Diabetes Master Clinician Program
Edward Shahady, M.D., Medical Director Diabetes Master Clinician Program
Florida Academy of Family Physicians Foundation.
Click on an area for articles related to the subject
1. Published articles describing the Diabetes Master Clinician Program
2. Case Reports Discussing Diabetes Treatment
3. Standards of Care for Diabetes
4. Laboratory Evaluation in Diabetes
5. Pathophysiology of Diabetes
6. Pre-Diabetes Guidelines for Treatment
7. Treatment of Hyperglycemia Goals for A1C 2009-Clearing Up the Controversy
8. Diabetes Treatment Guidelines
9. Lifestyle Changes for Diabetes
10. Oral Medications for Diabetes
11. Use of Insulin in Diabetes
12. Hypertension and Diabetes
13. Hyperlipidemia and Diabetes
14. Non Alcoholic Fatty Liver Disease (NAFLD)
15. Statin Safety with Elevated Hepatic Enzymes
16. Barriers to Diabetes Care
17. Literacy Issues in Diabetes
18. Group Visits in Diabetes
19. Depression and Diabetes
20. Neuropathy in Diabetes
21. Retinopathy and other eye problems in Diabetes
22. Nephropathy and Chronic Renal Disease in Diabetes
23. Cardio-metabolic Risk in Diabetes
24. Online Resources for Diabetes Care and Patient Education
25. Medicare Coverage of Blood Glucose Monitors and Testing Supplies
26. Patient Centered Medical Home
27. Diabetes University
A. Published articles describing the Diabetes Master Clinician Program
1. The Florida Diabetes Master Clinician Program: Facilitating Increased Quality and Significant Cost Savings for Diabetic Patients. Clinical Diabetes 2008;26: 29-33
This article describes the master clinician program, its reports and the cost savings generated as of January 2008.
2. How a diabetes disease registry and team care improved quality and created the foundation for a Patient Centered Medical Home - The Florida Experience 2009 Published online May 8th 2009
This article describes how the master clinician program, its registry and emphasis on team care helps a practice become an NCQA certified medical home. It demonstrates which reports can be used and the number of points the report aids you in obtaining for the certification. Can also be accessed at http://medicaleconomics.modernmedicine.com/buildhome
3. Users manual for the Master Clinician Registry
This manual provides a step by step process for entering data into the Diabetes Master Clinician Registry. It is up to date as of January 2009.
4. Diabetes Registries, and Teamwork: Keys to a Patient Centered medical home for diabetes Practical Diabetology 2010;29:20-25
This article describes how the diabetes master clinician program helps a practice become a NCQA certified medical home. Included are discussions of criteria for certification, barriers to becoming a medical home and the importance of office teams for success in a medical home.
B. Case Reports Discussing Diabetes Treatment
3. Shahady EJ, Treating Complicated Diabetes, Advances in Primary Care Medicine Clinical Update Consultant supplement 2007;4:11-14
These three articles begin with a case of a diabetic patient seen in the primary care setting. The case presentation is followed by a set of questions for the reader to answer.The author then provides an answer and provides the evidence to support the answer. The case then continues with the results of the treatment or diagnostic options revealed.Another set of questions is provided for the reader to answer and this again is followedby the author’s answers with evidence to support the answer.
C. Standards of Care for Diabetes
1. Standards of Medical Care in Diabetes—2009 American Diabetes Association. Diabetes Care 2009; 32:S13-S61
The ADA annually in January publishes their updated standards of care. This extensivedocument is the reference document that clinicians can use to guide their decisions for clinical care. All recommendations are evidenced based with extensive references at the end of the article. This is a state of the art publication for standards for diabetes care.
D. Pathophysiology of Diabetes
1. DeFronzo RA, Pathogenesis of type 2 diabetes mellitus, Med Clin N Am 88 (2004) 787–835
This article is an extensive and comprehensive review of the pathogenesis of Type 2diabetes. For those who want to better understand all the intricate mechanisms ofdiabetes this article is for you. It builds on normal glucose metabolism to aid understanding of the multiple metabolic abnormalities that lead to Type 2 diabetes.
