Diabetes study offers glimmer of hope


New research1 reveals new type 2 diabetes cases falling or stable—offering hope for Australian screening and prevention efforts.

The annual rates of new cases of adults diagnosed with type 2 diabetes (T2D) is falling or stable in Australia and many high-income countries, a new global study finds.1

Australian researchers who led the study say they are “cautiously optimistic”.

Analysis of data reporting diabetes incidence over time found the number of people diagnosed with T2D during the past decade has been stable or falling across Australia, Europe and the US.

The results, which span 21 countries and include more than 22 million diabetes diagnoses, provide an alternative to reports that outline a rising total number of people living with diabetes, in more than 80% of the countries examined in this study.

The study,1 published in The Lancet Diabetes and Endocrinology and funded by the Centers for Disease Control and Prevention in the US and Diabetes Australia, is the first to systematically focus on diabetes incidence—that is, the number of people who develop T2D each year.

While prevalence is a useful measure, say the study authors, incidence can be much more informative, especially for understanding the changing risk status in a population.

Of the 24, mostly ‘whole of population’-based data sources examined from 19 high-income and two middle-income countries, 23 data sources contained data from 2010 onwards, among which 19 had a downward or stable trend, with an annual estimated change in incidence ranging from –1.1% to –10.8%. Among the four data sources with an increasing trend from 2010 onwards, the annual estimated change ranged from 0.9% to 5.6%. The Australian data from the National Diabetes Services Scheme includes more than 850,000 incident diabetes cases over a 13-year period.

Lead researchers at the Baker Heart and Diabetes Institute say that preventive strategies, public health education and awareness campaigns may have contributed to this flattening of rates of new cases in high-income countries, providing some assurance that global efforts to curb the diabetes epidemic might be showing promise.

Head of diabetes and population health at the Baker Institute, Professor Dianna Magliano, says the analysis of one of the largest consortia of data is encouraging, and highlights the need to continue to invest in large-scale monitoring and prevention. The study also highlights the ability of researchers to harness big data sets to identify trends in healthcare.

“This study shows that after decades of rising diabetes prevalence and incidence, incidence is falling and/or stable in many high-income countries since around 2010. It is important to use incidence rate at which new cases of diabetes develop) rather than prevalence (the proportion of all cases of diabetes) because prevalence is affected by population ageing and improved medical care which means people are living longer with diabetes, and less likely to die. In developed countries, ageing populations, coupled with good medical care of those with diabetes, means prevalence of diabetes will rise even if the incidence is falling. So, if we really want to understand whether our interventions are having any impact and whether the epidemic is improving, we need to track incidence,” Prof Magliano tells the AJP.

There could be several reasons for the plateau or decline in diabetes incidence during the past decade in many high-income countries, including Australia.

“We may be starting to reap the benefits of T2D prevention activities, including increased awareness, education and risk factor modification. We have seen improvements in diabetes screening, the addition of health education programs in schools and workplaces, and changes to the physical environment such as the introduction of bike tracks and exercise parks.”

Strategies to tackle diabetes such as the reformulation of foods, including the removal of trans fats from manufactured food in the US and the reduction in intake of sugar-sweetened beverages in high-income countries, may also have had an impact.

“Other factors may have also influenced reported diabetes incidence. For example, none of the studies screened for undiagnosed diabetes. It is possible that one factor is a reduction in the number of people being screened for diabetes, although in the data we had access to there is no direct evidence that this has happened,” Prof Magliano says. However, she also points out the plateau or decline does not align with obesity rates—with OECD rates continuing to show projected increases in obesity in the coming decade.

“There is no doubt that adiposity is a major driver of T2D. However, not everything is captured in studies reporting the prevalence of increased BMI. For example, increasing physical activity has minimal effect on obesity, but has a greater effect on metabolic function. Increasing dietary fibre intake might also have a greater effect on metabolism than on body weight. Thus, the small changes in diabetes incidence that we report could certainly be consistent with apparently dissimilar trends in obesity,” she says.

…pharmacists certainly have a role in encouraging people who are either at risk of developing diabetes, or who already have diabetes, to follow healthy lifestyles.

