The Alphabet Strategy
The Alphabet Strategy
The Steno-2 study and UKPDS showed that targeted intensified intervention on modifiable cardiovascular risk factors in patients with type 2 diabetes reduces morbidity and mortality. The Alphabet POEM strategy (Practice Of Evidence-based Medicine) assessed the effect of systematic application of the Alphabet Strategy to care of patients with type 2 diabetes. In comparison to the Steno-2 intensive cohort, Alphabet POEM fared similarly with regard to diastolic blood pressure (BP), HbA1C, aspirin and angiotensin-converting enzyme (ACE) inhibitor use, but less well with respect to systolic BP, total cholesterol and use of statins. Alphabet POEM achieved better systolic and diastolic BP than UKPDS but glycaemic control was significantly worse. The standards achieved in the Steno-2 study and UKPDS are in principle, at least, partially achievable in a district general hospital in the UK, but fully achieving them in practice will probably need a radical restructuring, and greater provision of resources.
The lives of people with diabetes are reduced in quality by its many complications and in duration mainly by premature cardiovascular (CV) disease. The evidence-base clearly shows that the onset ofthese complications can be delayed, if not entirely prevented, if stringent management targets are achieved. However, doubt remains whether the targets set in such studies as the UKPDS and the Steno-2 study are achievable in everyday clinical practice, away from the research environment.
The prevalence of type 2 diabetes in the UK is about 4% in white Caucasians and 20% in Indo-Asian subjects. Individuals with type 2 diabetes have reduced life expectancy of 5-10 years due to CV complications. The relative risk of CV mortality among people with diabetes compared with the non-diabetic population is three and six times higher for men and women respectively. About 9% of the national healthcare budget is consumed by diabetes care and nearly half of this by the management of CV complications. Tight control of blood glucose and blood pressure (BP) can significantly reduce this morbidity and mortality.
The UKPDS 8 report showed that the relative risk of complications to be 10 times greater in individuals with a systolic BP of > 160 mmHg and HbA1C > 8.0% than in patients with a systolic BP < 130 mmHg and HbA1C < 6.0%. The HOT study concluded that for subjects with diabetes there was a 51% reduction in major CV events in the group targeted to a diastolic BP ≤ 80 mmHg compared with the group targeted to < 90 mmHg. This study has helped inform the National Service Framework (NSF) for Diabetes BP target of 130/80 mmHg.
The Steno-2 study compared the effect of targeted intensified mutifactorial intervention with that of conventional treatment in subjects with type 2 diabetes at high risk of CV disease because of the presence of microalbuminuria. Target BP was 130/80 mmHg and the target HbA1C 6.5%. The authors concluded that the intensified intervention reduced the risk of CV and microvascular events by about 50%.
The NSF for Coronary Heart Disease states that "excellence requires that important, simple things are done right all the time". The same maxim can be applied to diabetes care. There are eight important, simple things we can do for our patients with diabetes and we have called this simple template the Alphabet Strategy ( Table 1 ). There is a substantial evidence-base for its components: smoking cessation, BP lowering, cholesterol reduction by use of statins, diabetes control, eye and foot examination, and the wide use of aspirin and angiotensin-converting enzyme (ACE) inhibitors.
The Alphabet Strategy management targets ( Table 1 ) are similar to those of the UKPDS, but slightly less stringent than those of the intensive therapy group in the Steno-2 ( Table 2 ).
In this paper, the standards achieved by systematic application of the Alphabet strategy are compared with the results of the Steno-2 study and the UKPDS. This comparison was an extension of an audit project called Alphabet POEM (Practice Of Evidence-based Medicine). Delivery of the Alphabet strategy within diabetes outpatient services is summarised in Table 3 .
The Steno-2 study and UKPDS showed that targeted intensified intervention on modifiable cardiovascular risk factors in patients with type 2 diabetes reduces morbidity and mortality. The Alphabet POEM strategy (Practice Of Evidence-based Medicine) assessed the effect of systematic application of the Alphabet Strategy to care of patients with type 2 diabetes. In comparison to the Steno-2 intensive cohort, Alphabet POEM fared similarly with regard to diastolic blood pressure (BP), HbA1C, aspirin and angiotensin-converting enzyme (ACE) inhibitor use, but less well with respect to systolic BP, total cholesterol and use of statins. Alphabet POEM achieved better systolic and diastolic BP than UKPDS but glycaemic control was significantly worse. The standards achieved in the Steno-2 study and UKPDS are in principle, at least, partially achievable in a district general hospital in the UK, but fully achieving them in practice will probably need a radical restructuring, and greater provision of resources.
The lives of people with diabetes are reduced in quality by its many complications and in duration mainly by premature cardiovascular (CV) disease. The evidence-base clearly shows that the onset ofthese complications can be delayed, if not entirely prevented, if stringent management targets are achieved. However, doubt remains whether the targets set in such studies as the UKPDS and the Steno-2 study are achievable in everyday clinical practice, away from the research environment.
The prevalence of type 2 diabetes in the UK is about 4% in white Caucasians and 20% in Indo-Asian subjects. Individuals with type 2 diabetes have reduced life expectancy of 5-10 years due to CV complications. The relative risk of CV mortality among people with diabetes compared with the non-diabetic population is three and six times higher for men and women respectively. About 9% of the national healthcare budget is consumed by diabetes care and nearly half of this by the management of CV complications. Tight control of blood glucose and blood pressure (BP) can significantly reduce this morbidity and mortality.
The UKPDS 8 report showed that the relative risk of complications to be 10 times greater in individuals with a systolic BP of > 160 mmHg and HbA1C > 8.0% than in patients with a systolic BP < 130 mmHg and HbA1C < 6.0%. The HOT study concluded that for subjects with diabetes there was a 51% reduction in major CV events in the group targeted to a diastolic BP ≤ 80 mmHg compared with the group targeted to < 90 mmHg. This study has helped inform the National Service Framework (NSF) for Diabetes BP target of 130/80 mmHg.
The Steno-2 study compared the effect of targeted intensified mutifactorial intervention with that of conventional treatment in subjects with type 2 diabetes at high risk of CV disease because of the presence of microalbuminuria. Target BP was 130/80 mmHg and the target HbA1C 6.5%. The authors concluded that the intensified intervention reduced the risk of CV and microvascular events by about 50%.
The NSF for Coronary Heart Disease states that "excellence requires that important, simple things are done right all the time". The same maxim can be applied to diabetes care. There are eight important, simple things we can do for our patients with diabetes and we have called this simple template the Alphabet Strategy ( Table 1 ). There is a substantial evidence-base for its components: smoking cessation, BP lowering, cholesterol reduction by use of statins, diabetes control, eye and foot examination, and the wide use of aspirin and angiotensin-converting enzyme (ACE) inhibitors.
The Alphabet Strategy management targets ( Table 1 ) are similar to those of the UKPDS, but slightly less stringent than those of the intensive therapy group in the Steno-2 ( Table 2 ).
In this paper, the standards achieved by systematic application of the Alphabet strategy are compared with the results of the Steno-2 study and the UKPDS. This comparison was an extension of an audit project called Alphabet POEM (Practice Of Evidence-based Medicine). Delivery of the Alphabet strategy within diabetes outpatient services is summarised in Table 3 .
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