with
orthoses to accommodate the changes to the foot shape, thereby
preventing further ulcerations caused by excessive plantar
pressures and ill fitting footwear.
Key fact For every 1 spent in orthotics the NHS saves 4.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium: pg 1 View
document >
Diabetes toolkit 8
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
Physiotherapists
Physiotherapy practitioners using their knowledge of the
neurological, musculoskeletal and cardiovascular systems would be
able to identify those patients who had developed or are at risk of
developing diabetes and those complications associated with it.
These could include lower limb peripheral neuropathy, contracted
(frozen) shoulder, vascular changes in the lower limb and foot
which can potentially lead to lower limb amputation and other
cardiac complications such as myocardial infarction.
Physiotherapists can also identify those patients who may be at a
risk of falls.
Cade, W.T., (2008) Diabetes Related Microvascular and
Macrovascular Diseases in the Physical Therapy Setting, Physical
Therapy. 38(11):pp 1322 1335
Hanchard N, Goodchild L, Thompson J, OBrien T, Richardson C,
Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011)
Evidence-based clinical guidelines for the diagnosis, assessment
and physiotherapy management of contracted (frozen) shoulder v.1.5,
standard physiotherapy. Endorsed by the Chartered Society of
Physiotherapy. See website >
Key fact 80% of patients referred to musculoskeletal
physiotherapy were found to have diabetes or associated risk
factors. Identification of these issues during physiotherapy
assessment ensures optimum treatment planning and management.
Kirkness, CS, Marcus RL, LaStayo PC, Asche CV, Fritz JM (2008).
Diabetes and Associated Risk Factors in Patients Referred for
Physical Therapy in a National Primary Care Electronic Medical
Record Database. Physical Therapy. 2008; 88:1408-1416. See website
>
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Podiatrists
Once the level of risk for foot injury or ulceration has been
determined by the podiatrist, appropriate management schemes
including footwear recommendations and orthotic provision are
provided by community podiatry or the specialist and surgical
podiatrists.
How can we improve the care of the diabetic foot. Wounds UK
2008. Vol 4. No.4
Direct referral to diabetologists and/or vascular surgeons
ensures quality of care in a timely manner which also aids
efficient use of NHS resources.
Community podiatrists provide specialist clinical care for
patients who are deemed at high risk of a foot/lower leg problem.
These interventions help reduce hospital stay and ensure seamless
care across primary and secondary care.
Podiatrists with advanced scope of practice within diabetes also
provide supplementary prescribing services, e.g. antibiotics, pain
relief and referral for diagnostic imaging and surgery.
Putting feet first Commissioning specialist services for the
management and prevention of diabetic foot disease in hospital.
Diabetes UK. June 2009 Download the report >
Orthotists
Within diabetic foot clinics orthotists provide orthoses to
complement podiatry treatment and enable mobilisation. Orthoses
include shoes to accommodate dressings, insoles to reduce plantar
pressures and offloading devices to aid wound healing.
Munro, The orthotist, the diabetic foot and the future. The
diabetic foot journal vol 13, no 3 2010
Orthoptists
Orthoptists treat double vision and visual field loss to enhance
adaptation and navigation.
Dietitians
Dietetic treatment aims to optimise glycaemic control, improve
HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce
hypertension.
It also addressed associated dietary issues such as renal diets,
coeliac diets, low residue diets and high kcal diets as required to
achieve and maintain appropriate BMI.
The implementation of nutritional advice for people with
diabetes. Nutrition Subcommittee of Diabetes Care advisory
Committee of Diabetes UK (2003) Diabetic Medicine 20, 786-807.
Home
Benefits of AhP input: treatment stage
navigate to:AHPs contributions at the treatment stage.
Diabetes toolkit 9
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
Physiotherapists
Physiotherapists aim to optimise glycaemic control, improve
HbA1c, improve lipid profiles and reduce hypertension. Physical
activity and exercise also help to manage other comorbidities and
patients fear avoidance behaviours, especially in relation to
pain.
Cade, W.T., (2008) Diabetes Related Microvascular and
Macrovascular Diseases in the Physical Therapy Setting, Physical
Therapy. 38(11):pp 1322 1335
National Institute for Health and Clinical Excellence. Behaviour
change at population, community and individual levels. (PH6).
London: National Institute for Health and Clinical Excellence;
2007. See website >
Physical activity reduces diabetic related complications by 32%
and diabetic related mortality by 42%.
Boule NG, Hadded E, Kenny GP, et al.(2001) Effects of exercise
on glycemic control and body mass in type 2 diabetes mellitus: a
meta-analysis of controlled clinical trials. Journal of the
Americal Medical Association.; 286(1218-27)
Chartered Society of Physiotherapy, Physical Activity: Evidence
Briefing (2012) URL: See website >
Chartered Society of Physiotherapy, Facilitating Behaviour
Change: Evidence Briefing (2012). See website >
Key fact Exercise significantly improves glycaemic control and
reduces visceral adipose tissue and plasma triglycerides in people
with type 2 diabetes.
Thomas D, Elliott EJ, Naughton GA (2006) Exercise for type 2
diabetes mellitus. Cochrane Database of Systematic Reviews, Issue
3. Art. No.: CD002968. DOI: 10.1002/14651858.CD002968.pub2
Key fact A new report published in March 2012 by NHS Diabetes
sets out the shocking cost to both patients and the NHS of poor
quality diabetic foot care. The report shows that around 650
million (or 1 in every 150 the NHS spends) is spent on foot ulcers
or amputations each year. It also highlights the devastating
consequences of foot problems in people with diabetes. Around 7% of
people with diabetes currently have, or have had, a foot ulcer,
which can lead to amputation. 50% of people who have a major
amputation die within two years; many of these amputations could be
avoided with the right care.
NHS Diabetes is calling on the NHS to set up specialist diabetes
foot care teams as a matter of urgency. Foot care multi
disciplinary teams (MDTs) can generate savings for the NHS that
substantially outweigh the cost of the team. One example shows how
a local hospital team costing around 33,000 a year generated
savings of almost million a year for the local NHS. Most
importantly MDTs have been shown to reduce amputations by up to two
thirds. See report >
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Home
Podiatrists
The podiatrist liaises with primary care and diabetes specialist
teams in the management of general diabetes care, in particular in
advanced practice in preventing limb loss.
The partnership between the diabetologist, vascular surgeon, and
podiatrist is a natural one. The complementary skills and knowledge
of each professional can improve limb salvage and functional
outcomes. Comprehensive multidisciplinary foot care programmes have
been shown to increase quality of care and reduce amputation rates
by 36% to 86%.
