Diabetes Management in Primary Care - Case Study Example

The aim of this work is to discuss the importance of the primary care in diabetes management. As it is known, diabetes is usually divided into type 1 and type 2, which are different in their symptoms, causes and thus their management is also different. It is necessary to define the main principles of managing diabetes in primary care taking into account both physical and psychological needs of patients, with noting the most appropriate tools for diagnosis and assessment of the patients who suffer from diabetes. Diabetes management in primary care For people suffering from diabetes of both types, primary care appears to play the key role in management and meeting the challenges which the disease sets for them in their daily life. It is evident, that paying more attention to the way the management of diabetes is performed, may play for the benefit of the patient in the following ways: first of all, it may allow decreasing retinopathic blindness as one of the most widely spread consequences of diabetes; to twice decrease the number of diabetic gangrene amputations; to make pregnancy for women with diabetes possible and normal; to make the lives of patients with diabetes psychologically normal or close to normal. As diabetes is one of the most common diseases in the world, and is often hereditary, affecting people of all ages, social and other statuses, this chronic disease should acquire new approach in its primary care. Diabetes mellitus is caused by a deficiency of, or insensitivity to, the hormone insulin, resulting in an inability to control the use and storage of glucose - blood glucose levels therefore rise.  There are two main types of diabetes:   Type 1 diabetes, previously referred to as insulin-dependent diabetes mellitus (IDDM), which results from an absolute deficiency of insulin and more commonly presents acutely before the age of 30 Type 2 diabetes, previously referred to as non-insulin-dependent diabetes mellitus (NIDDM), which results from a relative deficiency of, or insensitivity to, insulin and is more commonly diagnosed over the age of 40. Although the onset of Type 2 diabetes is usually less dramatic than that of Type 1 diabetes, the long-term sequelae are similar and equally devastating. (Hillson, 1996) In managing diabetes, especially in its primary care stage, it is essential to remember about the meticulous metabolic control, which is one of the principal ways of preventing the possible complications of diabetes, or at least delaying them. It is, of course, understood, that the bigger portion of these complications may be prevented at the early stage in case they are detected in time and are managed in the proper way. The aims of the primary care in diabetes may be defined in the following way. The main aim of any care system in relation to diabetes, or any other chronic disease, is to provide people suffering from this disease with chances to live quality life as well as to reduce the complications. The keys to achieve these aims are in metabolic control, which should be performed on the constant basis with deep analysis of the received results, as well as the maintenance of the normal glucose level in blood to prevent the complications of diabetes. Any metabolic crises should be avoided. In managing diabetes through primary care, any specialist should be aware of the threats, which such addictions as smoking, alcohol, wrong diet and physical inactivity may bring to their patients, thus in this relation, careful management should also take place. However, even more important is involving patients into their own primary care, as the patient himself is the one playing crucial role in the process of management, thus it is very important to support such people not only physically, but psychologically, giving them enough motivation for that. Effective, ongoing education, matched to each patients ability and capacity to learn, can enable people with diabetes to take responsibility for their own health.  People with diabetes should also be empowered to obtain the maximum benefit from healthcare services so that, as far as possible, they are able to participate in activities open to those without diabetes (McKinnon, 1995) In diabetes primary care the first and one of the most important stages is identifying people with diabetes. According to the estimates, about 80 percent of those, who are diagnosed with diabetes, are able to be taught and to be managed within the limits of the primary care, though the potential patients with Diabetes Type 2 are really diagnosed, as they may live for years without any evident symptoms of the disease, that is why all specialists in all spheres of medicine must always be alert in relation to possible discovery of diabetes among their patients through other symptoms, which at first seem to have no connection with diabetes itself. In order to increase the effectiveness of the diabetes management in primary care it is necessary undertake the following steps: 1. It is necessary to check all pregnant women on the subject of diabetes; 2. People, who have at least one possible symptom of diabetes, should be carefully investigated for the possible confirmation of diagnosis; 3. Taking into account that the rates of diabetes among older people are higher than those among the younger, and that the rates of disease are higher among African, Caribbean and Asian races, with those who have hereditary cases in no relation to race or age, should be subjected to special control for discovering the correct diagnosis in time. New criteria for diagnosis and definition of diabetes of both types have been recently announced by the World Health Organization. According to the new definitions and criteria, the indices of glucose have been lowered to the 7.0 mmol/l, thus at present diabetes will be diagnosed at bigger amount of patients, though this will allow more through management and control of diabetes in primary care. These indices are used for the patients, who have no visual symptoms and the analysis should be repeated several times during several days. For the patients without any diabetes symptoms, the analysis and diagnosis is usually based on the glucose determination only. (Standards of clinical care for people with diabetes, 1994) It is important to note the changes in the blood and plasma glucose levels, and in the diabetes primary care patients usually have their blood glucose measured with the help of glucose meter. After the diagnosis has been confirmed and primary procedures and analyses have been performed, it is necessary to carry out the initial diagnosis assessment. It happens sometimes, that the patient under investigation may feel unwell and thus will need hospitalization, or insulin therapy. In diabetes primary care it is very important to provide initial discussion, which will include the discussion of the illness history, the inquiries and talks for defining the possible diabetes causes. The patient should be explained of what diabetes is and how it should be treated – any fears and anxieties of patients should be clarified. In this relation any specialist should also be aware of the patient’s life style, as at the moment diabetes is diagnosed the patient must stop smoking, etc. The patient may also be offered assistance through visiting the meetings of various organizations created by similar patients and for patients, where the person may receive any advice necessary. These organizations play major role in maintaining the appropriate psychological state of