2. Shahady E., Understanding Diabetes
This article begins with a discussion of normal glucose metabolism and uses thatinformation to describe the metabolic abnormalities that lead to diabetes. Insulinresistance, inflammation, endothelial dysfunction and other consequences ofhyperglycemia hare included. The article concludes with a description of the emotionalchallenges of diabetes as highlighted by patient stories.
3. Shahady E. Type 2 Diabetes, the Metabolic Syndrome, Inflammation, and Arteriosclerosis: Steps to Stem a Rising Epidemic. Consultant 2005;45:1579-86
This article discusses the metabolic syndrome, its similarity with and evolution into Type2 diabetes. In patients with the metabolic syndrome and diabetes, elevated levels of small,dense low-density lipoprotein cholesterol (LDL-C) particles stimulate an inflammatoryprocess that leads to plaque instability and susceptibility to rupture, thus triggeringcardiovascular events. Measurement of high-sensitivity C-reactive protein can helpstratify risk levels in patients with the metabolic syndrome. Statins and aspirin are important options in treating the inflammatory cascade created by diabetes and themetabolic syndrome. Because of their beneficial effects on glucose, blood pressure,inflammation, and lipid levels, several drugs may have a role in the treatment of the metabolic syndrome.
4. Laboratory Evaluation in Diabetes
Shahady E, Laboratory Evaluation in Diabetes
This brief article describes the lab tests that are commonly used to evaluate a patientwith diabetes.
E. Pre-Diabetes Guidelines for Treatment
1. Nathan DM et al, Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for care Diabetes Care 2007;30:753-59
This article is an ADA consensus statement on treatment recommendation for individualswith impaired fasting glucose (IFG) 100 to125mg/dl and impaired glucose tolerance(IGT) 140 TO 199mgdl. The suggested treatment is lifestyle changes and Metformin 850mg BID if IFG or IGT and any one of the following exist:
60 years of age
BMI _35 kg/m2
Family history of diabetes in first degree relatives
Elevated triglycerides
Reduced HDL cholesterol
Hypertension
A1C _6.0%
2. Shahady .E, 16 year journey of a patients struggle with the metabolic syndrome and diabetes
The article describes the 16 year journey of a patient that resembles many of those thatare treated daily by all primary care offices. The words tell the medical story of this mansplight and asks you to think about what you would have done to help him. Hopefully thestory will motivate you to want to explore other options for the care of patients in your practice that are like this unfortunate man.
F. Treatment of Hyperglycemia
Goals for A1C 2009-Clearing Up the Controversy
1. Kausik KR et al Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomized controlled trials Lancet 2009;373:1765-1762
This meta-analysis reviewed five prospective randomized controlled trials of 33 040participants to assess the effect of an intensive glucose-lowering regimen on death andcardiovascular outcomes compared with a standard regimen. The mean HbA1cconcentration was 0•9% lower for participants given intensive treatment than for thosegiven standard treatment. Intensive control resulted in a 17% reduction in events of nonfatalmyocardial infarction, and a 15% reduction in events of coronary heart disease.Intensive control had no significant effect on events of stroke or all-cause mortality.
2. Kahn S, Glucose Control in Type 2 Diabetes Still Worthwhile and Worth Pursuing JAMA ; 2009:301:1590-3
This Journal of the American Medical Association (JAMA) commentary discusses theissues raised by the ACCORD, ADVANCE and VADT trials that questioned tight glucosecontrol. They suggest the appropriate goal for HbA1c level should be less than 7% foryounger patients who have a shorter duration of disease, no history of a priorcardiovascular event, and who can sense hypoglycemia. On the other hand, a moreliberal target of less than 7.5% would seem appropriate for patients with long-standingdisease, are older, have advanced diabetes-related complications, or who experiencesevere hypoglycemia. The key is the ability of the patient to sense hypoglycemia..
