Transcript Achieving Good Glycemic Control

Achieving Good Glycemic Control:
The importance of Self Monitoring Blood
Glucose
by:
Nina Hibbard, CRNP Student
Auburn University/ Auburn Montgomery Joint Program
Aim
Provide practical guidance on improving
diabetes
care through highlighting the need to:
• Understanding of importance of SMBG
• Improve overall control of diabetes patients
• See the affects of SMBG on HA1C values
Definition and Description of the Problem
• Diabetes has been identified as one of the top 20
priority areas for national action according to the
Institute of Medicine
• 25.8 million children and adults in the United States
which is 8.3% of the population that have diabetes
• Self Monitoring Blood Glucose (SMBG) is a very
simple way patients can control short and long term
affects of diabetes complications
Diabetes: a global call to action
Global prevalence of
diabetes (millions)
350
The numbers of diagnosed diabetes is growing stronger
each year
333 million
300
250
200
150 million
150
100
50
30 million
0
1985
2000
2025
Year
http://www.idf.org/home/
Diabetes is associated with serious
complications
Stroke
Diabetic
Retinopathy
Leading cause
of blindness
in adults1,2
2- to 4-fold increase in
cardiovascular
mortality and stroke5
Cardiovascular
Disease
8/10 individuals with
diabetes die from CV
events6
Diabetic
Nephropathy
Leading cause of
end-stage renal disease3,4
1UK
Diabetic
Neuropathy
Leading cause of
non-traumatic lower
extremity amputations7,8
Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes
Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.
6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost.
The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Individuals suffering ‘extreme problems’
in quality of life
Diabetes
General population
Individuals reporting
‘extreme problems’ (%)
10.0
*
7.5
*
*
5.0
2.5
*
*
0
Mobility
Self-care
Usual
activities
Pain/
discomfort
Anxiety/
depression
*Significant versus general population
Williams R, et al. The true costs of type 2 diabetes in the UK. Findings from T2ARDIS and CODE-2 UK, 2002.
Department of Health. Health Survey for England 1996. London: HMSO, 1997.
Costs of diabetes are rising
Indirect costs
Cost per year (US$ billion)
140
$132
Direct costs
120
$98
$92
100
80
60
40
$20
20
0
19871
Estimated US costs
1Huse
19922
19973
20024
Year
DM, et al. JAMA 1989; 262:2708–2713. 2Javitt JC & Chiang Y-P. In Diabetes in America, 1995; 601–611. NIH Publication No. 95–1468.
3American
Diabetes Association. Diabetes Care 1998; 21:296–309. 4American Diabetes Association. Diabetes Care 2003; 26:917–932.
Hospitalizations account for the majority
of the costs of managing Diabetes
Ambulatory care
18%
Antidiabetic drugs
7%
Other drugs
21%
Hospitalizations
55%
= €29 billion/year
Jönsson B. Diabetologia 2002; 45 (Suppl.):S5–S12.
Lowering HbA1c reduces the risk of
complications
21%
Deaths related
to diabetes
37%
Microvascular
complications
14%
Myocardial
infarction
HbA1c
1%
Stratton IM, et al. BMJ 2000; 321:405–412.
Two thirds of individuals do not achieve
target HbA1c
Saydah SH, et al. JAMA 2004; 291:335–342.
Liebl A, et al. Diabetologia 2002; 45:S23–S28.
Barriers to achieving good
glycemic control
Lack of clarity over definition of
good glycemic control
Inadequate monitoring of glycemia
Complexity of managing hyperglycemia
relative to dyslipidemia and hypertension
Insufficient involvement of physician and
team
What is good glycemic control?
The Global Partnership recommends:
Aim for good glycemic
control = HbA1c < 6.5%*
< 6.5%
*Or fasting/preprandial plasma glucose < 110 mg/dL (6.0 mmol/L) where assessment of HbA1c is not possible
Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.
