IDC4.1

ProblemsProblems High incidence and prevalence of diabetesHigh incidence and prevalence of diabetes Reliance on primary care providersReliance on primary care providers Significant variation in practiceSignificant variation in practice High costs and poor outcomesHigh costs and poor outcomes Translating recent findings into clinical Translating recent findings into clinical

practicepractice Unclear national and international Unclear national and international

standardsstandards

IDC4.2

Principles of SDMPrinciples of SDM1.1. Customized practice guidelines to assure Customized practice guidelines to assure

community-wide acceptancecommunity-wide acceptance

2.2. Therapeutic goals, with realistic timelines, Therapeutic goals, with realistic timelines, set with the patientset with the patient

3.3. DecisionPaths to assure rapid selection, DecisionPaths to assure rapid selection, initiation and adjustment of effective initiation and adjustment of effective therapiestherapies

4. 4. Movement between sequential therapeutic Movement between sequential therapeutic options when goals are not metoptions when goals are not met

IDC4.3

SDM Process: Customization and Training

SDM Process: Customization and Training

Review and modification of practice Review and modification of practice guidelines and Master DecisionPathguidelines and Master DecisionPath screening and diagnostic criteriascreening and diagnostic criteria selection of therapiesselection of therapies metabolic targets and timelinesmetabolic targets and timelines complications surveillancecomplications surveillance

Case studiesCase studies review of SDM materialsreview of SDM materials application of SDM to site casesapplication of SDM to site cases

IDC4.4

Type 2Type 2 Master DecisionPath Master DecisionPath

Fasting > 350 mg/dLCasual > 400 mg/dL

Fasting > 350 mg/dLCasual > 400 mg/dL

Insulin Stage 3A*R/N – 0 – R – N

Insulin Stage 3A*R/N – 0 – R – N

Insulin Stage 2*R/N – 0 – R/N – 0

Insulin Stage 2*R/N – 0 – R/N – 0

Insulin Stage 4A*R – R – R – N

Insulin Stage 4A*R – R – R – N

Fasting < 200 mg/dLCasual < 250 mg/dL

Fasting < 200 mg/dLCasual < 250 mg/dL

Oral Agent Stage*Oral Agent Stage*

Food Plan & Exercise Stage*Food Plan & Exercise Stage*

Fasting 200–350 mg/dLCasual 250–400 mg/dL

Fasting 200–350 mg/dLCasual 250–400 mg/dL

Combination Therapy Stage*OA - 0- OA- 0 or OA – 0 – 0 – N

Combination Therapy Stage*OA - 0- OA- 0 or OA – 0 – 0 – N

For conversion to mmol/L divide mg/dLby 18

IDC4.5

Type 2 DiabetesType 2 DiabetesFasting BG Fasting BG >> 126 mg/dL126 mg/dLCasual BGCasual BG >> 200 mg/dL 200 mg/dL

Type 2 DiabetesType 2 DiabetesFasting BG Fasting BG >> 126 mg/dL126 mg/dLCasual BGCasual BG >> 200 mg/dL 200 mg/dL

Systematic Approach to Management of Type 2 Diabetes

Hemoglobin AHemoglobin A1c1c

Every 3-6 monthsEvery 3-6 months

Target Target << 7.0% 7.0%

SMBGSMBGPre-meal 80-140 mg/dLPre-meal 80-140 mg/dL

(~ 50% of readings)(~ 50% of readings)

Hemoglobin AHemoglobin A1c1c

Every 3-6 monthsEvery 3-6 months

Target Target << 7.0% 7.0%

SMBGSMBGPre-meal 80-140 mg/dLPre-meal 80-140 mg/dL

(~ 50% of readings)(~ 50% of readings)

LDL CholesterolLDL CholesterolAnnual testingAnnual testing

Target LDL < 130 mg/dlTarget LDL < 130 mg/dlWith CVD < 100 mg/dlWith CVD < 100 mg/dl

Triglycerides Triglycerides < 200 mg/dl< 200 mg/dl

HDLHDL> 40 mg/dl> 40 mg/dl

LDL CholesterolLDL CholesterolAnnual testingAnnual testing

Target LDL < 130 mg/dlTarget LDL < 130 mg/dlWith CVD < 100 mg/dlWith CVD < 100 mg/dl

Triglycerides Triglycerides < 200 mg/dl< 200 mg/dl

HDLHDL> 40 mg/dl> 40 mg/dl

Blood PressureBlood Pressure (every visit)(every visit)

Dx of HTN > 130/85Dx of HTN > 130/85Rx Target < 130/85Rx Target < 130/85

Blood PressureBlood Pressure (every visit)(every visit)

Dx of HTN > 130/85Dx of HTN > 130/85Rx Target < 130/85Rx Target < 130/85

Annual ScreeningAnnual ScreeningNephropathyNephropathy

Microalbuminuria ScreeningMicroalbuminuria Screening

RetinopathyRetinopathyDilated retinal examDilated retinal exam

NeuropathyNeuropathyComprehensive foot examComprehensive foot exam

Annual ScreeningAnnual ScreeningNephropathyNephropathy

Microalbuminuria ScreeningMicroalbuminuria Screening

RetinopathyRetinopathyDilated retinal examDilated retinal exam

NeuropathyNeuropathyComprehensive foot examComprehensive foot exam

Foot CareFoot CareAspirin UseAspirin Use

Tobacco cessationTobacco cessationFlu Shot + Pneumovax Flu Shot + Pneumovax

Psychosocial SupportPsychosocial SupportQOL - Pt. satisfactionQOL - Pt. satisfaction

Foot CareFoot CareAspirin UseAspirin Use

Tobacco cessationTobacco cessationFlu Shot + Pneumovax Flu Shot + Pneumovax

Psychosocial SupportPsychosocial SupportQOL - Pt. satisfactionQOL - Pt. satisfaction

Glycemic ControlGlycemic ControlGlycemic ControlGlycemic Control Management ofManagement ofDyslipidemiaDyslipidemia

Management ofManagement ofDyslipidemiaDyslipidemia

HypertensionHypertensionManagementManagement

HypertensionHypertensionManagementManagement

ComplicationsComplicationsManagementManagement

ComplicationsComplicationsManagementManagement

CareCareRecommendationsRecommendations

CareCareRecommendationsRecommendations

HyperglycemiaHyperglycemiaHyperglycemiaHyperglycemia Lipid DisordersLipid DisordersLipid DisordersLipid Disorders HypertensionHypertensionHypertensionHypertension ComplicationsComplicationsComplicationsComplications Other ComponentsOther Componentsof Careof Care

Other ComponentsOther Componentsof Careof Care

© International Diabetes Center© International Diabetes Center

IDC4.6

Annual Comprehensive Diabetes Review

Annual Comprehensive Diabetes Review

Vascular DiseaseVascular Disease RetinopathyRetinopathy NephropathyNephropathy NeuropathyNeuropathy Foot DiseaseFoot Disease Oral and DermatologicalOral and Dermatological Hospitalizations, Hypoglycemia, DKA and Hospitalizations, Hypoglycemia, DKA and

Hyperosmolar Nonketotic Coma (HONK)Hyperosmolar Nonketotic Coma (HONK)

IDC4.7

Comparison of Clinics on Standards of Care

Comparison of Clinics on Standards of Care

0%

17%

35%

52%

70%

87%

104%H

bA

1c BP

ED

SM

BG

Ftx

am

EY

Exa

m

Clinic 1

Clinic 2

Clinic 3