Multidisciplinary Diabetes Care

Multidisciplinary Diabetes Care

Introduction

In most cases, patients with diabetes are managed by primary care physicians, which is occasionally obstructed by limited time and clinical inertia, making it hard to attain treatment goals. It is, therefore, necessary that a new approach is developed to take care of the increasing population of people living with diabetes to attend to patients’ psychosocial and medical needs. Interdisciplinary care can be applied to take care of diabetes patients by combining efforts of practice nurses, primary physicians, and clinical pharmacists that can obtain improved clinical processes and results at realistic costs. It is estimated that people with diabetes in the United States are more than 23 million. (1) Projections indicate that the number is likely to increase to more than 48.3 million people by 2050. (1). Cholesterol control, blood pressure, and improved glycemic can significantly reduce the risk of diabetes complications. These results were obtained through extensive studies, such as the U.K. prospective diabetes study, the diabetes control, and complications trial and multiple studies on the reduction of cardiovascular risk. An evidence-based process and outcome recommendations have been developed by the American Diabetes Association to meet the cardiovascular and metabolic goals. However, it has not proven very easy to meet these set guidelines.

Primary care practices are the most prevalent healthcare sources for patients with diabetes. Healthcare providers in theses clinics face a lot of challenges to meet the psychosocial and medical needs of the patients. There is a lack of intensified therapy and timely treatment due to limited time of providers with patients and long intervals between patient visits resulting in clinical inertia. It is hard to take care of the educational, medical, and psychosocial needs of diabetes patients in the infrequent short visits with a single provider as the issues are often involved. The problems of providing the necessary care to patients are well illustrated in an electronic system study that reminds physicians of needed diabetes care in each visit. Health care providers suggested the electric system, but it again could not deliver the required diabetes care as with it, the physicians only managed to carry out about a third of the automated reminders (2). The barriers identified by the doctors included competing for assistance among patients and time constraints.

The increase in diabetes prevalence makes it even harder for medical care practitioners to overcome the problem. The addition of more resources to deal with the barriers that physicians experience in the current system of healthcare is needed to meet the rising demand. Care teams are now being formed whereby pharmacists, physicians, and nurses join hands to provide better care of diabetes patients. There have been calls for the expansion of the role of nurses into the coordination of health care and delivery of primary care. Research indicates that nurses can provide care for routine management of chronic diseases and acute illnesses with results similar to those of primary care physicians. A trial involving the use of community clinical pharmacist in taking care of diabetes patients together with clinical physicians showed improvement in the level of care outcomes at a realistic cost (2). Nurses and pharmacists should join primary care physicians in delivering services such as family and patient counseling, patient education, monitoring of health outcomes for diabetes patients, among others, to improve patient care outcomes. Such an approach can meet the complex needs of diabetes patients.

Multidisciplinary care for diabetes patients is achievable through interventions for quality improvement, including the addition of mid-level practitioners and should get directed towards improving the primary care setting. It involves the redistribution of responsibilities for pharmacists and nurses, the use of electronic tools, data exchange, and communication facilitation between the provider and the patient.

Chapter 1: Purpose and Significance of The Study

The primary purpose of this study is to investigate the effects of multidisciplinary care on a patient with diabetes.  The study will also look at the impact of primary interdisciplinary responsibility on the control of glycemic and risk reduction in a diabetes program. The significance of the study is to provide insight into how multidisciplinary care of diabetes patients can help improve the living standards of the patients by providing better and quality care.

Chapter 2: Literature Review

Problem Size in Caring for Diabetes Patients

Diabetes is a chronic disease that is caused by either failure of the pancreas to produce enough insulin, which is a hormone that is involved in the regulation of glucose or blood sugar, or when the body is not able to use the insulin, it produces effectively. Diabetes has become a public health problem and is among the top priority noncommunicable diseases targeted for control in the world. The prevalence and number of diabetes cases have been increasing in the past few decades.

