Managing diabetes in primary care in the caribbean
A Critical AppraisalAndre Sookdar - Class of 2013
Objective To critically appraise the Caribbean Health Research Council’s (CHRC) Guidelines on the Primary Care Management of Diabetes in the Caribbean
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.
Aim To produce a unified, evidence-based approach to the management of diabetes in the Caribbean.
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
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
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.
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)
Gestational DM Traditional 100g OGTT Rescreening at 24-28 weeks for at-risk patients
Education Goals Treatment options Nutritional management Physical activity Monitoring Medication use and compliance Preventing Chronic complications
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
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?
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?
ConclusionCHRC Guidelines for DM in Primary Care are simple, cost effective and focuses on primary prevention where ever possible