Standards of Medical Standards of Medical Care for Patients with Care for Patients with Diabetes MellitusDiabetes Mellitus

John Guzek, MDJohn Guzek, MD

March 2003March 2003

Screening:Screening:RationaleRationale

Almost 8 percent of the adult population Almost 8 percent of the adult population have diabeteshave diabetes

Almost 19 percent of the population older Almost 19 percent of the population older than the age of 65 yearsthan the age of 65 years have diabeteshave diabetes

Screening:Screening:ADA GuidelineADA Guideline

Screen for diabetes in high-risk, Screen for diabetes in high-risk, asymptomatic, undiagnosed asymptomatic, undiagnosed adults adults (Expert Consensus)(Expert Consensus)

Screen for diabetes in pregnancy Screen for diabetes in pregnancy using risk factor analysis using risk factor analysis (Expert (Expert Consensus)Consensus)

Screening:Screening:PHAPHA

If BMI >30, Logician uses protocol If BMI >30, Logician uses protocol for annual fingerstick BG or fasting for annual fingerstick BG or fasting BG or plasma BGBG or plasma BG

No protocol for pregnancy at No protocol for pregnancy at presentpresent

? Protocol for all persons >65 years? Protocol for all persons >65 years

Pneumovax Pneumovax

One time pneumococcal One time pneumococcal vaccine to all persons with vaccine to all persons with diabetes (C-level evidence: diabetes (C-level evidence: uncontrolled studies)uncontrolled studies)

Pneumovax 2002 Documentation Pneumovax 2002 Documentation PHAPHA

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

A B C D E F G H I

Glycemic Control:Glycemic Control:RationaleRationale

Lowering A1C has been Lowering A1C has been associated with a reduction of associated with a reduction of microvascular and neuropathic microvascular and neuropathic complications of diabetes (A-complications of diabetes (A-Level Evid.)Level Evid.)

Glycemic Control:Glycemic Control:ADA Guidelines:ADA Guidelines:

A1C test at least two times a A1C test at least two times a year in patients who are meeting year in patients who are meeting treatment goals. treatment goals. (Expert consensus) (Expert consensus)

Quarterly A1C if not at goal. Quarterly A1C if not at goal. (Expert consensus) (Expert consensus)

Glycemic Control:Glycemic Control:ADA TargetADA Target

Develop or adjust the management Develop or adjust the management plan to achieve normal or near-plan to achieve normal or near-normal glycemia with an A1C test normal glycemia with an A1C test goal of goal of <<7%. 7%.

Required: 93% to have A1C w/i 1yr Required: 93% to have A1C w/i 1yr Required: 55% of A1C values to be Required: 55% of A1C values to be

<8%<8%

2002 PHA A1C Documentation2002 PHA A1C Documentation

0%

20%

40%

60%

80%

100%

A B C D E F G H I

93% Required

A1c <8.0 PHA 2002A1c <8.0 PHA 2002

0%

20%

40%

60%

80%

100%

A B C D E F G H I

55% Required

Glycemic Control:Glycemic Control:PHAPHA

Protocol suggests A1C level every 4 Protocol suggests A1C level every 4 months IF problem list has “Dx of” coded months IF problem list has “Dx of” coded “250.”“250.”

HEDIS “red flag” for A1C level >6.5 HEDIS “red flag” for A1C level >6.5 (“borderline”); (“borderline”);

and for A1C level >7.5 (“high”)and for A1C level >7.5 (“high”)

Blood Pressure Control:Blood Pressure Control:

JNC 6JNC 6: Patients with diabetes should be : Patients with diabetes should be treated to a therapy blood pressure goal treated to a therapy blood pressure goal of below 130/85 mm Hg.of below 130/85 mm Hg.

