Scottish Diabetes Framework
Scottish Diabetes Framework
Scottish Diabetes Framework
Heart Disease
CSBS Standard 4 - Clinical Review
All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required and support for the modification of lifestyle risk factors.
CSBS Standard 6 - Clinical Management: Cardiovascular Status
All people with diabetes who have identified associated cardiovascular problems are managed according to locally agreed protocols and are considered for referral and additional treatment as clinically indicated.
54. Cardiovascular disease is between two and five times more common in people with diabetes and is the principal cause of death. People with diabetes have an increased incidence of angina, myocardial infarction (heart attack), heart failure, stroke and peripheral vascular disease (disease of arteries to the legs, which potentially leads to gangrene/amputation).
55. The classical cardiovascular risk factors of hypertension (high blood pressure), hyperlipidaemia (high levels of fat in the blood) and smoking are more common in people with diabetes. The greater the number of risk factors, the greater the risk of premature mortality. Modifying these risk factors and improving glycaemic control is likely to reduce the burden of cardiovascular disease. In particular, the traditional management of type 2 diabetes, which focuses on glycaemic control with a little emphasis on risk factor management is now inappropriate. Patients with diabetes should have aggressive risk factor management and attempts to achieve good glycaemic control. Treatment with beta-blockers, ACE-inhibitors, aspirin and statins are more likely to be effective therapies in people with diabetes, and are probably under prescribed.
56. The key issues for clinical management of cardiovascular disease are:
- Secondary Prevention. Patients with myocardial infarction, angina, cerebral or peripheral vascular disease are a priority in management. In addition to lifestyle interventions, clinicians should treat these individuals with aspirin, ACE-inhibitors, beta-blockers and statins unless there are clear contra-indications.
- Controlling hyperlipidaemia. Each 1 mmol/l reduction of LDL cholesterol represents a 36% reduction in the risk of cardiovascular disease. Using the joint British chart a 10-year risk of 30% should trigger the introduction of a statin.
- Controlling Hypertension. Each 10 mmHg reduction in systolic blood pressure is associated with a 15% reduction in the risk of diabetes related death. Patients will often require multiple therapies. The blood pressure target should be 140/80.
- Anti-Smoking Strategies. It has been calculated that men with diabetes who stop smoking live on average three years longer than those who continue to smoke. Smoking should be highlighted/discussed at every interview with a health care worker.
- Good Diabetic Control. Each 1% reduction in HbA1c is associated with a 21% reduction in the risk of diabetes related death. Metformin is the drug of choice in obese patients with type 2 diabetes. There should be agreed local guidelines for the management of hyperglycaemia.
57. Both coronary heart disease and type 2 diabetes are more commonly associated with deprivation, and as such it is important to target health care resources to such areas.
58. Regular screening for cardiovascular risk factors should be a central part of a diabetes service. Equally, because of the high risk of CHD amongst people with diabetes, people who come into contact with CHD services (e.g. admitted to hospital with a suspected heart attack) should be routinely screened for diabetes.
ACTION POINT
Good practice models for screening for cardiovascular risk factors in diabetic patients will be defined and disseminated by December 2002.
59. Guidelines published by SIGN and standards defined by the Clinical Standards Board for Scotland for aspects of cardiovascular disease will benefit people with diabetes. The CSBS has recently completed its first round of reviews of performance against the clinical standards for Secondary Prevention following Acute Myocardial Infarction. Local and national reports were published in October 2001.
The Coronary Heart Disease and Stroke Reference Group
60. In taking forward work on CHD, the Scottish Diabetes Group will be working closely with the Coronary Heart Disease and Stroke Reference Group which is developing national policy in this area.
