American Diabetes Association. 2007 Clinical Practice Recommendations Strategies for Improving Diabetes Care 8 - 9 CCNC Diabetes Management Guide …
American Diabetes Association
2007 Clinical Practice Recommendations
Standards of Medical Care for Patients with Diabetes
Summary of Recommendations and Goals
Related to the Diabetes Measures of the
Diabetes Disease Management Program for
Community Care of North Carolina
The information contained in this document is a summary of the publication
found in the Diabetes Care: Volume 30, Supplement 1, January 2007, Clinical
Practice Recommendations wwwdiabetesorg
Table of Contents
TOPIC PAGE
CCNC Diabetes Management Guide 2 - 4
Summary ADA 2007 Clinical Practice Recommendations Revisions 4 - 7
Strategies for Improving Diabetes Care 8 - 9
Standards of Medical Care: A1C and Glycemic Goals 9 - 11
Standards of Medical Care: Blood Pressure 11
Standards of Medical Care: Lipid Screening 11
Standards of Medical Care: Retinopathy Screening
12
Standards of Medical Care: Neuropathy Screening 12
Standards of Medical Care: Foot Exam Neuropathy Screening 12
Standards of Medical Care: Flu and Pneumococcal Vaccination 13
Standards of Medical Care: Nephropathy Screening 13
Standards of Medical Care: Smoking Cessation 13
Standards of Medical Care: Anti-Platelet Agents 14
Standards of Medical Care: Self Management Education 14
2007 Standards of Medical Care in Diabetes, American Diabetes Association
The entire article can be found in the January 2007, Volume 30, Supplement
I of Diabetes Care, published by the American Diabetes Association
wwwdiabetesorg These standards of care are intended to provide
clinicians, patients, researchers, payors and other interested individuals
with the components of diabetes care, treatment goals, and tools to
evaluate the quality of care While individual preferences, comorbidities,
and other patient factors may require modification of goals, targets that
are desirable for most patients with diabetes are provided These standards
are not intended to preclude more extensive evaluation and management of
the
patient by other specialists as needed
CCNC adopts the ADA Standards of Medical Care in Diabetes in its entirety
as the standard of diabetes care it strives to provide all enrollees
Content most relevant to the CCNC Diabetes Disease Management Program is
contained in summary form in this document Please refer to the entire
article for further rationale supporting these recommendations
CCNC Diabetes Management Guide
CCNC providers are dedicated to providing care according to the Standards
of Medical Care in Diabetes as defined by the American Diabetes
Association Key components of these standards are aimed at screening for
and reducing the risks of diabetes related complications CCNC has adopted
these key components of prevention as measures for their Diabetes Disease
Management Program CCNC providers receive data reports based on chart
audits for the highlighted measures below
Documentation should exist in the PCP medical record for Adults with
diabetes on the following
2 Continued Care Visits per year that address diabetes
Blood Pressure at every visit
A1C test at least 2 times in 12 months
Lipid Panel
every year
Dilated eye exam every year
Foot Exam with sensory assessment monofilament or other device every
year
Flu Vaccine every year
Pneumococcal Vaccine at least once and repeated according to CDC
guidelines
Tobacco Counseling at every visit
Aspirin Therapy as appropriate
Microalbuminuria Screen every year
Serum Creatinine every year to estimate the GFR
Neuropathy Screening autonomic peripheral by simple clinical tests
and review of systems/history
Self Management Skills and Diabetes Education Needs assessed frequently
Documentation should exist in the PCP medical record for
Children with diabetes on the following
2 Continued Care Visits per year that address diabetes
Blood Pressure at every visit
A1C test at least 2 times in 12 months
Lipid Panel begin at age 2 ONLY if family hx CVD, hypercholesterolemia or
unknown family hx Otherwise, begin at puberty or age 12 If abnormal,
