Clinical Practice Guideline Key Points

Transcription

1 Clinical Practice Guideline Key Points Clinical Practice Guideline 2008 Key Points Diabetes Mellitus Provided by: Highmark Endocrinology Clinical Quality Improvement Committee In accordance with Highmark s commitment to quality care, the Highmark Endocrinology Quality Improvement Committee, consisting of network Primary Care Physicians and Specialists, has adopted the current American Diabetes Association s Clinical Practice Recommendations as appropriate for use throughout the Highmark networks. Selected Clinical Guidelines The full guideline is available on the following World Wide Web Site: Key Points Some flexibility in specific cases will require deviations from guideline recommendations. All providers are responsible for individualizing recommendations to the specific clinical characteristics of each patient. Diagnostic and Classification Criteria 1. Symptoms of diabetes, (polyuria, polydipsia, and unexplained weight loss) and a casual plasma glucose 200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. 2. Fasting plasma glucose (FPG) 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 hours h plasma glucose 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test (OGTT). The test should be performed using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. The diagnosis must be confirmed, on a subsequent day, using one of the methods above

2 A1C < 7% for patients in general For the individual patient, A1C as close to normal (<6%) as possible without significant hypoglycemia A1c Testing Lowering A1C has been associated with a reduction of microvascular and neuropathic complications of diabetes and possibly macrovascular complications. Correlation between A1C level and mean plasma glucose levels: Mean plasma glucose: A1c mg/dl mmol/l Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when needed. Twice/year if meeting glycemic goals At least quarterly if poor glycemic control or a change in treatment has occurred Glycemic Control Lipid Management Diabetic Retinal Eye Exam Avg. pre-prandial glucose mg/dl Avg. bedtime glucose mg/dl Peak post-prandial glucose <180 mg/dl Total cholesterol <200 mg/dl LDL Cholesterol <100 mg/dl HDL Cholesterol >40 mg/dl Triglycerides <150 mg/dl Patients with diabetes aged >40 with total cholesterol 135 mg/dl without overt cardiovascular disease, recommend statin therapy with a goal to reduce LDL 30-40% (primary LDL goal <100 mg/dl) Patients with diabetes aged <40 without overt cardiovascular disease but with other risk factors or long duration of diabetes and inability to achieve lipid goals with lifestyle changes alone, recommend statin therapy to decrease LDL to <100 mg/dl Those with diabetes and overt cardiovascular disease, recommend treatment with a statin with an LDL goal of <70 mg/dl. Dilated retinal exam for diabetic retinal disease Twice/year if meeting glycemic goals Quarterly, or more often, if poor glycemic control Yearly, or more frequently to achieve goals Type 1 diabetes, initial comprehensive and dilated eye exam 3-5 years after diagnosis Type 2 diabetes, initial comprehensive and dilated eye exam at the time of diagnosis, then - 2 -

3 Yearly subsequent exams for Type 1 and Type 2 More frequently if retinopathy is progressing Nephropathy Monitoring Blood Pressure Routine Foot Inspection Comprehensive Foot Exam Vaccinations Depression Screening Test annually for micro-albuminuria using one of the following: 24 hour Timed Spot microalbumin:creatinine ratio Test serum creatinine at least annually for the estimation of glomerular filtration rate (GFR) in all adults with diabetes regardless of the degree of urine albumin secretion. To reduce the risk of nephropathy, protein intake should be limited to 0.8 to 1.0 g/kg body weight per day in individuals with diabetes and the earlier stages of chronic kidney disease (CKD) and to 0.8 g/kg body weight per day in the later stages of CKD. This may improve the measures of renal function (e.g. urine albumin excretion rate and glomerular filtration rate) and is recommended. Systolic Blood Pressure < 130 mmhg Diastolic Blood Pressure < 80 mmhg Sensation Skin integrity Sensation with monofilament testing Structure and biomechanics Vascular status Skin integrity Flu vaccine to all patients with diabetes, 6 months and older; and for household contacts and caregivers of adults or children with diabetes Pneumococcal vaccine to all patients with diabetes, age 2 and older Two question screening tool: 1. Over the past 2 weeks have you felt down, depressed, or hopeless? 2. Over the past 2 weeks have you felt little interest or pleasure in doing things? A Yes response to either question indicates a need for further evaluation. Yearly for Type 1 diabetics with diabetes duration 5 years, and all Type 2 diabetics starting at diagnosis If systolic BP 130 mmhg or diastolic BP 80 mmhg, BP should be confirmed on separate day Yearly More frequently if one or more high-risk foot conditions or if neuropathy is present Flu vaccine yearly Pneumonia vaccine one time; a second dose is recommended five years after the first for patients with chronic kidney disease and those vaccinated before age

