Diabetes mellitus care in Malta The role of the family doctor Jean K Soler
Diabetes mellitus care in Malta The role of the family doctor Aims and objectives of care
Aims of diabetes care Avoiding complications Reducing impact of the disease/risk factor Patient quality of life
Objectives Manage weight Manage high blood pressure Manage risk due to lipids +/- manage blood sugar levels
Appropriate interventions? “For almost 40 years, there has been evidence that intensive lowering of glucose levels in patients with type 2 diabetes mellitus (DM) can lead to significant harm and has limited benefits. In contrast to the effects of lowering blood glucose level, RCTs of reducing either BP or blood cholesterol levels have found major reductions in both macrovascular and microvascular disease.” Havas, S. Arch Intern Med 2009; 169 (2): 150-4 “ Blood pressure below 130/80 mm Hg was not associated with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease. Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for poor outcomes.” Vamos et al; BMJ 2012;345:e5567
Appropriate interventions? Diabetes management in primary care, outpatient and community settings can be improved by interventions targeting health professionals, and organisational interventions that increase continuity of care Renders, CM, Valk, GD, Griffin, SJ, Wagner, E, van Eijk, JThM andAssendelft, WJJ. Cochrane Collaboration; 21 January 2009. The review found that multifaceted professional interventions (for example combinations of postgraduate education, reminders, audit and feedback, local consensus processes, and peer review) could enhance the performance of care providers. Organisational interventions that increased structured recall, such as central computerised tracking systems or nurses who regularly contacted patients, could also lead to improved care for patients with diabetes. The effectiveness of these interventions on patient outcomes (glycaemic control, cardiovascular risk factors, wellbeing) is less clear.
Diabetes mellitus care in Malta The role of the family doctor Epidemiology
Epidemiology of DM in Malta Period 2001-2005 2001 2002 2003 2004 2005 New Diabetics 144 16 14 28 42 38 Active pts 27634 4258 5394 5759 5943 6246 Incidence 0.50% 0.40% 0.30% 0.50% 0.70% 0.60% Period 2001-2005 2001 2002 2003 2004 2005 Diabetics 559 126 142 161 218 215 Active pts 13736 4258 5394 5759 5943 6246 Prevalence 4.07% 2.96% 2.63% 2.80% 3.67% 3.44%
Epidemiology of DM in Malta Non-standardised incidence = 0.5% (95% C.I. 0.4% to 0.6%) Non-standardised prevalence = 4.1% (95% C.I. 3.8% to 4.4%) Standardised prevalence = 5.9% (Malta 2002)
Population based study of NIDDM Schranz described an incidence of 0.8% per annum in males and 0.65% per annum in females 15 years and older. Average 0.7% in the sample. Indirect standardisation to Malta 2002 = 0.57% Prevalence 7.7% in those aged 15 and older in the sample. Indirect standardisation to Malta 2002 = 6.24% Previously known 5.9%, new 1.8% (3:4 known) Schranz AG. 1989. A population based longitudinal study of the natural history of NIDDM and IGT in Malta. Diabetes Research and Clinical Practice, 7: 7-16.