people suffering from diabetes, as getting to know the fact of illness makes many people shocked and needs time to accept this situation main stages of management here will include: ‘Initial dietary assessment and advice Referral to state registered dietitian Referral to specialist diabetes team, if indicated Referral to state registered podiatrist, ophthalmologist or other specialist, if necessary Discussion and agreement of initial management plan Discussion and agreement of individual management targets Next appointment - regular reviews will initially be required. (Farr & Watkinson, 1993) In diabetes primary care special attention should be paid to the education of people with this chronic disease, which is especially necessary for those, who are insulin-dependent, as injections are usually made every several hours. The general impact of the message about being ill with diabetes is sometimes underestimated, though it is a common mistake among specialists. Each patient should receive certain amount of education in relation to diabetes, and this education should be carried out with the account of possible cultural differences of patients, as well as their possible previous wrong beliefs and thoughts about the disease. Education in diabetes primary care should usually include several stages, as each aspect of the disease should be taken into account and be clarified to the patient. First of all, the patient must understand the nature of this chronic disease, its significance and the types of treatment available at present, the consequences and possible complications in case the disease is not properly managed, the importance of preventing these complications as well as the importance of annual control. In diabetes primary care there is also the notion of the daily management, as the patient must control the disease every day together with his doctor. First of all, it concerns ‘self-monitoring’ – that is, the level of glucose should be constantly controlled by the patient through the use of the glucose meter; second, the insulin dose should be regulated and adjusted to the patient individually; third, the patient should be taught careful foot hygiene. (Gatling, Hill & Kirby 1997) Diabetes is the disease, which may cause serious complications to the ill person out of sudden, even in the street. This is why the patient should be also given certain psychological directives and lifestyle directives, as in most cases diabetes is the disease with which this person will have to live the rest of his life. A person with diabetes should be taught and used to carrying any personal identification with him, with some kind of a warning card, which will include the name and contact details of the person who may be of help. People with diabetes should be especially careful of driving, and diabetes implications should be included into their life insurance and work insurance, etc. The same relates to the diet, which the diabetes patients should follow in their management and primary care. All patients are obliged to make certain changes in their diet, which may also sometimes make them feel uncomfortable in the society, that’s why psychological support is very important in managing diabetes. In routine and annual review for any patient, the primary care management must look as follows: 1. Glycemic control - dietary management - consider referral to state registered dietitian - treatment regimen - oral hypoglycemic or insulin. - understanding of the relationship between blood glucose, dietary intake and physical activity 2. Management of identified cardiovascular risk factors   3. Management of long-term complications  4. Individual management targets   5. Management plan for next twelve months - referral to state registered dietitian, state registered podiatrist, specialist diabetes clinic or other specialist, as indicated - contraception and plans for future pregnancies, where appropriate - future reviews. (Guidelines for the care of patients with diabetes, 1993) Thus, from all said above it is understood, that planning and carrying out the primary care in diabetes management is crucial for each patient, his life, his moral and psychological state, and for the prevention of the possible complications. Each doctor should be attentive towards possible disease symptoms, and should also be aware of the importance of giving each patient all the information necessary for his normal life in future with minimum daily references and reminders of the disease, however, the patient should always carry in his mind that he is not 100% healthy person and should follow strict instructions as for his life style and treatment. Conclusion There are the two key elements as for the effective diabetes management, one of which is in creating a planned program for every patient with the diagnosed diabetes, and another is in creating careful management plan, which will account the individual needs of the patient with all necessary elements of the successful treatment. Sometimes the third element is added to the previous two, and is presented by creation of the special lists (or registers) for making regular calls to patients easier. If the primary care management in diabetes is successfully created, it will lead to better achievements in the following areas: better and earlier identifications of diabetes patients; stabilization of the disease and constant control of physical indices and symptoms; better assessment of the new patients; more regular reviews of patients with diabetes; better management of complications (if they are present); earlier detection of long-term complications; constant quality assurance and control. Each diabetes management program in primary care should be subjected to audit; there should be chosen certain criteria and standards for judgment. This will ensure high quality of managing diabetes and the higher results in decreasing the amount of short and long-term complications. Despite the fact, that diabetes is rather serious disease, and should be managed in very thorough way, it should be admitted that in case it is properly addressed, the complications may be decreased to minimal level, while the patient will feel minimal changes in his lifestyle. The crucial thing here is that management should be carried out on the appropriate level, with accounting all major and minor factors of disease and individual, with creating individual management plan for each patient separately. References Department of Health, British medical Association and Royal College of General Practitioners. (1992). Better living, better life. Henley-on-Thames, Knowledge House. Farr, J. & Watkinson, M. (1993). Diabetes: a guide to patient management for practice nurses. 2nd edition. Oxford, Redcliffe Medical Press. Finucane, P. & Sinclair, A.J. editors. (1995). Diabetes in old age. Chichester, John Wiley and Sons, Ltd. Gatling, W., Hill, R.D. & Kirby, M. (1997). Shared care for diabetes. Iris Medical media. Guidance on local diabetes services advisory groups. (1995). London, BDA. Guidelines for the care of patients with diabetes. (1993). London, Royal College of General Practitioners. Hillson, R. (1996) Practical diabetes care. Oxford, Oxford Medical Publications. MacKinnon, M. (1995). Providing diabetes care in general practice: a practical guide for the primary care team. London, Class Publishing. Standards of clinical care for people with diabetes. Report of a clinical standards advisory group and the government response. (1994). London, HMSO. What diabetes care to expect. (2000). London, Diabetes UK. Read More