Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes

Developed by Department of Health Loddon Mallee Region

Department of Health

Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes

These evidence - based pathways have been developed to help guide clinicians in the Loddon Mallee region in the appropriate care and management of people with prediabetes and diabetes. The pathways provide guidelines for the identification and management of prediabetes, type 1, type 2 and gestational diabetes, and are not intended to replace professional judgement or clinical expertise. National and international guidelines have informed the development of these pathways and it is anticipated that they will be reviewed and updated as changes to national guidelines arise.

These pathways are endorsed by Diabetes Australia - Victoria.

Pathways for prediabetes, type 1, type 2 and gestational diabetes were developed by Department of Health, Loddon Mallee Region. The pathways were prepared by Collaborative Health Education and Research Centre (CHERC), a business unit of Bendigo Health.

DH Loddon Mallee 2009 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Department of Health, Loddon Mallee Region.
Graphic Design - www.youngbloodink.com.au

Table of Contents
Acknowledgements ................................................................................................. 4 Glossary of Acronyms & Abbreviations ......................................................... 5 Explanatory Notes.................................................................................................... 6 Prediabetes: - Prediabetes Clinical Pathway .................................................................................... 8 - Prediabetes Ongoing Self-Management Pathway................................................. 9 Type 1 Diabetes: - Type 1 Diabetes Clinical Pathway ........................................................................... 10 - Type 1 Ongoing Self-Management Pathway ......................................................... 11 Type 2 Diabetes: - Type 2 Diabetes Clinical Pathway ........................................................................... 12 - Type 2 Diabetes Ongoing Self-Management Pathway ........................................ 13 Gestational Diabetes: - Gestational Diabetes Clinical Pathway .................................................................. 14 - Gestational Diabetes Ongoing Self-Management Pathway ............................... 15 References .................................................................................................................. 16

August, 2009 PAGE 3

Acknowledgements
Design of the Loddon Mallee Regional Diabetes Pathways has been based on the collective contribution of all members of the working party. The working party consisted of clinical experts from within the region, who have freely given of their time to guide and direct the development of these four pathways. Their enthusiasm, expertise and willingness to participate has ensured successful development of the pathways. Members of the LMR Regional Diabetes Model Pathway project working party: Professor Frank Alford.................Endocrinologist St. Vincents Hospital, Melbourne Jacqui Cesco.................................Diabetes Educator/Care Co-ordinator, Sunraysia Community Health Services, Mildura Michelle Chappel..........................Practice Nurse, Central Victorian General Practice Network, Bendigo Fran Degrandi................................Pharmacist, Central Highlands General Pratice Network, Gisborne Kate Edwards ................................Dietitian, Bendigo Community Health Services, Bendigo Lyn Flavell ......................................CDE, Sunraysia Community Health Services, Mildura Raelene Gibson .............................Diabetes Educator, Mildura Base Hospital, Mildura Linley Grylls ...................................CDE, Diabetes Team Leader, Bendigo Health, Bendigo Dr. Greg Harris ..............................Physician, Bendigo Ange Jewson ................................Community Health Nurse / CDE, Swan Hill District Health, Swan Hill Tracy Kemp ....................................Podiatrist, Sunraysia Community Health Services, Mildura Susan Kennett ...............................Podiatrist, Bendigo Community Health Services, Bendigo Claire Kerslake ..............................Diabetes Educator, Deniliquin Elizabeth Lacey .............................Diabetes Educator, Kyneton District Health Service, Kyneton Robyn Lindsay ...............................Physiotherapist, Bendigo Health, Bendigo Jane McCaig .................................Exercise Physiologist, Bendigo Health, Bendigo Dr. Sydney Paul .............................General Practitioner, Deniliquin Wendy Pogue ................................CDE, Kyabram and District Health Service, Kyabram Angela Roney ................................Diabetes Educator, Northern District Community Health Service, Kerang Christine Schaller .........................Dietitian, Bendigo Health, Bendigo Catherine Shultz............................Diabetes Educator (acute) Swan Hill District Health, Swan Hill Katrina Sparrow............................Registered Nurse Div 1, Bendigo Health, Bendigo Fiona Williams ...............................Practice Nurse/Diabetes Educator, Maldon Medical Clinic, Maldon Janette Woolley ............................CDE, Bendigo Community Health Services, Bendigo

August, 2009 PAGE 4

Glossary of Acronyms & Abbreviations

ADEA ......................Australian Diabetes Educators Association ADIPS .....................The Australasian Diabetes in Pregnancy Society ATSI.........................Aboriginal and Torres Strait Islander AUSDRISK.............The Australian type 2 diabetes risk assessment tool BGL..........................Blood glucose level BMI .........................Body mass index BP ............................Blood pressure CDE..........................Credentialled diabetes educator CHO .........................Carbohydrate CVD .........................Cardiovascular disease DAA.........................Dietitians Association of Australia DAFNE ....................Dose adjustment for normal eating DA Ltd .....................Diabetes Australia (national organization) DAV .........................Diabetes Australia (Victoria) DE ............................Diabetes educator DMMR....................Domiciliary medication management review EPC ..........................Enhanced primary care FBG..........................Fasting blood glucose GAD.........................Glutamic acid decarboxylase GCT..........................Glucose challenge test GDM........................Gestational diabetes mellitus GP ............................General practitioner HbA1c.....................Glycated haemoglobin HDL..........................High density lipoprotein HMR ........................Home medicines review Ht..............................Height Hx.............................History ICU...........................Intensive care unit IFG ...........................Impaired fasting glucose/glycaemia IGT ...........................Impaired glucose tolerance K10...........................Kessler psychological distress scale