3. Shahady E., Diabetes and Cardiovascular Disease-does lowering A1C help or harm? Submitted for publication to Consultant. June 2009
This article reviews all current publications and includes the reports issued at the ADAmeeting in June 2009. It begins with two cases. One is a newly diagnosed diabetic andthe other is a patient with long standing diabetes. Treatment options are discussed withthe recent UKPDS 10 year study, ACCORD, ADVANCE and VADT trials in mind. Thearticle provides evidenced based suggestions for how to approach the question of “howlow should I go” with A1C.
G. Diabetes Treatment Guidelines
1. Nathan DM, Buse JB, Davidson, MB, Ferrannini E, Holman RR, Sherwin RB, Zinman B. Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. 2009; Diabetes Care 32:193–203
The consensus algorithm was initially published in August 2006 and updated in January2008 to address safety issues with TZD’s. This revision focuses on new classes ofmedications that now have more clinical data and experience. This consensus guidelinefor treating hyperglycemia and lowering HbA1c . The algorithm provides a 3 stepprocess to follow. It suggests starting with lifestyle changes and metformin and makingchanges if the A1C is ≥7%. It lists some treatments as well validated and others as lesswell validated.
2. Jellinger PS, Davidson JA, Blonde L, et al. ACE/AACE Diabetes Road Map Task Force. Road maps to achieve glycemic control in type 2 diabetes mellitus: ACE/AACE Diabetes Road Map Task Force. EndocrPract. 2007;13:260–268
The Diabetes Road Map is another good guideline for treating hyperglycemia andlowering HbA1c. It is published by the American College of Clinical Endocrinologists(AACE) is evidenced based. It provides one road map if the patient is naive to therapyand another if the patient is currently being treated. The AACE goal or A1C is ≤6.5%compared to the ADA goal of ≤7.0 An additional feature of the AACE road map that Ifind helpful is the guidance it provides by level of A1C. If the presenting A1C is 6 to 7 therecommendations are different than those with an A1C is 7 to 8.
H. Lifestyle Changes for Diabetes
1. Fowler MJ, Diabetes Treatment Part 1: Diet and Exercise, Clinical Diabetes 2007;25: 105-109
This article provides an overview of the impact of dietary carbohydrate, protein and faton diabetes. The section on exercise discusses benefits as well as cautions to consider indiabetic patients who take insulin or have other complications like retinopathy.
2. Basic Tips for Nutrition and Exercise
This contains three handouts that can be given to patients to help them understand basic nutrition and physical activity.
3. Oral Medications for Diabetes
Inzucchi SE: Oral antihyperglycemic therapy for type 2 diabetes. JAMA 287: 360 – 372, 2002
This article first describes the metabolic defects in Type 2 diabetes and then discusses how each medication impacts these metabolic defects. Although it was written in 2002 it discusses basic concepts that are very applicable to today’s medical practice.
4. Shahady E. Oral agents for treating diabetes 2009
This article reviews all the current oral agents available in 2009 for the treatment of diabetes. The article also discusses mechanism of action.
5. Use of Insulin in Diabetes
Mallik TK, Lando HM, Milliger G, A unique tool to educate and empower clinic patients using Intensive Insulin Therapy First Messenger Jan/Feb 2009;17-20
This is a practical article from the American Association of Clinical Endocrinologistsnewsletter. It discusses how to individualize treatment for each patient, lists goals and adescription of available insulin products. Its focus is insulin programs for Type 2Diabetes. Suggestions for initial programs and progressive add on insulin for those whodo not reach goal. Several examples of how to adjust insulin are included. Included in thediscussion are some suggestions for EM coding for individual and group insulin training.
I. Hypertension and Diabetes
1. Whalen KL, Steward RD. Pharmacologic Management of Hypertension in Patients with Diabetes Am Fam Physician. 2008;78:1277-1282
This article provides an evidenced based review of medications that are most effective for treatment of hypertension in diabetes. Angiotensin-converting enzyme inhibitors slowprogression to kidney failure and reduce cardiovascular mortality. These agents are thepreferred therapy for managing coexisting diabetes and hypertension. Angiotensinreceptor blockers can prevent progression of diabetic kidney disease and are a first-linealternative for patients intolerant of angiotensin-converting enzyme inhibitors. Thiazidediuretics provide additional antihypertensive effects when combined with angiotensinconverting enzyme inhibitors or angiotensin receptor blockers. Calcium channel blockersare excellent add on drugs. Beta blockers reduce cardiovascular events and are useful ina multidrug regimen.
