DIABETES PRACTICE GUIDELINES

TREATMENT GOALS 1) Normalize blood or attain glycosylated hemoglobin levels within 115% of the upper limit of normal for the reference lab 2) Prevent or effectively treat cardiovascular, renal, and opthalmologic complications related to 3) Prevent or effectively treat risk factors associated with the development of diabetic complications (e.g. hypertension, smoking, triglycerides, cholesterol, obesity) 4) Prevent acute exacerbations of diabetes (e.g. ketoacidosis that requires ER use or hospitalization) 1 INITIAL EVALUATION Medical History Physical Exam Lab Evaluation Management Plan S Symptoms, results of laboratory tests, and special S Height/weight S A1C S Medications (, oral glucose- examination results related to the diagnosis of measurement (and S Fasting lipid lowering agents, glucagon, diabetes comparison to profile (total antihypertensive and lipid-lowering S Prior A1C records norms in children cholesterol, HDL agents, aspirin therapy, other S Eating patterns, nutritional status, and weight history; and adolescents) cholesterol, endocrine drugs and other growth and development in children and adolescents S Sexual maturation triglycerides, and medications) S Details of previous treatment programs, including (if peripubertal) LDL cholesterol) S Recommendations for appropriate nutrition and diabetes self-management education, S Blood pressure on patients O 2 lifestyle changes (e.g. exercise, attitudes, and health beliefs determination, years old smoking cessation, weight S History: family; exercise; previous treatment programs including S Serum creatinine reduction) (including nutrition and diabetes self-management orthostatic in adults (also in S Dental hygiene training); gestational history; treatment of other measurements children if S Patient and family education for conditions, including endocrine and eating disorders when indicated, proteinuria is self-management of diabetes, S Current treatment, including medications, meal plans, and comparison to present) including nutritional counseling results of glucose monitoring and patient’s use of the age-related norms S Urinalysis for (preferably provided by a Certified data S Evaluation of ketones, protein, Diabetes Educator and/or Registered S Other medications that may affect blood glucose pulses and sediment Dietician) 4 levels S Hand/finger S Microalbuminuria S Monitoring instructions: self- S Frequency, severity, and cause of acute complications examination 3 screen monitoring of blood glucose such as ketoacidosis and S Foot examination2 S Thyroid- (SMBG), urine ketones, and use of a S Prior or current infections to skin, feet, dental, and S Skin examination stimulating record system genitourinary (including insulin (TSH) S Annual comprehensive dilated eye 5 S Symptoms and treatment of: chronic eye, kidney, injection sites) in all type 1 examination nerve, and heart disease; genitourinary, bladder, and S Thyroid palpation diabetic patients; S Consultation for podiatry and other gastrointestinal function; peripheral vascular, foot and S Fundoscopic in type 2 if special services as needed cerebrovascular complications examination clinically S Agreement on continuing support, S Risk factors for atherosclerosis: smoking, S Neurological indicated follow-up, and return appointments hypertension, obesity, dyslipidemia, and family examination S EKG (adults only S Instructions on how and when to history S Abdominal if needed) contact the physician S History and treatment of other conditions, including examination S For women of childbearing age, endocrine and eating disorders S Cardiac discussion of contraception and the S Family history of diabetes and other endocrine examination necessity of optimal blood glucose disorders S Oral examination control before conception and S Lifestyle, cultural, psychosocial, education, and S Signs of diseases during pregnancy economic factors that might influence the that can cause S Pneumococcal vaccine management of diabetes secondary diabetes S Annual influenza vaccine S Tobacco, alcohol and/or controlled substance use (e.g., S Consultation with a behavioral S Contraception and reproductive and sexual history hemochromatosis, specialist, as indicated pancreatic disease)

