and diabetes self-management postpubertal patients who have had type 1 diabetes ³ 10 years old and have had diabetes for at least 3-5 years; are > …
DIABETES PRACTICE GUIDELINES TREATMENT GOALS 1 Normalize blood glucose or attain glycosylated hemoglobin levels within 115 of the upper limit of normal for the reference lab 2 Prevent or effectively treat cardiovascular, renal, and opthalmologic complications related to diabetes 3 Prevent or effectively treat risk factors associated with the development of diabetic complications eg hypertension, smoking, 4
triglycerides, cholesterol, obesity Prevent acute exacerbations of diabetes eg ketoacidosis that requires ER use or hospitalization
INITIAL EVALUATION 1
Medical History
Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes Prior A1C records Eating patterns, nutritional status, and weight history; growth and development in children and adolescents Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs History: family; exercise; previous treatment programs including nutrition and diabetes self-management training; gestational history; treatment of other conditions, including endocrine and eating disorders Current treatment, including medications,
meal plans, results of glucose monitoring and patients use of the data Other medications that may affect blood glucose levels Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia Prior or current infections to skin, feet, dental, and genitourinary Symptoms and treatment of: chronic eye, kidney, nerve, and heart disease; genitourinary, bladder, and gastrointestinal function; peripheral vascular, foot and cerebrovascular complications Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history History and treatment of other conditions, including endocrine and eating disorders Family history of diabetes and other endocrine disorders Lifestyle, cultural, psychosocial, education, and economic factors that might influence the management of diabetes Tobacco, alcohol and/or controlled substance use Contraception and reproductive and sexual history
Physical Exam
Height/weight measurement and comparison to norms in children and adolescents Sexual maturation if peripubertal Blood pressure determination, including orthostatic measurements when indicated, and comparison to age-related norms Evaluation of
pulses Hand/finger examination Foot examination2 Skin examination including insulin injection sites Thyroid palpation Fundoscopic examination Neurological examination Abdominal examination Cardiac examination Oral examination Signs of diseases that can cause secondary diabetes eg, hemochromatosis, pancreatic disease
Lab Evaluation
A1C Fasting lipid profile total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol on patients 2 years old Serum creatinine in adults also in children if proteinuria is present Urinalysis for ketones, protein, and sediment Microalbuminuria 3 screen Thyroidstimulating hormone TSH in all type 1 diabetic patients; in type 2 if clinically indicated EKG adults only if needed
Management Plan
Medications insulin, oral glucoselowering agents, glucagon, antihypertensive and lipid-lowering agents, aspirin therapy, other endocrine drugs and other medications Recommendations for appropriate lifestyle changes eg exercise, smoking cessation, weight reduction Dental hygiene Patient and family education for self-management of diabetes, including nutritional counseling preferably provided by a Certified Diabetes Educator and/or Registered Dietician 4
Monitoring instructions: selfmonitoring of blood glucose SMBG, urine ketones, and use of a record system Annual comprehensive dilated eye examination 5 Consultation for podiatry and other special services as needed Agreement on continuing support, follow-up, and return appointments Instructions on how and when to contact the physician For women of childbearing age, discussion of contraception and the necessity of optimal blood glucose control before conception and during pregnancy Pneumococcal vaccine Annual influenza vaccine Consultation with a behavioral specialist, as indicated
The assessment should be initiated on the first visit Data may need to be gathered in more than one session or by other physicians Examine for the loss of protective sensation neuropathy severe enough not to feel injury, structural deformities, and skin and nail deformities In pubertal and postpubertal patients who have had type 1 diabetes 5 years and in all patients with type 2 diabetes 4 Services may be rendered by any professional designated by the referring physician, but claims must be submitted by a physician using the following codes: 9920M brief interval
