Dr Matthew Lockyer describes how his practice diabetes clinic uses a protocol drawn up with input from both primary and secondary care
Diabetes is becoming more common. Type 1 (previously called insulin-dependent) diabetes is increasing in prevalence for reasons that are not understood, while Type 2 (non-insulin-dependent) diabetes is increasing even faster, probably in parallel with obesity and the decline in exercise among the general population, both of which predispose to insulin resistance.
There are now 1.5 million people with diabetes in the UK.1 It has been estimated that this figure will double by 2010 because of increasing obesity and an ageing population.1 The resource problems resulting from the condition make it a priority for effective management.
Much more is now understood about diabetes management as a result of landmark studies over the last decade (see 'Linking evidence to practice'). The overall message is that attention to simple clinical checks and investigations coupled with the appropriate use of existing treatments greatly improve morbidity and mortality from diabetes.
The large number of simple checks and tests considered mandatory for good diabetes management make it an ideal condition to be seen in a clinic setting. This does not prevent the follow-up and management of individual problems in normal surgeries, but it does mean that follow-up and problem solving can be done on a secure base of routine checks.
Running a clinic should be viewed as formalising work that is already done in general practice, and not as a dumping ground for extra work.
Efficient case finding and management are not linked to the prescription of expensive new drugs, so that running a clinic will not cause a hike in the drug budget. However, it does require a dedicated practice nurse, who may need extra training. I hope many PCGs will find funds for clinic staff expenses as diabetes will be a part of many health improvement plans.
Our practice has run a successful diabetes clinic for the past 10 years. In this article we offer some details of how it runs and our experiences of it as one model of care.
After discussion with all the partners, it was decided that the clinic would be run by one GP and one practice nurse. A protocol for assessing the patients was agreed (see Figure 1, below).
|Figure 1: The practice protocol for assessing patients with diabetes in the diabetes clinic|
We then compiled a register of patients with diabetes by carrying out a search on repeat prescriptions and history entries, and by reporting cases noted opportunistically to the compiling doctor and nurse.
We also discussed our clinic with the local diabetologist and diabetes specialist nurse (DSN). This helped us refine our protocol and establish possible patterns for shared care. The GP attended the local ophthalmology clinic for refresher sessions on iabetic retinopathy.
By the time the clinic started we had identified about 130 patients with diabetes. We were reassured because this corresponded to about 2% of our list size, and diabetes affects around 3% of the population.1
We ran the clinic on one weekday evening surgery. The nurse saw only patients with diabetes in 30-minute appointments. The GP joined her for 10 minutes of the consultation and spent the remaining time seeing a routine surgery.
Initially the five or six slots provided enough annual review appointments for the GP to see each patient every year, even allowing for annual leave. As our list size has risen and our register has become more comprehensive, the number of patients with diabetes has risen above 200. We now run clinics even when the main doctor and nurse are on leave, to ensure that annual follow-up is maintained.
We share the care of most patients with Type 1 diabetes, alternating with the hospital clinic. Type 2 patients are often cared for in the practice unless there are specific problems. We consider it inappropriate to care for children under 16 years or pregnant women in the primary care clinic.
Patients are invited by letter to the diabetes clinic. A call/recall system is operated by the practice nurse.
Patients attend the practice or the local hospital one week before their clinic date and have a glycosylated haemoglobin (HbA1c) taken. The practice nurse may use her discretion to add electrolytes, urea and creatinine measurement to this if the patient has renal problems or is on ACE inhibitors. This means that the patient should be seen at the clinic with the HbA1c result to hand.
On the day of the clinic the patient is seen by the practice nurse. She has 20 minutes to carry out a protocol of history and examination.
If the patient is not under the care of the hospital eye department, tropicamide eye drops 0.5% are instilled after acuity has been measured. Patients are warned not to drive themselves, although the effect of tropicamide 0.5% drops on accommodation is said to be minimal.
History includes the patient's general health, smoking and alcohol status. Weight is measured and used as the basis for discussing diet. Treatment is checked and recorded, and home testing of blood or urine is reviewed. pecific events such as hypoglycaemic episodes are enquired after.
