Does My Practice Have Evidence

To Back It Up? Using Evidence To

Strengthen Daily Practice

Associate Professor Marg McGill AM

Associate Director
Diabetes Centre
Royal Prince Alfred Hospital
Sydney

Centre of Health
Professional Education

Evidence

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Guidelines from

ISPAD

ADA

CDA

IDF

etc

However, guidelines are just that!

Knowledge versus Wisdom

Overview

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Evidence

Clinical and Education

A model to implement the evidence

Evidence of implementation

Science versus art

Professional development

Evidence Based Care Requires

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Good understanding of diabetes care

Open mind

Strategies to:

Question existing practices

Monitor and evaluate care and services

Change things

Using Evidence Wisely

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We cannot be evidence purists

By definition clinical trials are done in specific
populations
Results are not directed at an individual
individualise our treatments and approaches
Often not in paeds eg Statin trial
If too purist may not benefit some patients eg JCN8
and BP targets
Some areas not suitable for RCT eg Day 1 Tx
Progress overtakes research eg technology

Evidence versus Dogma

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Nutrition and Diabetes

No evidence for ideal macronutrient mix

Inconclusive evidence re recommended amount

of CHO intake for diabetes

No evidence to have a mid meal snack or not

Modest evidence for substituting low glycaemic

foods instead of high

Diabetes Care Volume 37, Supplement 1, January 2014

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Evidence Says:

MDI or Pump therapy in type 1

Intensive therapy early
Reduce hypoglycaemia
CHO counting
Annual screening for :

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Eyes,
Kidneys
Feet
etc

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But how do you do it in clinical practice ?

You need a system it wont just happen!

Team Care : Differences In A1c

A Meta Analysis

Shojania, K. G. et al. JAMA 2006;296:427-440

RPA: A Multi-disciplinary Diabetes Centre

(Education is Integrated with Clinical Service and Care is Shared
Joint decision making ; team in same room as patient)

Referring Doctor

Pregnancy
Clinic
High Risk
Foot Clinic

Acute Intervention
Clinic

Complications and
Metabolic Management
(Type 1 & 2)

Follow-Up Clinic

Review Clinic

Overland J, McGill M et al : Diabetes Res Clin Pract 1999 ; 44(2):123-8

Team Care : An Example

Complications Assessment

Single visit full assessment started 1986

Nurse spends 30 - 45 mins with patient taking
detailed history, doing full assessment ;
Nurses do not just procedures but truly
understand and interpret results and treatment in
light of clinical trial results
Doctor spends 5 10 mins depending on
complexity of case and experience of nurse =
high quality care and high throughput of patients

Royal Prince Alfred Hospital Diabetes Centre model for 25 years

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Health Care Delivery Evidence

Diabetic
Clinic
Care

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Diabetes
Centre

Diabetic Clinic Care +

Annual Complications
Screening

Complications Screening
in 12 months (%)
Eyes review

88

100

86

Lipids Measurement

72

96

92

Microalbuminuria

56

94

72

Cholesterol < 4mmol/L

24

24

27

BP

26

35

28

HbA1c within 1% of
normal range

29

44

41

Target Achieved (%)

ANDIAB Survey : Cheung NW et al : Diab Med 2008 ; 25(8) : 974-8

Monitoring By A Senior Nurse

After Visits

Daily team clinical

meeting

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All patients medical records

reviewed ; possible
mistakes and omissions
identified and appropriately
questioned
Bidirectional feedback
Safety net
Standardises party line
message and upskill staff
Collects data

Weekly Training Sessions ALL Staff

Must Attend!

Strengthening Clinical Practice

Evidence does this

Obtaining our own evidence does it better!

The reality test is a great test for evidence

applied to practice

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Why Should Diabetes Educators

Participate In Research?

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Professional basis for practice

Professional accountability and responsibility
Demonstrate quality and value of diabetes
education
Obtain support and funding
Dealing with increasingly well informed
consumers
Core component of the role

Research/Practice Gap

Most diabetes educators:

Do not undertake research

Read a limited amount of research

May or may not be in a position to apply research

findings

Often do not have research skills

Resources and time available to participate in

research is often limited

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The Joys of Research!

Integrate research into our routine work

Dont think Im too busy to do research
Make it a part of your work, for example, something
simple like applying the Diabetes Distress
Questionnaire to different ethnic groups and
comparing results

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Abstract
Presentation
Paper

Makes work more interestingit is your work

Research In A Multi-disciplinary
Setting: Less Linear Than Thematic

Do We Know What Our Patients Want?

