diabetic challenges in primary care susan neal nurse practitioner north street medical care
TRANSCRIPT
Diabetic Diabetic Challenges in Challenges in Primary CarePrimary Care
Susan NealSusan Neal
Nurse PractitionerNurse Practitioner
North Street Medical CareNorth Street Medical Care
IntroductionIntroduction
What are the issues?What are the issues? In the practiceIn the practice What sort of care?What sort of care? Where?Where? Some casesSome cases Key management issuesKey management issues How might this patient be managed in primary How might this patient be managed in primary
care? What key elements need to be in place?care? What key elements need to be in place?
Diabetes – the Challenge Diabetes – the Challenge in primary Carein primary Care
One million diagnosed diabetics in England (1 in 49)One million diagnosed diabetics in England (1 in 49)
1 in 20 people age > 651 in 20 people age > 65
1 in 5 people age > 851 in 5 people age > 85
2% - 3% of population have diabetes2% - 3% of population have diabetes
40-60 patients per General Practitioner40-60 patients per General Practitioner
41% NHS funding for Type 2 spent on inpatient care 41% NHS funding for Type 2 spent on inpatient care
for management complicationsfor management complications
Finding Diabetes Finding Diabetes
50% diabetes undiagnosed i.e. 1 million50% diabetes undiagnosed i.e. 1 million
True onset of diabetes may be 7-12 years before clinical True onset of diabetes may be 7-12 years before clinical
recognitionrecognition
25% have evidence of microvascular complications at 25% have evidence of microvascular complications at
clinical diagnosisclinical diagnosis
Value of population screening has not been establishedValue of population screening has not been established
Early interventions of diet & lifestyle amongst at-risk groups Early interventions of diet & lifestyle amongst at-risk groups
is preventative and worthwhileis preventative and worthwhile
Focus on “at risk” populationsFocus on “at risk” populations
At risk populationsAt risk populations All with CV disease All with CV disease
Those with BMI > 30Those with BMI > 30
Skin sepsis especially if recurrentSkin sepsis especially if recurrent
Thrush especially if recurrentThrush especially if recurrent
Those with +ve FH of DMThose with +ve FH of DM
Ethnic groups especially at certain agesEthnic groups especially at certain ages
Annual BS in those with IGT or h/o gestational Annual BS in those with IGT or h/o gestational
diabetesdiabetes
What are the problems What are the problems in diabetes?in diabetes?
Mortality from CHD 5 times higherMortality from CHD 5 times higher
Mortality from CVA 3 times higherMortality from CVA 3 times higher
Leading cause of renal failureLeading cause of renal failure
Leading cause of blindness in working ageLeading cause of blindness in working age
Second commonest cause of lower limb Second commonest cause of lower limb
amputationamputation
Aims of diabetes NSFAims of diabetes NSF
Identify those with DM and related conditionsIdentify those with DM and related conditions
Improve quality of service for diabetic patientsImprove quality of service for diabetic patients
Tackle variations in careTackle variations in care
Make best practice the normMake best practice the norm
Reach communities at greatest riskReach communities at greatest risk
Reduce complication ratesReduce complication rates
Eliminate discriminationEliminate discrimination
However…..However…..
Natural trend of disease is of deteriorating beta Natural trend of disease is of deteriorating beta cell functioncell function
50% of those on monotherapy require 50% of those on monotherapy require additions at 3 yearsadditions at 3 years
50% of patients with chronic illness do not take 50% of patients with chronic illness do not take medications as prescribedmedications as prescribed
Achieving & sustaining long term lifestyle Achieving & sustaining long term lifestyle change is difficult – over time non medication change is difficult – over time non medication Rx becomes ineffectiveRx becomes ineffective
Diabetics at NSMCDiabetics at NSMC
• 12,500 patients12,500 patients
• Register of 403 (3.2%)Register of 403 (3.2%)
• Type 1 = 40 (10%)Type 1 = 40 (10%)
• Type 2 = 357(90%)Type 2 = 357(90%)
• 97 with IGT97 with IGT
• Approx 40 Type 2 are treated with insulinApprox 40 Type 2 are treated with insulin
The team ~The team ~
6 partners (5.5 wte)6 partners (5.5 wte) 1 GP registrar1 GP registrar 1 nurse-practitioner1 nurse-practitioner 3 practice nurses3 practice nurses 1 health care assistant1 health care assistant
Also ~Also ~ 1 practice manager1 practice manager 3 administrative staff 3 administrative staff
- deputy practice manager - deputy practice manager (finance)(finance)
- deputy practice manager - deputy practice manager (IM&T)(IM&T)
- PIO- PIO Data entry team of 3Data entry team of 3 Reception manager & her teamReception manager & her team
What type of care?What type of care?