repeat every year If normal repeat every 5 years
Dilated eye exam begin within 3-5 years after diabetes diagnosed, once
the child has reached the age of 10 Repeat every year
Foot Exam with sensory
assessment monofilament or other device every
year
Flu Vaccine every year begin at age 6 months
Pneumococcal Vaccine begin at age 2 see Pediatric Red Book
Tobacco Counseling at every visit
Microalbuminuria Screen - Type 1 begin when child is age 10 and has had
diabetes 5 years; then annually Type 2 begin at diagnosis of diabetes;
then annually
Self Management Skills and Diabetes Education Needs assessed frequently
Summary of Revisions for the 2007 ADA Clinical Practice Recommendations
Additions to the Standards of Medical Care in Diabetes
Diabetes Care - Algorithm for the initiation and adjustment of therapy
for type 2 diabetes
Emergency and disaster preparedness
Table of agents to treat Distal Symmetric Polyneuropathy DPN pain
Celiac disease
Revisions to the Standards of Medical Care in Diabetes
Components of the Comprehensive Diabetes Evaluation Table
Lowering A1C has been associated with a reduction of microvascular and
neuropathic complications of diabetes and possibly macrovascular
disease
Reduction of protein intake to 08 - 10 g/kg body weight per day in
individuals with diabetes and the earlier stages of chronic kidney
disease CKD Reduction of protein to 08 g/kg body weight per day in
the later stages of CKD may improve measures of renal function and is
recommended
Preconception Care - Based on recent research, ACE inhibitors should
also be discontinued before conception
Diabetes Care in the School and Day Care Setting - a 504 plan should
be developed and implemented by the family, school nurse, and diabetes
health care team
Diabetes Care in the Hospital - using correction dose or
supplemental insulin to correct premeal hyperglycemia in addition to
scheduled prandial and basal insulin is recommended
Nutrition Recommendations and Interventions for Diabetes Position
Statement - This statement updates previous position statements,
focuses on key references published since the year 2000, and uses
grading according to the level of evidence available based on the
American Diabetes Association evidence-grading system Since
overweight and obesity are closely linked to diabetes, particular
attention is paid to this area of
MNT
Algorithm for the initiation and adjustment of therapy for type 2
diabetes
A consensus statement from the ADA and the European Association for the
Study of Diabetes on the approach to management of hyperglycemia in
individuals with type 2 diabetes has recently been published 1 Early
intervention with metformin in combination with lifestyle changes MNT and
exercise with continuing, timely augmentation therapy with additional
agents including early initiation of insulin therapy as a means of
achieving and maintaining recommended levels of glycemic control ie, A1C
7 for most patients are highlights of this approach See Fig 1 for
metabolic management of type 2 diabetes
Figure 1
Figure 1- Algorithm for the metabolic management of type 2 diabetes
Reinforce lifestyle intervention at every visit Check A1C every 3 months
until 7 and then at least every 6 months Although three oral agents can
be used, initiation and intensification of insulin therapy is preferred
based on effectiveness and expense
Table of agents to treat Distal Symmetric Polyneuropathy DPN pain
Symptomatic treatments - DPN
The first step in management of patients with DPN should be to aim for
stable
and optimal glycemic control Although controlled trial evidence is
lacking, several observational studies suggest that neuropathic symptoms
improve not only with optimization of control, but also with the avoidance
of extreme blood glucose fluctuations Most patients will require
pharmacological treatment for painful symptoms: many agents have efficacy
confirmed in published randomized controlled trials, though none are
specifically licensed for the management of painful DPN See Table 10 for
examples of agents to treat DPN pain
Table 10- Table of drugs to treat symptomatic DPN