1 The assessment should be initiated on the first visit. Data may need to be gathered in more than one session or by other physicians. 2 Examine for the loss of protective sensation (neuropathy severe enough not to feel injury), structural deformities, and skin and nail deformities. 3 In pubertal and postpubertal patients who have had O 5 years and in all patients with type 2 diabetes 4 Services may be rendered by any professional designated by the referring physician, but claims must be submitted by a physician using the following codes: 9920M (brief interval follow-up to review care plan, to be performed every 3-6 months), 9921M (outpatient diabetic self-care programs; 3-6 hours of individual counseling for survival skills to include medication administration, diet basics, potential emergencies, and glucose testing), 9922M (comprehensive outpatient diabetic self-care program; 12-16 hours with a minimum of 4 hours of individual counseling to include pre and post assessment, review of survival skills, medication adjustment, exercise, pathophysiological teaching and preventive aspects), and 9923M (follow-up review of diabetic self-care program; minimum of 2 hours, to be performed at 6 months, 12 months and annually thereafter). 5 Performed on patients who: are O 10 years old and have had diabetes for at least 3-5 years; are > 30 years old who have visual symptoms and/or abnormalities; or are pregnant (performed in the first trimester).

Page 1 of 3 Originated: 7/97 Updated: 3/98, 3/00, 1/01,1/02, 3/03

DIABETES PRACTICE GUIDELINES

FOLLOW-UP VISITS Recommended frequency: semi-annually for stable patients and quarterly for patients who are not meeting goals. Medical History Physical Exam Lab Evaluation Management Plan S Frequency, causes, and S Height (until S A1C 8 S Determine progress in meeting goals severity of hypoglycemia or maturity) and S Fasting lipid profile (serum and to identify problems weight cholesterol, triglyceride, S Review control of blood glucose S Results of SMBG (self- S Sexual HDL cholesterol, and LDL levels, assessment of complications, monitoring blood glucose) maturation (if cholesterol) 9 control of blood pressure, control of S Adjustments by the patient peripubertal) S Routine urinalysis annually dyslipidemia, nutrition assessment, of the therapeutic regimen S BP readings in adults frequency of hypoglycemia, S Problems with adherence S Foot S Microalbumin screen by one adherence to all aspects of self-care, S Reported symptoms examination if of the following tests:10 evaluation of the exercise regimen, suggesting development of at risk 6 1) albumin to creatinine follow-up of referrals, and the complications of S Comprehensive ratio in a random, spot psychosocial adjustment. diabetes dilated eye and collection S Reassess knowledge of diabetes and S Other medical illnesses visual exam 7 2) 24-hour urine with self-management skills at least S Current medications S Fundoscopy creatinine and creatinine annually 11 S S Psychosocial issues and (referral if clearance Continuing education should be lifestyle changes (e.g. retinopathy 3) timed collection provided or encouraged 11 smoking cessation) detected) S Smoking cessation, family planning S Annual influenza vaccine

REFERRAL GUIDELINES Specialty care is recommended for the conditions below. Specialty care may also be appropriate for other conditions or indications. Condition/Indication Specialist Diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic Diabetologist or endocrinologist syndrome where: S initial clinical/biochemical state is markedly abnormal S initial response to standard therapy is unsatisfactory S metabolic complications or cerebral edema occurs S recurrence of DKA Chronically uncontrolled patients or recurrent hypoglycemia (A1C Diabetologist or endocrinologist persistently above 12%) Macular edema, any proliferative diabetic retinopathy (PDR) or severe Ophthalmologist nonproliferative diabetic retinopathy (NPDR) Patients with diabetes who become pregnant or who are planning a Multidisciplinary team (diabetologist/endocrinologist, pregnancy internist/FP/GP; obstetrician; diabetes educator) History of previous foot lesions, especially prior amputations Podiatrist or appropriate surgeon Onset of overt nephropathy Registered dietitian (for design of protein-restricted meal plans) 11 GFR <70 ml/min-1 or serum creatinine >2.0 mg/dl or when difficulties Nephrologist occur in management of hypertension or hyperkalemia 6Risk factors for development of foot ulcers: loss of protective sensation (neuropathy severe enough not to feel injury) or vascular disease. Additional risk factors in these patients are structural deformities and skin and nail deformities. 7 Performed on patients who: are O 10 years old and have had diabetes for at least 3-5 years; are > 30 years old; who have visual symptoms and/or abnormalities; or are pregnant (performed in the first trimester). 8Twice per year if stable; quarterly if treatment changes or patient is not meeting goals 9Conduct annually until values fall within an acceptable range; then repeat every 2 years for adults or every 5 years for children older than 2 years old 10In pubertal and postpubertal patients who have had type 1 diabetes O 5 years and in all patients with type 2 diabetes 11Services may be rendered by any professional designated by the referring physician, but claims must be submitted by a physician using the following codes: 9920M (brief interval follow-up to review care plan, to be performed every 3-6 months), 9921M (outpatient diabetic self-care programs; 3-6 hours of individual counseling for survival skills to include medication administration, diet basics, potential emergencies, and glucose testing), 9922M (comprehensive outpatient diabetic self-care program; 12-16 hours with a minimum of 4 hours of individual counseling to include pre and post assessment, review of survival skills, medication adjustment, exercise, pathophysiological teaching and preventive aspects), and 9923M (follow-up review of diabetic self-care program; minimum of 2 hours, to be performed at 6 months, 12 months and annually thereafter).

