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Recommendations Summary

DM: Coordination of Care (2015)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    DM: Coordination of Care

    The registered dietitian nutritionist (RDN) should implement medical nutrition therapy (MNT) and coordinate care with an interdisciplinary health care team, the adult with diabetes and important others (e.g., family, friends and colleagues). Care systems should support team-based care and community involvement to meet patient needs, ensuring productive interactions between a prepared, proactive practice team and an informed, activated patient.
     

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      None.
       

    • Potential Costs Associated with Application

      Costs of MNT sessions and reimbursement vary. However, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Strategies for Improving Care

      • Treatment decisions should be timely and founded on evidence-based guidelines tailored to individual patient preferences, prognoses and co-morbidities. Grade B
      • Care should be aligned with components of the Chronic Care Model (CCM) to ensure productive interactions between a prepared, proactive practice team and an informed, activated patient. Grade A
      • When feasible, care systems should support team-based care, community involvement, patient registries and decision support tools to meet patient needs. Grade B
      Initial Evaluation and Diabetes Management Planning

      Consider assessing for and addressing common co-morbid conditions (e.g., depression, obstructive sleep apnea) that may complicate diabetes management. Grade B

      Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization
      • Include assessment of the patient’s psychological and social situation as an ongoing part of the medical management of diabetes. Grade B
      • Psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect and mood, general and diabetes-related quality of life, resources (financial, social and emotional) and psychiatric history. Grade E
      • Routinely screen for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders and cognitive impairment. Grade B
      • Older adults (aged 65 years or older) with diabetes should be considered a high-priority population for depression screening and treatment. Grade B
      • Patients with co-morbid diabetes and depression should receive a stepwise collaborative care approach for the management of depression. Grade A
      Approaches to Glycemic Treatment
      • Bariatric surgery may be considered for adults with BMI higher than 35kg/m2 and type 2 diabetes, especially if diabetes or associated co-morbidities are difficult to control with lifestyle and pharmacological therapy. Grade B
      • Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and medical monitoring. Grade B
      • Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI 30kg/m2 to 35kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI less than 35kg/m2. Grade E
       Microvascular Complications and Foot Care
      • Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. Grade A
      • Optimize blood pressure control to reduce the risk or slow the progression of diabetic kidney disease. Grade A
      • Continued monitoring of urine albumin-to-creatinine ratio (UACR) in patients with albuminuria is reasonable to assess progression of diabetic kidney disease. Grade E
      • When estimated glomerular filtration rate (eGFR) is less than 60ml per minute per 1.73m2, evaluate and manage potential complications of chronic kidney disease (CKD). Grade E
      • Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease, difficult management issues or advanced kidney disease. Grade B
      • Optimize glycemic control to reduce the risk or slow the progression of retinopathy. Grade A
      • Optimize blood pressure control to reduce the risk or slow the progression of retinopathy. Grade A
      • Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within five years after the onset of diabetes. Grade B
      • Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. Grade B
      • If there is no evidence of retinopathy for one or more eye exams, then exams every two years may be considered. If diabetic retinopathy is present, subsequent examinations for patients with type 1 diabetes and type 2 diabetes should be repeated annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then examinations will be required more frequently. Grade B
      • Women with pre-existing diabetes who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and be counseled on the risk of development and progression of diabetic retinopathy. Eye examination should occur in the first trimester, with close follow-up throughout pregnancy and for one year postpartum. Grade B
      • Tight glycemic control is the only strategy convincingly shown to prevent or delay the development of diabetic peripheral neuropathy (DPN) and cardiovascular autonomic neuropathy (CAN) in patients with type 1 diabetes (Grade A) and to slow the progression of neuropathy in some patients with type 2 diabetes. Grade B
      • A multi-disciplinary approach is recommended for individuals with foot ulcers and high-risk feet (e.g., dialysis patients and those with Charcot foot, prior ulcers, or amputation). Grade B

    • Recommendation Strength Rationale

      The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades A, B and E.
       

    • Minority Opinions

      Consensus reached.