In the world, it is estimated that over 422 million people were living with diabetes in 2014, compared to 108 million in 1980 (2). Diabetes prevalence globally with age-standardized has almost doubled from 1980, increasing from 4.7% to 8.5% (2). the rise can get attributed to risk factors such as being obese or overweight. In the past decade, diabetes prevalence in low- and middle-income countries has increased at a higher rate compared to prevalence in high-income countries. In 2012, diabetes was responsible for 1.5 million deaths globally (2). Blood glucose levels higher than optimal caused an additional 2.2 million deaths by increasing cardiovascular risk and other conditions (2). 43% of the deaths occurred before the age of 70. The percentage of deaths occurring before the age of 70 years is low in high-income countries and high in low- and middle-income countries (2).

Diabetes Aetiology

There are two types of diabetes, which include type one and type two. Both diabetes has different causes, which should get investigated to understand how multidisciplinary care can assist in improving the health care provided to diabetes patients

Type 1 diabetes is also known as insulin-dependent diabetes or juvenile diabetes, and it is characterized by the failure of the pancreas to produce enough insulin. Insulin is needed by the body to allow glucose to enter body cells to produce energy. Various factors contribute to the occurrence of type 1 diabetes. Type 1 diabetes is mostly noticed during childhood and adolescence, but it can also occur in adults. The disease has no cure despite the numerous researches done on it. Treatment is focused on blood sugar level management using insulin, lifestyle, and diet to avoid complications.

The exact cause of type 1 diabetes is not known. It mostly occurs when the body’s immune system responsible for fighting harmful viruses and bacteria destroy cells producing insulin in the pancreas. Other causes may be genetic or exposure to environmental factors such or viruses. To understand how type 1 diabetes occurs, it is necessary first to evaluate the role of insulin in the body. After the destruction of a significant number of islet cells, the body produces little to no insulin. The pancreas is located below the stomach and is responsible for secreting insulin. Insulin then circulates in the body enabling sugar to enter body cells. This process helps to reduce the amount of sugar in the bloodstream. A decrease in the amount of sugar in the blood is accompanied by a reduction in the amount of insulin secreted by the pancreas. Glucose is the primary source of energy for cells, tissues, and muscles. Risk factors leading to type one diabetes. First, family history exposes one to type 1 diabetes, whereby anyone with a parent or sibling with the disease has higher chances of developing the illness. The other risk factor is genetics, whereby specific genes in the body increase the chances of one having type 1 diabetes. Geographically, the incidence of type 1 diabetes tends to increase as you move away from the equator. Age is also a risk factor with type 1 diabetes more common in children between the ages of 4-7 and adolescents between 10 and 14 years (3).

Metabolic and genetic factors mostly determine type 2 diabetes. Genetic factors are in the form of a family history of diabetes, ethnicity, and previous gestational diabetes, together with old age. Risk factors of diabetes include obesity and overweight, unhealthy diet, smoking, and physical inactivity. The most substantial risk factor of type 2 diabetes is overweight and obese, which is measured by the presence of excess body fats and a lack of physical exercise and poor diet. The aspect of being overweight is estimated to be the leading diabetes burden globally. A high body mass index and high waist circumference are linked with a high risk of type 2 diabetes, although the connection varies in diverse populations. For example, communities in European regions develop type two diabetes at a higher level of BMI compared to people in southeast Asia.

Particular dietary practices expose an individual to type 2 diabetes due to unhealthy body weight. Diets containing high intake of saturated fatty acids, low intake of dietary fiber and high total fat intake, high consumption of sugar-sweetened beverages, and those with a high content of free sugar put one at risk of becoming obese and overweight especially for young children. Effects of nutrition during early childhood affect the risk of type 2 diabetes in later stages of life. Factors such as low birth weight, weak fetal growth, and high birth weight increase the chances of one getting the disease. Heavy smoking elevates the chances of one getting type 2 diabetes, and the risk remains raised for about ten years after stopping smoking.