Kg/m2......................Kilograms/metres2 LDL...........................Low density lipoprotein LSMP ......................Lifestyle modification program MBS ........................Medical benefits schedule mmol/L....................Millimoles per litre NCCCC....................National Collaborating Centre for Chronic Conditions NCCWCH...............National Collaborating Centre for Womens and Childrens Health NDSS ......................National Diabetes Services Scheme NHMRC ..................National Health and Medical Research Council NHPAC ...................National Health Priority Action Council NICE ........................National Institute for Health and Clinical Excellence OGTT .......................Oral glucose tolerance test OHA.........................Oral hypoglycaemic agent PD ............................Prediabetes PG ............................Plasma glucose PWD........................Person with diabetes RACGP....................Royal Australian College of General Practitioners RBG .........................Random blood glucose SBGM .....................Self blood glucose monitoring T1DM ......................Type 1 diabetes mellitus T2DM ......................Type 2 diabetes mellitus TCA..........................Team care arrangement WHO .......................World Health Organisation Wt ............................Weight 2hrG.........................2 hour OGTT

= Decision

= Action

PREDIABETES TYPE 1 DIABETES TYPE 2 DIABETES GESTATIONAL DIABETES

August, 2009 PAGE 5

Explanatory Notes
Annual Cycle of Care
The Annual Cycle of Care (Diabetes) provides minimum guidelines of care for a person with diabetes. General practitioners working in an accredited practice, can apply for the Practice Incentive Program (PIP) with Medicare Australia and receive a Service Incentive Payment (SIP) for each cycle of care completed for a person with diabetes, within an 11 to 13 month period. It would be anticipated that most people with T1DM and T2DM require more frequent monitoring and review. 7 24 The minimum requirements include: Activity Assess diabetes control by measuring HbA1c Ensure that a dilated fundus examination and visual acuity assessment is carried out by an ophthalmologist or optometrist Measure weight, height & calculate BMI Measure blood pressure Examine feet Measure total cholesterol, triglycerides and HDL Test for microalbuminuria Provide self-care education Review diet Review levels of physical activity Review smoking status Review medication Frequency / Description At least once every cycle At least every two years At least twice every cycle At least twice every cycle At least twice every cycle At least once a cycle At least once a cycle Assess self-management practices ( at least once a year) & review feedback from diabetes educator Reinforce key messages from dietitian and review nutrition (at least once a year) Reinforce importance of regular and appropriate levels of physical activity (at least once a year) At least once a year At least once a year and consider referral for DMMR / HMR

Diabetes Educators
Credentialled Diabetes Educators (CDE) are nationally accepted as providing quality assured provision of diabetes self-management education. An ADEA CDE is recognised as having met the following criteria: Authorisation to practice in an eligible health discipline Completion of an ADEA accredited graduate certificate course of study in diabetes education and care 1800 hours of experience in providing diabetes self-management education as defined by ADEA and in accord with the Standards of Practice identified by ADEA Submission of a refereed report by a CDE Completion of a mentoring program Evidence of continuing education across all domains of practice for CDEs Commitment to the ADEA Code of Conduct for Diabetes Educators 40 The following disciplines are eligible for recognition as a CDE Registered nurse (in Victoria this applies to division one registered nurses only) Accredited practising dietitian (APD) Registered medical practitioner Registered pharmacist who is also accredited by either the Australian Association of Consultant pharmacy (AACP) or the Society of Hospital Pharmacists Australia (SHPA) While recognising Credentialled Diabetes Educators (CDE) as the gold standard in the provision of diabetes self-management education, the term diabetes educator for the purpose of these pathways is taken to mean a person who has successfully completed an ADEA accredited graduate certificate in diabetes education and management. The term diabetes resource nurse and Aboriginal health worker, applies to a person employed within a health care service who has undertaken an appropriate and recognised level of training in diabetes. A number of diabetes courses are available, including 2 day diabetes workshops conducted by Diabetes Australia (Victoria) and an online training course Diabetes Management in the General Care Setting, developed by the National Association of Diabetes Centres (NADC) a joint initiative between the Australian Diabetes Educators Association (ADEA) and the Australian Diabetes Society (ADS). Neither of these courses, on completion, entitles a person to use the title Diabetes Educator.

Kessler Psychological Distress Scale (K10)

A simple screening tool, which can be used during a consultation to assess the mental health state of a person with diabetes18

August, 2009 PAGE 6

Explanatory Notes
Prediabetes
Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are conditions in which blood glucose levels are elevated but not high enough for a diagnosis of diabetes to be made. People with prediabetes are at increased risk of developing diabetes, cardiovascular and other macrovascular disease12

Self-Management
Self-management is the cornerstone of diabetes care. Actively encouraging, supporting and involving people with diabetes in their self-management, promotes health and well being, improves quality of life, reduces depression and anxiety, significantly increases satisfaction with their treatment and reduces utilisation of health services 6 Optimal and effective self-management of diabetes is best supported by an evidence-based and collaborative approach to care involving ongoing feedback and communication between all parties.

Systems for Care

People with diabetes require a systematic approach to their management, particularly annual review, from all members of a multi-disciplinary team. A systematic approach for GPs is facilitated by the use of: A disease register An active recall system to facilitate timely recall of all people when aspects of diabetes management require review ( pathology, complication screening, monitoring, reviews and care planning). Flow charts Review charts The RACGP and General Practice networks have resources to assist practices in establishing such systematic approaches to the care of their patients with diabetes 6 7

August, 2009 PAGE 7

Prediabetes Clinical Pathway

The Australian Type 2 Diabetes Risk Assessment (AUSDRISK) is a questionnaire screening tool which accurately predicts a persons risk of developingT2DM within the next five years 2 3 5

Everyone can be screened using AUSDRISK tool but people identified at high risk of T2DM should be screened 1

People at risk of developing T2DM and PD

-

A family history of T2DM Aged 55 years and over Aged 45 years and over with 1 or more associated CVD risk factor Aboriginal and Torres Strait Islanders (ATSI) From culturally and linguistically diverse backgrounds aged 35 years and over Pacific Islanders, Maltese, people from the Middle East, North Africa, Indian sub-continent, China, Vietnam

