PS1.276The follow-up of diabetic patients in a family health unit

Tiago Tavares(1), M Rocha(2), M Correia(3), M Ferreira(1), P Vasconcelos(1), AP Pinheiro(1)
(1) USF Viseu Cidade, Viseu, Portugal
(2) USF Infante D. Henrique, Viseu, Portugal
(3) USF Grão Vasco, Viseu, Portugal
Corresponding author: Dr Tiago Tavares, USF Viseu-Cidade, Family Medicine, Viseu, Portugal.
Background & Aim: Type 2 diabetes (DM2) is one of the major causes of early illness and death worldwide. It affects approximately 6,4% of the population, varying from 3,8 to 10,2% by region. Due to it’s complications, mainly micro and macrovascular disease, it´s essential to follow this patients closely. The aim of this paper is to demonstrate how we follow DM2 patients in a Family Health Unit (FHU).
Methods:  This is a clinical experience report, based on our daily routine in a FHU.
Results: In our FHU each family doctor (FD) is responsible roughly for 1900 patients. When a patient is diagnosed with DM2, he/she starts a follow-up plan with regular diabetes appointments. This consultations are free and are scheduled at least twice a year. First, the patient has a consultation with the nurse, where is availed the weight,  height, BMI, waist circumference, blood pressure and glycemia. The examination of  the diabetic foot is performed once a year and if some problem is identified, the patient can be referred for a specific consultation in the FHU. Following this consultation, the patient has another consultation with the FD where each year an analytic study is requested: complete blood count, fasting glucose, lipid profile, plasma creatinine concentration and microalbuminuria. Each 6 months, at least, the HbA1c value is determined. In these patients we also screen diabetic retinopathy once a year.
Conclusions: This multistep, multidisciplinary approach allowed us to achieve higher rates of disease controlled patients and mitigate some of the factors that contributed to the complications of DM2. With this follow up plan the patients are more aware of the consultations that they have and are also more motivated because they know they have someone to recur in case of doubts or difficulties.
No conflict of interest declared.