Non-Insulin Using Type 2 Diabetes DCPNS Decision Tool

Transcription

1 Non-Insulin Using Type 2 Diabetes DCPNS Decision Tool

2 Nova Scotia Activities COMPUS Report Released (06/09) Café Scientifique: Public Providers (02/10) DCPNS SMBG Working Group DCPNS SMBG Working Group/Workshop Consensus Development Provider: Decision Tool Development DCPNS Provincial Workshop DEs) Academic Detailing MDs &DEs Academic Detailing Rx Pharmacists) Videos Development (1 & 2) Inter-professional Workshops (Community-based) 02/11. 2

3 DCPNS s Process Working group formed (SMBG Interventions)-July 2009 DCPNS Workshop delivered Jan/10 With Clinical Champions (key) Consensus building.plenary sessions (4), used draft decision tool, case-based discussions Publication submission (Chronic Diseases Can) Newsletter articles Provincial conference (April /10) Refined the provider decision tool (to May/10) Video Development (May to Jan/11) Draft patient-focused tool Diabetes Educators from each of 9 DHAs Community Pharmacists MDs generalists and specialists Observers (CADTH, CDA, DoH, FNIH, Dal CME/College of Pharm, CH Behavior Change institute) Champions For Change

4 Does this person need to test? Why? Is he/she interested (willing and able)? Will he/she interpret and act on the results? Will you and other members of your team use the results to adjust treatment? If you do decide testing is needed, what is the minimum amount of testing required, when should you test, and for how long?

5 1 Instructions How to Use 1 2 Indications for Testing: Patient safety Health care team action Individual knowledge, skills, willingness to act and interpret 2 3 Recommendations: Low and high intensity Time limited testing 3

6 2 Key Areas for Consideration

7 3 Low Intensity testing: Used to individual s and/or provider s understanding of effects of treatment. May assist clinicians in guiding therapeutic adjustments, providing more timely feedback regarding potential medication changes, and to identify postprandial hyperglycemia, if in question. 1 Examples for use at diagnosis and ongoing follow-up (times can vary for 1 to 3 wks depending on the purpose (prior to office visit, new dx): 3 tests/day for 2 days/wk one weekday and one weekend day (fasting and ac/ pc at the largest meal [often supper]) for 2-3 wks. 2 tests/day varying times (ac breakfast/supper; ac lunch/bedtime; etc.) for 1-wk. 1 test/day at staggered times (ac breakfast, lunch, supper, or bedtime) for 1-2 wks. 1 test/wk between office visits. 1 International Diabetes Federation. Self-Monitoring of Blood Glucose in Non- Insulin Treated Type 2 Diabetes. Brussels, Belgium: Author; 2009.

8 3 Used for pattern analysis, to create BG profiles that can identify daily BG patterns that lead to action-based on results. Should be used only for a specific time and for a specific purpose; e.g., change in treatment (adding insulin), acute illness (flu, GI upset, etc.) resulting in symptoms or added risk, etc 1. Examples: Generally 5-7 x/day for 1-3 days, Staggered testing, 2x/day (ac & pc testing for alternating meals) x 1 wk, or over a 2-3 wk period. 1 Duration of testing depends on medication and degree of hyperglycemia (what change is expected over what period of time). Results should be reviewed by phone or during an office visit immediately after the testing period. Note: Gestational DM or women with type 2 DM planning for pregnancy/or in the early stages of pregnancy will be required to test more routinely for extended periods of time.

9 SAMPLE: Newly Diagnosed Type 2 DM (Elderly) Age: 75 Gender: Female Occupation: Widowed Homemaker Fasting PG: 8.3 mm A1C: 7.7% BMI: 29 Diet: Makes healthy meal choices; no major changes required Activity: Generally inactive; enjoys short walks. Socially active (bridge) Targets: 5 to 9 mm ac meals; A1C: < 8% Comments: Experiencing some recent short-term memory loss. Daughter reports that she at times repeats herself. Goal/Plan: Maintain weight; continue social activities. Encouraged to increase frequency of short walks DM Medication: None

10 Case 1 Note: A1C will be the telling factor; cognition is a possible issue; not much to be gained through tightening meal plan and activity she does the best she can.

11 SAMPLE CASE:FOLLOW UP: TYPE 2 DM ON ORAL AGENTS Age: 55 Gender: Female Occupation: Store Clerk Fasting PG: 7.9 A1C: 7.4 BMI: 32 (was 33) Diet: 3 meals plus occasional hs snack-finds it difficult to limit portion size Activity: Cannot find the time-walks 10 once per week Targets: 4 to 7mM ac meals; 5 to 10 mm pc meals; A1C: < 7% Comments: Is testing daily (2x per day, staggered). Recording results Goal/Plan: Refocus on portion control, weight loss and regular exercise. DM Medication: Adding metformin to her regimen

12 Sample Case

13 SAMPLE CASE: NEW DX TYPE 2 Age: 47 Gender: Male Occupation: Account Manager (Bank) Fasting PG: 11.7 mm (symptomatic: thirst, urination) A1C: 8.7% BMI: 35 Diet: Frequently misses meals, poor meal choices; ++ juice to quench thirst Activity: Sedentary Targets: Short-Term: < 10 mm ac meals Long Term: 4 to 7 mm ac meals; 5 to 10 mm pc meals A1C: < 7% Comments: Keen likes numbers, understands. Would like some control (wants to understands the hows and whys ) Goal/Plan: Weight reduction through healthy meal plan; increased physical activity DM Medication: Metformin 500mg BID

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15 The Vast majority of this population do not need to test. Testing will be considered when: There are safety issues (hypoglycemia risks). There is a planned treatment change, addition of insulin or a 2 nd or 3 rd oral agent. There is a compelling reason to test despite no responses (provider judgment). Weaning routine, frequent testers off an unnecessary testing regimen.

16 Providers need to use clinical judgment; but always remember: No evidence of benefit The cost to the individual and the system The potential harm (guilt associated with testing for some) Wastage, with no use of results

17 The time-limited concepts needs to be understood and applied (it is not forever). What is the specified period (next visit, phone in, if result is stop, etc.) and what happens at the end of the specified period? Need to be clear in instructions for the patient and between providers (see me bring results, call me with results, stop if numbers are ).

18 This is where we will have the greatest differences in interpretation With introduction of metformin, still no real reason to test. If hypo is the concern, be specific: Test to verify/validate symptom (am I low?) Test at times that may precipitate hypo (unplanned/planned exercise/activity), driving long-distance, in presence of alcohol (this will need to individually determined and discussed) depending on real risk and circumstances. With stable diet only or diet and oral meds, if ongoing testing is required/ requested: Once/day, once/week until next assessment to demonstrate no change and then you could make the shared decision to discontinue testing all together. Testing time should be consistent (fasting or around the time of day when usually the highest). Looking for trends.

19 Really reserved for those moving toward insulin (agents have failed) and this is but a stepping-stone to a change in treatment regimen. It would be time limited testing followed by a decision most likely related to insulin dosing. With the addition of a 2 nd or 3 rd oral medication, could justify intensive testing for a specified period of time to assess immediate impact and risk of hypo.

20 VIDEOS Part 1: SMBG Decision Tool for Health Care Providers Provides: rationale for the decision tool with the help of key opinion leaders Part 2 : Use of the SMBG Decision Tool and Case Studies It introduces: the features of the tool, works through a sample case, provides summary caveats and principles to guide future application of the tool, and leaves three cases for the viewers to work through on their own. To locate the videos: DCPNS website

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