follow-up to review care plan, to be performed every 3-6 months, 9921M outpatient diabetic self-care programs; 3-6 hours of individual counseling for survival skills to include medication administration, diet basics, potential emergencies, and glucose testing, 9922M comprehensive outpatient diabetic self-care program; 12-16 hours with a minimum of 4 hours of individual counseling to include pre and post assessment, review of survival skills, medication adjustment, exercise, pathophysiological teaching and preventive aspects, and 9923M follow-up review of diabetic self-care program; minimum of 2 hours, to be performed at 6 months, 12 months and annually thereafter 5 Performed on patients who: are 10 years old and have had diabetes for at least 3-5 years; are 30 years old who have visual symptoms and/or abnormalities; or are pregnant performed in the first trimester
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DIABETES PRACTICE GUIDELINES FOLLOW-UP VISITS
Recommended frequency: semi-annually for stable patients and quarterly for patients who are not meeting goals Medical History Physical Exam Lab Evaluation Management Plan 8 A1C Determine progress in
meeting goals Frequency, causes, and Height until Fasting lipid profile serum and to identify problems severity of hypoglycemia or maturity and cholesterol, triglyceride, hyperglycemia weight Review control of blood glucose HDL cholesterol, and LDL levels, assessment of complications, Results of SMBG self Sexual cholesterol 9 control of blood pressure, control of monitoring blood glucose maturation if Routine urinalysis annually dyslipidemia, nutrition assessment, peripubertal Adjustments by the patient in adults frequency of hypoglycemia, of the therapeutic regimen BP readings adherence to all aspects of self-care, Microalbumin screen by one Problems with adherence Foot evaluation of the exercise regimen, of the following tests:10 examination if Reported symptoms 6 follow-up of referrals, and 1 albumin to creatinine at risk suggesting development of psychosocial adjustment ratio in a random, spot Comprehensive the complications of collection Reassess knowledge of diabetes and dilated eye and diabetes 2 24-hour urine with self-management skills at least visual exam 7 Other medical illnesses 
creatinine and creatinine annually 11 Fundoscopy Current medications
clearance Continuing education should be referral if Psychosocial issues and 3 timed collection provided or encouraged 11 retinopathy lifestyle changes eg Smoking cessation, family planning detected smoking cessation Annual influenza vaccine
REFERRAL GUIDELINES
Specialty care is recommended for the conditions below Specialty care may also be appropriate for other conditions or indications
Condition/Indication
Diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome where: initial clinical/biochemical state is markedly abnormal initial response to standard therapy is unsatisfactory metabolic complications or cerebral edema occurs recurrence of DKA Chronically uncontrolled patients or recurrent hypoglycemia A1C persistently above 12 Macular edema, any proliferative diabetic retinopathy PDR or severe nonproliferative diabetic retinopathy NPDR Patients with diabetes who become pregnant or who are planning a pregnancy History of previous foot lesions, especially prior amputations Onset of overt nephropathy GFR 70 ml/min-1 or serum creatinine 20 mg/dl or when difficulties occur in management of hypertension or hyperkalemia
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Specialist
Diabetologist or
endocrinologist
Diabetologist or endocrinologist Ophthalmologist Multidisciplinary team diabetologist/endocrinologist, internist/FP/GP; obstetrician; diabetes educator Podiatrist or appropriate surgeon Registered dietitian for design of protein-restricted meal plans 11 Nephrologist
Risk factors for development of foot ulcers: loss of protective sensation neuropathy severe enough not to feel injury or vascular disease Additional risk factors in these patients are structural deformities and skin and nail deformities 7 Performed on patients who: are 10 years old and have had diabetes for at least 3-5 years; are 30 years old; who have visual symptoms and/or abnormalities; or are pregnant performed in the first trimester 8 Twice per year if stable; quarterly if treatment changes or patient is not meeting goals 9 Conduct annually until values fall within an acceptable range; then repeat every 2 years for adults or every 5 years for children older than 2 years old 10 In pubertal and postpubertal patients who have had type 1 diabetes 5 years and in all patients with type 2 diabetes 11 Services may be rendered by any professional designated by the referring physician, but claims must