- Overweight or obese (BMI > 25kg/m2). Waist circumference is an indicator of abdominal fat which increases risk of T2DM and CVD - Women who have had GDM - Women with Polycystic Ovarian Syndrome who are overweight - Smokers - Physical inactivity - Those taking certain medications, antipsychotic medication & steroids

Person performs self-assessment of T2DM risk using AUSDRISK tool3

<5

AUSDRISK score Low risk < 5 Intermediate risk 6 14 High risk > 15 4 6 - 14 > 15 GP/health professional confirms AUSDRISK score 4

Promote importance of healthy lifestyle choices for prevention of T2DM, PD and CVD. Provide information on local community based LSMP/self-management interventions. Encourage continued good health5 Recheck FBG 3 yearly 2 Yes Are there identified risk factors for T2DM & PD? < 5.5 Low Risk diabetes unlikely*

No Perform FBG (laboratory tested) if not done in last 12 months. Results indicate: < 5.5 (diabetes unlikely) 5.5 6.9 (diabetes uncertain) > 7.0 (diabetes likely)*2

> 7.0 diabetes likely

5.5 - 6.9 diabetes uncertain

Are symptoms of diabetes present? NO Recheck FBG > 24 hours. In the presence of illness wait until well *2

YES

Perform OGTT Results indicate: FBG < 6.1 or 2hrG < 7.8 (diabetes unlikely) FBG 6.1 6.9 or 2hrG < 7.8 (IFG) FBG < 7.0 or 2hrG 7.8 11.0 (IGT) FBG > 7.0 or 2hrG > 11.1 (diabetes)*2

< 7.0 Result of FBG

F. > 7.0 Person diagnosed with prediabetes. Refer to - LSMP - Diabetes educator - Dietitian LINK TO REVERSE

Link to Type 2 Diabetes Clinical Pathway

* People with AUSDRISK score of 15 or more with a FBG of < 5.5 are eligible for Life! Program
August, 2009 PAGE 8

Prediabetes Ongoing Self-Management Pathway

DESIRED OUTCOMES - identify and screen for T2DM & PD - diagnosis and early intervention for people diagnosed with PD - prevent and delay progression to T2DM with intensive, evidence based lifestyle modification interventions - annual screening for T2DM and CVD

A person with prediabetes requires referral for intensive LSMP by GP

T2DM has been excluded with recent FBG 3

Score 14 & less Lifestyle Modification Program Not eligible for Life! Program. Consider referral to other locally available LSMPs - Consider Life on Line or telephone coaching

Reassess AUSDRISK score Prediabetes adds 6 points to initial AUSDRISK score 4

Score 15 & over

Consider referral to appropriate and locally agreed allied health professional: - dietitian - diabetes educator - exercise physiologist/physiotherapist

Role of GP: - provide a systematic approach to PD management with systems for care - annual review of modifiable lifestyle risk factors for T2DM and CVD - annually perform a clinical CVD risk assessment including BMI, waist circumference, BP, FBG & fasting lipids - consider referral to other allied health professionals based on local community availability and persons need - psychosocial stress may increase individual risk of developing T2DM. Screening with K10 tool can identify people with depression and anxiety - support and promote self-management practices People with Prediabetes should receive same target goals of BP and lipid management as people with T2DM. consider using these MBS Item numbers Item 710 ATSI adult health check if person is aged 15 - 54 years (inclusive) Item 713 T2DM Risk Evaluation if aged 40 - 49 years (inclusive). Item 717 45 year old health check Refer to MBS for full item descriptor and explanatory notes on all these item numbers 5 6 7 8 9 10 11 12

Lifestyle Modification Program - if aged 40 years & over, eligible for subsidised LSMP eg. Life! Program. - an ATSI adult person aged 15 54 years is also eligible for Life! Program - a person of any age is also eligible for Life! Program, under WorkHealth initiative - consider referral to other locally available self-management interventions & LSMPs

A person with PD understands T2DM may be prevented or delayed by adopting healthier lifestyle modifications

Role of LMP FACILITATOR/DIABETES EDUCATOR Provide evidence-based interventions which promote and support healthier lifestyle change & choices in prevention of T2DM. LSMPs promote self-management and selfdetermination by addressing modifiable lifestyle risk factors for T2DM using behaviour change techniques, counselling and goal setting. eg. - The Life! Program - diabetes educators (based on local agreement) - other community based diabetes self-management groups and LSMPs available in the Loddon Mallee region Contact local Division of General Practice and Community Health Centres for available programs in your area

Role of ABORIGINAL HEALTH WORKER Provide culturally appropriate support and counselling to promote understanding of PD and T2DM prevention 7

Role of DIETITIAN Assess nutritional needs, develop personalised eating plans, offer nutritional counselling, support, weight management and specific nutritional advice for people with PD, dyslipidaemia & hypertension 21 Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPIST Provide individual assessment, exercise prescription and behaviour-change counselling - regular physical activity is a key message, and should be provided by all members of the multidisciplinary team. - exploring individual preference for physical activity and providing information about local exercise interventions, and advise appropriate to the persons age and level of fitness. 5

Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with prediabetes 6

Role of PRACTICE NURSE, COMMUNITY HEALTH NURSE & DIABETES RESOURCE NURSE - Establish and maintain systems for care and identify people who may be at risk of T2DM and PD and access for aged-related health checks. - promote healthy lifestyle modification with high emphasis placed on T2DM being preventable - consistent with Dietary Guidelines for Australian Adults & Physical Activity Guidelines for Australian Adults - support ongoing self-management practices with advice and information which is current & appropriate. - reinforce feedback key messages from LSMP facilitators and other members of the multidisciplinary team. 7 12

REFERENCES:
1Diabetes Australia Victoria 2009 2 NHMRC 2001. 3 Diabetes Australia 2009 4 Diabetes Australia Victoria 2009 5 Royal Australian College of General Practitioners 2009 6 National Health Priority Action Council 2006 7 Royal Australian College of General Practitioners 2008 8 9 10 Department of Health and Ageing 2009. 11 Department of Health (WA) Diabetes Australia (WA) 2005 12 Twigg et al 2007