|CLASS |EXAMPLES |TYPICAL DOSES |
|Tricyclic drugs |Amitriptyline |10-75 mg at bedtime |
| |Nortriptyline |25-75 mg at bedtime |
| |Imipramine |25-75 mg at bedtime |
|Anticonvulsants |Gabapentin |300-1200 mg tid |
| |Carbamazepine |200 - 400 mg tid |
| |Pregabalin |100 mg tid |
|5-hydroxytryptamine and |Duloxitine |60 - 120 mg qd
|
|norepinephrine uptake | | |
|inhibitor | | |
|Substance P inhibitor |Capsaicin cream |0025-0075 applied |
| | |tid-qid |
Dose response may vary; initial doses need to be low and titrated up
STRATEGIES FOR IMPROVING DIABETES CARE
In recent years, numerous health care organizations of all sizes have
implemented strategies to improve diabetes care Successful programs have
published results showing improvement in important patient outcomes A1C,
blood pressure, lipid levels as well as process measures eye exams, foot
exams, etc Features of successful programs include the following, are
recommended by the ADA, and supported by CCNC:
Recommendations
Focus improvement interventions at these levels
Health care professionals
Delivery systems
Patients
Provide formal and informal health care professional education
regarding the standards of care
Provide Diabetes Self-Management Education which has been shown to
increase
adherence to standard of care
Adopt practice guidelines with participation of health care
professionals in the process
Ensure that guidelines are readily accessible at the point of service,
such as
on patient charts in the form of checklists, flow sheets, visit
forms, etc
in examining rooms
on wallet or pocket cards
on PDAs
on office computer systems
Guidelines should summarize major recommendations and then instruct
health care professionals what to do and how to do it
Use Checklists/Flow sheets that mirror guidelines
Automated reminders to health care professionals and to patients
Reporting of process and outcome data to providers
Identification of patients at risk because of failure to achieve
target values or a lack of reported values
Continuous quality improvement cycles of analysis and intervention
with provider performance data
Clustering dedicated diabetes visits into specific times within a
primary care practice schedule
Visits with multiple health care professionals on a single day PCP,
RD, CDE, Podiatrist, etc
Group Medical Visits
Tracking systems - EMR or patient registry - to identify those
requiring assessments and/or treatment modifications
Nonautomated systems - mailing reminders to patients, chart stickers,
flow sheets - to prompt both providers and patients
Case Manager Services
-nurse, pharmacists, other non-physician health care provider
using detailed algorithms working under the supervision of
physicians
-nurse education calls
-dietitians using Medical Nutrition Therapy guidelines
Expert consultants - endocrinologists and diabetes educators
Evidence suggests that these individual interventions work best when
provided as components of a multifactorial initiative disease
management Optimal diabetes management requires
-an organized, systematic approach
-involvement of a coordinated team of health care providers
-an informed, prepared patient
2007 Standards of Medical Care in Diabetes American Diabetes Association
The entire article can be found in the January 2007, Volume 30, Supplement
I of Diabetes Care, published by the American
Diabetes Association
wwwdiabetesorg Content most relevant to the Standards of Diabetes Care
promoted by CCNC is contained in summary form in this document Please
refer to the entire article for further rationale supporting these
recommendations
A1C Glycemic Goals
By performing an A1C test, health providers can measure a patients average
glycemia over the preceding 2-3 months and, thus, assess treatment
efficacy A1C testing should be performed routinely in all patients with
diabetes, first to document the degree of glycemic control at initial
assessment and then as part of continuing care Since the A1C test reflects
mean glycemia over the preceding 2-3 months, measurement approximately
every 3 months is required to determine whether a patients metabolic
