Little improvements can lead to very big gains: ‘Aggregated Marginal Gains’


The « Winning Edge » theory

  • By making lots of ‘small incremental gains’, you can potentially make very big improvements to your patient’s clinical outcomes and well-being, delivered at a lower overall cost and reduced burden to both providers and healthcare systems.
    Big gains come but once in a lifetime if you are lucky!
  • From its diagnosis in 1500 BC to today, there has been one major gain in the treatment of Diabetes Mellitus, Insulin!


The concept behind “winning edge theory”

  • The philosophy of doing the little things that adds up to make a big difference.
    • We have to remove ourselves from our comfort zone in order to find that 1%.
    • But the rewards will be well worth the effort.


Can you think of any elements of your patients care where you can find that 1% margin for improvement?

  • Here is a great example of marginal gains: The British Olympic cycling team 2012
    • Team GB Cycling Team won 7 of the 10 available Gold medals!
    • How did they do it? Dark Arts? Best Bikes? Best Athletes? Biggest most powerful legs?
    • The answer is 'Aggregated Marginal Gains'!
    Director of Marginal Gains Team GB Cycling, Dave Brailsford: "The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together."


Examples of how GB Cycling Team found marginal gains and aggregated them in order to win

  • Each team member used their own special pillow to help ensure they had a great nights sleep. A well rested athlete will perform much better
  • Each team member was taught to wash their hands properly and use alcohol hand gel frequently to minimize the risk of bacterial or viral infections which would seriously hamper their performanceif any disease was contracted
  • Each team member wore 'hot pants' before the race. Hot pants were electrically heated pants that warmed the muscles of the legs drawing blood and oxygen to the leg muscles readying for ultimate power right from the start of the race, whilst minimizing the risk of muscle or tendon injury
  • Each team member's bike tires were thorougly cleansed immediately before each race with alcohol wipes. This ensured that tires were spotlessly clean and had the most grip to transmit power from the rider to the ground with no risk of slip or loss of grip when it is needed most
Aggregated Aggregated

How many elements of injection and infusion technique can you identify that could be improved by a minimum of 1%?

Here are some examples to get you started:

  • Use needles once only
  • Facilitate correct rotation technique
  • Optimise to 4mm pen needles
  • Screen patients for lipohypertrophy frequently
  • Teach patients how to screen themselves for lipohypertrophy
  • Help patients stop injecting into lipohypertrophy


How might all those small gains be aggregated to achieve big improvements for your patients?

Improvements that have been demonstrated by a multimodal approach to clinical care of injection technique:

  • Fewer hypos
  • Fewer glycaemic variation excursions
  • Reduced HbA1c by clinically significant amounts
  • Lipohypertrophy lesion reduction or disappearance
  • Higher levels of patient satisfaction
  • Critical patient behavioural changes
  • Improved adherence
  • Patient empowerment & enablement


What marginal gains can you make to deliver big improvements in your clinical care to make you and your patients FITTER?

Act now and try to fully implement the FITTER International Recommendations or your Local Recommendations.

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