History of the team approach to amputation prevention: pioneers
and milestones. Sanders LJ. Robbins JM, Edmonds ME. J Vasc Surg
2010 Sep;5293Suppl);3s-16S. See pubmed.gov website >
Podiatrists help mobilise patients post ulcer care by providing
insoles and other orthotics. The podiatrist forms an essential part
of the foot protection team whose stated aim is to reduce the rate
of limb loss in diabetes by 2013.
Jeffcoate, Putting feet first: halving the number of major
amputations by 2013. The diabetic foot journal, vol 13, no.1,
2010.
Orthotists Dietitians
Dietitians support diabetic patients rehabilitation by focusing
on their nutritional status, muscle strength and respiratory
function. Nutrition also helps maintain tissue viability and
patient mobility which supports wound healing and prevents wound
breakdown.
Monique et al (2009) Cost Effectiveness of Lifestyle
Modification in Diabetic Patients, Diabetes Care Volume 32 No 8
Concludes that: Implementation of lifestyle interventions would
probably yield important health benefits at reasonable costs. Some
good QALY, prevention CVD incidents and life-years gained data. See
American Diabetes Association website >
Benefits of AhP input: rehabilitation stage
navigate to:AHPs contributions at the rehabilitation stage.
Right first timeOrthotic input within the multi-disciplinary
team in the diabetic foot clinic achieves right first time
quality.
GOLDen nuGGeT
The prevention and management of foot problems in type 2
diabetes, NICE guideline, page 25
See NICE website >
Orthotists provide immobilisation and off-loading techniques in
the care of people with Charcot osteoarthropathy to reduce healing
time, prevent further deterioration, maintain tissue viability and
prevent the need for hospitalisation.
Diabetes toolkit 10
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
Physiotherapists
Physiotherapists can play a significant role in the
rehabilitation of people with diabetes with associated
complications.
Utilising their expertise in exercise therapy, physiotherapists
can prescribe individual or group exercise programmes focussing on
improvements in glycaemic control, the symptoms of pain and reduced
activities of daily living associated with intermittent
claudication and to assist in weight management.
Physiotherapists also provide tailored rehabilitation programmes
for individuals with lower limb peripheral neuropathy. These will
focus upon improving balance, walking, functional activity, falls
prevention strategies and foot care.
Physiotherapists can also provide advice and education to carers
and other members of the multidisciplinary team around the
positioning and moving and handling of patients with associated
complication of diabetes.
Individuals with diabetes are also at increased risk of
developing contracted (frozen) shoulder. Physiotherapists can use a
number of treatment modalities to address the symptoms of pain,
loss of range of motion, strength and function associated with this
condition.
Physiotherapy plays a crucial within the rehabilitation of those
patients who have undergone a lower limb amputation as a
complication of diabetes both immediately post-operatively and
following limb fitting.
Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputation. View the BACPAR
report >
Hanchard N, Goodchild L, Thompson J, OBrien T, Richardson C,
Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011)
Evidence-based clinical guidelines for the diagnosis, assessment
and physiotherapy management of contracted (frozen) shoulder v.1.5,
standard physiotherapy. Endorsed by the Chartered Society of
Physiotherapy. See website >
Chartered Society of Physiotherapy (2011). Physiotherapy Works:
Cardiac Rehab. See website >
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Home
Podiatrists
Podiatrists help patients get mobile and remain active, which
reduces risk of further costly ulceration.
An integrated care pathway exists for all patients admitted to
hospital with suspected foot emergencies
Putting feet first- Commissioning specialist services for the
management and prevention of diabetic foot disease in hospital.
Diabetes UK. June 2009 See Diabetes UK report >
Physiotherapists
Physiotherapists provide client centred assessments in the
community to negotiate longer term measurable goals in
collaboration with clients, carers and the multidisciplinary/
interagency team. They can provide support to carers to facilitate
sustained participation in community life and return to work,
social and life roles.
Individual or group exercise programmes can be used to improve
and maintain patients levels of function, focussing upon strength,
endurance, range of movement and physical functioning.
Physiotherapists can provide advice and guidance on lifestyle
management focussing upon physical activity and exercise.
Physiotherapists will play a crucial role with those patients
who have undergone lower limb amputation, and in this stage will
aim to promote functional independence, participation, inclusion,
and enhanced quality of life
Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputation. View the BACPAR
report >
Chartered Society of Physiotherapy (2011). Physiotherapy Works:
Cardiac Rehab. See website >
Chartered Society of Physiotherapy, Physical Activity: Evidence
Briefing (2012) See website >
Chartered Society of Physiotherapy, Facilitating Behaviour
Change: Evidence Briefing (2012). See website >
Benefits of AhP input: re-ablement stage
navigate to:AHPs contributions at the re-ablement stage.
Dietitians
Dietitians provide ongoing review and support for people
struggling to maintain glycaemic control or requiring support to
adopt healthy eating practices or achieve and maintain a healthy
weight.
Reduced risk of disabilityThe podiatrist reduces the risk of
disability and foot complications which can have costly and
devastating consequences for people with diabetes.
GOLDen nuGGeT
A guide to the benefits of podiatry to patient care. The Society
of Chiropodists and Podiatrists. 2010. Read the report >
education is effective54 out of 80 studies demonstrated
effectiveness of therapeutic patient education in terms of
clinical, psychosocial and educational outcomes.
GOLDen nuGGeT
Albano, M.G., Crozet, C., dIvernois, J.F. (2008). Analysis of
the 2004-2007 literature on therapeutic patient education in
diabetes: results and trends. Acta Diabetologia, 45, 211-219.
Orthotists
Orthotists ensure patients with diabetes have suitable and
appropriate footwear and insoles, which prevent recurrent
ulceration and enable safe ambulation. Orthotists also provide
regular reviews and ensure the patient can easily re-access the
diabetic service.
Occupational therapists
Occupational therapists provide functional and vocational advice
that facilitates a return to employment and helps the patient
maintain independence and improve their quality of life.
OTs also provide equipment and home adaptations to facilitate
independent living and review participation in leisure
activities.
COT (2011) Occupational therapy with people who have had lower
limb amputations London: College of Occupational Therapists.
Diabetes toolkit 11
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
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Home
Benefits of AhP input: long-term gain
navigate to:AHPs contributions to long-term gain.
Dietitians
Amputation preventableOf the 70 amputations performed per week,
80% are potentially preventable.
Nov 2010 The NHS Atlas of variation in Healthcare. p.29. See
website >
GOLDen nuGGeT
Orthotists
Orthotists early intervention can improve quality of life for
the patient through the provision of suitable footwear and
insoles.
A patient focused strategy and proven implementation plan to
improve and expand access to orthotic care services and transform
the quality of care delivered.
Download orthotic pathfinder >
Occupational therapists
For people with diabetes who go on to have lower limb
amputations, occupational therapy forms a key part of a
multi-disciplinary team. The specific focus of occupational therapy
is to facilitate independence in activities of daily living, return
to work where relevant, and participation in leisure or other
meaningful activities.