control has been reached and maintained within the target range Thus,
regular performance of the A1C test permits detection of departures from
the target in a timely fashion For any individual patient, the frequency
of A1C testing should be dependent on the clinical situation, the treatment
regimen used, and the judgment of the clinician Glycemic control is best
judged by the combination of the results of the patients SMBG
testing as
performed and the current A1C result The A1C should be used not only to
assess the patients control over the preceding 2-3 months but also as a
check on the accuracy of the meter or the patients self-reported results
and the adequacy of the SMBG testing schedule
Recommendations
Perform the A1C test at least two times a year in patients who are meeting
treatment goals and who have stable glycemic control
Perform the A1C test quarterly in patients whose therapy has changed or who
are not meeting glycemic goals
Goal Ranges
Lowering A1C has been associated with a reduction of microvascular and
neuropathic complications of diabetes and possibly macrovascular
disease
The A1C goal for patients in general is an A1C goal of 7
The A1C goal for the individual patient is an A1C as close to normal
6 as possible without significant hypoglycemia
GLYCEMIC CONTROL - Goal ranges for adults
A1C 70
Pre-prandial capillary plasma glucose 90-130
mg/dl
Peak postprandial capillary plasma glucose 180
mg/dl
Referenced to a
nondiabetic range of 40-60 using a DCCT-based assay
Postprandial glucose measurements should be made 1-2 h after the
beginning of the meal, generally peak levels in patients with diabetes
GLYCEMIC CONTROL - Goal ranges for type 1 diabetes by age group
|Age Group |Goal range |Goal range |A1C |Rationale |
| |Before |HS/Overnight| | |
| |Meals | | | |
|Toddler |100 - 180 |110-200 |75 and |High risk |
|preschool 6 | | |85 |vulnerability to |
|yo | | | |hypoglycemia |
|School age 6 -|90 - 180 |100 - 180 |8 |Risks of |
|12 yo | | | |hypoglycemia and |
| | | | |relatively low risk |
| | | | |of complications |
| | | | |prior to puberty |
|Adolescents- |90-130 |90-150 |75 |Risk of severe |
|Young adult 13| | |
|hypoglycemia |
|- 19 yo | | | |developmental |
| | | | |psychological |
| | | | |issues A lower goal|
| | | | |7 is reasonable |
| | | | |if it can be |
| | | | |achieved without |
| | | | |excessive |
| | | | |hypoglycemia |
plasma blood glucose
Correlation between A1C level and mean plasma glucose levels
on multiple testing over 2-3 months
|A1C |Mean Plasma |
| |Glucose mg/dl |
|6 |135 |
|7 |170 |
|8 |205 |
|9 |240 |
|10 |275 |
|11 |310 |
|12 |345 |
Blood Pressure
Screening and diagnosis
Blood pressure should be measured at every routine diabetes visit Patients
found to have systolic blood pressure 130 mmHg or
diastolic blood pressure
80 mmHg should have blood pressure confirmed on a separate day
Goals
Patients with diabetes should be treated to a systolic blood pressure 130
mmHg
Patients with diabetes should be treated to a diastolic blood pressure 80
mmHg
Lipid Screening
Recommendations
In adult patients, test for lipid disorders at least annually and more
often if needed to achieve goals In adults with low-risk lipid values
LDL 100 mg/dl, HDL 50 mg/dl, and triglycerides 150 mg/dl, lipid
assessments may be repeated every 2 years
Prepubertal children: a fasting lipid profile should be performed on all
children 2 years of age at the time of diagnosis after glucose control
has been established IF there is a family history of hypercholesterolemia
total cholesterol 240 mg/dl or a history of a cardiovascular event
before age 55 years, or if family history is unknown If family history is
not of concern, then the first lipid screening should be performed at
puberty 12 years If values are within the accepted risk levels LDL
100 mg/dl; 26 mmol/l, a lipid profile should be repeated every 5 years
Pubertal children 12 years old: a fasting lipid profile should
be
performed at the time of diagnosis after glucose control has been
established If values fall within the accepted risk levels LDL 100
mg/dl; 26 mmol/l, the measurement should be repeated every 5 years
