|Dr. J. R. Conway, Diabetes Clinic, Smiths Falls, K7A 2H6
Note: Numbers in parentheses refer to slide numbers of this presentation (click here to download).
Diabetes: The Scope of the Problem
Diabetes is an important disease in family practice, there is a dramatic increase in the prevalence of Type 2 Diabetes and as our population ages we see increasing numbers of Diabetics. We are aware that 50% of Diabetes is undiagnosed. Of significance is that there are twice as many people with Impaired Glucose Tolerance (IGT) as there are with Diabetes and these people have all the Cardiovascular Risks of Diabetes. The significance of Diabetes is that it kills; Diabetes is a cardiovascular disease and 80% of Diabetics will die of a cardiovascular event compared to 40% of non diabetics. This is a Family Practice Disease, almost all Diabetics receive their care from primary care practitioners. While we may feelthat Diabetes is not that significant in our practice; the Diascan Study by Larry Leiter, published 2000 in Diabetes Care 2000, shows that in a family practice setting almost 1 in 4 consecutive patients presenting in our offices for any reason, are diabetic (whether diagnosed or not), if we include patients with IGT then probably over half our office visits concern patients with Diabetes or Pre-Diabetes. A Quebec screening showed that in family practice 79% of people who had more than 2 risk factors for Diabetes, 79% were tested and the statistics were what we would expect, 7% were Diabetic and 13% had IGT. The disconcerting thing is that 74% of these people identified with IGT or Diabetes received NO TREATMENT ADVICE. Dr. Stewart Harris from the University of Western Ontario published a study last year that demonstrates that in family practice around London Ont our treatment of Diabetes & Macrovascular complications is fair, 84% of Diabetics had an A1c within the past year (the goal is an A1c every 3 months), 88% had a Blood Pressure measurement recorded on the chart but in our management of microvascular complications we had only checked for Nephropathy in 28% of patients and the results were even more dismal for Neuropathy with only 15% having had a foot exam. In summary: Diabetes is a growing problem that is treated mainly in our offices and we could do better in treatment.
Canadian Diabetes Association, 2003 Clinical Practice Guidelines
CDA Guidelines suggest that care of the person with Diabetes be organized using a team approach and the Guidelines give us a structured care approach to prevention & treatment. It has been repeatedly demonstrated that a structured care approach improves outcomes. An example of this is the GREACE by Athyros et al published in 1992. In this study post MI or angioplasty patients were randomized to receive follow up care either by their family physician or to follow up using a structured multidisciplinary care approach in an outpatient clinic with a protocol to achieve NCEP LDL target. The results showed about a 50% reduction in all end points, Total Mortality, MI, Unstable Angina, Stroke etc in the structured care group. The conclusion is that structured care saves lives and reduces morbidity. The CDA Guidelines give us a framework to improve diabetes outcomes.
What are the problems that face us in dealing with Diabetes in family practice?
- We have a growing problem with increased prevalence in our ageing practice.
- The buck stops at the family practice level, this is a family practice disease.
- Whether or not we realize it, Diabetes & its precursors affect half our patient visits.
- In order to effectively deal with this we need a structured care or protocol based approach
- We need members of a health care team working cooperatively to improve outcomes.
- We need to consider the multiple co morbidities; 90% of diabetics are hypertensive etc.
- While we need to provide comprehensive care, we only have limited time and funding.
How do we deal with these problems?
- Diabetic patients are complex but there are insufficient specialists to refer them all.
- We have Education Programs through most hospitals as well as community based.
- The CDA Guidelines give us a road map which we need to keep available for reference.
- Consider a Diabetes Day in the office to see all diabetic patients together.
- Since Diabetes & complications for a large part of our practice we need to learn more.
- Use our staff or bring in special skills to give more effective comprehensive care.
- Use a flow sheet and have readily available guideline algorithms.
- Pick a day per week, 2 weeks or month to see Diabetic patients for follow up.
- Prepare a protocol for office staff to follow.
- All patients should be monitoring glucose levels, consider meter download software
- Delegate jobs so that support staff do Wt, BP, Review Glucose log
- Have educational or support material available in one location.
- Put copies of Guideline Algorithms on the wall for ready reference.
- Use a Flow Sheet, in Ontario bill K030 (oral meds) 3 times/yr or K029 (insulin)
- Consider extra staff, educator, dietician, pharmacist get financial support.
- Follow up is important, no patient should leave the office without a follow up appt.
- Lab work should be done before the next visit with results available.
CDA Materials, www.diabetes.ca
List of educational web sites
Hospital Diabetes Education & Dietician Programs
Community Based Diabetes Programs & Support Groups
- Post these in the office where you have easy access, staff should be familiar with these.
- This series of algorithms I have found them handy, they are from the CDA web site www.diabetes.ca
Diabetes Care Flow Sheets
These are a useful tool to allow you to see that care is done in a systematic way and guideline values should be present to assist you. By using a flow sheet you can bill the codes K030 for diet & medication treated diabetics up to 3 times a year or K029 for those on intensive insulin management (up to 6 times a year). The spreadsheet shown here can be faxed after every visit (with the patient’s consent) to the Canadian Centre for Research on Diabetes, they will input your data into the computer and will automatically do calculations such as BMI, Creatinine Clearance etc and send back a new spreadsheet with results outside of guideline values highlighted along with relevant guideline sections for areas which do not meet targets. This gives the physician some ongoing assistance.
At each visit consider the ABC of Diabetes; A1c <7%, BP <130/80, Chol TC/HDL<4, LDL<2.5 remember the prevention with ASA and ACE.
Diabetes is a self controlled disease, the physicians role is to give advice and prescriptions to assist the patient in achieving goals. The person with diabetes need to take ownership of the disease. It is important to document progress toward achieving treatment goals. Our business cards give our web site address which contains educational material directed toward the patient. Our appointment cards are on the back of the business card and show the major goals in diabetes treatment. Each patient should have a card or record of all medications. Glucose log book should be kept and this can also serve as a BP record as well as a medication record. Another good resource is the Health Record for People with Diabetes developed for the CDA, copies can be obtained by calling 1-800-561-0070.