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Brent Diabetes Launch Day - Presentation
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Transcript of Brent Diabetes Launch Day - Presentation
Welcome to the Brent Intermediate Diabetes Care Services Launch
10th May 2006 Clay Oven , Wembley
Brent Diabetes Services
Dr. Senan Devendra MD MRCPConsultant in Endocrinology & Integrated Diabetes Care
Brent tPCT & Central Middlesex Hospital
The Team• Claire Lawler• Nina Patel, Julia Anthony & Lucy Ogida (DSN’s)• Sala Salih & Camelia Kirollos (Diabetes Edu. Network)• Salma Butt, Helen Davies & Farhat Hamid (dietetics)• Rakhee, Gaytree & E. Shillingford (podiatry)• Leena Sevak & Maggie McClelland (pathway
managers)• Rowland Hughes (DPAG chair)• Silvia Sedeghian & G.Vafidis(retinal screening)• Ricky Banarsee & Azeem Majid (Imperial - research)• Kirsten Darylmple (Imperial – education faculty)• JKC – too many to mention
www.brentpct.nhs.uk
Referral criteria to ECC
• Young adults with Type 1 diabetes (<35yrs)
• Poor glycaemic control despite on insulin (needing insulin pump)
• Hypoglycaemia unawareness
• eGFR < 30
• Foot ulcers requiring intensive management
• Women with diabetes who are pregnant
• Very obese who failed therapy
Higher tariff set in Payment by Results system for diabetes treatment
New figures issued by the Department of Health show that the tariff set for the treatment of people with diabetes under the payment by Results system has been increased. New tariffs for 2006/2007 are as follow Tariff 2005/06 New tariff 2006/2007New adult (i.e. adult receiving their first treatment) £152 £241 Follow up appointment (adult) £61 £88
Diabetes UK 2006
Diabetes SPA total referrals per locality (according to GP post code)
20.02.06 – 26.04.06 total = 207 x £241= £50,000
0
10
20
30
40
50
60
70
80
Wembley Kingsbury Harlesden Kilburn Willesden
total referrals
Brent Diabetes Services
• Clinical support: MDT approach
- Intermediate care clinics
- Email consultations
- Liaising with District Nurses/out of hours
- Up-skilling Primary Care colleagues
- Telephone support clinics for patients
Brent Diabetes Services
• Education: MDT approach
- patient education
- health care professional education
• Research & Audit
Photo Courtesy of Prof. G.Williams
Dean of Medicine, Univ. of Bristol
100 years of hormones
Expected Standard of Care& Microalbuminuria Pathway
Dr Encarna Fernandez
Diabetes GPWSI – Kilburn Locality
Weight Management in Diabetes Intermediate Care
By Helen Davies & Salma Butt
Specialist Diabetes Dietitians
The business case !
• Type 2 DM – overweight at diagnosis• Av. BMI = 28-29• Relationship with macrovascular disease• Weight loss associated with survival• Does weight need to be managed
“differently” in DM
Current services
• Diabetes education sessions
• MDT intermediate care clinics
• Fit for Life programme
• Obesity clinic at Central Middx
MDT intermediate care clinic
• Initial assessment
• Readiness to change
• Brent options
• Refer to pathway
(enclosed in conference pack)
Fit for Life
• 12 week weight management programme
• Nutrition education + exercise
• Group support
• Referral through Diabetes SPA
Obesity clinic at CMH
• Patients with complications/poor control + maximum oral therapy
• Failed at Intermediate care clinic
• Intensive weight management advice
• Long term support if necessary
• Bariatric surgery
New package of care for improving Glycaemic control
in primary care
Nina Patel
DSN Brent tPCT
AIM
• To provide focused intensive input to improve HbA1c with a clear supportive plan and exit strategy
Referral criteria
• Patient on maximum doses of oral hypoglycaemic
(see protocol for the use of oral hypoglycaemic agents*)
• HbA1c > 8 % (age < 75)
*www.brentpct.nhs.uk
Where will the patient be seen?
