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Structured Diabetes Care in General Practice


Structured Diabetes Care in General Practice Dr Velma Harkins GP Lead National Diabetes Programme NAGP AGM 14th November 2014 – PowerPoint PPT presentation

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Title: Structured Diabetes Care in General Practice

Structured Diabetes Care in General Practice
  • Dr Velma Harkins
  • GP Lead National Diabetes Programme
  • 14th November 2014

Objectives of Programme
  • Principle is that the greatest benefit to patient
  • being and the health service lies in the
  • early detection and the management of
    complications of
  • diabetes 1
  • To reduce the number of people developing Type 2
    diabetes through appropriate screening and early
  • To reduce the microvascular and macrovascular
    complication rate among those with Type 2
  • To reduce and manage the progression of
    microvascular and macrovascular complications
  • To empower patients with Type 2 diabetes to be
    active partners in their care
  • 1. Roberts, S. Turning the Corner Improving
    Diabetes Care Report from Dr Sue Roberts,
    National Clinical Director for Diabetes, to the
    Secretary of State for Health June 2006

Quality Objectives
  • To develop and implement an integrated care
    system for
  • people with Type 2 diabetes based on best
  • guidelines to improve diabetes control.
  • By developing all healthcare professionals
    practice so that they can be confident and
    competent in managing patients with Type 2
    Diabetes over their lifetime
  • By focusing on prevention through the provision
    of lifestyle advice (including diet and exercise)
    especially for high risk patients.
  • By screening high risk patients to prevent early
  • By providing high quality patient information,
    appropriate to the patients needs.
  • By regular monitoring of clinical indicators and
    intensive management of blood glucose, blood
    lipids and blood pressure.
  • By surveillance for early signs of complications,
    including retinopathy, nephropathy and neuropathy
    screening by developing a retinopathy screening
    programme for diabetes to prevent blindness and
    developing a foot care screening and treatment
    service to prevent foot ulceration and subsequent
  • Develop a National Diabetes Register.

Access Objectives
  • To expand availability of primary care diabetes
    structured care
  • programmes to all of Ireland.
  • All patients diagnosed with Type 2 diabetes
    invited to enroll in structured integrated
    diabetes programme
  • GPs will provide highest proportion of care
    patients with Type 2 diabetes
  • Access to specialist hospital-based services
    available for patients with identified clinical
    need e.g. at diagnosis, onset of complications or
    immediate support in complicated cases. Patient
    care pathways supported by fast-track referral
    systems agreed locally between primary and
    hospital care.
  • Access to structured patient education programmes
    provided to compliment one-to-one patient
    education at GP practice and hospital level.
  • All patients diagnosed with Type 2 diabetes will
    have structured review at Primary Care level at
    least 3 times per year
  • To ensure patients have up to date information in
    relation to availability of diabetes services in
    their local area.

National Diabetes Working Group
  • In the context of this a National Diabetes
  • Working Group was established.
  • Cost Objectives
  • To reduce the current cost of diabetes related
    complications to both the patient and the health
    system by reducing the number of hospital bed
    days used, the average length of stay and the
    overreliance on OPD services.
  • Work was divided into the following work streams

National IntegratedModel of Care
Integrated Care Diabetes Package
  • Patients with Type 1 diabetes, complex genetic
    will be managed in Secondary Care only (30,000
  • Patients with Uncomplicated Type 2 Diabetes will
    be managed in Primary Care only (100,000
  • 3 visits per year to GP -one to be annual review
  • Practices to be supported by community based
    Diabetes Nurse Specialists
  • Patients with Complicated Type 2 Diabetes will be
    managed by both Primary and Secondary Care
    (60,000 patients)
  • 2 visits per year to GP
  • Annual review to secondary care

Hospital Care
  • All Type 1 diabetes
  • Pregnancy and diabetes
  • Diabetes and Continuous Subcut Insulin Infusion -
    CSII (usually T1 diabetes)
  • Adolescent diabetes
  • Maturity Onset Diabetes of the Young - MODY
  • Cystic Fibrosis Related Diabetes - CFRD
  • Insulin resistance syndromes
  • Secondary causes of diabetes
  • Transplant diabetes
  • Genetic causes of diabetes (Turners/Klinefelters
  • Diabetes in adults lt30 years of age (would
    envisage some care could be shared)
  • Complicated type 2 diabetes (refer on) (depending
    on level of complications most type 2 tend have
    some level of complications)
  • Type 2 diabetes on insulin (this may evolve into
    the community once community DNS in place)

