Early adoption of the Annual Diabetes Cycle of Care

Early interventions targeting multiple risk factors can significantly reduce complications of diabetes.^1-3 Patients who are actively engaged in their own care are more likely to have beneficial outcomes.⁴ The annual diabetes cycle of care can be a useful framework for the care of people with diabetes.⁵ This therapeutic brief focuses on veterans who have been recently diagnosed with diabetes; it advocates the provision of support, resources and education to veterans.

Recent analysis of DVA health claims dataset identified 29,400 veterans with diabetes, of which over 12,800 had been diagnosed within the previous two years.⁶ Results of this analysis suggest diabetes services and processes of care are generally under-utilised among this group of veterans (Table 1).

Table 1: Services funded by DVA between 1 July 2010 and 30 June 2011, as part of the diabetes management for recently diagnosed veterans

	controlled with diet alone (N=7503)	recently initiated on medicines (N=5388)
HbA1c test	62%	59%
Microalbuminuria test	35%	33%
HDL test	59%	49%
Podiatrist visit	60%	50%
Dietitian service	5%	5%
HMR/RMMR	8%	7%
Diabetes educator	2%	2%
Exercise physiologist	3%	4%
Veterans with at least one service between 1 Jul 2009 and 30 Jun 2011 (2 year period)
Ophthalmology/optometry visit	63%	56%

HbA1c = glycosylated haemoglobin; HDL=high density lipoprotein (lipid tests)
HMR=Home Medicines Review; RMMR=Residential Medication Management Review

Implement the Diabetes Cycle of Care

There are a number of elements in the diabetes annual cycle of care. The Diabetes Management in General Practice Guidelines 2012/13 outlines recommended care (Diagram 1).¹ Provision of recommended services fulfil the requirements for the Annual Cycle of Care Medicare Benefits Scheme rebate. Consider a General Practice Management Plan (GPMP) (Medicare item 721) as part of this process.¹ Refer to Insert for DVA funded services available for veterans with diabetes.

 

Diagram 1: The Cycle of Care as recommended by the Diabetes Australia Guidelines 2012/13.

Address cardiovascular risk

Blood pressure and cholesterol control are as important as glucose control in reducing cardiovascular complications. Assessment of absolute cardiovascular risk will help identify people who need active intervention such as drug therapy and risk factor monitoring (absolute 10 year cardiovascular disease risk more than 15%). A cardiovascular risk calculator can be accessed at www.cvdcheck.org.au/. An ECG is recommended every second year if a patient is over 50 years of age with one or more other vascular risk factors.¹

Targets for blood pressure, blood lipids and HbA1c should be individualised according to patient and treatment factors. As a general guide, patients with diabetes should be encouraged to achieve the goals for optimum diabetes management listed in Box 1.¹

Box 1: Goals for optimum diabetes management¹

HbA1c	less than or equal to 7% or 53 mmol/mol
Blood pressure	less than or equal to 130/80 mm Hg
Total cholesterol	Less than 4.0 mmol/L
HDL-C	more than 1.0 mmol/L
LDL-C	Less than 2.0 mmol/L
Non-HDL-C	Less than 2.5 mmol/L
Triglycerides	Less than 2.0 mmol/L

Address glycaemic control

For every one percent decrease in HbA1c, the risk of microvascular complications is reduced by 37%.⁷ Patients with recently diagnosed diabetes benefit from intensive glycaemic control since this improves long-term cardiovascular outcomes.⁸ Target HbA1c is less than or equal to 42 mmol/mol (6%) for patients with a recent diagnosis, long life expectancy and no known cardiovascular disease.^9, 10

Less intensive glycaemic goals (HbA1c less than 53 mmol/mol or 7%) may be appropriate in patients with recurrent or severe hypoglycaemia, older people and patients with co-morbidities or limited life expectancy.^1, 2, 10 Always individualise HbA1c targets as strict glycaemic goals may increase the risk of hypoglycaemia and even mortality.^11-13

A baseline HbA1c should be performed at the time of diabetes diagnosis. In patients who are not achieving HbA1c goals or whose diabetes treatment has altered, HbA1c should be measured at least three monthly.² Otherwise review at least six monthly. Note; some conditions such as anaemia, chronic renal failure and variant haemoglobins may invalidate the HbA1c results.

The reporting of HbA1c will move towards a standard based on the chemistry of HbA1c, resulting in reported values presented as mmol of HbA1c per mol of haemoglobin (SI units) rather than %.¹⁴ A general conversion table for clinical use is provided in Box 2.

Box 2: Conversion for haemoglobin A1c (HbA1c) values

HbA1c as percentage (old units)	HbA1c in mmol/mol (new units)
6	42
6.5	48
7	53
8	64
9	75
10	86

Address nephropathy/microalbuminuria

Microalbuminuria is a marker of early renal damage, an independent predictor of end-stage renal disease and also a strong predictor of cardiovascular disease.¹

Screen all patients for microalbuminuria at the time of diabetes diagnosis and at least twelve monthly. Monitor three to six monthly if microalbuminuria is confirmed.

