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Programme:
1pm Introduction
1.05pm CCG diabetes update Neel Basudev
Clinical Network Lead
1.30pm Pregnancy and pre-conception Anna Brackenridge
Consultant GSTT
2.30pm – 3pm Refreshments
3pm Renal disease and SGLT2 agents Janaka Karalliedde
Consultant GSTT
4pm HELP Diabetes Orla O’Donnell
Kingshuk Pal
4.30pm Close
Lambeth CCG Diabetes Learning
Events
Thursday 19th November 2015
Dr Neel Basudev
Lambeth CCG Diabetes Lead
Overview
• GP delivery Scheme update
• Diabetes Template and Virtual Clinics
• National Diabetes Audit data
• CCG update
GP Delivery Scheme
• What is it?
– Part of the 2015/16 GPD…Proactive Care –
Innovation and Integration…Long Term Conditions
(Part A 20% weighted payment)
• I still have no idea!
– http://nww.lambethccg.nhs.uk/Directorates/ICA/
MedicinesManagement/Pages/Medicines-
Optimisation-Prescribing-Resources.aspx
GP Delivery SchemeSnapshot
• Hold 2 Virtual Clinics– Please book with melanie.bahadur@nhs.net
• Identify patients with HbA1c 64 mmol/mol or greater prescribed sub-optimal medicines
– Use the searches
– 2 audit cycles and use the two VCs (proformas to complete)
• Produce a diabetes service development plan– System change? What can be done differently? Learning gaps? What if you got run over…how
do you disseminate information?
• Participate in the National Diabetes Audit– You all have for 2013/14 and for 2014/15!
• Continue CPD– Attend learning events
– INFORM course if not done recently
– Insulin Mentorship Programme
Data Capture III
Diabetes Virtual Clinic Action Log and Outcomes Summary
EMIS number Date of Last
HbA1c
HbA1c
value
Date of
last BPBP
Date of
last
cholesterol
cholesterolBMI and
date
eGFR and
date
ACR and
date
Agreed action plan with
healthcare professional in virtual
clinc
Details of agreed care plan with
patient
Date patient
seen and care
plan
implemented
Date of Last HbA1cHbA1c
value
Date of
last BPBP
Date of last
cholesterolcholesterol
BMI and
date
eGFR and
date
ACR and
date
Goals
achieved?
Comments/additional
actions
First virtual clinic Implementing actions from virtual clinic Review of outcomes at second virtual clinic
Practice Name:
Date of first virtual clinic:
Details of those attended (please bold): DSN Consultant GP Practice Nurse Other
Number of patients discussed at virtual clinic:
First virtual clinic - to discuss 20 patients
Date of second virtual clinic:
Details of those attended (please bold): DSN Consultant GP Practice Nurse Other
Number of patients discussed at virtual clinic:
Second virtual clinic - to review outcomes from first virtual clinic and review additional 20 patients
GPDOptimise Prescribing
Clinical Inertia What else do we know?
05
1015202530354045
CCG
Me
• Treatment stagnation
• Even when on treatment, can be suboptimal dosing
– Metformin 11%
– Gliclazide 25%
• Mean HbA1c for study was 10.2±1.7
• Mean duration of poor control prior to insulin initiation was 26 months
NDA DataVariability
• 8 care processes varies from – 16.8% to 90.6% (2013/14)
– 10% to 77.6% (2014/15)
• Achieving HbA1c <58mM/M varies from– 54.6% to 81.7% (2013/14)
– 51.7% to 81.5% (2014/15)
• Blood pressure (<140/80) varies from– 51% to 89.9% (2013/14)
– 50.6% to 92.2% (2014/15)
• Statin less so 71.6% to 89.7%....why is that?
