07/04/2015
Su Mok Alex Lawrence
Research Support Coordinator Industry Development Officer RACPG Exercise & Sports Science Australia su.mok@racgp.org.au Alex.Lawrence@essa.org.au
Re: Stakeholder feedback on General practice management of type 2 diabetes
Dear Su Mok,Thank you for providing Exercise & Sports Science Australia (ESSA) with the opportunity to submit feedback regarding the 2014-15 clinical guidelines for the General practice
management of type 2 diabetes, developed by the Royal Australian College of General Practitioners (RACGP). ESSA is a professional association representing 4,734 members, including university qualified Exercise Scientists, Sports Scientists and Accredited Exercise Physiologists (AEPs). ESSA would like to bring to your attention the following:
Section 4: Preventing Type 2 Diabetes
ESSA supports the RACGP’s position on the importance of identifying and promoting lifestyle modification for the prevention of Type 2 Diabetes Mellitus (T2DM). Peer reviewed evidence validates the efficacy of exercise and dietary lifestyle interventions for individuals with Impaired Glucose Tolerance (IGT), Impaired Fasting Glucose (IFG), Metabolic Syndrome and preventing progression of pre-diabetes to T2DM [1, 2, 3].
ESSA believes that optimal benefits are achieved when interventions are developed using an integrated, patient-centred approach by appropriately qualified and credentialed allied health professionals such as AEPs, Accredited Practising Dietitians (APDs) and Credentialed Diabetes Educators (CDEs).
ESSA would also like to make the RACGP aware of Exercise Scientists and their role in the prevention of pre-diabetes. An Exercise Scientist holds an undergraduate degree in the field of exercise and sports science, specalising in the design, implementation and evaluation of exercise and physical activity for healthy people. They provide programs for improving general health, the prevention of chronic diseases and health promotion.
Suggestions:
1)
Recommend a change to sentence structure.
Under sub heading “Lifestyle modification”, the last paragraph states:
“Plans could involve other practice team members and may include referral to allied health professionals such as dietitians, diabetes educators and exercise physiologists or physiotherapists and may include a structured goal- oriented program”
ESSA suggests changing “exercise physiologists or physiotherapists” to
AEPs deliver specialised exercise interventions, which incorporate an individualised approach and follow up, and significantly delay disease progression from pre-diabetes to diabetes. It is imperative that physical activity interventions account for the frequent presence of
comorbidities in this patient population, whereby 75% of adults with T2DM have at least one comorbid chronic disease [4] and up to 40% have at least three [5, 6]. AEPs effectively account for this increased clinical complexity (associated with comorbid conditions, risk factors and obesity). An AEP is also able to promote behaviour change and facilitate self-management to ensure long-term benefits. As such, ESSA believes AEP services should be considered sui generis.
2)
Recommend reference to The Healthy Eating Activity and Lifestyle (HEAL™)
program.
In the recommendations table reference is made to “Structured diabetes prevention programs
are available”. ESSA suggests including reference to the Healthy Eating Activity and Lifestyle
(HEAL™) program, a lifestyle modification program that enables participants to develop lifelong healthy eating and physical activity behaviours.
HEAL™ consists of 8 weekly group education and group exercise sessions as well as individual consultations pre- and post-program and 5 and 12 month follow-up health consultations. Each week participants undertake 1 hour of supervised group-based low to moderate intensity physical activity followed by a 1 hour group-based healthy lifestyle education class. HEAL™ is conducted by South Western Sydney Medicare Local Ltd (SWSML) in partnership with ESSA.
A recent study assessing the efficacy of the HEAL™ program indicates that participation results in significant improvements in major pre-diabetes and T2DM risk factors. The study found an increase in the frequency and volume of physical activity, reductions in daily sitting time and increases in fruit and vegetable consumption. Whilst also, reducing total body mass, body mass index, waist circumference and blood pressure and improving functional capacity [7].