Examination includes height and weight for body mass index calculation, blood pressure, urinalysis including albumin:creatinine ratio, foot examination, assessment of pedal pulses, assessment for neuropathy, assessment of injection sites, and visual acuity.
Once these are done the GP is informed of this by a message to his computer screen, and comes to clinic as his next surgery appointment. He reviews history and findings with the nurse and patient. The nurse is able to highlight specific areas for futher history, examination or investigation. If appropriate the doctor carries out fundoscopy.
Further management and follow-up are then discussed, again involving the nurse as appropriate. One major advantage is prior knowledge of the HbA1c, which means that management can often be discussed in advance of the clinic. This allows the doctor and nurse to reinforce the same advice.
During the time of the clinic we have also concentrated on special areas for a particular year's recall. For example, we have checked the cholesterol levels of all diabetes patients. This year we are paying particular attention to lower blood pressure limits.
At first we kept a written record, but for the last 5 years we have recorded our findings on the practice computer. We also run a separate spreadsheet for maintaining the patient register and recording data for audit. Two hours a week administrative time is allocated to the practice nurse for this.
This enables us to supply our MAAG with high-grade data and provides us with ongoing audit on care. A small clinic such as this cannot audit outcomes – but we can see changes year on year in HbA1c levels in the different patient groups (diet control, oral hypoglycaemic agents, and insulin dependent), and audit our provision of checks. An early audit comparing clinic and pre-clinic care showed a greater than 50% improvement in recorded diabetic examinations.
Over the past decade we have become more efficient at HbA1c testing. We used to check a fingerprick glucose at clinic, but this is now considered redundant. Microalbuminuria screening has made routine dipsticking of urine of less value. Otherwise our clinic protocol has remained largely unaltered.
We have become much more confident about changing patients from tablets to insulin under practice care and adjusting insulin regimens.
One aspect of our clinic that could be improved is access to support specialties, especially chiropody and dietetics. As in many areas of the UK, these services are poorly represented in the community. We do refer patients to our community dietitian and I discuss cases in person with the chiropodist.
It is comparatively rare for diabetic emergencies to present in the clinic but some problems do warrant urgently referral. These include frequent or unexplained hypoglycaemia, rapidly deteriorating control with ill health, and newly presenting complications.
The most common complication to present is deterioration in cardiovascular status. Also common are newly presenting foot ulcers – these deteriorate fast and are often more advanced than may be supposed at diagnosis, so urgent referral with discussion with the hospital clinic is appropriate.
A less common but important foot emergency is the acute Charcot presentation. This presents as a painful foot with redness and swelling over the affected bones. It occurs when there is already a neuropathy but well preserved blood supply. Bed rest and bisphosphonates can help to preserve anatomy and foot function.
Finally, watch out for sudden falls in acuity which may indicate macular oedema. It is difficult to diagnose this condition with the ophthalmoscope. Any changes in retinal appearance are also a trigger for referral.
Our nurse has gained the diploma in diabetes care.This has led to much (reater sharing of management decisions. The GP involved has been a clinical assistant in diabetic medicine for 5 years. We also have a close relationship with the hospital consultant and DSNs, who have been very supportive.
Our attendance rate is good. Patients express satisfaction with the clinic and the hospital team are happy with the shared care arrangements.
When we started the clinic, several objections were raised. It was suggested that having one partner and nurse dedicated to diabetes would lead to a deskilling of the other clinicians. However, the reverse seems to be true in that the overall level of confidence in diabetes management has risen throughout the practice.
It was also suggested that patients would find fixed appointment times too restrictive. In fact, patients seem to like the dedicated time and continuity, and several patients with Type 1 diabetes whose care we would like to share with the hospital refuse to attend the hospital clinic.
We feel that we can recommend this clinic model as a successful approach to diabetic care in the community.
- Testing Times: a review of diabetes services in England and Wales. Abingdon, Oxon, Audit Commission Publications, 2000 (tel 0800 502030).