DSN clinic in own locality
• Kilburn Kilburn Square clinic
• Wembley WembleyWCHC
• Willesden Willesden CHC
• KingsburyChalkhill Health Centre
• Harlesden Monks Park CHC
First Review – Consultation 1
• Patient considered for education session• Medication review – address compliance• Dietetic assessment – weight management pathway• Assessment of motivation, health beliefs, readiness to
change• Set realistic goals• Obtain a contract with agreed roles of DSN and patient
(minimum 1.5% HbA1c reduction by 3 months) • Start Blood glucose monitoring• Insulin discussed or started
Consultation 2: (2 to 3 wks post visit 1)
• Assess blood glucose results• If not started, start insulin e.g. once daily long-
acting or twice daily mix. Insulin
(this can be done with practice nurse/ district nurse)
• Given algorithm to follow• Address weight gain issue with insulin
Titration of insulin doses over telephone with daily or weekly contact.
Consultation 3: (4 to 6 weeks post visit 1)
• Weight check/ WC
• Blood glucose control
• BP
• Injection sites
• Management of pen device.
• Hypo’s
• Consider prandial insulin
• Titration of insulin doses over telephone with daily or weekly contact.
• Also consider• Orlistat/Sibutramine• Weight management
clinic• Exercise classes• Patient support group• Expert patient course
Consultation 4: 3 month review
• Check HbA1c (1 week before appointment)
• Further titration of insulin
• Add pre-meal soluble insulin
• Check weight gain/WC & dietitian review
• Titration of insulin doses over telephone with daily or weekly contact.
Exit strategy
• Hba1c less than 7.5% (or desired goal achieved) return to the care of GP and Practice nurse.
• Maintain regular contact (telephone of link DSN or Diabetes SPA given)
• If HbA1c goal not achieved – consider other options (eg. restart package of care, JKC - insulin pump therapy, novel therapeutic agents)
Joint British Societies Guidelines 2 on prevention of Cardiovascular Disease in
Clinical Practice (JBS2):implications for Brent
Dr. Joan St John
Gpwsi Diabetes
Wembley Locality
Introduction
• How will the new guidelines affect the management of people with diabetes in Brent
• What are the workforce and cost implications
• What is the most effective way to implement the new guidelines ?
JBS – 2 2005
High risk patients • Established athero-sclerotic disease• 1ry prevention CVD risk >20%• DiabeticsALSO elevated risk due to a single risk factor
BP >160/ >100 (or less if target organ damage)
Elevated TC: HDL >6 or FH of hyperlipidaemia
JBS-2 targets for high risk patients
Total cholesterol <4 (25% reduction)
LDL-cholesterol <2 (30% reduction)
***P<0.001 vs Rosuvastatin 10mg; ^^^P<0.001 vs Rosuvastatin 20mg
LDL-C reduction & cost across statin dose ranges
0 -10 20 -30 -50 -60-5 -15 -25 -35 -45 -55
20mg
£22.64
40mg
£28.21
80mg
£24.07
-40
20mg
40mg
80mg
LDL-C: Mean change (%) from baseline at week 6
20mg
£2.34
40mg
£4.23
40mg‡ ‡
20mg
rosuvastatin
simvastatin
atorvastatin
10mg £18.03
10mg
10mg£ 18.03
10mg
pravastatin
p<0.002 vs. rosuvastatin 10mg ‡ p<0,002 vs, rosuvastatin 20mg p<0.002 vs. rosuvastatin 40mg
Next Steps
• What is the most effective way to implement the new guidelines ? In Primary care or Intermediary care
• Guidelines for Titration of Simvastatin or
• Trying to treat to target with one drug one visit
“Highest” Risk Group ( Diabetes + one of the following)
• Previous CV event• Peripheral Vascular disease• Family history of Premature (<60yrs) death from IHD• Renal Impairment (eGFR < 60)• Micro-albuminuric patients
Treatment Pathway for High Risk Group
CHOLESTEROL < 5.5 OR LDL < 3.8 CHOLESTEROL > 5.5 OR LDL >3.8 Start Simvastatin 20mg Start Atorvastatin 20mg (titrate to 80mg) to 40mg if needed to achieve target or Rosuvastatin 10mg od
