Diabetes: stratified care could improve prevention and management
Approximately 4 million people in the UK have been diagnosed with type 2 diabetes; this is expected to rise to 5.5 million by 2030.
Diabetes costs the NHS around £10 billion a year; most consultations for type 2 diabetes take place in primary care. Stratified care could help prevent and manage diabetes, and optimise use of NHS resources.
Stratified care recognises that different groups of people, all with the same condition, may have different needs. Personal characteristics, such as age, ethnicity, other conditions or body mass index (BMI), influence decisions on the most appropriate care pathway, and how best to manage someone’s condition.
Here, we present examples of NIHR research on stratified approaches to the treatment of diabetes in primary care. It is a shortened version of: Can stratified care help primary care teams manage long-term conditions?
Ethnicity guides diabetes prevention
Higher body weight is linked with type 2 diabetes, but has different effects on different ethnic groups. For example, National Institute for Health and Care Excellence (NICE) guidelines on diabetes prevention recommend weight loss programmes for white people with BMIs of 30+ but for South Asian and Chinese people with lower BMIs (of 27.5+). Research suggests that stratification based on ethnicity could be refined.
A study included almost 1.5 million adults who had not been diagnosed with type 2 diabetes. It found that South Asian, Arab, Chinese and Black people were more at risk than white people. For example, South Asian people with a BMI of 24, or Black Caribbean people with a BMI of 26 had a similar risk of diabetes to white people with a BMI of 30. The research suggests that people from many ethnic groups could benefit from diabetes prevention and weight management services at lower BMIs than would currently prompt action.
BMI, sex, and kidney function could influence choice of treatment
In another study, researchers examined the choice of medication for different groups of people with type 2 diabetes. They explored the potential benefits of using an individual’s characteristics to influence the choice of second- or third-line diabetes treatments (medications started when first-line treatments, usually metformin, fail to control blood glucose levels).
It showed that people with:
- a high BMI (30+) benefited more from pioglitazone than sitagliptin; those with a lower BMI benefited more from sitagliptin
- poor kidney function benefited more from sitagliptin than from canagliflozin; the reverse was true for those with better kidney function.
These results suggest that information routinely collected by GPs (BMI and kidney function) can be used to stratify people with type 2 diabetes, and identify the treatments most likely to be suitable for them.
A database study, involving more than 22,000 people, stratified patients in other ways. It showed that for:
- men with a BMI less than 30, sulfonylureas were more effective than thiazolidinediones
- women with a BMI 30+, thiazolidinediones were more effective than sulfonylureas.
GPs could discuss these findings with patients when deciding on medication.
Do people at low risk of ulcers need an annual foot check?
Foot ulcers are a major complication from diabetes that GPs aim to predict and prevent. Research evidence could help GPs do this and save resources.
For example, NICE guidance recommends using 8 to 10 tests to assess the risk of a foot ulcer. Researchers developed an accurate tool that requires only 3 pieces of information and is simpler and quicker to carry out. The information required is: a pulse in the foot, previous ulcers or amputation, and the monofilament test (which measures ability to feel a single strand of nylon).
NICE guidelines recommend that people with type 2 diabetes have an annual assessment for risk of foot ulcers. Other research suggests that these foot checks could be scaled back. It found that few (5%) people at low risk progressed to medium risk after two years. Fewer still (0.4%) developed ulcers in that time. Screening people at low risk every 2 years instead of annually could save time and money.
NICE reviewed both of these foot ulcer studies but did not include the findings in the 2023 update of guidelines. This was partly because of insufficient evidence about the tool’s use in practice and also because more frequent checks offer an opportunity to teach people how to look after their feet.
Conclusion
Stratified care is not a silver bullet and needs to be supported by strong evidence before it is implemented in practice. GPs and commissioners could use this evidence to make better use of stratification in the treatment of diabetes in primary care.
Author: Brendan Deeney, Science Writer, NIHR
This is an edited version of: NIHR Evidence; Can stratified care help GPs manage long-term conditions?; September 2024; doi: 10.3310/nihrevidence_63807
Disclaimer: This Collection is based on research which is funded or supported by the NIHR. It is not a substitute for professional healthcare advice. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.