If lipids are abnormal, annual monitoring is recommended in both age-
groups
Retinopathy Screening
Recommendations
Optimal glycemic control can substantially reduce the risk and progression
of diabetic retinopathy
Optimal blood pressure control can reduce the risk and progression of
diabetic retinopathy
Screening
Adults with type 1 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist within 3-
5 years after the onset of diabetes
Patients with type 2 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist shortly
after the diagnosis of diabetes
Subsequent eye examinations for type 1 and type 2 diabetes patients should
be repeated annually by an ophthalmologist or optometrist
First ophthalmologic examination should be obtained once child is 10
years of age or older and has had diabetes for 3-5 years After the
initial examination, annual
routine follow-up is generally
recommended
Neuropathy Screening autonomic peripheral
Recommendations
All patients should be screened for distal symmetric polyneuropathy
DPN at diagnosis and at least annually thereafter, using simple
clinical tests
The symptoms of autonomic dysfunction should be elicited carefully
during the history and review of systems, particularly since many of
these symptoms are potentially treatable Major clinical
manifestations include resting tachycardia, exercise intolerance,
orthostatic hypotension, constipation, gastroparesis, erectile
dysfunction, sudomotor dysfunction, impaired neurovascular function,
brittle diabetes and hypoglycemic autonomic failure
Foot Exam Neuropathy Screening
Screening
All patients should be screened for distal symmetric polyneuropathy
DPN at diagnosis and at least annually thereafter, using simple
clinical tests
The symptoms of autonomic dysfunction should be elicited carefully
during the history and review of systems
Perform a comprehensive foot examination and provide foot self-care
education annually on patients
with diabetes to identify risk factors
predictive of ulcers and amputations The foot exam can be performed
in a primary care setting and should include:
1 use of a monofilament
2 use of a tuning fork
3 palpation
4 visual examination
Flu Pneumococcal Vaccine
Recommendations
Annually provide an influenza vaccine to all diabetic patients 6 months of
age or older
Provide at least one lifetime pneumococcal vaccine for adults with
diabetes A one-time revaccination is recommended for individuals 64 years
of age previously immunized when they were 65 years of age if the vaccine
was administered 5 years ago Other indications for repeat vaccination
include nephrotic syndrome, chronic renal disease, and other
immunocompromised states, such as after transplantation
The Centers for Disease Controls Advisory Committee on Immunization
Practices recommends influenza and pneumococcal vaccines for all
individuals 65 years of age as well as for all individuals of any age with
diabetes
Nephropathy Screening
Recommendations
To reduce the risk and/or slow the progression of nephropathy, optimize
glucose control
To reduce the risk
and/or slow the progression of nephropathy, optimize
blood pressure control
Screening
Perform an annual test for the presence of microalbuminuria in type 1
diabetic patients with diabetes duration of 5 years and in all type 2
diabetic patients, starting at diagnosis and during pregnancy
Serum creatinine should be measured at least annually for the
estimation of glomerular filtration rate GFR in all adults with
diabetes regardless of the degree of urine albumin excretion Use the
serum creatinine to estimate GFR and stage the level of chronic kidney
disease
The role of annual microalbumuria assessment is less clear after
diagnosis of microalbuminuria and institution of ACE inhibitor or ARB
therapy and blood pressure control Most experts, however, recommend
continued surveillance of microalbumin/proteinuria to assess both
response to therapy and progression of disease Some experts suggest
that reducing urine microalbuminuria to the normal or near-normal
range, if possible, may improve renal and cardiovascular prognosis