J. Hyperlipidemia and Diabetes
1. Shahady E. Hyperlipidemia in diabetes-etiology, consequences and treatment 2008
This article discusses how diabetes leads to cardiovascular disease. The dysfunctional fat cell produces excessive free fatty acids and cytokines that lead to endothelial dysfunction.Medications to address excess LDL, triglycerides and decreased HDL is included.
2. Shahady EJ, Non-HDL When and How to Treat. Consultant 2008;48:745-752
This article reviews the when and how of using Non-HDL Cholesterol. After LDL isreduced to goal significant residual risk may remain in the triglycerides and HDL are notat goal. When triglycerides are above 200 Non-HDL is a more precise target to reduceCV risk. Non-HDL values are a reflection of the number of small LDL particles in theserum. The article discusses how the value is derived (with no extra testing) and offersoptions for treating.
K. Non Alcoholic Fatty Liver Disease (NAFLD)
1. Cusi K Non Alcoholic Fatty Liver Disease. First Messenger 2008; 17:7-9
This article defines NAFLD as a liver condition characterized by hepatic fataccumulation (in the absence of other causes) and insulin resistance with progressiveliver damage (NASH) in about 40% of patients. NAFLD is more common in obesity and Hispanics. It has the lowest incidence in African-Americans. Two thirds of patients withNAFLD may have normal liver ALT and AST. Lifestyle intervention is the only accepted long-term treatment, although thiazolidinediones have proven to be safe & effective inshort-term studies. Some newer studies with GLP-1 agonists indicate some benefit.
2. Statin Safety with Elevated Hepatic Enzymes
L2 Cohen DE, Anania FA, Chalasani N. Assessment of Statin Safety by Hepatologists. Am J Cardiol 2006; 97(8A): 77C-81C
This article is a consensus statement by a group of Hepatologists known as the LiverExpert Panel. The panel believes there is no evidence that a relation exists betweenelevated serum aminotransferase levels and significant liver injury, or that routine monitoring of liver biochemistries will identify individuals likely to develop rare cases of idiosyncratic liver failure. The panel suggests that the requirement for routine liverbiochemistry monitoring in patients receiving any of the currently marketed statintherapies should be reexamined. The panel is concerned that isolated elevations in aminotransferases may prompt health professionals to discontinue statin therapyinappropriately in patients otherwise at increased risk for an adverse cardiovascularevent. The Panel is also concerned that patients may be unduly alarmed by the perceivedimplications of monitoring and may choose to discontinue or refuse statin therapy.
3. McKenney JM, Davidson MH, Jacobson TA, Guyton JR. Final conclusions and recommendations of the National Lipid Association Statin Safety Assessment Task Force. Am J Cardiol. 2006; 97(suppl 8A):89C-94C
This article is an excellent evidenced based discussion of all the safety issues related tostatins. It has a specific section devoted to liver safety and statins. The task force believesthat patients with chronic liver disease, nonalcoholic fatty liver disease, or nonalcoholicsteatohepatitis may safely receive statin therapy. Because of the package insert mostclinicians’ measure transaminase levels during statin treatment. Routine monitoring ofliver function tests is not supported by the available evidence. Fractionated bilirubin,which, in the absence of biliary obstruction, is a more accurate prognosticator of liverinjury than isolated aminotransferase levels. If an isolated asymptomatic transaminaselevel is found to be >3 times normal during a routine evaluation of a patientadministering a statin, the test should be repeated and, if still elevated, other etiologiesshould be ruled out. Consideration should be given to continuing the statin, reducing itsdose, or discontinuing it based on clinical judgment.