eHID – GP EPR for research Diabetes Prevalence Adults 2005 non standardised 250 200 Belgium UK Bham 150 UK Nottm Rate per 1000 Netherlands France Spain 100 Italy Denmark Malta 50 0 15-24 25-44 45-64 65-74 75+ Age Groups
eHID – GP EPR for research Diabetes Prevalence 2005 standardised 70 60 50 Rate per 1000 40 M F 30 20 10 0 Belgium UK Bham UK Nottm Netherlands France Spain Italy Denmark Malta
Diabetes mellitus care in Malta The role of the family doctor Diagnosis
Diagnosis of DM in Maltese FM What is the contribution of patients’ reasons for encounter and doctors’ interventions to the diagnosis of new cases of diabetes mellitus? Maltese Transition Project 55,359 encounters 12,227 patients 2001 to 2004 450 episodes of care (398 [88%] type II, 52 [12%] type I), of which 100 (22.2%) new
121 RfE in 100 New Episodes of care of DM Code Label Total 1 *60 Result test/procedure 21 2 *34 Blood test 18 3 *62 Administrative procedure 12 4 *61 Result exam/test/lett oth provider 10 5 *64 Encounter/prob initiated by provider 9 6 *35 Urine test 8 7 U02 Urinary frequency/urgency 7 8 T90 Diabetes non-insulin dependent 5 9 T01 Excessive thirst 4 10 T08 Weight loss 4 11 *45 Observ/health educat/advice/diet 2 12 A91 Abnormal result investigation NOS 2 13 N17 Vertigo/dizziness 2 14 A98 Health maint/preventive medicine 2 15 D10 Vomiting 2 16 *31 Medical examin/health eval partial 1 17 P12 Bedwetting/enuresis 1 18 L17 Foot/toe symptom/complaint 1 19 A04 Weakness/tiredness general 1 20 *65 Enc/prob init by other than pt/prov 1 Total 121
Likelihood of a new episode of type II DM starting with selected RfE or history elements. Comparison of data from Malta and Dutch Transition Projects. Dutch data on RfE alone, excluding history, and use ICPC-1 where diabetes type I and II are included in T90. Reason for encounter LR+ (95% CI) LR- (95% CI) LR+ (95% CI) LR- (95% CI) Malta Malta Dutch Dutch (* significant) U02 (Urinary 6.55 0.95 2.99 0.98 frequency) (2.99-14.33)* (0.90-1.00) (1.96-4.57)* (0.97-0.99)* T90 (Diabetes type 797 0.95 543.58 0.86 II) (156.56- (0.90-0.99)* (392.09- (0.83-0.88)* 4057.38)* 753.61)* T01 (Excessive 136.63 0.97 107.26 0.85 thirst) (35.87- (0.93-1.00) (86.37-133.19)* (0.83-0.88)* 520.5)* T08 (Weight loss) 19.62 0.96 11.00 0.97 (7.29-52.77)* (0.92-1.00) (7.43-16.28)* (0.95-0.98)* A91 (Abnormal 49.05 0.98 7.83 1.00 result inv.) (11.22- (0.95-1.01) (2.49-24.57)* (0.99-1.00) 214.39)* A04 (Weakness/ 0.32 1.02 1.00 1.00 tiredness) (0.04-2.22) (1.00-1.05) (0.74-1.37) (0.98-1.02)
Diagnosis of DM in FM Patient suspects he/she has diabetes Excessive thirst Abnormal results of investigations Weight loss Urinary frequency Soler JK, Okkes IM. 2005. Diagnosis of diabetes mellitus in Malta. The contribution of patients’ reasons for encounter and doctors’ interventions to the final diagnosis of diabetes. Poster presentation. EGPRN meeting, Tartu, Estonia. www.egprn.org
Diagnosis of DM using HGT Protocol where capillary fasting plasma glucose tested during usual care in patients at risk Repeat another day if >6.0 mmol/L Test positive if second >= 7.0 or if first reading >= 7.0 and second reading > 6.0 Positive predictive value of 82% Klein Woolthius EP, de Grauw WJC, van Gerwen WHEM, et al. 2005. Portable blood glucose meters useful in stepwise screening for Type 2 diabetes in general practice. Poster presentation. EGPRN meeting, Tartu, Estonia. www.egprn.org
Diabetes mellitus care in Malta The role of the family doctor Strengthening the role of the family doctor
The evidence base for models of primary health care
The evidence base for models of primary health care
The evidence base of primary health care At least among western industrialised nations, a primary care orientation of a country’s health service system is associated with lower costs of care, higher satisfaction of the population with its health services, better health levels, and lower medication use. Starfield B. Is primary care essential? The Lancet 1994, 344: 1129-33 The strength of a country’s primary care system was negatively associated with: all-cause mortality, all-cause premature mortality, and cause specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease and heart disease. Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination and community orientation were associated with improved population health Macinko J., Starfield B and Shi L. 2003. The contribution of primary care systems to health outcomes within OECD countries, 1970- 1998. Health Services Research 38(3): 831-865 What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? WHO Regional Office for Europe’s Health Evidence Network (HEN) January 2004
Core elements of primary health care Starfield: Primary contact, continuity, comprehensiveness and coordination Starfield B. Is primary care essential? The Lancet 1994, 344: 1129-33 EURACT: primary care management, specific problem-solving skills, community orientation, comprehensive approach, holistic approach, patient centeredness. Heyrman J, editor. EURACT educational agenda. EURACT;2005.
Features of a good primary health care system Patient registration First contact Longitudinality Electronic patient records Longitudinality Coordination Access to special investigations Comprehensiveness Integrated national health care systems First contact Longitudinality Comprehensiveness Coordination
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