Models of Diabetes Care in PHC

Dr Nabil Sulaiman

The University of Sharjah

The University Melbourne

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This Presentation Trends in diabetesLifestyle interventions- evidenceModels of interventions in PHC:

Diabetes Nurse Educator (DNE)

COACH model Chronic Disease Self management

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Diabetes in UAEHigh prevalence in the Gulf Countries. In the UAE the prevalence is:

24% of adults

40% with diabetes and IGT

Diabetes is occurring in younger age

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Environmental and behavioral changes

New dietary habits (what and how we eat),

Lack of physical activity,

Overweight/ obesity, and

Stresses of urbanization and working condition will lead to further rise of CVD and diabetes, and their risk factors. Brought to you by

Evidence RCT in Finland and the USA have demonstrated that the incidence of diabetes can be reduced by about 57% by modifying:• Physical activity and • Diet

(Tuomilehto et al 2001, Knowler et al 2002)

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Lifestyle ChangesHowever, uptake of such lifestyle changes has been poor

Programs developed to enhance the uptake, such as:

Diabetes Nurse Educator Coach program Chronic Disease Self- management Others

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In Primary Health CareIn Australia, people with T2D have 80% of their care in General Practice

Diabetes requires the GP to practise biomedical, anticipatory and psychosocial care using evidence-based and patient-centred medicine and

Patient to engage actively in managing their illness.

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Diabetes Nurse Educator

Trained nurse

Engage, educate and empower patient to manage diabetes and impact of disease on patient and family

Based on trust and partnership between PHC centre- Diabetes nurse educator and patient

Patient determines agreed targets

Continuity and access Brought to you by

Diabetes Coach ProgramTested in Melbourne using RCTs for CVD

Trained nurse or dietitian to do COACH

Following diagnosis or after discharge from hospital

Education and empowerment

Patient determines agreed targets

Follow up consultation or phone calls

Showed benefit in several outcomes

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Chronic disease self management

Is an effective way in which patients are empowered to become more active and effective in managing their disease.Patient engages in “activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes” Brought to you by

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Chronic Disease Self Management

(CDSM) Stanford University

Kate LorigDirector of the Stanford Patient Education Research Center Brought to you by

Is a workshop where people with different chronic diseases attend

Teaches the skills needed in the day-to-day management of treatment and to maintain and/or increase life’s activities.

The Program has been adopted by NHS, the Diabetes Society of British Columbia in Canada, Kaiser Permanente, etc

It has been translated into Chinese, Vietnamese, Norwegian, and Italian. The patient book is available in Japanese

Stanford CDSM Program

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Small-group workshops,

Generally 6 weeks long,

Meeting once a week for about 2 hours,

Led by a pair of lay leaders with health problems of their own,

The meetings are highly interactive, focusing on building skills, sharing experiences and support.

Stanford Program

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One Step Ahead

Seminars for people with pre diabetes

Evidence of reduction of 0.5% HbA1C

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Patient empowerment through CDSM

Patient empowerment has a crucial role in the treatment of chronic disease:knowledge and skill development to understand and manage one’s condition and the confidence to use that training for better self care and greater compliance Feeling of control and skill development to achieve a more interactive relationship with health care professionals, with the capacity to demand good quality careThe patient becomes a better self advocate/agent, more able to get from the health system what they need in particular.

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Uptake of lifestyleHowever, uptake of such lifestyle changes has

been poor

Programs developed to enhance the uptake, such as:

Diabetes Nurse Educator Coach program Chronic Disease Self- management Others

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Number of people

< 5,0005,000–74,00075,000–349,000350,000–1,500,000> 1,500,000No data available

Total cases = 300 million adults

Projected prevalence of diabetes in 2025

Adapted from World Health Organization. The World Health Report: life in the 21st century, a vision for all. Geneva: WHO, 1998.