Key fact Podiatrists help prevent hospital admissions due to
foot ulceration by providing regular foot care, particularly for
those patients who have existing medical conditions as a result of
diabetes, such as renal failure.
Podiatrists
Key fact Two studies have shown that nutrition therapy is
cost-effective, judged by savings in drug therapy or reduction in
utilisation of medical services.
Albano, M.G., Crozet, C., dIvernois, J.F. (2008). Analysis of
the 2004-2007 literature on therapeutic patient education in
diabetes: results and trends. Acta Diabetologia, 45, 211-219
Dietitians provide key clinical input in type 1 and type 2
diabetics by supporting behaviour, lifestyle and dietary changes to
reduce long term complications and obesity. The multidisciplinary
approach encourages improved compliance and reduced risk of
complications
How can we improve the care of the diabetic foot. Wounds UK
2008. Vol 4. No.4 Download the report >
Diabetes toolkit 12
Prevention >
Assessment/diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
navigate to:
Diabetes literature review and analysis
Appendix 1: Improving outcomes, the economic arguments and case
studies
References
Physiotherapists
The role of physiotherapy in Health Promotion emphasises the
importance of lifelong participation in programmes of exercise and
physical activity. This is particularly important for people with
diabetes to assist in glycaemic control, weight management and
optimising health and well-being and prevention of associated
complications. Physiotherapist can continue to monitor patients and
identify if they are at risk of developing further complications
associated with their condition.
Regular reviews should be offered to individuals who have
received physiotherapy rehabilitation and re-ablement programmes
associated with the complications of their diabetes, providing them
with clear advice and information on how they can access
physiotherapy services
Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputation. View the BACPAR
report >
Chartered Society of Physiotherapy (2011). Physiotherapy Works:
Cardiac Rehab. See website >
Chartered Society of Physiotherapy, Physical Activity: Evidence
Briefing (2012). See website >
Chartered Society of Physiotherapy, Facilitating Behaviour
Change: Evidence Briefing (2012). See website >
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Home Diabetes toolkit 13
Diabetes literature review and analysis
The Strategic Allied Health Professionals Leads Group (SAHPLE)
commissioned York Health Economics Consortium (YHEC) to carry out
economic analysis of the impact of AHP interventions across
diabetes care pathways. SAHPLE provided YHEC with a framework which
highlighted a series of specific interventions by AHPs classified
under six categories:
Prevention Assessment/Diagnosis Treatment Rehabilitation
Re-ablement Long-term gain.
Introduction
YHEC reviewed literature around each of the interventions
included in each of the five pathways. This has been a considerable
undertaking with up to 40 interventions being identified in each
pathway. We carried out broad searches for literature using
databases including Medline, the Cochrane Database of Systematic
Reviews and NHS Evidence. We sought evidence from a range of
sources in the following sequence: DH/NHS policy documents;
clinical guidelines; case studies; published literature; individual
NHS organisations; and expert opinion. We were also provided with a
range of literature references from a range of AHP clinicians which
we reviewed.
These searches represent an extensive but not exhaustive search
of the available literature. With the resources available we were
not able to search other sources such as literature held by the
Royal Colleges which are available for members only. We contacted
the Chartered Society of Physiotherapy, the Royal College of Speech
and Language Therapists and the College of Occupational Therapists
who provided some clinical
Our approach
guidelines. However, our search is likely to have identified the
highest quality evidence. The view from SAHPLE is that there is
more extensive literature on interventions by AHPs but that much of
this is not published.
YHEC has used the data obtained to present the evidence in two
ways:
n Examples of economic analysis across the pathways where AHPs
can make a significant impact on patient care and, potentially,
costs. Three scenarios are presented below:
Prevention of diabetes and diabetes-related complications
through education and self management
Eye care for patients with type 2 diabetes
Foot care for patients with type 2 diabetes.
n Evidence to support the effectiveness and potential economic
benefits for each of the interventions included in the SAHPLE
framework. This is provided at Appendix A. We have colour-coded the
evidence obtained to provide an indication of the level of
robustness of the evidence as follows:
Evidence supported by published study or literature in GREEN
Evidence supported by observational study or case study in
AMBER
Evidence supported by clinical opinion or assumption in RED.
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Home Diabetes toolkit 14
Diabetes literature review and analysis
scenario 1: Prevention of diabetes and diabetes-related
complications through education and self management
DietitianPhysiotherapist
A
DietitianPhysiotherapist
b
Referral for patients at risk of developing diabetes
Supported self-management for people with diabetes
Avoided costDevelopment of diabetes (annual cost 3,000)
Avoided costAvoidance of complications
NICE and SIGN guidelines on diabetes recommend dietary and
exercise advice as part of a comprehensive management plan to
improve glycaemic control for people at risk of developing
diabetes. The cost of providing a programme of education including
a dietitian and a physiotherapist would be around 100 per hourly
session, less than the cost of attendance at a consultant-led
outpatient clinic. The avoided healthcare costs of treating someone
who develops diabetes is around 3,000 per year.1
The Diabetes Prevention Programme and a Finnish study into
lifestyle intervention found a 58% and 43% reduction in the
incidence of diabetes respectively. In a caseload of 50 patients
the reduction in diabetes incidence would be 29 and 22
respectively, generating annual savings of 87,000 and 66,000
respectively. If we assume AHP input of 0.5 wte dietitian and 0.5
wte physiotherapist then the cost of the intervention would be
around 50,000 so this approach shows potential to generate
savings.
Intervention A
50% of people with type 2 diabetes have complications on
diagnosis, which could have been prevented if diabetes had been
detected earlier.2 A study that examined a cohort of more than
17,000 diabetes patients in Wales reported the incidence of
vascular co-morbidities. Excluding eye and foot related
complications which are explored in scenarios 2 and 3, the
incidence of major complication is given in Table 1.3
Intervention b
1 The First National Bariatric Surgery Registry Report to March
2010. Royal College of Surgeons of England.2 UK Prospective
Diabetes Study Group, Intensive Blood Glucose Control with
Sulphonylureas or Insulin Compared with Conventional Treatment and
Risk of Complications in Patients with Type 2 Diabetes (UKPDS 33).
The Lancet 1998; 352:837-53)3 Estimated costs of acute hospital
care for people with diabetes in the United Kingdom: a routine
record linkage study in a large region. C. Ll. Morgan, J. R.
Peters, S. Dixon and C. J. Currie. Diabetic Medicine.
TAbLe 1
CO-mORbIDITy InCIDenCe %
Coronary heart disease 18.4
Cerebrovascular disease 6.4
Nephrology/renal failure 3.6
Continued overleaf >
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Home Diabetes toolkit 15
Diabetes literature review and analysis
scenario 1: Prevention of diabetes and diabetes-related
complications through education and self management
Table 2 shows the costs of serious complications that can arise
from the co-morbidities in table 1 and the costs of treatment.