CCG Update
• Darzi Fellow appointed
– Review structured education
• DXS being updated
– Referral pathways
– Useful reference information
• Your data and feedback is useful and has a
purpose! Please continue to collate and
submitTHANK YOU FOR YOUR CONTINUED SUPPORT AND EFFORTS
Format
• Introduction
– Pre-existing diabetes in pregnancy– Gestational diabetes
• 2 cases
• Discussion, questions, take home messages
Risks of diabetes in pregnancy
Congenital malformations
Miscarriage
Fetal macrosomia
Birth trauma
Induction of labour and Caesarean Section
Stillbirth
Neonatal morbidity
Neonatal death
Pregnancy in Women with Diabetes
CEMACH data 2002-2003
2767,
73%
1041,
27%
Type 1
Type 2
3808 pregnancies
1 in 260 births
Blood glucose control in first trimester
T1DM 75% HbA1c > 53mmol/mol (7%)
T2DM 54% HbA1c > 53mmol/mol (7%)
Data from 2013 NPID audit
Adverse pregnancy outcomes A comparison with the population of England,
Wales and N Ireland in 2003
26.8
31.8
9.35.7
8.5
3.6
0
5
10
15
20
25
30
35
Stillbirth rate* Perinatal death
rate*
Neonatal death
rate**
Diabetes General maternity
Maternal age-adjusted
*per 1000 total births **per 1000 live births
Prevalence of confirmed
major congenital anomalies 2002/3
Pregnancy in women with type 1
and type 2 diabetes in 2002-03
Women in general - EUROCAT
21 per 1000 births
Women with diabetes
41.8 per 1000 births
x 3.4 risk of neural tube defects
x 3.3 risk of congenital heart disease
Preconception care
• Glycaemic control
• BP control
• Medication review
– Diabetes medication
– Statin, ACE
• Complication screening
– Retinopathy, nephropathy
• Smoking, alcohol, weight
• Folic acid 5mg
Antenatal care
• Immediate referral to joint diabetes and antenatal clinic
• GSTT phone 0207 188 1981
• 1-2 weekly appointments• Diabetes team, Consultant Obstetrician, Midwife
• Extra scans• Fetal cardiac scan 20 weeks, growth scans 28, 32 and 36
weeks
• Offer induction of labour 38 weeks
Postnatal care
• Diabetes management
– If breastfeeding
• Reduction in insulin
• Metformin allowed by NICE
• Review BP medication (enalapril safe)
• Contraception
• Planning of future pregnancies
Gestational diabetes
• ‘Glucose intolerance that first occurs or is first identified during pregnancy’
• No consensus on screening or diagnosis
• GSTT and KCH have not implemented NICE guidelines
• Looking at how to do this currently
• Implications for whole model of care
GSTT vs. 2015 NICE
NICE GSTT
Previous GDM Early GTT Early GTT
Previous big baby, stillbirth GTT 24-28 weeks GTT 24-28 weeks
FH, high risk ethnicity, BMI
>30
GTT 24-28 weeks Random glucose 24 weeks,
GTT if > 6.7mmol/l
Diagnostic levels
Fasting glucose 5.6mmol/l 6.1mmol/l
2 hour glucose 7.8mmol/l 7.8mmol/l
Current management of GDM
• Women seen in nurse led or joint antenatal clinic
• All given dietary advice
• All taught blood glucose monitoring– Fasting < 5.5 mmol/l, post prandial < 7 mmol/l
• If BG above targets– Metformin
– Insulin
• Growth scans 32, 36 weeks
• IOL by 40 weeks– By 39 weeks if insulin treated or obstetric indication
Postnatal
• HbA1c at 3 months with GP
• High risk
– HbA1c and GTT at 3 months at GSTT
• Advised to self refer early in future
pregnancies
Summary
• Increased risk of pregnancy in diabetes
strongly associated with glycaemic control
• Importance of preconception care
Women with type 2 diabetes far less likely to
attend preconception services
Refer urgently all pregnant women with
diabetes
Summary
• Pregnancy screening for gestational diabetes
may unmask pre-existing diabetes
• Postnatally
– Screening for diabetes in those with GDM
– Contraception, discussion of planning future
pregnancies
Work Package A
Qualitative work with
patients with T2DM
Work Package C
Development of the
intervention
Work Package B
Qualitative work with
health professionals
Work Package D
Randomised Control Trial
Work Package E
Implementation study
Preparatory Work: Systematic review
Yea
rs 1
-2Ye
ars
3-5
Timeline
Background
Focussed on supported self careManagement of a long term condition:
Medical Management
•Taking medicines, working with professionals, adopting healthy behaviours
Emotional Management
• Guilt, anger, shame, stigma, despair, anxiety
Role Management
• Adapt to changes in social roles and relationships caused by chronic illness
Corbin and Strauss: Unending Work and Care. 1988
Orla O’Donnell (Project Manager)
Dr Kingshuk Pal (GP; Senior Clinical Research Associate; technical lead)
Rebecca Owen and Helen Gibson (Diabetes Specialist Nurses; Education leads)
Core team for roll out:
Who is HeLP-Diabetes for?