Address eye complications

Eye complications associated with diabetes include refractive errors, glaucoma, cataracts, retinopathy and maculopathy, which can lead to major vision impairment and blindness.¹

Refer to ophthalmologist or optometrist for a comprehensive eye examination at the time of diagnosis and at two yearly intervals.

Address foot complications/neuropathy

Educate patients about the importance of daily foot care. Early referral to a podiatrist is recommended. This is to assess potential abnormal foot architecture and to review peripheral neuropathy, vascular disease or deformity due to poor hygiene, poor foot-care and inappropriate footwear. An examination should be done at the time of diabetes diagnosis, preferably by a podiatrist. This can be followed by three monthly reviews with the GP or practice nurse. At twelve months, consider referral for a detailed assessment with a podiatrist, or earlier if required. Refer to Insert for DVA funded services.¹ Refer to the Insert for DVA funded services.

Review medicines

Patients with diabetes may receive an in-pharmacy review of medicines with a focus on the diabetes medicines management. For more information on the Diabetes MedsCheck services refer www.5cpa.com.au/medscheck.

Home Medicines Reviews undertaken by pharmacists can enhance patient compliance and understanding of their medicines. See Topic 29: Home Medicines Review: The benefits for you and your patient www.veteransmates.net.au/topic-29-therapeutic-brief. The review of medicines should be considered at least twelve monthly.¹

Monitor emotional wellbeing

Living with diabetes may have a profound effect on the emotional and psychological wellbeing of a patient. One in five patients with type 2 diabetes may experience depressive symptoms.¹⁵ It is important to monitor the patient's wellbeing during routine visits.¹⁶ Patients experiencing difficulties accepting the diagnosis of diabetes or who experience emotional or psychological distress may benefit from the support of a psychologist, social worker or counsellor.¹ Refer to Insert for DVA funded services. Refer to the Insert for DVA funded services.

Provide patient self-management education

Evidence suggests engaged patients who are actively involved in their health care achieve better health outcomes.⁴

Provide self-care education to patients initially and review their self-care skills frequently in the first year. Improving patient’s skills, knowledge and confidence to manage their own condition will help reduce complications and is the foundation of diabetes care.

This may include:

• establishing a healthy eating plan
• encouraging physical activity
• self-monitoring, such as home blood glucose monitoring
• proper medication usage
• managing high and low blood glucose levels
• establishing good foot-care and hygiene habits
• interacting with the multidisciplinary health care team and support services.¹

Refer patients with recently diagnosed diabetes to a diabetes educator initially, and then as considered necessary. Refer to the Insert for DVA funded services.

Diabetes education is ongoing and needs to continue for the rest of the patient’s life.

Promote lifestyle interventions

Adopting a healthy lifestyle is the essential component of diabetes management.

Diet and exercise may provide sufficient weight loss to result in near normal glycaemic control, blood pressure and lipid profiles.¹

The Royal Australian College of General Practitioners’ SNAP (Smoking, Nutrition, Alcohol and Physical activity) guide provides recommendations for implementing healthy lifestyle choices.¹

Smoking

Check smoking status, advise patient of the risks of smoking and encourage cessation frequently. Referring patients to the QUIT help line or website may also be useful.

Nutrition and Alcohol

Review and reinforce information about appropriate dietary choices frequently. Referral to a dietitian is important initially to ensure comprehensive education, thereafter as considered necessary. Refer to the Insert for DVA funded services. Advise your patients to restrict their alcohol intake to no more than two standard drinks (20 g) per day.¹⁷

Physical activity

Lifestyle modifications (diet together with at least 150 minutes of exercise per week) can achieve sufficient weight loss to improve glycaemic control in the majority of patients with recently diagnosed diabetes.¹ Review and reinforce information about appropriate levels of physical activity at least twelve monthly. Referral to an exercise physiologist may be recommended. Refer to the Insert for DVA funded services.

INSERT: What to discuss with your veteran patient with recently diagnosed diabetes

How DVA supports a comprehensive cycle of care for veterans with diabetes

The Department of Veterans’ Affairs supports high quality care for veterans with diabetes and recognises the key role allied health professionals play in providing treatment. The table on the following page summarises the treatment services available to entitled members of the veteran community which allied health professionals are eligible to claim through DVA. A Team Care Arrangements (TCA) can be arranged but is not a requirement to access these services. If you are unsure of a person’s eligibility for treatment, DVA can be contacted on 1800 550 457.

In most cases the provider of the service determines the type, number and frequency of the treatment services. Some services have treatment thresholds and prior financial authorisation requirements (details for the respective health care provider are available via the links included in the table on the following page).

A referral is generally required and is valid for 12 months, unless the referring provider has indicated on the referral that treatment is necessary for a chronic condition and that the referral is open-ended and ongoing. It is important to check that the service provider you refer an entitled person to accepts DVA arrangements.

