Welcome

Diabetes Learning

Event

The Foundry

19th November 2015

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

Goodbye

New team members

Resources from today

www.lambethdiabetes.nhs.uk

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

Insulin Mentorship

Data Capture I

Data Capture II

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

LCCG_Diabetes Template 2015

Template Sections

Template Virtual Clinic

Template Care Planning

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

Diabetes and Pregnancy

Anna Brackenridge

Diabetes Consultant, Guy’s and St.

Thomas’

Format

• Introduction

– Pre-existing diabetes in pregnancy– Gestational diabetes

• 2 cases

• Discussion, questions, take home messages

Pre-existing diabetes in pregnancy

Risks of diabetes in pregnancy

Congenital malformations

Miscarriage

Fetal macrosomia

Birth trauma

Induction of labour and Caesarean Section

Stillbirth

Neonatal morbidity

Neonatal death

Relationship between HbA1c and

adverse outcome

Congenital malformation

Pregnancy in Women with Diabetes

CEMACH data 2002-2003

2767,

73%

1041,

27%

Type 1

Type 2

3808 pregnancies

1 in 260 births

National Pregnancy in Diabetes Audit

2013

http://www.hscic.gov.uk/npid

Blood glucose control in first trimester

T1DM 75% HbA1c > 53mmol/mol (7%)

T2DM 54% HbA1c > 53mmol/mol (7%)

Data from 2013 NPID audit

Folic acid supplementation

Early appointment with joint antenatal

diabetes team

Pregnancy outcome

Stillbirths 26/1606 equivalent to 16/1000

London stillbirth rate 2013 was 5/1000

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

HbA1c values for those receiving and not

receiving preconception care, GSTT data

2009

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

Cases

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

Introducing…..

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)

Documents available for

practices/clinics:

• Posters

• Leaflets

• EMIS flyer

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

Structured diabetes self-management

education:

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 Vs Distress

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

Demonstration

www.help-diabetes.org.uk