L. Barriers to Diabetes Care
1. Shahady E. Barriers to care in Chronic Disease: How to bridge the Treatment Gap Consultant 2006;46 (10)::1149-1152
Our knowledge of chronic diseases has advanced significantly in recent decades, butpatient outcomes have not kept pace. This is largely because the traditional acute caremodel does not adequately address the needs of patients with chronic disease. Patientsplay an active role in the management of chronic disease, and successful outcomes arehighly dependent on adherence to treatment. Thus, clinicians need to have skills incoaching and encouraging as well as an awareness of factors in patients’ backgroundsthat are likely to affect their ability or willingness to follow treatment plans. Provider andsystem-related factors, such as lack of reimbursement for counseling and highcopayments, can also act as barriers to compliance. Among the strategies that canimprove adherence are the use of community resources, multidisciplinary approaches, and regular follow-up.
2. Shahady E. Recognizing and overcoming Barriers to effective Diabetes Care to be published in Consultant July/August 2009
This article uses patient stories to describe barriers and offers solutions by addressingcommunication barriers and depression. The author describes diabetes as the mostdemanding chronic illness. It challenges every fiber of a patient’s body and spirit anddemands a system of care that ministers to the biological, social and psychologicalaspects of the illness. Clinicians who recognize these facts are usually more successful inovercoming the barriers to effective care.
3. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educ. 2000;26:597-604
Non-compliant is a dysfunctional term. It places blame on the patient and does notfacilitate consideration of other causes and solutions. It is a word that reflects thefrustration that health care providers use when despite all their efforts the patient is not at goal. Unfortunately medical culture seeks to find blame. A shift in medical culture thatconsiders systems of care as the cause rather than blaming produces a less defensiveposture and facilitates finding solutions.
4. Anderson RM, Patrias R. The Diabetes Concerns Assessment Form. Clinical Diabetes 2007;25:141-143
This article provides a short form that can be given to the patient to complete before theyare seen by the clinician. Discovering and prioritizing the diabetic’s patients concerns isa challenge and the form aids that process. The form helps the patient more effectivelyexpress themselves. The patient can also let the clinician know what they hope will be done for their concern.
M. Literacy Issues in Diabetes
1. Words to watch-Fact Sheet
This article provides a list of words commonly used in medicine and offers alternativesthat may be easier for patients to understand. E.g. benign= will not cause harm; is notcancer. Many people, even highly literate people, have trouble understanding words usedin health care. In some instances, a word may be totally unfamiliar. In other cases, a word may be familiar, but the person may not understand it in a health care context.
2. Johnson K, Weiss BD How Long Does It Take to Assess Literacy Skills in Clinical Practice? J Am Board Fam Med 2008;21:211–214
This is a nice article that reviews the effectiveness of a 6 question instrument to accessliteracy. The test is administered by presenting patients a nutrition label and asking 6questions about the content of the label. The questions ask patients to compute thenumber of calories in various amounts of food; to interpret the effect on daily fat andcarbohydrate consumption if the amount of the food is changed; to identify ingredients inthe food; and to determine whether the food can be consumed if an individual is allergicto one of those ingredients. A score is given that aids level of literacy. The test takes 2 to 3 minutes to administer.
3. My Diabetes Self Management Goals
These three pages were prepared by Agnes McMurray and the Big Bend Rural HealthNetwork. They are excellent tools with pictures and words that aid the patient withunderstanding and reaching basic goals for nutrition, exercise, ABC’s and yearly activities of diabetes care. These sheets are highly recommended for all patients andespecially those who may not be as literate.
N. Group Visits in Diabetes
1. Davis A, Sawyer DR, Vinci L, The Potential of Group Visits in Diabetes Care Clinical Diabetes 2008;26:58-62
This article provides and excellent description of the literature on group visits indiabetes. The authors also include their experience with group visits and the lessons theyhave learned from a Midwest and a West Coast Practice. They explore practical issuesand describe the impact of group visits on their staff and patients. There is somediscussion of reimbursement. The reference list is excellent.
2. Shahady E, Group visits with a focus on Diabetes
This document is the manual that is used by the Diabetes Master Clinician Program totrain master clinicians and associates on how to conduct group visits. It includes: patientevaluations, coding and charging, planning, conducting and recruiting for group visits.Examples of HIPPA and permission forms and how to document a group visits andreferences are included.
