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A Critical Appraisal

Andre Sookdar - Class of 2013

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Objective

To critically appraise the CaribbeanHealth Research Councils (CHRC)

Guidelines on the Primary Care

Management of Diabetes in theCaribbean

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Introduction

Diabetes mellitus (DM) is one of the leadinghealth problems in the Caribbean, contributingsignificantly to morbidity and mortality andadversely affecting both the quality and lengthof life.

The disease also places a heavy economicburden on already limited health care resourcesin the Caribbean. Costs are related directly totreatment of the disease and its complications,and indirectly to loss of earning power in thoseaffected.

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Aim

To produce a unified, evidence-basedapproach to the management ofdiabetes in the Caribbean.

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Objectives

To prevent or delay the onset of DM and co-morbid conditions of obesity, hypertensionand dyslipidaemia

To promote earlier diagnosis of DM To improve the quality of care of persons

with DM

To prevent and treat acute and long-termcomplications of DM

To promote education and empowerment ofthe patient, family and community, and

health care worker

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Guidelines

Definition DM is defined by the WorldHealth Organization as a metabolic disordercharacterized by chronic hyperglycaemia

with disturbances of carbohydrate, fat andprotein metabolism resulting from defects ininsulin secretion, insulin action, or both.

Classification Type 1, Type 2, GestationalDiabetes

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Guidelines - Screening

Fasting Plasma Glucose (FPG) is theRecommended Screening Test

Testing the Urine Glucose is not

recommended for screening.

Blood Glucose Meters can be used forinitial screening but not for diagnosis.

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Guidelines - Diagnosis

American Diabetes Association Criteria was usedin 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)

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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%

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Guidelines - Effective Deliveryof Care

Effective Delivery of Care

Personnel Multidisciplinary team

Facilities

Equipment and Supplies

Information system Data collection,storage, analysis

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Effective Delivery of Care

Consultation

History

Examination

Lab tests

Referrals

Follow-up Annual reviews

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Metabolic Control

International Diabetes Federation

Blood glucosePreprandial 90-130 mg/dLPostprandial 180 mg/dL

HbA1c

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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 & IntensiveInsulin

*Other classes may be considered in Step2

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Glycaemic Control

Self Monitoring of Blood Glucose

Hypoglycaemia symptoms, selftreatment

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Complications

Nephropathy screening (albuminuria)

Retinopathy Ophthalmologist review

Neuropathy

Foot Care

Cardiovascular Disease

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Gestational DM

Traditional 100g OGTT

Rescreening at 24-28 weeks for at-riskpatients

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Education Goals

Treatment options

Nutritional management

Physical activity

Monitoring

Medication use and compliance

Preventing Chronic complications

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Appraisal

Is the guideline dealing with a POEM or DOE?

Patient Oriented

Who produced the guideline? What is theirreason for producing the guideline?

CHRC - AIM

Who is on the guideline panel and how werethey selected?

Endocrinologists, Primary Care doctors,Nutritionists, Epidemiologist

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Appraisal

Was any conflict of interest of panelmembers addressed and appropriatelymanaged?

No duality of interest was identified(stated)

Was the literature search transparent,rigorous and comprehensive, includingall relevant data?

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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 apractice similar to yours been tested or

considered?Would you consider implementing the guideline

in your practice?

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Conclusion

CHRC Guidelines for DM in Primary Careare simple, cost effective and focuseson primary prevention where ever

possible

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The End

Feedback?

Questions?

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References

http://www.chrc-caribbean.org/Guidelines.php

http://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-

%20Pocket%20Edition.pdf

http://www.chrc-caribbean.org/Guidelines.phphttp://www.chrc-caribbean.org/Guidelines.phphttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/files/Pocket%20/Diabetes%20Guidelines%20-%20Pocket%20Edition.pdfhttp://www.chrc-caribbean.org/Guidelines.phphttp://www.chrc-caribbean.org/Guidelines.phphttp://www.chrc-caribbean.org/Guidelines.php

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