Monitoring and organisation of diabetes care

As a chronic disease, diabetes needs chronic attention. A patient with diabetes is confronted with lifestyle choices, environmental changes, intercurrent disease and other factors affecting glucose control on a daily basis. The active involvement of the patient in his/her own treatment (patient empowerment) is therefore a key success factor. Diabetes care providers (hospitals, doctors, diabetes nurses etc.) should aim to identify the needs and abilities of the individual patient and adjust their services accordingly. Education, medication, therapeutic aids (e.g. glucose monitors, insulin pumps) and regular follow-up consultations should be available for all patients. At the societal level, these services should be structured in an efficacious and efficient way in order to optimally treat the large numbers of diabetes patients with limited resources.

The basic needs of the diabetes patient and the goals of treatment were broadly outlined in the St. Vincent declaration in 1989. The declaration put particular emphasis on the involvement of the patient and the establishment of high quality care as a means to reduce the long-term complications of diabetes. However, while structured care in itself has been shown to improve the quality of diabetes care, no single organisation model has emerged as superior.

Monitoring of glycaemia

Given the established close relationship between glycaemia and the occurrence of complications, the first step in assuring the adequacy of diabetes care over time is to monitor glycaemia. Apollinaire Bouchardat already advocated the regular measurement of urinary glucose in 1875, and urinary glucose measurement was part of standard treatment well into the 1970's. It was replaced by home blood glucose measurements as the principal tool for assessing glycaemia on a daily basis. It must be noted that due to the hourly fluctuations in glucose levels, a single glucose is a relatively poor reflection of average glucose control over time. However, glucose has a tendency to attach itself to proteins, and this is the basis for the measurement of HbA1c (a glycated fraction of hemoglobin) to assess average glycaemia over the preceding 6-8 week period. The measurement of fructosamine (glycated plasma proteins) is less commonly used and reflects average glycaemia over a 2-3 week period. Other measurements of glycaemia have been proposed but have not gained great popularity.

The diabetes team

As Elliot Joslin noted, "intensive education is needed by all diabetic patients ....It demands more time than the doctor can spare. Consequently he must utilize the services of others...to do the teaching". Joslin went on to suggest that one could recruit secretaries or family members to give diabetes education, but nowadays the diabetes nurse and nurse practioners working for GPs are fulfilling this role. They have a crucial role in the diabetes team because they are available to counsel patients on a daily basis, regarding all aspects of diabetes and diabetes therapy. In hospital settings, a dietician and a psychologist should be readily available. For specialized foot care, a podotherapist, a (vascular) surgeon, revalidation specialists and an orthopaedic shoemaker should be available as well. Finally, consultation should be available from specialists regarding the complications of diabetes (e.g. ophtalmologists, nephrologists, neurologists and cardiologists).

In-hospital glucose control and peri-operative care

While the diabetes team will function primarily in outpatient clinics, care should be taken to provide appropriate in-hospital diabetes care. Due to the increasing prevalence of diabetes, and the increased risk for hospitalisation of diabetes patients, about 1 in 5 hospitalised patients will have diabetes. During hospitalisation glycaemic control tends to worsen due to infection, inflammation or immobility. Uncontrolled hyperglycaemia is generally associated with worse outcomes. Thus, even though the benefits of tight glycaemic control are disputable, uncontrolled hyperglycaemia should be avoided. This will require daily consultation of a person specialized in diabetes treatment, such as an in-hospital diabetes nurse or an endocrinologist.

The yearly check-up

Most patients with diabetes will consult their caregivers several times per year to discuss topics such as their therapy and the glycaemic control and blood pressure attained. As a rule of thumb, a yearly check-up is mandatory to screen for the complications of diabetes, notably retinopathy, nefropathy and neuropathy. Less frequent screening may be suitable for very well controlled patients with few other (vascular) risk factors. In addition, in type 1 diabetes biannual screening for auto-immune thyroid disease may be considered. While all untreated patients should have their cholesterol levels checked regularly, the usefulness of repeated checking in (the majority of) patients that already use a maximal dose of statins can be disputed.

Information technology in diabetes care

Whether it is in the form of an electronic patient record that ensures that all care providers have up-to-date information, of email-consultation of doctors by patients or in the form of the modern glucose meters that allow patients to upload, analyze and visualize their data, information technology plays an important part in modern-day diabetes care. It is expected that in the future current standalone solutions will be integrated into a single system where patient and doctor share data on a single platform.

Quality assurance

In this era of evidence-based medicine, diabetes care-givers should try to assess and improve the quality of their treatment both on the individual and the patient population level.

The first step in this quality improvement process is proper (preferably electronic) documentation of patient data. These data can then be used cross-sectionally to identify patients in good or poor control, and longitudinally to assess changes in health and quality of care over time.

A second important step is to set treatment targets. On the individual level these are usally outcome-targets, such as HbA1c or the percentage of patients with retinopathy. On the population level, process-targets can be used as well, such as the percentage of patients that was screened for retinopathy in a given year. Recent international guidelines increasingly acknowledge the need to individualize these targets. For instance, the widely used target HbA1c of < 7% (53 mmol/mol) may be inappropriate in very old patients, or in patients with repeated severe hypoglycaemia.

The final step is to analyze whether patients achieve the goals set and to assess whether the therapy given has contributed to attaining these goals. More importantly, if patients fail to attain their targets, one should try to determine which factors contributed to this failure. Remarkably often the therapy will prove to be have been inappropriate or the patient will have misunderstood some aspect of the theraputic advice given. Of particular importance is the identification of structural flaws in treatment that affect groups of patients rather than individuals (for instance, failing to provide non-native speakers with appropriate translations of educational material).

Quality usally benefits from exchange and discussion with colleagues, and formal benchmarking -where caregivers compare their (group level) results- and intervision - where caregivers discuss individual treatment decisions, should be encouraged. However, when performing population level comparisons, care should be taken to adjust for differences in the case-mix of patients between practices; for instance a higher than averaged frequency of adverse cardiovascular outcomes in a population with a higher than average fraction of South-Asians may reflect the genetic background of the population rather than poor quality of care.

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