ADAADA: Patients with diabetes should be : Patients with diabetes should be treated to a diastolic blood pressure treated to a diastolic blood pressure <80<80 mmHg (A) and to a systolic blood mmHg (A) and to a systolic blood pressure of pressure of <130<130 mmHg (B-evidence) mmHg (B-evidence)

Blood Pressure Control: Blood Pressure Control: ADA Award Requires:ADA Award Requires:

65% of patients must have BP <140 65% of patients must have BP <140 systolicsystolic

97% of patients must have at least one 97% of patients must have at least one BP documented with last 12 monthsBP documented with last 12 months

Blood Pressure Control:Blood Pressure Control:PHAPHA

““Red flag” on HEDIS if BP over ADA Red flag” on HEDIS if BP over ADA target (<130/80)target (<130/80)

Lipid Management:Lipid Management:RationaleRationale

Lowering low density lipoprotein Lowering low density lipoprotein cholesterol is associated with a reduction cholesterol is associated with a reduction in cardiovascular events. (A-Level in cardiovascular events. (A-Level Evidence)Evidence)

Lower low density lipoprotein cholesterol Lower low density lipoprotein cholesterol to <100 mg/dL is the primary goal of to <100 mg/dL is the primary goal of therapy for adults. (B-Level Evidence)therapy for adults. (B-Level Evidence)

Lipid Management:Lipid Management: ADA Award Requires:ADA Award Requires:

63% of patients must have LDL 63% of patients must have LDL cholesterol <130 mg/dLcholesterol <130 mg/dL

85% of patients must have LDL 85% of patients must have LDL cholesterol checked within preceeding 12 cholesterol checked within preceeding 12 monthsmonths

Lipid Management:Lipid Management:PHAPHA

LDL (CALCUL) every 10 months by LDL (CALCUL) every 10 months by protocolprotocol

Reminder on HEDIS Cholesterol if Reminder on HEDIS Cholesterol if LDL/HDL/TG out of rangeLDL/HDL/TG out of range

Nephropathy AssessmentNephropathy Assessment

To reduce the risk and/or slow the To reduce the risk and/or slow the progression of nephropathy, optimize progression of nephropathy, optimize glucose control. glucose control. (A-Level Evidence)(A-Level Evidence)

To reduce the risk and/or slow the To reduce the risk and/or slow the progression of nephropathy, optimize progression of nephropathy, optimize blood pressure control. blood pressure control. (A-Level Evidence)(A-Level Evidence)

Nephropathy Treatment 1Nephropathy Treatment 1

In hypertensive and nonhypertensive type 1 In hypertensive and nonhypertensive type 1 diabetic patients with microalbuminuria or diabetic patients with microalbuminuria or clinical albuminuria, angiotensin-converting clinical albuminuria, angiotensin-converting enzyme inhibitors are the initial agents of enzyme inhibitors are the initial agents of choice choice (A-Level Evidence)(A-Level Evidence)

In hypertensive type 2 diabetic patients with In hypertensive type 2 diabetic patients with microalbuminuria or clinical albuminuria, microalbuminuria or clinical albuminuria, angiotensin receptor blockersangiotensin receptor blockers are the initial are the initial agents of choice agents of choice (A-Level Evidence)(A-Level Evidence)

PRIME: SummaryPRIME: Summary

The renal benefits of irbesartan are independent of The renal benefits of irbesartan are independent of its BP-lowering effectsits BP-lowering effects

IRMA 2IRMA 2**

70% relative risk reduction in the progression from 70% relative risk reduction in the progression from microalbuminuria to overt diabetic nephropathy with microalbuminuria to overt diabetic nephropathy with irbesartan 300 mg/d vs control (irbesartan 300 mg/d vs control (PP<.001)<.001)

More frequent restoration of normoalbuminuria with More frequent restoration of normoalbuminuria with irbesartan 300 mg/d vs control (irbesartan 300 mg/d vs control (PP=.006)=.006)

IDNTIDNT††

20% and 23% relative reduction in composite risk of 20% and 23% relative reduction in composite risk of progression of nephropathy or total mortality vs control progression of nephropathy or total mortality vs control ((PP=.02) and amlodipine (=.02) and amlodipine (PP=.006), respectively=.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.