August, 2009 PAGE 9

Type 1 Diabetes Clinical Pathway

Person presents with: - hyperglycaemia (RBG > 11.1 mmol/L) - polyuria - polydipsia 31 Does person have? - non-fasting ketonuria - marked weight loss *30 YES NO Ignoring age & BGL, are there symptoms of: ketonuria (may be absent) polyuria, polydipsia & weight loss no other features of the metabolic syndrome & BMI < 25 family hx of autoimmune disease in 80% of people GAD & IA2 antiibodies will be present 13 14 NO Link to Type 2 Diabetes Clinical Pathway

Person with initial diagnosis of T1DM requires immediate referral to medical practitioner

YES

Person well ambulatory service provision Criteria include: - BGL elevated - no acute illness - no signs of ketoacidosis - 24 hr access to clinical advice 31 33

Options

Paediatric clients-emergency department admission Criteria includes: - all children under 5 years of age to be admitted to a paediatric acute setting or consider ICU 31

Person acutely unwell emergency department admission Criteria includes: - BGL >11.1mmol/L - ketoacidosis - admission to ICU/acute setting Clinical findings - polyuria - polydipsia - weight loss - abdominal pain - weakness - vomiting - confusion Clinical signs - dehydration - deep sighing (kussmaul) respirations - smell of ketones - lethargy, drowsiness Biochemical signs - ketones in urine or blood - acidaemia pH<7.3 13 14 31

Person well acute hospital admission Criteria includes: - geographically isolated - physical/mental disability which may impede self-management - no telephone available in the home - language or communication difficulties - profound grief reaction in family - individual dependant on a carer who is unable to take responsibility for safe insulin administration 32 33 37

All people with T1DM, family & carers should receive immediate referral for survival skills education and self-management support

Refer to diabetes educator Person seen 1-2 hrs daily over 4-5 days

Refer to mental health worker/social worker If assessed at high priority, to be seen within one week. If at low priority, within one month of diagnosis. Up to 1 hr consultations several sessions over first month and then annually unless indicated more frequently 32

Refer to endocrinologist/ physician (adults) and paediatric endocrinologist/ paediatric physician (children and adolescents)

Refer to dietitian Initial contact within first week then 4-6 sessions over first month 32

Following survival skills phase and initial management, GP to refer all people with T1DM, family and carers for assessment, education and treatment within the first 12 months. Feedback between GP, PWD, carers and multi-disciplinary team

Refer to: - podiatrist - ophthalmologist/optometrist - exercise physiologist/physiotherapist - community Health/Sexual Health worker(adults only)

Link to Type 1 Diabetes Ongoing Self-Management Pathway

August, 2009 PAGE 10

Type 1 Diabetes Ongoing Self-Management Pathway

DESIRED OUTCOMES: - achieve optimal target management goals of BGLs, BP and lipid control - support optimal psychosocial adjustment to diabetes - monitor growth and development (children and adolescents) - prevent / early detection of macrovascular and microvascular complications with screening - promote self-management practices - quality of life 6 7 14 15 18 21 26 27 Role of ENDOCRINOLOGIST/PHYSICIAN/PAEDIATRICIAN Review - 3 monthly for children and adolescents & minimum of annually for adults. Initial contact-assessment of client including medical history, complications, recent diabetes history, family history, vascular risk factors, foot/eye/vision examination, urine albumin excretion, urine protein, serum creatinine, BP & fasting lipids - insulin initiation and adjustment as required

TYPE 2 DIABETES ONGOING MANAGEMENT PATHWAY

Ongoing contact - HbA1c measurements based on individual need. - screening for microvascular and macrovascular complications. - assess sexual health, discuss contraception and provide pre-conception advice as needed 13 31 Mircrovascular complications screening is critical for person with T1DM.

Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPIST Educate on - the link between physical activity and arterial risk - exercise in relation to insulin, nutritional needs pre and post exercise - establish and maintain a system of recall and review 6 13 Role of PODIATRIST - annual structured foot surveillance as minimum for adults, children and adolescents - check for skin conditions, shape and deformity, shoes, impaired sensory nerve function and vascular supply - establish and maintain a system of recall and review 6 13 Role of OPHTHALMOLOGIST/OPTOMETRIST - on diagnosis and yearly assessment for adults. adolescents after 2 years of diabetes and 5 years for children - assess visual acuity, new vessel formation - urgent referral to ophthamologist if sudden changes occur 13 Role of GP - annual cycle of care - systems for care - management planning, TCA & mental health care plan (as needed) - ensure recommended annual screening completed - assess sexual health, discuss contraception and provide pre-conception advice as needed - support for family & carers - ATSI people should receive culturally appropriate interventions - assess oral health & refer to oral health professional under available Medicare Australia dental items 7 31

Optimal adjustment to living for a person with T1DM, their family and carers *18

Role of DIABETES EDUCATOR Initial contact survival education - describing the diabetes disease process and treatment options - monitoring blood glucose, urine/blood ketones (when appropriate) discuss and demonstrate - insulin initiation and skill acquisition - preventing, detecting and treating acute complications eg.hypoglycaemia/ hyperglycaemia - VicRoads notification - NDSS registration - on-going self-management plan - peer support - sick day management Ongoing contact minimum of annual review - pathophysiology of diabetes - agreed self-management plan - insulin adjustment - long term complications - glycaemic control - effects of physical activity - hypoglycaemia - travel and diabetes - promoting pre-conception care and management during pregnancy (if appropriate) - children & carers (discuss childcare, preschool and school sick day management) - age-appropriate education on sexuality, smoking, alcohol and drugs, employment, fitness to drive - re-assess education requirements - establish and maintain a system of recall and review 6 31 38

Role of PHARMACIST - conduct an annual DMMR/HMR

22

Role of MENTAL HEALTH WORKER Initial contact - assess for client adjustment issues, limited social supports, needle phobia, depression, anger, anxiety. - assess the typical range of emotional reactions to the diagnosis of T1DM - guilt and grief - marital/personal stress - treatment adherence - anxiety and depression assessment and increased risk factors - children and adolescents need age-related assessment - establish and maintain a system of recall and review - provide support for family & carers 6 30 31

Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with T1DM, their family and carers. 6

Role of DIETITIAN Initial contact- survival education - family Hx, including beliefs about T1DM - medical Hx, conditions that may impact on diet - social situation, family structure, cultural issues - diet Hx (establish usual diet, energy intake, total and saturated fat, CHO intake and distribution, appetite and food preferences) - usual routine and activity - motivation and ability to ensure appropriate nutritional intervention such as hypoglycaemic measures Ongoing contact- minimum of annual review - height, weight, BMI - usual nutritional intake and appetite - meal planning/carb counting/DAFNE - self management - management of life activities and growth - method of treatment of hypoglycaemia - CHO intake & adjustment pre and post exercise - alcohol intake and advice - consideration of new medical conditions - re-educate where required - establish and maintain a system of recall and review 6 31 32

REFERENCES:
6. NHPAC (2006) 7. DA & RACGP (2008) 13. NCCCC adult (2004) 26. NHMRC 2008 30. Bristol, North Somerset and South Gloucestershire (2009). 32. National Institute for Clinical Excellence (NICE) 2004 33. ADEA 2004 31. NHMRC 2005 38. ADEA (2006)

August, 2009 PAGE 11

Type 2 Diabetes Clinical Pathway

Ignoring age & BGL, are there symptoms of: ketonuria (may be absent) polyuria, polydipsia & weight loss no other features of the metabolic syndrome & BMI < 25 family hx of autoimmune disease in 80% of people GAD & IA2 antiibodies will be present 13 14 YES Link to Type 1 Diabetes Clinical Pathway

Person with initial diagnosis of T2DM

CONSIDER Children & adolescents with T2DM need referral to paediatric endocrinologist / physician.

Does person have T2DM?

YES

First visit to GP

Provide information and registration / notification forms for NDSS & VicRoads

Assess modifiable lifestyle risk factors 5

Explore and identify psychosocial issues, reaction to diagnosis, factors affecting coping, adjustment & barriers to learning. Screen for depression

Clinical assessment & screening for CVD risk factors 5 6 1 4

Agreed individualised target goals of weight management, BGLs, BP and lipid management. Identify individual health priority and needs. Information resources should be current, consistent and consider culture, language, literacy, age and special learning needs.

Assess for 3 month trial of lifestyle modification only, with assistance from multi-disciplinary team. Are there symptoms of hyperglycaemia with BGL > 20mmol/L? 7 NO

YES

Assess individual needs Annual Cycle of Care GP management planning Refer to multi-disciplinary team members using TCA & allied healthgroup services to promote and support self-management practices 7 16 17

Consider commencing Metformin as first line OHA of choice 7

Refer to diabetes educator within one month of diagnosis. Based on priority of need should be seen within 6 weeks. May require earlier appointment

Refer to ophthalmologist /optometrist 26

Refer to dietitian within one month of diagnosis 21

Refer to exercise physiologist / physiotherapist

Refer to podiatrist 27

Mental health worker Social worker Smoking cessation program Aboriginal health worker Oral health professional (based on individual need assessment)

Refer to

Ongoing multi-disciplinary review based on clinical assessment and individual need, with feedback between PWD, GP & multi-disciplinary team. 19

Review by GP following 3 months trial of lifestyle modification. Recheck HbA1c,BMI, waist circumference and other investigations based on clinical assessment and individual need. Review medication management - consider referral for DMMR/HMR

Link to reverse for Type 2 Diabetes Ongoing SelfManagement Pathway

YES

Are individualised, agreed goals of management being achieved?

NO

August, 2009 PAGE 12

Type 2 Diabetes Ongoing Self-Management Pathway

DESIRED OUTCOMES: - achieve optimal target management goals of BGLs, BP and lipid control - support optimal psychosocial adjustment to diabetes - prevent / early detection of macrovascular and microvascular complications with screening - promote self-management practices - quality of life 6 7 14 15 18 21 26 27

Role of DIABETES EDUCATOR - provide & consolidate knowledge and understanding of diabetes. - identify and address gaps in learning and provide ongoing support and counselling, facilitating optimal adjustment to living with diabetes. - annual review is part of care and a minimum requirement. - establish and maintain a system of recall and review. 6 18 19 20

Role of PHARMACIST - conduct an annual Domiciliary Medication Management Review (DMMR) for people with diabetes living at home, who meet eligible criteria, using MBS Item 990 22

Role of DIETITIAN - provide nutritional assessment and nutrition prescription, education, goal setting and ongoing reviews - annual review is part of care - establish and maintain a system of recall and review * 6 20 21

Role of COMMUNITY HEALTH NURSE - promote and support optimal health and well being and assist with optimal adjustment to living with diabetes - establish and maintain a system of recall and review * 6

Role of ABORIGINAL HEALTH WORKER - provide culturally appropriate practical support and counselling to promote understanding of T2DM amongst Indigenous people - establish and maintain a system of recall and review * 6 7

Optimal adjustment to living for a person with T2DM 18

Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPIST - provide individual assessment, physical activity advice, exercise prescription and behaviour-change counselling - annual review is part of care - establish and maintain a system of recall and review
6 7 28

Role of GP - provide continuity and coordination of care - annual cycle of care - management planning & TCA - multi-disciplinary referrals using allied health service MBS items - review metabolic control (HbA1c, self-monitoring of BGLs) - surveillance and screening for macrovascular & microvascular complications, annual fasting lipids, U&Es & microalbuminuria - explore psychosocial issues, particularly depression, social isolation, sexual health, family stress. Screen using K10 screening tool and refer to appropriate allied mental health professional - people with an HbA1c > 8% for 6 months should be referred to an endocrinologist /physician for assesment and management Role of PRACTICE NURSE - establish & maintain systems for care, and under direction from GP assist with GP management planning, TCA and annual cycle of care. - conduct annual nursing review 6 7 8 14 15 16 17 19 23 24 26

Role of PODIATRIST - perform initial foot assessment, at diagnosis - following initial assessment, a podiatrist may consider a PWD at low risk of foot complications and able to receive ongoing foot screening from an appropriately trained health professional - people with high risk feet should be managed and assessed by a podiatrist - annual foot assessment should be conducted by a podiatrist, and is part of ongoing care - establish and maintain a system of recall and review 6 27

Role of OPHTHALMOLOGIST / OPTOMETRIST - ensure all PWD receive a dilated fundus examination and visual acuity assessment at initial diagnosis and at least every 2 years 7 22

Role of ENDOCRINOLOGIST / PHYSICIAN - ensure all people with complicated problems related to their diabetes receive expert clinical advice and management - reviews are based on clinical judgment and individual need.

