Page 8 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

150 VOLUME 9 NUMBER 4 • NOVEMBER 2012
REVIEW SA JOURNAL OF DIABETES & VASCULAR DISEASE
Lipids should be monitored to attain the recommended targets
according the 2012 lipid guidelines. 23 Aspirin should be given to
all diabetics with a 10-year risk of cardiovascular disease of more
than 10%.
All diabetics should be strongly advised to stop smoking or
they should undergo smoking cessation therapy. Brief motivational
interviewing techniques should be employed.24 All diabetics should
be assessed annually or more often if indicated, preferably by a
cardiologist.
Regular physical activity and medical nutritional therapy should
be instituted in all cases. Hypertension should be treated strictly
according to the current guidelines. A waist circumference of < 94
cm in men and < 88 cm in women should be the target, except in
South Asians when it should be < 90 cm in men and < 80 cm in
women. All patients with uncontrolled diabetes should be referred
to a specialist physician or family physician with a special interest
in managing diabetes or to a diabetologist or endocrinologist.
Diabetes self-management education
Evidence shows that people with diabetes who do not receive
diabetes education have a four-fold risk of a major complication.
Therefore, educationmust be a planned, life-long process in diabetes
management as the condition evolves and life circumstances
change. 25
The diabetes nurse educator has a very important role in
patient education and training. The South African Nursing Council
currently does not recognise the diabetes nurse educator as a
special category for nurse training. A recommendation has been
made to the Nursing Council to investigate this.
Diabetes self-management education is one of the most
important aspects of diabetes care. Motivating behavioural
change in patients with diabetes should be an important function
of the family physician. If this is done according to the accepted
guidelines, the family physician should be confident to provide
shared care with the patient or hand over most of the care to him/
her, having scheduled regular follow-up visits and a recall system or
arrangements for self-referral.25
The general principles as set out in the 2012 SEMDSA guidelines
should be adhered to for all patients, both individually and in
groups.18 Family physicians can provide this service at clinics and
at district hospitals. This can be an important learning experience
about the realities of diabetic patient care, the varied issues that
diabetic patients encounter and the multiple problems that one has
to deal with at this level.
Tools family physicians can use include key open questions,
listening to the answers, a non-judgemental approach, defining
action plans and time scales, and developing the ADDIE model
( Analyse, Design, Develop, Implement and Evaluate) as a patient
education model or programme. Adult education principles should
be adopted (problem solving, self-efficacy), taking into account
social, cultural, economic and emotional issues, and including
personalised goal setting. People are much more likely to adhere to
decisions they make themselves than those made for them, and to
goals they have set themselves.
Critical components of behavioural change are knowledge,
concern, self-esteem and self-efficacy. These are the areas to be
engaged in when making decisions and setting goals.25 Diabetics
should be encouraged to take responsibility for their diet, smoking
cessation and exercise, to take ownership of their diabetes, identify
their motivations, outline their needs and wants, and break down
misconceptions.
The role of the family physician in patient education is to
promote active and successful decision-making by finding ways of
empowering and enabling the patient to think through and decide
what actions to take. Diabetes magazines are invaluable with
regard to patient education.
Health professional education
Good control of diabetes as well as the common co-morbidities
of hypertension, dyslipidaemia and the hypercoagulable state is
vital to prevent or delay the devastating long-term complications
of diabetes. To achieve optimal care, health professionals need
to be updated with knowledge, skills and recent advances in the
management of diabetes, especially the wide range of available
medications and treatment strategies, with an emphasis on risk-
factor control and, importantly, approaches to prevent or delay the
onset of diabetes or even ‘cure’ diabetes.22,26
There is a definite advantage to moving towards a team-
management strategy. Nurses and doctors who care for patients
with diabetes are strongly advised to undertake a training course in
diabetes management. Training courses, conferences, workshops,
certificate courses and diabetes journals, continuing medical
education (CME) and review articles are readily available throughout
South Africa and a three- or five-day advanced course in diabetes
care for health professionals is provided by the Centre for Diabetes
and Endocrinology.27
Family physicians as members of the diabetes management
team can play a valuable role in providing education for nurses and
doctors in the district clinics and local hospitals. As an example,
family physicians together with the consultant endocrinologist have
developed a certificate course for nurses at Greys Hospital. This has
been implemented for all PHC nurses in the Natal midlands and
currently at the Edendale Hospital diabetes clinic. Similar courses
will be held at other hospitals and clinics in the Natal midlands in
the near future.
Evaluation and monitoring of this educational impact can be
undertaken by family physicians working in these facilities. Regular
updates and advanced courses can also be arranged by them.
Maintaining quality in diabetes care
Quality of care requires the family physician to constantly
check whether the standard of care is being met and that the
recommended guidelines are being implemented effectively to
achieve the best outcomes possible, given the available resources.
To achieve this, the family physician would have to implement
the quality-improvement (QI) cycle. To achieve the best health
outcomes, one needs to make quality assurance a routine part of
daily practice. It is important to allocate enough time and resources
to a process of continuous quality improvement. The QI cycle needs
to become an integral part of continued professional development.
The cycle consists of four steps: 28
Set target standards and agree on criteria for this. •
Collect practice data or observe the practice. •
Evaluate data or information, i.e. performance versus targets. •
Plan care and implement change. •
The system must be managed for the benefit of the patient. This
includes appointment, record, referral and communication systems,
making sure there are adequate drug supplies, and ensuring