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Diabetes mellitus care in Malta The role of the family doctor Jean - - PowerPoint PPT Presentation
Diabetes mellitus care in Malta The role of the family doctor Jean - - PowerPoint PPT Presentation
Diabetes mellitus care in Malta The role of the family doctor Jean K Soler Diabetes mellitus care in Malta The role of the family doctor Aims and objectives of care Aims of diabetes care Avoiding complications Reducing impact of the
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Aims of diabetes care
Avoiding complications Reducing impact of the disease/risk factor Patient quality of life
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Objectives
Manage weight Manage high blood pressure Manage risk due to lipids +/- manage blood sugar levels
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Appropriate interventions?
“For almost 40 years, there has been evidence that intensive lowering of glucose levels in patients with type 2 diabetes mellitus (DM) can lead to significant harm and has limited benefits. In contrast to the effects of lowering blood glucose level, RCTs of reducing either BP or blood cholesterol levels have found major reductions in both macrovascular and microvascular disease.”
Havas, S. Arch Intern Med 2009; 169 (2): 150-4 “Blood pressure below 130/80 mm Hg was not associated
with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease. Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for poor outcomes.”
Vamos et al; BMJ 2012;345:e5567
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Appropriate interventions?
Diabetes management in primary care, outpatient and community settings can be improved by interventions targeting health professionals, and organisational interventions that increase continuity of care
Renders, CM, Valk, GD, Griffin, SJ, Wagner, E, van Eijk, JThM andAssendelft, WJJ. Cochrane Collaboration; 21 January 2009.
The review found that multifaceted professional interventions (for example combinations of postgraduate education, reminders, audit and feedback, local consensus processes, and peer review) could enhance the performance of care providers. Organisational interventions that increased structured recall, such as central computerised tracking systems or nurses who regularly contacted patients, could also lead to improved care for patients with diabetes. The effectiveness of these interventions on patient outcomes (glycaemic control, cardiovascular risk factors, wellbeing) is less clear.
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Diabetes mellitus care in Malta
The role of the family doctor Epidemiology
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Epidemiology of DM in Malta
Period 2001-2005 2001 2002 2003 2004 2005 New Diabetics
144 16 14 28 42 38
Active pts
27634 4258 5394 5759 5943 6246
Incidence
0.50%
0.40% 0.30% 0.50% 0.70% 0.60%
Period 2001-2005 2001 2002 2003 2004 2005 Diabetics
559 126 142 161 218 215
Active pts
13736 4258 5394 5759 5943 6246
Prevalence
4.07%
2.96% 2.63% 2.80% 3.67% 3.44%
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Epidemiology of DM in Malta
Non-standardised incidence
= 0.5% (95% C.I. 0.4% to 0.6%)
Non-standardised prevalence
= 4.1% (95% C.I. 3.8% to 4.4%)
Standardised prevalence
= 5.9% (Malta 2002)
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Population based study of NIDDM
Schranz described an incidence of 0.8% per
annum in males and 0.65% per annum in females 15 years and older. Average 0.7% in the sample. Indirect standardisation to Malta 2002 = 0.57%
Prevalence 7.7% in those aged 15 and older in
the sample. Indirect standardisation to Malta 2002 = 6.24%
Previously known 5.9%, new 1.8% (3:4 known)
Schranz AG. 1989. A population based longitudinal study of the natural history of NIDDM and IGT in
- Malta. Diabetes Research and Clinical Practice, 7: 7-16.
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eHID – GP EPR for research
Diabetes Prevalence Adults 2005
non standardised 50 100 150 200 250 15-24 25-44 45-64 65-74 75+ Age Groups Rate per 1000 Belgium UK Bham UK Nottm Netherlands France Spain Italy Denmark Malta
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eHID – GP EPR for research
Diabetes Prevalence 2005 standardised
10 20 30 40 50 60 70 Belgium UK Bham UK Nottm Netherlands France Spain Italy Denmark Malta Rate per 1000 M F
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Diabetes mellitus care in Malta
The role of the family doctor Diagnosis
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Diagnosis of DM in Maltese FM
What is the contribution of patients’
reasons for encounter and doctors’ interventions to the diagnosis of new cases of diabetes mellitus?
