Diabetes Dashboard for Primary Care

A streamlined Diabetes Dashboard for managing diabetes recalls in primary care settings, designed to optimize patient follow-up and streamline assessment, testing, and recall workflows. This tool helps healthcare providers identify, segment, and manage cohorts of diabetic patients for recalls, including online pre-assessments, blood tests, foot checks, and clinician reviews.

The dashboard integrates with Tally forms and Accurx SMS invites, allowing users to quickly prepare and send cohort-specific SMS invitations. The app is accessible directly online at diabetesdashboard.streamlit.app.

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Features

• Guideline-Based Recalls: Provides guidelines-based recall frequencies for key diabetic metrics including HbA1c, blood pressure, lipid profile, renal function, and more.
• Patient Cohort Segmentation: Enables filtering of patient cohorts based on clinical need, recent results, and due statuses for recalls.
• Streamlined Data Processing: Supports uploading of the latest Diabetes Register and Dashboard files for easy integration and updates.
• Tally Form Integration: Guides cohort selection and prepares patients for online pre-assessment, with integration options for Tally forms and Google Sheets.
• Cohort-Specific SMS Generation: Downloads custom CSV files compatible with the Accurx SMS tool for efficient patient communication.
• Visualization: Displays histograms and other visual summaries of key metrics to help clinicians quickly interpret patient distribution data for key metrics.

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Guidelines for Diabetes Management

The tool supports diabetes management according to NICE (National Institute for Health and Care Excellence) guidelines, with recommendations and recall frequencies for various diabetic metrics:

1. HbA1c (Glycated Hemoglobin):

   • If < 53 mmol/mol: Annual check.
   • If 53–75 mmol/mol: Every 3-6 months.
   • If > 75 mmol/mol: Every 3 months.

2. Blood Pressure:

   • < 140/80 mmHg or < 130/80 mmHg (for those with renal, ocular, or cerebrovascular disease).
   • Check annually if stable or every 1–3 months if above target.

3. Lipid Profile (Cholesterol):

   • Annual check if stable and on statins.
   • Re-check at 3 months when initiating or changing therapy.

4. Renal Function (eGFR and ACR):

   • Annual check if normal, every 6 months if reduced renal function or albuminuria.

5. Eye Screening:

   • Annual check if no signs of retinopathy; every 6 months if high risk.

6. Foot Examination:

   • Annual check if low risk; more frequent checks if moderate or high risk.

7. Body Mass Index (BMI) and Weight:

   • Annual check if stable or every 6 months if BMI > 30 or weight loss is a goal.

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Quick Start Guide

Diabetes Recall Workflow

The tool is optimized to assist with the following steps in the diabetes recall process:

1. Online Pre-Assessment:

   • Use Tally forms for the online pre-assessment questionnaire with advanced logic to enhance completion speed. Note: NHS network blocks Tally; set up at home or via a mobile internet connection.
   • Integrate Tally forms with Google Sheets or Notion for easy management of patient responses.

2. Recall Tool Usage:

   • Prepare your Diabetes Register SMS CSV for Accurx invites. Required columns include NHS number, Preferred Telephone number, Date of birth, First name, Email.
   • Save your latest Diabetes Dashboard as a CSV file.
   • Upload both files to the tool.
   • Navigate through the interface to segment and optimize patient cohorts for recall.
   • Download targeted SMS CSV files for each patient cohort as needed.

3. Cohort-Specific SMS Generation:

   • Customize and generate downloadable CSV files with patient lists specific to each recall activity.
   • Send SMS notifications through the Accurx SMS Tool using the generated files.

Visualization of Patient Metrics

• Access a 2x5 grid of histograms displaying age, diagnosis duration, HbA1c, blood pressure, lipid profiles, and more.
• Quickly interpret data distributions to inform recall priorities and interventions.

Links and Resources

• Tally Form Template: Preview and download a pre-configured Tally form template for online patient assessments.
• GitHub Repository: Star the project and connect with the developer for support or improvements.

For questions or assistance with using the tool or setting up Tally integrations, please open a GitHub issue.

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If you like this project please STAR it on GitHub