TAbLe 2
CO-mORbIDITy COmPLICATIOnCosts of fatality
()non-fatal costs
year 1 ()
non-fatal costs subsequent
years ()
CHD Myocardial infarction 1,366 5,199 856
Heart failure 3,007 3,007 1,054
Ischaemic heart disease 2,696 2,696 891
CVD Stroke 4,011 3,180 601
Renal failure Renal failure 30,000 30,000
Assuming a cohort of 200 patients and using the costs and
prevalence described in Tables 1 and 2, table 3 shows the costs of
complications.
TAbLe 3: COsTs OF TReATIng seRIOus vAsCuLAR COmPLICATIOns OveR A
5-yeAR PeRIOD
COmPLICATIOns FIve-yeAR COsT ()
Myocardial infarction survived 55,288
Heart failure survived 10,230
Ischaemic heart disease survived 71,648
Myocardial infarction died 10,928
Heart failure died 6,014
Ischaemic heart disease died 5,392
Stroke survived 43,820
Stroke died 16,044
Renal failure 720,000
Total cost 939,364
The cost of providing a programme of education including a
dietitian and a physiotherapist would be around 100 per hourly
session. A structured set of twice yearly education sessions for
each patient to support self management would cost around 1,000 per
patient over five years or around 200,000 in total.
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Home Diabetes toolkit 16
Diabetes literature review and analysis
scenario 2: eye care for patients with type 2 diabetes
The Royal College of Ophthalmologists Preferred Practice
Guidance on Diabetic Retinopathy Screening (DRS) and the
Ophthalmology Clinic set up in England (2010) details the
importance of providing DRS to reduce visual impairment due to
diabetic eye disease. The guidance refers to the requirement, under
the English National Screening Programme for Diabetic Retinopathy,
that all diabetes patients should be sent screening appointments
for DRS. Grades 0 and 1 (no diabetic retinopathy and background
diabetic retinopathy) of patients should be seen in clinic
annually. Patients with higher grades than 1 should be treated in
an ophthalmology clinic.
A systematic review of diabetic retinopathy screening has found
that systematic screening for diabetic retinopathy is cost
effective in terms of sight years preserved compared with no
screening.4 NICE puts the cost of blindness at 1,358 in the year of
the event with a cost of 575 in subsequent years. 5
The make-up of the staff for DRS eye clinics includes consultant
and trainee ophthalmologists and AHPs under supervision, as well as
nurses, photographers and technicians. As with diabetic foot
clinics, where DRS eye clinics do not exist, the cost of
establishing such a team may be considerable and will need to be
offset against any savings.
4 Diabetic retinopathy screening: a systematic review of the
economic evidence. S Jones and R Edwards. Diabetic Medicine.
(2010).5 NICE guideline CG66 Type 2 diabetes.
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Home Diabetes toolkit 17
Diabetes literature review and analysis
scenario 3: Foot care for patients with type 2 diabetes
Podiatrist (52 per session)
A
Podiatrist, OTOrthotist, Dietitian
b
OT, PhysiotherapistOrthotist
C
Referral for patients with established risk factors (25%)
Treatment for patients with history of previous
ulceration (8%)
Avoided costReferral to specialist (169 per session)
Avoided costAvoid progression
to ulcer
Progression to ulcer (7,500) Recovery
Avoided costAvoid progression to amputation
Amputation (65,000)
Intervention descriptions overleaf >
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Home Diabetes toolkit 18
Diabetes literature review and analysis
scenario 3: Foot care for patients with type 2 diabetes
There are a number of guidelines that refer to the importance of
multidisciplinary care, including AHP interventions, in the
provision of foot care for patients with type 2 diabetes. These
include the NICE Guideline Type 2 diabetes: prevention and
management of foot problems (2004) and the Diabetes Competency
Framework for prevention, treatment and management of diabetic foot
disease (2010). Potential savings are identified at three
intervention points but these must be treated with caution as they
are reliant on AHPs and multi-disciplinary foot care teams being
funded and in place. In areas where there is no multi-disciplinary
foot care team, the cost of establishing such a team may be
considerable (podiatrist, orthotist, physiotherapist, OT,
dietitian, diabetes nurse specialist, clinicians).
Intervention A:
Patients with established risk factors but who have never
ulcerated comprise around 25-30% of the adult diabetes population.
National guidelines recommend that this group of patients has
regular podiatry care, depending on individual need. If this is
provided by direct referral to a podiatrist rather than a
consultant, then there is a potential cost saving. If podiatry
services are not available then this will not be possible.
Potential annual saving in England, based on annual review of
all patients with established risk factors:
550,000 patients x (169-52) = 64m
Intervention b:
Patients with a history of previous ulceration or amputation
comprise between 8-12% 0f the diabetes population. These patients
have between 40-50% risk of re-ulcerating each year. These patients
should be treated by appropriately skilled diabetes specialist
podiatrists linked to a multi-disciplinary diabetes foot team.
Provision of a specialist diabetes foot team staffed by
podiatrists, OTs, orthotists and dietitians may help to prevent
re-ulceration.
Potential annual saving in England, based on reduction in levels
of ulceration by 5%:
175,000 patients x 5% x 7,500 = 66m
Intervention C:
1-5% of patients have active foot ulcers or foot disease. These
should be reviewed frequently in diabetes foot multidisciplinary
clinics with a network of community podiatry and nursing teams to
continue care in between specialist clinic visits. According to
Diabetes UK and the Atlas of Variation in Healthcare there are 70
major amputations per week relating to diabetes, 80% of which are
avoidable.
Potential annual saving in England, based on reducing the
avoidable amputation rate by 50%:
70 amputations x 52 weeks x 40% x 65,000 = 95m
.
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Home Diabetes toolkit 19
Appendix A
Framework of interventions provided by clinicians in a range of
settingsPrevention (1 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Dietitians provide individualised diet therapy for those with
impaired glucose regulation and metabolic syndrome to reduce risk
of progression to diabetes.
(NHS Outcomes Framework: Domains 1 & 2)
NICE guidance states that the major consensus-based
recommendations from the UK and USA emphasise sensible practical
implementation of nutritional advice for people with Type 2
diabetes. It recommends individualised and ongoing nutritional
advice from a healthcare professional with specific expertise and
competencies in nutrition and the integration of dietary advice
with a personalised diabetes management plan, including other
aspects of lifestyle modification, such as increasing physical
activity and losing weight.
National Collaborating Centre for Chronic Conditions. Type 2
diabetes: national clinical guideline for management in primary and
secondary care (update). London: Royal College of Physicians,
2008.
