Consensus Guidelines for the Management of
Insulin-Dependent (Type 1) Diabetes — Chapter 1
Index of chapters
1. INTRODUCTION AND ORGANIZATION
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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
- Insulin-dependent (Type 1) diabetes is found in all regions and countries of the world, although its incidence does vary from place to place and with time.
- IDDM is primarily a hormone deficiency disease, due to auto-immune destruction of pancreatic islet B-cells. It should be equated with Type 1 diabetes.
- IDDM must be distinguished from insulin-treated non-insulin-dependent diabetes, a condition whose different metabolic aspects need a somewhat different approach to management. However, greater overlap exists with some forms of secondary pancreatic diabetes.
- While peak incidence is in the years around puberty, onset can be at any time between birth and very old age.
- While it has been possible to treat IDDM since 1922, optimal management, to ensure high quality of life while preventing late tissue damage, demands a high degree of skill by both patient and their professional advisor.
- Diabetes and its management affects most aspects of day to day living. Management is therefore inevitably patient-centred, and is heavily dependent on patient empowerment, patient education, and self-monitoring of the results of self-care ( empowerment ) ( education ) ( self-monitoring ).
- Relief of symptoms is not an adequate target for diabetes care, as the degree of abnormality of metabolic control may still be associated with the devastating secondary problems of blindness, renal failure, cardiovascular disease, nerve damage, and leg amputation, as well as adverse pregnancy outcome.
- Children with diabetes have some special needs. These special needs are not addressed within the present guidelines, but most of these guidelines are applicable to children with only minor modification ( special note ).
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
- All people with diabetes should be receiving continuing preventative care through education and medical interventions to achieve metabolic targets while maintaining a high quality of life.
- People with diabetes need annual surveillance to detect early on the development of late tissue damage, and where this is detected access to adequate protocols and resources for its management ( annual review ).
- All people with diabetes should have continuing access to a diabetes team ( see below ), for help in diabetes management and social difficulties arising from their diabetes.
- People with diabetes have a role in the development and organization of the service of which they are a part.
- All diabetes management teams should have an active policy of quality improvement ( quality monitoring ).
- Appropriate special care should be offered to those with special needs, including pregnant women ( pregnancy management ).
1.31 Framework for Diabetes Care
- The organization of care should indicate the allocation of responsibility between the patient, the primary care physician and the specialist service. This needs to take account of local resources and patterns of care. The role of the primary care physician in this partnership will depend upon acquiring and maintaining appropriate skills and expertise.
- Each locality should have a resource centre for diabetes care through which all IDDM patients can be registered and the principles of their care organized.
- The diabetes team comprises the patient and the professionals: diabetologist, diabetes nurse specialist, podiatrist (chiropodist), and dietitian, supported by their colleagues as required (obstetrician, ophthalmologist, nephrologist, psychologist, and others).
- Access to care should be available at all times, but the frequency of visits will be determined by individual metabolic control, complications and self-management skills. Three-monthly consultations with a physician familiar with the patient's care should represent an acceptable standard. Assessment of blood glucose control by determination of glycated haemoglobin should be available. At least once a year a full review for complications should be undertaken (see below).
- The diabetes record should be consistent with the European standard dataset of the DIABCARE Group.
- Care guidelines should be made available to all members of the diabetes team, drawing upon the present document and the recommendations of the Working Groups of the St Vincent Declaration Steering Committee.
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:
- Friendly greeting of patient and early establishment of rapport
- Understanding of any recent events disturbing the patient's life-style
- Enquiry after general well-being and identification of new difficulties
- Review of self-monitored results, and discussion of their meaning ( self-monitoring )
- Review of dietary behaviours and physical activity ( nutrition )
- Review of diabetes education, skills, and foot care (education )
- Review of insulin therapy ( insulin ) and experience of hypoglycaemia ( hypoglycaemia )
- Review of other medical conditions and therapy affecting diabetes
- Management of complications and other problems identified at Annual Review
- Summary and agreement on main points covered in consultation
- Agree targets for future months ( targets )
- Agree and explain changes in therapy
- Agree interval to next consultation
- Completion of a structured record of the consultation
Additionally, at Annual Review there should be surveillance for:
- Symptoms of ischaemic heart disease, impotence, neuropathy, peripheral vascular disease ( IHD impotence neuropathy foot problems )
- Foot condition including absent pulses, sensory impairment, deformity or poor skin condition, ulceration, ischaemia ( foot problems )
- Impaired visual acuity
- Retinopathy by ophthalmoscopy/retinal photography ( eye problems )
- Kidney damage by albumin excretion and serum creatinine ( kidney problems )
- Hypertension ( blood pressure )
- Dyslipidaemia ( blood fats )
- 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
- The development of quality in health care is an ongoing dynamic process. This has been formally recognized in the St Vincent Declaration.
- Quality development is particularly important in a chronic condition like diabetes, where the patient is often asymptomatic for many years until the adverse late complications signal a failure of earlier care.
- Quality development implies that health care goals are identified, together with strategies required to meet them, that those strategies should be implemented, and the resulting outcome measured and compared to the expected standard. Feedback is then provided to enhance the further delivery of care. In diabetes health care delivery this process should be seen as an integral part of care.
- The long-term nature of the condition requires that targets must be set for the short-, medium-, and long-terms, using different objective measures.
- Indicators of quality to be chosen will reflect structure and process, but particularly intermediate and patient outcomes.
- The strategy and the instruments to develop quality in diabetes care will generally be those proposed and under development by the DIABCARE initiative of the St Vincent Declaration.
1.51 Recommendations for Quality Development
- 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.
- Aspects of the process of care should be reviewed by regular meetings of diabetes team, comparing performance to local and external care-guidelines.
- 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.
- Diabetes services should always make available to their customers (the patients) the published results of such activities at regular intervals.
- 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
- Four features of diabetes care make continuing education of professionals more important than in other areas of health care:
- Education of patients is a major element; the skills involved in adult education and the changing of behaviour must be acquired ( patient education )
- The information and skill base is evolving rapidly; keeping up to date is increasingly difficult
- The multidisciplinary team must all act from the same assumptions if they are to communicate and liaise with each other effectively ( teams )
- Evaluation skills are an important part of diabetes care; these are not presently widely available.
- Continuing education (at least 2 days per year) is an essential part of skill maintenance.
- Professional education must aim to reach not only the immediate providers of advice and education (the diabetes team) but also health care managers, primary health care personnel, and people in diabetes associations.
- Resources for professional education will include patients, specialists in education, managers, and other groups with special skills relevant to diabetes care. Academic institutions should be able to co-operate in the provision of educational techniques and courses.
- Where appropriate systems of accreditation exist, then diabetes care should be provided by those with such accreditation.
- Funding of continuing education for diabetes professionals should be seen as a priority area providing a good return on resources invested.
IDDM CONSENSUS GUIDELINES Chapter 1 STRUCTURE: Training
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