Table 13 Coronary Heart Disease and Stroke Reference Group The Coronary Heart Disease/Stroke Task Force report was published on 11 September 2001. The report formed the basis of a comprehensive, three-month consultation exercise which was completed on 31 December 2001. To take the work of the Task Force forward and consider the response to the consultation, a Coronary Heart Disease and Stroke Reference Group was formed. Membership of the Group is wide ranging and includes patient representatives as well as clinicians. The Reference Group has been charged with developing a strategy for Coronary Heart Disease and Stroke Services in Scotland over the next decade that will be published in Spring 2002. In developing the strategy, the Reference Group has been asked to promote the development of managed clinical networks for both cardiac and stroke services. The Task Force report highlighted the importance of screening diabetics for cardiovascular risk factors and establishing linkages between care pathways to ensure optimum patient care. Scottish Executive Health Department, Coronary Heart Disease/ Stroke Task Force Report, September 2001 |
Eye Care
CSBS Standard 4 - Clinical Review
All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required and support for the modification of lifestyle risk factors.
CSBS Standard 5 - Clinical Management: Eyes
All people with diabetes who have identified signs of developing diabetes-related, sight-threatening retinopathy, are referred to an ophthalmologist for assessment, and, if necessary, treatment.
61. Damage to the blood vessels in the retina (retinopathy) is a well recognised and common complication of diabetes. It is the largest single cause of blindness amongst working age people in the UK. It has also been reported by people with diabetes that blindness is the most feared complication of their condition.
62. In its early stages, diabetic retinopathy is symptom-free. Consequently, regular eye surveillance is required in order to identify promptly damaging changes to the retina. Early identification of sight threatening retinopathy and treatment by laser therapy has been shown to be effective in preventing the onset of visual impairment. Protection lasts for over 10 years in two-thirds of treated patients. At any time, up to 10% of people with diabetes will have retinopathy requiring specialist ophthalmology follow-up or treatment. Investment in diabetic retinopathy screening has been proven in economic analyses to be good value for money.
63. A recent survey of Health Boards in Scotland found that many people with diabetes are already receiving regular screening for retinopathy but that there is huge variation in methodology, coverage, policy and quality. Excellent practice already exists. The challenge is to establish equitable access to an effective screening programme for all people with diabetes.
64. A first step towards improving eye care for people with diabetes is to improve record keeping to ensure that all patients have had their eyes checked at least once and are in the system to be called back for checks in the future. The Scottish Diabetes Survey 2001 provided some preliminary data about this. It reported that 42% of those on the register had had their eyes screened within the last 15 months and a further 12% had been screened for retinopathy at some point more than 15 months previously. Although these data need to be treated with some caution, the Survey provides an indication of the size of the challenge ahead to improve screening, as well as being a useful mechanism to measure change over time.
MILESTONE
All people with diabetes will have their eye status (retinopathy) recorded on the local diabetes clinical management system by September 2003.
Health Technology Assessment of Diabetic Retinopathy Screening
65. The importance of eye screening as a part of high quality diabetes care was recognised by Our National Health: A plan for action, a plan for change that highlighted: 'The Framework will include plans to establish a national screening strategy for diabetic retinopathy.' The Health Technology Board for Scotland (HTBS) selected the organisation of services for diabetic retinopathy screening as one of its first three assessments. That report will be published in April. The key findings of the HTBS report are set out in table 14.
MILESTONE
The Scottish Diabetes Group will produce plans to take forward the implementation of the report of the Health Technology Board for Scotland on the organisation of services for diabetic retinopathy screening by Summer 2002.
ACTION POINT
A national co-ordinator to support the implementation of the recommendations of the Health Technology Board for Scotland on the organisation of services for diabetic retinopathy screening will be appointed by September 2002.
Table 14 Health Technology Board for Scotland The Health Technology Board for Scotland (HTBS) provides evidence-based advice to NHSScotland on the clinical and cost effectiveness of new and existing health care interventions using a process called Health Technology Assessment (HTA). HTBS has conducted an HTA to determine the most effective and efficient approach to achieving, implementing and sustaining a quality assured, patient-centred comprehensive national screening programme for diabetic retinopathy. It considered all aspects involved in establishing a systematic screening programme including optical devices and patient and organisational issues. The HTA was issued for public consultation in November 2001 and was finalised in Spring 2002. It proposes:
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Initial and Continuing Care
CSBS Standard 3 - Patient Focus
All people with diabetes have equitable access to information and multidisciplinary programmes of education, which are tailored to individual needs and specific client groups.
