diabetes pandemic had affected an estimated 151 Diabetes accounts for an extraordinary amount of diabetes imposes staggering economic costs while …
Review
TRANSLATION RESEARCH FOR IMPROVING DIABETES CARE: A PERSPECTIVE FOR INDIA
Michael M Engelgau, KM Venkat Narayan By the end of the 20th century the worldwide diabetes pandemic had affected an estimated 151 million persons, distributed among both developed and developing countries1,2 India has more affected persons than any other country in the world Unfortunately, the future looks even worse, with a 170 increase expected by 2025 in developing countries and a corresponding 42 rise predicted for the developed countries Diabetes accounts for an extraordinary amount of human suffering as it is a major cause of blindness, kidney failure, amputations, and cardiovascular disease, and its complications substantially reduce both quality and length of life 3-5 In addition, diabetes imposes staggering economic costs while lowering productivity and wasting social capital 6,7 EFFICACIOUS TREATMENTS EXIST Fortunately, several efficacious treatments are currently available to reduce or prevent diabetes related complications Glycemic and blood pressure control can reduce micro vascular retinopathy and nephropathy complications 8,9; eye examinations with timely follow-up and photocoagulation
can prevent vision loss 10; foot care can decrease serious foot disease and amputations 11; control of blood pressure and lipids as well as aspirin use can prevent cardiovascular disease 9,12,13; angiotension-converting enzyme ACE inhibitors can reduce nephropathy and cardiovascular disease 14,15; and influenza and pneumococcal vaccines can reduce hospitalizations, respiratory conditions, and death 16 The current challenge is to effectively implement efficacious treatments across the population Unfortunately, numerous barriers to implementation exist, at a variety of levels, from the patient up through the provider, health care system and society 17 One particular problem is that most health care systems have evolved out of caring for acute diseases, not chronic diseases like diabetes Faced with treating other conditions requiring more urgent attention, it is not surprising that health care providers and systems often give diabetes and other chronic disease less attention than they merit That persons with diabetes need comprehensive, ongoing care may be overlooked because of a lack of appreciation that the disease is serious, that early diabetes is relatively asymptomatic or that
symptoms can go unrecognized, and that much of diabetes care relies on behaviors and selfmanagement Additional challenges include the fact that management of a life long chronic disease needs patient empowerment as well as care systems that are flexible and adaptive to local needs CURRENT DELIVERY OF DIABETES CARE In general, the quality of diabetes care remains suboptimal worldwide, regardless of a particular countrys level of development, health care system, or population The CODE-2 study, conducted in eight European countries has found suboptimal diabetes care in each, regardless of population size or type of health care system 18 In the United States of America, population-base surveys in the 1990s among adults 18-75 years old found that only 29 of the population had an A1C test, 63 a dilated eye exam, and 55 a foot examination within the last year The median A1C level was 75, but 18 had poor glycemic control A1C95 19 Lipids were tested in 85 within the last two years, but only 42 had low density lipoprotein LDL concentration indicating good control 34 mmol/L Finally, only 66 had a blood pressure of 140/90 mmHg In Asia, the Diabcare-Asia project, conducted in the late 1990s was
designed to provide large-scale, yet simple, standardized information about patient characteristics and care received from numerous centers across each participating country Results from Singapore, India and Taiwan, using similar methods, have found that between one third and one half of the diabetic population had poor glycemic control and that lipid control is suboptimal Table 1 20-22 These findings were surprisingly similar to both the European and USA studies 18,19 Thus, regardless of the health care system, country, region, or population, the level of care for diabetes is
Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia USA INT J DIAB DEV COUNTRIES 2004, VOL 24 7