Patients can be referred to the HEAL™ program for T2DM group services (MBS items 81100 to 81125), following the completion of a GP Management Plan. This group program involves an individual assessment by the AEP or APD, followed by 8 group exercise/education classes. These group sessions are in addition to the 5 individual allied health services available under Medicare (Item numbers 10950-10970).
Patients with chronic disease risk factors may also be referred to the HEAL™ program. Eligible patients include those:
• at high risk of developing T2DM
• with 2 or more cardiovascular disease risk factors • with a BMI greater than 30
Section 6: Lifestyle modification
ESSA supports the RACGP’s position on the importance of identifying and promoting lifestyle modification for the management of T2DM.
There is accumulating evidence that sedentary behaviour in patients with established T2DM is an independent risk factor for chronic complications of diabetes [8]. Increasing physical activity facilitates improved metabolic control in biochemical indicators, removing symptoms and maintaining or improving quality of life [8].
Suggestions:
1)
Recommend reiterating importance of team care approach.
Patient-centered care is defined as an approach to “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” [9]. Lifestyle interventions, including diet and physical activity are an effective single management strategy for T2DM [10, 11]. ESSA supports a team care approach, utilising approrpaite allied health services such as AEP interventions, to help the patient and GP make informed decisions regarding their lifestyle modification
requirements. ESSA feels that more awareness should be placed on GP led education of patients on available Allied Health services.
Collectively, Diabetes is the second highest cause of death in remote areas [12, 13]. Yet despite the recognised, important role of allied health professionals for the prevention, early
detection, management, and treatment of T2DM, access to allied health professionals in rural and remote areas is severely lacking [13]. ESSA calls for enhanced access to allied health services, in particular AEPs, in rural and remote areas. ESSA acknowledges that the inability of AEPs to bill for Telehealth video consultations is a significant barrier to the delivery of timely exercise interventions to patients with T2DM in eligible remote, regional and outer
metropolitan areas. Whilst ESSA has lobbied for existing provisions under Telehealth to be extended to all allied health, we also encourage RACGP to ensure that all GPs (in both rural, remote and metropolitan regions) are aware of value of AEP interventions when considering appropriate care for patients with T2DM.
The ESSA “Find an Exercise Physiologist” online search facility can assist GPs with finding an AEP in their local area to refer patients requiring physical activity or exercise interventions.
Section 6.1: Physical activity
ESSA supports the RACGP’s position on the importance of identifying and promoting physical activity for the management of T2DM.
Exercise is regarded as a cornerstone for diabetes management and whilst generic physical activity can have a favourable impact on improving glycemic control, reducing cardiovascular risk and reducing overall mortality [11, 14], more specialised and individualised exercise prescription can achieve superior benefits [11]. We advocate greater emphasis placed on AEP led, individualised exercise prescription. AEPs are recognised allied health professionals who specialise in the targeted delivery of individualised exercise prescription and lifestyle education for the prevention and
management of chronic diseases and injuries. An AEP is able to conduct and interpret specific tests, prescribe an exercise program in consideration of comorbidities, set appropriate goals, identify barriers, and facilitate self-management and behaviour change, leading to increased patient
Suggestions:
1)
Recommend removal of the term “exercise specialist”.
Due to the lack of consensus and regulation of the term Exercise Specialist, ESSA contends that it would not be pertinent to give reference to the term given the context of this document, as it may lend to potential confusion. “Exercise Specialist” terminology is more applicable to an American audience, where the use of the term is more extensively used with in the literature. Because the term “Exercise Specialist” is not officially recognised in Australia, it has become synonymous with any professional that provides exercise advice, regardless of qualification, skill set, or in this case ability to effectively and safely provide services to
patient’s with T2DM. For example a number of RTO providers of Fitness certifications, actively advertise their product with the phrase: “become an Exercise Specialist with the Diploma of Fitness”.