CSBS Standard 4 - Clinical Review
All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required and support for the modification of lifestyle risk factors.
CSBS Standard 8 - Clinical Management: Glycaemia
All people with diabetes have HbA1c measured and recorded as clinically indicated.
66. As soon as possible after diagnosis, people with diabetes should be offered an initial assessment of their condition and of risk factors. The quality and timing of early contacts following diagnosis are recognised as important because it is often during this period that a patient's attitude and response to their diabetes are formed. Early dietetic intervention is a crucial element of initial care, although at present in many areas this is sporadically provided.
67. Beyond initial diagnosis, education and treatment, people with diabetes require long-term and responsive continuing care, typically based around an annual review. An annual review should include provision of advice on lifestyle, assessment of glycaemic control, surveillance for cardiovascular risk, surveillance for long-term complications and surveillance for psychological complications. Table 15 sets out the tests and issues which people with diabetes might expect an annual review to include.
68. Although annual review is the most usual time interval, management and monitoring at more frequent intervals should be undertaken when this is clinically indicated. Difficulties in concordance with treatment and management plans need to be recognised and support developed for patients. Throughout their association with the NHS, support should be available to patients and carers who wish to make lifestyle changes.
69. An important part of the annual review is providing patients with information about their care and their health, including the results of the tests which they undergo. These need to be presented in ways which are understandable and meaningful to patients. Ideally, test results (and in particular HbA1c) should be available and discussed during the annual review. Good practice would include ensuring that the patient has the information he/she needs about his/her diabetes and any changes or complications which are emerging, a review of how the person is living with diabetes and what might help with this. Emotional support for people with diabetes is an integral part of good care. There should also be time for the person to raise any matters of concern and ask questions.
Table 15: Range of tests and issues likely to be covered during a diabetes annual review. |
|
Test |
Explanation |
HbA1c |
HbA1c measures the average level of blood sugar over the previous two-three months. Good glycaemic control is defined by SIGN as a HbA1c of 'around 7%'. However, targets need to be set to suit individual patients and such a challenging target may not be applicable in certain groups of individuals, such as those patients on insulin with hypoglycaemic unawareness, or those who are terminally ill. |
Although HbA1c is the gold standard for the assessment of glycaemic control in diabetes, standardisation of results between different laboratories is problematical. Local laboratories should measure HbA1c and correct it to the Diabetes Control and Complication Trial (DCCT) standard. |
|
Total cholesterol |
High cholesterol levels increase the risk of arteriosclerosis in people with diabetes. |
HDL cholesterol |
High Density Lipoproteins help to reduce the amount of cholesterol in the blood stream. This test would be carried out if total cholesterol is raised. |
Triglyceride |
High triglyceride levels increase the risk of arteriosclerosis. |
Creatinine |
High levels indicate deteriorating kidney function. |
Blood pressure |
High blood pressure is related to the development of heart disease, stroke, kidney and eye damage. SIGN recommend that the target blood pressure for all people with diabetes should be <140/80mm Hg. |
Microalbuminuria |
Presence of albumin in the urine indicates deterioration of kidney function which could lead to kidney failure. |
Visual acuity |
Deterioration in the 'VA' - the ability to appreciate visual detail - may indicate worsening diabetes control and/or retinopathy. |
Retinal screening |
Early detection of changes to the retina (back of the eye) enables treatment to be started in order to preserve sight. |
Foot pulses |
A reduction in foot pulses suggests reduced circulation to the feet and legs. |
Foot nerves |
A reduction in the ability to feel heat, pain or touch suggests a reduction on the effectiveness of the nerve supply to the feet. |
Body Mass Index (BMI) |
BMI is an expression of adult weight in relation to height. The higher the BMI the greater the risk of heart disease/stroke. A BMI of 18-25 is considered a healthy weight. |
Lifestyle management |
Exercise and physical activity, healthy eating and smoking cessation are key aspects of managing diabetes and its complications. |
Review of drug therapy |
Patients with diabetes will often require multiple pharmaceutical interventions, especially in patients with type 2 diabetes. Studies from Scotland indicate the greater number of drugs that are prescribed the less chance that patients will actually take these medications. It is extremely important that patients receive the appropriate education as to the indications for the introduction of therapies to lower blood glucose and prevent or treat vascular disease. All healthcare professionals are involved with the education process, but in particular clinicians must be disciplined in titrating to the most effective dose. |
Mental well being |
Depression is more common in people with diabetes than in the general population. |
MILESTONE
Annual measurement of glycated haemoglobin (a measure of the amount of sugar in the blood; HbA1c) will be offered to all people with diabetes by September 2002. The results will be recorded on the local diabetes clinical management system.
