If you’re like many physicians, checking off all the boxes on your comprehensive diabetes care checklist can be a struggle.
Diabetes is quickly becoming endemic in the United States. Over 9% of the US population (30.3 million) has a diagnosis of diabetes and twice as many people (84.1 million) have prediabetes, according to a study released in 2015. (i,ii)
This creates challenges for the health systems that need to manage the growing diabetes population, especially for institutions that track and document quality metrics for comprehensive diabetes care. Patients and physicians need to be well educated in the management and treatment of diabetes in order to increase adherence for quality metrics and improve patient outcomes.
The more we can demystify what all is involved in deabetic management and why we do it, the better people will do in general.”
Dr. Jasmin Morrison, Primary Care Physician, Cedar Rapids, Iowa
What is comprehensive diabetes care?
For physicians, comprehensive diabetes care consists of key quality metrics that must be completed and documented to monitor a patient’s diabetes journey. (iii) These areas are:
- Hemoglobin A1c (HbA1c) testing
- Blood pressure control
- Retinal eye exam
- Medical attention for neuropathy (iv)
Each aspect of this documentation process speaks to a different potential complication and the steps necessary to manage diabetes as a whole.
HbA1c testing is a blood test that evaluates the average glucose level in a patient over the previous 2-3 months. The test assesses the level of glucose (sugar) that is attached to hemoglobin (protein) within the bloodstream.
According to Dr. Morrison, “A1c as an average suggests quality of control and is concerning when it is high. I aim for patients to maintain their A1c between 6.5-7, but at least under 8.” HbA1c levels that are too high may indicate poorly managed blood sugar levels, potentially leading to increased diabetes complications.
HbA1c testing is now available at point of care (POC) in many situations, eliminating the need for additional patient appointments and allowing easier documentation for physicians. However, some patients may still prefer lab testing when they have other lab work that needs to be done.
2. Blood pressure and cholesterol
Blood pressure and cholesterol control are priorities for all patients, but even more so for people living with diabetes. Increased blood pressure can lead to serious complications if blood glucose is not well maintained. Complications can range from kidney problems, to peripheral artery disease, to heart attack and stroke.
During diabetes wellness visits, Dr. Morrison looks for patients to have blood pressure levels that are “ideally below 135/85, depending on other cardiovascular risk factors.” Well managed blood pressure combined with well controlled blood sugar levels can help reduce potentially life-threatening complications for people with diabetes.
Elevated cholesterol levels are another risk factor for potential heart complications in addition to increased blood pressure. However, conducting an annual or bi-annual lipid panel and, when appropriate, adding statins into a patient’s diabetes care regimen can help reduce the risk of cardiovascular issues, according to Dr. Morrison.
3. Retinal eye exams
Retinal eye exams are another essential piece to diabetes care. Diabetic retinopathy and diabetic macular edema are common complications of diabetes, and leading causes of blindness in working age adults in the US. Retinal exams are typically completed by an eye care specialist. This requires physicians to refer patients for a separate appointment. Many patients never go, and physicians often do not receive required documentation for completed exams.
Physicians now have access to POC testing for diabetic retinopathy. New technologies like IDx-DR, an FDA-cleared autonomous AI system, are moving the retinal exam to primary care settings. This enables physicians to complete their patient’s comprehensive diabetes exam in one visit, allowing for increased compliance and much easier documentation.
4. Diabetic neuropathy
Diabetic neuropathy can affect many different areas of the body, from the hands and feet to the intestinal tract and even the retina. Neuropathy causes pain or numbness due to damage done to the nerves in different areas of the body.
The most common form of neuropathy is peripheral neuropathy, which causes pain or numbness in the extremities such as the legs and arms, feet and hands, and toes and fingers.
According to Dr. Morrison, “Physicians can check for cuts or sores on the patient’s extremities as well as performing a comprehensive foot exam that checks pulses and sensations using a monofilament test to detect potential signs of neuropathy.”
The above-mentioned quality metrics are vital for managing diabetes and are the traditional means by which a diabetes patient’s care is evaluated, but they are not the only considerations.
- Kidney Health is a diabetes care metric that should also be carefully monitored as diabetes is the leading cause of chronic kidney disease.v Consistently elevated blood pressure and blood glucose levels can lead to kidney damage that might not present symptoms until the kidneys are no longer able to perform.
"Kidney evaluation is a multifactorial process that takes into account inflammation, fibrosis and activation of oxidative species that contribute to the damage as related to high circulating blood sugar and dysregulation of insulin," Dr. Morrison paraphrased from Pathophysiology of Diabetic Kidney (vi). Evaluating kidneys through microalbumin, creatinine and eGFR can help prevent kidney disease, and in extreme cases, may even help to prevent kidney failure.
- Patient lifestyle considerations are another essential aspect of comprehensive diabetes care. Physicians should discuss topics such as weight management, cessation of tobacco and/or alcohol use, stress management, treatment for possible depression, consistent exercise routines, medication regimens, and continued monitoring of previous diagnoses or complications with their patients.
Each of these elements of comprehensive diabetes care are critical to having a thorough understanding of a diabetes patient’s health. For physicians educating patients on the reasons behind each aspect of diabetes care can help them be more successful at managing their diagnosis.
In addition to patient education, physicians can increase the number of well-managed diabetes cases by making it easier for patients to monitor these key metrics of diabetes health.
“POC management, whether it is through the retinal eye exam or hbA1c testing, is important to making all of this more accessible to patients,” said Dr. Morrison.
[v] Diabetic Kidney Disease [Internet]. National Institute of Diabetes and Digestive and Kidney Diseases. U.S. Department of Health and Human Services; 2017 [cited 2019, Nov 15]. Available from:https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-kidney-disease
[vi] Vallon V, Komers R. Pathophysiology of the diabetic kidney [Internet]. Comprehensive Physiology. U.S. National Library of Medicine; 2011 [cited 2019, Nov 22]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23733640