Frequent monitoring of glycemia is
important
• Cornerstone of diabetes care
• Ensures best possible glycemic
control by:
– assessing efficacy of therapy
– guiding adjustments in diabetes
care regimen, including diet,
exercise and medications
Who should monitor glycemia?
+
Patient
Self-monitoring
of blood glucose
Healthcare professionals
Regular monitoring of HbA1c
Diabetes care team
Combined synergistic efforts of
team are crucial to ensure effective
monitoring of glycemic control
Self-monitoring of blood glucose (SMBG)
• Regular SMBG increases the
90%
proportion of individuals
achieving their glycemic targets
• Individuals should monitor
postprandial glucose as part
of their SMBG schedule
• Regular discussion of results with
diabetes care team is essential
HbA1c  8.0
HbA1c > 8.0
80%
70%
60%
50%
40%
30%
20%
10%
0%
Regular
Irregular
SMBG
SMBG
Performers
Performers
(21%)
(42%)
Not
Monitored
(37%)
Blonde L, et al. Diabetes Care 2002; 25:245–246.
Physician input leads to better outcomes
in type 2 diabetes
17%
Individuals whom the physician
was directly involved in proactive
diabetes care had a substantially
improved chance of survival
Verlato G, et al. Diabetes Care 1996; 19:211–213.
Implementation
PLAN: Present to two groups
Group 1- Physician Group
Group 2- Patient Group
By presenting to two separate groups, the goal of the
presentation is to make both more aware of the
importance of SMBG and using this daily process as
a useful tool in helping control diabetes in the short
and long term.
Design
• Physician Group- Current preceptor group of 4
doctors
*Powerpoint
*Evidence Based Research articles
*Demonstrate SMBG
*Enforce focus of management of patient more
efficiently with this SMBG information
•
*Handouts provided for SMBG importance
Design
• Patient Group- Group of diabetes patients identified at
local retirement community.
• *Verbal explanation and demonstration of SMBG provided
• *Handouts provided for reinforcement
• *Question and answer session
Delivery of Project
Margaret Newman’s Theory of Health as Expand
Consciousness
• central thesis of this theory is that health is the expansion of
consciousness
• asserts that every person in every situation, no matter how
disordered and hopeless it may seem, is part of the universal
process of expanding consciousness” (Newman, 1992, p.60).
The Behavior and Skill of SMBG
Physician Group
• Physicians will begin with a survey of how often they tell
their patients to check blood glucoses
• SMBG demonstration
• Insurance discussion
The Behavior and Skill of SMBG
Patient Group
•
Review of handouts
•
Discussion
•
Demonstration
•
Insurance discussion
Evaluation of Project
Physician Group:
Negative: *Do not have time to teach the patient
*Too expensive for the patient
* A1C test gives all information needed
After discussion:
Positive: *Realize the ease of local resources and meter
companies to provide training
*Understood insurance coverage of strips
*Recognized useful in controlling medication
regimen more efficiently
Evaluation of Project
Patient Group: (31 Participants)
Negative: * All patients did not have their own SMBG meter
* Need not recognized. “My doctor keeps up with
my blood sugar when I see him every three months.”
* No understanding of insurance coverage
Positive: *All patients end of session had a SMBG meter
*Need recognized for daily monitoring and
communicating to physician of blood sugar logs
*Relieved to know of insurance coverage
Conclusion
The educational project for SMBG awareness has been
enjoyable and close to my heart. I truly have a passion for
diabetes because it is very controllable with the right tools,
support and education provided. This project is but the tip of
the iceberg, but of great importance. I hope to continue to
spread the news regarding SMBG and diabetes education for
many years to come.
Acknowledgements
Primary Care Internists of Montgomery, P.C.
Dr. Raghu Mukkamala and partners
1722 Pine Street, Suite 309
Montgomery, Al 36106
Eastdale Estates Retirement Community
1500 Eastdale Circle
Montgomery, Al, 36117