Identification/screeningIdentification/screening
Methods to decrease complicationsMethods to decrease complications
Lifestyle changesLifestyle changes
How to achieve themHow to achieve them
Clinical targetsClinical targets
Drugs to achieve these – achieving Drugs to achieve these – achieving
concordanceconcordance
Supporting patients to live with chronic illnessSupporting patients to live with chronic illness
Modifiable risk factorsModifiable risk factors
WeightWeight ExerciseExercise Alcohol reductionAlcohol reduction SmokingSmoking Blood pressureBlood pressure Glycaemic controlGlycaemic control
Clinical targetsClinical targets
BMIBMI 2525
HbA1c HbA1c 7%7%
BPBP 140/80 or below140/80 or below
Total cholesterolTotal cholesterol < 5< 5
LDL cholesterolLDL cholesterol < 3< 3
TriglycerideTriglyceride < 2.3< 2.3
DrugsDrugs Oral hypoglycaemic agentsOral hypoglycaemic agents
BMI > 25 metformin up to 1g tdsBMI > 25 metformin up to 1g tds
BMI < 25 gliclazide up to 160mg bdBMI < 25 gliclazide up to 160mg bd
Combination therapyCombination therapy Metformin + gliclazideMetformin + gliclazide
Metformin + rosiglitazone up to 8mg odMetformin + rosiglitazone up to 8mg od
Gliclazide + rosiglitazone up to 4mg odGliclazide + rosiglitazone up to 4mg od
Some will need insulin to try to achieve Some will need insulin to try to achieve
HbA1c targetHbA1c target
New developmentsNew developments
New drugsNew drugs glitazonesglitazones repaglinide / nategliniderepaglinide / nateglinide
New insulinsNew insulins glargineglargine other insulin analoguesother insulin analogues
AntihypertensivesAntihypertensives
BHS ABCD guidanceBHS ABCD guidance
Step 1 - CCB or Diuretic (older and higher risk)Step 1 - CCB or Diuretic (older and higher risk)
2 - ACEI + CCB or Diuretic2 - ACEI + CCB or Diuretic
3 - ACEI + CCB + Diuretic3 - ACEI + CCB + Diuretic
4 - Add alpha-blocker e.g. doxazosin4 - Add alpha-blocker e.g. doxazosin
Other drugsOther drugs
Aspirin 75mg daily - for hypertensive pts aged 50 Aspirin 75mg daily - for hypertensive pts aged 50
or more with either end-organ damage, Type 2 or more with either end-organ damage, Type 2
diabetes or 10-year CHD risk 15% or morediabetes or 10-year CHD risk 15% or more
Orlistat may be appropriate in some patientsOrlistat may be appropriate in some patients
Anti-lipid therapyAnti-lipid therapy
Statins – NSF advises increase dose to try Statins – NSF advises increase dose to try
to optimise cholesterolto optimise cholesterol
FibratesFibrates
EzetimibeEzetimibe
Cholestyramine – unpleasant to takeCholestyramine – unpleasant to take
What is done at the review?What is done at the review?
General health reviewGeneral health review
Diabetic understandingDiabetic understanding
Medication reviewMedication review
Smoking and alcoholSmoking and alcohol
Glycaemic controlGlycaemic control
Symptoms of complications?Symptoms of complications?