Role of ORAL HEALTH PROFESSIONAL - provide optimal dental care for people with chronic and complex care needs who require assistance with oral health.. Medicare dental items (85011 87777) are currently available for people with diabetes using the EPC program

Role of SOCIAL WORKER - assist a person with T2DM address social, emotional, financial and practical issues that may affect daily living. - establish and maintain a system of recall and review 6

Role of ALLIED MENTAL HEALTH PROFESSIONAL - provide psychological assessment and therapy from eligible clinicians using Medicare GP mental health care items and better outcomes in mental health care program. - establish and maintain a system of recall and review 2 3 6

Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with T2DM 6

REFERENCES:
6 NHPAC 2006 7 RACGP 2008 14 Cohen,M 2007 15 NHMRC 2004 16, 17 Department of Health and Ageing 2009 18 Eigenmann C & Colagiuri R 2007 19 ADEA 2004 20 ADEA & ADA 2005 21 ADA 2006 22 23 Department of Health and Ageing 2009 24 Medicare Australia 2009 25 MIMS Australia 2008 26 NHMRC 2008 27 NHMRC 2005 28 AAESS 2008

August, 2009 PAGE 13

Gestational Diabetes Clinical Pathway

This pathway is not designed for women with pre existing T1DM or T2DM

Perform Risk Screening for GDM GDM in previous pregnancy Previous baby > 4.5kg Previous unexplained stillbirth BMI > 30kg/m2 - Over 30 years - Indigenous Australians - Certain high risk ethnic groups Chinese, Vietnamese, North African, women from Indian sub-continent, Polynesian & Middle Eastern - Prediabetes (IFG & IGT) 35 36

Woman has Pregnancy Confirmed

YES

Risk factors identified *2

NO

At 12 - 16 weeks gestation woman requires OGTT (75g glucose load) if F>5.5 or 2hr PG>8.0, confirms diagnosis 35

At 26-28 weeks gestation woman requires GCT (50g oral glucose load) if PG > 7.8 at 1 hr indicates an elevated result 35

YES

Is diagnosis confirmed?

NO

YES

Is GCT elevated?

NO

Woman requires OGTT (75g glucose load) at 26-28 weeks gestation, or if persistent glycosuria during pregnancy. F >5.5 2hrs or PG >8.0, confirms diagnosis 35

YES

Is diagnosis confirmed?

NO

Follow up with GP/ obstetrician for routine care during pregnancy.

A woman with GDM is considered a high risk pregnancy *14

Refer to dietitian

Refer to diabetes educator

Refer to obstetrician

If FBG <5.5 and 2 hrs postprandial <7.0 Woman to continue with diet and exercise management 35

NO

Elevated SBGM

YES

Persistant hyperglycaemia (on more than 2 occasions) FBG>5.5 or 2 hour postprandial >7.0 Woman referred to obstetrician/endocrinologist for initiation of insulin 35

Clinically uncomplicated Usual pregnancy care with close BGL and clinical monitoring 35

Review SBGM

Clinically complicated Obstetric management and consider delivery <38 weeks 35

Good control and no mccrosomia or complications consider delivery full term 35

Review SBGM

Poor control macrosomia or complications consider delivery <38 weeks 35

Woman requires BGL monitoring in the first 24 hrs post delivery and an appointment with GP at 6 weeks. Essential part of hospital discharge plan - provide woman with OGTT pathology request form with results to be followed up with GP at first postnatal appointment
August, 2009 PAGE 14

Gestational Diabetes Ongoing Self-Management Pathway

DESIRED OUTCOMES: - achieves optimal glycaemic control through pregnancy - delivers a healthy baby - provision of ongoing advice, information and screening for prevention of T2DM *35 Role of OBSTETRICIAN & MIDWIFE All women with GDM are considered to have a high risk pregnancy Manage and monitor a woman through pregnancy. Timing and frequency of foetal monitoring depends on other complications such as pre-eclampsia, hypertension, ante-partum haemorrhage, intrauterine growth retardation. Ultrasonography should be considered at around 34 weeks gestation to detect abnormalities of foetal growth and polyhydramnios. Encourage breast feeding. Consider referral to a lactation consultant 35

Role of GP & PRACTICE NURSE

- establish & maintain systems for care to ensure recommended ongoing follow up & screening. - at first postnatal visit ensure OGTT has been performed and results reviewed. If OGTT normal, rescreen with FBG in 3 years. If OGTT abnormal rescreen FBG annually and link to appropriate pathway - screen with AUSDRISK tool to determine risk of T2DM. Link to appropriate pathway - provide contraception advice and pre-conception counselling and consider OGTT prior to future conceptions 7 35

Role of PAEDIATRICIAN - BGL should be checked 1 hour post delivery then before the first 4 feeds for up to 24 hours. - a paediatrician should be present at delivery if significant neonatal morbidity is suspected 35

Optimal adjustment for a women with Gestational Diabetes *18

Role of ABORIGINAL HEALTH WORKER - provide culturally appropriate practical support and counselling to promote understanding of GDM and long term prevention of T2DM amongst indigenous people 7

