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Process of Process of Disease Management Disease Management on on Diabetes Mellitus Diabetes Mellitus By By Elaine L Y Leung Elaine L Y Leung Nurse Consultant (Diabetes Care) HKWC Nurse Consultant (Diabetes Care) HKWC

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  • Process of Process of Disease ManagementDisease Management

    onon Diabetes MellitusDiabetes Mellitus

    ByBy

    Elaine L Y LeungElaine L Y Leung

    Nurse Consultant (Diabetes Care) HKWCNurse Consultant (Diabetes Care) HKWC

  • Diabetes MellitusDiabetes Mellitus

    Diabetes mellitus is a chronic disorder characterised

    by raised blood glucose

    levels, secondary to a complete or relative

    lack of insulin

    Affects almost 10% of HK adults

  • New Trends in DM New Trends in DM ManagmentManagment

    Emphasis on prevention:Emphasis on prevention:Prevention of diabetes Prevention of diabetes

    lifelife--style modifications in style modifications in prediabeticprediabetic statesstates (IGT/IFG)(IGT/IFG)58% 58% in DPT (US) and Finnish DM Studyin DPT (US) and Finnish DM Study

  • Subjects at Subjects at IIncreased ncreased RRisk of DMisk of DM

    DM in first degree relatives History of gestational diabetes Age over 45Other components of the Metabolic or Insulin Resistance syndrome:

    Obesity, hypertension, dyslipidaemia

  • New Trends in DM New Trends in DM ManagmentManagment

    Emphasis on prevention:Emphasis on prevention:Prevention of diabetes Prevention of diabetes

    lifelife--style modifications in style modifications in prediabeticprediabetic statesstates (IGT/IFG)(IGT/IFG)58% 58% in DPT (US) and Finnish DM Studyin DPT (US) and Finnish DM Study

    Prevention of complications Prevention of complications early DM early DM DxDx; effective control of ; effective control of glycaemiaglycaemia, BP, etc., BP, etc.

  • Current Treatment TargetsCurrent Treatment Targets

    ADAADA

    IDFIDF--WPRWPR

    HbAHbA1c 1c < 7%< 7% < 6.5%< 6.5%

    Blood pressure Blood pressure < 130/80 mmHg< 130/80 mmHg < 130/80< 130/80

    LDL cholesterol LDL cholesterol < 2.6 mmol/l< 2.6 mmol/l < 3.0< 3.0

    HDL cholesterol HDL cholesterol MenMen > 1.1 mmol/l> 1.1 mmol/l > 1.1> 1.1

    Women Women > 1.3 mmol/l> 1.3 mmol/l

    > 1.3> 1.3

    Triglycerides Triglycerides < 1.7 mmol/l< 1.7 mmol/l < 1.5< 1.5

  • AAction of commonly used oral antiction of commonly used oral anti-- diabetic agentsdiabetic agents

    Glucose

    Adipose tissue

    Gut

    Stomach

    Liver

    Sulphonylureas and meglitinides

    stimulate insulin secretion1

    Rosiglitazone decreases insulin resistance2 andimproves -cell

    function3

    Metformin primarily reduces hepatic

    glucose production1

    Muscle

    PancreasInsulin

    Adapted from 1Kobayashi M. Diabetes Obes Metab 1999;1(Suppl. 1):S32S40. 2Nattrass M & Bailey CJ. Baillieres Best Pract Res Clin Endocrinol Metab 1999;13:309329.

    3Del Prato S & Marchetti P. Diabetes Technol Ther 2004;6:719731.

    -glucosidase inhibitors

  • * Check A1C every 3 months until

  • New Trends in DM New Trends in DM ManagmentManagment

    Emphasis on patient selfEmphasis on patient self--carecare

    EmpowermentEmpowerment / / patient educationpatient educationEducation on selfEducation on self--management of diabetes management of diabetes mellitus is important since more than 95% of mellitus is important since more than 95% of diabetes care is selfdiabetes care is self--care.care.

  • New Trends in DM New Trends in DM ManagmentManagment

    Emphasis on prevention:Emphasis on prevention:Prevention of diabetes Prevention of diabetes

    lifelife--style modifications in style modifications in prediabeticprediabetic statesstates

    Prevention of complications Prevention of complications early DM early DM DxDx; effective control of ; effective control of glycaemiaglycaemia, BP, etc., BP, etc.