Co-author diabetes physician and researcher, Professor Jonathan Shaw, head of clinical diabetes and epidemiology, Baker Specialist Clinics, says, “Our findings suggest that population-level and individual-level interventions for preventing T2D may have had some success. But we have a long way to go. We need more of what we have done in the last 10 years. More encouragement to increase physical activity, reduce sedentary behaviour and improve healthy eating choices. Much of this needs to be at a societal level to make the healthy choices the easy and cheapest choices. As trusted health professionals, pharmacists certainly have a role in encouraging people who are either at risk of developing diabetes, or who already have diabetes, to follow healthy lifestyles.”

“These results provide important information in shaping healthcare planning and policy, including where best to address public health and clinical efforts,” Prof Magliano says.

Opportunities for pharmacists

Ascertaining the best use of pharmacists’ skills in diabetes care and preventative health has been the focus of research for decades.2-5 Since the 1990s and through successive Community Pharmacy Agreements, mounting clinical evidence and innovative practice changes has seen the roll out of services such as Clinical Interventions, HMRs, MedsChecks and Diabetes MedsChecks. All potentially offer pharmacists a greater role in preventative care and diabetes management, and alternative sources of remuneration beyond the supply function.7 Indeed for more than a decade, Ines Krass, Professor Emerita in Pharmacy Practice, University of Sydney and her colleagues have shown in their research that pharmacists can be hugely beneficial in helping patients make significant improvements in diabetes control. In turn, these improvements could realise reductions in cardiovascular risk and other complications, and have the potential to translate into future costs savings to the healthcare system by delaying and reducing complications.2,3 But her most recent research has turned attention to screening undiagnosed T2D and the cost effectiveness of it in a national pharmacy trial.6 The Pharmacy Diabetes Screening Trial (PDST), funded under the 6CPA, is the largest trial of its kind completed in Australia in diabetes screening.

Although Prof Krass and her team have completed their work—the government had yet to release its findings by April 2021.

“A lot of the earlier research2,3 I led was more focused on supporting people who already had a diagnosis and were on treatment. Our later research6—the PDST—was a primary prevention study looking at using pharmacists to identify people who were either at risk already, or were likely to have diabetes, and then refer them,” Prof Krass tells the AJP.

This had been informed by her previous work that showed the need for a diabetes service in community pharmacy and pharmacies had the capacity, time, and leadership to do it.

“Our models of care, when they worked well, demonstrated that pharmacy was really valuable to patients in the management of their diabetes, especially in helping with other modifiable lifestyle factors that could contribute to worsening of the disease, or other complications.

“It also emerged pharmacists could be very useful to the newly diagnosed. That’s a point where people need a lot of support and information—especially if they are self-monitoring their blood glucose.

“Also, we know from the basic epidemiology of T2D that it can have a very long latency period. Many people have either pre-diabetes, or may already have diabetes and don’t know it. So, the importance of picking them up and implementing some sort of management program is vital. If you already have diabetes, the longer you leave it untreated, the greater the risk of subsequent diabetes complications. If you’ve got continuing high blood glucose levels, it’s doing damage to your blood vessels—you already might be doing some damage to your nerves, your kidneys, your eyes, and so on. And if they have pre-diabetes, you want to try and prevent them from transitioning.

“And the argument for pharmacy is that it obviously taps into a population who might not necessarily be visiting their GP on a regular basis—typically people who see a doctor go when they get an acute health problem. They don’t necessarily routinely go for preventative health for screening or health checks. We also know that there’s not a very high rate of screening in GP practices so people are slipping through the net.”

Additionally, in pharmacy people can receive free health information about risk factors and they are also exposed to preventative health messages, regardless of their health issues. They may even receive pharmacist advice on reducing their risk factors. On the other hand, a criticism often directed at pharmacy is there’s no follow-up after screening—people often just ‘disappear’—something they attempted to address in the PDST.6

“If a patient’s test results showed they were at risk of T2D, they were given a referral, a copy of which was also sent to their nominated GP. The patient was contacted by the pharmacist a month later to find out what happened. The research team followed this up and managed to get responses from about 80% of GPs after a lot of hard work! 

