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Diabetes toolkit
Radiographers
Speech and Language Therapists
prevention
assessment
treatment
rehabilitation
re-ablement
long-term gain
This toolkit is one of a series of toolkits developed by NHS London
on behalf of the Strategic AHP Leads Group (SAHPLE)
Opening narrative
In line with NHS Diabetes stated aim Allied Health Professions
(AHPs) are proactively supporting initiatives and service
redesign which is evidenced based and addresses the QIPP
(Quality, Innovation, Productivity and Prevention) challenge.
The Strategic Health Authority Allied Health Profession Leads
(SAHPLE) commissioned a project to identify clinical pathways
where AHPs make a significant difference in the clinical
outcomes for a group of vulnerable patients including those
with diabetes.
AHPs include a number of professions who work both in
uniprofessional teams and often show their strengths in
diabetes care as part of a Multidisciplinary Team (MDT),
for example as part of a coordinated foot protection team
as highlighted in the redesign in Salford:
See the success stories on the NHS Diabetes website >
Key outcomes
Amputation rates have fallen by two thirds.
Number of foot ulcers has reduced by 300 over four years.
Estimated savings of over 1m over four years.
This success story is one of a number highlighted by NHS
Diabetes.
For further information please contact:
Dietitians
Dietetic treatment aims to optimise glycaemic control, improve
HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce
hypertension.
Occupational therapists
Optimise function and independent living. Provide functional and
vocational advice. Facilitate return to employment and leisure
activities, and maintain independence improving quality of life.
Orthoptists
Provide assessment of vision, visual fields and eye movements.
Diagnosis of low vision or visual field loss will aid prevention of falls.
Orthotists
Provide orthoses to complement podiatry treatment to enable
mobilisation. Orthoses include shoes to accommodate dressings,
insoles to reduce plantar pressures and offloading devices to aid
wound healing.
Physiotherapists
Provide specialist assessment, treatment and advice on improving
levels of physical activity, prescription and monitoring of
individualised exercise programmes. This helps optimise blood
glucose levels in those with diabetes and can help prevent/delay
the onset of type 2 diabetes. Physiotherapists also have a role to
play in the assessment and rehabilitation of complications and
comorbidities associated with diabetes.
Lesley Johnson
SHA Allied Health Professions Lead
NHS London
Southside
105 Victoria Street
London SW1E 6QT
Podiatrists
Lesley.Johnson@london.nhs.uk
Radiographers
Paramedics
Patients often present via the 999 system with acute or emergency
problems which involve peripheral neurovascular issues either directly
or indirectly. Paramedics are able to recognise such complaints and/
or co morbidities early on and refer to the most appropriate pathway,
either emergency or through alternative specialist pathways.
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Introduction >
Diabetes toolkit
Introduction
What does this toolkit do for you?
This toolkit has been developed by a range of clinicians working
in diabetes care. The information has been provided by a national
collaboration of clinicians in conjunction with their professional bodies
and is based on available research evidence.
The work has been reviewed by a range of specialists including
Dr. Rowan Hillson, the National Clinical Lead for Diabetes. The toolkit
has been endorsed by the Professional Bodies.
This toolkit provides information on the following:
Which interventions most positively benefit patient care
What range of interventions over time will reap the most benefits
during illness and lead to independence
How do the interventions match to the Outcomes Framework
Which interventions are able to save money to the system
How is the functional ability of patients enabled by using
Allied Health Professionals (AHPs).
prevention>
assessment>
treatment>
rehabilitation>
re-ablement>
long-term gain>
Audience
This information is aimed at those involved in commissioning or
developing diabetes care.
The toolkit will provide an interactive method of ensuring that
patient care is meeting quality standards and providing essential
elements of the QIPP agenda
If you are looking to re-design or provide diabetes services this
information will assist you meet the needs of your local population:
Contents
1. List of interventions by Allied Health Profession
2. A pathway graphic highlighting where each profession
significantly contributes to value-for-money high quality care
3. QIPP (Quality, Innovation, Productivity and Prevention) key facts
4. Matching interventions to the Outcomes Framework
5. Research evidence
6. Case studies
7. General information
We hope you find it valuable.
Assessment
Treatment
Rehabilitation
Re-ablement
Long-term gain
patient journey
Art, Music and Drama Therapists Dietitians Occupational Therapists Orthoptists Paramedics
Physiotherapists Podiatrists Prosthetists and Orthotists Radiographers Speech and Language Therapists
Home
Diabetes toolkit
Health risk
Referral to
Risk mitigated
Obesity
Development of Type 2
Diabetes
Prevention of diabetes
1,2
1,2
2,5
2,5
Outcome
Framework
domain
(download)
Cost saved
2,5
Risk of falls
3,5
Click this link to find out how AHPs save the NHS money, and the evidence and case studies
that support claims about the benefit of their interventions.
