So I hope you will enjoy this, hearing this talk as much as I have enjoyed writing it. It's a new area for me, this whole area of the social determinants of health. I'm going to be giving you a different perspective perhaps, a population perspective. I'm going to talk about some published work from Scotland which I found remarkable when I came across it, and some unpublished early data from our own centre in Galway. I'm going to finish by asking whose responsibility is it to tackle this challenge of poor outcomes associated with social deprivation. I'm going to start with a case because it is, I think, a clinical conference primarily. I tell my trainees that they should present cases that they're not proud of, which seems strange but you learn a lot more I think when you do that and people pay attention maybe a lot more. So this is a case that I'm not proud of. A 44 year old man developed diabetes in 2011, went through a Desmond self-management education program, a very comprehensive package of self-management education, started taking Metformin as you would expect to achieve target A1c within a short period of time, and then fell off the radar and wasn't seen again by any diabetes professional for about three years. He then presented to our emergency department having injured his foot. He let a heavy object fall on it and broke his toe. He didn't present for about a week because he had no pain and eventually presented when the wound became a little infected. He was discharged. He had an x-ray which showed the fracture discharged on oral antibiotics but came to the attention of one of our diabetes nurses who organized follow-up for him in our clinic and that's when I met him in a very busy diabetes clinic. Aoife will remember our Tuesday morning clinics and this was a brief encounter that we had with him. Everything on the left except for the ACR is out of target. So he's obese, hypertensive, his A1c is very high because he's not taking any medication for his diabetes. He's smoking and drinking to excess. On the right is confirmation of what we knew already which is that he has diabetic peripheral neuropathy because he had an absence of pain or sensation in his foot. So what did we do? Well we reinforced the messages that he got at the beginning of his journey with diabetes, the self-management imperative, reinforced some of the lifestyle advice, reintroduced the drug that he didn't take in the first place. We did get him seen by a podiatrist and we got his retina screened and we offered him follow-up at the clinic that he didn't come to. So what happened? He had one further follow-up visit. We stepped up therapy again and then he fell off the radar again and returned three years later with another diabetic foot problem, this time deemed to be limb threatening by our surgeons and had an urgent transmetatarsal amputation. So in the view of Graham Lees who's a diabetologist from Scotland who introduced me to this diabetic foot risk escalator, what I've just presented is a completely unnecessary amputation. Somebody who had a poor outcome. I've presented this case a few times and I keep asking myself did we fail him? Did he fail us? I think what we probably did was we didn't recognize his depression or his psychosocial distress in the busy clinic in which we saw him. We didn't get to the bottom of why he was not attending and why he was maybe struggling a bit. So in trying to understand the process that happened in that busy clinic, I think we were delivering evidence-based care. Screening his feet, his retina, recommending medication based on guidelines. We were constrained particularly in terms of time. We'd like to have had perhaps more time with him but I think it's really these patient or physician factors that impact on the clinical decision-making that are probably most relevant to the poor outcome that happened in this case. And recently to try and capture that a bit better. I really like this Venn diagram by the way. It's a really good way of trying to parse out the different components of what we do every day as clinicians which is make decisions with our patients. But this is an even better representation I think of what happened with our patient who had the poor outcome. So a lot of what's here in yellow is what we deal with day in day out and we have some control over these things like the frequency of visits, the prescriptions and the technology used nowadays. There are some individual factors but it's these social determinants that I think are relevant to the case that I presented. And so I'd like to take you through where I am in my head with thinking about these areas of not practice but areas of almost of life. These social determinants as they're called. So to do that I have to get you to think about the bigger picture. So this is a wonderful book that I came across a few years ago in search of the perfect health system written by Mark Brittenell. When I heard him speak about it he said he's writing a sequel and he's going to call it Still Searching. So what he's saying is that of course it doesn't exist but what he does really really beautifully is