Wednesday, June 13, 2012

The Difference Pathology Makes by Kathleen Harrison QML Pathology Credentialed Diabetes Educator

Credentialed Diabetes Educators support the GP with management of the patient with diabetes. In collaboration with the GP and the patient, the Educator can help the patient achieve mutually agreed clinical targets, improve health, and lessen or prevent the many serious complications of diabetes. Initial diagnosis, change in treatment or when clinical targets are not being met, are all occasions when an Educator’s input can help with patient outcomes.

How does pathology help the Diabetes Educator?
There are particular pathology tests that help guide management in the treatment of diabetes. These include but are not limited to, HbA1C, renal function tests including; eGFR, creatinine and urinary albumin investigations, and lipid studies.

Without current pathology tests, which provide information about patients’ glycaemic control and health in general, it is difficult for the Educator to focus on the areas in diabetes management which need to be improved or changed. It is not uncommon for a patient to arrive at their appointment with either little or no information to show how they have been managing their diabetes.

A current HbA1C result will give an indication of overall glycaemic control over the last three months. This can reveal how well the client is coping with diabetes. A result within target range can provide an opportunity to congratulate the patient on their management and provide positive feedback and support; an important part of keeping the client focused. A HbA1C reduction of 1% can reduce complication risks by 20-40%; a fact we can relay to patients to help keep them motivated and on track1. If the HbA1C is above target or below target range we can then explore what is happening.

Is the patient compliant with medications?
If on insulin, are there issues with their technique?
Do they require insulin adjustment or other medication changes?
What lifestyle factors are impacting on control?
Is the patient experiencing episodes of hypoglycaemia?

The HbA1C can help guide us to ask the right questions. Diabetic nephropathy is a serious complication of diabetes, and renal function tests are important investigations that help guide treatment. The effects of some diabetes medications can be prolonged or contraindicated in people with poor renal function.

The microalbumin test plays a central role in assessing and monitoring the effectiveness of diabetic control and progression of tissue damage, the end result of which is the catastrophic small and large blood vessel damage so characteristic of older, poorly controlled diabetic patients2.

It is recommended that the test should be performed in Type 1 patients, five years after diagnosis and at least annually thereafter, and in Type 2 diabetes, at least annually from the time of diagnosis. If a value is found to be abnormal, testing should be performed 3-6 monthly.

Lipid pathology is another important tool to evaluate management. Are cholesterol and triglycerides within current recommended ranges of <4 mmol/L for cholesterol and 1.5 mmol/L for triglycerides? The population with diabetes has twice the rate of infarctions than those without diabetes.

Monitoring cholesterol and triglycerides is an important part of ongoing management. If results are above target range the Educator can assist you with education in this area.

Pathology results are a vital link to help guide the GP and Diabetes Educator towards relevant education and treatment for the client with the ultimate aim of improving health outcomes for the patient with diabetes.

Kathleen Harrison, B Nursing (Grad Cert Diabetes) RN
QML Pathology Credentialed Diabetes Educator

1. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Lancet. 1998 Sep 12; 352 (9131): 837-853
2. Appleton, C. Diabetic tissue damage. QML Pathology Diabetes Pack, 2007
3. Boucher, M.S., & Hurrell, D.G. Cardiovascular disease and diabetes. Diabetes Spectrum. 2008 Jul; 21, 154-155

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