Referral from Primary Care to Predominantly
Hospital Care
  • Complicated Type 2 diabetes
  • History of lower limb amputation
  • Active or history of foot ulcer
  • High risk foot (as per national model of foot
  • Renal failure (Creatinine gt150umol/l or eGFR
    lt60ml/min) refer nephrology
  • Painful peripheral neuritis
  • Symptoms of autonomic neuropathy (except for
    erectile dysfunction)
  • Diabetic eye disease with active
    proliferative retinopathy / maculopathy or recent
    laser therapy (last 24 months)
  • Steroid induced hyperglycaemia (can be
    referred back once off steroids
  • or blood glucose levels settle)
  • Failing 2 or more glucose lowering agents -
    HBA1c gt7.5 on maximum glucose lowering agents
  • Type 2 diabetes requiring insulin not
    necessary to refer all once Community DNS in
  • Weight loss symptoms /- ketones

Educational Support
  • Development of
  • Education package for GPs Practice Nurses
  • Materials covering Targets, Guidelines, Treatment
    Algorithms etc
  • Patient Education Package
  • Provision of Regular Multi-disciplinary Meetings

Role of the GP
  • The GP carries overall responsibility and
    leadership in the
  • running of integrated diabetes care in the
  • Responsibilities
  • Ensure practice staff members familiarised with
    agreed programme models of care, including
    algorithms, patient information, guidelines etc.
  • Ensure all members of team are aware of their
    roles and responsibilities
  • Ensure that patients are treated in accordance
    with National Diabetes Programme Protocols
  • Ensure appropriate governance in place in order
    to ensure continuing improvements in quality,
    safety, access and cost effectiveness.
  • Maintain an up to date register of patients with
    type 2 diabetes.
  • Ensure regular register management takes place.
  • Be willing to adapt to new guidelines as they are
  • Other roles may arise in the future

Role of the Practice Nurse
  • Provide regular routine care in the practice to
    patients with diabetes as per visits set out in
    agreed model
  • Maintain practice diabetes register
  • Set targets with patients
  • Provide patient education re diet / lifestyle /
    exercise etc
  • Carry out initial and annual foot assessment as
    per national model
  • Refer patients to community diabetes nurse
    specialist, and refer patients for retinal
    screening, dietetics and podiatry as per national
  • Refer agreed patients to secondary or tertiary
    care as per agreed model
  • Return patient data as required

Role of the CommunityDiabetes Nurse
  • See individual patients referred to him / her by
    the GP / PN
  • Provide training and support to Practice Nurses
    within the GP practice to set up and deliver
    integrated diabetes care package
  • Deliver education programmes, in conjunction with
    the local nursing education units, for example
    the HETAC Certificate in Diabetes, along with
    annual multidisciplinary master classes
  • Liaise with secondary care and actively
    participate in team discussions regarding best
    quality care is provided for all diabetes
  • Carry out research and audit, including using
    audit data to influence the delivery of the
    integrated diabetes care package at practice
  • These nurses are highly skilled and have
    specialist post graduate training in diabetes

  • Symptoms of diabetes plus
  • random plasma glucose concentration gt 11.1
  • Random is defined as any time of day without
    regard to time since last meal.
  • or
  • Fasting Plasma Glucose 7.0 mmol/l.
  • Fasting is defined as no caloric intake for at
    least 8 hours
  • or
  • 2-hr plasma glucose gt 11.1 mmol/l during a 75g
    Oral Glucose Tolerance Test.
  • the test should be performed as described by
    W.H.O., using a glucose load containing the
    equivalent of 75 g anhydrous glucose dissolved in
  • or
  • A HbA1c 48 mmol/mol ( 6.5)
  • the test should be performed using a standardised
  • In the absence of unequivocal hyperglycaemia,
    the result should be confirmed by repeat testing
    on a different day. A HbA1c value of lt 6.5
    (IFCC lt 48mmol/mol) does not exclude diabetes
    diagnosed using the other glucose tests