he says he describes about 25 health systems that he's been involved in either living in or working in or advising. But he says if it did exist it might look like this and he takes elements of many health systems that you will be familiar with and sort of imagines what it might look like to put them together. And the point is that you know we do have strengths within our health systems. We're not always aware of them or maybe willing or able to recognize or acknowledge them but they do exist. Okay that's one big-picture perspective. This is the other big-picture perspective that I really like. I trained in the States and during my time in America Frank Vinokur was a public health doctor working at the CDC. He was president of the ADA and I could never find a published version of this but he included this in a talk he gave at ADA one year and I just it really resonated with me. So he said this diabetes thing is straightforward really. You either have it or you don't. If you have diabetes it's either recognized that you have it or it's not. If it's recognized that you have diabetes you're either getting care for it or you're not. And if you're getting care for your diabetes it's either good care or it's not. So it's really it's really simple and from his perspective the ivory tower of the CDC looking at the whole population of people it helps him to target because you can't just tackle diabetes at the level of those who have it, who know they have it, and who come to you for care. That's what we anguish about at this level here. The quality of the care that we deliver. But actually you need to be you need to have a different perspective and and that's that's the journey I'm on in terms of in our in our health service in Ireland trying to and and this this publication ten years ago now is a really interesting report from a group in Scandinavia who basically came up with very similar to Frank Vinokur asking questions like at a national level do you know who has diabetes? Have you got an approach to prevention? Are you offering care? Is there equity around the care you're offering and what are the outcomes like? And impossible I know to read this but I just want to reflect he scored or they scored 30 countries in Europe against these parameters prevention, case-finding and so on. Ireland to my dismay was 20th of 30 nations in the ranking. So the podium places went to Sweden, Denmark and the Netherlands. The UK for all it's all the failings of the NHS I don't know if there's anybody here from the NHS but it actually ranked fourth and yeah it's it's basically the point of this slide for me and something that I have been trying to progress in our health system now for some years is that five of the top ten nations in this Euro diabetes index have a national diabetes registry and only one of the bottom ten has. So it's not that having a registry equals good care but it's it's probably and it's necessary but not sufficient and very recently I came across this paper which was quite stark for me. So it takes the Euro diabetes index that I've just presented to you and it ranks the countries in quartiles and they then crossed that data set with a European wide score at a national level for depression. So we know there's an association between diabetes and depression but it turns out if you believe this paper in the European Journal of Public Health that the more your health system scores poorly in terms of diabetes care the stronger the association. I found this quite depressing because Ireland is at the bottom of the of the ranking but it says to me that and I'm not sure I've read the paper a couple of times but if you're if you're living and existing you know with diabetes in a health system that isn't perhaps as coordinated or joined up as it might be that has a burden. Okay so I'm a few minutes good few minutes into my talk and I haven't yet introduced social deprivation but here's the introduction to the concept. So it's it's limited access to society's resources due to poverty discrimination or other disadvantage. The American Psychology Association I think. And the reason for the lengthy preamble and the introduction of the population perspective is that although I presented a case that I believe to be you know relevant to this talk you really to actually assess it and measure it you have to do it at a population level. You can do it at an individual level just looking at income or education or occupation but really the majority of the time when people look at social deprivation they look at composite indicators or at a geographical level. So in Ireland it turns out we have a very good indicator of social deprivation called the HP or the public HP index. So it takes small areas and and it profiles them based on parameters that are present in our central statistics around three main main demography social class and and employment essentially. And it profiles the country and I showed you the map. So a lot of countries have this approach of being able to come up with a composite indicator of what social deprivation means. And Scotland does this really, really well. So this