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Improving diabetes treatment in primary care

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Adding structure to diabetes care in general practice is beneficial and saves time, writes Dr Tony O’Sullivan.

Diabetes care is changing rapidly; so is primary care. The reality is that modest levels  of investment are reaping significant rewards in both areas. At the same time, patchy investment leads to patchy services.

As is so often the case, uncertainty exists about the determination of health management to press ahead and finish the job in either case, but despite these difficult times, perhaps we need to suspend our cynicism and make some progress at a clinical level.

For me, diabetes services are being delivered in two models in the primary care setting in Ireland today. They are either structured or unstructured. Most practices participate in diabetes care for at least a proportion of their patients, but unfortunately in the majority of cases, the care is unstructured.

My proposal is that adding some structure to the care of patients with diabetes adds huge advantages in terms of their well-being, therapeutic safety and long-term outcomes. It isn’t too difficult, actually saves time in the practice, is highly valued by patients and is a clinically rewarding area for the practice.

What’s the difference?

Unstructured care is how we usually practice – we allow people to come along to see us when they want to discuss something. We do invite some people back, but they are as often driven by the need to pick up a prescription as by any clinical impetus.

This model serves general practice very well; it offers prompt access, and empowers patients to pick their moment. In particular, it seems a fair way to deal with patients who have to fork out a consultation fee at each visit.

Structured care is a modification of this to tackle an insidious, progressive condition with few symptoms but many long-term complications, all of which are preventable by managing the condition appropriately.

The approach is eminently suited to diabetes, but can also be applied to many other chronic conditions from heart failure to COPD, depression to drug addiction and some cancers.

Essentially in structured care we are setting out to provide a comprehensive package of care to each and every person in the practice with the condition in question, even those who are poor attenders or disorganised medication-takers.

Hence we need a register of those included in that group.

The register needs to be accessible to all professionals in the practice, so it should be available to all computers or on paper in a central location; it needs to be as complete as possible, so it has to be updated when patients arrive, die or leave; ideally one person should take responsibility for its maintenance; it should be simple, otherwise the effort of maintenance is excessive; it should include pre-diabetes patients to enable them to access interventions to prevent progress to diabetes, and it should contain only enough information to allow intended uses, which might include care planning, appointment recall, audit and research.

Secondly, we are trying to capture all those on our register within a package of care. One could write a book about the limitations of our commitment to dragging patients along in the face of stubborn resistance (or more likely apathy), but the reality is that with any illness, most patients will be easy to manage, some more difficult, and a few will really test us.

Diabetes will eat away at those patients, so that they are worth a considerable extra effort to motivate and manage them.

This was brought home to me recently when a 50 year-old patient with diabetes had a toe amputated. She had been in denial for some time, and did not come to clinics or take medications for a few years. She became much more willing after she suddenly lost the sight in one eye, but despite being well-controlled, the vision in the other eye went too.

She also had early renal failure and significant neuropathy, and as a result burned her toes when resting them on a radiator, eventually losing one.

I’ve learned two important lessons from this case: even if a patient seems to have made a decision with regard to managing a chronic illness, that decision is amenable to change and should be considered interim and not fixed.

I also learned that when a routine approach is failing, it might be better to change the approach rather than either persevering or giving up.

Most patients with diabetes who are rejecting the condition are influenced by irrational fears, anxiety or depression, and an approach that engenders even more fear is likely to be counter-productive. At least, I’m convinced that a recall system for non-attenders is needed in structured care.

The UKPDS study showed that type 2 diabetes is progressive. Indeed, we now understand that it is caused by a combination of insulin resistance (linked to central obesity and a sedentary lifestyle) and beta-cell loss.

It is estimated that as many as 70 per cent of beta cells are already lost at the time of diagnosis in type 2, and the main difference between types 1 and 2 is the speed with which the remaining beta cells die off. Glucose levels gradually rise even when the person is fully adherent to effective treatment.

Hence, structured care of any progressive condition requires regular review of the patient to assess this change. On detecting this upward drift, it should be attributed to the disease, not to variation around the mean, so we have to respond with stepwise intensification of our treatments, with an eye on side effects and maintaining quality of life.

This approach does negate the drift, as shown by comparing the less intensive and less frequent approach to glycaemic control of UKPDS with the more intensive and more frequently reviewed cohort in the more recent ACCORD study. A similar drift applies to weight, blood pressure and lipids in patients with type 2, and it demands a similar approach.

Some modern elements

As our understanding of diabetes improves, we have modified structured care to incorporate change. Patients spend a few minutes with us, then months on their own, trying to make it all happen.

This cannot be a passive condition, we need them to actively understand and respond to the many added demands placed on them; giving up smoking, changing diet, losing weight, exercising, moderating alcohol, taking tablets, attending check-ups, monitoring blood sugars, taking special care at work, when driving or contemplating pregnancy and much more. We need to provide education and enable people to make choices they had not considered previously.

An associated aspect is that GPs cannot do all of this ourselves, that effective education and motivation is not one of our natural skills, and in any case the workload of diabetes care can be considerable.

A team-based approach is needed. We should rely on the skills of nurses and dieticians with training in motivation skills to provide much of this education and empowerment, and we should use the resources of the wider primary care team including mental health services, and secondary care diabetes services as appropriate. Increasingly, diabetes education is being offered in groups.

Such packages can be accessed from a number of community-based resources, and the Diabetes Federation of Ireland offers one of these (CODE) but also offers free training in motivational skills to practice nurses.

It does not make much sense to manage a deadly condition like diabetes in such a complex way, if we allow it to develop for some time before making the diagnosis. In UKPDS, 50 per cent of patients had some retinopathy at the time of diagnosis of type 2 diabetes, suggesting that the delay from onset to diagnosis was around seven years.

Over 50 per cent of patients attending with a first CVD event have diabetes or an abnormal blood glucose level, and we know that the added CVD risk begins even before glucose levels reach the diabetes range.

We owe it to our patients to have an approach in our practice to early detection of diabetes. This might simply mean keeping a glucose meter on our desks and finger-prick testing everyone with risk factors or potential symptoms.

What about integrated care?

Integrated care (shared care to some) adds another layer of complexity, but also shares the workload and adds value in terms of additional support, complication screening and rapid access when needed. It is still structured care, as all diabetes care should be structured.

Changing your practice to provide this structured type of care takes a bit of effort, but it is a forward step for a practice to take. It is crystal clear that structured care for a number of chronic conditions including diabetes will be part of a future reform of general practice.

Planning for that reform, and implementing changes in practice should start now. We might think we cannot afford to change now, but our patients with diabetes cannot afford to wait.

Dr Tony O’Sullivan, Irishtown Primary Care Centre, Dublin 4


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