Diabetes: the annual review in lockdown and beyond

Social media has fuelled debate about the pros and cons of face-to-face versus remote consultations but is it possible to truly meet the needs of patients with conditions such as diabetes without seeing them in the surgery?

The COVID-19 pandemic has led to a sea change in how primary care has delivered services, with more and more care being managed remotely. In last month’s issue, we outlined the general principles that should be borne in mind when engaging in remote consultations.¹ In this article, we consider how a virtual diabetes consultation might be carried out, highlighting the potential advantages and disadvantages of this approach.

By the end of this article you should be able to:

• Recognise the key areas that should be covered in a diabetes review
• Evaluate the appropriateness of remote consultations in achieving these aims
• Identify people with diabetes who can be reviewed in a remote consultation
• Implement good quality, holistic diabetes care tailored to the needs of the patient

KEY AREAS THAT SHOULD BE COVERED IN A DIABETES REVIEW

When carrying out a diabetes review, it is important to consider what the aims and objectives of the review should be. It could be argued that one of the key aims should be to reduce the risk of long term complications following a diagnosis of diabetes. Assuming that to be so, supporting people to implement pharmacological and lifestyle measures, and screening for existing complications will be a key objective. These aims are supported by the Quality Outcomes Framework (QOF) as well as by evidence-based guidelines such as the American Diabetes Association and European Association for the Study of Diabetes (ADA/EASD) consensus statement.²

However, the importance of personalised care is also highlighted in these guidelines so targets and interventions need to be tailored to the individual, depending on the person’s situation – job, age, frailty scores, for example – and that can only take place after listening to the patient’s point of view and involving them in ongoing actions.

An aide memoire for the essential elements that make up a comprehensive diabetes review is the Diabetes UK 15 Healthcare Essentials publication, which can be accessed at https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/15-healthcare-essentials. Although not all 15 Essentials will apply to all individuals (some refer to inpatient care and management of diabetes in pregnancy, for example) the core essentials highlight the relevant tests and early warning systems that should be evaluated in order to ensure that any complication risks are identified and reduced as far as possible. The 15 Healthcare Essentials also cover topics such as the importance of lifestyle interventions and education to support self-management.

The 15 Healthcare Essentials are:

• HbA1c
• Blood pressure
• Lipids
• Dietary advice
• Microvascular complication screening:
  • nephropathy
  • neuropathy, and
  • retinopathy
• Emotional and psychological well-being
• Structured education
• Specialist care
• Flu jabs
• Inpatient care
• Sexual wellbeing
• Smoking cessation
• Pregnancy care

EVALUATING THE APPROPRIATENESS OF REMOTE CONSULTATIONS IN ACHIEVING THESE AIMS

Of the areas identified in the 15 Healthcare Essentials, most can be addressed in a remote consultation, whether that is carried out by telephone, by video or through a group video consultation. However, there are some tests which cannot be completed remotely, specifically the microvascular screening and the blood tests. These will need to be done as part of the face-to-face annual review, later in the year once the lockdown rules have been relaxed. Further tests should also be carried out if new medication is introduced or doses are changed or if abnormalities are detected. For many people, however, the routine six monthly review is the ideal time to carry out a remote consultation. So how can the other areas be addressed?

Remote consultations can include:

• HbA1c and lipid profile optimisation. Once the test itself has been done (see below in the ‘Face-to-face’ section), new therapies can be initiated and doses titrated based on shared decision making with the patient.
• Blood pressure checks. These can be carried out remotely using the patient’s own equipment, if they have it. If they don’t have a monitor, they can order one online and can be taught to use it via a video consultation. Many people, including the elderly, are getting used to using technology to keep in touch with family and friends so it is important to keep an open mind as to whether patients will be able to access or use a smart phone in order to have a ‘virtual’ appointment.
• Non-pharmacological support and education. Lifestyle interventions such as smoking cessation, dietary advice and discussions about physical activity levels can be carried out remotely. Depending on privacy levels and with respect to confidentiality issues, it is also possible to discuss psychological, emotional and sexual wellbeing in the context of a remote consultation. If problems are identified, more and more organisations offer telephone support and advice these days and there are also websites and apps which can help. For example, for those suffering from stress, relaxation and mindfulness apps can be helpful.
• Foot checks – pulses, sensation, skin. As detailed below, foot checks should be completed as a hands-on assessment at least once a year but in between times people should be checking their own feet regularly. Normally they are advised to check for blisters or lesions that might become infected and to ensure that their foot care and hygiene is scrupulously maintained. During the pandemic, I have taken the opportunity to talk to patients about how to check their own pulses. To my mind, this might help to increase awareness of the importance of foot care and foot checks and as anything the patient does will be in addition to the clinic foot checks, I consider home pulse checking to be a potential bonus to routine care.