Comment. As a measure of average glycaemic control, HbA1c is an essential part of monitoring diabetes. This is a very challenging target - the Scottish Diabetes Survey 2001 reported that of the patients whose data were included in the survey, 73% had had at least one measurement of HbA1c during the previous 15 months. The 2002 Survey will demonstrate if this milestone has been reached.
Feet
CSBS Standard 4 - Clinical Review
All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required and support for the modification of lifestyle risk factors.
CSBS Standard 7 - Clinical Management: Feet
All people with diabetes who have identified associated foot problems are referred for specialist assessment and, if necessary, treatment.
70. People with diabetes are between 15 and 70 times more likely to undergo lower limb amputations than people without diabetes. Diabetic foot problems are the most expensive of diabetes-related admissions. There is good evidence that people at high risk of developing lower limb complications can be identified and offered effective treatment. The key to the prevention of diabetic foot problems is education in good foot care. Feet checks are an important part of the annual review which all people with diabetes should undergo. An individual baseline (including vascular assessment, neurological assessment, and assessment of function and deformity) should be established for each patient. Personnel trained to assess the presence of risk factors for foot ulceration should undertake annual assessment of the lower limbs. Neuropathy, ischaemia or any deformities of the foot are the key risk factors and a previous history of ulceration infers highest risk. At present, there are wide variations in how thoroughly such checks are carried out and concerns about the quality of health education about foot care available to patients.
Kidney and Nerve Problems
CSBS Standard 4 - Clinical Review
All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required and support for the modification of lifestyle risk factors.
CSBS Standard 7 - Clinical Management: Feet
All people with diabetes who have identified associated foot problems are referred for specialist assessment and, if necessary, treatment.
CSBS Standard 9 - Clinical Management: Renal
All people with diabetes and identified associated kidney problems are referred for specialist assessment and, if necessary, treatment.
71. Kidney (or renal) disease and nerve problems (neuropathy) are both complications of diabetes caused by damage to the small vessels. It is for this reason that they have been combined together in the same building block. However, the fact that neuropathy plays a part in two other building blocks (feet and sexual health) serves to underline the limitations of the building block model in a clinical setting and acts as a reminder that patient management requires a holistic approach.
Renal Disease
72. End stage renal disease is one of the most serious complications of diabetes and one of the most costly for the NHS. Diabetic renal disease (diabetic nephropathy) usually develops over 15-25 years following the development of diabetes; (although the time may appear shorter in type 2 patients if diabetes had been present but undiagnosed for a number of years). People with diabetes account for 20% of patients undergoing renal replacement therapy in Scotland.
73. In people with diabetes, the presence of microalbuminuria (very small amounts of protein in the urine) and stroke, or an elevated serum creatinine (excess creatinine in the blood) increases the risk of kidney damage and failure. This is especially true in people with problems with kidney function who have high blood pressure. The presence of renal impairment in diabetes is also predictive of a high cardiovascular morbidity and mortality. Diabetic renal disease is also more likely if retinopathy is present. People of South Asian and Afro-Caribbean origin are at higher risk of developing renal disease and renal failure than the white population.