    Prevention of severe Prevention of severe sequelaesequelae of DM complicationsof DM complicationsCxCx screening & screening & its managementits management

  • Diabetic ComplicationsDiabetic Complications

  • Diabetic ComplicationsDiabetic Complications

    It is a major public health problem in both It is a major public health problem in both developing and developed countries.developing and developed countries.

    Costs of treating diabetes and its complications Costs of treating diabetes and its complications are high.are high.

  • Patient Recruitment

    Doctor / Nurse

    Background DM information collection

    Nurse

    Arrange blood test Nurse

    Measure BP, BMI,WHR

    HCA

    Foot assessment HCA/ Podiatrist

    VA

    Retinal phtotgraphyHCA / Nurse

    Retinal photo reviewed by Diabetologist

    NAD

    Abnormal

    Workflow of complication screening Workflow of complication screening

    Regular Cx

    screening

    ReferEye

    Clinic

  • Current Challenge for Management Current Challenge for Management of Chronic Diseaseof Chronic Disease

    Prevalence:Prevalence:10% population in 1995, > 700,000 today10% population in 1995, > 700,000 todayincrease with time and ageing populationincrease with time and ageing population

    More referrals with More referrals with

    public awareness:public awareness:50% undiagnosed, expect more referrals as 50% undiagnosed, expect more referrals as population become more health consciouspopulation become more health conscious

  • Current Status of Diabetes ClinicCurrent Status of Diabetes Clinic

    fulfill predefined criteria, but still long waiting time

    SOPDSOPDDMDM

    ClinicClinicNew DM patients

    Unplanned hospitalized

    inadequate information

    Develop complications

    ? early appt? continue to wait

  • PrePre--clinic Case Management Programclinic Case Management Program A NurseA Nurse--led clinicled clinic

    Visit 1 (45 Visit 1 (45 minsmins))

    Baseline assessmentBaseline assessmentBlood IxBlood IxInfection screeningInfection screeningComplication assessmentComplication assessmentFoot assessmentFoot assessmentDM EducationDM EducationDietiDietittian aian advicedviceFU planningFU planning

    New caseNew caseAdmissionAdmissionOther clinic FUOther clinic FU

    Visit 2 (30 Visit 2 (30 minsmins))

    Review Ix resultsReview Ix resultsAssess progressAssess progressModification of RxModification of RxFU planningFU planning

    New caseNew caseAdmissionAdmissionOther clinic FUOther clinic FU

    Visit 3 (30 Visit 3 (30 minsmins))Assess progressAssess progressModification of RxModification of RxFU planningFU planning

    New caseNew caseAdmissionAdmissionOther clinic FUOther clinic FU

  • Waiting Time for Waiting Time for PrePre--clinic Case Management Programclinic Case Management Program

    n = 104

  • Waiting Time for Waiting Time for DM Clinic First ConsultationDM Clinic First Consultation

    n = 300

    > 6 months69%

  • ConclusionsConclusions

    PrePre--clinic Case Management Program is:clinic Case Management Program is:a triage program with incorporated risk a triage program with incorporated risk stratification, ensuring high risk patients have stratification, ensuring high risk patients have timely access to specialist caretimely access to specialist carea form of implicit rationing for the limited a form of implicit rationing for the limited resources, in preparation for the expected resources, in preparation for the expected increase in service needincrease in service needable to minimize the risk of deterioration in able to minimize the risk of deterioration in condition while awaiting appointmentcondition while awaiting appointment

  • Thank YouThank You

    Process of Disease ManagementonDiabetes MellitusDiabetes MellitusNew Trends in DM ManagmentSubjects at Increased Risk of DMNew Trends in DM ManagmentCurrent Treatment TargetsAction of commonly used oral anti-diabetic agentsSlide Number 8New Trends in DM ManagmentNew Trends in DM ManagmentDiabetic ComplicationsDiabetic ComplicationsWorkflow of complication screening Slide Number 14Current Challenge for Management of Chronic DiseaseCurrent Status of Diabetes ClinicPre-clinic Case Management ProgramA Nurse-led clinicWaiting Time for Pre-clinic Case Management ProgramWaiting Time for DM Clinic First ConsultationConclusionsThank You