Managing diabetes in primary care in the caribbean

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Managing diabetes in primary care in the caribbean

  1. 1. A Critical AppraisalAndre Sookdar - Class of 2013
  2. 2. Objective To critically appraise the Caribbean Health Research Council’s (CHRC) Guidelines on the Primary Care Management of Diabetes in the Caribbean
  3. 3. Introduction Diabetes mellitus (DM) is one of the leading health problems in the Caribbean, contributing significantly to morbidity and mortality and adversely affecting both the quality and length of life. The disease also places a heavy economic burden on already limited health care resources in the Caribbean. Costs are related directly to treatment of the disease and its complications, and indirectly to loss of earning power in those affected.
  4. 4. Aim To produce a unified, evidence-based approach to the management of diabetes in the Caribbean.
  5. 5. Objectives To prevent or delay the onset of DM and co- morbid conditions of obesity, hypertension and dyslipidaemia To promote earlier diagnosis of DM To improve the quality of care of persons with DM To prevent and treat acute and long-term complications of DM To promote education and empowerment of the patient, family and community, and health care worker
  6. 6. Guidelines Definition – DM is defined by the World Health Organization as a metabolic disorder characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. Classification – Type 1, Type 2, Gestational Diabetes
  7. 7. Guidelines - Screening Fasting Plasma Glucose (FPG) is the Recommended Screening Test Testing the Urine Glucose is not recommended for screening. Blood Glucose Meters can be used for initial screening but not for diagnosis.
  8. 8. Guidelines - DiagnosisAmerican Diabetes Association Criteria was used in 2006 and in 2010 Fasting Plasma Glucose ≥126 mg/dL (≥7.0 mmol/L) (No caloric intake for at least 8 hours) 2 hour post-load glucose ≥200 mg/dL (≥11.1 mmol/L) during an OGTT In a patient with classic symptoms, a random plasma glucose ≥200 mg/dl (11.1 mmol/1) New diagnostic criteria include HbA1c (≥6.5%)(lab certified by a glycohemoglobin standardization program and standardized to the Diabetes Control and Complications Trial (DCCT) reference assay)
  9. 9. GuidelinesIncreased Risk for Future Diabetes: Impaired Fasting GlucoseFasting plasma glucose 100-125 mg/dl Impaired Glucose Tolerance2h plasma glucose 140-199 mg/dl Elevated HbA1c*HbA1c 5.7-6.4%
  10. 10. Guidelines - Effective Delivery ofCareEffective Delivery of Care Personnel – Multidisciplinary team Facilities Equipment and Supplies Information system – Data collection, storage, analysis
  11. 11. Effective Delivery of CareConsultation History Examination Lab tests Referrals Follow-up Annual reviews
  12. 12. Metabolic ControlInternational Diabetes FederationBlood glucose Preprandial 90-130 mg/dL Postprandial 180 mg/dLHbA1c <6.5%Total cholesterol <200 mg/dLHDL cholesterol >40 mg/dLLDL cholesterol <70 mg/dLFasting triglycerides <150 mg/dlBlood Pressure ≤130/80 mmHgBody Mass Index 18.5-25 kg/m2Waist Circumference - General: Women <80 cm (<32”) Men <94 cm (<37”)East Indians/Chinese: Women <80 cm (<32”) Men <90 cm (<35”)
  13. 13. Glycaemic ControlAmerican Diabetes Association 2010Step 1 – Lifestyle & MetforminStep 2 – Add Sulfonylurea; if HbA1c > 8.5% or symptomatic of hyperglycaemia, add Basal Insulin (Lantus, NPH)Step 3 – Lifestyle & Metformin & Intensive Insulin*Other classes may be considered in Step 2
  14. 14. Glycaemic ControlSelf Monitoring of Blood GlucoseHypoglycaemia – symptoms, self treatment
  15. 15. Complications Nephropathy – screening (albuminuria) Retinopathy – Ophthalmologist review Neuropathy Foot Care Cardiovascular Disease
  16. 16. Gestational DM Traditional 100g OGTT Rescreening at 24-28 weeks for at-risk patients
  17. 17. Education Goals Treatment options Nutritional management Physical activity Monitoring Medication use and compliance Preventing Chronic complications
  18. 18. AppraisalIs the guideline dealing with a POEM or DOE?Patient OrientedWho produced the guideline? What is their reason for producing the guideline?CHRC - AIMWho is on the guideline panel and how were they selected?Endocrinologists, Primary Care doctors, Nutritionists, Epidemiologist
  19. 19. AppraisalWas any conflict of interest of panel members addressed and appropriately managed?No duality of interest was identified (stated)Was the literature search transparent, rigorous and comprehensive, including all relevant data?
  20. 20. AppraisalWere all impacts of the intervention considered, including QOL and cost-effectiveness?Primary prevention and cost effectiveness were stated as keyHas the feasibility of implementation in a practice similar to yours been tested or considered?Would you consider implementing the guideline in your practice?
  21. 21. ConclusionCHRC Guidelines for DM in Primary Care are simple, cost effective and focuses on primary prevention where ever possible
  22. 22. The EndFeedback?Questions?
  23. 23. References http://www.chrc- caribbean.org/Guidelines.php http://www.chrc- caribbean.org/files/Pocket%20/Diabetes %20Guidelines%20- %20Pocket%20Edition.pdf

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