3. Shahady E, Group Visits for Diabetes: An Innovative Way to Overcome Barriers and Achieve Quality Care Consultant 2010; 50:480-486
This article is a good description of the nuts and bolts criteria for group visits. It includes specific suggestions for ICD 9 and CPT coding, documenting, how to invite and prepare and other useful suggestions.
O. Depression and Diabetes
1. Gonzalez JS et al, Depression and Diabetes Treatment Nonadherence A Meta-Analysis Diabetes Care 31:2398–2403, 2008
This article describes meta-analysis to examine the relationship between depression andtreatment non adherence in patients with type 1 and type 2 diabetes. Results from 47studies showed that depression was significantly associated with non adherence todiabetes treatment. Treatment non adherence may represent an important pathwaybetween depression and worse diabetes clinical outcomes.
2. Shahady E, Depression and Diabetes
This article describes the epidemiology of depression in diabetes including evidence thatdepression may lead to diabetes. Patients who are not reaching diabetes goals are oftendepressed. The anger and frustrations of diabetes are experienced by patients, office staffand the clinicians. Patient stories enrich the chapter. Suggestions are made for when toscreen for depression and a tool that has proven reliable in primary care (PHQ-9) isincluded.
P. Neuropathy in Diabetes
1. Lewis MG et al Pharmacologic options for the management of diabetic peripheral neuropathy Formulary. 2005;40:438–452
This article discusses one of the most common complications of diabetes, diabetic peripheral neuropathy. Treatment options that includes prevention through strictglycemic control and and pharmacologic agents for symptomatic management. A vast array of pharmacologic agents such as non-steroidal anti-inflammatory drugs(NSAID’s), antidepressants, analgesics, and antiepileptic drugs are used alone or incombination for symptomatic management. The discussion also includes pathophysiologyand symptoms.
2. Boulton AJ et al Comprehensive Foot Examination and Risk Assessment A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists Diabetes Care 2008;31:1679-1685
This article provides the current standards for a comprehensive history and physicalexam for the foot in diabetic patients that stresses sensory and vascular assessment.Graphics are included that demonstrate use of a monofilament and ankle brachial index.Guidelines for when to obtain a consultation are also included.
3. Retinopathy and other eye problems in Diabetes
TumosaN,Eye Disease and the Older Diabetic. ClinGeriatr Med 2008;24:515–527
This is an excellent review article of all the different eye problems the diabetic patient may have. Retinopathy, macular edema, macular degeneration, glaucoma, cranial nervepalsys and dry eye syndrome are discussed. It lists symptoms and consequences ofdiabetic eye disease. The article reinforces prevention, early recognition and a briefdiscussion of surgical options. Well written for a primary care audience.
4. Nephropathy and Chronic Renal Disease in Diabetes
Johnson CA, Levey AS, Coresh J, Levin A, Lau J, Eknoyan G. Clinical Practice Guidelines for Chronic Kidney Disease in Adults: Part I. Definition, Disease Stages, Evaluation, Treatment, and Risk Factors. Am Fam Physician 2004;70:869-876
In 2002, the Kidney Disease Outcome Quality Initiative of the National Kidney Foundation published clinical practice guidelines on chronic kidney disease. The first sixof the 15 guidelines are of the greatest relevance to family physicians. Part I of this twopartarticle reviews guidelines 1, 2, and 3. Chronic kidney disease is defined by thepresence of a marker of kidney damage, such as microalbuminuria. Disease staging isbased on the glomerular filtration rate. Evaluation should be directed at determining thetype and severity of chronic kidney disease. Treatment goals include preventing diseaseprogression and complications. Risk factors for chronic kidney disease include diabetesmellitus, hypertension, family history of chronic kidney disease, age older than 60 years,and U.S. racial or ethnic minority status. The guidelines recommend testingfor proteinuria and estimating the glomerular filtration rate in patientsat risk for chronic kidney disease.