A significant difference exists between the
wants and needs for education identified by
people with diabetes, and those identified by
their care givers

Changed our practice !

Genev N. Practical Diabetes Int. 1992

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23

Prevalence Of Severe Hypoglycemia in

Type 1

2009 n=562

Metabolic Syndrome in Type 1 Diabetes

McGill M et al : J Diabetes Complications 2008 ; 22(1) : 18-23

RPAH Audit T1D Adults

BMI (kg/m2)

15% on Metformin Features of Metabolic Syndrome

40
35
30
25
20
15
10
5
0

p<0.0001

25.2

T1D Not on
Metformin, n=67
Mean SD

29.7

T1D on
Metformin,
n=385
WHO 1999 criteria

G.Tun, M. Constantino, T. Wu, M. McGill, J. Wong et al

In prep.

Youth Onset Type 2 Diabetes

Arent you lucky you dont

need the needle?
Or are you......?
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Youth Onset Type 2 Diabetes :

Micro And Macrovascular Complications
Type 2 Diabetes
N=354

Type 1 Diabetes
N=354

p-value

Duration of
diabetes (yrs)

11.6
[4.5-22.6]

14.0
[7.3-22.2]

0.06

eGFR

98 39.2

93 32

0.3

Retinopathy (%)

37

40

0.5

Albuminuria (%)

47.4

13.1

<0.0001

ACR

2.2
[0.8-12.8]

0.7
[0.4-1.5]

<0.0001

VPT Z score

2.3 1.3

1.8 1.3

<0.0001

Stroke (%)

4.3

0.6

0.002

IHD (%)

12.6

1.6

<0.0001

Constantino MI et al. Diabetes care 2013;36:3863-3869

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Youth Onset Type 2 Diabetes :

A Less Favourable Risk Factor Profile
Type 2 Diabetes

Type 1 Diabetes

p-value

49.3

24.8

<0.0001

Systolic BP (mm/Hg)

126 17

122 17

0.02

Diastolic BP
(mm/Hg)

78 10

75 9

<0.0001

38.3

28.8

<0.0003

5.2 1.5

4.9 1.2

0.007

Triglycerides
(mmol/L)

1.9 [1.3-3.0]

1.0 [0.7-1.5]

<0.0001

HDL (mmol/L)

1.2 0.4

1.5 0.4

<0.0001

LDL (mmol/L)

3.0 1.1

2.8 0.9

0.2

41

46

0.2

Antihypertensive
Treatment (%)

Statins (%)
Cholesterol (mmol/L)

Ever smoked (%)

Constantino MI et al. Diabetes care 2013;36:3863-3869

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Survival Analysis

Constantino MI et al. Diabetes care 2013;36:3863-3869

Strengthening Our Practice

This data from our Diabetes Centre has

changed our approach to :

educating patients

managing Type 1 DM with features of metabolic

syndrome

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managing youth onset type 2 diabetes

teaching of other health professionals

The Art and Science of Medicine

Individual Case Studies

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Another level of evidence albeit weaker

We learn from our patients
Not to be neglected
Eg once a day basal versus MDI therapy

Girl with obsessive CHO counting

Strengthening Practice Through

Communication

The greatest motivational act one person

can do for another is to listen in order to hear
what people have to say

Evidence for this may be weak but if the

person continues to return then you are

doing something right!

Ralph G. Nichols, University of Minnesota

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Stress versus Burnout

Stress

Burnout

Characterised by over-engagement Characterised by disengagement

Emotions are over-reactive

Emotions are blunted

Produces urgency and

hyperactivity

Produces helplessness,
hopelessness, and resentfulness

Loss of energy

Loss of motivation, ideals, and

hope

Leads to anxiety disorders

Leads to detachment and

depression

Primary damage is physical

Primary damage is emotional

Smith M, et al. Available at:

ttp://www.helpguide.org/mental/burnout_signs_symptoms.htm.

Sustaining A Program Heath Professional

Needs Generosity Of Spirit At Work

Teamwork can help to inoculate ourselves

against burnout1

Establish trust with colleagues

Cultivate supportive relationships
Recognise and celebrate the achievements of
colleagues
Engage in mentoring
Be open to being mentored
Avoid negative communication

Maintain a generosity of spirit, both to help intellectually

and on a day-to-day basis
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1. Espeland KE. J Contin Educ Nurs. 2006;37:178-184.

Take Home Messages

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Yes my practice does have evidence to back

it up but....
Obtaining our own evidence is fulfilling and
has strengthened my daily practice
Use it wisely !