Aim
description
Transcript of Aim
Achieving Good Glycemic Control:The importance of Self Monitoring Blood
Glucose
by:
Nina Hibbard, CRNP Student
Auburn University/ Auburn Montgomery Joint Program
Aim
Provide practical guidance on improving diabetes
care through highlighting the need to:
• Understanding of importance of SMBG
• Improve overall control of diabetes patients
• See the affects of SMBG on HA1C values
Definition and Description of the Problem
• Diabetes has been identified as one of the top 20 priority areas for national action according to the Institute of Medicine
• 25.8 million children and adults in the United States which is 8.3% of the population that have diabetes
• Self Monitoring Blood Glucose (SMBG) is a very simple way patients can control short and long term affects of diabetes complications
Diabetes: a global call to action
The numbers of diagnosed diabetes is growing stronger each year
0
50
100
150
200
250
300
350
1985 2000 2025
Year
Glo
bal
pre
vale
nce
of
dia
bet
es (
mill
ion
s)
30 million
150 million
333 million
http://www.idf.org/home/
DiabeticRetinopathy
Leading causeof blindnessin adults1,2
DiabeticNephropathy
Leading cause of end-stage renal disease3,4
CardiovascularDisease
Stroke
2- to 4-fold increase in cardiovascular mortality and stroke5
DiabeticNeuropathy
Leading cause ofnon-traumatic lower extremity amputations7,8
8/10 individuals with diabetes die from CV events6
Diabetes is associated with serious complications
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.
6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
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2.5
5.0
7.5
10.0
Ind
ivid
ual
s re
po
rtin
g
‘ext
rem
e p
rob
lem
s’ (
%)
Diabetes
General population
Mobility Self-care Usualactivities
Pain/discomfort
Anxiety/depression
*Significant versus general population
**
*
*
*
Individuals suffering ‘extreme problems’ in quality of life
Williams R, et al. The true costs of type 2 diabetes in the UK. Findings from T2ARDIS and CODE-2 UK, 2002.
Department of Health. Health Survey for England 1996. London: HMSO, 1997.
Indirect costs
Direct costs
Co
st p
er y
ear
(US
$ b
illio
n)
0
20
40
60
80
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120
19871 19922 19973
$98$92
$20
Estimated US costs Year
20024
$132140
Costs of diabetes are rising
1Huse DM, et al. JAMA 1989; 262:2708–2713. 2Javitt JC & Chiang Y-P. In Diabetes in America, 1995; 601–611. NIH Publication No. 95–1468.3American Diabetes Association. Diabetes Care 1998; 21:296–309. 4American Diabetes Association. Diabetes Care 2003; 26:917–932.
Antidiabetic drugs 7%
Hospitalizations55%
Other drugs 21%
Ambulatory care 18%
= €29 billion/year
Hospitalizations account for the majority of the costs of managing Diabetes
Jönsson B. Diabetologia 2002; 45 (Suppl.):S5–S12.
Microvascular complications
Myocardial infarction
HbA1c
37%
14%
Lowering HbA1c reduces the risk of complications
Deaths related to diabetes21%
1%
Stratton IM, et al. BMJ 2000; 321:405–412.
Two thirds of individuals do not achieve target HbA1c
Saydah SH, et al. JAMA 2004; 291:335–342.
Liebl A, et al. Diabetologia 2002; 45:S23–S28.
Barriers to achieving good glycemic control
Lack of clarity over definition of good glycemic control
Insufficient involvement of physician and team
Complexity of managing hyperglycemia relative to dyslipidemia and hypertension
Inadequate monitoring of glycemia
What is good glycemic control?
*Or fasting/preprandial plasma glucose < 110 mg/dL (6.0 mmol/L) where assessment of HbA1c is not possible
The Global Partnership recommends:
Aim for good glycemic control = HbA1c < 6.5%*
< 6.5%< 6.5%
Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.
Frequent monitoring of glycemia is important
• Cornerstone of diabetes care
• Ensures best possible glycemic control by:
– assessing efficacy of therapy– guiding adjustments in diabetes
care regimen, including diet, exercise and medications
Who should monitor glycemia?
PatientSelf-monitoring of blood glucose
Healthcare professionalsRegular monitoring of HbA1c
+
Diabetes care teamCombined synergistic efforts of
team are crucial to ensure effective monitoring of glycemic control
Self-monitoring of blood glucose (SMBG)
• Regular SMBG increases the proportion of individuals achieving their glycemic targets
• Individuals should monitor postprandial glucose as part of their SMBG schedule
• Regular discussion of results with diabetes care team is essential
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Not Monitored
(37%)
Regular SMBG
Performers (21%)
Irregular SMBG
Performers (42%)
HbA1c 8.0
HbA1c > 8.0
Blonde L, et al. Diabetes Care 2002; 25:245–246.
Physician input leads to better outcomes in type 2 diabetes
17% Individuals whom the physician was directly involved in proactive diabetes care had a substantially improved chance of survival
Verlato G, et al. Diabetes Care 1996; 19:211–213.
Implementation
PLAN: Present to two groups
Group 1- Physician Group
Group 2- Patient Group
By presenting to two separate groups, the goal of the presentation is to make both more aware of the importance of SMBG and using this daily process as a useful tool in helping control diabetes in the short and long term.
Design
• Physician Group- Current preceptor group of 4 doctors
*Powerpoint *Evidence Based Research articles *Demonstrate SMBG *Enforce focus of management of patient more
efficiently with this SMBG information
• *Handouts provided for SMBG importance
Design
• Patient Group- Group of diabetes patients identified at local retirement community.
• *Verbal explanation and demonstration of SMBG provided
• *Handouts provided for reinforcement
• *Question and answer session
Delivery of Project
Margaret Newman’s Theory of Health as Expand Consciousness
• central thesis of this theory is that health is the expansion of consciousness
• asserts that every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness” (Newman, 1992, p.60).
The Behavior and Skill of SMBG
Physician Group
•Physicians will begin with a survey of how often they tell their patients to check blood glucoses
•SMBG demonstration
•Insurance discussion
The Behavior and Skill of SMBG
Patient Group
•Review of handouts
•Discussion
•Demonstration
•Insurance discussion
Evaluation of Project
Physician Group:
Negative: *Do not have time to teach the patient *Too expensive for the patient * A1C test gives all information needed
After discussion:Positive: *Realize the ease of local resources and meter companies to provide training *Understood insurance coverage of strips *Recognized useful in controlling medication regimen more efficiently
Evaluation of Project
Patient Group: (31 Participants)
Negative: * All patients did not have their own SMBG meter * Need not recognized. “My doctor keeps up with my blood sugar when I see him every three months.” * No understanding of insurance coverage
Positive: *All patients end of session had a SMBG meter *Need recognized for daily monitoring and communicating to physician of blood sugar logs *Relieved to know of insurance coverage
Conclusion
The educational project for SMBG awareness has been enjoyable and close to my heart. I truly have a passion for diabetes because it is very controllable with the right tools, support and education provided. This project is but the tip of the iceberg, but of great importance. I hope to continue to spread the news regarding SMBG and diabetes education for many years to come.
Acknowledgements
Primary Care Internists of Montgomery, P.C.Dr. Raghu Mukkamala and partners1722 Pine Street, Suite 309Montgomery, Al 36106
Eastdale Estates Retirement Community1500 Eastdale CircleMontgomery, Al, 36117