• Adults registered in Lambeth CCG with type 2
diabetes
• Health Professionals working with Lambeth
• Also offer carers logins
How do I refer to HeLP-Diabetes?
• Print out our ‘EMIS Flyer’ (already available)
• Patient contacts HeLP team for information/questions
• HeLP team register patient over the phone and explain the programme to them
• HeLP team monitor progression through the Structured Education pathway (and send emails/phone patients up)
5 years of reading summarised in 5
papers in 5 minutes
• Why people don’t attend DSME
• Reacting to fear arousal
• Depression Vs Distress
Reasons people give for not
attending DSME
• Don’t understand why it is
important
• Inconvenience
• Stigma
Characteristics of people not
attending
• Men
• Smokers
• Poor glycaemic control
• Registered with a practice not achieving glycaemic control targets
THREAT
(risks of
Diabetes)
EVALUATION
1. Susceptibility
(Does this apply to me?)
2. Severity
(Is this serious?)
IGNORE
Denial
High Self-efficacy
“I can and will do something
about this”
Accept message
Control danger
Low Self-efficacy
“I can’t do anything about this”
Scared
Defensive OR Anxious
Avoidance or Worry
NO
Depression
• Higher rates of diabetes in
patients who have
depression and high rates of
depression in people with
diabetes
• Mixed evidence linking
depression with poor
glycaemic control
• Treating depression does
not seem to improve
glycaemic control
Distress
“Significant negative emotional reactions to:
• the diagnosis of diabetes
• threat of complications
• self-management demands
• unresponsive providers
• and/or unsupportive interpersonal relationships”
Diabetes related distress
Depression
• Treating depression can
help improve some self-
management behaviours
Distress
• Cross-sectional and
prospective data correlate
high distress with worse
glycaemic control
• Reducing distress can
improve HbA1c
• It is presumed that reducing
distress increases
adherence
THREAT
(risks of
Diabetes)
EVALUATION
1. Susceptibility
(Does this apply to me?)
2. Severity
(Is this serious?)
IGNORE
Denial
High Self-efficacy
“I can and will do something
about this”
Accept message
Control danger
(Guilty)
Low Self-efficacy
“I can’t do anything about this”
Scared (Angry)
Defensive OR Anxious
Avoidance or Worry
(Ashamed)
NO
References
• Winkley K, Evwierhoma C, Amiel SA, Lempp HK, Ismail K, Forbes A. 2015a. Patient explanations
for non-attendance at structured diabetes education sessions for newly diagnosed Type 2
diabetes: a qualitative study. Diabetic Medicine 32(1):120-8.
• Winkley K, Stahl D, Chamley M, Stopford R, Boughdady M, Thomas S, Amiel SA, Forbes A, Ismail
K. 2015b. Low attendance at structured education for people with newly diagnosed type 2
diabetes: General practice characteristics and individual patient factors predict uptake. Patient
Education and Counseling.
• Witte, K. (1994). Fear control and danger control: A test of the extended parallel process model.
Communication Monographs, 61(2), 113-134.
• Lustman PJ, Anderson RJ, Freedland KE, de GM, Carney RM, Clouse RE. 2000. Depression and
poor glycemic control: a meta-analytic review of the literature. Diabetes Care 23(7):934-42.
• Aikens JE. 2012. Prospective Associations Between Emotional Distress and Poor Outcomes in
Type 2 Diabetes. Diabetes Care 35(12):2472-8
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