I have been asked by my VP-Medical to draw up guidelines that are
appropriate for
monitoring DM in long-term care. The motivator is cost and nursing
workload, as far as I can tell.
>From what I can tell, there is presently no evidence that I can point to
which clearly demonstrates that outcomes improve with improved glycemic
control IN THIS POPULATION, i.e. seniors in homes for the aged (Cdn),
nursing homes(Cdn and US), chronic care (Cdn), skilled nursing
facilities (US), or long stay geriatric beds (UK). We have reviewed the
studies of Grobin (done here at Baycrest), Sinclair (in the UK),
Wolffenbuttel (in NL), UKPDS (UK), UGDP, Ohkubo (Japan), and Abraira
(US) but the results have not been sufficiently convincing.
That being the case, until now I have suggested the following blood
glucose monitoring, using point-of-care testing:
Type I DM - at least BID, if not more frequently (we only have 3-4
patients in the whole institution with Type I)
Type II DM
a) Diet alone - Q 2 weeks, before lunch (to get away from the
controversy of the effectiveness of fasting blood glucose monitoring)
b) Oral agents plus diet
If unstable - monitor at least 2/week, at least AC breakfast and
supper
If stable - monitor at least Q2weeks, AC breakfast and supper
c) Insulin plus diet
If unstable - monitor at least 2/week, at least AC breakfast and
supper
If stable - monitor at least weekly, AC breakfast and supper
All diabetics are supposed to have an A1C done Q3months. Our compliance
is somewhere around 60%, despite aggressive follow-up.
I would respectfully ask for your help with any comments that I could
share with my boss. Regrettably, I was asked this today, with a deadline
of 1 week from now of Feb. 8th, 1999. As my boss' suggestion is one
blood glucose monthly for this population, except for the
insulin-requiring clientele, and quarterly A1Cs, with the forced
trade-off of the institution's losing some other aspect of nursing care
if the recommendation is to use more frequent monitoring, I need to have
a fairly sound basis for whatever my final recommendations will be. It
would help our seniors with diabetes considerably if I could at least
point to best expert opinion, which is my reason for seeking your
opinion.
I have a feeling that I'll suggest:
Type I DM - at least BID, if not more frequently (we only have 3-4
patients in the whole institution with Type I)
Type II DM
a) Diet alone - Q 1 month, before lunch (to get away from the
controversy of the effectiveness of fasting blood glucose monitoring)
b) Oral agents plus diet
If unstable - monitor at least 2/week, at least AC breakfast and
supper
If stable - monitor at least monthly, AC breakfast and supper
c) Insulin plus diet
If unstable - monitor at least 2/week, at least AC breakfast and
supper
If stable - monitor at least Q2weeks, AC breakfast and supper
and a strong suggestion that we do A1C quarterly on ALL diabetics,
regardless of type and means of control. I'll suggest that we shoot for
overall targets in keeping with the Canadian guidelines [CMAJ - Oct. 20,
1998; 159 (8Suppl) S1-S29]
http://www.cma.ca/cmaj/vol-159/issue-8/0973.htm
and http://www.cma.ca/cmaj/vol-159/issue-8/diabetescpg/index.htm
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