Diabetic Challenges in Primary Care

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?

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Diabetes the Challenge in primary Care

• One million diagnosed diabetics in England (1 in
  49)
• 1 in 20 people age gt 65
• 1 in 5 people age gt 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

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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

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At risk populations

• All with CV disease
• Those with BMI gt 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

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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

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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

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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

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• 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

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The team

• 6 partners (5.5 wte)
• 1 GP registrar
• 1 nurse-practitioner
• 3 practice nurses
• 1 health care assistant

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Also

• 1 practice manager
• 3 administrative staff
• - deputy practice manager (finance)
• - deputy practice manager (IMT)
• - PIO
• Data entry team of 3
• Reception manager her team

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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

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Modifiable risk factors

• Weight
• Exercise
• Alcohol reduction
• Smoking
• Blood pressure
• Glycaemic control

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Clinical targets

• BMI 25
• HbA1c 7
• BP 140/80 or below
• Total cholesterol lt 5
• LDL cholesterol lt 3
• Triglyceride lt 2.3

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Drugs

• Oral hypoglycaemic agents
• BMI gt 25 metformin up to 1g tds
• BMI lt 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

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New developments

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

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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

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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

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Anti-lipid therapy

• Statins NSF advises increase dose to try to
  optimise cholesterol
• Fibrates
• Ezetimibe
• Cholestyramine unpleasant to take

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What is done at the review?

• General health review
• Diabetic understanding
• Medication review
• Smoking and alcohol
• Glycaemic control
• Symptoms of complications?

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Examination

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

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Investigations

• Urinalysis for protein consider screening for
  microalbuminuria
• HbA1c
• U Es
• Cholesterol / lipid profile

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• 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

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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?

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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

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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

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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

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Case 4 William

• Age 84, lives with wife
• Hypertensive, IHD, BMI 22, smoker
• New patient screen Sept 03
• Diagnosed x2 FBS
• Asymptomatic

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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

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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

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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

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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

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Feed back 3 - Michael

• Given 3/12 trial diet/lifestyle
• Trying to stop smoking
• Cholesterol will need Rx
• BP target not achieved if diabetic

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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

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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

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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

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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