REMOTE AREA DIABETES CLINIC MODEL

MINIA EXPERIENCE

Mesbah Sayed Kamel

MD

INTRODUCTION

Diabetes mellitus, as a chronic disease, can be very depressing. Therefore a lot of the role of the diabetic clinic is not just the science, but also the emotional and psychological support for the patient, particularly during times when this may be feeling low or having a flare-up of complications.

The complications of diabetes mellitus are all related to poor diabetic control. Therefore if patients with diabetes mellitus can be assisted to keep good control of their blood glucose levels, they will get fewer complications in later life.

Currently there are limited services for diabetes care in remote areas.Those that exist are primarily in the capital and large cites. Most patients in these areas - if they are aware of their condition - seek care from traditional healers, private practitioners or travel to capital and large cities.

In addition, the public health service in Egypt is almost entirely geared towards treating acute illnesses with very little provision for managing chronic diseases. There is no framework for structured outpatient care by physicians at a referral hospital level for patients with non-communicable diseases (NCDs), such as diabetes .

It is hoped that this model could provide a model for the establishment of outpatient care, which could be rolled out to other areas and eventually expanded to cover other NCDs.

AIM OF DIABETIC CLINIC

Create a Data Base - to register and label any patient of diabetes.:

To identify the magnitude of the problems dealing with.

To help future plan and design of Remote D. clinics. To help decision makers, at local and higher level,

better plan for human resources, management and medications.

To make sure that all patients with diabetes mellitus have appropriate and adequate treatment.

The clinic provides the opportunity for patient assessment and education involving specialist provider and other allied health services.

INTRODUCTION

Population of Minia is 4.14 Milions. 5.8% total national population Urban:19.3% total population. Covering area --32279-- square kilometers.

(3.2%)

National Total Quantity Item

469 643 Population per bed

1545.7 2222.2 Population per doctor

734.1 1178.5 Population per nurse

39.79 46.52 Ambulance car per person

36.9 1.3 Health insurance coverage (million)

National Free health coverage

1429.23 26.09 Number (1000)

1617,9 41.59 Cost (Million)

4151.5 2935.8 Income per capita

Reference: Ministry Of Health and Population 2006

CHALLENGES

Overwhelmed by the number of patients seeking care

Over crowded Primary Health care clinic

Does not bring optimal care to patients

Demoralises and frustrates healthcare givers

Ends with unsatisfied end user

IMPORTANCE

Re-structure the service to enable complicated and/or poorly controlled cases receive the required extra attention and are not ‘lost’ among the far greater number of other patients.

Without this step: Care can be delivered, but the number of lost

cases is high. Improvement will still continue, but the

improvement cannot be measured.

SETUP OF THE DIABETES CLINIC

The Diabetes clinic will not function optimally in isolation from other healthcare services.

It needs to be clearly and firmly placed within the healthcare system or any existing Diabetes programme.

Should be linked horizontally and vertically within the primary healthcare (PHC) programme.

Well trained Care-giving team on function and protocol usage headed by a family physician.

Good communication between PHC and their colleagues in referral institutions.

PROTOCOLS FOR DIABETES CLINIC

Purpose of Protocols : Guide and Standardise the care Ease the job on:

Diagnosis Management Assessment of complications Clear indications for referral

Few protocols are already implementedThe actual content of Protocols should depend on local resources, chances for referral, and availability of as any further treatment or investigations.

DIABETES CLINIC MODEL

•D .Clinic

Eastern Desert

Nile River

Established at 2006.

Goals :-1. Providing diabetes care according to standard

parameters at least minimal level aiming to reach upmost one.

2. Diabetes rigestry for the draining area aiming to extend to whole governorate in case that patients attending the clinic come from various parts of the governorate.

3. Multidiciplinary diabetes care through Teamwork involving different specialities.

4. Decrease the micro and macrovascular complications through good glycemic control and elimination of risk factors e.g obesity. Smoking,dyslipidemia and hypertension.

PROTOCOL Every patient has a medical file including

all the personal and medical data stressing on detailed history and comperhensive examination.

This file is kept in the clinic and mini-copy (Card) kept with the patient both have the same NO. and data.

FLOW CHART FOR DIABETESHISTORY PARTArab Repuplic of

Egypt

Samalout one day surgery hospital

Age --------------------------

Date -------------------------------Ministry of Health and

Population

FLOW CHART FOR DIABETES HISTORY PART

FLOW CHART FOR DIABETESASSESSMENT PART

FLOW CHART FOR DIABETES ASSESSMENT PART

FLOW CHART FOR DIABETESFOLLOW-UP

Monthly followup

Yearly as a routine or as required

FLOW CHART FOR DIABETES FOLLOW-UP

FLOW CHART FOR DIABETES FOLLOW-UP AND MANAGEMENT

PROTOCOL CONT.

The patients are classified into two groups:

New patients :follow procedure of

registration,filing,medical examination,education,management plan and next follow-up date.

FOLLOW-UP GROUP

Check weight,waist,BP,B.S ,Every visit,HBA1C every 3 months,other lab .results if previously requested.

