Transcript DIABETES IN PRIMARY CARE CLINIC

DIABETIC CLINIC
MANAGEMENT
SERDANG HOSPITAL 11.11.08
CONTENTS :
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Introduction
Objectives
Team members and function
Basic principles
Activities
Record keeping
Quality improvements
Challenges
INTRODUCTION
UNTIL LATE 1990s….
 Clear the crowd concept
 “Continue the same – CST ”
phenomenon
 Quality care?
AUDIT/DATA
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Poor diabetic control
Poor documentation
Increased complication
Escalating cost of treatment
Unsure of health education given
“Ticking Clock” Hypothesis
For
The “clock starts ticking”
Microvascular
complications
At onset of hyperglycemia
Macrovascular
complications
Before the diagnosis of
hyperglycemia
WHO. Diabetologia 1985;28:615-640; Haffner SM et al. JAMA 1990;263:2893-2898.
Complications of Diabetes at
diagnosis
Complications
Prevalence (%)
Any complications
50
Retinopathy
21
Abnormal ECG
18
Absent foot pulses ( 2) and/or ischaemic feet
14
Impaired reflexes and/or decreased vibration sense 7
AMI/angina/claudication
~2-3
Stroke/transient ischaemic attack
~1
* Some patients had more than one complication at time of diagnosis
Adapted from UKPDS VIII. Diabetologia 1991; 34: 877–90.
Implication
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Early death
Sudden death
Reduced quality of life
High cost
Medical costs of diabetes
Costs of treating diabetic complications in the USA
CVD
Neurological disease
Renal disease
Peripheral vascular disease
Ophthalmic disease
Others
0
1
2
3 4
5 6 7
Costs (US$ billion)
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10
$44.1 billion total healthcare spend attributable to diabetes in the
USA1
Costs for a person in the USA with diabetes are more than three
times those for someone without diabetes1
Costs are high around the globe: e.g. $1.2 billion in Australia,
~ $3000 for every person diagnosed with diabetes2
1ADA.
Diabetes Care 1998; 21: 296–309. 2www.health.gov.au
MAIN OBJECTIVE :
To provide optimum care for diabetic
patients
SPECIFIC OBJECTIVES :
 Identify the high risk groups
 Early detection through screening
program
 Provide appropriate treatment
 Provide counseling / health education
 Early detection of complication,
appropriate treatment and delay
complication
 Referral to other disciplines if needed
THE TEAM
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Doctors : MO / FMS
Paramedics : AMO / SN / CN
Pharmacists / Assistant pharmacists
Medical laboratory technologist (MLT)
Health attendants
Dietician / Nutritionist
Others : Podiatrist, Physiotherapist,
Occupational therapist etc
PARAMEDICS (AMO/SN/CN)
 Basic clinical assessment (able to detect
abnormal result, when to give
appointment)
 Specific clinical assessment eg: foot
examination, eye examination ( VA +
fundus camera)
 Order blood investigation following
schedule (yearly HbA1c, 6/12ly lipid profile
and renal profile)
 Provide reliable data for “reten”
 AMO – treat patient with normal
parameters
 Refer to MO/FMS if not controlled
MEDICAL OFFICER
 Initiate medical treatment (oral /
insulin therapy)
 Treat uncontrolled patient (blood
sugar, blood pressure, lipid etc)
 Refer to FMS if indicated
 Lead the team (clinic without fms)
 Quality improvement activities
FAMILY MEDICINE SPECIALIST
 Initiate list A medication including insulin
penfill
 Treat patient with complications
 Refer to specialist clinic in the hospital
(further evaluation / management)
 Treat patient with other illnesses / comorbidities eg: depression, PTB
 Refer back to MO/AMO once well controlled
 Lead the team
 Quality improvement activities
PARAMEDICS / MO / FMS
 Counseling/health education on diet,
exercise, foot care, anti-diabetic agents,
disease complication
 Insulin injection technique
 Self monitoring of blood glucose (SMBG)
 Counseling for poorly controlled blood
sugar and poor compliance
 Monitoring – screening of complication/comorbidities, side effects of medication,
defaulter tracing, update diabetic record
Health
Attendant
Registration
Trace lab result and paste in the patient’s green
book
MLT
Urine and blood test – urine albumin
/microalbumin / 24 hr urine protein, FSL, RP, LFT,
HbAIC.
