Guidelines:

ADA	AACE
•A1c levels <7% •Initial therapy: lifestyle + metformin •Self Management Education •Rapid transition to add new medications, as needed •Early addition of insulin, as needed	•A1c levels <6.5% •Initial therapy: dependent on A1c level and complication risk •Monitor and advance therapy as need q2-3 mo

 

Guidelines published by the American Diabetic Association suggest glycemic goals as the achievement of hemoglobin A1c levels at less than 7%, fasting glucose levels of 70-130 milligrams per deciliter, and an after meal glucose level of less than 180 milligrams per deciliter. While the concept is similar, there is a lack of consensus on these recommendations by the American Association of Clinical Endocrinologists, which has issued guidelines with lower hemoglobin A1c goals at less than or equal to 6.5%. Both recommend lifestyle changes and rapid advancement of medication therapy if glycemic control is not achieved.

AADE: •All patients should have access to diabetes self-management education (DSME) •Focus primarily on supporting behaviors that promote self-management •Follow a 5-step process •Delivered by competent, prepared personnel •Barriers: ◦Lack of awareness, reimbursement, staffing, resistance to change

Guidelines published by the American Association for Diabetes Educators in 2017 suggested that there should be universal access to diabetes self-management education or “DSME”. This recommendation has a high grade (grade A) for the evidence that supports it. The AADE guidelines further state that the focus of DSME should be on supporting the types of behaviors that will promote successful self-management and follow a 5-step process, which includes assessment, goal setting, planning, implementation, and evaluation/follow-up.

Adherence Barriers

"Most patients do not meet glucose control goals" Goals may be unrealistic »Too much too fast Factors not always in the patient's control: »Aging, costs, insurance Relationship factors »Provider-patient »Family/support network-patient Patient's medical conditions

According to a report in Diabetes Therapy in 2013, “Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies”

Goal setting that is more aggressive or restrictive than a patient is able to achieve in a short period may impose too much stress on the patient. Patients will often not adhere to treatment plans if they are not able to maintain them and make the desired progress. Pacing goals realistically for individual patients is key.

 

 Those items that are not determined by the client with diabetes include barriers such as genetic predispositions or physiologic functions,  cost and older age.

Sound patient education on causes of disease process, and how these impact progress give patients realistic goals and relieve the burden of shame when progress is limited.

 Underinsurance can lead to decisions based on economic concerns rather than health needs.

Other factors include items that make it difficult for clients to implement needed changes, such as patient health belief models, poor caregiver and patient relationships, and difficult family dynamics.

In addition, depression, personality or other psychiatric disorders, and drug abuse can affect adherence to therapies.

Non-adherence can lead to adverse outcomes. Recurrent diabetic crisis, increased health care costs, and progression to irreversible vascular damage have been related to therapy non-adherence. Effective assessment of non-adherence issues and support for adherence to therapies can improve outcomes and reduce unnecessary health care costs.