is a remarkable slide, I think. This is everybody with type 1 diabetes in Scotland. These are A1C data across the entire population, so no error bars because this is the real story. Here's male versus female, here's age breakdown, and I'm not going to dwell on that. But this is the thing that I want you to focus on. This is the Scottish index of multiple deprivation, and the single best thing you can do in Scotland if you want good outcomes from your type 1 diabetes is to be born wealthy. That's what these data tell me anyway. I mean there's a massive difference between the first and the fifth category. So the work that I'm going to present now, I'm really grateful to Joanne Hurst, who's an academic podiatrist from Fermanagh, who did her PhD with James Woodburn, another academic podiatrist in Glasgow. I heard this paper presented at the International, what is it called, ISDF, the International Symposium on the Diabetic Foot. It's like the Olympic Games of the diabetic foot. It's every four years. It's a remarkable meeting. It's global, so people come from all over the world to a small place in the Netherlands. And I heard this paper was presented as one of the three most impactful papers in the four years since the last ISDF, if you follow me. So I heard it presented and then I realized that Joanne was coming to work in Galway and she kindly has shared some of her slides. So this is an area that I was not familiar with, of geospatial mapping. And what they've done, because Scotland has such an incredible handle on its diabetes population, and they have this thing called the CHI number, which is a unique patient identifier, they're able to link data sets in a way that I think is truly remarkable. So they have this thing called CHI diabetes, a registry for the entire population updated almost daily because the data just flow through from GP surgeries and from hospital clinics. So they linked the CHI diabetes data set to these other national data sets. And then Joanne in her work looked at diabetic foot outcomes, including foot ulceration, amputation, and mortality after DFU. So this idea of linkage is what they've done really well. And they use the Scottish index of multiple deprivation that I introduced you to, this composite indicator of affluence or deprivation. And they basically mapped the area that they were in, Greater Glasgow and Clyde, so the urban area and the hinterland around Glasgow City. And this is what you come up with. So this is a map of deprivation and our affluence in a city of several million people. But then the remarkable thing is that they were able to, because they know where the people with diabetes live in this city, and they have the outcomes, ulceration, amputation, and mortality, and so they're able to do this geospatial map. And they're able to tell us where the bad outcomes come from. And as you might imagine, almost 50% of them come from the area of greatest deprivation. The most deprived contribute 42% of the poor outcomes in diabetic foot. But this is where they're able to... So this is the spatial distribution of people with diabetes. They come up, and I can't explain it because I'm not a geographer, but they have hotspots for deprivation or hotspots for affluence. And they applied that approach again with the cohort that they had and with the rich data that they have. You can see the numbers here. Close to 4,000 foot ulcerations, 1,500 amputations, and then mortality subsequently. And they're able to do this kind of thing. So these are hotspots for poor outcomes. So in my opinion, if you overlay deprivation and poor outcomes, they overlay each other. So the poor outcomes come from areas of deprivation, and that's true for the four areas, foot ulceration, amputation, and mortality after one or the other. And this is another way of representing it. So I just think that this paper deserved the kudos that it got. I hadn't previously come across it in terms of the approach using geography and geospatial mapping, but it was very impactful, certainly for me. So we have started to explore this, and Cuiva Casey, who's a recent graduate of our endocrine training program, working with a data set developed by another colleague, Tomas Griffin. We looked at our experience in Galway in a university teaching hospital with diabetic kidney disease. So what Cuiva did was she took a data set that Tomas assembled about 10 or 12 years ago now for his PhD. So about four and a half thousand people living with diabetes. And she basically extended the cohort's follow-up. So we have up to 10 years or 10 or 11 years of renal outcomes in this cohort. Now this to me sounds big. Four and a half thousand people followed for up to 11 years. But as I'll explain, it's not big. When you do this, you have to do it at the Scottish level. And that's what we're learning. So Cuiva wanted to look at the Publ HP index, which I told you about in Ireland. And these are preliminary data, not yet published, but we're starting to explore. So for example, smoking status. There are more smokers in the disadvantaged group compared to the affluent group. Blood pressure is higher in