The Diabetes Prevention Program has drawn up a lifestyle
protocol, which includes weight loss and activity goals; individual
case managers; intensive ongoing intervention; individualisation
through a toolbox of adherence strategies; materials and strategies
that address the needs of an ethnically diverse population.
The Diabetes Prevention Program: description of the lifestyle
intervention. Diabetes Care 24: 2165-2171.
The Dose Adjustment for Normal Eating (DAFNE) educational
programme is associated with a net cost saving over 10 years of
2,679 per patient and a higher number of quality adjusted life
years (QALYs).
NICE guidance on the use of patient education models for
diabetes. Technology Appraisal 60. 2003.
Avoiding progression to diabetes can save the NHS a considerable
amount for each case prevented: The First National Bariatric
Surgery Registry Report estimates the average cost of treating
patients with diabetes at 3,000 per year.
The First National Bariatric Surgery Registry Report to March
2010. Royal College of Surgeons of England.
Specialist diabetic orthotists provide accommodating footwear
and insoles to prevent ulcers and amputation. They also offer
regular reviews, where foot care advice is provided, and facilitate
re-referral to the high risk foot clinic if necessary.
Studies show that high risk patients without prescribed footwear
will develop ulcers.
(NHS Outcomes Framework: Domain 2)
The SIGN guideline on diabetes states that programmes which
include education with podiatry show a positive effect on minor
foot problems at relatively short follow up. Access to a podiatrist
reduces the number and size of foot calluses and improves self
care. More recent studies assessing the effectiveness of structured
education programmes for patients at high risk of
diabetes-associated foot disease found an improvement in overall
knowledge and foot care behaviours but no change in the incidence
of foot ulceration or in amputation rates. Foot care education is
recommended as part of a multidisciplinary approach (including a
podiatrist and an orthotist) in all patients with diabetes.
Scottish Intercollegiate Guidelines Network, Management of
Diabetes A national clinical guideline, March 2010.
The cost to the NHS to heal one ulcer is between 3,000 and
7,500. Should this progress to amputation the cost is estimated to
escalate to 65,000. This is much higher than the cost of
preventative orthoses.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium: pg 12-13.
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Home Diabetes toolkit 20
Appendix A
Framework of interventions provided by clinicians in a range of
settingsPrevention (2 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes ReFeRenCes CAse
sTuDIes
Physiotherapists are skilled in assessing and treating people
with complex pathologies and in developing exercise/physical
activity programmes that are person centred.
(NHS Outcomes Framework: Domain 2)
Physiotherapists help to optimise blood glucose control with
exercise/physical activity to help with prevention/delay of type 2
diabetes. Physiotherapists are able to use their expertise in
exercise therapy and physical activity to provide advice, education
and tailored exercise programmes for those individuals identified
as being at risk of developing type 2 diabetes.
The increasing worldwide prevalence of obesity and a sedentary
lifestyle are directly linked to the rising rate of metabolic
syndrome and type 2 diabetes
Exercise and physical activity are important lifestyle
interventions that can prevent or delay the onset of both pre
diabetes and type 2 diabetes,
People with IGT and type 2 diabetes often present with complex
biopsychosocial issues.
It is acknowledged that there are already many exercise
facilities available for the general public to access, however
there appears to still be a population who have increased barriers
to exercise. Physiotherapists can empower people to make gradual,
positive changes in their ability to become more active and enable
participation in exercise and to address the barriers which may
make change difficult.
The ultimate achievement will be sustainable lifestyle changes
which incorporate increased exercise/physical activity and which
individual participants feel have a positive affect on their own
physical and emotional well being.
1 Ferguson, B. and Kingdom, A. (2006) Diabetes Key Facts. York:
Yorkshire and Humber Public Health Observatory.
2 Alberti, K.G.M.M., Zimmet, P., Shaw, J., (2006) Metabolic
Syndrome - a new world wide definition. A Consensus Statement from
the International Diabetes Federation. Diabetes Medicine 23:pp
469-480.
3 American College of Sports Medicine (ACSM) and American
Diabetes Association Joint Position Statement.(2010) Exercise and
Type 2 Diabetes. Medicine and Science in Sports and Exercise vol 42
No.12, pp 2282-2303.
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Home
Appendix A
Framework of interventions provided by clinicians in a range of
settingsPrevention (3 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Dietitians provide support and guidance on lifestyle changes to
help patients reduce weight and improve their health thus reducing
risk of developing diabetes.
(NHS Outcomes Framework: Domains 1 & 2)
Risk factors for Type II diabetes and Coronary Heart Disease
(CHD) are influenced by lifestyle factors such as poor diet, lack
of exercise and smoking. These are potentially reversible factors
and research has shown that lifestyle interventions in the form of
individualised therapy, provided by dietitians, may prevent the
onset of diabetes in individuals with impaired glucose regulation
and metabolic syndrome.
Forms of individualised therapy may include the prescription of
a healthy low-calorie, low fat diet, engagement in a physical
activity regime of moderate intensity for at least 150 minutes per
week and a one-to-one educational programme providing information
on diet, exercise and smoking cessation.
The Diabetes Prevention Programme Research Group (2000)
Reduction in incidence of Type 2 diabetes with lifestyle
intervention or metformin. New Eng J Med 346: 393-403.
Nutritional advice and information is essential for the
prevention of diabetes in those at risk of Type 2 diabetes and for
the effective management of the condition for those with Type 1 and
Type 2 diabetes. This advice and information enables people with
diabetes to make appropriate choices on the type and quantity of
the food which they eat. The advice must take account of the
individuals personal and cultural preferences, beliefs and
lifestyle, and must respect their wishes and willingness to change.
It must be adapted to the specific needs of the individual, which
may change with time and circumstance; for example, age, pregnancy,
hospital admission, nephropathy, intercurrent illness and other
illnesses. The beneficial effects of physical activity in the
prevention and management of diabetes and the relationship between
activity, energy balance and body weight, are an integral part of
nutritional counselling.
An Integrated Career and Competency Framework for Dietitians and
Frontline Staff. Professional Education Working Group. Diabetes UK.
December 2010.
The average cost to the NHS of treating patients with diabetes
at 3,000 per year.
The First National Bariatric Surgery Registry Report to March
2010. Royal College of Surgeons of England.
In 2002 The NSF for diabetes stated that the average personal
cost for people with diabetes was 802 per person per year plus lost
earnings for people without any complications. One in twenty people
with diabetes incurred social services costs of around 2,450,
mostly for residential and nursing care and home help
National Service Framework for Diabetes, Department of Health,
2002.
Two studies have suggested that lifestyle interventions for
those at risk of diabetes could reduce the occurrence of diabetes
by 43% and 58% respectively..
Diabetes in the UK 2004, Diabetes UK.
