Protocol for Shared Care Diabetes in Malta
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Protocol for Shared Care Diabetes in Malta

Introduction

Following agreement reached between the Department of Primary care and the Department of Endocrinology and Diabetes of the Mater Dei Hospital in 2009, it was planned that a major change is brought about in the provision of diabetes care in this country.

The implementation of shared care diabetes in all health centres will establish a single register of all patients with diabetes in Malta and will provide information of the actual costs of diabetes care and the burden on the National Health budget, as well as laying the foundations for the implementation of a National Diabetes Plan and assist health policy makers to improve and sustain diabetes care.

The shared care diabetes program should facilitate and reassure that patients are provided with timely and equitable access to secondary care specialists as well as routine visits to primary care and regional specialist diabetes services providing multidisciplinary and holistic approach to Diabetes care. The share care program should also provide more effective screening for prevention of the long term complications of diabetes including eye diseases and prevention of diabetic foot problems due to micro and macro vascular disease. This model of integrated care will hence be addressing the quality of life issues such as the disability which is caused as a result of amputations. This program should also provide for the prevention and timely intervention of diabetes in the general population which in Malta is showing a proportionate increase in prevalence and incidence in both children and adult age groups.

The international Diabetes Federation has published new data on the increasing numbers of people with diabetes worldwide and refers to this as a global epidemic which has gone out of control. New Data is showing that a staggering 382 million people worldwide have Diabetes in 2013 and that this number will explode to 592 million by the year 2035. The IDF Atlas also predicts that diabetes will cost the world economy at least US$548 billion in 2013, or 11.6% of total world healthcare expenditure and that by the year 2035, this number is projected to exceed US$627 billion. More than 80% of diabetes spending is in the world’s richest countries and not in the poorer countries, where over 70 percent of people with diabetes now live.

The published data for Malta , through the IDF Diabetes Atlas estimate that the diabetes prevalence in Malta is 10.14% of the Adult Population, representing 33,260 people in 2013 and the atlas forecasts a rise in prevalence to 11.6% of the Adult population, representing 36,600 people by 2025 (Data from IDF Atlas 6th edition and FEND report 2008).

As the Diabetes prevalence rates in Europe continue to rise and are predicted to reach an average of 10.3% of the EU population by 2025 – this will have a global economic effect and will precipitate a burden which national healthcare systems will find hard to bear and this does not exclude our country.

In June 2014, a National Diabetes Strategy 2015 - 2020 Steering Group was set up and as a representative of primary care on this steering committee I am pleased to note that all the information that has been gathered so far through the implementation of this program has been made use of in the publication of the National Diabetes Strategy.
 
Definition: Shared Care -The planned delivery of structured diabetes care jointly by primary and secondary care teams, with agreed protocols and enhanced communication over and above routine referral and discharge letters.


Aims and Objectives

Diabetes shared care programmes aim to:
  • Establish criteria for who should have the major responsibility for an individual's diabetes care;
  • Introduce clinical management guidelines for diabetes which set minimum standards of care;
  • Introduce a system of documentation for the doctor's records and to facilitate communication between the interdisciplinary team.

Diabetes shared care program objectives include:
  • Controlling the symptoms of diabetes, prolonging life and preventing the long-term complications of the condition, while preserving quality of life.
 

The Potential Benefits from the Perspective of Specialists in Family Medicine:
  • Improving the overall standard and Quality of diabetes care and patient outcomes;
  • The opportunity to enhance his or her knowledge of diabetes care;
  • Improving access to Hospital specialists for patients with problems that require specialist care;
  • Reducing overall diabetes-related health care costs;
 

The Priorities for the delivery of care to patients with Diabetes:
  • Quality care is delivered to patients with Diabetes by General Practitioners, Nurses and other health care professionals with a special clinical interest in Diabetes.
  • As a basic standard of care, people with Diabetes should have regular access to general practitioners, diabetes specialists, nurse and dietician.
  • All patients with Type 2 diabetes should have access to Hospital Specialist services such as: Diabetologist, Endocrinologist, ophthalmologist, Nephrologist, vascular surgeon and psychologist as the case may be.
  • Care provision begins with an initial assessment and a drawing out of an individualized management plan, and adherence to agreed protocols and guidelines unless clinically indicated.
  • Initial assessment should be followed up with regular review that includes a comprehensive annual review. This is regarded as a crucial element of shared care diabetes.
  • Patient education and patient engagement are important in order to motivate significant lifestyle changes as these are as important as clinical examination and prescribing.
  • Annual Screening for diabetic retinopathy using digital imagery fundoscopy or other technologies are mandatory. Screening for glaucoma including visual acuity and visual fields is also recommended. 
  • Screening for foot conditions through annual podiatry referral for level one assessment with progression to level two and three according to intial outcomes from level one assessment.
  • People with type 2 diabetes have an increased risk of depression, which is consistent with the association between increased frequency of depression among people with other chronic diseases and referral to a psychologist should be considered.
  • People with diabetes therefore need long-term care. Type 2 diabetes is gradually progressive, requiring frequent reassessment and modification of treatment.
  • All patients should be entered into a register which would be linked between primary care and Mater Dei to allow for regular review and recall.
  • Patient data is entered into a Diabetes Management Computerized System which is shared between Secondary and Primary Care and its access is limited for use by General Practitioners.

People with Diabetes therefore need long-term care that is consistent, holistic, offers continuity and is accessible. It should take into account patients' varying requirements as well as their personal wishes. General Practitioners together with the necessary specialist support, have a key role in the care of chronic diseases such as diabetes.

 
The Multidisciplinary care team involves:
  • The Patient
  • General Practitioner with special clinical interest in Diabetes
  • Diabetes Nurse
  • Diabetologist and Endocrinologist
  • Dietician
  • Ophthalmologist
  • Ophthalmic Nurse
  • Podiatrist
 

Parameters and Investigations:
  • Height 
  • Weight
  • Calculate BMI
  • Blood Pressure
  • Smoking Status
  • HbA1c (6 monthly)
  • Lipids
  • Urea
  • Creatinine
  • Electrolytes
  • Thyroid Function
  • Urinalysis
  • Microalbuminuria
  • Diabetes meds
  • Insulin
  • Other medications
  • Fundoscopy