ueda2011 remote area diabetes clinic model-d.mesbah

1. REMOTE AREA DIABETES CLINIC
MODEL
MINIA EXPERIENCE
Mesbah Sayed
Kamel
MD

2. 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.

3.  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.

4. 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.

5.  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.

6. 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.

7. 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%)

8. NationalTotalQuantityItem
469643
Population per bed
1545.72222.2
Population per doctor
734.11178.5
Population per nurse
39.7946.52
Ambulance car per person
36.91.3
Health insurance coverage
(million)
National Free health coverage
1429.2326.09
Number (1000)
1617,941.59
Cost (Million)
4151.52935.8Income per capita
Reference: Ministry Of Health and Population 2006

9. 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

10. 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.

11. 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.

12. 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 implemented
The actual content of Protocols should depend on local
resources, chances for referral, and availability of as any
further treatment or investigations.

14. DIABETES CLINIC
MODEL

15. •D .Clinic
Eastern Desert
Nile River

21. 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.

22. 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.

23. FLOW CHART FOR DIABETES
HISTORY PARTArab Repuplic of Egypt
Samalout one
day surgery
hospital
Age --------------------------
Date ----------------------------
---Ministry of Health and
Population

24. FLOW CHART FOR DIABETES
HISTORY PART

25. FLOW CHART FOR DIABETES
ASSESSMENT PART

26. FLOW CHART FOR DIABETES
ASSESSMENT PART

27. FLOW CHART FOR DIABETES
FOLLOW-UP
Monthly followup
Yearly as a routine or as required

28. FLOW CHART FOR DIABETES
FOLLOW-UP

29. FLOW CHART FOR DIABETES
FOLLOW-UP AND MANAGEMENT

30. 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.

31. 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.

34. 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.

36. 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

37. NEW PATIENTS
 Registration and file completion.
 Clinical examination.
 Lab request :
FBS.PP,RF,LIPIDS,ECG and any
other investigations accordingly.
 Health Education session.

38. HEALTH EDUCATION
Items 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.

45. 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 pens
4. Presevation of insulin.
5. Symptoms of hypoglycemia and how to deal with.
 At last pt. will has prescription and next visit
appointment.

46. 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.

47. NUMBER OF PATIENTS ATTENDING THE
CLINIC 2006-2010
0
500
1000
1500
2000
2500
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
2006
2007
2008
2009
2010

48. BODY MASS INDEX AT REGISTRATION
0%
10%
20%
30%
40%
50%
60%
18-25 25-30 <30
Male
Female
1118
18-25 25-30 >30

49. BMI AFTER 9 MONTHS
0%
1000%
2000%
3000%
4000%
5000%
6000%
18-25 25-30 <30
Male
Female
18-25 25-30 >30
60%
50%
40%
30%
20%
10%

50. BMI AFTER 18 MONTHS
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
18-25 25-30 <30
Male
Female
>

51. HBA1C 2006-2008
0%
10%
20%
30%
40%
50%
60%
<7% <8 8-10% >10%
2006
2007
2008

52. %OF CONTROLLED BP(130/80)
2006-2008
0
10
20
30
40
50
60
2006
2007
2008

53. % HIGH LDL (>100) 2006-2008
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2006
2007
2008

54. % HDL INCREASE (>40) 2006-2008
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2006
2007
2008

55. % TG CHANGES 2006-2008
0%
10%
20%
30%
40%
50%
60%
2006 2007 2008
TG>150
TG>150

56. HYPOGLYCEMIA-DIABETIC KETOSIS
2006-2008
0
2
4
6
8
10
12
2006 2007 2008
Hypoglycemia
Diabetic ketosis

57. CVS MORTALITY 2006-2008
0
1
2
3
4
5
6
7
2006 2008
Death from CVS cause
Stroke
MI
CABG

58. 2006 2008 Relative RR
New or worsening retinopathy
354 287 7%

59. 2006 2008 Relative RR
New or worsening nephropathy
292 200 21%

60. % LOSS OF FOLLOW UP 2006-2010
0
1
2
3
4
5
6
7
2006 2007 2008 2009 2010
‫األول‬ ‫النصف‬
‫الثاني‬ ‫النصف‬
1st Half
2nd Half
2006 2007 2008 2009 2010

61. CAUSES OF FOLLOW UP LOSS
0
10
20
30
40
50
60
70
80
Insurance
uncover
Transportation
Waiting time
Uncontrol
Bad
communication
Drug
affordability

62. OBSTACLES
 Transportation.
 Limited space.
 Trained manpower.
 Drug affordability.
 Limited resources.

63. CONCLUSION
A 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.

64. 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.