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Diabetes care in the community

It is estimated that there are approximately 190,000 people in Ireland with diabetes, with type 2 diabetes accounting for approximately 90 per cent of all cases.

The Institute of Public Health now predicts a 62 per cent (up from 37 per cent) increase in the number of people with diabetes by 2020. It also predicts that the prevalence of diabetes will increase to 5.9 per cent of the population in 2020.

The overall prevalence of type 2 diabetes among adults aged 50 years and over in Ireland is 8.5 per cent and is increasing in line with global trends, driven primarily by rising levels of obesity and ageing populations.

The true prevalence of type 2 is underestimated and many cases are undiagnosed because hyperglycaemia develops gradually and at earlier stages is often not severe enough for the patient to notice any of the classic symptoms of diabetes, notes the ICGP. Recent data shows 5.5 per cent of adults aged 50 years and over in Ireland have pre-diabetes, placing them at increased risk of developing type 2 diabetes in the future

The explosion in the prevalence type 2 diabetes in Ireland has led to the recognition that the adequate care of these patients requires a formal and more structured involvement of primary and secondary care sectors together.

National Integrated Model of Care  

Under a proposed National Integrated Model of Care patients with uncomplicated type 2 diabetes will be seen three times a year in primary care in a structured fashion. The visits will be every four months with an annual review occurring every 12 months. Patients who develop complications will
 be referred from primary to secondary or tertiary care for an expert specialist opinion and their care will become shared between primary and secondary or tertiary care. These patients will be seen at least once a year in secondary care for their annual review or more frequently according to the severity of the diabetes related complication and up to twice a year in primary care at four-monthly intervals. 

Earlier this year the ICGP launched A Practical Guide to Integrated Type 2 Diabetes Care, which outlines a new model of care for the disease in the community. Care of patients with uncomplicated type 2 diabetes will now be delivered locally for patients by GPs and practice nurses with support from clinical nurse specialists in diabetes, states the College.

Dr Velma Harkins, former HSE co-lead on diabetes and author of the guidelines, said: “Diabetes is a major chronic disease in Ireland alongside heart failure, coronary heart disease, asthma and depression. Chronic disease is forecast to affect up to 40 per cent of Irish adults by 2020. However, there has been an explosion in the prevalence of diabetes mellitus, predominantly type 2, which, between 2007 and 2020, is forecast to increase by up to 62 per cent….

“While, in the past, care of diabetes was unstructured and sometimes delivered in an opportunistic manner, the current reality is that as the population has aged, the majority of interactions are with people with chronic diseases who require a more pro-active model of care. General practice, which has continuity of care at its core, is uniquely placed to ensure the flexibility to deal with the diverse demands of people at different stages of their disease.”

Screening

The onset of type 2 diabetes is subtle and early detection in general practice requires clinical suspicion combined with systematic and opportunistic case-finding, as diagnosis is frequently delayed until complications appear, according to the ICGP guidelines. None of the major diabetes guidelines currently recommend general screening for type 2 diabetes, notes the ICGP document. Many, however,  recommend targeted screening in certain predefined groups while others recommend screening in those patients who have been risk assessed and subsequently identified at high risk.

The approach recommended by the ICGP is in line with American Diabetes Association (ADA) 2015 recommendations.

Early identification of patients and initiation of treatment can reduce the development of complications of diabetes and therefore testing for diabetes in asymptomatic patients with risk factors associated with the development of diabetes is recommended.

See Table 1 for testing criteria.

Criteria for testing for diabetes in asymptomatic adult individuals

1. Testing for diabetes should be considered in all adults who are overweight (BMI ≥ 25kg/m2) and who have one or more additional risk factors:

• Physical inactivity

• First-degree relative with diabetes

• Are hypertensive (≥140/90mmHg) or on therapy for hypertension

• Dyslipidaemia – HDL< 0.9 and/or triglycerides >2.82;

• Have established arterial disease (IHD, CVA, PVD);

• High-risk ethnicity (eg, African, Asian, Hispanic etc);

• Members of the Travelling community;

• Have delivered a baby weighing >4.1kgs or have a history of gestational diabetes mellitus (GDM);

• On previous testing had Impaired Glucose Tolerance (IGT) or impaired Fasting Glucose (IFG);

• Have other clinical conditions associated with insulin resistance (eg, polycystic ovary syndrome, acanthosis nigricans, long-term steroid use or severe obesity).