currently suboptimal and regions are much more similar in the deficit than they are different Table 1 Studies of the Quality of Diabetes Care in Selected Asian Countries
Country Characteristics Total sites n Total patents n Year of study Age mean, yrs Duration of diabetes mean, yrs Type 2 diabetes Level of care A1c Mean Poor control Lipids mmol/l
Total cholesterol52
Singapore20 22 1697 1998
58
India21 26 2269 1998 54
Taiwan22 25 2446 1998 61
strategies for delivering better care The assessment uncovers deficiences and provides a benchmark against which future assessments The second aspect of translation research is to determine the barriers to improving care The barriers to providing routine preventive care, which includes eye and foot examinations, A1C tests, urine testing for microalbumin and monitoring cardiovascular risk factors, need to be understood These barriers may differ dramatically by region Armed with knowledge about deficient areas and significant barriers, researcher and public health workers can test new and locally modified approaches and pursue those found suitable The relationship of translation research to public health surveillance, epidemiology, and clinical research is shown in the figure 1 Both surveillance and epidemiology help to characterize the problems being addressed; this information leads to the development of clinical trials, which lead to potential Fig 1 : Relationship between Translational Research to Clinical Application
10 91
10 91
10 97
80 32
89 50
81 35
67 48
46 54
43 47
Triglycerides 17
See references 20
Singapore, 21 India, and 22 TaiwanIn Singapore and Taiwan, diabetes clinics study sites were defined as medical facilities primary care and restructured hospital diabetes clinic that managed 100 or more diabetic patients per month In India, diabetes centers study sites were both public and private sector from across the country with no specific criteria used to select centers 2 above the upper limit of normal range
TRANSLATION RESEARCH To improve the level of diabetes care, enough to achieve better outcomes, research efforts are needed to translate efficacious clinical and public health interventions into forms that can be delivered uniformly in typical clinical settings 23 This task is not trivial, however, because biological, social, educational, geographical urban/rural, cultural and psychological influences on the patient, provider, health care system, and society, all need consideration Any of these domains may present barriers or opportunities Translation research involves i assessing the level of care being delivered, ii determining the barriers to improving care and iii developing new
solutions to improve care Clinical trials, however, are usually developed with an
emphasis on highly rigorous methods, and they aim for internal consistency and essentially to discover what can be accomplished under ideal circumstances Thus, their findings tend not to apply in a typical health care setting In contrast, translation research focuses on interventions that can be readily and easily applied in the real world
8
INT J DIAB DEV COUNTRIES 2004, VOL 24
While there are similarities between etiological research and translation research, the major differences between them are in their emphasis Translation research focuses on changing practices that improve care at the level of patient, provider, or health systems and can be generally applied across various setting Etiological research, in contrast, focuses on understanding the causes, patient-level risk factors, and it emphasizes internal validity and controlled conditions In addition, translation research emphasizes the absolute benefit of an intervention in terms of its population-level impact, while etiological research tends to focus on relative risk ratios which only contrast the two groups being studied one with the risk factor and one without The elements of care studied with translation research
include, how the health care system is structured eg single provider, group, hospital based, the processes of care eg retinal and foot examinations, screening for cardiovascular risk factors and the outcomes of care eg visual impairment/blindness, amputations, cardiovascular disease The goal is to achieve better process of care, better control of risk factors eg A1C, blood pressure, cholesterol and ultimately, better clinical outcomes eg cardiovascular, kidney, eye disease CONCLUSION Despite our vast knowledge of how to prevent diabetes related morbidity and premature mortality, the level of diabetes care being delivered across the globe is well below what we need Fortunately, opportunities currently exist to translate this knowledge into readily usable interventions that can be implemented into routine practice across all settings Taking advantage of these opportunities, which is at the core of translation research, is essential if we are to turn the tide against the global pandemic REFERENCES :