A study by the Diabetes Prevention Program Research Group found
that lifestyle intervention in 1,079 participants resulted in a 58
per cent reduction in the incidence of type 2 diabetes in persons
who were at high risk for diabetes. The intervention consisted of a
16-lesson curriculum taught by case managers on a one-to-one basis
during the first 24 weeks after enrolment. This was done flexibly
and on an individual basis for each person. Subsequent individual
sessions were held monthly and group sessions were also held.
Wylie-Rosett J and Delahanty L (2002) An integral role for the
dietitian: implications of the Diabetes Prevention Program. Journal
of the American Dietetic Association 102: 1065-1068.
A Finnish study of a similar approach found a 43 per cent
reduction in the incidence of type 2 diabetes. The participants in
that programme had face-to-face consultation sessions (30 min 1
hour) with the study nutritionist at weeks 0, 1-2 and 5-6 and at 3,
4, 6 and 9, ie, seven sessions in the first year and every three
months thereafter. In addition, there were voluntary group
sessions, expert lectures, low-fat cooking lessons, visits to local
supermarkets, and between-visit phone calls and letters.
Sustained reduction in the incidence of type 2 diabetes by
lifestyle intervention: follow-up of the Finnish Diabetes
Prevention Study (Lindstrom et al, 2006) The Lancet, Vol368, Issue
9548: 1673-1679
Home Diabetes toolkit 21
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Home Diabetes toolkit 22
Appendix A
Framework of interventions provided by clinicians in a range of
settingsPrevention (4 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Podiatrists provide structured diabetes education and deal with
all aspects of foot health and lifestyle modifications, such as
smoking cessation, footwear education and falls prevention. They
also provide foot screening an essential part of the prevention
programme for patients with diabetes and foot health advice to all
other health professionals and carers.
(NHS Outcomes Framework: Domain 2)
NICE guidelines recommend that as part of an annual review,
podiatrists should examine patients feet to detect risk factors for
ulceration and discuss a management plan which includes foot care
education, encourages self-care and minimises inadvertent
self-harm. Foot screening and education helps to avoid ulceration
as well as subsequent treatments or potential amputations.
The prevention and management of foot problems in type 2
diabetes, NICE guideline CG10 (2004).
The Society of Chiropodists and Podiatrists reported that
between 15-20 per cent of patients with diabetes will develop a
foot ulcer during their lifetime and that foot ulceration precedes
85 per cent of amputations. Eighty five per cent of amputations
could be avoided by early detection of foot complications, timely
intervention, involvement of a diabetic foot care team, good
diabetes control and patient education. The report found that
investing in foot clinics and podiatrists could reduce waiting
times and amputation rates, improve patient outcomes and lower the
need for consultant time due to podiatry autonomy.
A guide to the benefits of podiatry to patient care. The Society
of Chiropodists and Podiatrists. 2010.
A 1998 study by McCabe and colleagues reported a screening and
protection programme conducted in an English diabetic outpatient
clinic setting which randomised 2001 patients.
Patients in the intervention group (n=1001) were screened and
patients at raised risk (n=259) were recalled. Following a second
assessment, 192 (19.2%) patients were entered into a foot
protection programme. When compared to the control group, the
intervention group demonstrated non-significant trends in reduced
ulceration and minor amputations, and statistically significant
reductions in overall and major amputation. Of those presenting
with ulcers significantly fewer progressed to amputation in the
intervention group suggesting that ulcers were spotted sooner and
treated more effectively. The cost per patient was around 100,
significantly less than treatment for ulceration or amputation.
McCabe CJ, Stevenson RC, Dolan AM (1998) Evaluation of a
diabetic foot screening and protection programme. Diabetic Medicine
15: 8084.
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Home Diabetes toolkit 23Home
Appendix A
Framework of interventions provided by clinicians in a range of
settingsAssessment/Diagnosis (1 of 3)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Podiatrists perform full assessments and evaluation of skin,
soft tissue, musculoskeletal, vascular and neurological conditions
in the foot and lower limb. They identify risk factors for lower
limb amputation and develop care plans to prevent deterioration.
National guidelines are in place for the management of the foot in
diabetes.
(NHS Outcomes Framework: Domains 1 & 2)
Guidelines for the prevention and management of foot problems
for people with diabetes provide guidance on risk identification
and assessment; management of low/increased /high risk feet;
management of ulcerated feet.
The guidelines assist NHS podiatrists and managers to review,
plan and provide specific best care for people with diabetes, from
both a clinical and cost effectiveness perspective, creating equity
of care across the region, including minimum standards.
Guidelines for the prevention and management of foot problems
for people with diabetes. North West Podiatry Services, Diabetes
Clinical Effectiveness Group.
A study in Wales found that the mean hospital length of stay for
people with vascular-related diabetic foot problems was 15 days.
The current cost for a general medicine bed day is around 123 so an
average inpatient stay would cost 1,845. If risk factors are
managed better through podiatrist assessments any reduction in bed
days for these complications would provide cost efficiency
savings.
Estimated costs of acute hospital care for people with diabetes
in the UK: a routine record linkage study in a large region. C
Morgan et al. Diabetic Medicine 2010.
Salford Community Health has reorganised its care pathway for
people with diabetes to ensure seamless care across community and
acute services and reorganising the case load of podiatry services.
This has included annual foot screening and risk stratification and
preventative and specialist foot care services. This has resulted
in a reduction in the number of foot ulcers by 300 over 4 years. At
a cost of 3,500 per ulcer this represents a saving of over 1m over
4 years.
Integrated foot care service. NHS Diabetes Case study. 2010.
Orthoptists provide assessment of vision, visual fields and eye
movements. Diagnosis of low vision or visual field loss helps
prevent falls while diagnosis of cranial nerve palsy, often linked
to microvascular pathology, prompts diabetes detection.
(NHS Outcomes Framework: Domains 1 & 2)
Retinopathy can be treated by laser which is very successful if
the condition is caught early. There is little evidence relating to
the effects of diabetic retinopathy and falls. Because retinopathy
affects an individuals visual field, this in itself may increase
the risk of falling but other diabetic factors also need to be
taken into account such as lower limb neuropathy which could also
affect balance.
P Turpin. RNIB Care Homes Falls Prevention Project: A review of
the literature. 2011.
PCTs are responsible for implementing the English National
Screening Programme for Diabetic Retinopathy (ENSPDR). ENSPDR
recommends that patients are seen in diabetic eye clinics including
AHPs under supervision.
The Royal College of Ophthalmologists. Preferred Practice
Guidance. Diabetic Retinopathy Screening (DRS) and the
Ophthalmology Clinic set up in England. September 2010.
Systematic screening for diabetic retinopathy is cost-effective
in terms of sight years preserved compared with no screening.
