1. DIABETIC CLINIC MANAGEMENT
DR. NORRALIZA BINTI MD. ZAIN,
KK KUALA SELANGOR
SERDANG HOSPITAL

2. CONTENTS : Introduction Objectives Team members and function
Basic principles
Activities
Record keeping
Quality improvements
Challenges

3. INTRODUCTION

4. UNTIL LATE 1990s…. Clear the crowd concept
“Continue the same – CST ” phenomenon
Quality care?

5. AUDIT/DATA Poor diabetic control Poor documentation
Increased complication
Escalating cost of treatment
Unsure of health education given

6. “Ticking Clock” Hypothesis
For
Microvascular complications
Macrovascular complications
The “clock starts ticking”
At onset of hyperglycemia
Before the diagnosis of hyperglycemia
"Ticking Clock" Hypothesis
It has been suggested that for microvascular complications of diabetes, such as renal disease and retinopathy, the clock starts ticking, or the period of increased risk for diabetic complications begins, at the onset of hyperglycemia. Therefore, to prevent microvascular complications, prevention of type 2 diabetes is not really necessary, just early and aggressive treatment of diagnosed diabetes. However, for macrovascular complications of type 2 diabetes, like stroke or myocardial infarction, the period of increased risk begins, or the clock starts ticking, even before the onset of hyperglycemia. Therefore, prevention of type 2 diabetes and aggressive treatment of cardiovascular risk factors may be more important to prevent macrovascular complications.
References:
Diabetes Drafting Group. Prevalence of small vessel and large vessel disease in diabetic patients from 14 centres: the World Health Organisation Multinational Study of Vascular Disease in Diabetics. Diabetologia 1985;28 (suppl):
Haffner SM, Stern MP, Hazuda HP, Mitchell BD, Patterson JK. Cardiovascular risk factors in confirmed prediabetic individuals. Does the clock for coronary heart disease start ticking before the onset of clinical diabetes? JAMA 1990;263:
WHO. Diabetologia 1985;28: ; Haffner SM et al. JAMA 1990;263:

7. Complications of Diabetes at diagnosis
Complications Prevalence (%)
Any complications 50
Retinopathy 21
Abnormal ECG 18
Absent foot pulses ( 2) and/or ischaemic feet 14
Impaired reflexes and/or decreased vibration sense 7
AMI/angina/claudication ~2-3
Stroke/transient ischaemic attack ~1
The UKPDS was a multicentre, prospective, randomised, intervention trial of 5100 newly-diagnosed patients with type 2 diabetes, which aimed to determine whether improved blood glucose control would prevent complications and reduce associated mortality and morbidity.
Newly-presenting patients with type 2 diabetes aged 25–65 years inclusive (median age 53 years), median BMI 28 kg/m2, and median FPG 11.3 mmol/l, were recruited and treated initially by diet. Those who remained hyperglycaemic (> 6 mmol/l) were randomly allocated either to diet policy, or to active policy with either insulin or sulphonylurea (metformin in obese patients), aiming to reduce the FPG to < 6 mmol/l.
The data show that approximately half the patients already had some evidence of diabetic tissue damage at diagnosis.
UKPDS VIII. Diabetologia 1991; 34: 877–90.
* Some patients had more than one complication at time of diagnosis
Adapted from UKPDS VIII. Diabetologia 1991; 34: 877–90.

8. Implication
Early death
Sudden death
Reduced quality of life
High cost

9. Medical costs of diabetes
Costs of treating diabetic complications in the USA
CVD
Neurological disease
Renal disease
Peripheral vascular disease
Ophthalmic disease
Others 1 2 3 4 5 6 7 8 9 10
Costs (US$ billion)
Diabetes-related complications account for a major part of healthcare budgets – in the USA alone they accounted for about US$100 billion in 1997.
Medical, behavioural, public health and policy changes that can delay the onset or slow the progression of diabetes have tremendous potential to mitigate the costs associated with the disease.
American Diabetes Association. Diabetes Care 1998; 21: 296–309.
$44.1 billion total healthcare spend attributable to diabetes in the USA1
Costs for a person in the USA with diabetes are more than three times those for someone without diabetes1
Costs are high around the globe: e.g. $1.2 billion in Australia, ~ $3000 for every person diagnosed with diabetes2
1ADA. Diabetes Care 1998; 21: 296–309. 2www.health.gov.au

10. To provide optimum care for diabetic patients
MAIN OBJECTIVE :
To provide optimum care for diabetic patients

11. SPECIFIC OBJECTIVES : Identify the high risk groups
Early detection through screening program
Provide appropriate treatment
Provide counseling / health education
Early detection of complication, appropriate treatment and delay complication
Referral to other disciplines if needed

