Alphabet Strategy for diabetes care: A multi-professional, evidence-based, outcome-directed approach to management

Table 1 Effect of the Alphabet Strategy on change in achievement of target care processes

	Alphabet strategy	Preimplementation	Post implementation	P value
A	Smoking (%)	18.2 (77)	15.7 (66)	NS
B	Blood pressure (mmHg)	146/82	140/76	< 0.0001
C	Total cholesterol (mmol/L)	5.7	4.9	< 0.0001
	HDL cholesterol (mmol/L)	1.1	1.39	< 0.001
D	HbA1c (%)	7.9	8.3	< 0.0001
E	Eye examination (%)	85.0	95.5	< 0.001
F	Foot examination (%)	69.8	83.5	< 0.001
G	Aspirin (%)	29.0	83.5	< 0.001
	ACEI/ARB (%)	32.0	73.0	< 0.001
	Lipid lowering (%)	16.8	55.0	< 0.001

NS: Not significant.

Table 2 Comparison of achievement of Alphabet Strategy components between practice of evidence-based medicine audits

	Alphabet strategy	POEM 1n = 420	POEM 2n = 1071	P value
A	Smoking status (%)	15.5	14.7	0.83
B	Blood pressure (mmHg)	141/77	136/76	0.007
C	Total cholesterol (mmol/L)	4.9	4.5	< 0.001
	LDL cholesterol (mmol/L)	2.5	2.4	< 0.001
	Creatinine (mmol/L)	109	105	0.036
D	HbA1c (%)	8.3	7.9	0.09
E	Eye examination (%)	95.5	97.1	0.72
F	Foot examination (%)	83.5	97.3	< 0.001
G	Aspirin (%)	83.5	88.0	0.20
	ACEI/ARB (%)	73.0	74.4	0.75
	Lipid lowering (%)	55.0	73.4	< 0.001

POEM: Practice of evidence-based medicine.

Table 3 Clinical trial standards of United Kingdom Prospective Diabetes Study and Steno-2 compared to those in practice of evidence-based medicine studies

Variable	Steno-2(intensive arm)	UKPDS	Alphabet strategy
			POEM	POEM2004
Systolic BP (mmHg)	≤ 130	≤ 144	≤ 140	≤ 130
Diastolic BP (mmHg)	≤ 80	≤ 82	≤ 80	≤ 80
HbA1c (%)	≤ 6.5	≤ 7	≤ 7	≤ 7
Cholesterol (mmol/L)	≤ 4.5	NA	≤ 5	≤ 4

POEM: Practice of evidence-based medicine; UKPDS: United Kingdom Prospective Diabetes Study.

Table 4 Percentage of practice of evidence-based medicine cohort attaining trial standards compared to original study treatment arms

	Intensive arm	POEM 1 post implementation	POEM 2	P value (intensive vs POEM 2)
Steno-2
SBP ≤ 130 mmHg	45%	34%	36%	0.07
DBP ≤ 80 mmHg	70%	67%	67%	0.51
TC ≤ 4.5 mmol/L	72%	36%	54%	< 0.001
HbA1c ≤ 6.5%	15%	13%	15%	1.000
Aspirin	73%	83%	88%	< 0.001
Statin	71%	52%	69%	0.66
ACEI	66%	66%	58%	0.09
ARB	39%	10%	20%	< 0.001
Either ACEI/ARB	58%	73%	74%	0.001
UKPDS
SBP ≤ 144 mmHg	50%	58%	73%	< 0.001
DBP ≤ 82 mmHg	50%	73%	74%	< 0.001
HbA1c ≤ 7%	50%	22%	29%	< 0.001

POEM: Practice of evidence-based medicine; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; UKPDS: United Kingdom Prospective Diabetes Study.

Table 5 Change in care process performance following implementation of the alphabet strategy in a low-resource diabetes clinic

	Elements	Pre implementation	Post implementation	P value
A	Body mass index	99%	99%	NS
	Smoking status	99%	99%	NS
	Smoking cessation	100%	100%	NS
B	Blood pressure	99%	99%	NS
C	Total cholesterol	60%	99%	< 0.001
	Lipid profile	10%	64%	< 0.001
	Creatinine	5%	49%	< 0.001
	Proteinuria	48%	93%	< 0.001
D	Fasting and postprandial glucose	41%	97%	< 0.001
E	Eye examination	98%	100%	NS
F	Feet examination	95%	100%	NS
G	Aspirin therapy	6%	71%	< 0.001
	ACEI/ARB therapy	7%	57%	< 0.001
	Statin therapy	5%	38%	< 0.001
	All three	2%	20%	< 0.001

NS: Not significant.

Table 6 Care process performance by consultant, registrars, and junior doctors

Care process	Cons A/%n = 125	Cons B/%n = 132	Cons C/%n = 36	Cons D/%n = 101	Junior drs/%n = 86	Registrars/%n = 70
Smoking status	100	97.7	94.4	99	98.8	98.6
BMI	92.8	93.2	91.7	95	98.8	98.6
Blood pressure	100	100	100	100	100	100
Total cholesterol	100	100	100	100	98.8	100
Creatinine	100	100	100	100	100	100
Urine albumin creatinine ratio	87.2	78.8	75	82.2	74.4	78.6
HbA1c	100	100	100	100	100	100
Eye examination	97.6	98.5	97.2	99	97.7	97.1
Foot Examination	100	77.3	83.3	68.3	96.5	84.3
All care processes performed	80.8	59.1	55.6	51.5	73.3	67.1
P value all care processes vs Cons A (χ2)	-	< 0.0001	< 0.0001	< 0.0001	0.057	< 0.0001

BMI: Body mass index.