“This trial was unique in the sense that it used a representative sample of the population and our pharmacies across Australia. And thanks to our methodology, we were able to collect data from several different sources to determine the rate of diagnosis of diabetes and pre-diabetes.”

Trial feedback

Pharmacists who took part in the trial were overwhelmingly positive about the experience in a follow-up PDST interview-survey7—in particular, about ease of implementation; impact on workflow; engagement with patients, doctors and other specialists.

“It was a good way to engage with patients on a more clinical level. It was something that pushed us to offering further services to patients.” (PharmID 355H).7

“Long term vision of my pharmacy… is continuing being more patient focused and with increased customer service. Less behind the counter and more out…Offering services that people might want as well, cholesterol, warfarin testing, things like that. Like BP testing, MedsChecks.” (PharmID 176H).7

However, some pharmacists in the trial said location of the pharmacy was also crucial to the success of any screening program.

“I guess it depends on where you are and what sort of population group you have have… Maybe like… rural pharmacies a lot of these services would be excellent to have if they didn’t have a doctor, or if the doctor was struggling.” (PharmaID 377 H).7

GP to ‘CP-care’

The pharmacy location and how that relates to services offered was a key metric in a paper co-authored by Prof Krass, and Deakin University’s Associate Professor Kevin McNamara and colleagues.8 The 2015 state-wide census of Victorian community pharmacies (CP) investigated the prevalence and uptake of cardiovascular (CVD) prevention services. Along with location, the survey also considered area level socioeconomic demographics (SES) to see if what is known as the Inverse Care Law applied.9 The Inverse Care Law posits that the availability of good medical or social care varies inversely with the needs of the population served.

In general, services were more frequently available from pharmacies in lower SES and rural communities—where there might be reduced access to GPs. Factors predicting the likelihood of pharmacies receiving non-government reimbursement services included having a counselling room and more than one pharmacist on duty.

In rural areas, evidence suggests that people with a high risk of CVD onset or undiagnosed diabetes see the pharmacist between four and six times a year so there are considerable opportunities to support people in communities with limited service access or diminished quality of care.8

“A blood pressure testing service was the one most frequently seen in our survey,” Prof McNamara tells the AJP. Other services included cholesterol testing, blood glucose testing, flu vaccination, sleep apnoea testing, weight management, waist measurement, diet-focused support, arterial fibrillation, proteinuria testing and programs supporting increased physical activity.

“In rural areas, and because they are more likely to be in a lower social demographic, patients might be more inclined to substitute GP-care for CP-care as access to doctors can be difficult or they don’t bulk bill,” Prof McNamara says.

Additionally, pharmacies were more likely to receive remuneration for non-government-funded service if they are located in a lower SES area, had better access to acute cardiac services, a second pharmacist available and a private room.

“Although it is a hypothesis, it could be that access to primary care is reduced in more rural and lower SES communities. And if those people cannot access a GP, perhaps they will go to their pharmacy. This behaviour could be driving pharmacy as an alternative source of care. Whereas, in more affluent areas people can afford and expect to deal with a doctor.

“Additionally, there is literature showing that pharmacists are highly trusted professionals and frequently engaged for advice in rurally-based communities. They have really good relationships with a lot of their community and, therefore, it may make it easier for them to recruit patients into preventative health screening services,” Prof McNamara says.

Given the very high response rate to the survey—about 75%—the findings add to growing evidence bolstering the case for the uptake and implementation of cost-effective preventative health programs in community pharmacy—such as the model used in the PDST trial.

“This study adds a nice complementary perspective to the PDST research; however, one of the limitations of the data is that it is self-reported by the pharmacists in our survey,” Prof McNamara adds.

“More broadly though, a lot of information pharmacists receive when conducting a diabetes screening will be relevant to CVD screening and you’ll also have efficiencies if you are measuring multiple conditions as once. A lot of the burden for pharmacists offering these types of preventative services to a really high standard comes from all the documentation and administration required, as much and possibly more than actually doing the testing. Plus, there’s the work involved in GP referral, and even sitting with the patient and explaining the service to them. And if the service is externally-funded, you also need to administer claims for payments.”