Check hight at first visit for adults then every visit for childern.

Every patient then has an interview with physician to assess his diabetic state ,discuss problems if present ,remind of education list.

Clinical examination. New lab requests or referral to other specialities

accordingly. Management plan and next follow up date.

PERIODIC CHECK UP

Every 6-12 months(or according to case) Dental check Ophthalmological exam. Abd.U/S. ECG ,Echocardiography ,stress

ECG,doppler and referral for CAG if req. Lab : RF,LF,Lipid profile.

Every visit: Foot examination for skin

changes ,callositis,cracklings,ulcers&interdigital exam.

Neurological assessment using monofilament,fork and hammer.

Check peripheral pulsations. Doppler may be requested.

Examination of shoes if ulcer is predicted. Treatment of any inflammatory condition.

Foot care

NEW PATIENTS Registration and file completion. Clinical examination. Lab request :

FBS.PP,RF,LIPIDS,ECG and any other investigations accordingly.

Health Education session.

HEALTH EDUCATIONItems to be discussed: What is diabetes.(Nature of the disease,Symptoms and

Signs,clinical varieties,). Magnitude of the problem. Risk factors for diabetes and diabetic complications. Importance of glycemic control. Goals of therapy. Self monitoring.(Symptoms and signs of Hypos.&Hyper

and what to do,BS measurement) Misconceptions. Insulin. Foot care. Life style modifications. Smoking.

PATIENT REVIEW AFTER LAB RESULTS

At this stage:every patient has an interview with physician for:

Assessment of the diabetic state and overview of the whole clinical situation.

Management plan (individualized). In case insulin introduced :1. Explain the rational for use.2. Training for injection skills and motivation for self

injection.3. Insulin syringes and pens4. Presevation of insulin. 5. Symptoms of hypoglycemia and how to deal with. At last pt. will has prescription and next visit

appointment.

EVALUATION Evaluation Parameters: 1. Number of pt. attending the clinic

during the 5 years.2. Parameters of glycemic control FBS,PP

and HBA1C.3. BP and lipid control.4. Evidences for life style changes : Body

weight,frequency of exercise and stop smoking.

5. Decreased micro and macrovascular complications.

NUMBER OF PATIENTS ATTENDING THE CLINIC 2006-2010

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr0

500

1000

1500

2000

2500

2006

2007

2008

2009

2010

BODY MASS INDEX AT REGISTRATION

18-25 25-30 <300%

10%

20%

30%

40%

50%

60%

MaleFemale

111818-25 25-30 >30

BMI AFTER 9 MONTHS

18-25 25-30 <300%

1000%

2000%

3000%

4000%

5000%

6000%

MaleFemale

18-25 25-30

>30

60%

50%

40%

30%

20%

10%

BMI AFTER 18 MONTHS

18-25 25-30 <300%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

MaleFemale

>

HBA1C 2006-2008

<7% <8 8-10% >10%0%

10%

20%

30%

40%

50%

60%

2006

2007

2008

%OF CONTROLLED BP(130/80)2006-2008

Series10

10

20

30

40

50

60

2006 2007

2008

% HIGH LDL (>100) 2006-2008

Series10%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2006 2007

2008

% HDL INCREASE (>40) 2006-2008

Series10%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2006 2007

2008

%TG CHANGES 2006-2008

2006 2007 20080%

10%

20%

30%

40%

50%

60%

TG>150

TG>150

HYPOGLYCEMIA-DIABETIC KETOSIS2006-2008

2006 2007 20080

2

4

6

8

10

12

Hypoglycemia

Diabetic ketosis

CVS MORTALITY 2006-2008

2006 20080

1

2

3

4

5

6

7

Death from CVS causeStrokeMICABG

2006 2008 Relative RR

New or worsening retinopathy

354 287 7%

2006 2008 Relative RR

New or worsening nephropathy

292 200 21%

% LOSS OF FOLLOW UP 2006-2010

2006 2007 2008 2009 20100

1

2

3

4

5

6

7

األول النصفالثاني النصف

1stHalf

2ndHalf

2006 2007 2008 2009 2010

CAUSES OF FOLLOW UP LOSS

Series10

10

20

30

40

50

60

70

80 Insurance uncover

Transportation

Waiting time

Uncontrol

Bad commu-nication

Drug affordabil-ity

OBSTACLES

Transportation. Limited space. Trained manpower. Drug affordability. Limited resources.

CONCLUSIONA quite big number of cases with chronic illnesses are seen by doctors in the primary care setup.

The Health centres are overwhelmed by the number of patients seeking care, which frustrates health care giver and doesn't bring optimal care to patients.

It is important to structure the service so that those whose condition is complicated and/or poorly controlled receive the required extra attention and are not ‘lost’ among the far greater number of people with uncomplicated and easily controlled NCDs.

CONCLUSIONS 2

Inspite of all encountered difficulties, Diabetes clinic with well structured care can be established in remote areas where maximum benefits can be obtained from the limited resources ,however this is largely dependent on better understanding of diabetes care , enthusiasm of the team and considering patient –centered care to be first priority.