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Building population-based care programs improves diabetes care and outcomes


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Naveed Sattar, MD, PhD
Naveed Sattar, MD, PhD

Detailed data is a key element in successful population-based diabetes care programs. Another is connected data.

“If you have good connectivity, you can do quite detailed and rapid research to better understand risks, find novel uses, and inform public policy,” said Naveed Sattar, MD, PhD, Professor of Metabolic Medicine, University of Glasgow Institute of Cardiovascular & Medical Sciences, Scotland.

Dr. Sattar opened ADA Diabetes Care Symposium—Population-Based Regional Programs for Diabetes—Successes, Limitations, and Opportunities on Saturday, June 4, with an overview of how connected health data is being used in the United Kingdom, Denmark, Sweden, and Finland. The session was livestreamed and can be viewed on-demand by registered meeting participants at If you haven’t registered for the 82nd Scientific Sessions, register today to access the valuable meeting content.

In Scotland, unique patient identifiers unite patient-level data from inpatient, outpatient, prescribing, insurance claims, birth, death, and other databases. One immediate result is improved access to care, Dr. Sattar said. A 2015 survey found that 99% of U.K. residents have access to appropriate care compared to 61% in the U.S.

Jaakko Tuomilehto, MD, PhD
Jaakko Tuomilehto, MD, PhD

A secondary result of such data is improved outcomes. A 2017 review found that while cardiovascular deaths in Sweden had fallen 29% between 1998 and 2013, cardiovascular mortality had dropped 44% for patients with type 2 diabetes.

“These kinds of data tell us that the younger you are at the time of diabetes diagnosis, the higher your risk of mortality,” Dr. Sattar said. “If you can delay the onset of diabetes, you can do quite a bit of good for a lot of people. That means targeting your screening in the highest risk groups for greater impact at lower cost compared to universal screening.”

Finland used connected data to take diabetes prevention from proof-of-concept to national intervention, reducing the risk of type 2 diabetes in individuals with impaired glucose tolerance by 58% using lifestyle intervention.

“When you begin population-based diabetes prevention, you will see an initial increase in type 2 diabetes reimbursement due to improved testing and treatment, followed by decreased reimbursement in later years,” said Jaakko Tuomilehto, MD, PhD, Professor of Medicine, Finnish Institute for Health and Welfare and University of Helsinki, Finland. “The absolute risk difference between intervention and control groups is still seen at least 15 years after intervention stops.”

Multimodal intervention is the most effective approach, he said. The Finnish program targeted weight reduction of greater than 5%, fat intake of less than 30%, saturated fat intake of less than 10%, fiber consumption of 15 g or more per 1,000 kcal, and at least 30 minutes of physical activity per day.

Ewan Pearson, MD, PhD
Ewan Pearson, MD, PhD

“Science provides the facts, but it does not change behavior or culture,” Dr. Tuomilehto said. “Prevention lives in the community. Working in the community is much more complex than a clinical trial, but it can be just as successful.”

Scotland has launched a similar data-driven program to improve diabetes care and management. The program, based on the Diabetes Audit and Research in Tayside Study launched in 1996, was rolled out across Scotland in 2006 as SCI-Diabetes.

“We, like Sweden, have a unique identifier for all health-related interactions,” said Ewan Pearson, MD, PhD, Professor of Diabetic Medicine, University of Dundee, Scotland. “It allows us to take fragmented data sites and join them up into unified data and unified care for every diabetes patient in Scotland.”

Point-of-care clinical decision support encourages guideline-based care. Improvements include better foot screening with corresponding reductions in foot ulcers and amputations in both type 1 diabetes (HR=5.43) and type 2 diabetes (HR=3.12), Dr. Pearson reported.

Data on hypoglycemia revealed that sulfonylurea use has one-third the rate of severe hypoglycemia compared to insulin. Among sulfonylureas, glyburide has the highest rate of severe hypoglycemia and gliclazide modified release the lowest, which has altered prescribing patterns.

Andrew JM Boulton, MD, DSc
Andrew JM Boulton, MD, DSc (Hon), FACP, FICP, FRCP

An interactive website, My Diabetes My Way, gives individuals access to their own test results, clinical letters, treatment plans, information, education, and news. Economic analysis showed cost savings of £118 (US$145) per person over 10 years.

“That is a potential savings of £19 million (US$23.4 million) if just half the Scottish population engaged,” Dr. Pearson said.

Andrew JM Boulton, MD, DSc (Hon), FACP, FICP, FRCP, Professor of Medicine, University of Manchester, United Kingdom, and University of Miami, and Associate Editor, Diabetes Care, presented the annual Profiles-in-Progress Awards. The 2022 honorees were Daniel Mintz, MD, Founding Scientific Director of the University of Miami Diabetes Research Institute, who died in 2020, and Paul Zimmet, MD, PhD, Professor of Diabetes, Monash University and Founder of the International Diabetes Institute, Melbourne, Australia.

“They have been mentors, colleagues, and pioneers in diabetes,” Dr. Boulton said. “As Huang Dee wrote in the first Chinese medical text around 2600 BCE, inferior doctors treat full-blown disease, mediocre doctors treat disease before it is evident, and superior doctors prevent the disease. Prevention is what both of these fine doctors have done.”