Consensus Guidelines for the Management of
Insulin-Dependent (Type 1) Diabetes — Chapter 1

Index of chapters

1. INTRODUCTION AND ORGANIZATION

1.1 Preamble: Delivery of Care for the Person with IDDM
1.2 Some Background to IDDM
1.3 Organization of Diabetes Care
1.4 The Diabetes Consultation
1.5 Quality Monitoring and Development in Diabetes Care
1.6 Professional Training and Continuing Education

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The tools of diabetes care can only be used 
effectively and optimally when combined with 
the process of patient education and 
with continuing evaluation of the outcomes of care.
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IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Preamble
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1.1 Preamble: Delivery of Care for the Person with IDDM

Recommendations designed to assist the implementation of high quality health care make a number of assumptions. Amongst these is that the culture of a specialist area has developed enough harmony across a wide geographical area to achieve consensus on what can be implemented. The stimulus to the European IDDM Policy Group has been the successful demonstration by its elder sister (the NIDDM Policy Group) that such guidelines can be written, and manifestly can be useful.

In diabetes it is apparent that the resources available to care vary widely within Europe. However, the primary resource for diabetes care is now recognized as the patients themselves, supported by enthusiastic and well-trained professionals. Both these resources are in good supply nearly everywhere. It is our hope then, that with the present and other suggestions, diabetes care for people with IDDM can be organized to the benefit of all.

Underlying the St Vincent Declaration is the recognition that care must not only be effective, but also efficient, and that it must be responsive both to individual needs, and to cultural and behavioural differences. Intentionally then, these consensus guidelines allow for considerable flexibility in the delivery of care. However, this does not undermine a concept that runs throughout the document, namely that the tools of diabetes care (including insulin and self-monitoring strips) must be supported by the twin pillars of patient education and of evaluation of all processes and resulting outcomes.

We believe professionals in this area are fortunate in practising medicine in a particularly fulfilling area. We hope you will enjoy implementing these shared ideas.



Figure 1.1.1: Charateristics of quality health care
   Quality health care must be:							
   —> effective   :   to achieve the desired outcome
   —> efficient   :   for resources are limited
   —> equitable   :   whatever the restraints of
                         geography and economics
   —> appropriate :   individual needs vary
   —> responsive  :   to the cultural and behavioural needs
                         of the individual

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Preamble

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Background

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1.2 Some Background to IDDM




Figure 1.2.1: Objectives of Diabetes Management
     Optimal       Optimal         Lower    	
     patient       self-care       perceived	
     skills        behaviours      barriers 	
       |_____________|               |
       |             |               |
       V             V               V
     Optimal       Minimal         Confident	
     metabolic     hypo-           life-style	
     control       glycaemia         |
       |  |__________|               |
       |             |               | 
       V             V               |
     Avoid late    Avoid             |
     tissue        acute             |   
     damage        problems          |
       |_____________|_______________|
                     |
                     V  
          Optimal quality of life


IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Background

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Organization
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1.3 Organization of Diabetes Care

1.31 Framework for Diabetes Care
IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Organization

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Consultations
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1.4 The Diabetes Consultation

An effective diabetes consultation may include:
  1. Friendly greeting of patient and early establishment of rapport
  2. Understanding of any recent events disturbing the patient's life-style
  3. Enquiry after general well-being and identification of new difficulties
  4. Review of self-monitored results, and discussion of their meaning ( self-monitoring )
  5. Review of dietary behaviours and physical activity ( nutrition )
  6. Review of diabetes education, skills, and foot care (education )
  7. Review of insulin therapy ( insulin ) and experience of hypoglycaemia ( hypoglycaemia )
  8. Review of other medical conditions and therapy affecting diabetes
  9. Management of complications and other problems identified at Annual Review
  10. Summary and agreement on main points covered in consultation
  11. Agree targets for future months ( targets )
  12. Agree and explain changes in therapy
  13. Agree interval to next consultation
  14. Completion of a structured record of the consultation
Additionally, at Annual Review there should be surveillance for:
  1. Symptoms of ischaemic heart disease, impotence, neuropathy, peripheral vascular disease ( IHD impotence neuropathy foot problems )
  2. Foot condition including absent pulses, sensory impairment, deformity or poor skin condition, ulceration, ischaemia ( foot problems )
  3. Impaired visual acuity
  4. Retinopathy by ophthalmoscopy/retinal photography ( eye problems )
  5. Kidney damage by albumin excretion and serum creatinine ( kidney problems )
  6. Hypertension ( blood pressure )
  7. Dyslipidaemia ( blood fats )
  8. Injection site damage
An effective consultation requires that adequate time is available, as well as access to all appropriate members of the diabetes team. Results of all assessments should be discussed with the patient and provided to them on a suitable record (such as International CareCard Diabetes). Communication should also be made to others involved in the patient's diabetes care, including the primary care physician.

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Consultations

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Quality
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1.5 Quality Monitoring and Development in Diabetes Care

1.51 Recommendations for Quality Development

  1. The dataset gathered at Annual Review should be aggregated onto a computerized database, and analyzed in line with published recommendations to allow comparison of performance with other providers of diabetes care.
  2. Aspects of the process of care should be reviewed by regular meetings of diabetes team, comparing performance to local and external care-guidelines.
  3. Particular attention should be given to the performance of education programmes and communication with patients, even though formal instruments for assessment of these areas are not yet available.
  4. Diabetes services should always make available to their customers (the patients) the published results of such activities at regular intervals.
  5. Biochemical measurements, whether performed by the laboratory, professional or patient, must be supported by quality assurance programmes.



Table 1.5.1: Examples of biomedical measures of quality of care
    True patient outcomes
        Incidence of above ankle amputation *
        Incidence of myocardial infarction and stroke *
        Incidence of foot ulceration
    Intermediate outcomes
        Percent patients with grades of retinopathy
        Percent patients with microalbuminuria	
        Percent patients with HbA1c in 'poor' category ^
    Risk factor control
        Percent patients with defined (and treated) hypertension ^
        Percent patients still smoking
    Process of care	
        Percent patients screened for retinopathy in year
        Percent patients seeing nurse educator in year

*, St Vincent Declaration outcome target ^, See section on targets for categories of control


IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Quality


IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Training

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1.6 Professional Training and Continuing Education

IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Training


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