A Critical Appraisal Andre Sookdar - Class of 2013

Objective

To critically appraise the Caribbean Health Research Councils (CHRC) Guidelines on the Primary Care Management of Diabetes in the Caribbean

Introduction

Diabetes mellitus (DM) is one of the leading health problems in the Caribbean, contributing significantly to morbidity and mortality and adversely affecting both the quality and length of life. The disease also places a heavy economic burden on already limited health care resources in the Caribbean. Costs are related directly to treatment of the disease and its complications, and indirectly to loss of earning power in those affected.

Aim

To produce a unified, evidence-based approach to the management of diabetes in the Caribbean.

Objectives
To prevent or delay the onset of DM and comorbid conditions of obesity, hypertension and dyslipidaemia To promote earlier diagnosis of DM To improve the quality of care of persons with DM To prevent and treat acute and long-term complications of DM To promote education and empowerment of the patient, family and community, and health care worker

Guidelines

Definition DM is defined by the World Health Organization as a metabolic disorder characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

Classification Type 1, Type 2, Gestational Diabetes

Guidelines - Screening
Fasting Plasma Glucose (FPG) is the Recommended Screening Test Testing the Urine Glucose is not recommended for screening. Blood Glucose Meters can be used for initial screening but not for diagnosis.

Guidelines - Diagnosis
American Diabetes Association Criteria was used in 2006 and in 2010 Fasting Plasma Glucose 126 mg/dL (7.0 mmol/L) (No caloric intake for at least 8 hours) 2 hour post-load glucose 200 mg/dL (11.1 mmol/L) during an OGTT In a patient with classic symptoms, a random plasma glucose 200 mg/dl (11.1 mmol/1) New diagnostic criteria include HbA1c (6.5%)
(lab certified by a glycohemoglobin standardization program and standardized to the Diabetes Control and Complications Trial (DCCT) reference assay)

Guidelines
Increased Risk for Future Diabetes: Impaired Fasting Glucose Fasting plasma glucose 100-125 mg/dl Impaired Glucose Tolerance 2h plasma glucose 140-199 mg/dl Elevated HbA1c* HbA1c 5.7-6.4%

Guidelines - Effective Delivery of Care

Effective Delivery of Care Personnel Multidisciplinary team Facilities Equipment and Supplies Information system Data collection, storage, analysis

Effective Delivery of Care

Consultation History Examination Lab tests Referrals Follow-up Annual reviews

Metabolic Control
International Diabetes Federation Blood glucose Preprandial 90-130 mg/dL Postprandial 180 mg/dL HbA1c <6.5% Total cholesterol <200 mg/dL HDL cholesterol >40 mg/dL LDL cholesterol <70 mg/dL Fasting triglycerides <150 mg/dl Blood Pressure 130/80 mmHg Body Mass Index 18.5-25 kg/m2 Waist Circumference - General: Women <80 cm (<32) Men <94 cm (<37) East Indians/Chinese: Women <80 cm (<32) Men <90 cm (<35)

Glycaemic Control
American Diabetes Association 2010 Step 1 Lifestyle & Metformin Step 2 Add Sulfonylurea; if HbA1c > 8.5% or symptomatic of hyperglycaemia, add Basal Insulin (Lantus, NPH) Step 3 Lifestyle & Metformin & Intensive Insulin *Other classes may be considered in Step 2

Glycaemic Control
Self Monitoring of Blood Glucose Hypoglycaemia symptoms, self treatment

Complications
Nephropathy screening (albuminuria) Retinopathy Ophthalmologist review Neuropathy Foot Care Cardiovascular Disease

Gestational DM
Traditional 100g OGTT Rescreening at 24-28 weeks for at-risk patients

Education Goals
Treatment options Nutritional management Physical activity Monitoring Medication use and compliance Preventing Chronic complications

Appraisal
Is the guideline dealing with a POEM or DOE? Patient Oriented Who produced the guideline? What is their reason for producing the guideline? CHRC - AIM Who is on the guideline panel and how were they selected? Endocrinologists, Primary Care doctors, Nutritionists, Epidemiologist

Appraisal
Was any conflict of interest of panel members addressed and appropriately managed? No duality of interest was identified (stated) Was the literature search transparent, rigorous and comprehensive, including all relevant data?

Appraisal
Were all impacts of the intervention considered, including QOL and cost-effectiveness? Primary prevention and cost effectiveness were stated as key Has the feasibility of implementation in a practice similar to yours been tested or considered? Would you consider implementing the guideline in your practice?

Conclusion
CHRC Guidelines for DM in Primary Care are simple, cost effective and focuses on primary prevention where ever possible

The End
Feedback? Questions?

References

http://www.chrccaribbean.org/Guidelines.php http://www.chrccaribbean.org/files/Pocket%20/Diabetes %20Guidelines%20%20Pocket%20Edition.pdf