5. Johnson CA, Levey AS, Coresh J, Levin A, Lau J, Eknoyan G. Clinical Practice Guidelines for Chronic Kidney Disease in Adults: Part II. Glomerular Filtration Rate, Proteinuria, and Other Markers. Am Fam Physician 2004:70:1091-1097
Part II of this two-part review covers guidelines 4, 5, and 6. Glomerular filtration rate isthe best overall indicator of kidney function. It is superior to the serum creatinine level,which varies with age, sex, and race and often does not reflect kidney functionaccurately. The glomerular filtration rate can be estimated using prediction equations.In many patients, estimates of the glomerular filtration rate can replace 24-hour urinecollections for creatinine clearance measurements. To quantify proteinuria, the ratioof protein or albumin to creatinine in an untimed (spot) urine sample is an accuratealternative to measurement of protein excretion in a 24-hour urine collection. Patientswith persistent proteinuria have chronic kidney disease. Other techniques for evaluatingpatients with chronic kidney disease include examination of urinary sediment, urine dipstick testing for red and white blood cells, and imaging studies of the kidneys(especially ultrasonography).
Q. Cardio-metabolic Risk in Diabetes
1. Greenland et al 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults JJ Am Col Cardiology 2010; 56 published on line ahead of print
This Report from the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines is an evidenced based review of all currently avialble ways of assessing cardiovascular risk in asymptomatic patients. Diabetic patients are mentioned in the discussion. This is an up to date review of all current literature (as of December 2010).
2. Liviakis et all Carotid intima-media thickness (CMIT) for the practicing Lipidologist JClinLipidology 2010; 4: 24–35
Good discussion of the evidence for use of CMIT as a screening tool and a surrogate marker for CVD. The case is made for the safety of CMIT compared to the radiation with Coronary Artery Calcium scores.
3. Zoungas et al Severe Hypoglycemia and Risks of Vascular Events and Death N.Engl J. Med 2010;363:141018
This article discusses a 20 country study that examined the associations between severe hypoglycemia and the risks of macrovascular or microvascular events and death among 11,140 patients with type 2 diabetes. Severe hypoglycemia was associated with a significant increase in the adjusted risks of major macrovascular events, major microvascular events, death from a cardiovascular cause, and death from any cause.
4. Mazzone et al Intensive Glucose Lowering and Cardiovascular Disease Prevention in Diabetes: Reconciling the Recent Clinical Trial Data Circulation 2010;122;2201-2211
This article provides a comprehensive review of all the recent studies that discusses intensive lowering of A1C and reduction of CV events. Significant reductions in CV disease are noted with intensive glucose lowering in three meta-analysis and other studies. Appropriate qualifiers for these conclusions include the specific pharmaco-therapeutic interventions used, the patient population studied (especially with respect to age, duration of diabetes, and cardiovascular risk factors, including preexisting CVD), the baseline glycemic control, the glycemic goals, duration of the therapeutic intervention, and the period of observation.
5. Cardio-Metabolic Risk in Diabetes Slide set used by Ed Shahady at the December 10th workshop
R. Online Resources for Diabetes Care and Patient Education
1. http://www.diabetes.org
This is the web site for the American Diabetes Association. It has great resources for the professional and the patient. Consider joining the ADA and suggest your patients join.
2. http://diabetes.niddk.nih.gov
This is the web site for the national diabetes education project.
S. Medicare Coverage of Blood Glucose Monitors and Testing Supplies
This article reinforces information supplied in special edition MLN Matters® article SE0738, which is available at http://www.cms.gov/MLNMattersArticles/downloads/SE0738.pdf
This article is informational only and represents no Medicare policy changes.
Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. These supplies include:
• Blood glucose monitors
• Blood glucose test strips
• Lancet devices and lancets
• Glucose control solutions for checking the accuracy of testing equipment and test strips.
Medicare Part B covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies. Medicare provides coverage of blood glucose monitors and associated accessories and supplies for insulin-dependent and non-insulin dependent diabetics based on medical necessity.
T. Patient Centered Medical Home
1. The Patient Centered Medical Home, The Family Medicine Model
U. Diabetes University
1. Diabetes University, Learning How to Stop Diabetesl