How to organize good diabetes care team. Sunitaya Chandraprasert, MD.

Transcription

1 How to organize good diabetes care team Sunitaya Chandraprasert, MD.

2 Scope Overview of DM Multidisplinary team

3 What is diabetes Metabolic disorder of multiple etiology Chronic hyperglycemia result from defect in insulin secretion, action or both Long term damage or dysfunction and failure of various organ

4 Type of diabetes Type 1 Type 2 Gestational diabetes Other specific types

5 Type 1 DM Auto immune process Idiopathic β-cell destruction Need insulin for survive More common in childhood and puberty

6 Type 2 DM Insulin resistance and insulin deficiency β-cell dysfunction Dramatic world wide increases in prevalence Aging population Increasing in young people

7 What is insulin resistance? Major defect in individuals with type 2 diabetes Reduced biological response to insulin Strong predictor of type 2 diabetes Closely associated with obesity

8 Insulin resistance reduced response to circulating insulin Insulin resistance IR Liver Muscle Adipose tissue Glucose output Glucose uptake Glucose uptake Hyperglycemia

9 What is β-cell dysfunction? Major defect in individuals with type 2 diabetes Reduced ability of β-cell to secrete insulin in response to hyperglycemia

10 Why does the β-cell fail? Oversecretion of insulin to compensate for insulin resistance 1,2 Glucotoxicity 2 Lipotoxicity 3 Chronic hyperglycemia Pancreas High circulating free fatty acids β-cell dysfunction 1 Boden G & Shulman GI. Eur J Clin Invest 2002; 32: Kaiser N, et al. J Pediatr Endocrinol Metab 2003; 16: Finegood DT & Topp B. Diabetes Obes Metab 2001; 3 (Suppl. 1):S20 S27.

11 Insulin resistance and β-cell dysfunction are core defects of type 2 diabetes Genetic susceptibility, obesity, Western lifestyle Insulin resistance IR β β-cell dysfunction Type 2 diabetes Rhodes CJ & White MF. Eur J Clin Invest 2002; 32 (Suppl. 3):3 13.

12 Sign and Symptoms of hyperglycemia Polyuria Polydipsia Nocturia Visual disturbance Fatigue Weight loss Inflection

13 Diabetes complications Acute : DKA, hyperglycemia, coma Chronic : Microvascular : Macrovascular

14 Type 2 diabetes is associated with serious complications Diabetic Retinopathy Leading cause of blindness in adults 1,2 Diabetic Nephropathy Leading cause of end-stage renal disease 3,4 Stroke 2- to 4-fold increase in cardiovascular mortality and stroke 5 Cardiovascular Disease 8/10 individuals with diabetes die from CV events 6 Diabetic Neuropathy Leading cause of non-traumatic lower extremity amputations 7,8 1 UK Prospective Diabetes Study Group. Diabetes Res 1990; 13: Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99 S The Hypertension in Diabetes Study Group. J Hypertens 1993; 11: Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94 S98. 5 Kannel WB, et al. Am Heart J 1990; 120: Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, Blackwell Sciences. 7 King s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78 S79.

15 Causes of Mortality in Patients With Diabetes in Thailand malignan neoplasms 14% diabetes 7% inflection 22% stroke 17% others 20% heart diseases 20% Thai Diabetes Registry 2006

16 Causes of Mortality in Patients With Diabetes Heart disease 55% other, 5% pneumonia/i nfluenza, 4% malignant neoplasms, 13% cerebovascula r disease, 10% diabetes, 13% Geiss LS, et al. In:Diabetes in America. 2 nd ed. NIH Publication No :

17 Management - Aims Correct symptoms of hyperglycemia Prevent or delay complication Improve quality of life

18 Holistic management of diabetes Glycemic goal Blood pressure goal Lipid goal Diabetes education and self care ACEI or ARB in selected cases Aspirin in selected cases Quit smoking Approach desirable body weight Annual screening of diabetes complications

19 Intensive Diabetes Therapy: Reduces incidence of complications DCCT Kumamoto UKPDS HbA 1c 9 7.2% 9 7% 8 7% Retinopathy 63% 69% 17% to 21% Nephropathy 54% 70% 24% to 33% Neuropathy 60% Improved - Cardiovascular Dis 41%(p=0.06) - 16%(p=0.052) Diabetes control and complication Trial (DCCT) Research Group. N.Engl J Med. 1993;329: Ohkubo Y et al. Diabetes Ros Clin Proct. 1995;28: UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1993;352:

20 Lowering HbA 1 C reduces the risk of complications 21% Deaths related to diabetes HbA 1c 37% 1% Microvascular complications 14% Myocardial infarction Stratton IM, et al. BMJ 2000; 321:

21 Diabetes management guidelines: HbA 1c CDA (Canada) 4 HbA 1c 7% APPG (Asia Pacific) 7 HbA 1c <6.5% NICE (UK) 5 HbA 1c % ADA (US) 1 HbA 1c < 7% IDF (Europe) 3 AACE (US) 2 HbA 1c 6.5% ALAD (Latin America) 6 HbA 1c <6 7% HbA 1c 6.5% Australia 8 HbA 1c 7% 1 American Diabetes Association. Diabetes Care 2004; 27 (Suppl. 1):S15 S34. 2 American Association of Clinical Endocrinologists. Endocr Pract 2002; 8 (Suppl. 1): European Diabetes Policy Group. Diabet Med 1999; 16: Canadian Diabetes Association. Can J Diabetes 2003; 27 (Suppl. 2):S1 S National Institute for Clinical Excellence Available at: 6 ALAD. Rev Asoc Lat Diab 2000; Suppl Asian-Pacific Policy Group. Practical Targets and Treatments (3rd Edition). 8 NSW Health Department

22 Majority of type 2 diabetes patients are not at HbA 1c goal 100 US 1 EU Subjects (%) % 64% Subjects (%) % 69% < 7% 7% 0 6.5% > 6.5% HbA 1c HbA 1c 1 Koro CE, et al. Diabetes Care 2004; 27: Liebl A. Diabetologia 2002; 45:S23 S28.

23 Barriers to achiving good glycemic control Patients - Misconception about diabetes - Lack of knowledge - Non adherance to therapy Health care team - Lack of experts in diabetes management

24 Multidisplinary team - Aims Increased patient understanding of diabetes Encorage patient education and self care Share responsibility for patient to manage their diabetes in achieve glycemic goal

25 Component of team member Core member A dded member - Patient - Podiatist - Educator - Nurse - Physical - Physician therapist - Nutritionist - Orthopedist - Pharmacist - Specialists

26 Teaching process Assessment Planning Implementation Evaluation

27 Accessment Prior knowledge Current health status Current self care practices Cultural and health beliefs

28 Accessment : Why? Encourage participation Save time Determine method and tools Establish trust Determine priorities Determine family role or other support Identify carriers to learning

29 Planning Develop together - What do you want to know? - What must you know? Offer choice -Individual - Classes Write objective together

30 Implementation Communication - Simple word - Encouragement - Positive feed back - Active listening - Repetition

31 Implementation Determine priorities Conductive environments Be specific Simple to complete Repeat

32 Evaluation Individual Group

33 Establish a partnership between patient and healthcare professional Establish rapport Exchange information Agree mutual agenda Work together to: Reduce resistance to change Discuss importance of implementing change Build confidence that change is possible

34 Motivating patients to achieve and maintain glycemic control I ve reached my glucose target by eating properly, exercising more and taking my tablets This is great news. Continue with the good work and keep your blood sugar under control you ll feel better for it! Heisler M, et al. Diabetes Care 2005; 28:

35 Use a patient-centered approach Healthcare professional Patient Active listening Negotiation Provides information (when required) INFORMATION EXCHANGE Active Expresses views In control Decision maker Muhlhauser I, et al. Diabet Med 2000; 17:

36 Initial consultation: where to start? What does type 2 diabetes mean: to you? to your family/friends? What are your fears/expectations? How will type 2 diabetes affect: your everyday life? your family? your job? your social life? What can we do about it together?

37 Subsequent consultations How are you? Have you been regularly monitoring sugar levels? You are not yet at goal how can I help? Discuss options and reach mutual decision Agree when and how to review options Apart from diabetes, what else is new?

38 Helping patients to accept their condition Diagnosis of type 2 diabetes = loss of patient s accustomed state of health Patient s willpower and ability to improve outcomes depend on degree of acceptance of the serious nature of their condition Relationship between healthcare professional and patient is critical in this process Lacroix A, et al. Schweiz Rundsch Med Prax 1993; 82:

39 Motivating and supporting patients to change their lifestyle Provide practical and realistic advice on implementing and sustaining lifestyle change Discuss steps that can be implemented now Where possible, involve other members of the diabetes care team, particularly family and friends

40 Impact of implementing an educational program via a multidisciplinary team VARIABLE TIME PERIOD AFTER ATTENDING EDUCATION COURSES 0 MONTHS 12 MONTHS FPG (mmol/l) * HbA 1c (%) * Body weight (kg) * Systolic BP (mmhg) * Diastolic BP (mmhg) * Cholesterol (mmol/l) * Triglycerides (mmol/l) * *Significant improvement versus 0 months Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:

41 Impact of a multidisciplinary team on glycemic control and hospital admissions HbA 1c Hospitalizations Change in HbA 1c from baseline (%) Control Multidisciplinary team Hospitalizations/1000 person-months Control Multidisciplinary team Sadur CN, et al. Diabetes Care 1999; 22:

42 A multidisciplinary team can reduce costs Annual cost of treatment Cost of pharmacotherapy/year (US$) 120, ,000 80,000 60,000 40,000 20, months 12 months -62% Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:

43 Other benefits of a multidisciplinary team approach to type 2 diabetes care Improved glycemic control 1,2 Improved quality of life 1 Increased patient follow-up 1 Higher patient satisfaction 1 Lower risk of complications 2 Decreased healthcare costs 2 1 Codispoti C, et al. J Okla State Med Assoc 2004; 97: Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:

44 Thank you. SUNITAYA CHANDRAPRASERT.