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Diabetes toolkit
Presenting condition
Health risk
Referral to
Risk mitigated
Deterioration of diabetes
control with exacerbation
of co-morbidities and loss of
independence
Amputated foot/leg
Prosthetists, physiotherapists,
occupational therapists and podiatrists
provide a coordinated team alongside
medical and nursing colleagues to optimise
patient rehabilitation
Outcome
Framework
domain
(download)
2,4
Cost saved
1,2,3
Click on one of the professions above to find out how AHPs save the NHS money,
and the evidence and case studies that support claims about the benefit of their interventions.
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Diabetes toolkit
Key fact
In terms of interventions, the cost of targeting
high risk groups at population level to prevent
or delay raised glucose levels is likely to be lower
than the cost of one-to-one interventions to stop
people with raised glucose levels progressing to
type 2 diabetes.
NICE Guideline Costing statement: Preventing type 2
diabetes: population and community interventions
May 2011.
Navigate to:
Orthotists
Podiatrists
65k
The cost on the NHS to heal one ulcer is 3k to
7.5k. Should this progress to amputation the cost
is estimated to escalate to 65k. This is much more
than the cost of preventative orthoses.
Hutton and Hurry 2009, Orthotic Service in the NHS:
Improving Service Provision. York Health Economics
Consortium: pg 12,13. See website >
International Diabetes Federation, The diabetic foot:
amputations are preventable, 2005. See website >
Prevention >
Assessment/
diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
Navigate to:
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Home
Diabetes toolkit
Physiotherapists
Key fact
Diabetes UK says obese people are up
to 80 times more likely to develop Type 2
diabetes than those who maintain a
healthy weight.
Home
Navigate to:
Prevention >
Treatment >
Key fact
Physical activity has been shown to improve
glycaemic control to levels comparable to
pharmaceutical intervention.
Yates, T., Khunti, K., Davies, M., (2011) Physical Activity:
Efficacy and Application in the Management of Type 2
Diabetes, Diabetes & Primary Care 13(5)pp: 311-316
Assessment/
diagnosis >
Rehabilitation >
Re-ablement >
Long-term gain >
Navigate to:
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Diabetes toolkit
Navigate to:
Podiatrists
Orthoptists
Radiographers
Physiotherapists
Orthotists
Prevention >
Dietitians
Treatment >
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Radiographic Advanced
Practitioners can also refer patients
with suspected Charcots foot for
further imaging (such as CT) and
orthopaedic opinion.
Paramedics
Paramedics are trained in all
aspects of pre-hospital emergency
care ranging from acute problems
such as cardiac arrest to urgent
problems such as minor illness and
injury. On arrival at an accident they
assess the patients condition, start
any necessary treatment and refer
as appropriate. They assess diabetes
patients and can highlight frequent
problems via a range of pathways.
Download report >
Assessment/
diagnosis >
Rehabilitation >
Re-ablement >
Long-term gain >
Key fact
For every 1 spent in
orthotics the NHS saves 4.
Hutton and Hurry 2009, Orthotic Service
in the NHS: Improving Service Provision.
York Health Economics Consortium: pg 1
View document >
Key fact
80% of patients referred to musculoskeletal physiotherapy were
found to have diabetes or associated risk factors. Identification of
these issues during physiotherapy assessment ensures optimum
treatment planning and management.
Kirkness, CS, Marcus RL, LaStayo PC, Asche CV, Fritz JM (2008). Diabetes and
Associated Risk Factors in Patients Referred for Physical Therapy in a National Primary
Care Electronic Medical Record Database. Physical Therapy. 2008; 88:1408-1416.
See website >
Navigate to:
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Diabetes toolkit
Podiatrists
Orthoptists
Orthoptists treat double
vision and visual field loss
to enhance adaptation and
navigation.
Home
Navigate to:
Key fact
A new report published in March 2012 by NHS
Diabetes sets out the shocking cost to both
patients and the NHS of poor quality diabetic foot
care. The report shows that around 650 million
(or 1 in every 150 the NHS spends) is spent
on foot ulcers or amputations each year. It also
highlights the devastating consequences of foot
problems in people with diabetes. Around 7%
of people with diabetes currently have, or have
had, a foot ulcer, which can lead to amputation.
50% of people who have a major amputation
die within two years; many of these amputations
could be avoided with the right care.