ExaminationExamination
WeightWeight / BMI/ BMI Blood pressureBlood pressure Visual acuityVisual acuity Consideration of retinopathyConsideration of retinopathy Consideration of foot care and Consideration of foot care and
neuropathyneuropathy
InvestigationsInvestigations
Urinalysis for protein – consider Urinalysis for protein – consider
screening for microalbuminuriascreening for microalbuminuria
HbA1cHbA1c
U & E’sU & E’s
Cholesterol / lipid profileCholesterol / lipid profile
WorkloadWorkload
• 344 patients attending DC344 patients attending DC• Type 1 = 31(78%) seen DC in last 15 monthsType 1 = 31(78%) seen DC in last 15 months• Type 2 = 317(90%)seen DC in last 15 monthsType 2 = 317(90%)seen DC in last 15 months• Other 60 mixture of Other 60 mixture of
hosp/recidivists/houseboundhosp/recidivists/housebound• 896 dedicated diabetic or DC/CVS appts (17 896 dedicated diabetic or DC/CVS appts (17
appts weekly)appts weekly)• 2/3 appts per pt annually on average2/3 appts per pt annually on average• 4 clinicians4 clinicians
Cases from Practice Cases from Practice
Consider the clinical management of the Consider the clinical management of the patientpatient
What processes and structures need to What processes and structures need to be in place to deliver good diabetic care be in place to deliver good diabetic care to this patient?to this patient?
Case 1 - AlisonCase 1 - Alison
Age 33, marriedAge 33, married2 children – younger one died Nov 02 at 5 yrs2 children – younger one died Nov 02 at 5 yrsNo FH DMNo FH DMPMH “borderline” gestational diabetesPMH “borderline” gestational diabetesBMI 20, non smoker, BP 118/70, total chol 4.5, BMI 20, non smoker, BP 118/70, total chol 4.5, LDL 2.9LDL 2.9Presents June 03 – thirst, polyuria, weightPresents June 03 – thirst, polyuria, weightloss. BS 12.7 with ketones++loss. BS 12.7 with ketones++
Case 2 - ArthurCase 2 - Arthur
Age 57, lives aloneAge 57, lives alone
BMI 52, smoker, BP 136/78, chol 4.7BMI 52, smoker, BP 136/78, chol 4.7
PMH dilated cardiomyopathy 1999PMH dilated cardiomyopathy 1999
DM diagnosed Nov 03 on x1 random BS DM diagnosed Nov 03 on x1 random BS at 19.4 mmolsat 19.4 mmols
Symptoms reported retrospectively – Symptoms reported retrospectively – thirst/polyuriathirst/polyuria
Case 3 - MichaelCase 3 - Michael
Age 56, divorced, lives alone Age 56, divorced, lives alone
Hypertensive, smoker, cholesterol 7.2, Hypertensive, smoker, cholesterol 7.2, BMI 30 BMI 30
Diagnosed DM April 04 on x2 FBS – 7.7 Diagnosed DM April 04 on x2 FBS – 7.7 AsymptomaticAsymptomatic
Case 4 – WilliamCase 4 – William
Age 84, lives with wifeAge 84, lives with wife
Hypertensive, IHD, BMI 22, smokerHypertensive, IHD, BMI 22, smoker
New patient screen Sept 03New patient screen Sept 03
Diagnosed x2 FBSDiagnosed x2 FBS
Asymptomatic Asymptomatic
Case 5 - DavidCase 5 - David
Age 54, married, DM diagnosed 1988Age 54, married, DM diagnosed 1988
BMI 41, non smoker. BMI 41, non smoker.