General information about DVA supported services and an explanation of the procedures to be followed when providing health care services to entitled persons can be accessed at http://www.dva.gov.au/health-and-wellbeing/treatment-your-health-conditions.

The Department of Veterans’ Affairs also provides funded services and consumables to support wound management for eligible veterans with diabetes, along with aids and appliances designed to help veterans with diabetes maintain functional independence in their homes.

DVA funded services to support diabetes management include:

Diabetes Educator Diabetes educators can enhance knowledge about diabetes and self-management of the condition. A claim for diabetes education services cannot be provided to veterans receiving community nursing services from a DVA-contracted community nursing provider. Further information For health professionals and veterans: www.dva.gov.au/factsheet-hsv29-diabetes-educator-services Referral required: Yes

Dietitian Dietetic and nutritional services can help veterans with diabetes to manage their health through dietary and nutritional support. Further information For health professionals and veterans: www.dva.gov.au/factsheet-hsv21-dietetic-services Referral required: Yes

Podiatrist Podiatry services assess potential abnormal foot architecture and review peripheral neuropathy, vascular disease or deformity. Further information For health professionals and veterans: www.dva.gov.au/factsheet-hsv20-podiatry-services Referral required: Yes

Optometry services Optometrists can check for eye complications associated with diabetes including refractive errors, glaucoma, cataracts, retinopathy and maculopathy. One initial consultation and one subsequent optometric consultation can be claimed in a two-year period, unless the entitled person has a significant change in visual function or develops a new condition. Further information For health professionals and veterans: www.dva.gov.au/factsheet-hsv18-optical-services-and-supplies Referral required: No

Exercise Physiologist Exercise physiologists are university trained with knowledge and skills to design and deliver clinical exercise to manage chronic diseases such as diabetes. DVA does not provide exercise physiology services for generalised and ongoing exercise regimes or gym programs. Further information For health professionals and veterans: www.dva.gov.au/factsheet-hsv30-exercise-physiology-services Referral required: Yes

Psychologist and Mental Health Social Worker Psychologists and mental health social workers help prevent, assess, diagnose and treat a wide range of emotional problems that interfere with the normal functioning of daily life. Psychologists provide a range of psychological therapies and strategies including cognitive-behavioural therapy which helps to change negative patterns of thinking and behaviour. Further information For health professionals and veterans: www.dva.gov.au/factsheet-hsv99-mental-health-support Referral required: Yes

 

This information can also be accessed on the DVA websites indicated above. The full list of DVA funded health services is available on the DVA website at http://www.dva.gov.au/sites/default/files/files/health%20and%20wellbeing/healthservices.pdf

References

1. Diabetes Australia. Diabetes Management in General Practice 18th edition 2012/13. 2012[accessed 16 October 2012]; Available at: http://www.diabetesaustralia.com.au/Documents/DA/What's%20New/12.10.02%20Diabetes%20Management%20in%20General%20Practice.pdf
2. American Diabetes Association. Standards of medical care in diabetes - 2012. Diabetes Care 2012; 35 Suppl 1: S11-63.
3. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383-93.
4. Roehr B. Potential benefits of ‘well engaged patients’ are akin to those from a blockbuster drug, say experts. BMJ 2013; 346:1886.
5. AIHW (Australian Institute of Health and Welfare) Annual Cycle of Care: report of the AIHW Cardiovascular, Diabetes and Kidney Unit (CDK). Canberra: AIHW. 2012 [accessed 12 November 2012]; Available at: http://www.aihw.gov.au/diabetes-indicators/annual-cycle-of-care/
6. DVA Health Claims Database, University of SouthAustralia, QUMPRC. [accessed March 2012]
7. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321(7258): 405-12.
8. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359(15): 1577-89.
9. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012; 35(6): 1364-79.
10. Cheung NW, Conn JJ, d'Emden MC, et al. Position statement of the Australian Diabetes Society: individualisation of glycated haemoglobin targets for adults with diabetes mellitus. Med J Aust 2009; 191(6): 339-44.
11. Boussageon, R., T. Bejan-Angoulvant, et al. Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials. BMJ 2011; 343: d4169.
12. Hemmingsen, B., S. S. Lund, et al. Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. BMJ 2011 343: d6898.
13. Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes: results from the Action to Control Cardiovascular Risk in Diabetes Study G. N Engl J Med 2008; 358(24): 2545-59.
14. Jones GR, Barker G, Goodall I, et al. Change of HbA1c reporting to the new SI units. Med J Aust 2011; 195(1): 45-6.
15. Speight J, Browne JL, Holmes-Truscott E, et al. on behalf of the Diabetes MILES – Australia reference group (2011). Diabetes MILES – Australia 2011 Survey Report. Diabetes Australia – Vic, Melbourne. [accessed 15 November 2012]; Available at: http://www.diabetesaustralia.com.au/Documents/DA/What's%20New/12.05.16%20Diabetes%20MILES%20Report.pdf
16. Speight J. Managing diabetes and preventing complications: what makes the difference? Med J Aust 2013; 198 (1): 1-2. doi: 10.5694/mja12.11489

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