NHS Diabetes is calling on the NHS to set up
specialist diabetes foot care teams as a matter
of urgency. Foot care multi disciplinary teams
(MDTs) can generate savings for the NHS that
substantially outweigh the cost of the team. One
example shows how a local hospital team costing
around 33,000 a year generated savings of
almost million a year for the local NHS. Most
importantly MDTs have been shown to reduce
amputations by up to two thirds. See report >
Dietitians
Dietetic treatment aims to optimise glycaemic
control, improve HbA1c, reduce hypoglycaemia,
improve lipid profiles and reduce hypertension.
It also addressed associated dietary issues such
as renal diets, coeliac diets, low residue diets and
high kcal diets as required to achieve and maintain
appropriate BMI.
Physiotherapists
Physiotherapists aim to optimise glycaemic control,
improve HbA1c, improve lipid profiles and reduce
hypertension. Physical activity and exercise also help
to manage other comorbidities and patients fear
avoidance behaviours, especially in relation to pain.
Prevention >
Treatment >
Assessment/
diagnosis >
Rehabilitation >
Re-ablement >
Long-term gain >
Navigate to:
Key fact
Exercise significantly improves glycaemic control
and reduces visceral adipose tissue and plasma
triglycerides in people with type 2 diabetes.
Thomas D, Elliott EJ, Naughton GA (2006) Exercise
for type 2 diabetes mellitus. Cochrane Database of
Systematic Reviews, Issue 3. Art. No.: CD002968. DOI:
10.1002/14651858.CD002968.pub2
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Navigate to:
Orthotists
Podiatrists
Dietitians
Physiotherapists
Golden nugget
Right
first time
Orthotic input within
the multi-disciplinary
team in the diabetic foot
clinic achieves right first
time quality.
The prevention and management
of foot problems in type 2
diabetes, NICE guideline, page 25
See NICE website >
Orthotists provide
immobilisation and offloading techniques in the
care of people with Charcot
osteoarthropathy to reduce
healing time, prevent further
deterioration, maintain tissue
viability and prevent the need
for hospitalisation.
Prevention >
Assessment/
diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
Navigate to:
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Home
Diabetes toolkit
10
Navigate to:
Podiatrists
Physiotherapists
Dietitians
Occupational therapists
Occupational therapists
provide functional and
vocational advice that
facilitates a return to
employment and helps
the patient maintain
independence and improve
their quality of life.
Golden nugget
Orthotists
Orthotists ensure patients with diabetes have suitable and
appropriate footwear and insoles, which prevent recurrent
ulceration and enable safe ambulation. Orthotists also
provide regular reviews and ensure the patient can easily
re-access the diabetic service.
Golden nugget
Education
is effective
54 out of 80 studies
demonstrated
effectiveness of
therapeutic patient
education in terms of
clinical, psychosocial and
educational outcomes.
Albano, M.G., Crozet, C.,
dIvernois, J.F. (2008). Analysis
of the 2004-2007 literature on
therapeutic patient education in
diabetes: results and trends.
Acta Diabetologia, 45, 211-219.
Prevention >
Assessment/
diagnosis >
Treatment >
Rehabilitation >
Re-ablement >
Long-term gain >
Navigate to:
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Home
Diabetes toolkit
11
Key fact
Podiatrists help prevent
hospital admissions due
to foot ulceration by
providing regular foot
care, particularly for those
patients who have existing
medical conditions
as a result of diabetes,
such as renal failure.
Golden nugget
Amputation
preventable
Of the 70 amputations
performed per week,
80% are potentially
preventable.
Nov 2010 The NHS Atlas of
variation in Healthcare. p.29.
See website >
Orthotists
Orthotists early intervention
can improve quality of life
for the patient through the
provision of suitable footwear
and insoles.
A patient focused strategy and
proven implementation plan
to improve and expand access
to orthotic care services and
transform the quality of care
delivered.
Download orthotic pathfinder >
Occupational therapists
For people with diabetes who
go on to have lower limb
amputations, occupational
therapy forms a key part
of a multi-disciplinary
team. The specific focus of
occupational therapy is to
facilitate independence in
activities of daily living, return
to work where relevant, and
participation in leisure or
other meaningful activities.
Navigate to:
Dietitians
Key fact
Two studies have shown that nutrition therapy
is cost-effective, judged by savings in drug therapy
or reduction in utilisation of medical services.
Albano, M.G., Crozet, C., dIvernois, J.F. (2008). Analysis of the
2004-2007 literature on therapeutic patient education in diabetes:
results and trends. Acta Diabetologia, 45, 211-219
Physiotherapists
The role of physiotherapy in Health Promotion emphasises
the importance of lifelong participation in programmes
of exercise and physical activity. This is particularly important
for people with diabetes to assist in glycaemic control,
weight management and optimising health and well-being
and prevention of associated complications. Physiotherapist
can continue to monitor patients and identify if they are
at risk of developing further complications associated with
their condition.