Variation in compliance rates, age of onset of diabetes, glycaemic
control and screening sensitivities influence the
cost-effectiveness of screening programmes and are important
sources of uncertainty in relation to the issue of optimal
screening intervals. There is controversy in relation to the
economic evidence on optimal screening intervals.
Diabetic retinopathy screening: a systematic review of the
economic evidence. Jones & Edwards. Diabetic Medicine 2010.
Falls cost the NHS and social care an estimated 6m per day or
2.3bn per year in hip fractures alone. This figure does not take
into account other costs associated with falls that do not result
in hip fracture but that may still require treatment or care. There
are also other costs involved, for example, falls cost 115 per
ambulance call-out There is growing evidence to show that investing
in falls prevention services is cost-effective. The Department of
Health currently estimates that if every strategic health authority
in England invested 2m in falls and bone health early intervention
services they could each save 5m (net 3m) each year through reduced
NHS costs, such as 400 fewer hip fractures.
Age UK. Stop Falling: Start Saving Lives and Money. 2010.
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Home Diabetes toolkit 24
Appendix A
Framework of interventions provided by clinicians in a range of
settingsAssessment/Diagnosis (2 of 3)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Continued from page 23
Orthoptists provide assessment of vision, visual fields and eye
movements. Diagnosis of low vision or visual field loss helps
prevent falls while diagnosis of cranial nerve palsy, often linked
to microvascular pathology, prompts diabetes detection.
(NHS Outcomes Framework: Domains 1 & 2)
Patients with clinically isolated single cranial nerve palsies
associated with diabetes or hypertension are likely to recover
spontaneously within 5 months and initially require observation
only. However, patients with unexplained binocular diplopia and
those who progress or fail to recover should be investigated to
establish the underlying aetiology and managed as appropriate.
Causes and outcomes for patients presenting with diplopia to an
eye casualty department. Comer et al. Eye (2007).
For falls various interventions, such as programmed
inter-disciplinary involvement, have shown promise, however these
need further confirmation of their efficacy and cost effectiveness.
An added confounder may be that an intervention (eg, cataract
extraction) paradoxically affects an individuals future activity
level and behaviour, thereby increasing the risk of falling. With
an ageing population the importance of this topic is likely to
increase, as will the potential benefits of optimising our
assessment and management of these patients.
Visual loss and falls a review. Dhital et al. Eye (2010).
NICE guidance recommends eye screening at, or around, the time
of diagnosis of diabetes and that arrangements should be made for a
repeat of structured eye surveillance annually.
National Collaborating Centre for Chronic Conditions. Type 2
diabetes: national clinical guideline for management in primary and
secondary care (update). London: Royal College of Physicians,
2008.
For diabetic retinopathy (DR), RNIB estimate that in 2010,
748,000 have background DR with 85,484 having more advanced DR. By
2020 will be 938,000 and 107,218. 40,982 in 2010 will be partially
sighted and 24,976 blind. By 2020 will be 46,473 and 29,957
respectively.
The cost of is estimated at: 680m in 2010 for detection,
treatment and provision of state and family social care for all
diabetics at risk of eye disease. In 10 years to 2020 cumulative
cost will be 6.4bn (1.6bn health costs, 3.4 bn personal and social
care costs and 1.03bn lost productivity).
Future sight loss UK (2) An epidemiological and economic model
for sight loss in the decade 2010-2020. RNIB (2009).
Retinopathy screening can prove very cost effective for all type
2 diabetes with an incremental cost effectiveness ratio as low as
1,400 per QALY.
Yorkshire & Humber Public Health Observatory. Diabetes: key
facts. 2006.
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Home Diabetes toolkit 25
Appendix A
Framework of interventions provided by clinicians in a range of
settingsAssessment/Diagnosis (3 of 3)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Radiographers provide expert imaging and interpretation to
identify disease progression/complications (such as
arthroplasty/osteomyelitis/renal/visual complications.
(NHS Outcomes Framework: Domains 1 & 2)
During reviews, specialist diabetic orthotists will be able to
identify possible new episodes, such as Charcot changes, and
re-refer to a specialist clinic or AHP.
In orthotic-only clinics patients are assessed and provided with
orthoses to accommodate the changes to the foot shape, thereby
preventing further ulcerations caused by excessive plantar
pressures and ill fitting footwear.
(NHS Outcomes Framework: Domains 1 & 2)
It is well documented within the EU that between 30-44% of high
risk patients will have further foot pathologies (mainly ulceration
and amputation). Studies show, that high risk patients without
prescribed footwear will develop ulcers and the cost of healing one
ulcer is 3000-7500 as published by the International Diabetic Foot
2005. Should this progress to an amputation the cost is estimated
to be around 65,000.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium.
The average cost per patient for this type of care was estimated
to be 501 in a sample of 103 patients over a two year period. This
is less than 300 per year, a fraction of the cost of an amputation,
and far less than the cost of treating a single foot ulcer.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium.
The orthotic service has a dramatic impact on patients lives: I
know the complications diabetic patients can have with their feet.
Since I have been wearing diabetic footwear I have the confidence
to be more active. I do a lot of walking and have lost a
considerable amount of weight (4 stones). Generally my health has
improved.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium.
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Home Diabetes toolkit 26Home
Appendix A
Framework of interventions provided by clinicians in a range of
settingsTreatment (1 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Within diabetic foot clinics orthotists provide orthoses to
complement podiatry treatment and enable mobilisation. Orthoses
include shoes to accommodate dressings, insoles to reduce plantar
pressures and offloading devices to aid wound healing.
Once the level of risk for foot injury or ulceration has been
determined by the podiatrist appropriate management schemes,
including footwear recommendations and orthotic provision, are
provided by community podiatry or the specialist and surgical
podiatrists.
(NHS Outcomes Framework: Domains 2, 3 & 4)
To individual patients the correct supply and fitting of
orthotic devices can be a major factor in the management of their
condition or the prevention of future problems. The technology of
orthoses can appear deceptively simple, such as foot insoles or
orthoses made for back problems but the selection and fitting of
the most appropriate device requires detailed knowledge of the
functioning of the musculo-skeletal system. Many orthotic devices
have to be fitted specifically for the individual patient. Delivery
of a service of this kind can only be carried out by those with a
proper professional training in orthotics and a broad experience of
the range of products available.
Orthotics services can assist in the achievement of major policy
objectives of the NHS, including reducing referral to treatment
times; facilitating choice for people with long term conditions;
and providing seamless health care with service provision by those
best placed to meet patient needs. Orthotic services can play an
important role in meeting the NHS objective of keeping people
mobile and independent and therefore reducing the need for acute
treatment or social care services.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium.
100 people a week have an amputation due to foot ulceration.
