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
Screening for
diabetes and
prediabetes
Diagnosis and
classifying
types of
diabetes
and
prediabetes
Prevention of
progression
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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
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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.