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DIABETES PRACTICE GUIDELINES

HOSPITAL ADMISSION GUIDELINES Inpatient care may be appropriate in the situations listed below, as well as in the following situations: newly diagnosed diabetes in children or adolescents; substantial and chronic poor metabolic control that necessitates close monitoring of the patient; uncontrolled or newly discovered insulin- requiring diabetes during pregnancy. There may be situations in which admission is appropriate although the patient’s clinical profile does not comply with these guidelines. Acute Metabolic Diabetic ketoacidosis: Complications Plasma glucose >250 mg/dl (>13.9 mmol/l) with 1) arterial pH<7.30, venous pH<7.30, or serum bicarbonate level<15mEq/l and 2) ketonuria and/or ketonemia.

Hyperglycemic hyperosmolar nonketotic state: Impaired mental status and elevated plasma osmolality in a patient with hyperglycemia. This usually includes severe hyperglycemia (e.g. plasma glucose >600 mg/dl [>33.3 mmol/l]) and elevated serum osmolality (e.g. >320 mOsm/kg [>320 mmol/kg]).

Hypoglycemia with neuroglycopenia: S blood glucose <50 mg/dl (<2.8 mmol/l) and the treatment of hypoglycemia has not resulted in prompt recovery of sensorium or S coma, seizures, or altered behavior (e.g. disorientation, , unstable motor coordination, dysphasia) due to documented or suspected hypoglycemia or S hypoglycemia caused by a sulfonylurea drug or S hypoglycemia has been treated but a responsible adult cannot be with the patient for the ensuing 12 hours (in a juvenile with diabetes or in an adult incapable of self care)

Uncontrolled Diabetes Treatment has been refractory to outpatient therapy, consultant therapy has been applied or considered, and the patient has: S Hyperglycemia associated with volume depletion or, S Recurring episodes of severe hypoglycemia (i.e., <50 mg/dl [<2.8 mmol/l]) despite intervention or S Persistent refractory hyperglycemia associated with metabolic deterioration or S Recurring fasting hyperglycemia > 300 mg/dl or a glycosylated hemoglobin level of O 100% above the upper limit of normal or S Recurring episodes of severe hypoglycemia (<50 mg/dl) despite intervention or S Metabolic instability manifested by frequent swings between hypoglycemia (<50 mg/dl) and fasting hyperglycemia (>300 mg/dl) or S Recurring diabetic ketoacidosis without precipitating infection or trauma or S Repeated absence from school or work due to severe psychosocial problems causing poor metabolic control that cannot be managed on an outpatient basis. Complications of S Chronic cardiovascular, neurological, renal, peripheral vascular (foot ulcers) and other diabetic complications Diabetes or other Acute may progress to the stage where hospital admission is appropriate. Medical Conditions S Presence of diabetes must be considered in all admissions and may result in patients requiring admission who otherwise might be managed on an outpatient basis.

PROCESS AND OUTCOME TARGETS Indicator Population Annual dilated eye exam All patients with diabetes A1C test O 2 times/year All patients with diabetes No ER visits All patients with diabetes No hospital admissions All patients with diabetes Physician office visits O 2 times/year All patients with diabetes Self-monitoring of blood glucose All patients with diabetes who are on medication Referrals to specialists All patients with diabetes who meet referral guidelines References American Diabetes Association: Clinical Practice Recommendations 2002, Diabetes Care, Volume 26, Supplement 1, January 2003; The American Association of Clinical Endocrinologists (AACE) Medical Guidelines for the Management of Diabetes Mellitus, 2003 update. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Page 3 of 3 Originated: 7/97 Updated: 3/98, 3/00, 1/01,1/02, 3/03