Primary Care Diabetes
www.bradfordvts.co.uk
Dr Bruce Davies
09/04/2008 1
Introduction - Diabetes
2% of UK population. 66% have been diagnosed. Each GP will find 2-3 new cases per year. 20-30 cases per GP on their lists. 5-10% of NHS budget. Childhood DM doubling every 10 years.
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Topics of Discussion
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Detection Education & counselling Components of continuing care Aims Management Who to refer CDM and future NSF Audit
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Detection – How / When
Symptoms New patient checks 75+ checks Medicals Systematic Opportunistically ANC Other risk factors
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Diagnostic Criteria
Random glucose > 11mmol Fasting glucose > 7mmol 2 hours after 75g glucose orally > 11mmol
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Education
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Lifelong disease Knowledge is power 3 times more likely to die prematurely Reactions vary to what is really bad news Lifestyle changes are needed Specialist health education material Specialist educators
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Education
BDA A on going process Not one off Need more information as and when they can use it
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Education
Partnership with health professionals – Full multidisciplinary teams
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At Diagnosis
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Full examination Explanations See a dietician +/- follow-up See a chiropodist +/- follow-up Monitoring education Implications for driving, insurance, DVLA, script charges etc BDA Education about lifestyle 9
Once Reasonably Controlled
At least annual review Eye surveillance Education when necessary Formal medical review
Weight Urine Bloods (HbA1, cholesterol) Review of control Blood pressure Legs and feet Discuss any problems
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Time and Resources
Annual check takes about 30 minutes Most practices use a practice nurse
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Aims
Patient takes pragmatic responsibility for own health
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Minimise symptoms Glycaemic control Weight Blood pressure Cholesterol
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Who to Refer?
Acutely unwell at diagnosis Insulin treatment required Child Pregnant or pre-conceptual Complications Patient request
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Real Life
Mrs A is a 68 year old widow who attends often because of her angina and COPD. She is getting more tired and feels it is due to old age. Must be the angina or breathing getting worse ?
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Maybe Not!
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Mea Culpa
I’ve forgotten to test these peoples urine on more than one occaision
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Questions
No evidence that self blood monitoring does any good Some evidence of harm! Control of BP in diabetics may be better for long term outcome than blood sugar! How can compliance be improved?
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Questions
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Many type 2 diabetics would be better off not knowing their diagnosis? The government should have better diet and exercise policies? Hospital care is better than practice care? Primary care is better?
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Homework
What drugs when? Treatment of cholesterol? Treatment of BP Treatment of complications
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CDM and Future NSF
Small annual fee per GP for “systematic care” + Audit NSF next year will make it better defined and ? Bigger fee
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Audit
Heaps of possibilities. Diagnosis. Follow-up. Monitoring. How well controlled. Etc.Etc.
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References
Gallichan M. Self-monitoring by people with diabetes: evidence based practice. BMJ 1997;314:964-7 UKPDS 33. Lancet 1998;352:83753 Diagnosis and classification. Diabetes care 1997;20:1183-97
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