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Standards of Medical Care for Patients with Diabetes Mellitus John Guzek, MD March 2003
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Screening: Rationale Almost 8 percent of the adult population have diabetes Almost 19 percent of the population older than the age of 65 years have diabetes
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Screening: ADA Guideline Screen for diabetes in high-risk, asymptomatic, undiagnosed adults (Expert Consensus) Screen for diabetes in pregnancy using risk factor analysis (Expert Consensus)
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Screening: PHA If BMI >30, Logician uses protocol for annual fingerstick BG or fasting BG or plasma BG No protocol for pregnancy at present ? Protocol for all persons >65 years
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Pneumovax One time pneumococcal vaccine to all persons with diabetes (C-level evidence: uncontrolled studies)
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Pneumovax 2002 Documentation PHA
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Glycemic Control: Rationale Lowering A1C has been associated with a reduction of microvascular and neuropathic complications of diabetes (A- Level Evid.)
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Glycemic Control: ADA Guidelines: A1C test at least two times a year in patients who are meeting treatment goals. (Expert consensus) Quarterly A1C if not at goal. (Expert consensus)
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Glycemic Control: ADA Target Develop or adjust the management plan to achieve normal or near- normal glycemia with an A1C test goal of <7%. Required: 93% to have A1C w/i 1yr Required: 55% of A1C values to be <8%
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2002 PHA A1C Documentation
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A1c <8.0 PHA 2002
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Glycemic Control: PHA Protocol suggests A1C level every 4 months IF problem list has “Dx of” coded “250.” HEDIS “red flag” for A1C level >6.5 (“borderline”); and for A1C level >7.5 (“high”)
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Blood Pressure Control: JNC 6: Patients with diabetes should be treated to a therapy blood pressure goal of below 130/85 mm Hg. ADA: Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (A) and to a systolic blood pressure of <130 mmHg (B-evidence)
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Blood Pressure Control: ADA Award Requires: 65% of patients must have BP <140 systolic 97% of patients must have at least one BP documented with last 12 months
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Blood Pressure Control: PHA “Red flag” on HEDIS if BP over ADA target (<130/80)
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Lipid Management: Rationale Lowering low density lipoprotein cholesterol is associated with a reduction in cardiovascular events. (A-Level Evidence) Lower low density lipoprotein cholesterol to <100 mg/dL is the primary goal of therapy for adults. (B-Level Evidence)
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Lipid Management: ADA Award Requires: 63% of patients must have LDL cholesterol <130 mg/dL 85% of patients must have LDL cholesterol checked within preceeding 12 months
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Lipid Management: PHA LDL (CALCUL) every 10 months by protocol Reminder on HEDIS Cholesterol if LDL/HDL/TG out of range
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Nephropathy Assessment To reduce the risk and/or slow the progression of nephropathy, optimize glucose control. (A-Level Evidence) To reduce the risk and/or slow the progression of nephropathy, optimize blood pressure control. (A-Level Evidence)
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Nephropathy Treatment 1 In hypertensive and nonhypertensive type 1 diabetic patients with microalbuminuria or clinical albuminuria, angiotensin-converting enzyme inhibitors are the initial agents of choice (A-Level Evidence) In hypertensive type 2 diabetic patients with microalbuminuria or clinical albuminuria, angiotensin receptor blockers are the initial agents of choice (A-Level Evidence)
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PRIME: Summary The renal benefits of irbesartan are independent of its BP-lowering effects its BP-lowering effects IRMA 2 * 70% relative risk reduction in the progression from microalbuminuria to overt diabetic nephropathy with irbesartan 300 mg/d vs control (P<.001) More frequent restoration of normoalbuminuria with irbesartan 300 mg/d vs control (P=.006) IDNT † 20% and 23% relative reduction in composite risk of progression of nephropathy or total mortality vs control (P=.02) and amlodipine (P=.006), respectively * Parving H-H et al. N Engl J Med. 2001;345:870-878. † Lewis EJ et al. N Engl J Med. 2001;345:851-860.
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22 IRMA 2 Primary End Point: Time to Overt Proteinuria RRR, relative risk reduction. Control defined as placebo. * Adjunctive antihypertensive therapies (excluding ACE inhibitors, ARBs, and dihydropyridine CCBs) could be added to all groups to help achieve target BP levels. Adapted from Parving H-H et al. N Engl J Med. 2001;345:870-878. 03612182224 0 5 10 15 20 Follow-up (mo) Control (n=201)* Irbesartan 150 mg/d (n=195)* Irbesartan 300 mg/d (n=194)* RRR=39% P=.08 RRR=70% P<.001 Patients (%)
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Nephropathy Treatment 2 If angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are used, monitor serum potassium levels for the development of hyperkalemia. (Expert consen) Consider referral when serum creatinine has increased to >2.0 mg/dL or when the glomerular filtration rate has fallen to either 2.0 mg/dL or when the glomerular filtration rate has fallen to either <70 mL/min -1 /1.73 m -2 (Expert consensus)
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Nephropathy Assessment ADA Award Requires: Urine dip for protein Urinary microalbumin or 24 hour urine protein 73% of patients required to achieve measure
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Foot Exam The foot examination can be accomplished in a primary care setting and should include the use of a Semmes-Weinstein monofilament, tuning fork, palpation, and a visual examination. (B- level evidence) Educate all patients, especially those with risk factors or prior lower-extremity complications, about the risk and prevention of foot problems, and reinforce self-care behavior. (B-level evidence)
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Foot Exam 2 Perform a comprehensive foot examination annually on patients with diabetes to identify risk factors predictive of ulcers and amputations. Perform a visual inspection of patients’ feet at each routine visit. (Expert consensus)
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Foot Exam ADA Award Requires 80% of patients with specific diabetic foot exam documented on chart in last 12 months
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Foot Exam PHA Logician prompts to do foot exam for diabetics annually Quarterly reminder by protocol if “Dx of” Diabetic neuropathy
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Eye Exam ADA Award Requires: 61% of patients must have diabetic eye exam done to achieve measure
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Logician Reports Your Diabetic Profile High Blood Pressure: A Serious but Common Disorder Take Care of Your Feet
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Logician Diets American Heart Association Diet Restaurant Eating for persons with Diabetes
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Educational Videos Available from Avandia rep
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Standards of Medical Care for Patients with Diabetes Mellitus American Diabetes Association (revised 2001 Oct)
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Standards of Medical Care for Patients with Diabetes Mellitus John Guzek, MD March 2003
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