11th April 2020, Dr Chee L Khoo
You are probably overwhelmed by the whole Covid-19 saga. Just because we are dealing with Covid-19 “everywhere”, doesn’t mean existing chronic diseases can take a breather. Patients with chronic illness especially diabetes and hypertension are affected by the current Covid-19 chaos in more ways then one. GPs play a vital role in managing these patients during this difficult and challenging time especially when there is much emphasis on telehealth. We need to be aware of all the issues affecting patients with diabetes or else, these patients will fall through the cracks during this period.
The medical risks
Patients with diabetes probably have a higher susceptibility to Covid-19 but the reasons are unclear. In a retrospective, multicentre cohort study, 191 patients from two hospitals in Wuhan were studied. 30% of patients had hypertension, 19% had diabetes and 8% had coronary heart disease (CAD) (1). Many of our patients with diabetes have both hypertension and CAD.
Not every infection is Covid-19. With winter around the corner, our patients are susceptible to the usual complications of influenza infections – pneumonia, heart failure, atrial fibrillation and sepsis. In the Covid-19 centric hospital systems, non-Covid-19 conditions may be overlooked. These patients come back to their GPs when the swabs are negative.
Telehealth can have its downsides
Patients with chronic illness are aware of their increased susceptibility. They seek to minimise their exposure through self-isolation. Many of our older patients have been in self-isolation weeks before social distancing rules come into effect. Unfortunately, that means missing appointments at hospital outpatients, with specialists as well as with GPs. Chronic illnesses await no one. The damage from suboptimally controlled diabetes marches on.
The availability of telehealth has allowed us to maintain some contact with patients with diabetes (and other morbidities) but without face to face consultations, many aspects of the diabetes care will be deficient. Feet need to be examined especially those patients with high risk feet. Patients with a history of heart failure need regular reviews. Patients with diabetic retinopathy also need their regular reviews. The optometrists are closed. Patients who have sub-optimal glycaemic control need more than just their regular blood tests.
We need to make our practices safe from cross infection. The steps that we take to minimise our patients’ exposure need to be transparent so that patients can be confident that they are safe when they present to see us.
One of the major effects of panic buying and hoarding is the price of ordinary items has skyrocketed. Some patients do not have the means to buy their food and other essentials weeks ahead. They live week to week. While an increase in payment by centrelink helps, many may be missing out on visits to the doctors and on their regular prescriptions.
Many of you have already seen patients with significant psychological distress since the outbreak of Covid-19. Self-isolation is likely to exacerbate the distress. The Lancet recently published a review of the psychological impact of quarantine (2). People who are quarantined are very likely to develop a wide range of symptoms of psychological stress and disorder, including low mood, insomnia, stress, anxiety, anger, irritability, emotional exhaustion, depression and post-traumatic stress symptoms.
With gyms, pools and parks all off limits during the Covid-19 lock down, patients will miss out on their usual physical activity and exercises. Being stuck at home may mean more snacks and poorer diet for most of our patients with diabetes. As we have better rapport and more frequent encounters with our patients in primary care, we have a huge role during the covid-19 crisis to encourage and motivate our patients with their ongoing lifestyle measures.
Regular reviews and regular exercises will also assist our patients who are as psychologically overwhelmed as we are with the covid-19 pandemic.
Working together –who does what
As GPs, we are often the patient’s first contact when things go wrong. Patients may not know which outpatients are still running and which aren’t. Trying to get in contact with their specialists can sometimes be challenging. Over the last few weeks, I have fielded a number of calls about insulin dosing.
4 things to keep in mind
- Usual care must continue
- Sick day management – plan for sick days especially in high risk groups
- Stay in touch – telehealth plus face to face if possible
- Not everything is Covid-19
GPs have a vital role in not only minimising our patients’ exposure to the virus during the Covid-19 pandemic but also continue to monitor the well-being of our patients with diabetes. Diabetes doesn’t come to a standstill because we have a Covid-19 pandemic. The hospital system is stretched to the limit managing inpatients with Covid-19. Telehealth is not the answer to everything
- Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 inWuhan, China: a retrospective cohort study. Lancet. 2020;S0140-6736(20)30566-3. doi:10.1016/S0140-6736(20)30566-3
- Brooks S, Webster R, Smith L, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet March 14, 2020. 395:10227, P912-920. DOI:https://doi.org/10.1016/S0140-6736(20)30460-8