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Applying Standards of Care to Conditions: Diabetes

Let’s take a look at how standards of care apply to some specific conditions. We will discuss a couple of big health risks in the U.S., and the standards of care that have been developed for their treatment. A good place to start is diabetes mellitus. Remember that the standards of care are derived from guideline recommendations that are validated with a rating system. The system developed by the American Diabetes Association (ADA) is as follows:

--strong for (the use of the recommendation),

--weak for,

--weak against, and

--strong against.

 

The American Diabetes Association (the ADA) has taken the lead in developing standards of care for diabetes, and for keeping them current with new technology and treatments. The standards of care for diabetes fill a fairly large book published by the ADA, so let’s take a brief overview of the categories of recommendations included which have a “strong for” rating.

American Diabetes Association (ADA) develops SOCs

Best practices for:

Screening for diabetes and prediabetes

Diagnosis and classifying types of diabetes

and prediabetes

Prevention of progression

Monitoring methods

Tailored treatments

Let’s look at screening for diabetes as an example. Updated recommendations include testing for prediabetes and type 2 diabetes in children younger than 18 years of age who are overweight (body mass index or BMI between 25 and 30) or obese (BMI between 30 and 40) and have one or more additional risk factors for diabetes, such as maternal history of diabetes or gestational diabetes during the child’s gestation, family history of type 2 diabetes, or specific races/ethnicities that may be at higher risk, and signs of insulin resistance. Race/ethnicity risk includes Native Americans, African Americans, Latinos, Asian Americans and Pacific Islanders.

 

With regard to what we are talking about here, there are recommendations for best practices in diagnosing and classifying the types of diabetes and prediabetes, including:

Categories of Increased Risk for Diabetes (Prediabetes)

Type 1 Diabetes

Type 2 Diabetes

Gestational Diabetes Mellitus

Monogenic Diabetes Syndromes

Cystic Fibrosis–Related Diabetes

Post-transplantation Diabetes Mellitus

 

Guidelines include the prevention or delay of type 2 diabetes through lifestyle and pharmacologic interventions. Interventions include establishing and maintaining glycemic targets, ongoing assessment of glycemic control, and obesity management.

 

In some cases, research and experience with monitoring methods are outlined in specific guidelines. For instance, continuous glucose monitors or CGMs are described and updated. Recent guidelines suggest that CGM may not require confirmation with finger sticks. Also, testing often includes hemoglobin A1c levels and the standard of care for this monitoring test has additional language added to that specific standard of care to ensure the appropriate use of the A1C test results.

 

The ADA’s standards of care for diabetes include recommendations for tailoring the treatments to reduce disparities in the quality and types of care given in different populations.

Establish technical performance

Assumptions:

Quality of care increases

Costs are lowered

Outcomes are better

Guidelines have been established for diabetes throughout the lifecycle, including children, adolescents, and older adults, diabetes in pregnancy, and diabetes management in the acute care setting.

 

In 2018 the ADA made several changes and inclusions to the standards. For instance, guidelines for diabetes in older adults includes three new management recommendations to differentiate the individuality of required pharmacologic therapy for older adults. Treatment considers overall treatment goals, neuro-cognitive function, hypoglycemia, pharmacologic therapy, treatment in skilled nursing facilities and nursing homes, and end-of-life care.

 

For pregnant women with preexisting type 1 or type 2 diabetes a new guideline suggests low-dose aspirin daily starting at the end of the first trimester to reduce the risk of pre-eclampsia.

 

Patient-centered care recommendations reflect an increased sensitivity towards those factors that may affect treatment in certain groups. For instance, the high cost of medications in low-income and uninsured individuals, or geographic areas that lack access to healthy foods. 

 

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