Prevention >
Re-ablement >
Assessment/
diagnosis >
Treatment >
Rehabilitation >
Navigate to:
Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References
Home
Diabetes toolkit
12
Our approach
Prevention
Assessment/Diagnosis
Treatment
Rehabilitation
Re-ablement
Long-term gain.
Home
Diabetes toolkit
13
Dietitian
Physiotherapist
Avoided cost
Development of diabetes
(annual cost 3,000)
Home
Dietitian
Physiotherapist
Supported self-management
for people with diabetes
Avoided cost
Avoidance of
complications
Intervention A
Intervention B
TABLE 1
Co-morbidity
incidence %
18.4
Cerebrovascular disease
6.4
Nephrology/renal failure
3.6
UK Prospective Diabetes
Study Group, Intensive
Blood Glucose Control
with Sulphonylureas or
Insulin Compared with
Conventional Treatment
and Risk of Complications
in Patients with Type 2
Diabetes (UKPDS 33). The
Lancet 1998; 352:837-53)
Estimated costs of
acute hospital care for
people with diabetes in
the United Kingdom: a
routine record linkage
study in a large region. C.
Ll. Morgan, J. R. Peters,
S. Dixon and C. J. Currie.
Diabetic Medicine.
Diabetes toolkit
14
Assuming a cohort of 200 patients and using the costs and prevalence described
in Tables 1 and 2, table 3 shows the costs of complications.
TABLE 2
Costs of fatality
()
Non-fatal costs
year 1 ()
Non-fatal costs
subsequent
years ()
Myocardial infarction
1,366
5,199
856
Heart failure
3,007
3,007
1,054
2,696
2,696
891
CVD
Stroke
4,011
3,180
601
Renal failure
Renal failure
30,000
30,000
Co-morbidity
COMPLICATION
CHD
55,288
10,230
71,648
10,928
6,014
5,392
Stroke survived
43,820
Stroke died
16,044
Renal failure
Total cost
720,000
939,364
Home
Diabetes toolkit
15
Home
Diabetic retinopathy
screening: a systematic
review of the economic
evidence. S Jones and
R Edwards. Diabetic
Medicine. (2010).
Diabetes toolkit
16
Podiatrist
(52 per session)
Podiatrist, OT
Orthotist, Dietitian
Avoided cost
Referral to specialist
(169 per session)
Avoided cost
Avoid progression
to ulcer
OT, Physiotherapist
Orthotist
Recovery
Amputation (65,000)
Avoided cost
Avoid progression
to amputation
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Diabetes toolkit
17
Home
Intervention A:
Intervention B:
Intervention C:
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (1 of 4)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
19
Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (2 of 4)
Intervention in pathway
Improving outcomes
The increasing worldwide prevalence of obesity and a
sedentary lifestyle are directly linked to the rising rate of
metabolic syndrome and type 2 diabetes
references
1 Ferguson, B. and Kingdom, A. (2006) Diabetes
Key Facts. York: Yorkshire and Humber Public Health
Observatory.
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (3 of 4)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (4 of 4)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Assessment/Diagnosis (1 of 3)
Intervention in pathway
Improving outcomes
Case studies
Home
Systematic screening for diabetic retinopathy is costeffective in terms of sight years preserved compared
with no screening. Variation in compliance rates, age
of onset of diabetes, glycaemic control and screening
sensitivities influence the cost-effectiveness of screening
programmes and are important sources of uncertainty in
relation to the issue of optimal screening intervals. There
is controversy in relation to the economic evidence on
optimal screening intervals.
Diabetic retinopathy screening: a systematic review
of the economic evidence. Jones & Edwards. Diabetic
Medicine 2010.
Falls cost the NHS and social care an estimated 6m
per day or 2.3bn per year in hip fractures alone. This
figure does not take into account other costs associated
with falls that do not result in hip fracture but that may
still require treatment or care. There are also other costs
involved, for example, falls cost 115 per ambulance callout There is growing evidence to show that investing in
falls prevention services is cost-effective. The Department
of Health currently estimates that if every strategic health
authority in England invested 2m in falls and bone
health early intervention services they could each save
5m (net 3m) each year through reduced NHS costs,
such as 400 fewer hip fractures.
Age UK. Stop Falling: Start Saving Lives and Money.
2010.