Face-to-face consultations are needed for:

• HbA1c – the urgency of getting an up to date HbA1c will depend on the individual patient. People who are poorly controlled (often defined as those with an HbA1c of 75mmol/mol or more) should be a priority unless they are being shielded and people who have not had an HbA1c for over 6 months or more should also be considered. Some people will be carrying out home blood glucose monitoring but although this is useful for detecting hypoglycaemia (or hyperglycaemia in acute concurrent illness) the reading will not always offer an accurate reflection of the overall blood glucose control. The risks and benefits of getting the person in for an up to date venous blood test should be evaluated for each individual. However, once the test itself has been performed, ongoing management can be done via a remote consultation
• Microvascular complication screening for nephropathy, neuropathy and retinopathy will need to be done in a real world setting. Blood and urine tests need to be carried out to assess renal function, retinopathy screening needs to be done face-to-face and foot checks for neuropathy as well as to check foot pulses are should be carried out at least once a year.
• Flu vaccination. It is not possible to offer flu immunisation remotely but advice about its importance, which has been underlined by the pandemic, where immunisation has not been possible, can be given at any consultation – remote and face-to-face. It could be argued that this is an ideal time to discuss the importance of protection in anticipation of the upcoming flu season.

One of the 15 Healthcare Essentials is that patients should be able to access specialist care, although there is no clarification as to what constitutes ‘specialist’. People with diabetes should be supported to self-manage by someone who is competent in diabetes care and who is aware of, and practises in line with, current best evidence. Specialist care may include different members of the diabetes multi-disciplinary team, such as dieticians, podiatrists and others. In essence, then, the general practice nurse is well placed to ensure that all aspects of diabetes care are managed to the optimum level through her own interventions or via referral to other members of the team, including GPs, pharmacists, and secondary care teams when required. This would include recognising when the expertise of other teams is required, such as for inpatient and pregnancy care. The Nursing and Midwifery Code of Conduct offers a sound reminder as to how consultations – both remote and face-to-face – should be conducted: by prioritising the person, practising effectively, preserving safety and promoting professionalism and trust.³

IDENTIFYING PEOPLE WHO CAN BE REVIEWED IN A REMOTE CONSULTATION

As mentioned above, outside the restrictions imposed by the pandemic, the six monthly review is an ideal time to carry out a remote consultation. Remote reviews could also take place following initiation of a new drug treatment to check for adherence and possible side effects. Insulin initiation and titration could also be done remotely via video consultations although the initial appointment might still be better face-to-face to assess and supervise injection technique. Remote consultations are also ideal for people who find it hard to get into the surgery because they are housebound, or work away or are at university. In fact, there are very few situations where remote consultations will not be a viable option, and the key exceptions will be if blood, urine, feet and eye checks are needed. It would be important to communicate closely with patients as to their preference, though. Some people will still prefer face-to-face once lockdown restrictions have been lifted and even those who opt for remote appointments might want to consider whether telephone, video or even group video consultations would work better for them.

IMPLEMENTING GOOD QUALITY, HOLISTIC DIABETES CARE TAILORED TO THE NEEDS OF THE PATIENT

An example of how a remote consultation might work is given here.

Heather is a 58-year-old bar worker who has had diabetes for two years and is treated with metformin 2g daily. She has a BMI of 32kg/m2. She has been laid off from work since lockdown. Just before lockdown, she had attended to have her blood tests done but her follow up face-to-face review appointment had to be cancelled. She was offered a remote review instead. Her results indicated that her HbA1c is 58mmol/mol, she has a total cholesterol 4.9mmol/mol with an HDL-cholesterol 1.1mmol/mol. Her eGFR is >90ml/min, and her albumin creatinine ration (ACR) is 3.5mg/mmol. Her QRisk score is 11.3% and her blood pressure, taken at home, averages out at 134/81mm/Hg.

