Miriam E. Tucker
December 03, 2020
A group of British endocrinologists have issued guidance on how to best stratify risk in adult patients with diabetes amid the ongoing disruption caused by COVID-19 and with an eye to also better streamline routine care after the pandemic.
"The focus on emergency response to COVID-19 in the first few months has had a major knock-on impact on the delivery of routine clinical care for diabetes," says the panel that issued the advice.
"Key challenges as we enter the second wave of the pandemic include a backlog of appointments [and] delays in accessing care, such as structured education, and initiating insulin, [other glucose-lowering drugs], or diabetes technology...In the coming months, it is unlikely that we can return to normal, and so we feel it will be essential to identify patients at greatest risk and prioritize their care," they write.
The document, entitled, "A roadmap to recovery: Association of British Clinical Diabetologists recommendations on risk stratification of adult patients with diabetes in the post COVID-19 era," was published online November 23 as a letter in Diabetic Medicine by Pratik Choudhary, MBBS, professor of diabetes at the University of Leicester, UK, and colleagues. The recommendations were made in collaboration with Diabetes UK and the Primary Care Diabetes Network.
"Primary care and specialist [endocrinology] teams need to work together to identify those in 'urgent' and 'priority' groups [as defined below]. Shared databases will help identify patients at risk, minimize duplication, and provide joined up care between specialists and primary care teams," the panel urges.
At the same time, Diabetes UK is urging the public not to let the COVID-19 pandemic stop them from seeking medical help if they are concerned that a child or adult may have symptoms of type 1 diabetes — the 4Ts: going to the toilet a lot and being thirsty, tired, and thin (losing weight). "Timely diagnosis is essential and, if left untreated, symptoms of type 1 diabetes can lead to diabetic ketoacidosis, a potentially life-threatening disorder that requires hospital treatment," the charity urges.
Right Patient at Right Time: Categorize Into Urgent, Priority, and Routine
Explaining the rationale behind the roadmap, Choudhary told Medscape Medical News that during the pandemic there has been "a lot of variability across the country...We were told to scrap all routine activity. We decided we needed to prioritize our time for those who absolutely need it."
The document does that by categorizing patients into "urgent," "priority," and "routine" based on multiple risk factors and gives a timeframe within which each should be seen in-person or virtually.
It's meant as a guide during the pandemic as well as after, Choudhary said.
"We can use this reset so we don't end up where we were a year ago. We can land on a different tomorrow that uses telemedicine with a focus on right patient, right time, right way [rather than] this routine of having patients come back in every 6 months or 4 months as a routine follow-up," he said.
"Instead, let's choose the right patient to be seen remotely and who needs to be seen face-to-face, when they need to be seen. Let's use technology to stratify people and see the right person at the right time."
Three Categories of Patients, With Additional Considerations
The document stratifies patients into the following three categories, presented on the ABCD website as red, amber, and green in a color-coded chart.
Red: Review urgently (within 3 months, virtually or face-to-face, and possibly more contact within the year).
A1c > 10% (> 86 mmol/mol).
Blood pressure > 160/100 mmHg.
Hospital admission for diabetic ketoacidosis, hyperosmolar hyperglycemic syndrome, or unstable cardiac/cerebrovascular disease in past year.
Recently discharged with treatment changes.
Estimated glomerular filtration rate (eGFR) < 30 mL/min or renal function decline > 15 mL/min/year.
Active diabetic foot disease.
Other factors to consider: Severe mental illness, learning difficulties, frailty, women planning pregnancy.
Amber: Review as priority (within 6 months, virtually or face-to-face, and possibly more contact over the year).
A1c 8.5%-10% (70-86 mmol/mol).
Suboptimal blood pressure (> 140-160/90 mm/Hg or total cholesterol > 5 mmol/L).
Impaired hypoglycemia awareness (Gold score 4-6), or > 5 episodes/week or > 20% time < 4 mmol/L.
A1c < 6.5% (48 mmol/mol) on insulin or sulfonylureas, with other comorbidities or cognitive impairment.
eGFR 45-30 mL/min, albumin-to-creatinine ratio > 30.
Age < 40 years with complications.
No diabetes review for over 18 months.
Green — routine: Patients without any of the above listed risk factors should be informed that they might not be seen until summer 2021. They should be provided with educational resources and instructed what to do if their situation changes.
Choudhary said that although it might not be possible to search for all of these factors, enough of them are typically available in laboratory records, primary care databases, and/or downloaded data from diabetes devices.
"Rather than just doing business as usual, if you dedicate some of your time to finding the right people, that might be better than just seeing whoever shows up or happens to have an appointment...You might need to find a person to do it, but the capability exists."
Such streamlining of care could dramatically improve efficiency within health systems like the UK National Health Service, he said.
"I get a block contract to deliver care to these people. Greater use of virtual care and greater risk stratification allows us to divert our resources to people who need it the most. The value of remote monitoring with Libre [the "flash glucose monitor] and cloud [fingerstick] monitoring devices really come to the fore."
The hope, he said, is that greater adoption of this approach will also lead to better communication between primary and secondary care systems to further improve efficiency.
"We can deliver much better care...All of these things are silver linings of the pandemic."
The paper did not receive funding from any source. Choudhary has received personal fees from Novo Nordisk, Lilly, Sanofi, Abbott UK, Dexcom, Medtronic, Insulet, and Novartis.
Diabet Med. Published online November 23, 2020. Letter