Chronic Disease Management

Question 1

What are the factors that contribute to poor diabetes management in the developing world (10)

Answer 1

Healthcare system-related
1. Availability and affordability of insulin and oral hypoglycemics
2. Poor access to healthcare in rural areas compared to urban areas results in many cases only presenting late with complications of disease
3. Lack of primary healthcare model with screening and treatment in rural areas

Physician related
4. Lack of education and confidence in diabetes care and management e.g. commencing insulin and risk of hypoglycemia
5. Lack of local guidelines for diabetes management
6. Excessive workload which does not permit appropriate education and counseling for patients

Patient-related
7. Lack of awareness of and education about diabetes
8. Preference for other modes of therapy
9. Sociocultural factors around dietary practices, food choices, religious practices
10. Availability and affordability of appropriate foods
11. Women often have less physical activity levels than men due to sociocultural norms of women staying at home and men performing physically laborious jobs

Practical issues
12. Refrigeration of insulin
13. Long working hours makes TDS dosing difficult
14. Cost of blood glucose strips is a barrier which leads to inadequate monitoring

Question 2

How can the factors that contribute to poor diabetes management in resource-poor settings be overcome?

Answer 2

1. Campaigns to improve public awareness of diabetes, its symptoms and its complications
2. Programs and campaigns that empower communities to improve exercise and activity levels for all, particularly women and children, and making healthier food choices
3. Developing improved rural primary care models that are nurse-led with referrals to central hospitals for complex patients and those with complications
4. Developing established local guidelines for nurse-led protocols for the initial screening, diagnosis, and management of diabetes and when to refer to doctors/central hospitals
5. Government investment in procuring a stable supply of oral hypoglycemics and insulin
6. Increasing number of healthcare providers through investment in education and training to allow for adequate coverage across the country and to achieve manageable workload that will allow for adequate time to provide counseling on prevention and management of chronic diseases
7. Government and insurance providers subsidizing/covering cost of oral hypoglycemics, insulin, and insulin monitoring devices/glucose strips
8. Political will and investment in improving food supply that incentivizes purchase/consumption of nutritious food and disincentivizes purchase/consumption of energy-dense, low nutrient foods
9. Collaboration across healthcare programs/providers to screen for, manage, and prevent complications complications diabetes in certain special populations and high risk groups such as pregnant women, those with high blood pressure, and those with TB
10. Establishing adequate surveillance systems to quantify the burden of diabetes and its complications to inform needs assessments and the economic cost of diabetes on the healthcare system and society

Question 3

Describe how you would organize delivery of diabetes care in a rural community in africa (20)

Answer 3

Prevention
1. Improve community awareness and prevention of diabetes in general by developing community education programs and working with schools and other healthcare services on awareness of diabetes and its symptoms

Initial screening, diagnosis, and management
2. Establish appropriate local nurse-led protocols for the screening, diagnosis, and initial treatment of diabetes
3. Develop patient educational materials and group education sessions for management of early diabetes with diet and exercise
4. Establish appropriate laboratory testing capacity for fasting blood glucose and glucose challenge tests
5. Establish pathways for local procurement and supply of oral hypoglycemics and insulin for patients with appropriate refrigeration for insulin
6. Establish local supply to the pharmacy for stocking of glucose monitoring strips
7. Develop group patient education programs for patients diagnosed with diabetes related to understanding medication (oral hypoglycemics, insulin), their importance, side effects, and recognising symptoms of hypo and hyperglycemia

Referral system for complex patients
8. Establish referral pathways as part of the nurse-led algorithm for complex cases requiring insulin or with complications to a central hospital

Staff education and training
9. Develop training for new staff to increase capacity related to providing diabetes education, screening, and initial management as well as ongoing refresher training for existing staff

Management of emergencies
10. Establish medical protocols at local healthcare facilities for the recognition and treatment of diabetic ketoacidosis with fluids, insulin, glucose monitoring etc.

Screening, prevention, and management of complications
11. Diabetic foot care - establish appropriate complication screening and education for patients diagnosed related to diabetes complications e.g. diabetic foot care, podiatrists to make regular community visits if available
12. Retinopathy screening - local training of healthcare staff to perform basic retinopathy/vision screening with referral to optometrists or regular community visit schedule of optometrists if available

Special populations
13. Hypertension - Develop nurse-led algorithms for the management of hypertension in those with diabetes (and in general) with similar referral pathways established for complex patients
14. Pregnant women - Collaborate with antenatal services to establish appropriate screening of pregnant women and referral pathways for management of Gestational Diabetes Mellitus
15. Smokers - Develop nurse-led algorithms for smoking cessation advice/brief interventions and materials for patients on how smoking can worsen some of the complications of diabetes

Surveillance
16. Develop surveillance system to monitor local prevalence/incidence of diabetes as well as proportion of patients developing complications with ongoing monitoring to identify unmet needs

Subsidies
Identify potential funding sources to assist patients with the costs of medications, travel for referrals, and monitoring devices/strips

Question 4

List 7 factors that lead to higher rates of epilepsy in low and middle income countries

Answer 4

1. Malaria
2. Neurocysticercosis
3. Head injury secondary to trauma e.g. MVA
4. Higher rates of bacterial meningitis
5. Higher rates of birth-related injuries
6. Lack of preventive programs to prevent development of epilepsy
7. Lack of emergency medical care to reduce complications of medical conditions that may lead to epilepsy