Target:
T. Cholesterol = 4
LDL = 2
Law, BMJ 2003
Education
Diabetes Education Diabetes Education NetworkNetwork
Dr Camelia KirollosDr Camelia KirollosAssociate SpecialistAssociate Specialist
Central Middlesex HospitalCentral Middlesex Hospital
* Please refer to handout for details
Brent Diabetes Education Brent Diabetes Education NetworkNetwork
DSNs
Commun.Nurses
Dietician
Podiatry
CMH
Int Care
GPsWI
GPs
Brent PCT
Diabetes Education Diabetes Education NetworkNetwork
• Professionals’ EducationProfessionals’ Education
• Nurses: Practice nurses, District nurses, Twilight nurses, Residential homes, Nursing Homes
• Doctors: GPs, GPwSI, Hospital Doctors
• Health care Assistants
Diabetes Education Diabetes Education NetworkNetwork
• Patients’ EducationPatients’ EducationShort courses - 2 days
Long courses 6 weeks
Tailored Ethnic or Cultural courses
Eg. For Pakistani, Gujarati Communities
Attendants of diabetes patient education Attendants of diabetes patient education courses courses
between July 2004 and March 2006
Attendance of diabetes education courses between July 2004 and March 2006
Wembley30%
Kingsbury30%
Kilburn14%
Willesden20%
Harlesden6%
Total = 550
Patients’ self-management Patients’ self-management coursescourses
• DAFNE: For Type 1 Diabetes (since 2002)
Alternate Months at JKDC (CMH)
Available soon in intermediate care
• DESMOND: For newly diagnosed Type 2 Diabetes (NSF requirement)
DAFNE Improvement lastsDAFNE Improvement lasts
6
7
8
9
0
5
10
15
20
25
30
HbA
1c (
%)
Severe hyp
oglycemia
per 100 pt y
0 1 2 3 6Years of follow-up
Certificate in Diabetes Care: Certificate in Diabetes Care: Warwick CoursesWarwick Courses
• Warwick Diabetes care – Run twice a year: February and September
• Includes 4 units (Each is a whole day)• Understanding Diabetes• Therapeutic Options• Preventing & Managing Complications• Life Times
Consultant led seminars
• Insulin for life programme (Insulin initiation)
• MERIT (Insulin initiation)
• Consultant notes review service
(eg. HbA1c >7.5%)
Educational NeedsEducational Needs
• The network needs to extend and invite the front line workers:– Eg: Health care assistants– Twilight nurses– Pharmacist in the community and hospitals– Local initiatives for day release education.– Courses for Hospital staff.– Junior Doctors programmed trained.
Competency & Skills“A Mandatory Requirement ”
Ram Dhillon FRCSConsultant Surgeon, Northwick Park Hospital,
Harrow
Hon. Professor, Middlesex University, London
National Clinical Lead, Elective Care Team
(m): 07 958 450 544
(e): [email protected]
No Mans Land(Locus of Demand & Need for Capacity, Competency & Skills)
0%
50%
100%
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11
Practitioner
Pa
tie
nts
(F
CE
)
2nd Opinion
No Mans LandIntermediate Tier Level Care
Home to: (PwSIs) GPwSIs, NwSIs, AHPwSIs
What is Fundamentalfor
Acquisition of Competency & Skills
1. Knowledge & Skills2. Knowledge & Skills3. Knowledge & Skills4. Knowledge & Skills
Adequate Training & Accreditation
A Model for Competency/Skills Training & Accreditation in Respiratory Medicine for Primary
Care ( Dr Vincent Mak & Prof. Ram Dhillon)
• NB. Further details on Postgraduate Training for Special Interests : www.pgdip.com
Clinical activity * Local mentoring *
Directed learning *
SEM M1 M2 M3 SEMREGn + EX PGCert CPD
Clinical Case Studies *
Seminars #(lectures, practical skills)
OSCE #VIVAS #
Middlesex University, LondonRoyal College of General Practitioners (RCGP)
PwSIswith
Special Interests
( competent & skilled )Potential effects
• NSFs• Demand• Capacity• Access• Integrate 1*/2*
• Retention/Recruitment• Clinical Pathways• Clinical Governance• Community Care• Cost-Effective Care