Prev Hx ^ alcoholPrev Hx ^ alcohol
New patient 1999, on MetforminNew patient 1999, on Metformin
Diabetic or alcoholic neuropathy, retinopathyDiabetic or alcoholic neuropathy, retinopathy
Hypertensive = Lisinopril, Atenolol + NifedipineHypertensive = Lisinopril, Atenolol + Nifedipine
Statin and Aspirin added June 2000Statin and Aspirin added June 2000
Proteinuria 2001Proteinuria 2001
Case 6 - JeremyCase 6 - Jeremy
Age 46, married, HGV driver Age 46, married, HGV driver Presented August 03 with BS 20mmols Presented August 03 with BS 20mmols plus and ketonesplus and ketones
Symptomatic – weight loss, recent Symptomatic – weight loss, recent infections, thirst/polyuria, tiredinfections, thirst/polyuria, tiredNot acutely unwellNot acutely unwellBMI 24BMI 24Devastated by diagnosis and implicationsDevastated by diagnosis and implications
Feed back 1 - AlisonFeed back 1 - Alison
Glicazide to max, Rosiglitasone (SE) - Glicazide to max, Rosiglitasone (SE) - symptomatically improved but control not symptomatically improved but control not achieved. achieved.
Aug 03 commenced Glargine- taught in Aug 03 commenced Glargine- taught in practicepractice
Nov 03 HBA1c 6.9%Nov 03 HBA1c 6.9% No end-organ damage indicatedNo end-organ damage indicated
Feed back 2 - ArthurFeed back 2 - Arthur
Treated Metformin 250mg bd and ^Treated Metformin 250mg bd and ^ Discussions ongoing re smoking, weight, Discussions ongoing re smoking, weight,
diet, etcdiet, etc On furosemide & lisinopril for On furosemide & lisinopril for
cardiomyopathycardiomyopathy HBA1c improving now at 7.9%HBA1c improving now at 7.9% Now for Aspirin and statinNow for Aspirin and statin
Feed back 3 - Michael Feed back 3 - Michael
Given 3/12 trial diet/lifestyleGiven 3/12 trial diet/lifestyle Trying to stop smokingTrying to stop smoking Cholesterol will need RxCholesterol will need Rx BP target not achieved if diabeticBP target not achieved if diabetic
Feed back 4 - WilliamFeed back 4 - William
Diet & lifestyle discussion initiallyDiet & lifestyle discussion initially DNA to clinic 3 months laterDNA to clinic 3 months later At 6 months no dietary change, no At 6 months no dietary change, no
compliance with blood testscompliance with blood tests Asymptomatic but BS 23mmols/l (HBA1c Asymptomatic but BS 23mmols/l (HBA1c
9.8%)9.8%) Commenced Glicazide 40 mg ODCommenced Glicazide 40 mg OD BP controlled, chol 3.9BP controlled, chol 3.9
Feed back 5 - DavidFeed back 5 - David
Diabetic control fair on 1gm Metformin bd Diabetic control fair on 1gm Metformin bd HBA1c 7.4%HBA1c 7.4%
BP struggle to control now on MinoxidineBP struggle to control now on Minoxidine Deteriorating renal function, rising Deteriorating renal function, rising
creatinine, ^ 24 hr urinary protein, under creatinine, ^ 24 hr urinary protein, under urologistsurologists
Feed back 6 - JeremyFeed back 6 - Jeremy
Became unwell in next few days – Became unwell in next few days – commenced insulincommenced insulin
Coped well with technicalitiesCoped well with technicalities Marital stress – EDMarital stress – ED Work stressWork stress Lifestyle changes very difficult – food etcLifestyle changes very difficult – food etc Control now good with Novorapid/LantusControl now good with Novorapid/Lantus Marital breakdownMarital breakdown
Processes and StructuresProcesses and Structures Responsible health professional - doctor or nurseResponsible health professional - doctor or nurse
Use the teamUse the team
Disease register - ITDisease register - IT
Adequate protected time, numbers of appointments – “diabetic clinic”Adequate protected time, numbers of appointments – “diabetic clinic”
Clinical protocol – what management, records, ITClinical protocol – what management, records, IT
Use the stepped guidelines, use the IT to guide practiceUse the stepped guidelines, use the IT to guide practice
Prioritise – life long condition - KISS!Prioritise – life long condition - KISS!
Appropriate use of expertsAppropriate use of experts
SupportSupport
Recall system - ITRecall system - IT
Regular audit – new contract Q & O frameworkRegular audit – new contract Q & O framework
Exception coding Exception coding