Authors (including presenting author) :
Ozaki R, Wong RYM, Lee KY, Chan WS, Loo KM
Affiliation :
Diabetes and Endocrine Centre, Prince of Wales Hospital
Introduction :
Diabetes is associated with disabling microvascular and macrovascular complications as well as reduction in life expectancy by an average of 10-12 years. Studies have shown that these complications are highly preventable if blood glucose, blood pressure and blood lipid profile are optimized using a multidisciplinary team approach. We are seeing a rising trend in the incidence of diabetes and if not well managed, this will result in heavy economic burden on our healthcare system. Local data have shown that about 57% of diabetic patients seen at General Medical Specialist Out-Patient Clinics (GM SOPC) are suboptimally controlled with glycated hemoglobin (HbA1c) >7%. In parallel, it is also observed that diabetic patients seen in GM SOPC Clinics are relatively less likely to have formal diabetes education or diabetes complication screening compared with their counterparts seen in the Diabetes Specialist Clinic.
Objectives :
This program aims to enhance diabetes service and education to suboptimally controlled diabetic patients during their follow up at GM SOPC with the support of diabetes nurse sitting in the general medical clinic to provide educational support to selected patients.
Methodology :
Prior to every GM SOPD Clinic, a list of diabetic patients whose diabetes control is suboptimal as defined by HbA1c >7% were identified. Arrangements were made for the diabetes nurse to sit in the GM SOPD to see those selected patients before their medical consultation. During the nurse consultation, the diabetes nurse conducted a structured assessment of the patient’s compliance to medication, dietary restriction and physical exercise, home blood glucose monitoring (HMBG), home blood pressure monitoring and knowledge on hypoglycaemia management. Patients were also invited to rate his/her self-perceived compliance to drugs, diet and exercise. The evaluated findings during the nurse consultation were then documented in the consultation summary of hospital clinical management system to enhance the medical consultation by physicians. At the end of the nurse consultation, a structured summary of the patient’s recent metabolic profile highlighting: HbA1c, lipids, renal function and blood pressure were given to the patient with the intention to empower the patient in self-care. After the evaluation, an additional DM Nurse Clinic follow up in-between GM SOPD was arranged if needed. Diabetic complication screening and further diabetic education would also be arranged by diabetes nurses according to clinical needs. Baseline data was collected on the day of recruitment (pre-treatment) and at the subsequent GM SOPD follow up date (post-treatment).
Result & Outcome :
A total of 105 patients were recruited into the program. 47.6% were male and 52.4% were female with mean age of 67 years. 64% patients have long disease duration of over 10 years and 61.5% have family history of diabetes. Half of the patients received at least secondary school education or above education. 25% of patients were working full or part-time and 75% patients were either retired, housewives or students. About 10.8% patients were smokers, 3.8% were drinkers. Most patients 58.1% were on oral anti-diabetic drugs (OAD) only, 30.5% patients were on both OAD and insulin, 7.6% on insulin while 3.8% on diet alone. Patients treated with ACE/ARB and statin were 60% and 71.4% respectively. The mean HbA1c at pre-treatment was 8.05% (±SD1.12). Subsequent to the intervention, there was a significant improvement in HbA1c to 7.6% (±SD1.03, p < 0.05). Upon review of patient adherence to medication, diet and performance of HMBG pre and post-intervention, there was a noted improvement in adherence (Medication: 78.1% versus 92.4%, Diet: 10.9% versus 27%, HMBG: 58.4% versus 73.3%, p< 0.05) With increasing incidence in diabetes, not all diabetic patients can be managed by Diabetes Team. The pilot program outlines a new care model to provide enhanced services to diabetic patients managed in GM SOPC with relatively less access to specialist evaluation. These results highlight how a structured patient empowerment outreach program run by diabetes nurses and supported by Endocrinologist may effectively alter a patient’s lifestyle patterns and self-care skills translating into improvement in glycaemic control.
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