The Diabetes Knowledge Assessment (DKN) scales were developed to meet a specific need for rapid and reliable knowledge assessment in diabetic patients. Item format and item selection from an initial pool of 89 items were determined by pilot-testing over 300 diabetic subjects. Reliability analysis of the resulting 40 multiple-choice items, with a further sample of 56 subjects, gave a Cronbach's alpha coefficient of 0.92. Parallel forms DKNA, DKNB, and DKNC, each of 15 items selected from the parent set, had alpha coefficients above 0.82 and correlated 0.90 with each other. A full clinical trial, using DKNA, DKNB, and DKNC in randomized order of presentation, was conducted with 219 subjects attending a 2-day diabetes education program. Overall DKN scores improved from 7.6 (51%) to 11.3 (75%). Analysis of variance confirmed that DKNA, DKNB, and DKNC were equivalent forms at pretest. Mean posttest scores on DKNB were lower than the other scales (P less than 0.001), but variances were equivalent for all three. A specific local change in the education program format was found to account for this discrepancy in the DKNB posttest mean. In situations where comprehensive assessment of diabetes knowledge would be time-consuming and unnecessary, these results indicate that rapid and reliable assessment is possible with a scale of only 15 validated items. The development of parallel forms of the scale extends the range of retesting possibilities for diagnosis and research.
Trauma, in the form of pressure and/or friction from footwear, is a common cause of foot ulceration in people with diabetes. These practical recommendations regarding the provision of footwear for people with diabetes were agreed upon following review of existing position statements and clinical guidelines. The aim of this process was not to re-invent existing guidelines but to provide practical guidance for health professionals on how they can best deliver these recommendations within the Australian health system. Where information was lacking or inconsistent, a consensus was reached following discussion by all authors. Appropriately prescribed footwear, used alone or in conjunction with custom-made foot orthoses, can reduce pedal pressures and reduce the risk of foot ulceration. It is important for all health professionals involved in the care of people with diabetes to both assess and make recommendations on the footwear needs of their clients or to refer to health professionals with such skills and knowledge. Individuals with more complex footwear needs (for example those who require custom-made medical grade footwear and orthoses) should be referred to health professionals with experience in the prescription of these modalities and who are able to provide appropriate and timely follow-up. Where financial disadvantage is a barrier to individuals acquiring appropriate footwear, health care professionals should be aware of state and territory based equipment funding schemes that can provide financial assistance. Aboriginal and Torres Strait Islanders and people living in rural and remote areas are likely to have limited access to a broad range of footwear. Provision of appropriate footwear to people with diabetes in these communities needs be addressed as part of a comprehensive national strategy to reduce the burden of diabetes and its complications on the health system.
ata from the Australian Institute of Health and Welfare (AIHW) suggest that one Australian loses a lower limb every 3 hours as a direct result of diabetes-related foot disease (DRFD). 1 Further data suggest there has been a 30% increase in diabetes-related amputations in Australia over the past decade, with 8% of diabetes-related deaths being attributable to foot disease. 1,2 These statistics are especially disappointing given the exponential growth in knowledge, research and published guidelines on managing DRFD. 3,4 In order to reduce this significant burden, several complementary measures are therefore urgently required.To allow for long-term surveillance of DRFD in Australia, it is paramount that data collection is initiated at a national level. The health system does not currently allow for collection of information from both public and private sectors, and ignores the large group of people managed solely in the community. Effective allocation of resources and care coordination are likely to be hindered by this lack of data, as are identification of at-risk patient groups and development and evaluation of preventive strategies. Solutions for improving data collection would include creation of specific Medicare item numbers for DRFD and development of web-based data collection forms and databases.The inclusion of chronic disease management items in the Medicare Benefits Schedule (MBS) is acknowledged as a step forward in the fight against DRFD. Reports suggest that 1.3 million consultations were provided by podiatrists under this program in 2004-2008, accounting for 34% of all consultations. 5 It is important to note, however, that this funding arrangement does not allow for more frequent follow-up for individuals with acute DRFD complications or needing intensive secondary prevention due to previous ulceration and/or amputation. Recurrence rates for foot ulceration range from 20%-80% annually, with many of these ulcers leading to amputation. 6 Improved access to publicly funded specialised foot care services, and increasing the number of rebates available under the MBS, are seen as cost-effective necessities for people with current or past foot complications. The cost of this would be recouped by preventing future hospitalisations and amputations.Improved access to appropriately skilled health care providers and multidisciplinary teams is required, and could be achieved if Australian health care policymakers adopt a standardised national model of care for DRFD. This model must sustain a continuum of care between community-based health care and local hospitals. Research supports the resourcing and implementation of well defined treatment pathways provided under a multidisciplinary model of care. 7,8 A standardised national service model would also support a national network of interdisciplinary DRFD clinics, in turn facilitating the development of a national database to assist with referral pathways, data collection, initiation of quality improvement programs and benchmarking across organisations. Such a mod...
