Improving care by continuing research

The importance of delivering clinically relevant research to a high international standard cannot be underestimated in the area of diabetes. With worldwide prevalence of the condition rising from around 150 million people in 1980 to 300 million people in 2008, and an additional 50 million people with increased glucose levels, research plays a key role in all facets of the disease.

Prof Andrew Farmer, professor of general practice, a GP and researcher at Oxford University, was on hand at the recent Inaugural Conference of the National Clinical Programme for Diabetes in Farmleigh, Dublin, to highlight the need for relevant research. 

His initial move into research, he admitted, was as a ‘sideline’. In the mid-80s, he had just started his GP training and had never done any research before. However, his GP trainer was “really keen” to make sure he did “something worthwhile” and guided him in the direction of research.

He had been studying dermatology and had come across a lot of teenagers with psychological problems and decided to delve further into this. His subsequent paper on his research was published in the Journal of the Royal College of General Practitioners in 1986.

That project introduced him to the intricacies of research – applying for research grants, ethics, bias, questionnaires, note audits, data entry. He noted that he is “still doing the same things now in essence, but I have more people to help”.

With ever-increasing numbers, diabetes is a condition that continually needs high quality, clinically relevant research. In England, there are thought to be over three million people with the condition, although only 2.3 million have been diagnosed. By 2020, 3.8 million are expected to have it – more than one-in-12 of the total population. As a result, research and its outcomes have significant implications for the NHS, both today and in the future, Prof Farmer insisted.

In Ireland, an estimated 120,000 people had diabetes in 2007. Current figures estimate that there are 225,840 people living with diabetes and up to 30,000 people with undiganosed diabetes.

When it comes to one of the most costly factors of diabetes – complications – research has shown the proportion of complications that are preventable, and the figures are quite startling.

Research published in various medical journals has revealed that up to 50% of diabetes-related heart disease and stroke could be prevented with improved control of blood pressure, cholesterol and lipid levels. Some 50% of diabetes-related kidney failure could be prevented with better control of blood pressure and blood glucose levels, while 40% of neuropathy could be prevented with a 1% reduction in HbA1c.

When it comes to blindness, up to 90% of diabetes-related complications could be prevented with proper screening and care, while up to 85% of amputations could be prevented with the implementation of footcare programmes which incorporate regular examinations and patient education.

It is clear that delivering consistent, high-quality care is essential in diabetes and this has to be informed by constant high-quality research. 

Prof Farmer pointed out that one of the key aspects of the condition, blood glucose monitoring, did not have tremendous amounts of research behind it initially, but has in recent years become a multibillion-dollar market.

The first record of monitoring blood glucose in the home was in 1975 and this was followed by the first case reports of the use of home blood glucose monitoring in 1978. The first well designed trial in home blood glucose monitoring in relation to type 2 diabetes only took place in 1986, while the first systematic review, again with type 2 diabetes, only took place in 2000. But by 2009, the home blood glucose monitoring market was already worth $9 billion worldwide.

Aside from diabetes products, research is essential to tell us about patients and their ability to cope with the condition. For example, research has shown that a lack of acceptance of insulin therapy by some patients is down to a number of factors, including anxiety about the pain of injection, social embarrassment, perceived restrictions in lifestyle, concern about weight gain and fear of hypoglycaemia.

While it is undeniable that research is essential, there are a number of barriers when it comes to delivering research into practice. Prof Farmer emphasised that the translation of research findings into sustainable improvements in clinical outcomes and patient outcomes ‘remains a substantial obstacle to improving the quality of care’. A major reason for this is simply the complexity of healthcare.

If carrying out trials in a primary care setting, he believes simplicity should be key, eg. choosing a common condition, having minimum requirements for clinic visits and clinical measurement, and having clinically important outcomes that can be captured easily.

When asked if it is possible for single-handed GPs to carry out research, Prof Farmer is adamant that it is.

“If it is well organised, then yes. You would need a practice manager for administrative purposes and a practice nurse to help gather data, but there is no reason why a well-organised one-hand practice cannot carry out a research project like a group practice can,” he stated.