Screening blood glucose
Ensure reliable result
Continuous service (adequate reagents)
Pharmacist
/ dispenser
Dispense medication
Counseling on medication (especially patient with
multiple drugs therapy and poor compliance
Ensure adequate supply of medication
BASIC EQUIPMENTS
Glucometer / lancet
BP set
Stethoscope
Weighing machine with height measurement
Snellen chart + pin hole
Opthalmoscope set
Mydriacyl eye drops
CNS diagnostic set (tendon hammer, cotton wool,
pin, Tuning fork (128 mhz)
 Stool for foot examination
 Monofilament
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Urine albumin strips
Microalbumin and strips
BMI chart
Chemistry analyzer
Computers
Fundus camera
THE BASIC PRINCIPLES :
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7 basic parameters
Prioritize the patients
Treat to target
Appropriate drugs
Continuing health education
Patient empowerment
MOST IMPORTANT
 Dedicated diabetic team
 Empowerment of paramedics
 Adhered to Clinical Practice Guidelines
(CPGs)
i)
7 BASIC PARAMETERS
 Blood glucose level (fasting/random/2HPP)
 Weight, Body mass index (BMI), waist
circumference
 Blood pressure (BP)
 Urine albumin / microalbumin
 Biochemical investigations - FSL,RP + ECG
 Foot examination
 Eye examination
ii) PRIORITIZATION
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A - TYPE 1 DM
B - DM + HPT + Albuminuria
C - DM + Albuminuria - HPT
D - DM + HPT- Albuminuria
E - DM – HPT - Albuminuria
PRIORITIZATION
 ACE inhibitor - B,C,D
 Blood investigations – all groups
 Group A – D : given priority for eye
examination, foot examination and
blood investigations
PHASE SYSTEM
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PHASE 1 (MAIN TARGET)
Registration
BP measurement
Urine albumin
BMI measurement
PHASE 2(SECOND TARGET)
Foot examination (100%)
Blood investigations : FSL, RP (40%)
Eye examination (10%)
PHASE 3 : CONSOLIDATION
 ACE inhibitor for indicated patients
 Blood investigations – all patients in
category B,C,D
 Eye examination – as many patients
in category B,C,D
iii) TREAT TO TARGET
FBS/Preprandial (mmol/l) < 6 (4.4 - 6.1)
RBS (2HPP)
< 8 ( 4.4 – 8.0)
HBA1C (%)
< 6.5
BP (mmHg)
130/80,
Nephropathy with albuminuria >
1gm/24 hrs: < 125/75
BMI (kg/m2)
Men < 23,
Women < 22
Waist
Circumference (cm)
Men < 90cm,
Women < 80cm
TREAT TO TARGET
Urine Albumin
Urine
microalbuminuria
Serum creatinine
negative
negative
< 115 µmol/l
Total Cholestrol
< 4.5 (mmol/l)
HDL
> 1.1 (mmol/l)
LDL
< 2.6 (mmol/l)
TG
< 1.5 (mmol/l)
TREAT TO TARGET
Feet examination
Tiada neuropathy
Eye examination
Tiada retinopathy
Urine albumin:
creatinine
250mg/mol - men,
350mg/mol - women
Exercise
150min/week
iv)
APPROPRIATE
TREATMENT
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Anti-diabetic agents
ACE Inhibitors / ARBs
Statins / lipid lowering agents
Aspirin
Primary sites of action of oral
anti-diabetic agents
-glucosidase inhibitors
Carbohydrate
Gut
Glucose
Sulfonylureas and
meglitinides
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Adipose tissue
Insulin
Pancreas
I
Liver
Muscle
Thiazolidinediones
Biguanides
Adapted from Kobayashi M. Diabetes Obes Metab 1999; 1 (Suppl 1):S32–S40.
ACE INHIBITORS
 First line to treat hypertension in diabetics
 First line to treat diabetic nephropathy / or
ARB if develop side effects with ACE
Inhibitors
 Eg : Captopril 25 mg, Perindopril 4 mg,
Enalapril 5 / 10 mg, Ramipril 5 mg
 Requires renal profile monitoring
 Contraindicated in renal artery stenosis
STATINS/
LIPID LOWERING AGENTS
 Depending on the level cholesterol in
the blood
 Base line LFT
 Titrate until reached target level
 May used double therapy
 Look for side effects
v) CONTINUING
EDUCATION
STAFFs EDUCATION
 Continuing medical education
 Post basic course for paramedics –
diabetic educator, diabetic clinic
management
 Diploma in DM
PATIENT’S EDUCATION
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About DM
Treatment (non-p & pharmacological)
Target parameters
Complications
Include carer / family members
vi) PATIENT EMPOWERMENT
 Self blood glucose monitoring
 Dos adjustment - insulin
ACTIVITIES
SCREENING
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High risk groups
Screening schedule
How to get reliable figures?
Availability of time?
REGISTRATION
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BILANGAN
NOMBOR KAD PENGENALAN
NAMA
UMUR
JANTINA
BANGSA
ALAMAT
NOMBOR TELEFON
PEKERJAAN
DIAGNOSIS : DM &HPT
DM & PROTIENURIA
DM & HPT & PROTIENURIA
DM & OTHERS
TREATMENT
 - Non-pharmacological /
pharmocological
 - Exercise / physical activities
 - Dietary intake
 - Foot care
 - Medications
DETECTION OF
COMPLICATIONS
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-
Nephropathy
Retinopathy
Neuropathy
Stroke
Coronary Artery Disease
Peripheral Vascular Disease
Erectile Dysfunction
REHABILITATION
 Physiotherapist – foot exercise / amputation /
physical exercise
 Dietician – dietary counseling, weight
reduction, physical exercise
 Ophthalmologist – treat eye complication
 Nephrologist – treat kidney complication
 Psychologist / psychiatrist – treat psychological
problems
 Other agencies – Social and Welfare
Department / Pusat Zakat / NGOs – financial
and social assistance
RECORD KEEPING
 Diabetes record book for each patient
 Diabetes registry (manual /
electronic)
 Appointment date for each patient
 Defaulter tracing
QUALITY
IMPROVEMENTS
 QA Primer – Appropriate
management of DM
 Audit Clinical Diabetes
 District Specific Approach (DSA)
 Clinic Specific Approach
CHALLENGES
Inadequate staffing
Multitasking – ownership?
Increasing number of diabetic patient
Increasing number of patient with
complications
 Different level of skills/knowledge
among the staff
 Data – difficult to ensure reliability
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