1 Zimmet P, Alberti KGMM, Shaw J Global and societal implications of the diabetes epidemic Nature 2001;414:782-7 King H, Aubert RE, Herman WH Global burden of diabetes, 1995-2025:
prevalence, numerical estimates, and projections Diabetes Care 1998;21:1414-31 Klein R, Klein BEK, Moss SE Visual impairment in diabetes Ophthalmology 1984;91:1-9
4
Wetterhall SF, Olson DR, DeStefano F, Stevenson JM, Ford ES, German RR, Will JC, Newman JM, Sepe SJ, Vinicor F Trends in diabetes and diabetic complications Diabetes Care 1992;15:960-7 Geiss LS, Engelgau M, Frazier E, Tierney E: Diabetes Surveillance, 1997 Atlanta, GA, Centers for Disease Control and Prevention US Department of Health and Human Services, 1997 The Economics of Diabetes and Diabetes Care A Report of the Diabetes Health Economics Study Group Gruber W, Lander T, Leese B, Songer T, Williams R, Eds Brussels Belgium: International Diabetes Federation, 1997 http://wwwpittedu/tjs/diabeconhtml Accessed Aug 16, 2002 American Diabetes Association Economic consequences of diabetes mellitus in the U S in 1997 Diabetes Care 1998;21:296-309 The 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 Lancet 1998;352:837-53 The UK Prosective Diabetes Study Group Tight blood
pressure control and risk of macrovascular and microvascular complications in type 2 diabetes UKPDS 38 BMJ 1998;317:703-13
5
6
7
8
9
10 EarlyTreatment Diabetic Retinopathy Study Research Group Early photocoagulation for diabetic retinopathy: ETDRS 9 Ophthalmology 1991;98 Supp 5: 766-85 11 Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, BIld DE, Ford ES, Vinicor F Reduction of lower extremity clinical abnormalities in patients with non-indulin-dependent diabetes mellitus: a randomized controlled trial Ann Inter Med 1993;119:36-41 12 Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease: a subgroup analysis of the Scandinavian Simvastatin Survival Study 4S Diabetes Care 1997;20:614-20 13 ETDRS Investigators Asprin effects on mortality and morbidity in patients with diabetes mellitus: Early Treatment Diabetic Retinopathy Study Report 14 JAMA 1992;268: 1292-1300 14 Ravid M, Lang R, Rachmani R, Lishner M Long term renoprotective effects of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus: A 7-year follow-up
study Arch Intern Med 1996;156:286-9 9
2
3
INT J DIAB DEV COUNTRIES 2004, VOL 24
15 Heart Outcomes Prevention Evaluation HOPE Study Investigators Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE study Lancet 2000;355:253-9 16 Nichol KL, Wuorenma J, Von Sternberg T Benefits of influenza vaccination for low-intermediate- and high-risk senior citizens Arch Intern Med 1998;158:1769-76 17 Blonde L, Dey J, Testa MA, Gutherie RD Defining and measuring quality of diabetes care Prim Care 1999;26:841- 55 18 Liebl A, Mata M, Eschwege E ODE-2 Advisory Board Evaluation of risk factors for development of complications in Type II diabetes in Europe Diabetologia 2002;45:S23-8 19 Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, Narayan KMV A diabetes
report card for the United States: quality of care in the 1990s Ann Intern Med 2002;136:565-74 20 Lee WRW, Lim HS, Thai AC, Chew WLS, Emmanuel S, Goh LG, Lau HC, Lee HC, Soon PC, Tambyah JA, Tan YT, Jorgensen LN, Chua A, Yeo JP A window on the current status of diabetes mellitus in Singapore - the Diabcare- Singapore 1998 study Singapore Med J
2001;42:501-7 21 Raheja BS, Kapur A, Bhoraskar A, Sathe SR, Jorgensen LN, Moorthi SR, Pendsey S, Sahay BK Diabcare Asia - India Study: Diabetes care in India current status JAPI 2001;49:717-22 22 Chuang LM, Tsai ST, Huang BY, Tai Ty The current state of diabetes management in Taiwan Diabetes Res Clin Pract 2001;54 suppl 1: S55-S65 23 Narayan KMV, Gregg EW, Engelgau MM, Moore B, Thompson TJ, Williamson DF, Vinicor FV Translation research for chronic disease: the case for diabetes Diabetes Care 2000;23:1794-8
INT J DIAB DEV COUNTRIES 2004, VOL 24
10
Source:educationforhealth.net