Maltese Transition Project
55,359 encounters 12,227 patients 2001 to 2004 450 episodes of care (398 [88%] type II, 52
[12%] type I), of which 100 (22.2%) new
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Code Label Total
1 *60 Result test/procedure 21 2 *34 Blood test 18 3 *62 Administrative procedure 12 4 *61 Result exam/test/lett oth provider 10 5 *64 Encounter/prob initiated by provider 9 6 *35 Urine test 8 7 U02 Urinary frequency/urgency 7 8 T90 Diabetes non-insulin dependent 5 9 T01 Excessive thirst 4 10 T08 Weight loss 4 11 *45 Observ/health educat/advice/diet 2 12 A91 Abnormal result investigation NOS 2 13 N17 Vertigo/dizziness 2 14 A98 Health maint/preventive medicine 2 15 D10 Vomiting 2 16 *31 Medical examin/health eval partial 1 17 P12 Bedwetting/enuresis 1 18 L17 Foot/toe symptom/complaint 1 19 A04 Weakness/tiredness general 1 20 *65 Enc/prob init by other than pt/prov 1 Total 121
121 RfE in 100 New Episodes of care of DM
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Likelihood of a new episode of type II DM starting with selected RfE or history elements. Comparison of data from Malta and Dutch Transition Projects. Dutch data on RfE alone, excluding history, and use ICPC-1 where diabetes type I and II are included in T90.
Reason for encounter LR+ (95% CI) Malta LR- (95% CI) Malta LR+ (95% CI) Dutch LR- (95% CI) Dutch (* significant) U02 (Urinary frequency) 6.55 0.95 2.99 0.98 (2.99-14.33)* (0.90-1.00) (1.96-4.57)* (0.97-0.99)* T90 (Diabetes type II) 797 0.95 543.58 0.86 (156.56- 4057.38)* (0.90-0.99)* (392.09- 753.61)* (0.83-0.88)* T01 (Excessive thirst) 136.63 0.97 107.26 0.85 (35.87- 520.5)* (0.93-1.00) (86.37-133.19)* (0.83-0.88)* T08 (Weight loss) 19.62 0.96 11.00 0.97 (7.29-52.77)* (0.92-1.00) (7.43-16.28)* (0.95-0.98)* A91 (Abnormal result inv.) 49.05 0.98 7.83 1.00 (11.22- 214.39)* (0.95-1.01) (2.49-24.57)* (0.99-1.00) A04 (Weakness/ tiredness) 0.32 1.02 1.00 1.00 (0.04-2.22) (1.00-1.05) (0.74-1.37) (0.98-1.02)
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Diagnosis of DM in FM
Patient suspects he/she has diabetes Excessive thirst Abnormal results of investigations Weight loss Urinary frequency
Soler JK, Okkes IM. 2005. Diagnosis of diabetes mellitus in Malta. The contribution of patients’ reasons for encounter and doctors’ interventions to the final diagnosis of diabetes. Poster presentation. EGPRN meeting, Tartu, Estonia. www.egprn.org
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Diagnosis of DM using HGT
Protocol where capillary fasting plasma
glucose tested during usual care in patients at risk
Repeat another day if >6.0 mmol/L Test positive if second >= 7.0 or if first
reading >= 7.0 and second reading > 6.0
Positive predictive value of 82%
Klein Woolthius EP, de Grauw WJC, van Gerwen WHEM, et al. 2005. Portable blood glucose meters useful in stepwise screening for Type 2 diabetes in general practice. Poster presentation. EGPRN meeting, Tartu, Estonia. www.egprn.org
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Diabetes mellitus care in Malta
The role of the family doctor Strengthening the role of the family doctor
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The evidence base for models of primary health care
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The evidence base for models of primary health care
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The evidence base of primary health care
At least among western industrialised nations, a primary care orientation of a country’s health service system is associated with lower costs of care, higher satisfaction of the population with its health services, better health levels, and lower medication use.
Starfield B. Is primary care essential? The Lancet 1994, 344: 1129-33
The strength of a country’s primary care system was negatively associated with:
all-cause mortality,
all-cause premature mortality, and
cause specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease and heart disease.
Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination and community orientation were associated with improved population health
Macinko J., Starfield B and Shi L. 2003. The contribution of primary care systems to health outcomes within OECD countries, 1970-
- 1998. Health Services Research 38(3): 831-865
What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? WHO Regional Office for Europe’s Health Evidence Network (HEN) January 2004
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Core elements of primary health care
Starfield: Primary contact, continuity,
comprehensiveness and coordination
Starfield B. Is primary care essential? The Lancet 1994, 344: 1129-33
EURACT: primary care management,
specific problem-solving skills, community orientation, comprehensive approach, holistic approach, patient centeredness.
Heyrman J, editor. EURACT educational agenda. EURACT;2005.
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Features of a good primary health care system
Patient registration
First contact Longitudinality
Electronic patient records
Longitudinality Coordination
Access to special investigations
Comprehensiveness
Integrated national health care systems
First contact Longitudinality Comprehensiveness Coordination
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Strengthening the role of the family doctor to achieve better outcomes
Allowing specialists in family
medicine to prescribe, modify and monitor treatment, and arrange specialist care when needed
Investigations (access to iSoft) Prescriptions and Schedule V Referrals (easy access to out-patient
appointments, fast-track urgent cases)
Patient registration with family doctor
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