1 / 37

Diabetic Challenges in Primary Care

Diabetic Challenges in Primary Care. Susan Neal Nurse Practitioner North Street Medical Care. Introduction. What are the issues? In the practice What sort of care? Where? Some cases Key management issues

laird
Download Presentation

Diabetic Challenges in Primary Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Diabetic Challenges in Primary Care Susan Neal Nurse Practitioner North Street Medical Care

  2. Introduction • 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?

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. Diabetics at NSMC • 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

  10. The team ~ 6 partners (5.5 wte) 1 GP registrar 1 nurse-practitioner 3 practice nurses 1 health care assistant

  11. 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

  12. 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

  13. Modifiable risk factors • Weight • Exercise • Alcohol reduction • Smoking • Blood pressure • Glycaemic control

  14. Clinical targets • BMI 25 • HbA1c 7% • BP 140/80 or below • Total cholesterol < 5 • LDL cholesterol < 3 • Triglyceride < 2.3

  15. 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

  16. New developments • New drugs • glitazones • repaglinide / nateglinide • New insulins • glargine • other insulin analogues

  17. 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

  18. 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

  19. Anti-lipid therapy • Statins – NSF advises increase dose to try to optimise cholesterol • Fibrates • Ezetimibe • Cholestyramine – unpleasant to take

  20. What is done at the review? • General health review • Diabetic understanding • Medication review • Smoking and alcohol • Glycaemic control • Symptoms of complications?

  21. Examination • Weight / BMI • Blood pressure • Visual acuity • Consideration of retinopathy • Consideration of foot care and neuropathy

  22. Investigations • Urinalysis for protein – consider screening for microalbuminuria • HbA1c • U & E’s • Cholesterol / lipid profile

  23. Workload • 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

  24. 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?

  25. 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++

  26. 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

  27. 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

  28. Case 4 – William Age 84, lives with wife Hypertensive, IHD, BMI 22, smoker New patient screen Sept 03 Diagnosed x2 FBS Asymptomatic

  29. 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

  30. 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

  31. 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

  32. 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

  33. Feed back 3 - Michael • Given 3/12 trial diet/lifestyle • Trying to stop smoking • Cholesterol will need Rx • BP target not achieved if diabetic

  34. 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

  35. 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

  36. 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

  37. Processes and Structures • Responsible health professional - doctor or nurse • Use the team • Disease register - IT • Adequate protected time, numbers of appointments – “diabetic clinic” • Clinical protocol – what management, records, IT • Use the stepped guidelines, use the IT to guide practice • Prioritise – life long condition - KISS! • Appropriate use of experts • Support • Recall system - IT • Regular audit – new contract Q & O framework • Exception coding

More Related