Role of DIETITIAN Dietary therapy is the primary therapeutic strategy for the achievement of acceptable glycaemic control in GDM and should : - conform with the principles of dietary management of diabetes in general - meet the nutritional requirements of pregnancy - be individualised for each person depending on maternal weight and BMI - be culturally appropriate - moderate exercise is an adjunct therapy with benefits, when used with dietary modifications and / or insulin 35

Role of ENDOCRINOLOGIST / PHYSICIAN - Medically manage and monitor diabetes during pregnancy. Initiate insulin if blood glucose goals are exceeded on 2 or more occasions within a 1 2 week period, particularly in association with clinical or investigational suspicion of macrosomia 35

Role of LSMP/SELF-MANAGEMENT INTERVENTION - address modifiable lifestyle risk factors using behaviour change techniques, counselling and goal settings to prevent T2DM - refer to locally available community health self management and LSMPs 6

Role of DIABETES EDUCATOR Provide information, advice, support and assist with diabetes management. Important aspects of education for the woman and her partner include: - the implications of GDM to herself and her baby - the dietary and exercise recommendations - SBGM is the optimal choice of monitoring glycaemic control with one fasting and one postprandial BGL obtained daily as a minimum. - the frequency of testing can be increased or decreased depending on results and progress of pregnancy - insulin initiation and skill acquisition - survival skills and sick day management - contraception and pre-conception advice for future pregnancy - peer support 35 Minimum goals of SBGM: - fasting capillary BGL < 5.5 - 1hr postprandial capillary BGL< 8.0 - 2 hr postprandial capillary BGL < 7.0 35

Feedback and communication between all parties is crucial to achieving optimal health and well being for a woman with gestational diabetes 6

REFERENCES:
7 RACGP 2008 35 Australasian Diabetes in Pregancy Society (ADIPS) 2003.

August, 2009 PAGE 15

References
References used for Prediabetes, Type 1, Type 2 and Gestational Diabetes Pathway Design
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Diabetes Australia Victoria 2009, Who is at risk of type 2 diabetes?, Diabetes Australia, Melbourne, viewed 20 July 2009, www.diabetesvic.org.au NHMRC 2001, National evidenced based guidelines for the management of type 2 diabetes mellitus part 3 case detection and diagnosis of type 2 diabetes, National Health and Medical Research Council, Canberra, viewed 20 July 2009, <www.nhmrc.gov.au/publications/synopses/_files/di9.pdf> Diabetes Australia Victoria 2009, The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), Diabetes Australia, Melbourne, viewed 20 July 2009 www. diabeteslife.org.au/Portals/0/Risk-test.pdf> Diabetes Australia Victoria 2009, Program pathways, Diabetes Australia, Melbourne, viewed 20 July 2009 <www.diabeteslife.org.au/GPHealthProfessionals/ Programpathways/tabid89/Default.aspx> RACGP 2009, Guidelines for preventive activities in general practice 7thedn, Royal Australian College of General Practitioners, South Melbourne, viewed 20 July 2009 <www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheRedBook/redbook_7th_edition_May_2009.pdf> NHPAC 2006, National service improvement framework for diabetes, National Health Priority Action Council, Australian Government Department of Health and Ageing, Canberra, viewed 20 July 2009 www.health.gov.au/chronicdiseasestrategy DA & RACGP 2008. Diabetes management in general practice 2008 /09 a guide to type 2 diabetes, viewed 20 July 2009 www.diabetesaustralia.com.au/ PageFiles/763/DiabetesinGeneralPractice0809.pdf> Department of Health and Ageing 2009, Medicare benefits schedule item 710 aboriginal and torres strait islander adult health check,Canberra, viewed 20 July 2009 http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A27&qt=noteID&criteria=item%20710 Department of Health and Ageing 2009, Medicare benefits schedule item713 type 2 diabetes risk evaluation, Canberra,viewed20July2009 <http://www9.health. gov.au/mbs/fullDisplay.cfm?type=note&q=A29&qt=noteID&criteria=item%20713> Department of Health and Ageing 2009. Medicare Benefits Schedule item 717 45 year old health check , Canberra, viewed20July2009 http://www9.health.gov. au//mbs/fullDisplay.cfm?type=note&q=A31&qt=noteID&criteria=item%20717 Department of Health (WA) and Diabetes Australia (WA) 2005. Western Australian Impaired Fasting Glucose and ImpairedGlucoseToleranceConsensusGuideline s,viewed20July2009 http://www.diabetes.health.wa.gov.au/policy/docs/Western%20Australian%20IFG%20IGT%20Consensus%20Guidelines.pdf Twigg,SM, Kamp, MC, Davis, TM, Neylon, EK and Flack, JR 2007, Prediabetes: a position statement from the Australian Diabetes Society and Australian Diabetes Educators Association. MJA 166 : 9 7 May 2007. National Collaborating Centre for Chronic Conditions, 2004, Type 1 diabetes in adults: national clinical guideline for diagnosis and management in primary and secondary care. Royal College of Physicians, London, viewed 20 July 2009 http://www.nice.org.uk/nicemedia/pdf/G015_fullguideline_adults_development_ section.pdf Cohen, M. 2007. Handbook of diabetes management 8th edn. International Diabetes Institute, Caulfield. NHMRC 2004. National evidence based guidelines for the management of type 2 diabetes mellitus (part 5) prevention and detection of macrovascular disease in type 2 diabetes. Approved by the National Health and Medical Research Council 18 March 2004, viewed 20 July 2009 www.health.gov.au/internet/main/ Publishing.nsf/Content/pq-diabetes-guide Department of Health and Ageing 2009. Medicare benefits schedule item 721 GP management plan, viewed 20 July 2009 http://www9.health.gov.au//mbs/ fullDisplay.cfm?type=note&q=A29&qt=noteID&criteria=721 Department of Health and Ageing. Allied health group services under medicare people with type 2 diabetes items 81100 81125 information for GPs, viewed 20 July 2009 .http://www9.health.gov.au//mbs/fullDisplay.cfm?type=note&q=M3.1&qt=noteID&criteria=allied%20health%20group%20services%20under%20 medicare Diabetes Australia 2007, Outcomes and indicators for diabetes education a national consensus position. Diabetes Australia, Canberra, viewed 20 July 2009 http:// www9.health.gov.au//mbs/fullDisplay.cfm?type=note&q=M3.1&qt=noteID&criteria=allied%20health%20group%20services%20under%20medicare Australian Diabetes Educators Association 2004, The rationale for commonwealth government funding of diabetes self-management education. Prepared by Ann Nosworthy Consulting April 2004. View 20 July 2009 <www.adea.com.au/public/content/ViewCategory.aspx?id=39> Australian Diabetes Educators Association and Dietitians Association of Australia 2005, Joint statement on the role of accredited practicing dieticians and diabetes educators in the delivery of nutrition and diabetes self management education services for people with diabetes www.adea.com.au/public/content/ ViewCategory.aspx?id=40 Dietitians Association of Australia (2006). Evidence based practice guidelines for the nutritional management of type 2 diabetes mellitus for adults, viewed 21 July 2009, www.daa.asn.au Department of Health and Ageing 2009. Medicare benefits schedule items 900 and 903, domiciliary medication management review, viewed 21 July 2009 http:// www9.health.gov.au//mbs/search.cfm?q=item+900&sopt=S Department of Health and Ageing 2009. Medicare benefits schedule items 2710 to 2713 GP mental health treatment items, viewed 21 July 2009 http://www9. health.gov.au//mbs/search.cfm?q=item+2710&sopt=S Medicare Australia (2009). Practice incentive program (PIP) diabetes incentive. Last updated 18February2009, viewed 21 July 2009 http://www9.health.gov.au/ mbs/search.cfm?q=+PIP+diabetes&sopt=S MIMS Australia 2008