Foot ulceration preceded 85% of amputations and foot ulcers occur
in 15-20% of people with diabetes. International Diabetes
Federation estimates that 85% of amputations could be prevented by
early intervention from a diabetic foot team including specialist
podiatrists.
AHP key facts Bulletin 2 October 2010. Allied Health Professions
Federation.
A survey of 6 trusts involved in the 2004 Pathfinder project
which highlighted that for every 1 spent on orthotic services the
NHS saves 4. With current expenditure on orthotic service provision
estimated at 100 million this represents a saving of 400 million to
the NHS.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium.
In the UK adult population the incidence of foot ulcers is
55,211, and the prevalence is 154,592.
Costing statement: Diabetic foot problems: inpatient management
of diabetic foot problems NICE clinical guideline Draft, November
2011.
The annual cost of ulceration, infection and amputation
associated with diabetic foot is 251.5m.
Gordols et al, 2003.
Supplementary prescribing can reduce the number of appointments
in secondary care from weekly to six-weekly as podiatrists are able
to prescribe in primary care.
QIPP example - Supplementary prescribing in podiatry: Provided
by: NHS Central Lancashire.
The West Midlands Regional Orthotic Project in 2007 was designed
to develop orthotic services in one region of the English NHS,
along the lines proposed in the Pathfinder report. The key
recommendations were aimed at commissioners, orthotic service
managers and contracted service providers in order to improve
service delivery. The report also recommended collaboration between
commissioners and senior management in providing trusts. Similarly,
there was a need for more coordination between management levels
within providing trusts, from the orthotic service manager upwards.
Six key factors central to the achievement of change were
identified:
Clear service specifications Valuing health care professionals
Companies acting responsibly A clinical evidence base Cost savings
from appropriate provision to fund further developments Whole
system change to gain maximum benefit from orthotic services.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving
Service Provision. York Health Economics Consortium.
In Southampton 125k per year for 3 years has been invested in a
Diabetic Foot Protection Team including a lead podiatrist,
specialist nurse, dietitian and specialist podiatrist. Resulted in
reduction in inpatient stay from 50 to 18 days, creating 1.2m
savings in 3 years.
AHP key facts Bulletin 2 October 2010. Allied Health Professions
Federation.
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Home Diabetes toolkit 27
Appendix A
Framework of interventions provided by clinicians in a range of
settingsTreatment (2 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Continued from page 26
Within diabetic foot clinics orthotists provide orthoses to
complement podiatry treatment and enable mobilisation. Orthoses
include shoes to accommodate dressings, insoles to reduce plantar
pressures and offloading devices to aid wound healing.
Once the level of risk for foot injury or ulceration has been
determined by the podiatrist appropriate management schemes,
including footwear recommendations and orthotic provision, are
provided by community podiatry or the specialist and surgical
podiatrists.
(NHS Outcomes Framework: Domains 2, 3 & 4)
Between January 2002 and June 2003(18 months), 128 diabetic
patients with lower limb ischaemia were seen. Thirty-four (26.6%)
patients received medical treatment alone, and 18 (14.1%) were
deemed palliative due to their significant co-morbidities. The
remaining 76 (59.4%) patients underwent either angioplasty (n =
56), surgical reconstruction (n = 18), primary major amputation (n
= 2) or secondary amputation after surgical revascularisation (n =
1). Minor toe amputations were required in 35 patients. The
mortality in the intervention group was 14% (11/76). This
integrated multidisciplinary approach offers a consistent and
equitable service to diabetic patients with critically ischaemic
feet and appears to have a beneficial major/minor amputation
ratio.
An integrated care pathway to save the critically ischaemic
diabetic foot. K El Sakka et al. Int J Clin Pract, June 2006, 60,
6, 667669.
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Home Diabetes toolkit 28
Appendix A
Framework of interventions provided by clinicians in a range of
settingsTreatment (3 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Dietetic treatment aims to optimise glycaemic control, improve
HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce
hypertension.
It also addresses associated dietary issues such as renal diets,
celiac diets, low residue diets and high kcal diets as required to
achieve and maintain appropriate BMI.
(NHS Outcomes Framework: Domains 2, 3 & 4)
Overweight and obesity are major contributors to both type 2
diabetes and cardiovascular disease (CVD). Individuals with type 2
diabetes who are overweight or obese are at particularly high risk
for CVD morbidity and mortality. Although short-term weight loss
has been shown to ameliorate obesity-related metabolic
abnormalities and CVD risk factors, the long-term consequences of
intentional weight loss in overweight or obese individuals with
type 2 diabetes have not been adequately examined.
Look AHEAD Research Group (2003). Look AHEAD (Action for health
in diabetes): design and methods for a clinical trial of weight
loss for the prevention of cardiovascular disease in type 2
diabetes. Controlled Clinical Trials 24, 610-628.
Another study in New Zealand found that intensive dietary advice
has the potential to appreciably improve glycaemic control and
anthropometric measures in patients with type 2 diabetes and
unsatisfactory HbA1c despite optimised hypoglycaemic drug
treatment.
Nutritional intervention in patients with type 2 diabetes who
are hyperglycaemic despite optimised drug treatmentLifestyle Over
and Above Drugs in Diabetes (LOADD) study: randomised controlled
trial. Coppell K et al. BMJ 2010; 341:c3337.
Medical nutrition therapy is an integral component of diabetes
management and of diabetes self-management education. Yet many
misconceptions exist concerning nutrition and diabetes. Moreover,
in clinical practice, nutrition recommendations that have little or
no supporting evidence have been, and are still being, given to
persons with diabetes. This career and competency framework will
ensure that dietitians and supporting staff have the competences in
place to deliver sound and evidence-based therapy to support the
person with diabetes in self-managing their condition.
An Integrated Career and Competency Framework for Dietitians and
Frontline Staff. Professional Education Working Group. Diabetes UK.
December 2010.
An American study found that a multidisciplinary weight loss
program consisting of diet, exercise, and behaviour modification
provides good value for money, but more research is required to
confirm the impacts of such programmes on quality of life and the
likelihood of long-term weight loss maintenance.
For overweight and obese women, a three-component intervention
of diet, exercise, and behaviour modification cost $12,600 per
quality-adjusted life year gained compared with routine care. All
other strategies were either less effective and more costly or less
effective and less cost-effective compared with the next best
alternative.
Economic Evaluation of Weight Loss Interventions in Overweight
and Obese Women. L Roux et al. Obesity Research (2006) 14,
10931106.
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Home Diabetes toolkit 29
Appendix A
Framework of interventions provided by clinicians in a range of
settingsTreatment (4 of 4)
InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT
CAse sTuDIes
Community podiatrists provide specialist clinical care for
patients who are deemed at high risk of a foot/lower leg problem.
These interventions help reduce hospital stay and ensur