12. THE TEAM Doctors : MO / FMS Paramedics : AMO / SN / CN
Pharmacists / Assistant pharmacists
Medical laboratory technologist (MLT)
Health attendants
Dietician / Nutritionist
Others : Podiatrist, Physiotherapist, Occupational therapist etc

13. PARAMEDICS (AMO/SN/CN)
Basic clinical assessment (able to detect abnormal result, when to give appointment)
Specific clinical assessment eg: foot examination, eye examination ( VA + fundus camera)
Order blood investigation following schedule (yearly HbA1c, 6/12ly lipid profile and renal profile)
Provide reliable data for “reten”

14. AMO – treat patient with normal parameters
Refer to MO/FMS if not controlled

15. MEDICAL OFFICER Initiate medical treatment (oral / insulin therapy)
Treat uncontrolled patient (blood sugar, blood pressure, lipid etc)
Refer to FMS if indicated
Lead the team (clinic without fms)
Quality improvement activities

16. FAMILY MEDICINE SPECIALIST
Initiate list A medication including insulin penfill
Treat patient with complications
Refer to specialist clinic in the hospital (further evaluation / management)
Treat patient with other illnesses / co-morbidities eg: depression, PTB
Refer back to MO/AMO once well controlled
Lead the team
Quality improvement activities

17. PARAMEDICS / MO / FMS
Counseling/health education on diet, exercise, foot care, anti-diabetic agents, disease complication
Insulin injection technique
Self monitoring of blood glucose (SMBG)
Counseling for poorly controlled blood sugar and poor compliance
Monitoring – screening of complication/co-morbidities, side effects of medication, defaulter tracing, update diabetic record

18. Health Attendant
Registration
Trace lab result and paste in the patient’s green book
MLT
Urine and blood test – urine albumin /microalbumin / 24 hr urine protein, FSL, RP, LFT, HbAIC.
Screening blood glucose
Ensure reliable result
Continuous service (adequate reagents)
Pharmacist
/ dispenser
Dispense medication
Counseling on medication (especially patient with multiple drugs therapy and poor compliance
Ensure adequate supply of medication

19. BASIC EQUIPMENTS Glucometer / lancet BP set Stethoscope
Weighing machine with height measurement
Snellen chart + pin hole
Opthalmoscope set
Mydriacyl eye drops
CNS diagnostic set (tendon hammer, cotton wool, pin, Tuning fork (128 mhz)
Stool for foot examination
Monofilament

20. Urine albumin strips
Microalbumin and strips
BMI chart
Chemistry analyzer
Computers
Fundus camera

21. THE BASIC PRINCIPLES : 7 basic parameters Prioritize the patients
Treat to target
Appropriate drugs
Continuing health education
Patient empowerment

22. MOST IMPORTANT Dedicated diabetic team Empowerment of paramedics
Adhered to Clinical Practice Guidelines (CPGs)

23. i) 7 BASIC PARAMETERS Blood glucose level (fasting/random/2HPP)
Weight, Body mass index (BMI), waist circumference
Blood pressure (BP)
Urine albumin / microalbumin
Biochemical investigations - FSL,RP + ECG
Foot examination
Eye examination

24. ii) PRIORITIZATION A - TYPE 1 DM B - DM + HPT + Albuminuria
C - DM + Albuminuria - HPT
D - DM + HPT- Albuminuria
E - DM – HPT - Albuminuria

25. PRIORITIZATION ACE inhibitor - B,C,D Blood investigations – all groups
Group A – D : given priority for eye examination, foot examination and blood investigations

26. PHASE SYSTEM PHASE 1 (MAIN TARGET) Registration BP measurement
Urine albumin
BMI measurement
PHASE 2(SECOND TARGET)
Foot examination (100%)
Blood investigations : FSL, RP (40%)
Eye examination (10%)

27. PHASE 3 : CONSOLIDATION ACE inhibitor for indicated patients
Blood investigations – all patients in category B,C,D
Eye examination – as many patients in category B,C,D

28. iii) TREAT TO TARGET FBS/Preprandial (mmol/l) < 6 (4.4 - 6.1)
RBS (2HPP)
< 8 ( 4.4 – 8.0)
HBA1C (%)
< 6.5
BP (mmHg)
130/80,
Nephropathy with albuminuria > 1gm/24 hrs: < 125/75
BMI (kg/m2)
Men < 23,
Women < 22
Waist
Circumference (cm)
Men < 90cm,
Women < 80cm