the group with disadvantage compared to those with affluence. Interestingly, number of antihypertensives prescribed is higher in the disadvantaged group. So maybe it's that they're not encashing, they're getting prescriptions but not encashing them. And this is where it gets tricky trying to explain mechanisms around this whole area of deprivation. But this is again Cuiva's work. And we're still analyzing this data set, but we're seeing some, when we look at rate of renal function decline, there are some signals. They're not perhaps strong and they don't hold up when you have multi-variable models applied. But there are signals, even in a relatively small data set. And Cuiva has created this logistic regression model around rapid or non-rapid decliners. And again, we're maybe not as strong as you're seeing in Scotland with the diabetic foot, but you're seeing some signals around people who are below average in terms of their degree of affluence or disadvantaged people having slightly higher. Now when I was writing this talk I said why not look at Scotland. And this is separate, it's not Glasgow, this is Aberdeen or the area called Grampian or formerly called Grampian. And this again is the entire population. So this is at a macro level what we've been trying to explore at a clinic level. And it's remarkable. And the other contribution of this paper was to say that, you know, the work in Glasgow was based on neighborhood quintiles around the deprivation index. They did that, but they also looked at another indicator, this individual indicator of deprivation. And what they found was that people with both had the highest disadvantage, if you will. So kidney outcomes were worse in that group. But it's quite nuanced. You can be from an affluent area, but you know, if your individual indicator suggests a degree of disadvantage, you can still have, you know, poorer outcomes then. And finally, and I'm really glad that Ebba is here, this is one of the Kuwaiti podiatry students in Galway, Jana, who did a summer student project with Joanne Hurst, the academic podiatrist that I mentioned, and is doing a systematic review of, again, its foot outcomes in relation to social deprivation. But in this high-risk group who have both diabetes and CKD. And I'm not going to dwell on it, but really nice to see this coming through in terms of students from Kuwait coming to Galway. So what about the mechanism? I've just got a couple of minutes left. Yeah, this is the tricky bit, and I don't claim to have the answer here. Of course health-related behaviors may be worse in people who are from disadvantaged backgrounds. Risk factor control, I mentioned the antihypertensive prescriptions not being encashed. Poorer access, perhaps, to health care and the processes of care. This is another attempt by Cuiva to try and explain these interactions or this relationship between deprivation and poor outcomes. But I think, you know, to finish, I presented a case, I've talked to you about the social determinants of health, presented rich data from Scotland and very preliminary data from Galway. I'm going to finish with whose responsibility is it anyway? And what can we do or what should we do about it? So this again is an attempt to, I mean, it probably takes intervention or trying to impact on it at different levels. At the micro level, interventions tailored directly to individuals living in deprivation, maybe making more technology available. So much of our work now is around tech. At the community level, we're starting to explore that in Ireland, putting specialist teams for diabetes, heart failure and COPD into the community. That's another way. Or reorganizing. There's a community diabetologist in Belfast who does domiciliary visits. If you don't come to her clinic, she'll go to your home. Remarkable. And then at the macro level, I think it's getting a handle on the population and trying to structure our health system to provide more equitable access. So that's pretty much it. I wanted to finish with the 3DFD, as it's called. Three Dimensions for Diabetes. Fantastic work from a deprived area in London. This is work that I was introduced to by Anne Doherty, who's a psychiatrist, a liaison psychiatrist now back in Dublin. They deliver diabetes care in Lambeth and Southwark and these deprived areas of London with, believe it or not, a liaison psychiatrist, a psychologist and a social worker. There isn't a diabetologist or a diabetes nurse in the room. Why? Because if your problem is that your partner is beating you up, that you don't have money to put food on the table, then SMBG doesn't even get a look in, is the point. And I think this is remarkable work. And so maybe we need to think differently about our approach to diabetes care, particularly for some very, very vulnerable. And then finally, in Scotland, they have this deep-end GP model where they fund the practice to provide more time to those challenging individuals. Okay, that's it. Gaurav Mahagut is the Irish for thank you.

social determinants

diabetes management

health inequities

geospatial mapping

socio-economic factors

integrated care