4 Patient Education for Lifestyle Changes and Diabetes Self- Management Glycemic control Nutrition Weight management with a goal BMI Physical Activity with a goal of 30 minutes of cardiovascular activity on most days of the week, as tolerated (New guideline: 30 minutes on five days per week or more) Aspirin therapy Smoking cessation Foot care Management of hypoglycemia and hyperglycemia Medication administration Sick day management Risk prevention Physicians are encouraged to reference the Highmark Drug Formulary when selecting prescription drug therapy for eligible members, which may be found at Members with a Select (formerly the Highmark Closed Formulary) benefit do not have coverage for nonformulary drugs. When selecting prescription drug therapy for eligible Medicare Advantage members, please consider referencing the Highmark Medicare-Approved Formulary, which may be found at If appropriate, consider prescribing medications included in the formulary to avoid noncovered expenses for your patient. Physicians may request to have a nonformulary drug covered for an individual patient. Evidence to support the ineffectiveness of formulary alternatives for the particular patient s condition or a reasonable expectation of adverse reactions from the use of formulary products must be submitted for a request to be considered. Instructions and the request form for this process are located on the Provider Resource Center under Provider Forms. Resources for Your Highmark Patients Blues On Call SM nurse Health Coaches are available 24/7 to provide one-on-one telephonic support for patients regarding diabetes and many other health topics. Your Highmark patients can reach Blues On Call at (1-888-BLUE-428) toll free. Programs to assist your patients with diabetes include: HealthMedia Succeed - An online Health Risk Assessment that identifies individual risk, readiness and confidence to make lifestyle changes. HealthMedia Balance A weight management program HealthMedia Nourish A nutrition program HealthMedia Breathe A smoking cessation program HealthMedia Relax A stress management program HealthMedia Care For Your Health A self management program for chronic conditions HealthMedia Care For Diabetes, A diabetes management behavior change intervention HealthMedia Overcoming Binge Eating (July 2008) To access Highmark s Improve Your Health programs: Direct your Highmark patients to go to Highmark s website at and select the web address for the plan that serves them. Log on to the member website. Not registered? Select click here to get a password

5 HealthMedia programs can be found by clicking the tab heading on the top of the home page called Your Health and then Improve Your Health from the list of topics on the left side of the page. Telephone-based Smokeless Tobacco Cessation Programs include a one-year program with five scheduled, outbound calls by a professional tobacco cessation specialist and a self-administered tobacco cessation program that helps an individual quit at his/her own pace. For more information and to enroll, direct your Highmark patients to call Real Life Solutions to Everyday Wellness Challenges Wellness Programs are offered at regional Preventive Health Network sites and include: Clear the Air, a tobacco cessation program that provides the tools needed to get prepared, take action and quit tobacco for good. Discover Relaxation Within I and II, lifestyle improvement programs to help identify and reduce individual stressors through specific relaxation techniques. Eat Well for Life I and II lifestyle improvement programs promoting wellness and long-term weight management through balanced nutrition. Diabetes Awareness and Prevention, a lifestyle improvement program that addresses preventing and managing diabetes with valuable information whether employees are maintaining good health or have, or are at risk for, diabetes. Personal Nutrition Coaching, individual nutrition coaching by a registered dietitian to address weight management, heart health, or diabetes. There is no fee for Highmark members to participate in these wellness programs. Programs offered vary by location. For more information, direct your patients to call In addition, the following programs are offered at select regional locations. For more information, direct your patients to call The Dr. Dean Ornish Program for Reversing Heart Disease. Participants in this lifestyle improvement program have experienced improved lipid panels, weight loss, decreased blood pressure, and better blood glucose control. (Applicants with Diabetes, CHD or risk factors may qualify). Coverage for the Dean Ornish program varies by Highmark plan and members should call the 800 number on the back of their insurance card for eligibility information. Ornish Advantage, an educational program using the tenets of the Dr. Dean Ornish Program for Reversing Heart Disease for individuals who want to prevent heart disease, reduce the risks for developing a chronic disease or learn lifestyle changes that can help manage diabetes, hypertension, and heart disease. The Silver Sneakers Fitness Program provides senior members enrolled in Medicare Advantage or other Medicare supplement products the opportunity to get fit, healthy, and strong in participating fitness centers. For more information, call As with any insurance, members are eligible for services only as long as they are active members of the plan and the services are covered benefits of their group or direct pay contract