Appropriate assessment and management of diabetes-related foot ulcers (DRFUs) is essential to reduce amputation risk. Management requires debridement, wound dressing, pressure off-loading, good glycaemic control and potentially antibiotic therapy and vascular intervention. As a minimum, all DRFUs should be managed by a doctor and a podiatrist and/or wound care nurse. Health professionals unable to provide appropriate care for people with DRFUs should promptly refer individuals to professionals with the requisite knowledge and skills. Indicators for immediate referral to an emergency department or multidisciplinary foot care team (MFCT) include gangrene, limb-threatening ischaemia, deep ulcers (bone, joint or tendon in the wound base), ascending cellulitis, systemic symptoms of infection and abscesses. Referral to an MFCT should occur if there is lack of wound progress after 4 weeks of appropriate treatment.
The modern management of diabetes relies heavily on self-monitoring of blood glucose (SMBG), and therefore SMBG records are an important source of clinical data for management decision making. The development of a memory Glucometer has provided the opportunity to verify the validity of glucose records thus generated and observe the effects of different educational approaches on compliance with SMBG. Thirty-four patients without previous experience of SMBG were randomized into one of the following experimental groups differing in the model of diabetes care: mutual decision making, didactic, and authoritarian. Patients, unaware of the memory capacity of the glucose meter, were required to perform four glucose measurements per day over a 14-day observation period. Patient-generated blood glucose records were then compared with objective records stored in the glucose-meter memory. Patients with gestational diabetes mellitus recorded a lower proportion of correct results (63 vs. 79%, P = .049) and exhibited a tendency to invent results with lower blood glucose levels (5.3 vs. 7.5 mM, P less than .0001) than the results omitted compared with patients with non-insulin-dependent diabetes mellitus. Predictors of greater validity of records were perceived intelligence of the subject (chi 2 = 4.56, P less than .02) and private health-insurance status (chi 2 = 4.52, P less than .04), whereas the experimental group assignment was not significant. These findings reflect potential motivational and sociodemographic limitations in the validity of SMBG recordings within the management and education of patients with gestational and nongestational diabetes.
Abnormal glycaemia was present in almost half the patients presenting with IS/TIA, with the majority of cases undiagnosed. One-third of patients had abnormal glycaemia, hypertension and dyslipidaemia concurrently. Patients presenting with stroke should be routinely screened for abnormal glycaemia in concert with other vascular risk factors.
In 2000 the Diabetes Centre and the Medical Oncology Department of St Vincent's Hospital, Sydney established a joint clinic for the teaching of final-year medical students. The clinic was established amid concerns that hospitals are increasingly focused on acute care and have few resources available for teaching about chronic conditions. The clinic aimed to improve both patient care and learning opportunities by engaging students in useful activities with chronically ill patients. The students met with their patients regularly to monitor progress, adjust medication (under supervision) and arrange support services. The students and staff from both units met once a week in a coordination meeting where cases were reviewed and learning issues discussed. Students had informal interactions with medical and allied health staff at other times. Overall the clinic provided a rich learning environment for students with a focus on the development of the integrated skills required in the care of chronically ill people, rather than on the specific medical disciplines involved.
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