Standard 3: Care Management a.) Guidelines for important conditions

Initial Diagnosis History – Symptoms of hypoglycemia/hyperglycemia – Atherosclerotic risk factors – Exercise and diet – Pneumovax, influenza and Hep B status – Medications and allergies – Tobacco and alcohol use – Family history – Past medical history – Psychosocial history with assessment for mood disorder and factors that might affect management – Contraception and reproductive history Physical Exam – Blood pressure – Weight/height and BMI – Evaluation of pulses – Foot examination with monofilament testing – Retinal camera exam or dilated retinal exam by an eye specialist (Type2) Laboratory assessment – Hgb A1C point of care testing – Urine microalbumin – Fasting lipid pane – Serum creatinine and calculated GFR Management – Initiate treatment – Refer for Diabetes Education – Refer for nutrition counseling Diabetes Mellitus – Diagnostic Criteria (Non-Pregnant Adults) Casual plasma glucose > 200 mg/dl and symptoms of diabetes (polyuria, polydipsia, ketoacidosis, or unexplained weight loss) OR Fasting plasma glucose (FPG)* >126 mg/dl OR Results of a 2-hour 75-g Oral Glucose Tolerance Test (OGTT)* > 200 mg/dl OR A1C >6.5% * These tests should be confirmed by a repeat test, on a different day, unless unequivocally high University Internal Medicine Adult Type 2 Diabetes Practice Guideline Reference: Standards of Medical Care in Diabetes Diabetes Care January 2013 vol 36 no. Supplement 1 S11-S66. Metformin preferred

Quarterly to semi-annually Review patient self-management – Glucose testing, self-foot exam, exercise, diet – Importance of good dental care and regular exams At least once a year Test A1C – Point of care testing every 3 months, or twice yearly if in good control Annually Complete foot exam – Inspection, pulses, monofilament Nephropathy screening – No known nephropathy – urine microalbumin – (normal <30) – Known nephropathy – consider nephrology consult – Serum creatinine and GFR measurements Obtain fasting lipid panel – LDL goal <100, or <70 if CVD or high risk Retinal eye exam – Retinal images and/or dilated exam performed by eye care professional Every Visit Interval history – Symptoms of hypoglycemia/hyperglycemia – Review glucose testing results – Tobacco cessation counseling, if needed – Medication reconciliation Obtain weight – Calculate BMI – Review exercise and diet Adjust therapeutic regimen to goal – A1C <7% for most – individualize goals – BP < 140/<80 based on individualized risks – LDL <100; statin for all patients with CAD or high risk – Flu, pneumovax, Hep B up to date – ACEI/ARB for nephropathy – Anti-platelet agents – all patients for secondary prevention; primary prevention if 10 year risk of CAD >10% Reference: Standards of Medical Care in Diabetes Diabetes Care January 2013 vol 36 no. Supplement 1 S11-S66.

Hypertension Diagnostic Criteria Initial Diagnosis History – Symptoms – focused on secondary causes including OSA – Atherosclerotic risk factors – Exercise and diet – Medications and allergies – Tobacco and alcohol use – Family history – Past medical history – Psychosocial history with assessment for mood disorder and factors that might affect management – Contraception and reproductive history Physical Exam – Blood pressure properly measured – both arms – Weight/height and BMI – Retinal examination or retinal pictures – Palpation of thyroid – Auscultation for bruits: carotid, abdominal, femoral – Heart, lung and abdomen exam – Lower extremity exam – edema and pulses – Neurological exam Laboratory assessment – 12-lead EKG – Urinalysis – Complete metabolic panel (including calcium, creatinine and GFR) – Fasting lipid panel – Hematocrit Management – Lifestyle modifications (table 1) – Initiate treatment Goal: ≥ 60 yo: <150/<90<60 yo: <140/<90 The average of 2 or more BP readings in two or more office visits with properly sized blood pressure cuff, measured by auscultation, patient seated at least 5 minutes prior to the exam, feet on the floor and arm resting at heart level. University Internal Medicine Adult Hypertension Practice Guideline Reference: 2014 Evidence-Based Guideline for the management of high blood pressure in adults: report from the panel members appointed to the eight Joint National Committee (JNC 8). JAMA. 2014;311(5): doi: /jama JNC Table 1: Recommended Lifestyle Modifications Weight reduction Aerobic physical activity ― At least 30 minutes most days of the week Dietary Approaches to Stop Hypertension (DASH) diet ― Rich in fruits and vegetables, low in saturated fat Dietary sodium reduction ― <2.4 g Na or <6 g NaCl Moderation of alcohol consumption ― <2 drinks per day for men, 1 for women

Nephropathy screening – Serum creatinine and GFR measurements Obtain fasting lipid panel – LDL goal as per hyperlipidemia guidelines and risk factors Obtain CMP – Follow affects of drug therapy References: 2014 Evidence-Based Guideline for the management of high blood pressure in adults: report from the panel members appointed to the eight Joint National Committee (JNC 8). JAMA. 2014;311(5): doi: /jama JNC Annually

Prevention of Overweight and Obesity Advice for patients with weight concerns:  Decrease intake of energy-dense foods (animal fats, other high fat foods, sugary foods or beverages) by selecting low energy-dense foods instead (wholegrains, fruits, vegetables)  Reduce consumption of “fast food”  Decrease alcohol intake  Increase physical activity and decrease TV watching or other sedentary behaviors Overweight/Obesity– BMI Diagnostic Criteria (Non-Pregnant Adults) Overweight Obesity ≥ 30 University Internal Medicine Adult Obesity Practice Guideline Overweight and Obesity Treatment Goals W eight loss targets should be based on the individual’s comorbidities and risks, rather than their weight alone: ƒin patients with BMI obesity-related comorbidities are less likely to be present and a 5-10% weight loss (approximately 5-10 kgs) is required for cardiovascular disease and metabolic risk reduction. ƒin patients with BMI>35 obesity-related comorbidities are likely to be present therefore weight loss interventions should be targeted to improving these comorbidities; in many individuals a greater than 15-20% weight loss (will always be over 10 kg) will be required to obtain a sustained improvement in comorbidity Review secondary causes of Overweight/Obesity and Modify Smoking cessation Medications Atypical antipsychotics Beta adrenergic blockers Insulin in Type 2 Diabetics Lithium Sodium valproate Sulfonylureas Thiazolidinediones Tricyclic antidepressants Counsel Patients on the Health Benefits of Weight Loss improved lipid profiles ƒreduced osteoarthritis-related disability. lowered all-cause, cancer and diabetes mortality in some patient groups ƒreduced blood pressure ƒimproved glycaemic control ƒreduction in risk of type 2 diabetes ƒpotential for improved lung function in patients with asthma.

References: Scottish Intercollegiate Guidelines Network Management of Obesity NHLBI 1998http:// Assess willingness to change – discuss with patient then target weight loss interventions Weight management programs should include physical activity, dietary change and behavioral components Diet should be calculated to produce a 600kcal/day energy deficit Physical activity should equal kcal/week or min/week of moderate intensity physical activity Pharmacologic treatment should be considered as an adjunct to lifestyle interventions Bariatric surgery should be considered on an individual basis for all patients with BMI ≥ 40 or BMI ≥ 35 with one or more comorbid medical conditions (arthritis, obstructive sleep apnea, diabetes mellitus type 2, hypertension, dyslipidemia) who have completed a structured weight management program