Diabetes Care Path

Introduction

Clinical Judgment

This care path guide is intended to be broadly applicable, but it is not meant to substitute for clinical judgment. Clinicians and specialists should tailor processes and approaches to align with patient needs, abilities and goals for care.

While this guide is largely based on American Diabetes Association (ADA) guidelines, we have tried to present information that will allow use for individual patients in a different format. We also emphasize deprescribing information and include some local resources to help in the treatment of type 2 diabetes in adults.

Diabetes: A Heavy Burden on Public Health

Nationally, more than 23 million people have been diagnosed with diabetes,1 a chronic and complex condition that typically affects numerous aspects of patient health.2 The Centers for Disease Control and Prevention (CDC) estimated approximately 30.3 million people, or about 9.4% of the U.S. population, had diabetes in 2015.1 The CDC projects up to one-third of adults in the U.S. could have this condition by the year 2050.3

In the southeastern United States, diabetes rates are higher, with estimations varying from 11–14% of state populations. In most southern states, more than one-third of residents are estimated to have prediabetes.4 Combined with high poverty levels and lower rates of access to health insurance and healthcare in general in the southern U.S.,5 management of chronic conditions, such as type 2 diabetes, becomes a distinct challenge for patients who live in these regions and their care teams.6

Diabetes is also a costly problem nationally, accounting for $237 billion in medical costs and $90 billion across the U.S. in diminished productivity in 2017.7 In the Southeast, medical cost burden per state is estimated between $2.4 billion and $7.7 billion.8,9 The high costs are caused by a variety of circumstances: The numbers of people with diabetes and costs of care per person are rising, while among individual patient expenses, prices of antihyperglycemic medications are rising steeply10 and inpatient hospital stays are increasing.7

If uncontrolled, diabetes can result in amputations, blindness, cardiovascular disease, kidney disease, neuropathy and stroke.2 Early diagnosis and proper management of type 2 diabetes can help delay, moderate or prevent these complications. Similarly, detection and optimal management of prediabetes can delay or prevent the condition from progressing to type 2 diabetes.2 Therefore, a focus on type 2 diabetes and prediabetes can benefit individuals, communities and healthcare systems.

Emergency Room Use and Readmissions

People with diabetes account for a disproportionate fraction of those who come to the emergency department and are admitted to the hospital following an emergency visit. These visits are sometimes due to conditions arising from uncontrolled or poorly managed diabetes, such as diabetic ketoacidosis and hyperglycemia11 and more often for comorbid conditions, such as cardiovascular disease. Effective type 2 diabetes management has the potential to prevent costly emergency admissions and repeat visits to the emergency department.11,12

Historically, there has been little study about the effect of diabetes on hospital readmissions, but the disease is a comorbidity to many medical conditions that lead to readmission. Studies have shown that patients with diabetes have a higher risk for 30-day readmission.13 Patients admitted with a primary diagnosis of diabetes have higher readmission rates than those without diabetes, a 2017 study of more than 7,000 hospital admissions found.13

Table 1: Treatment Measures and Goals

Measure

Frequency

Goal

Hemoglobin A1c

Every six months

< 7.0%2 or patient-specific goal (see Table 3, page 13)

Blood pressure

Each office visit

Most patients with diabetes have a goal of 140/90 mmHg, but those with higher cardiovascular disease risk should aim for 130/80 mmHg.

Foot exam

Annually

Healthy skin, absence of deformities, full sensation, healthy vascular assessment2

Statin medication

Fasting lipid panel annually

ADA Guidelines: Prescribe for nonpregnant patients > age 40 OR ≤ age 40 who have 10-year ASCVD risk

> 20% +/- other cardiac risk factors2

———————————————

2019 AHA/ACC Guidelines: Prescribe moderate-intensity statin for all patients with diabetes and high intensity statin for patients who have had T2DM for ≥ 10 years, albuminuria ≥ 30 mcg albumin/mg creatinine, eGFR < 60 mL/min/1.73 m2, retinopathy, neuropathy, ABI < 0.9 14

Urine albumin/creatinine ratio

Annually

< 30 mg albumin/g of creatinine2

Serum creatinine

Annually

Normal2

Retinal/dilated eye exam

Annually or biannually; more often if condition is progressing

Normal2

Office visit

At least every three months for patients not meeting A1c goal; every six months for patients meeting goal; individualized to patient needs and then annually

Note: Visits may be distributed between primary care clinician and specialist

The Case for a Care Path Guide

Recent studies have demonstrated that inadequate, unnecessary, uncoordinated and inefficient care are responsible for waste in the healthcare system that may account for 35–50%15 of the nearly $3 trillion the United States spends annually on healthcare.16 Care path guides become tools for education, reporting, measurement and continuous improvement. Reduction of unnecessary variability is their primary goal. Care paths are designed to standardize care to reduce variability and assure a consistent level of quality for patients across time, venue and provider, combining workflow-friendly, evidence-based practice principles.

Health Status Measures and Patient-Reported Outcomes

Health status measures (HSMs) in general and patient-reported outcome measures (PROMs) in particular are becoming important standard components of patient care. These measures are validated tools that provide insight into patient relevant issues, improve patient/clinician communication and guide individual management. They provide a method to objectify outcomes and quality in a manner that can be shared with patients.

These measures require patient participation and have been shown to improve patient engagement in their own healthcare. These outcome measures are an important component of value-based care and are beginning to be important in health policy and reimbursement.

Sidebar 1
PROM TOOLS
GENERAL AND BEHAVIORAL

The following PROMs help clinicians evaluate general and behavioral health status that could affect outcomes and guide treatment:

PAID-5: A five-question screening tool to assess emotional distress related to having diabetes. The five questions are designed to identify feelings of fear, depression, anxiety about the future, resilience and coping. A score of eight or more is indicative of emotional distress and calls for further assessment. The PAID-5 is thought to be highly sensitive to identifying problem areas.17

ARMS-7: A seven-question screening tool designed to assess medication adherence behaviors. There is also an ARMS-D specific to patients with diabetes. The ARMS instrument is reliable and has the added benefit of identifying reasons for adherence problems.18

Patient Health Questionnaire-2 (PHQ-2): A two-question depression screening tool that can provide information about the patient’s mental health status. If the patient has a positive PHQ-2 score of three or higher, they should be further screened for depression.19,20

Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10: A 10-question screening tool designed to assess physical, mental and social health, including pain, fatigue and quality of life.

About This Care Path Guide

This care pathway was developed by Vanderbilt Health Affiliated Network to guide primary, mid-level and ancillary care clinicians and specialists in an evidence-based approach to diagnosis and treatment of prediabetes and type 2 diabetes in adults. We intend this guide to be useful to caregivers in an array of settings: the emergency department, the urgent care or walk-in clinic, the primary care clinician’s office, and the specialist’s office. This resource is based on national and international guidelines, as well as the expert opinions of members of our network.

This care path guide focuses on the diagnosis and treatment of prediabetes and type 2 diabetes in adults. In some cases, the type of diabetes may not be clear based on clinical presentation alone. The Prediabetes section contains a brief discussion of considerations for identifying other types of diabetes [e.g., type 1 diabetes in young adults, gestational diabetes and latent autoimmune diabetes in adults (LADA)] but does not detail specific treatment of these conditions.

By following this care path guide when assessing, diagnosing and treating patients who have prediabetes and type 2 diabetes, clinicians and specialists may reduce variability and individualize treatments with the objective of obtaining positive health outcomes for adults with these conditions. In achieving those positive health outcomes, clinicians will also improve patient satisfaction and reduce unnecessary spending and utilization.

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