There are several complications associated with the two types of diabetes, which lead to the need for multidisciplinary care of diabetes patients to help patients get through. The complications occur due to poor management of diabetes that may endanger the life of the individual. Poor quality of life and high mortality costs can be attributed to acute complications caused by diabetes. High levels of glucose in the blood can lead to one suffering from life-threatening conditions such as hyperosmolar coma and diabetic ketoacidosis (2). Low blood sugars, on the other hand, occur in all types of diabetes and leads to loss of consciousness and seizures. Diabetes may also damage the heart, eyes, blood vessels, nerves, and kidney and expose one to stroke and heart disease. These damages result in reduced flow of blood and loss of nerves in the feet, commonly known as neuropathy, increasing the chances of one suffering from foot ulcers, infection, and eventually the need to amputate the limb (2). Diabetes also damages blood vessels in the retina, which leads to blindness. It also exposes one to other vision conditions such as glaucoma and cataracts (2). High levels of sugars in the blood can be dangerous to both the mother and the child leading to pregnancy complications. It increases the risk of stillbirth, miscarriage, and birth defects in case diabetes is not adequately managed.

Diagnosis of Diabetes

Multidisciplinary diabetes care has a significant role in the diagnosis of diabetes. Several tests are carried out in the diagnosis of type 1 and type 2 diabetes. The American Diabetes Association recommends that the following people get screened for diabetes under its recommended guidelines. First, individuals with body mass index higher than 25 should get tested for diabetes irrespective of their age. Those with additional risk factors such as abnormal levels of cholesterol, high blood pressure, heart disease, sedentary lifestyle, close relatives with diabetes, and history of polycystic ovary syndrome. People aged over 45 years are advised to go for screening, and if their results are healthy, they should go for blood sugar screening every three years. Women with gestation diabetes should be screened every three years. Finally, individuals diagnosed with prediabetes should get tested every year.

Different tests are done to diagnose diabetes. The glycated hemoglobin (A1C) test is commonly used for type 1 and type 2 diabetes diagnosis. It is a blood sugar test that is used to measure blood sugar levels for the past two to three months by determining the blood sugar percentage attached to the hemoglobin (3). More sugar attached to hemoglobin indicates high levels of sugar in the blood. An A1C level below 5.7% is considered normal, while that above 6.5% in two separate tests means one has diabetes (3). Prediabetes is shown by an AIC ranging between 5.7% and 6.4%. Other tests can also be done in case the patient has a condition that makes the A1C results inaccurate such as pregnancy or a person with a rare form of hemoglobin (3). The test includes a random blood sugar test where blood is taken at a random time, and blood sugar level above 200 mg/dl indicates diabetes (3). Fasting blood sugar test is carried out where a blood sample is taken after overnight fasting. Fasting blood sugar level above 126mg/dl is considered diabetic while that below 100mg/dl is normal.

Prognosis

Type 1 diabetes, if not well managed under the multidisciplinary diabetes care, may result in diabetic ketoacidosis, a condition that is categorized by severe disturbances in fat, protein, and carbohydrates metabolism. There is, however, good news for type 1 diabetes patients whereby tight control of blood sugar levels through multidisciplinary care can help reduce cases of macrovascular and microvascular diseases.

References

1. Berkowitz SA, Eisenstat SA, Barnard LS, Wexler DJ. Multidisciplinary, coordinated care for Type 2 diabetes: A qualitative analysis of patient perspectives. Primary care diabetes. 2018 Jun 1;12(3):218-23.
2. Zare M, De Grubb MC, Klawans MR, Suchting R, Mathis J, Juneja M, Moreno C, Zoorob R. Multidisciplinary Diabetes Care in a Safety Net Clinic: Lessons Learned from a Quality Improvement Initiative. Journal of Clinical Outcomes Management. 2018 May;25(5):206-10.
3. American Diabetes Association. 4. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2019. Diabetes Care. 2019 Jan 1;42(Supplement 1): S34-45.