be submitted by a physician using the following codes: 9920M brief interval follow-up to review care plan, to be performed every 3-6 months, 9921M outpatient diabetic self-care programs; 3-6 hours of individual counseling for survival skills to include medication administration, diet basics, potential emergencies, and glucose testing, 9922M comprehensive outpatient diabetic self-care program; 12-16 hours with a minimum of 4 hours of individual counseling to include pre and post assessment, review of survival skills, medication adjustment, exercise, pathophysiological teaching and preventive aspects, and 9923M follow-up review of diabetic self-care program; minimum of 2 hours, to be performed at 6 months, 12 months and annually thereafter
Page 2 of 3 Originated: 7/97 Updated: 3/98, 3/00, 1/01,1/02, 3/03
DIABETES PRACTICE GUIDELINES
HOSPITAL ADMISSION GUIDELINES
Inpatient care may be appropriate in the situations listed below, as well as in the following situations: newly diagnosed diabetes in children or adolescents; substantial and chronic poor metabolic control that necessitates close monitoring of the patient; uncontrolled or newly discovered insulinrequiring diabetes during
pregnancy There may be situations in which admission is appropriate although the patients clinical profile does not comply with these guidelines Diabetic ketoacidosis: Acute Metabolic Plasma glucose 250 mg/dl 139 mmol/l with Complications 1 arterial pH730, venous pH730, or serum bicarbonate level15mEq/l and 2 ketonuria and/or ketonemia Hyperglycemic hyperosmolar nonketotic state: Impaired mental status and elevated plasma osmolality in a patient with hyperglycemia This usually includes severe hyperglycemia eg plasma glucose 600 mg/dl [333 mmol/l] and elevated serum osmolality eg 320 mOsm/kg [320 mmol/kg] Hypoglycemia with neuroglycopenia: blood glucose 50 mg/dl 28 mmol/l and the treatment of hypoglycemia has not resulted in prompt recovery of sensorium or coma, seizures, or altered behavior eg disorientation, ataxia, unstable motor coordination, dysphasia due to documented or suspected hypoglycemia or hypoglycemia caused by a sulfonylurea drug or hypoglycemia has been treated but a responsible adult cannot be with the patient for the ensuing 12 hours in a juvenile with diabetes or in an adult incapable of self care
Uncontrolled Diabetes
Complications of Diabetes or other
Acute Medical Conditions
Treatment has been refractory to outpatient therapy, consultant therapy has been applied or considered, and the patient has: Hyperglycemia associated with volume depletion or, Recurring episodes of severe hypoglycemia ie, 50 mg/dl [28 mmol/l] despite intervention or Persistent refractory hyperglycemia associated with metabolic deterioration or Recurring fasting hyperglycemia 300 mg/dl or a glycosylated hemoglobin level of 100 above the upper limit of normal or Recurring episodes of severe hypoglycemia 50 mg/dl despite intervention or Metabolic instability manifested by frequent swings between hypoglycemia 50 mg/dl and fasting hyperglycemia 300 mg/dl or Recurring diabetic ketoacidosis without precipitating infection or trauma or Repeated absence from school or work due to severe psychosocial problems causing poor metabolic control that cannot be managed on an outpatient basis Chronic cardiovascular, neurological, renal, peripheral vascular foot ulcers and other diabetic complications may progress to the stage where hospital admission is appropriate Presence of diabetes must be considered in all admissions and may result in patients requiring
admission who otherwise might be managed on an outpatient basis
PROCESS AND OUTCOME TARGETS
Indicator Population
All patients with diabetes Annual dilated eye exam All patients with diabetes A1C test 2 times/year All patients with diabetes No ER visits All patients with diabetes No hospital admissions All patients with diabetes Physician office visits 2 times/year All patients with diabetes who are on medication Self-monitoring of blood glucose All patients with diabetes who meet referral guidelines Referrals to specialists References American Diabetes Association: Clinical Practice Recommendations 2002, Diabetes Care, Volume 26, Supplement 1, January 2003; The American Association of Clinical Endocrinologists AACE Medical Guidelines for the Management of Diabetes Mellitus, 2003 update Blue Cross and Blue Shield
of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association
Page 3 of 3 Originated: 7/97 Updated: 3/98, 3/00, 1/01,1/02, 3/03
Source:bcbsnc.com