2222

IRMA 2 Primary End Point:IRMA 2 Primary End Point:Time to Overt ProteinuriaTime 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.

0 3 6 12 18 22 24

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

Pat

ient

s (%

)

Nephropathy Treatment 2Nephropathy Treatment 2

If angiotensin-converting enzyme inhibitors If angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are used, or angiotensin receptor blockers are used, monitor serum potassium levels for the monitor serum potassium levels for the development of hyperkalemia. development of hyperkalemia. (Expert consen)(Expert consen)

Consider referral when serum creatinine Consider referral when serum creatinine has increased to >2.0 mg/dL or when the has increased to >2.0 mg/dL or when the glomerular filtration rate has fallen to either glomerular filtration rate has fallen to either <70 mL/min<70 mL/min-1-1/1.73 m/1.73 m-2-2 (Expert consensus)(Expert consensus)

Nephropathy AssessmentNephropathy AssessmentADA Award Requires:ADA Award Requires:

Urine dip for proteinUrine dip for protein Urinary microalbumin or 24 hour urine Urinary microalbumin or 24 hour urine

proteinprotein 73% of patients required to achieve 73% of patients required to achieve

measuremeasure

Foot ExamFoot Exam

The foot examination can be accomplished in a The foot examination can be accomplished in a primary care setting and should include the use primary care setting and should include the use of a Semmes-Weinstein monofilament, tuning of a Semmes-Weinstein monofilament, tuning fork, palpation, and a visual examination. (B-level fork, palpation, and a visual examination. (B-level evidence)evidence)

Educate all patients, especially those with risk Educate all patients, especially those with risk factors or prior lower-extremity complications, factors or prior lower-extremity complications, about the risk and prevention of foot problems, about the risk and prevention of foot problems, and reinforce self-care behavior. (B-level and reinforce self-care behavior. (B-level evidence)evidence)

Foot Exam 2Foot Exam 2

Perform a comprehensive foot Perform a comprehensive foot examination annually on patients with examination annually on patients with diabetes to identify risk factors predictive diabetes to identify risk factors predictive of ulcers and amputations. Perform a of ulcers and amputations. Perform a visual inspection of patients’ feet at each visual inspection of patients’ feet at each routine visit. routine visit. (Expert consensus)(Expert consensus)

Foot ExamFoot ExamADA Award RequiresADA Award Requires

80% of patients with specific diabetic foot 80% of patients with specific diabetic foot exam documented on chart in last 12 exam documented on chart in last 12 monthsmonths

Foot ExamFoot ExamPHAPHA

Logician prompts to do foot exam for Logician prompts to do foot exam for diabetics annually diabetics annually

Quarterly reminder by protocol if “Dx of” Quarterly reminder by protocol if “Dx of” Diabetic neuropathyDiabetic neuropathy

Eye ExamEye ExamADA Award Requires:ADA Award Requires:

61% of patients must have diabetic eye 61% of patients must have diabetic eye exam done to achieve measure exam done to achieve measure

Logician ReportsLogician Reports

Your Diabetic ProfileYour Diabetic Profile High Blood Pressure: A Serious but High Blood Pressure: A Serious but

Common DisorderCommon Disorder Take Care of Your FeetTake Care of Your Feet

Logician DietsLogician Diets

American Heart Association DietAmerican Heart Association Diet Restaurant Eating for persons with Restaurant Eating for persons with

DiabetesDiabetes

Educational VideosEducational Videos

Available from Avandia repAvailable from Avandia rep

Standards of Medical Standards of Medical Care for Patients with Care for Patients with Diabetes MellitusDiabetes Mellitus

American Diabetes Association American Diabetes Association

(revised 2001 Oct)(revised 2001 Oct)

Standards of Medical Standards of Medical Care for Patients with Care for Patients with Diabetes MellitusDiabetes Mellitus

John Guzek, MDJohn Guzek, MD

March 2003March 2003