Transcript Diabetic Challenges in Primary Care

Diabetic Challenges
in Primary Care
Susan Neal
Nurse Practitioner
North Street Medical Care
Introduction
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What are the issues?
In the practice
What sort of care?
Where?
Some cases
Key management issues
How might this patient be managed in primary
care? What key elements need to be in place?
Diabetes – the Challenge
in primary Care
 One million diagnosed diabetics in England (1 in 49)
 1 in 20 people age > 65
 1 in 5 people age > 85
 2% - 3% of population have diabetes
 40-60 patients per General Practitioner
 41% NHS funding for Type 2 spent on inpatient care for
management complications
Finding Diabetes
 50% diabetes undiagnosed i.e. 1 million
 True onset of diabetes may be 7-12 years before clinical
recognition
 25% have evidence of microvascular complications at
clinical diagnosis
 Value of population screening has not been established
 Early interventions of diet & lifestyle amongst at-risk groups
is preventative and worthwhile
 Focus on “at risk” populations
At risk populations
 All with CV disease
 Those with BMI > 30
 Skin sepsis especially if recurrent
 Thrush especially if recurrent
 Those with +ve FH of DM
 Ethnic groups especially at certain ages
 Annual BS in those with IGT or h/o gestational
diabetes
What are the problems
in diabetes?
 Mortality from CHD 5 times higher
 Mortality from CVA 3 times higher
 Leading cause of renal failure
 Leading cause of blindness in working age
 Second commonest cause of lower limb
amputation
Aims of diabetes NSF
 Identify those with DM and related conditions
 Improve quality of service for diabetic patients
 Tackle variations in care
 Make best practice the norm
 Reach communities at greatest risk
 Reduce complication rates
 Eliminate discrimination
However…..
 Natural trend of disease is of deteriorating beta
cell function
 50% of those on monotherapy require
additions at 3 years
 50% of patients with chronic illness do not take
medications as prescribed
 Achieving & sustaining long term lifestyle
change is difficult – over time non medication
Rx becomes ineffective
Diabetics at NSMC
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12,500 patients
Register of 403 (3.2%)
Type 1 = 40 (10%)
Type 2 = 357(90%)
97 with IGT
Approx 40 Type 2 are treated with insulin
The team ~
 6 partners (5.5 wte)
 1 GP registrar
 1 nurse-practitioner
 3 practice nurses
 1 health care assistant
Also ~
 1 practice manager
 3 administrative staff
- deputy practice manager
(finance)
- deputy practice manager
(IM&T)
- PIO
 Data entry team of 3
 Reception manager & her team
What type of care?
 Identification/screening
 Methods to decrease complications
 Lifestyle changes
 How to achieve them
 Clinical targets
 Drugs to achieve these – achieving
concordance
 Supporting patients to live with chronic illness
Modifiable risk factors
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Weight
Exercise
Alcohol reduction
Smoking
Blood pressure
Glycaemic control
Clinical targets
 BMI
25
 HbA1c
7%
 BP
140/80 or below
 Total cholesterol
<5
 LDL cholesterol
<3
 Triglyceride
< 2.3
Drugs
 Oral hypoglycaemic agents
 BMI > 25 metformin up to 1g tds
 BMI < 25 gliclazide up to 160mg bd
 Combination therapy
 Metformin + gliclazide
 Metformin + rosiglitazone up to 8mg od
 Gliclazide + rosiglitazone up to 4mg od
 Some will need insulin to try to achieve
HbA1c target
New developments
 New drugs
 glitazones
 repaglinide / nateglinide
 New insulins
 glargine
 other insulin analogues
Antihypertensives
 BHS ABCD guidance
 Step 1 - CCB or Diuretic (older and higher risk)
 2 - ACEI + CCB or Diuretic
 3 - ACEI + CCB + Diuretic
 4 - Add alpha-blocker e.g. doxazosin
Other drugs
 Aspirin 75mg daily - for hypertensive pts aged 50
or more with either end-organ damage, Type 2
diabetes or 10-year CHD risk 15% or more
 Orlistat may be appropriate in some patients
Anti-lipid therapy
 Statins – NSF advises increase dose to try
to optimise cholesterol
 Fibrates
 Ezetimibe
 Cholestyramine – unpleasant to take
What is done at the review?
 General health review
 Diabetic understanding
 Medication review
 Smoking and alcohol
 Glycaemic control
 Symptoms of complications?
