Structured
Diabetes Care in
General Practice
Dr Velma Harkins
GP Lead National Diabetes Programme
NAGP AGM
14th November 2014
Objectives of Programme
Principle is that the greatest benefit to patient well
being and the health service lies in the prevention,
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 intervention
• To reduce the microvascular and macrovascular complication
rate among those with Type 2 diabetes
• 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 practice
guidelines to improve diabetes control.
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By developing all healthcare professional’s 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 complications.
By providing high quality patient information, appropriate to the
patient’s 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 amputation.
Develop a National Diabetes Register.
Access Objectives
To expand availability of primary care diabetes structured care
programmes to all of Ireland.
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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 Integrated
Model of Care
Person with
Diabetes
Uncomplicated
Type 1 Diabetes
Type 2 Diabetes
Primary
Care
Complicated
T2DM
Secondary
Care
Integrated Care
Diabetes Package
– Patients with Type 1 diabetes, complex & genetic will
be managed in Secondary Care only (30,000 patients)
– Patients with Uncomplicated Type 2 Diabetes will be
managed in Primary Care only (100,000 patients)
o 3 visits per year to GP -one to be annual review
o 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)
o 2 visits per year to GP
o 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 etc.)
• Diabetes in adults <30 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 care)
~ Renal failure (Creatinine >150umol/l or eGFR <60ml/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 >7.5% on
maximum glucose lowering agents
~ Type 2 diabetes requiring insulin – not necessary to refer all once
Community DNS in place
~ 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 community.
Responsibilities:
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Ensure practice staff members familiarised with agreed programme
models of care, including algorithms, patient information, guidelines etc.
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Ensure all members of team are aware of their roles and responsibilities
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Ensure that patients are treated in accordance with National Diabetes
Programme Protocols
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Ensure appropriate governance in place in order to ensure continuing
improvements in quality, safety, access and cost effectiveness.
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Maintain an up to date register of patients with type 2 diabetes.
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Ensure regular register management takes place.
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Be willing to adapt to new guidelines as they are developed
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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 model
• Refer agreed patients to secondary or tertiary care as per
agreed model
• Return patient data as required
Role of the Community
Diabetes Nurse Specialist
• 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 patients
• Carry out research and audit, including using audit data to
influence the delivery of the integrated diabetes care
package at practice level
• These nurses are highly skilled and have specialist post
graduate training in diabetes care.
Diagnosis
Symptoms of diabetes plus
random plasma glucose concentration > 11.1 mmol/l.
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 > 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 water.
or
A HbA1c ≥ 48 mmol/mol (≥ 6.5%)* †
the test should be performed using a standardised assay
*In the absence of unequivocal hyperglycaemia, the result should be confirmed by repeat
testing on a different day. †A HbA1c value of < 6.5% (IFCC < 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
Glucose
Control
Blood
Pressure
– should be individualised
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
Systolic ≤ 130mm/hg
Diastolic < 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
Lipid
Management
and Statins
– should be individualised
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 <40 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
Lifestyle
– should be individualised
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.
Serum creatinine and urine albumin/creatinine ratio (ACR) should be measured
Renal Disease 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
Diabetic Foot Disease
Eye Disease – Diabetic Retinascreen Programme
Renal Disease
Painful Diabetic Peripheral Neuropathy
Erectile Dysfunction
Foot Assessment
On diagnosis of diabetes and at annual review thereafter trained
practice nurse will examine patient’s 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
Moderate Risk
Active Foot Disease
High Risk
Low Risk Foot
CLINICAL FINDINGS
• Normal Sensation – intact pressure & vibration sensation
• 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
MANAGEMENT PLAN
• Annual foot screening in primary care by practice nurse
• Clinical Nurse Specialist &/or podiatrist to provide education to
practice nurse to provide screening
• Foot screening will be provided within structured care in GP
practice 4 monthly or at least annually
• Patient education / smoking cessation
At Risk Foot -Moderate Risk
CLINICAL FINDINGS
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)
MANAGEMENT PLAN
• Annual foot screening by foot protection team & on-going review
by podiatrist member of foot protection team based either in the
hospital or community
• 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
CLINICAL FINDINGS
• Peripheral Artery Disease and Sensory loss
and/or
• Previous diabetes related foot ulcer or lower limb amputation
and/or
• Previous Charcot neuroarthropathy
MANAGEMENT PLAN
• 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 hospital)
Active Foot Disease
CLINICAL FINDINGS
• Active Foot Ulceration
and/or
•
Charcot neuroarthropathy
MANAGEMENT PLAN
• 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
HEALED ULCER
• 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