74. There is good evidence that early detection and appropriate treatment can prevent the development and progression of renal impairment. All people with diabetes should therefore be offered an assessment of their renal function as part of the annual review (see Table 15). Those with signs of renal impairment (that is, classified as having microalbuminuria or proteinuria) should be advised about their risk of renal and cardiovascular disease and offered appropriate treatment including tight blood glucose control (HbA1c <7%) and tight blood pressure control (less than 120/70). Those with continuing deteriorating kidney function (serum creatinine over 130 mmol/l) should be referred for specialist joint diabetic/renal opinion.
Neuropathy
75. All people with diabetes should be offered at least annual surveillance for signs of neuropathy (peripheral nerve damage). The most common type of neuropathy is peripheral neuropathy in a 'glove and stocking' distribution but especially the lower limbs. This can be insidious from the onset and comprises loss of sensation that may result in ulceration foot deformity. Other symptoms include neuropathic pain. Autonomic neuropathy is also more common in people with diabetes and erectile dysfunction in men should always be considered (see paragraph 89).
Psychology/Mental Health
CSBS Standard 4 - Clinical Review
All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required and support for the modification of lifestyle risk factors.
76. The emotional and psychological needs and support of people with diabetes are not always a priority in primary and secondary care; physical disease management usually takes precedence. However, the demands of diabetes involving daily decisions about nutrition, physical activity, medication, blood glucose monitoring and stress management as well as additional financial and social burdens can adversely effect patients. Up to 1 in 5 of people with diabetes suffer from depressive disorders and the risk of clinical depression is even higher amongst those with co-morbidity and complications. Depression can have a damaging impact on self-management. At present, the availability of psychological support for people with diabetes is patchy at best with a recent survey reporting that 54% of local services had no psychology input to the care of people with diabetes. There is a need to raise awareness of the 'hidden problem' of depression and other psychiatric illness in diabetes and to introduce more active monitoring of the psychological wellbeing of people with diabetes.
'You get nothing about the emotional side - all the emphasis is on diet.' (Person with diabetes) |
77. Many people who have diabetes have described the value of peer support and of emotional support from other sources that do not involve psychology services. Empathetic support from staff as an integral part of delivering care and good information also have an impact on the mental wellbeing of people with diabetes.
'In addressing the emotional effects of diabetes, it is important to emphasise the quality of the patient/staff relationship, the need to provide emotional support, to listen, help set up support groups for patients and families, and to provide appropriate information.' (Professional, interviewed by Partners in Change) |
Diabetic Emergencies and Elective Care
CSBS Standard 10 - Clinical Management: Acute Management
All people with diabetes who experience an acute diabetic emergency including severe hypoglycaemia, diabetic ketoacidocis (DKA) or hyperosmolar non-ketotic state are rapidly assessed and managed according to local protocols.
Diabetic Emergencies
78. On occasion, people with diabetes will encounter difficulties with their treatment which lead to diabetic emergencies. The acute complications of diabetes can causes distress, disability or even death. The morbidity and mortality rates resulting from these acute complications continue to be high in Scotland. Cerebral oedema and ketoacidosis is the main cause of death, particularly in young people. Recurrent hypoglycaemia is a cause of profound morbidity and occasional mortality. It is also a disincentive for people to achieve tight blood glucose control in the management of their diabetes. Quality of life is affected by recurrent emergencies and recurrent hypoglycaemia may cause restrictions on lifestyle including education and employment, driving, sport and social activities. The prevalence of diabetic emergencies can be reduced through education of both people with diabetes and healthcare professionals on how to avert hypoglycaemic episodes. All hospitals should have a protocol or guideline for the management of diabetic emergencies. People presenting with diabetic ketoacidosis should be managed by a hospital team experienced in the up-to-date management of the diabetes and its acute complications.
Elective Care
79. People with diabetes are admitted to hospital twice as often and stay twice as long as those without diabetes. However, inpatient care for people with diabetes is too often not well managed, especially when diabetes was not the original reason for admission. Often, this is the result of inadequate knowledge amongst hospital staff. There is a need for greater recognition of the particular needs of people with diabetes when they are admitted to hospital. Although some units do provide good diabetes training for non-specialists, there is a need to identify and spread these examples of good practice.
'I was in a surgical ward so nobody knew anything about diabetes.' (Woman with diabetes) |
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