14. 15.

16. 17.

18. 19. 20.

21. 22. 23. 24. 25.

August, 2009 PAGE 16

References
26. 27. NHMRC 2008. Guidelines for the management of diabetic retinopathy. National Health and Medical Research Council, Canberra, viewed on 21 July 2009, viewed 21 July 2009 http://www.nhmrc.gov.au/publications/synopses/_files/di15.pdf NHMRC 2005. National evidence based guidelines for the management of type 2 diabetes mellitus (part 6) detection and prevention of foot problems in type 2 diabetes, National Health and Medical Research Council, Canberra, viewed on 21 July 2009 www.health.gov.au/internet/main/Publishing.nsf/Content/pqdiabetes-guide Australian Association for Exercise and Sports Science and Dietitians Association of Australia 2008. The collaboration of exercise physiologists and dietitians in chronic disease management, viewed 21 July 2009 http://www.daa.asn.au/files/Info%20for%20Professionals/Publications_and_Resources/PUB_AAESS_A4_ Brochures_FINAL_for_website.pdf World Health Organisation (WHO) 1999. Surveillance, definition, diagnosis and classification of diabetes mellitus and its complications www.who.int/diabetes/ publications/en/ Bristol, North Somerset and South Gloucestershire 2009. Diabetes mellitus integrated care 4th edn http://www.avondiabetes.nhs.uk/professional/pathway/ ICP%20Booklet%2009.pdf NHMRC 2005. Clinical practice guidelines: type 1 diabetes in children and adolescents. National Health and Medical Research Council, Canberra, viewed on 21 July 2009, Canberra www.nhmrc.gov.au/publications/synopses/_files/cp102.pdf National Collaborative Centre for Chronic Conditions 2004, Type 1 diabetes in adults national clinical guidelines for diagnosis in primary and secondary care, Royal College of Physicians, London, viewed 21 July 2009, www.nice.org.uk/nicemedia/pdf/CG015_fullguideline_adults_development_section.pdf ADEA 2004. National standards for the development and quality assessment of services initiating insulin therapy in the ambulatory setting. Australian Diabetes Educators Association, Holder , viewed on 21 July 2009 www.adea.com.au/public/content/ViewCategory.aspx?id=39 Queensland Health 2003 Best practice guidelines for the management of type 1 diabetes in children and adolescents summary for health professionals. www. health.qld.gov.au/publications/best_practice/16854.pdf Hoffman, L., Nolan, C. , Wilson J.D. and Simmons, D. 1998. Gestational diabetes mellitus management guidelines updated by Australasian Diabetes in Pregnancy Society (ADIPS) December 2002 MJA 2002 176(7):352 and updated guidelines endorsed by RANZCOG council February 2003 MJA 2004 181(6) : 342 veiwed on 21 July 2009 www.ranzcog.edu.au/publications/statements/coll-end-statements/ADIPS-gdm-management-guidelines.pdf Templeton, M. and Pieris-Caldwell I 2008. Gestational diabetes mellitus in Australia 2005 06. Diabetes series no. 10. Cat. No. CVD 44. Australian Institute of Health and Welfare : Canberra, viewed on 21 July 2009 www.aihw.gov.au/publications/cvd/gdmia05-06/gdmia05-06.pdf National Collaborating Centre for Womens and Childrens Health 2008. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. Royal College of Obstetricians and Gynaecologists, London, viewed 21 July 2009 www.nice.org.uk/nicemedia/pdf/ DiabetesFullGuidelineRevisedJULY2008.pdf ADEA 2006. Sick day management guidelines for diabetes. Australian Diabetes Educators Association, Weston, viewed 21 July 2009 www.adea.com.au/public/ content/ViewCategory.aspx?id=39 Department of Health and Ageing (2009) Dental services under medicare (medicare items 85011-87777) Viewed 30 July 2009 http://www.health.gov.au/internet/ main/publishing.nsf/content/dental+care+services ADEA 2007. The credentialled diabetes educator in Australia role and scope of practice, Australian Diabetes Educators Association. Viewed 5th August 2009. www.adea.com.au

28.

29. 30. 31. 32. 33. 34. 35.

36. 37.

38. 39. 40.

August, 2009 PAGE 17