IDC 4.1 Problems n High incidence and prevalence of diabetes n Reliance on primary care providers n Significant variation in practice n High costs and poor outcomes n Translating recent findings into clinical practice n Unclear national and international standards

IDC 4.2 Principles of SDM 1.Customized practice guidelines to assure community-wide acceptance 2.Therapeutic goals, with realistic timelines, set with the patient 3.DecisionPaths to assure rapid selection, initiation and adjustment of effective therapies 4. Movement between sequential therapeutic options when goals are not met

IDC 4.3 SDM Process: Customization and Training n Review and modification of practice guidelines and Master DecisionPath u screening and diagnostic criteria u selection of therapies u metabolic targets and timelines u complications surveillance n Case studies u review of SDM materials u application of SDM to site cases

IDC 4.4 Type 2 Master DecisionPath Fasting> 350 mg/dL Casual> 400 mg/dL Fasting> 350 mg/dL Casual> 400 mg/dL Insulin Stage 3A* R/N – 0 – R – N Insulin Stage 3A* R/N – 0 – R – N Insulin Stage 2* R/N – 0 – R/N – 0 Insulin Stage 2* R/N – 0 – R/N – 0 Insulin Stage 4A* R – R – R – N Insulin Stage 4A* R – R – R – N Fasting< 200 mg/dL Casual< 250 mg/dL Fasting< 200 mg/dL Casual< 250 mg/dL Oral Agent Stage* Food Plan & Exercise Stage* Fasting200–350 mg/dL Casual250–400 mg/dL Fasting200–350 mg/dL Casual250–400 mg/dL Combination Therapy Stage* OA - 0- OA- 0 or OA – 0 – 0 – N Combination Therapy Stage* OA - 0- OA- 0 or OA – 0 – 0 – N For conversion to mmol/L divide mg/dL by 18

IDC 4.5 Type 2 Diabetes Fasting BG > 126 mg/dL Casual BG > 200 mg/dL Type 2 Diabetes Fasting BG > 126 mg/dL Casual BG > 200 mg/dL Systematic Approach to Management of Type 2 Diabetes Hemoglobin A 1c Every 3-6 months Target < 7.0% SMBG Pre-meal mg/dL (~ 50% of readings) Hemoglobin A 1c Every 3-6 months Target < 7.0% SMBG Pre-meal mg/dL (~ 50% of readings) LDL Cholesterol Annual testing Target LDL < 130 mg/dl With CVD < 100 mg/dl Triglycerides < 200 mg/dl HDL > 40 mg/dl LDL Cholesterol Annual testing Target LDL < 130 mg/dl With CVD < 100 mg/dl Triglycerides < 200 mg/dl HDL > 40 mg/dl Blood Pressure (every visit) Dx of HTN > 130/85 Rx Target < 130/85 Blood Pressure (every visit) Dx of HTN > 130/85 Rx Target < 130/85 Annual Screening Nephropathy Microalbuminuria Screening Retinopathy Dilated retinal exam Neuropathy Comprehensive foot exam Annual Screening Nephropathy Microalbuminuria Screening Retinopathy Dilated retinal exam Neuropathy Comprehensive foot exam Foot Care Aspirin Use Tobacco cessation Flu Shot + Pneumovax Psychosocial Support QOL - Pt. satisfaction Foot Care Aspirin Use Tobacco cessation Flu Shot + Pneumovax Psychosocial Support QOL - Pt. satisfaction Glycemic Control Management of Dyslipidemia Dyslipidemia HypertensionManagementHypertensionManagement ComplicationsManagementComplicationsManagement CareRecommendationsCareRecommendations HyperglycemiaHyperglycemia Lipid Disorders HypertensionHypertensionComplicationsComplications Other Components of Care Other Components of Care © International Diabetes Center

IDC 4.6 Annual Comprehensive Diabetes Review n Vascular Disease n Retinopathy n Nephropathy n Neuropathy n Foot Disease n Oral and Dermatological n Hospitalizations, Hypoglycemia, DKA and Hyperosmolar Nonketotic Coma (HONK)

IDC 4.7 Comparison of Clinics on Standards of Care