Examination
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Weight / BMI
Blood pressure
Visual acuity
Consideration of retinopathy
Consideration of foot care and
neuropathy
Investigations
 Urinalysis for protein – consider
screening for microalbuminuria
 HbA1c
 U & E’s
 Cholesterol / lipid profile
Workload
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344 patients attending DC
Type 1 = 31(78%) seen DC in last 15 months
Type 2 = 317(90%)seen DC in last 15 months
Other 60 mixture of
hosp/recidivists/housebound
• 896 dedicated diabetic or DC/CVS appts (17
appts weekly)
• 2/3 appts per pt annually on average
• 4 clinicians
Cases from Practice
 Consider the clinical management of the
patient
 What processes and structures need to
be in place to deliver good diabetic care
to this patient?
Case 1 - Alison
Age 33, married
2 children – younger one died Nov 02 at 5 yrs
No FH DM
PMH “borderline” gestational diabetes
BMI 20, non smoker, BP 118/70, total chol 4.5,
LDL 2.9
Presents June 03 – thirst, polyuria, weight
loss. BS 12.7 with ketones++
Case 2 - Arthur
Age 57, lives alone
BMI 52, smoker, BP 136/78, chol 4.7
PMH dilated cardiomyopathy 1999
DM diagnosed Nov 03 on x1 random BS
at 19.4 mmols
Symptoms reported retrospectively –
thirst/polyuria
Case 3 - Michael
Age 56, divorced, lives alone
Hypertensive, smoker, cholesterol 7.2,
BMI 30
Diagnosed DM April 04 on x2 FBS – 7.7
Asymptomatic
Case 4 – William
Age 84, lives with wife
Hypertensive, IHD, BMI 22, smoker
New patient screen Sept 03
Diagnosed x2 FBS
Asymptomatic
Case 5 - David
Age 54, married, DM diagnosed 1988
BMI 41, non smoker.
Prev Hx ^ alcohol
New patient 1999, on Metformin
Diabetic or alcoholic neuropathy, retinopathy
Hypertensive = Lisinopril, Atenolol + Nifedipine
Statin and Aspirin added June 2000
Proteinuria 2001
Case 6 - Jeremy
Age 46, married, HGV driver
Presented August 03 with BS 20mmols
plus and ketones
Symptomatic – weight loss, recent
infections, thirst/polyuria, tired
Not acutely unwell
BMI 24
Devastated by diagnosis and implications
Feed back 1 - Alison
 Glicazide to max, Rosiglitasone (SE) symptomatically improved but control not
achieved.
 Aug 03 commenced Glargine- taught in
practice
 Nov 03 HBA1c 6.9%
 No end-organ damage indicated
Feed back 2 - Arthur
 Treated Metformin 250mg bd and ^
 Discussions ongoing re smoking, weight,
diet, etc
 On furosemide & lisinopril for
cardiomyopathy
 HBA1c improving now at 7.9%
 Now for Aspirin and statin
Feed back 3 - Michael
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Given 3/12 trial diet/lifestyle
Trying to stop smoking
Cholesterol will need Rx
BP target not achieved if diabetic
Feed back 4 - William
 Diet & lifestyle discussion initially
 DNA to clinic 3 months later
 At 6 months no dietary change, no
compliance with blood tests
 Asymptomatic but BS 23mmols/l (HBA1c
9.8%)
 Commenced Glicazide 40 mg OD
 BP controlled, chol 3.9
Feed back 5 - David
 Diabetic control fair on 1gm Metformin bd
HBA1c 7.4%
 BP struggle to control now on Minoxidine
 Deteriorating renal function, rising
creatinine, ^ 24 hr urinary protein, under
urologists
Feed back 6 - Jeremy
 Became unwell in next few days –
commenced insulin
 Coped well with technicalities
 Marital stress – ED
 Work stress
 Lifestyle changes very difficult – food etc
 Control now good with Novorapid/Lantus
 Marital breakdown
Processes and Structures
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Responsible health professional - doctor or nurse
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Use the team
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Disease register - IT
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Adequate protected time, numbers of appointments – “diabetic clinic”
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Clinical protocol – what management, records, IT
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Use the stepped guidelines, use the IT to guide practice
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Prioritise – life long condition - KISS!
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Appropriate use of experts
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Support
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Recall system - IT
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Regular audit – new contract Q & O framework
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Exception coding