Practice Management Structure
Initial Assessment By GP/PN Record B/P, BMI, Waist Circumference Record baseline blood investigations Review family medical history Assess lifestyle issues Screen for complications Refer for dietetic, chiropody, ophthalmic consult Educate Offer baseline diabetes self management education
Practice nurse educates on self management issues Review aims of Diabetes care Home blood glucose monitoring calibration, if appropriate Medication management Psychological support The guidelines for self-monitoring of blood glucose are currently under review
4 Monthly Review
Practice Nurse G.P Role Investigations Hba1c, Lipids (if raised at last visit), ACR, Serum Creatinine, Iron, Transferrin (if ferritin previously raised) Assess feet, injection sites Assess smoking status physical activity level Follow up on dietetic, podiatry, ophthalmic consults and annual review
Practice nurse educates on self management Issues Hypo/Hyperglycaemia Entitlements LTI/DFI Employment /Driving /Travel advice Pre-conceptual advice
Targets should be individualised
   Glucose Control HbA1c 53mmol/mol (7.0) is appropriate for the majority of patients with T2DM and has been shown to reduce diabetes related complications HbA1c 58mmol/mol ( 7.5) or less stringent A1c goals may be appropriate for patients with a history of severe hypoglycaemia, limited life expectancy, advanced micro vascular or macro vascular complications, extensive co-morbid conditions or where social circumstance may prevent tight glucose control
   Blood Pressure     Systolic 130mm/hg Diastolic lt 80mm/hg Hypertension should be treated aggressively with lifestyle modification and drug therapy . Measure blood pressure annually and at every routine practice visit if found to be above target level . Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.
Targets should be individualised
  Lipid Management and Statins   Primary target is the LDL cholesterol. Patients should be treated with a statin with the aim to reduce LDL Cholesterol 2.6mmol/l for patients without overt cardio-vascular disease LDL Cholesterol 1.8mmol/l for patients with history of overt cardio-vascular disease except for patients lt40 years with low risk of CVD, patients planning pregnancy or pregnant. In patients treated with maximum dose statins who do not reach target LDL, a reduction of 30-40 in LDL cholesterol from baseline is an alternative therapeutic goal. HDL cholesterol levels of 1.0mmol/l in men and 1.3mmol/l in women and fasting serum triglycerides of 1.7mmol/l are desirable, but the LDL cholesterol is primary target.
Anti-platelet Agents Anti-platelet therapy should be offered to all patients with T2DM (secondary prevention) who have a previous history of a cardiovascular or a cerebrovascular event. (For use of anti-platelet therapy in other patients see section on anti-platelets)
Targets should be individualised
   Lifestyle     Patients should be encouraged to lose weight if necessary, exercise regularly, eat healthily and all patients should be encouraged to stop smoking and given access to prescription medications which encourage smoking cessation.
  Renal Disease Serum creatinine and urine albumin/creatinine ratio (ACR) should be measured at diagnosis and annually thereafter.
Foot Care All patients should have feet checked at each visit and classified as either low, moderate, high risk or active according to National Model of Foot Care
Eye Care All patients with diabetes should have eyes examined at diagnosis and annually thereafter by Ophthalmologist or Retinal Screening Programme
Flu Vaccination All patients with diabetes should be offered flu vaccination annually
Prevention of Complications
Glucose Control Blood Pressure
Control Anti-platelet Therapy Smoking Lipids D
iabetic Foot Disease Eye Disease Diabetic
Retinascreen Programme Renal Disease Painful
Diabetic Peripheral Neuropathy Erectile
Foot Assessment
  • On diagnosis of diabetes and at annual review
    thereafter trained practice nurse will examine
    patients feet and lower limbs for risk
  • factors, this should include
  • Testing vibration and 10g monofilament sensation
  • Palpation of dorsalis pedis posterior tibial
    pulses in both feet
  • Inspection of any foot deformity
  • Inspection of footwear
  • Feet will be classified into three categories

Low Risk
At Risk
Active Foot Disease
Moderate Risk
High Risk
Low Risk Foot
  • Normal Sensation intact pressure vibration
  • No Peripheral Artery Disease (PAD) - all pedal
    pulses present

  • - no signs/symptoms of PAD
  • No previous ulcer or lower limb amputation
  • No foot deformity
  • Normal vision
  • Annual foot screening in primary care by practice
  • Clinical Nurse Specialist /or podiatrist to
    provide education to practice nurse to provide
  • Foot screening will be provided within structured
    care in GP practice 4 monthly or at least
  • Patient education / smoking cessation

At Risk Foot -Moderate Risk
  • Any one of the following
  • Loss of sensation / peripheral neuropathy
  • Peripheral Artery Disease
  • Structural foot deformity
  • Significant visual impairment
  • Physical disability (e.g. stroke or gross obesity)
  • Annual foot screening by foot protection team
    on-going review by podiatrist member of foot
    protection team based either in the hospital or
  • Education in foot protection
  • Vascular assessment, biomechanical, orthopaedic
    assessment and orthotics if indicated
  • Referral to community podiatry for non diabetic
    foot pathology

At Risk Foot High Risk
  • Peripheral Artery Disease and Sensory loss
  • and/or
  • Previous diabetes related foot ulcer or lower
    limb amputation
  • and/or
  • Previous Charcot neuroarthropathy
  • Called for formal annual review by foot
    protection team routine on-going review by
    GP/practice nurse/hospital diabetes clinic
  • Examination for deformity, neurological status,
    footwear and orthotics as indicated
  • Education in foot protection
  • If ulceration present then refer within 24 hours
    to multi-disciplinary foot care service (model 4

Active Foot Disease
  • Active Foot Ulceration
  • and/or
  • Charcot neuroarthropathy
  • Referral with rapid access (within 24 hours/next
    working day) to multidisciplinary foot care
    service in tertiary centre
  • Access to vascular, orthopaedics and orthotics
  • Access to vascular laboratory, radiology,
    microbiology infectious disease
  • Once ulcer healed refer patient back to the foot
    care team in the referral model 3 hospital
  • If the healed ulcer belongs to a patient who
    originated from the model 4 hospital they remain
    under the care of the specialist diabetes foot
    service in that hospital