Diabetes toolkit
23
Appendix A
Framework of interventions provided by clinicians in a range of settings
Assessment/Diagnosis (2 of 3)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Assessment/Diagnosis (3 of 3)
Intervention in pathway
Improving outcomes
Case studies
The average cost per patient for this type of care was
estimated to be 501 in a sample of 103 patients over a
two year period. This is less than 300 per year, a fraction
of the cost of an amputation, and far less than the cost
of treating a single foot ulcer.
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (1 of 4)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (2 of 4)
Intervention in pathway
Home
Improving outcomes
Case studies
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (3 of 4)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (4 of 4)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Rehabilitation (1 of 2)
Intervention in pathway
Improving outcomes
Case studies
diabetes care, in particular in advanced practices in Early recognition of the at risk foot
Prompt use if preventative measures
preventing limb loss.
The partnership between the diabetologist,
vascular surgeon, podiatrist is a natural one.
The complementary skills and knowledge of
each professional can improve limb salvage and
functional outcomes.
Comprehensive multidisciplinary foot care
programmes have been shown to increase quality
of care and reduce amputation rates by 36% to
86%.
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Rehabilitation (2 of 2)
Intervention in pathway
Improving outcomes
Case studies
Monique et al. Cost-Effectiveness of Lifestyle Modification The study concluded that implementation of lifestyle
in Diabetic Patients. Diabetes Care. 2009 August; 32(8):
interventions would probably yield important health
14531458.
benefits at reasonable costs. However, essential evidence
for long-term maintenance of health benefits was limited.
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Re-ablement (1 of 3)
Intervention in pathway
Improving outcomes
Case studies
The Ipswich Hospital NHS Trust has developed a multidisciplinary foot care team which has been running since
1997. Key outcomes have been a 70% reduction in
amputation rates over 11 years, a reduction in the length
of stay and bed days, and annual savings of around
0.5m to offset 120,000 annual expenditure.
Home
Diabetes toolkit
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Appendix A
Framework of interventions provided by clinicians in a range of settings
Re-ablement (2 of 3)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
33
Appendix A
Framework of interventions provided by clinicians in a range of settings
Re-ablement (3 of 3)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
34
Appendix A
Framework of interventions provided by clinicians in a range of settings
Long-term gain (1 of 1)
Intervention in pathway
Improving outcomes
Case studies
Home
Diabetes toolkit
35
References
Economic scenarios
Prevention
UK Prospective Diabetes
Study Group, Intensive
Blood Glucose Control with
Sulphonylureas or Insulin
Compared with Conventional
Treatment and Risk of
Complications in Patients with
Type 2 Diabetes (UKPDS 33).
The Lancet 1998; 352:837-53.
Estimated costs of acute
hospital care for people
with diabetes in the United
Kingdom: a routine record
linkage study in a large region.
C. Ll. Morgan, J. R. Peters,
S. Dixon and C. J. Currie.
Diabetic Medicine.
Diabetic retinopathy screening:
a systematic review of the
economic evidence. S Jones
and R Edwards. Diabetic
Medicine. (2010).
Type 2 diabetes: national
clinical guideline for
management in primary and
secondary care (update).
National Collaborating Centre
for Chronic Conditions.
London: Royal College of
Physicians, 2008.
Home
Reduction in incidence of
Type 2 diabetes with lifestyle
intervention or metformin. The
Diabetes Prevention Program
Research Group (2000). New
Eng J Med 346: 393-403.
An Integrated Career and
Competency Framework
for Dietitians and Frontline
Staff. Professional Education
Working Group. Diabetes UK.
December 2010.
National Service Framework
for Diabetes. Department of
Health, 2002.
Diabetes in the UK 2004.
Diabetes UK.
An integral role for the
dietitian: implications of the
Diabetes Prevention Program.
Wylie-Rosett J and Delahanty
L (2002). Journal of the
American Dietetic Association
102: 1065-1068.
Sustained reduction in the
incidence of type 2 diabetes by
lifestyle intervention: followup of the Finnish Diabetes
Prevention Study. Lindstrom et
al, 2006. The Lancet, Vol368,
Issue 9548: 1673-1679.
The prevention and
management of foot problems
in type 2 diabetes. NICE
guideline.
Treatment
Diabetes toolkit
36
References
Home
Absence management
annual survey report 2009.
Chartered Institute of
Personnel and Development.
A multi-disciplinary footcare
team. NHS Diabetes case
study. 2010.
Analysis of the 2004-2007
literature on therapeutic
patient education in diabetes:
results and trends. Albano et
al. Acta Diabetologia 14. 211219. 2008.
Department of Health
Gateway Reference 17269
Diabetes toolkit
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