This approach has not been formally evaluated in prospective trials
Children: Annual
screening for microalbuminuria should be initiated
once the child is 10 years of age and has had diabetes for 5 years
Screening may be done with a random spot urine sample analyzed for
microalbumin-to-creatinine ratio
Smoking Cessation
Recommendations
Advise all patients not to smoke
Include smoking cessation counseling and other forms of treatment as a
routine component of diabetes care
Anti-Platelet Agents
Recommendations
Use aspirin therapy 75-162 mg/day as a primary prevention strategy in:
type 1 and type 2 diabetes at increased cardiovascular risk over 40,
or family hx, or htn, or smoke, or dyslipidemia, or albuminuria
Use aspirin therapy 75-162 mg/day as a secondary prevention strategy in:
Diabetes with a history of myocardial infarction, vascular bypass
procedure, stroke or transient ischemic attack, peripheral vascular
disease, claudication, and/or angina
Consider aspirin therapy in people between the age of 30 and 40 years,
particularly in the presence of other cardiovascular risk factors
Some people are not candidates for aspirin therapy Other antiplatelet
agents may be a reasonable alternative for patients with high
risk Aspirin
therapy should not be recommended for patients under the age of 21 years
People under the age of 30 have not been studied
Self Management Education
Recommendations
People with diabetes should receive Diabetes Self Management Education
DSME according to national standards when their diabetes is
diagnosed and as needed thereafter
DSME should address psychosocial issues, since emotional well-being is
strongly associated with positive diabetes outcomes
Community Care of North Carolina
Diabetes Quality Improvement Initiative
|Community Care of North Carolina Diabetes Initiative |
|MANAGEMENT GUIDE At-A-GLANCE Adults |
EVERY VISIT
Blood Pressure
Foot Exam inspection of skin integrity, temperature, shape, nails,
pulses, strength, gait balance, footwear
Glucose Level/Home Monitoring Records
ASA Therapy 75-162 mg/day for pt 40; with CVD; with CV risk factor
Tobacco Counseling
Case Manager Referral as needed
Diabetes Education/Nutrition Referral as needed
EVERY 6 MONTHS
A1C Level at least 2 in 12 months if pt
meeting goals/stable glycemic
control Quarterly if pt not meeting glycemic goals or therapy has
changed
Continued Care Visit 2 per 12 months
Self Management Review - nutrition, exercise, BG records, foot care,
meds, etc
EVERY 12 MONTHS
Refer for Dilated Eye Exam
Comprehensive Foot Exam with Monofilament/Sensory Exam
Lipid Panel
Flu Vaccine
Microalbuminuria Screen begin at diagnosis of diabetes in type 2; begin
with diabetes duration 5 years in type 1
Urine Protein
Dental Exam
ONCE Repeat per CDC Guidelines
Pneumococcal Vaccine
Source: Diabetes Care: Volume 28, Supplement 1, January 2005 Clinical
Practice Recommendations http://carediabetesjournalsorg
Items tracked in CCNC Diabetes Audit Process
|Community Care of North Carolina Diabetes Initiative |
|ADULT - EXPECTED VALUES AT-A-GLANCE |
A1C
ADA Goal A1C 7
Complication Risk: Low A1C 65
Medium A1C 66 - 80
High A1C 81
2 Blood Pressure
130/80 mmHg
3 Lipid Levels
LDL 100 mg/dl Initiate therapy 100 mg/dl
HDL 40 mg/dl men
HDL 50 mg/dl women
Triglycerides 150
mg/dl
4 Nephropathy Screening preferred method
1 albumin-to-creatinine ratio 30 ug/mg creatinine
1 24 hour urine with creatinine clearance 30 mg/24 h
2 time collection 20 g/min
A positive screening result indicates the need to repeat the screen
5 Foot Exams
Visual Inspection: No abnormal findings related to skin integrity,
temperature, shape, nails, pulses, strength, gait
balance, footwear; perform at each routine visit
Comprehensive: No abnormal findings related to protective sensation, foot
structure and biomechanics, vascular status, and skin
integrity 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 Perform Annually to identify risk
factors predictive of ulcers and amputations
Source: Diabetes Care: Volume 28, Supplement 1, January 2005 Clinical
Practice Recommendations http://carediabetesjournalsorg