2. In the absence of the above additional risk factors, testing for diabetes should begin at age 45 years

3. If the results are normal, testing should be repeated at least at three-year intervals. Patients with IFG or IGT should be tested annually

(Adapted from the ADA Clinical Practice Recommendations 2015 Diabetes Care) Source: National Clinical Programme- Diabetes Working Group

Table 1

Diagnosis

In 2011 the World Health Organisation (WHO) approved HbA1c as a diagnostic test for diabetes and some international guidelines have updated to reflect this, the ICGP document notes. It states that to aid screening and early detection of diabetes the HbA1c can now also be used to diagnose diabetes.

“For diagnosis of type 2 diabetes probably the best combination of specificity and sensitivity is afforded by the first test being fasting blood glucose. If this is above 5.6mmol/L, the second test should be HbA1c or 75g Oral Glucose Tolerance Test (OGTT). This will allow for identification of impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes,” according to the ICGP guidelines.

The document points out that the following conditions will interfere with the HbA1c assay and exclude its use as a test to diagnose diabetes – plasma glucose criteria should be used instead to diagnose diabetes in the following conditions:

Haemoglobinopathies;

Sickle cell disease;

Haemolytic anaemia;

Recent blood transfusion;

Recent blood loss;

Iron deficiency anaemia.                See Table 2 for diagnosis criteria.

Criteria for diagnosis as per icgp guidelines (2016)

Diabetes is diagnosed using one of the following criteria:

Symptoms of diabetes plus random plasma glucose concentration > 11.1mmol/L.

Random is defined as any time of day without regard to time since last meal. 
The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

or

Fasting plasma glucose ≥ 7.0mmol/L.*
Fasting is defined as no caloric intake for at least eight hours.

or

Two-hr plasma glucose > 11.1 mmol/L during a 75g OGTT.

The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water.

or

A HbA1c ≥ 48mmol/mol (≥ 6.5%)* †
The test should be performed using a standardised assay.

*In the absence of unequivocal hyperglycaemia, the result should be confirmed by repeat testing on a different day. †A HbA1c value of < 6.5 per cent (IFCC < 48mmol/mol) does not exclude diabetes diagnosed using the other glucose tests.

Table 2

Diabetes care

For most people diagnosed with type 2 diabetes their condition is life-long and while new types of medication and medical devices are constantly being produced, the basic foundation for good diabetes care still focuses on healthy eating and physical activity, monitoring 
blood glucose levels and taking medication, according to the ICGP guidelines. “The management of type 2 diabetes involves behavioural change best achieved through integrated care and education. General practice is increasingly providing this service supported by current national policy.”

Integrated care

Three of the key components of a comprehensive diabetes service are patient registration, recall and regular review, say the ICGP guidelines. “Integrated care also includes allocation of protected time and adherence to a standard management protocol. An annual and comprehensive review is regarded as the crucial element of integrated diabetes care. Routine integrated care involves the patient, GP, practice nurse, diabetologist, clinical nurse specialist in diabetes, dietician, ophthalmologist and podiatrist. All patients with type 2 diabetes should have access to specialist services such as endocrinology, vascular, cardiology, nephrology and psychology as needed. Care provision begins with initial assessment and follows with regular review that includes a comprehensive annual review.”

In order to provide this level of care, protected time is required and this has funding implications for all levels of service (primary, secondary and tertiary care), acknowledges the document.

Patients with uncomplicated type 2 diabetes managed by primary care only

Uncomplicated patients with type 2 diabetes are defined by the ICGP guidelines as follows:

Type 2 diabetes patients not on insulin but on diet only or on two glucose lowering agents (not insulin) with a HbA1c (<58mmol/mol or <7.5 per cent) in patients with:

Low risk or moderate risk diabetic feet;

No active diabetic eye disease;

Controlled CV risk factors;

Normal hypoglycaemia awareness;

Patients with type 2 diabetes and satisfactory renal function defined as a serum creatinine <150umol/l or eGFR >60ml/min or albuminuria <70mmol/ml or PCR < 100mg/mmol;

No symptoms of autonomic neuropathy (with the exception of erectile dysfunction) If patients become complicated as defined below, then patients should be referred to 
secondary care diabetes service for a specialist opinion.

The ICGP document also classifies patients who need to be managed between both primary and secondary care, as well as patients who should be fully managed in secondary care.

For a full copy of the guidelines go to www.icgp.ie.

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