A recent paper by Bornstein et al⁴ has indicated that people with diabetes are at increased risk of getting COVID-19 and that the fatality rate is higher. This is especially true of people who are not well controlled so in this paper the authors recommend getting the HbA1c down to 53mmol/mol or less, which would be in line with NICE recommendations for someone like Heather.⁵ Her ACR indicates that she is at increased risk of renal impairment and cardiovascular disease in spite of her normal eGFR, and her BMI is in the obese range so it would be appropriate, based on the ADA/EASD consensus statement, to consider an SGLT2 inhibitor for Heather.² There is no reason why this should not be initiated immediately with the usual discussion about the advantages and disadvantages of different drug classes and advice about sick day rules.⁶ All of this can happen via a remote consultation and the next move would be to repeat the HbA1c, ideally in three months. An alternative would be to consider a weekly GLP1-RA, and she could potentially be taught how to inject via a video consultation. With regard to her blood pressure, this is acceptable and the SGLT2 inhibitor is likely to reduce it slightly so she can continue to monitor it at home. Her lipids need treating as her QRisk score is over 10%, so along with lifestyle advice she will need to start on a statin. The impact of this medication on her non-HDL cholesterol can be assessed in 3 months when her HbA1c is repeated. The target would be to reduce her non-HDL cholesterol by 40% or down to 2.5mmol/mol or less.^7,8 Again, this can be discussed and implemented via a virtual consultation, although it might be better to stagger the two new drugs by a few weeks in case of any unexpected side effects.

Importantly, this remote consultation should offer Heather the opportunity to discuss how she is feeling emotionally and psychologically as both the lockdown and the fact that she has been furloughed may be making her unhappy, which may lead to poor heath behaviours with regard to her diet, activity levels, smoking and alcohol intake. Simply asking her about her feelings, stress levels and sleep patterns may help to flag up any issues that she needs help with. A useful source of support may be via the Diabetes UK website or diabetes.co.uk which has many patient discussion groups to help her feel connected to people who may be in the same boat.

As soon as is practicable, Heather will need to have a foot check and retinopathy screen carried out, but there will be more information issued about how and when this will happen as the pandemic moves on. For the moment, however, there is a great deal that can be done to keep Heather as well as possible both physically and psychologically, until normal service is resumed.

CONCLUSION

The key areas that should be covered in a diabetes review are described in the 15 Healthcare Essentials publication, and can be tailored to each individual. Remote consultations offer a real opportunity to support people with diabetes who are unable to visit the surgery, both during lockdown and in the future. For many people, remote consultations may be the preferred way to consult, in line with 21st century living. Good quality, holistic diabetes care should and can be tailored to the needs of the patient, whether via a face to face appointment or remotely.

REFERENCES

1. Bostock-Cox B. Changing the way we work: virtual consultations now and in the future. Practice Nurse 2020;50(4):19-22

2. Buse JB, Wexler DJ, Tsapas A, et al. 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes care 2020;43(2):487–493. https://doi.org/10.2337/dci19-0066

3. Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates; 2018. https://www.nmc.org.uk/standards/code/

4. Bornstein SR, Rubina F, Khunti K, et al (2020) Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol; 23 April 2020: https//doi.org/10.1016/S2213-8587(20)^30152-2

5. NICE NG28. Type 2 diabetes in adults: management; 2015, updated 2019. https://www.nice.org.uk/guidance/NG28

6. Diabetes UK. Diabetes when you are unwell; 2020 https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/illness

7. NICE CG181. Cardiovascular disease: risk assessment and reduction, including lipid modification; 2016. https://www.nice.org.uk/guidance/cg181

8. Joint British Societies. Consensus recommendations for the prevention of cardiovascular disease (JBS3); 2014. Heart 2014;100:ii1–ii67. doi:10.1136/heartjnl-2014-305693