Nationally accepted quality measures of diabetes care are based on population results. Measures such as the % of patients with HgA1c < 7.0 are being used to identify “high quality” physicians and systems. Caring for a population of patients requires a care delivery model designed for proactive, planned care. The MCI goal is to exceed the 90th percentile on all measures. To achieve this Mercy Clinics recommends:

1. If feasible use a Diabetes Disease Registry in the care of diabetes patients.  The registry should be used to identify patients overdue for visits or not meeting goals and to generate performance reports.
2. Follow and address all the parameters as recommended in the ADA guidelines for treatment of diabetes.  Special attention should be given to:

   HgA1c < 7.0	Urine Microalbumin - yearly
   BP < 130/80	Eye Exam - yearly
   LDL Cholesterol < 100	Foot exam – yearly

   A plan for change should be developed with patients when parameters are not within the ADA guidelines.
3. Diabetes Education should be offered at the time of diagnosis and as needed thereafter.  It should include:

   Rationale for glycemic control	General diabetes pathophysiology
   Nutrition and weight control	Drugs used in the treatment of diabetes
   Foot and eye care	Hypoglycemia / sick day management
   Lipid and BP control	Tobacco cessation

   These should be reinforced as needed at routine office visits and/or classes through the Mercy Diabetes Institute (247-3838).
4. Self-Management-Support should be integrated into each visit to help patients achieve goals that are important to them.  Advice should be sensitive to the patient’s stage of change – an action plan should not be given to a patient in a pre-contemplative stage.       
5. Screening for diabetes and pre-diabetes with FBG should be done every 3 years beginning at age 45.  Testing should be considered at an earlier age or more frequently if diabetes risk factors are present.  The use of HgA1c is not recommended for screening but for following patients after the diagnosis of diabetes.
6. The diagnosis of diabetes is made by:

   FBG > 126 times two
   2 hr. post 75g GTT > 200
   RRandom Glucose > 200 and symptoms of diabetes.

7. Most patients with diabetes should be seen for office visits at least every 4 months.

Reference: 

American Diabetes association: Clinical Practice Recommendations 2006.

Available online at:  http://care.diabetesjournals.org/cgi/reprint/29/suppl_1/s4

Variation from this guideline is always acceptable if in the opinion of the attending physician, individual circumstances require it.