The survey looked at both non-remunerated and remunerated services—including government-renumerated services such as MedsChecks and Diabetes MedsChecks.

One quarter of the pharmacies surveyed said they offered 50 or more non-government funded services and 10 or more government-funded MedsChecks or Diabetes MedsChecks in an average month.

MedsChecks

Prof Krass’ earlier work2,3 on precursors to the what is now known as the Diabetes MedsCheck program—found that long-term interventions had crucial ongoing benefits to patients.

“I think the case could be made to ‘ramp up’ Diabetes MedsChecks so that there’s a follow-up component and continuity of care. Although, checking medication is important, the focus on medication can miss the complexity of this disease that requires targeted interventions and support over the long-term,” says Prof Krass.

…I strongly believe you’ve got to have funding mechanisms in place to drive and increase the uptake of pharmacy diabetes services.

“Diabetes MedsChecks are a kind of ‘watered-down version’ of what was put in place in our earlier diabetes screening trials. In the models we tested, there was ongoing support for the patient over a long period of time—which was a very important component. And that certainly came through when we talked to the patients who had been through the service. However, from the pharmacists’ perspective these models were quite intensive and many pharmacists struggled to actually deliver the service. Additionally, the program had to overcome issues like inconsistent demand for diabetes services and fragmentation of care among GPs, dietitians, credentialled diabetes educators, and pharmacists—potentially all offering different things,” Prof Krass says.

“Therefore, I strongly believe you’ve got to have funding mechanisms in place to drive and increase the uptake of pharmacy diabetes services. This means developing a better way of integrating pharmacists into primary care networks, so there is improved continuity between members of a patients’ healthcare team and a better mechanism for information exchange.”


References

  1. Magliano DJ, et al. Trends in the incidence of diagnosed diabetes: a multicountry analysis of aggregate data from 22 million diagnoses in high-income and middle-income settings. Lancet Diabetes Endocrinol. 2021;9(40):203-11. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(20)30402-2/fulltext
  2. Krass I, et al. The Pharmacy Diabetes Care Program: assessment of a community pharmacy diabetes service model in Australia. Diabetic Medicine. 2007;24(6):677-83. doi: 10.1111/j.1464-5491.2007.02143.x
  3. Krass I, et al. Diabetes Medication Assistance Service Stage 1: impact and sustainability of glycaemic and lipids control in patients with type 2 diabetes. Diabetic Medicine. 2011;28(8):987-93. https://doi.org/10.1111/j.1464-5491.2011.03296.
  4. Hughes JD, et al. The role of the pharmacist in the management of type 2 diabetes: current insights and future directions. Integr Pharm Res Pract. 2017;2017(6):15-27. doi: 10.2147/IPRP.S103783
  5. Amour CL, et al. Implementation and evaluation of Australian pharmacists’ diabetes care services. J Am Pharm Assoc (2003). 2004;44(4):455-66. doi: 10.1331/1544345041475625.
  6. Krass I, et al. Pharmacy Diabetes Screening Trial: protocol for a pragmatic cluster-randomised controlled trial to compare three screening methods for undiagnosed type 2 diabetes in Australian community pharmacy. BMJ Open. 2017;7: e017725. doi: 10.1136/bmjopen-2017-017725
  7. Siu AHY, et al. Implementation of diabetes screening in community pharmacy—factors influencing successful implementation. Res Social Adm Pharm. Dec 29;S1551-7411(20)31241-9. doi: 10.1016/j.sapharm.2020.12.013. Online ahead of print.
  8. Zonneveld S, et al. The Inverse Care law might not apply to preventative health services in community pharmacy. Res Social Adm Pharm. 2021;17(5):875-84. https://doi.org/10.1016/j.sapharm.2020.07.013
  9. Hart JT. The inverse care law. Lancet. 1971;297(7696):405-12. Doi:10.1016/s0140-6736(71)92410

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