1. Standards of Medical Care for Patients with Diabetes Mellitus John Guzek, MD March 2003

2. 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

3. 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)

4. 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

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

6. Pneumovax 2002 Documentation PHA

7. Glycemic Control: Rationale  Lowering A1C has been associated with a reduction of microvascular and neuropathic complications of diabetes (A- Level Evid.)

8. 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)

9. 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%

10. 2002 PHA A1C Documentation

11. A1c <8.0 PHA 2002

12. 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”)

13. 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)

14. 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

15. Blood Pressure Control: PHA  “Red flag” on HEDIS if BP over ADA target (<130/80)

16. 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)

17. 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

18. Lipid Management: PHA  LDL (CALCUL) every 10 months by protocol  Reminder on HEDIS Cholesterol if LDL/HDL/TG out of range

19. 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)

20. 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)

21. 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.

22. 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 (%)

23. 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)

24. Nephropathy Assessment ADA Award Requires:  Urine dip for protein  Urinary microalbumin or 24 hour urine protein  73% of patients required to achieve measure

25. 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)

26. 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)

27. Foot Exam ADA Award Requires  80% of patients with specific diabetic foot exam documented on chart in last 12 months

28. Foot Exam PHA  Logician prompts to do foot exam for diabetics annually  Quarterly reminder by protocol if “Dx of” Diabetic neuropathy

29. Eye Exam ADA Award Requires:  61% of patients must have diabetic eye exam done to achieve measure

30. Logician Reports  Your Diabetic Profile  High Blood Pressure: A Serious but Common Disorder  Take Care of Your Feet

31. Logician Diets  American Heart Association Diet  Restaurant Eating for persons with Diabetes

32. Educational Videos  Available from Avandia rep

33. Standards of Medical Care for Patients with Diabetes Mellitus American Diabetes Association (revised 2001 Oct)

34. Standards of Medical Care for Patients with Diabetes Mellitus John Guzek, MD March 2003