|Community Care of North Carolina Diabetes Initiative |
|MANAGEMENT GUIDE
At-A-GLANCE CHILD |
EVERY VISIT
Blood Pressure
Foot Exam inspection of skin integrity, temperature, shape, nails,
pulses, strength, gait balance, footwear
Glucose Level/Home Monitoring Records
Tobacco Counseling
Case Manager Referral as needed
Diabetes Education/Nutrition Referral as needed
EVERY 6 MONTHS
A1C Level at least 2 in 12 months if pt meeting goals/stable glycemic
control Quarterly if pt not meeting glycemic goals or therapy has
changed
Continued Care Visit 2 per 12 months
Self Management Review - nutrition, exercise, BG records, foot care,
meds, etc
EVERY 12 MONTHS
Refer for Dilated Eye Exam - begin within 3-5 years after the diabetes
is diagnosed, once the child has reached the age of 10
Comprehensive Foot Exam with Monofilament/Sensory Exam
Lipid Panel - Begin at age 2 ONLY IF family hx CVD, hypercholesterolemia
or unknown family hx Otherwise, begin at puberty or age 12 If abnormal,
repeat every year If normal repeat every 5 years
Flu Vaccine begin at 6 months
Microalbuminuria Screen - Type 1 begin when child is age 10 and has had
diabetes 5 years; then annually Type 2 begin
at diagnosis of diabetes;
then annually
Urine Protein
Dental Exam
ONCE Repeat per CDC Guidelines
Pneumococcal Vaccine begin age 2 - see Pediatric Red Book
Source: Diabetes Care: Volume 28, Supplement 1, January 2005 Clinical
Practice Recommendations http://carediabetesjournalsorg
Items tracked in CCNC Diabetes Audit Process
|Community Care of North Carolina Diabetes Initiative |
|CHILD - EXPECTED VALUES AT-A-GLANCE |
1 A1C Target Ranges
6 years old A1C 75 - 85
6-12 years old A1C 8
13-19 years old A1C 75
2 Blood Pressure
See norms based on sex and height
3 Lipid Levels
LDL 100mg/dl
HDL 35 mg/dl
Triglycerides 150 mg/dl
4 Nephropathy Screening
1albumin-to-creatinine ratio 30 ug/mg creatinine
1 24 hour urine with creatinine clearance 30 mg/24 h
2 time collection 20 g/min
A positive screening result indicates the need to repeat the screen
5 Foot Exams
Visual Inspection: No abnormal findings related to skin integrity,
temperature, shape, nails, pulses, strength, gait
balance, footwear; perform at each routine visit
Comprehensive: No
abnormal findings related to protective sensation, foot
structure and biomechanics, vascular status, and skin
integrity 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 Perform annually to identify risk
factors predictive of ulcers and amputations
Source: Diabetes Care: Volume 28, Supplement 1, January 2005 Clinical
Practice Recommendations http://carediabetesjournalsorg
Diabetes Websites
Professional education, tools, quality improvement, etc
wwwdiabetesorg American Diabetes Association
wwwncdiabetesorg
Diabetes Prevention and Control Unit/NC Dept of Health and Human
Services division of Public Health
http://wwwbetterdiabetescarenihgov/ Quality Improvement tools
wwwaadenetorg American Association of Diabetes Educators
http://ndepnihgov National Diabetes Education Program
patient and provider education materials
http://wwwncqaorg/dprp/ National Committee
for Quality Assurance
Diabetes Provider Recognition Program
http://wwwdiabetesorg/type1-diabetes/well-
being/linkforlifead/line_for_life/mainhtml
Making the link between diabetes and heart disease
wwwbdcom/diabetes
free education materials
wwwquitnowncorg free smoking cessation resources and training
opportunities
wwwncpreventionpartnersorg variety of tools to help improve the
health of NC
wwwstartwithyourheartcom
wwweatsmartmovemorenccom
Drug, meter, product companies that offer patient education materials,
samples, links to other resources
wwwlillydiabetescom wwwdiabeticproductscom
wwwLifeScancom wwwdesmattercom
wwwdiabeticsupplycom wwwminimedcom pump company
wwwaccu-chekcom wwwpfizercom
wwwactoscom wwwdiabetcarecom
wwwMediSensecom
———————–
Pneumococcal Vaccine
Annual Flu Vaccine
Annual Foot Exam and Sensory/Monofilament Exam
Annual Dilated Eye Exam
Annual Lipid Panel
A1C test at least two in 12 months
BP at every visit
2 Continued Care Visits per
year
Diabetes Documentation Tool/Flow Sheet/Patient Registry FRegistry
