Primary Care Diabetes

1
Primary Care Diabetes

• Dr Bruce Davies

2
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.

3
Topics of Discussion

• Detection
• Education counselling
• Components of continuing care
• Aims
• Management
• Who to refer
• CDM and future NSF
• Audit

4
Detection How / When

• Symptoms
• New patient checks
• 75 checks
• Medicals
• Systematic
• Opportunistically
• ANC
• Other risk factors

5
Diagnostic Criteria

• Random glucose gt 11mmol
• Fasting glucose gt 7mmol
• 2 hours after 75g glucose orally gt 11mmol

6
Education

• 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

7
Education

• BDA
• A on going process
• Not one off
• Need more information as and when they can use it

8
Education

• Partnership with health professionals
• Full multidisciplinary teams

9
At Diagnosis

• 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

10
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

11
Time and Resources

• Annual check takes about 30 minutes
• Most practices use a practice nurse

12
Aims

• Patient takes pragmatic responsibility for own
  health
• Minimise symptoms
• Glycaemic control
• Weight
• Blood pressure
• Cholesterol

13
Who to Refer?

• Acutely unwell at diagnosis
• Insulin treatment required
• Child
• Pregnant or pre-conceptual
• Complications
• Patient request

14
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 ?

15
Maybe Not!
16
Mea Culpa

• Ive forgotten to test these peoples urine on
  more than one occaision

17
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?

18
Questions

• 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?

19
Homework

• What drugs when?
• Treatment of cholesterol?
• Treatment of BP
• Treatment of complications

20
CDM and Future NSF

• Small annual fee per GP for systematic care
  Audit
• NSF next year will make it better defined and ?
  Bigger fee

21
Audit

• Heaps of possibilities.
• Diagnosis.
• Follow-up.
• Monitoring.
• How well controlled.
• Etc.Etc.

22
References

• Gallichan M. Self-monitoring by people with
  diabetes evidence based practice. BMJ
  1997314964-7
• UKPDS 33. Lancet 1998352837-53
• Diagnosis and classification. Diabetes care
  1997201183-97