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