advanced management of diabetes mellitus - … · diabetes mellitus • diabetes mellitus is a...
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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
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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
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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
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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
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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.
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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
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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
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* Check A1C every 3 months until
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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.
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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
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Diabetic ComplicationsDiabetic Complications
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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.
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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
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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
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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
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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
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Waiting Time for Waiting Time for PrePre--clinic Case Management Programclinic Case Management Program
n = 104
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Waiting Time for Waiting Time for DM Clinic First ConsultationDM Clinic First Consultation
n = 300
> 6 months69%
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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
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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