29. TREAT TO TARGET Urine Albumin negative Urine microalbuminuria
Serum creatinine
< 115 µmol/l
Total Cholestrol
< 4.5 (mmol/l)
HDL
> 1.1 (mmol/l)
LDL
< 2.6 (mmol/l) TG
< 1.5 (mmol/l)

30. TREAT TO TARGET Feet examination Tiada neuropathy Eye examination
Tiada retinopathy
Urine albumin: creatinine
250mg/mol - men, 350mg/mol - women
Exercise
150min/week

31. iv) APPROPRIATE TREATMENT

32. Anti-diabetic agents
ACE Inhibitors / ARBs
Statins / lipid lowering agents
Aspirin

33. Primary sites of action of oral anti-diabetic agents
Carbohydrate
-glucosidase inhibitors
Gut I
Sulfonylureas and
meglitinides
Glucose G I
Adipose tissue I G
Insulin G G I I G
Pancreas G
Different anti-diabetic agents target distinct sites as part of their primary mechanism of action in reducing hyperglycemia.
Sulfonylureas (e.g. glyburide) and meglitinides (e.g. repaglinide) stimulate insulin release from the pancreas.
Biguanides (e.g. metformin) mainly suppress hepatic glucose output.
-glucosidase inhibitors (e.g. acarbose) delay digestion and absorption of carbohydrates in the gastrointestinal tract.
Thiazolidinediones (e.g. rosiglitazone) decrease insulin resistance in adipose tissue, skeletal muscle and liver. In addition, these agents may have a beneficial effect on -cell function.
Kobayashi M. Diabetes Obes Metab 1999; 1 (Suppl 1):S32–S40. I G I
Thiazolidinediones G G I I G I G
Muscle G
Liver
Biguanides
Adapted from Kobayashi M. Diabetes Obes Metab 1999; 1 (Suppl 1):S32–S40.

34. ACE INHIBITORS First line to treat hypertension in diabetics
First line to treat diabetic nephropathy / or ARB if develop side effects with ACE Inhibitors
Eg : Captopril 25 mg, Perindopril 4 mg, Enalapril 5 / 10 mg, Ramipril 5 mg
Requires renal profile monitoring
Contraindicated in renal artery stenosis

35. STATINS/ LIPID LOWERING AGENTS
Depending on the level cholesterol in the blood
Base line LFT
Titrate until reached target level
May used double therapy
Look for side effects

36. v) CONTINUING EDUCATION

37. STAFFs EDUCATION Continuing medical education
Post basic course for paramedics – diabetic educator, diabetic clinic management
Diploma in DM

38. PATIENT’S EDUCATION About DM Treatment (non-p & pharmacological)
Target parameters
Complications
Include carer / family members

39. vi) PATIENT EMPOWERMENT
Self blood glucose monitoring
Dos adjustment - insulin

40. ACTIVITIES

41. SCREENING High risk groups Screening schedule
How to get reliable figures?
Availability of time?

42. REGISTRATION BILANGAN NOMBOR KAD PENGENALAN NAMA UMUR JANTINA BANGSA
ALAMAT
NOMBOR TELEFON
PEKERJAAN
DIAGNOSIS : DM &HPT
DM & PROTIENURIA
DM & HPT & PROTIENURIA
DM & OTHERS

43. TREATMENT - Non-pharmacological / pharmocological
- Exercise / physical activities
- Dietary intake
- Foot care
- Medications

44. DETECTION OF COMPLICATIONS
- Nephropathy
- Retinopathy
- Neuropathy
- Stroke
- Coronary Artery Disease
- Peripheral Vascular Disease
- Erectile Dysfunction

45. REHABILITATION
Physiotherapist – foot exercise / amputation / physical exercise
Dietician – dietary counseling, weight reduction, physical exercise
Ophthalmologist – treat eye complication
Nephrologist – treat kidney complication
Psychologist / psychiatrist – treat psychological problems
Other agencies – Social and Welfare Department / Pusat Zakat / NGOs – financial and social assistance

46. RECORD KEEPING

47. Diabetes record book for each patient
Diabetes registry (manual / electronic)
Appointment date for each patient
Defaulter tracing

48. QUALITY IMPROVEMENTS

49. QA Primer – Appropriate management of DM
Audit Clinical Diabetes
District Specific Approach (DSA)
Clinic Specific Approach

50. CHALLENGES

51. Inadequate staffing
Multitasking – ownership?
Increasing number of diabetic patient
Increasing number of patient with complications
Different level of skills/knowledge among the staff
Data – difficult to ensure reliability

52. TERIMA KASIH