models of diabetes care in phc dr nabil sulaiman the university of sharjah the university melbourne l.
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Models of Diabetes Care in PHC Dr Nabil Sulaiman The University of Sharjah The University Melbourne. This Presentation . Trends in diabetes Lifestyle interventions- evidence Models of interventions in PHC: Diabetes Nurse Educator (DNE) COACH model Chronic Disease Self management.

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models of diabetes care in phc dr nabil sulaiman the university of sharjah the university melbourne

Models of Diabetes Care in PHCDr Nabil SulaimanThe University of SharjahTheUniversityMelbourne

this presentation
This Presentation
  • Trends in diabetes
  • Lifestyle interventions- evidence
  • Models of interventions in PHC:
    • Diabetes Nurse Educator (DNE)
    • COACH model
    • Chronic Disease Self management
diabetes in uae
Diabetes in UAE
  • High 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
environmental and behavioral changes
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.
evidence
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)

lifestyle changes
Lifestyle Changes
  • However, 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
in primary health care
In Primary Health Care
  • In 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.
diabetes nurse educator
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
diabetes coach program
Diabetes Coach Program
  • Tested 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
chronic disease self management
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”
chronic disease self management cdsm stanford university
Chronic Disease Self Management(CDSM) Stanford University

Kate LorigDirector of the Stanford Patient Education Research Center

slide13

Stanford CDSM Program

  • 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 program
Stanford Program
  • 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.
one step ahead
One Step Ahead
  • Seminars for people with pre diabetes
  • Evidence of reduction of 0.5% HbA1C
patient empowerment through cdsm
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 care
  • The patient becomes a better self advocate/agent, more able to get from the health system what they need in particular.
uptake of lifestyle
Uptake of lifestyle

However, 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

slide18

Projected prevalence of diabetes in 2025

Number of people

< 5,000

5,000–74,000

75,000–349,000

350,000–1,500,000

> 1,500,000

No data available

Total cases = 300 million adults

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

the increasing global prevalence of diabetes
The increasing global prevalence of diabetes

Patients (millions)

250

200

150

Type 1

Type 2

100

50

1994

2000

2010

Year

Estimates from

McCarty and Zimmet, 1994

projected growth of type 2 diabetes by region
Projected growth of Type 2 diabetes by region

120

120

100

100

80

80

60

60

40

40

20

20

0

0

Asia

Asia

Africa

Africa

Europe

Europe

Oceania

Oceania

Latin America

North America

North America

Latin America

1997

2010

Type 2 diabetes prevalence (millions)

Amos et al. 1997

lifestyle modification
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.

type 2 diabetes in different populations
Type 2 diabetes in different populations

Lowest rates

Highest rates

(Rural India)

Asian Indian

(Fijian Indian)

(Rural Kiribati)

Micronesian

(Urban Kiribati)

(Rural Tunisia)

Arab

(Oman & UAE)

(Central Mexico)

Hispanic

(US Mexican)

(Rural China)

Chinese

(Mauritian Chinese)

(Rural W. Samoa)

Polynesian

(Urban W. Samoa)

(Rural Tanzania)

African

(US Afr. Amer.)

(Poland)

European

(Laurino, Italy)

(Rural Fiji)

Melanesian

(Urban Fiji)

0

5

10

15

20

25

Prevalence of Type 2 diabetes (%)

Amos et al. 1997

diabetes australia facts 2008

Diabetes Australia Facts 2008

T2DM in CALD populations:

Prevalence of diabetes

Prevalence of risk factors

Complications

Hospitalisations due to non-treatable diabetes

Death rates due to diabetes

diabetes australia facts 200824

Diabetes Australia Facts 2008

Prevalence of diabetes is increasing over time

Reduces quality of life

Preventable via lifestyle modifications

Some population groups are at higher risk including CALD

meta analysis of 11 trials in cald

Meta-analysis of 11 trials in CALD

Improved HbA1c after culturally at 3M

Weight Mean Difference -0.3% at 3M and 0.6% at 6M

Knowledge scores improved at 3M

Healthy life style improvement at

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)

2 qualitative study
2.Qualitative Study

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

slide29
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:

Diabetes

Physical activity

High cholesterol

Unhealthy eating (poor diet)

Smoking

interventions31
Interventions

Case-finding/ screening for prediabetes and diabetes in PHC

Consultation 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.