Transcript Tim Walter - GP Jackie Winterbourne - Practice Nurse - Falkland Surgery

Tim Walter - GP
Jackie Winterbourne - Practice Nurse
- Falkland Surgery
Janet Grimes – Diabetes Educator/Specialist Nurse
– NHS Berkshire West
Agenda
 TW - Introduction to Diabetes at Falkland Surgery –
diagnosis, prevalence, risk factors
 JG - Education programmes after diagnosis etc.
 JW- Conversion from oral treatment to insulin
Tim Walter
Background
 Falkland Surgery population of 14,400
 Main demographic is of an average age split but higher
than average elderly population c.f. locally (75yrs+)
 Some pockets of deprivation
 High level of employment
Diagnosis Trends
 2000 = 194 patients registered with DM
 2005 = 306 patients registered
 2008 = 435 patients registered
 1.3% / 2.1% / 3.0% of population
 National prediction 3.6% in 2007 – still a way to go
Trends in detail
 2000 Type 1 DM = 44 Type 2 DM = 150
 2005 Type 1 DM = 56 Type 2 DM = 250
 2008 Type 1 DM = 66 Type 2 DM = 369
 Therefore the massive increase in DM is
predominantly in the Type 2 group
 NB Caveats, re recording etc
Why?
 Demographics
 Ageing population
 Trend nationally towards obesity
 Clinical
 Better detection
 Lower thresholds Fasting BS of 7.8 down to 7
Type 2 DM is associated with age, ethnicity, family
history, weight/obesity and sedentary lifestyle
Actions we are taking to
prevent epidemic
 Weight clinics
 Exercise referrals
 Earlier screening and detection
 Public education and involvement
Weight Clinic
 Currently piloting a weight clinic – Julie
 Weekly clinic with interventions, advice,
encouragement, medication if appropriate
 Part of the Greenham project
 However we need to audit results to prove its
effectiveness, September 08 and review
Exercise referrals
 Ongoing work done via Northcroft Centre with April
Peberdy for any patient with a need
 Exercise “on prescription”
 Something like 70% of “early detected raised BS/DM”
can be managed by diet and exercise (but it takes
effort)
Early Detection
 Computer system analyses and flags up patients with
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previously raised sugar levels. Work done in University of
Warwick, published in BMJ and we have been running this
for about 2 years
Random BSs over 11, fasting over 7 without codes to
indicate diagnosed already
Retest to assess risk
Looked at 12 patients with potentially missed DM, 9 were
subsequently confirmed
Ongoing process as new patients arise
Second group with random BS over 7
National Initiatives
 We need to see co-ordinated education and action
 Publicity on healthy living
 Labelling
 Role models
 Newspapers/Magazines/Advertising
 Prevention better than cure
 However this costs money now, but won’t show
results for many years
Further interventions
 We are starting people on medication earlier and more
aggressively – not only for the DM but also statins,
aspirin, antihypertensive medication
 Converting to Insulin earlier and more frequently (see
later) as patients with Type 2 live longer
Recent NICE guidelines - 1
 Patient education
 Offer structured education to every person and/or
their carer at and around the time of diagnosis, with
annual reinforcement and review. Inform people and
their carers that structured education is an integral
part of diabetes care.
Recent NICE Guidelines - 2
 Setting a target HbA1c
When setting a target HbA1c:
– involve the person in decisions about their individual HbA1c target level,
which may be above that of 6.5% set for people with type 2 diabetes in
general
– encourage the person to maintain their individual target unless the resulting
side effects (including hypoglycaemia) or their efforts to achieve this impair
their quality of life
– offer therapy (lifestyle and medication) to help achieve and maintain the
HbA1c target level
– inform a person with a higher HbA1c that any reduction in HbA1c towards
the agreed target is advantageous to future health
– avoid pursuing highly intensive management to levels of less than 6.5%.
Recent NICE Guidelines - 3
 Self-monitoring
Offer self-monitoring of plasma glucose to a person newly
diagnosed with type 2 diabetes only as an integral part of
his or her self-management education. Discuss its
purpose and agree how it should be interpreted and
acted upon.
Recent NICE guidelines - 4
 Starting insulin therapy
 When starting insulin therapy, use a structured programme employing
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active insulin dose titration that encompasses:
structured education
continuing telephone support
frequent self-monitoring
dose titration to target
dietary understanding
management of hypoglycaemia
management of acute changes in plasma glucose control
support from an appropriately trained and experienced healthcare
professional.
Conclusion
 Massive rise in Diabetes diagnosed through better
detection but unfortunately also through higher
incidence.
 Provision of lifestyle interventions (weight / diet /
exercise)
 Still a way to go but somehow we need to prevent
problems arising
 Please put us out of a job!