QUESTIONS & ANSWERS

COORDINATE CARE OF THE DIABETIC PATIENT

INCREASE YOUR VALUE TO THESE PATIENTS BY IDENTIFYING THE OTHER REQUIRED MEMBERS OF THE HEALTH CARE TEAM

Charlie Ficco, O.D., Morrow, Ga.

AS OPTOMETRISTS, we can coordinate the care of patients who have diabetes because (1) many of us are the first to identify the disease, and (2) due to the visual issues (fluctuating and blurred vision, dry eye disease, etc.) that accompany the disease, optometrists tend to be the doctors that see these patients most often. When we help these patients maintain their health, we increase our value in their eyes. In addition, by coordinating their care, we can create referrals from the other members of the patients’ healthcare team. (See “The Power of Communication,” p. 25.)

Here, I explain whom these other health care team members are, so you know to whom and when to refer your diabetic patients.

PRIMARY CARE PHYSICIANS

Although practically every diabetic patient already has a primary care physician (PCP) by the time we examine his or her eyes, not everyone does. As PCPs establish blood glucose control measures, which lead to fewer complications from diabetes, we must be aware of well-established PCPs in the community who can prescribe aggressive therapy (a goal of 80 mg/dL to 120 mg/dL blood glucose levels on a daily basis and hemoglobin A1C readings of 4.4% to 5.8%). The best way to find these practitioners is to call or visit their offices and interview them.

ENDOCRINOLOGISTS

Most Type 1 diabetics and many who have the Type 2 form of the disease see this specialist of the endocrine system (hormones that control how the body works) when getting their disease under control is an issue. A referral to an endocrinologist is necessary when these patients have poor control of their blood sugar or when they have comorbidities of the endocrine system, such as hyperthyroidism, osteoporosis or thyroid cysts.

DIETICIANS

Although most PCPs or endocrinologists either employ certified dieticians or refer diabetic patients to them after the initial diagnosis, some patients do not follow through on seeing this specialist. This may be, in part, because they did not receive enough education on the importance of diet and exercise in controlling their disease.

For example, many patients think the answer to blood sugar control is cutting out “table sugar” from their diets. I, personally, have had thousands of conversations with patients who are amiss to hear that their precious cornbread and biscuits or peaches are just as bad, if not worse, at raising their blood sugar levels as “table sugar.” As a result, ask your diabetic patients whether they have seen a certified dietician who has designed a beneficial meal plan. (The best type of diet for a diabetic patient is one designed with five meals per day, high protein, low carbohydrates and low fat, with very small portion sizes. If the patient has not yet seen a dietician, provide him or her with a couple of names of dieticians. Simple conversations and education go a long way.

BEHAVIORAL PROFESSIONALS

It is quite common for newly diagnosed diabetic patients to suffer from depression and/or act out in anger because of suppressed stress suffered from the diagnosis. As we are one of the first medical professionals to evaluate newly diagnosed diabetic patients, we must talk with these patients to determine whether they have been feeling sad longer than a couple of weeks, guilty, hopeless, worthless and other symptoms associated with depression from a newly diagnosed medical condition. To do this, consider employing a questionnaire (see “Depression Screening Text,” http://bit.ly/19FdcTR). If the patient’s score reveals depression, refer him or her to a psychiatrists and/or psychologist.

CARDIOLOGISTS

At least 65% to 70% of diabetic patients age 65 or older will die from some form of heart disease. In fact, adults are 2x to 4x more likely to have heart disease or a stroke vs. adults without diabetes, according to the American Heart Association. Therefore, ask these patients — newly diagnosed or established — whether they’ve seen a cardiologist for a complete workup. If a patient has, we can contact his or her cardiologist to obtain a thorough review of symptoms, so we can ensure the patient gets the help he or she requires when in our office. If the patient has not, briefly educate him or her on the importance of the cardiologist, and refer him or her.

DENTISTS

Unfortunately, not everyone visits a dentist on a regular basis. As gum disease, including increased inflammation, infections, bleeding while brushing or flossing and xerostomia is quite common in diabetic patients, be sure to ask these patients whether they’ve seen their dentist within the last six months, as studies suggest that regular cleaning and treatment of periodontal disease can lower A1C levels in diabetic patients by at least 0.4%. If the patient has not, briefly discuss the A1C level findings, and refer him or her to a dentist.

PODIATRISTS

It’s a good idea to have one or more names of this specialist on hand, should the patient present with paresthesia or microvascular changes in the retina, noted on dilated examination, such as, micro aneurysms, intra-retinal hemorrhages, cotton wool spots, etc. This is because roughly 60% of all non-traumatic lower-limb amputations among people age 20 or older occur in people with diabetes, according to the American Diabetes Association, and microvascular changes in the retina are akin to microvascular changes in the extremities. This damages the nerves, and paresthesias develop.

NEPHROLOGISTS

If the diabetic patient’s recent history reveals chronic kidney disease and he or she hasn’t seen a nephrologist, refer the patient to one. The reason: Diabetes causes 44% of all new cases of kidney failure, according to the CDC. As a result, such patients require close monitoring.

OPHTHALMOLOGISTS

When we examine a patient who has diabetic retinopathy, it is extremely important to properly evaluate the level of pathology. In patients with mild to moderate retinopathy and no signs of clinically significant macular edema (CSME), we should follow up with these patients several times per year, depending on the level of pathology. When the patient shows signs of more severe retinopathy or any signs of CSME, we must refer him or her to a retinal specialist as soon as possible. It is difficult, but not impossible, to see CSME in a patient without the assistance of an OCT scan. However, if there is any question in a practitioner’s mind about whether CSME is present, it is always in the best interest of the patient to refer the patient for a comprehensive retinal evaluation.

COORDINATE

By far, the most effective way to prevent complications from diabetes is to manage the disease aggressively and early by utilizing a team approach. As mentioned in the beginning of this article, we, as O.D.s can play a role in coordinating care. By doing so, our diabetic patients have an excellent chance of maintaining their ocular and systemic health, they become loyal to us, and we receive referrals from other team members. Everyone wins. OM

DR. FICCO practices with 10 O.D.s and four M.D.s at Clayton Eye Center in Morrow, Ga. He serves as the clinical director, residency supervisor and externship coordinator. He lectures nationally on ocular disease and has written several articles on eyecare. E-mail him at charficco@aol.com. Comment at tinyurl.com/OMcomment.