In Australia, Certified Fitness professionals (Certificate III and IV, and Diploma of Fitness) are not equipped with the knowledge or skills to provide targeted exercise interventions for this patient population. Once a patient has been referred to an AEP and is deemed stable and not high risk, they may then be referred onwards to a fitness professional, or preferably, an Exercise Scientist, to supervise a patient undertaking an AEP prescribed exercise program.
2)
Recommend reference to group services.
Current evidence suggests that multidisciplinary and integrated care teams are best practice in the management of T2DM, preventing and decreasing the impact of complications and comorbidities, resulting in health care cost savings [14]. The HEAL™ program is an example of an allied health professional lead, group based self-management intervention, which has
been successful in reducing the cost of treatment, and enhancing the health and wellbeing of participants [7,12]. Group-based training that facilitates self- management in people with T2DM
is effective in improving fasting blood glucose levels, glycated haemoglobin and diabetes knowledge and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication [11].
Increasing time constraints placed on GPs pose a considerable challenge for the provision of patient-specific information and recommendations. Allied health Professional’s are well placed to provide the specialised advice and input crucial to the success of self-management programs and interventions.
Section 9: Managing cardiovascular risk
ESSA supports the RACGP’s position on the importance of identifying and promoting lifestyle interventions, and specifically physical activity, to reduce cardiovascular risk in patients with T2DM.
A sedentary lifestyle is one of the 5 major risk factors for cardiovascular disease and that risk is only compounded with the diagnosis of T2DM [16]. Over the past few decades, the scientific evidence supporting the role of exercise, for the prevention, management and treatment of cardiovascular disease are well established and robust [17].
1)
Recommend specific reference to AEPs referral for exercise interventions.
AEPs hold a four-year university degree and are allied health professionals who are the foremost experts in the delivery of exercise for the prevention and management of chronic and complex diseases and injury. AEPs are specialists in conducting and interpreting specific tests, setting appropriate goals, identifying barriers, and facilitating self-management and behaviour change, leading to increased patient independence and intervention adherence. AEPs are eligible to register with Medicare Australia, the Department of Veterans’ Affairs and WorkCover and are recognised by most private health insurers.Final Points
Thank you for the opportunity to provide comment on the 2014-15 General practice management of type 2 diabetes. We look forward to viewing the updated Guide and
welcome the opportunity to provide additional comments on content, particularly in regards to Section 6.1: Physical activity.
Please to contact Alex.Lawrence@essa.org.au with any questions or concerns.
Yours Sincerely,
Alex Lawrence Anita Hobson-Powell
Industry Development Officer Executive Officer
References:
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6. Maddigan, S.L., Feeny, D.H., & Johnson, J.A. (2005). Health-related quality of life deficits associated with diabetes and comorbidities in a Canadian National Population Health Survey. Qual Life Res. 14:1311–20.
7. Assessing the real world effectiveness of the Healthy Eating Activity & Lifestyle (HEAL™) program. Unpublished article, Health Promotion Journal of Australia. 8. Colagiuri, R., Colagiuri, S., Yach, D., & Pramming, S. 92006).The Answer to Diabetes
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9. Committee on Quality of Health Care in America: Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, The National Academies Press, 2001
10. National Institute for Clinical Excellence. (2003). Guidance for the use of patient-education models for diabetes. Technology appraisal 60. London: NHS.
11. Orozco, L.J., Buchleitner, A.M., Gimenez-Perez, G., Roqué I Figuls, M., Richter, B., & Mauricio, D. (2008).Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database of Systematic Review. 16(3). doi:
10.1002/14651858.CD003054
12. SARRAH. (2015). A Report Drafted for Services for Australian Rural and Remote Allied Health: Investigating the Efficacy of Allied Health: Reducing Costs and Improving Outcomes in the Treatment of Diabetes, Osteoarthritis and Stroke. Viewed 02 April
2015:https://sarrah.org.au/sites/default/files/docs/investigating_the_efficacy_of_alli ed_health_reducing_costs_and_improving_outcomes_-_final_report.pdf
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