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The increasing global prevalence of diabetes

50

100

150

200

250

1994 2000 2010Year

Patients (millions)

Type 1

Type 2

McCarty and Zimmet, 1994

Estimates from Brought to you by

Projected growth of Type 2 diabetes by region

Amos et al. 1997

Typ

e 2

dia

bete

s p

revale

nce (

million

s)

Africa

Asia

North A

meric

a

Latin A

meric

a0

120

Europe

Oceania

100

80

60

40

20

0

120

100

80

60

40

20

Africa

Asia

North A

meric

a

Latin A

meric

a

Europe

Oceania

1997 2010

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Lifestyle modification

• Diet• Exercise• Weight loss• Smoking

cessation

If a 1% reduction in HbA1c is achieved, you could

expect a reduction in risk of:

• 21% for any diabetes-related endpoint

• 37% for microvascular complications

• 14% for myocardial infarction

However, compliance is poor and most patients will require oral pharmacotherapy within a few years of diagnosis

Stratton IM et al. BMJ 2000; 321: 405–412.

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Type 2 diabetes in different populations

Amos et al. 1997

Melanesian

European

African

Polynesian

0 5 10 15 20

Prevalence of Type 2 diabetes (%)

25

Chinese

Hispanic

Lowest rates

Highest rates

Arab

Micronesian

Asian Indian(Rural India)

(Fijian Indian)

(Rural Kiribati)(Urban Kiribati)

(Rural Tunisia)(Oman & UAE)

(Central Mexico)(US Mexican)

(Rural China)(Mauritian Chinese)

(Rural W. Samoa)(Urban W. Samoa)

(Rural Tanzania)(US Afr. Amer.)

(Poland)(Laurino, Italy)

(Rural Fiji)(Urban Fiji)

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Diabetes Australia Facts 2008

T2DM in CALD populations:

1. Prevalence of diabetes2. Prevalence of risk factors3. Complications 4. Hospitalisations due to non-

treatable diabetes5. Death rates due to diabetes

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Diabetes Australia Facts 2008

1. Prevalence of diabetes is increasing over time

2. Reduces quality of life

3. Preventable via lifestyle modifications

4. Some population groups are at higher risk including CALD

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Meta-analysis of 11 trials in CALD

1. Improved HbA1c after culturally at 3M 2. Weight Mean Difference -0.3% at 3M and

0.6% at 6M3. Knowledge scores improved at 3M4. Healthy life style improvement at 5. No difference in secondary outcomes:

lipid levels, qoL, self-efficacy, BP,

Hawthorne K, Robles Y, Cannings-John R, Edwards S. Culturally appropriate health education for type 2 diabetes in ethnic minority groups. Cochrane Database of Systematic Revies 2008 (3)

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What are the main reasons for not taking any actions to lower your risks?

PRE POST

Practices n % n % p-valueNo time to cook own meal

35 37.2 18 20 0.004*

Like to eat fast food

23 24.5 10 11.1 0.029*

Too busy to follow a routine

23 24.5 34 37.8 0.053**

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Time in minutes you spent walking for recreation/exercise in the last week (mean)

PRE POST n n p-

valueExercise 180 258 0.007*

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2. Qualitative Study

Qualitative focus groups to investigate feasibility and cultural appropriateness, barriers and facilitators of known interventions in Sharjah

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Aims The target setting is primary health care centers. People visiting all primary health care centers/ Hospitals in Sharjah will be targeted. Risk factors are:

DiabetesPhysical activityHigh cholesterolUnhealthy eating (poor diet)Smoking

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Interventions

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Interventions Case-finding/ screening for prediabetes and diabetes in PHCConsultation with doctors, nurses and patients to identify appropriate diabetes intervention Engaging people with diabetes/ pre-diabetes in CDSM programs and the COACH Family study to look at the genetic profile CME for doctors and nurses in EB diabetes management Training nurses to be diabetes nurse educators (DNE) to provide the interventions in PHC centres.

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