Primary care providers, such as family physicians, internists, physicians’ assistants, and nurse practitioners, play an important role in providing routine high-quality diabetes care as well as referrals to other practitioners for specialty care. As new research and drugs become available and practice guidelines for diabetes evolve, it is critical for health care providers to stay abreast of standards of care and new evidence-based treatments and devices to support diabetes management. Important information for providers about diabetes care can be found at http://www.ndep.nih.gov/resources/health.htm, http://www.betterdiabetescare.org, http://care.diabetesjournals.org/content/vol28/suppl_1/. Possible action steps for the primary care provider include:
- Help patients control blood glucose levels. The DCCT and the UKPDS demonstrated that intensive therapy in blood glucose management is effective in delaying the onset of complications and slowing the progression of diabetes.76
- Educate patients on the “ABCs of Diabetes”77 (HbA1c, blood pressure, and cholesterol) to lower overall risks for heart disease. Goal ranges are HbA1c of less than 7 percent, blood pressure of less than 130/80, and cholesterol (LDL) of less than 100 mg/dl.78
- Develop flowcharts that ensure patients with diabetes receive preventive and diagnostic services. Table 5 contains examples of care practices to include in flow charts for patients with diabetes.79
- Advise women with diabetes considering pregnancy about the risks that diabetes poses for pregnancy and the importance of good blood glucose control before and during pregnancy.
- Incorporate information management systems, such as patient registries, to track patient health status and receipt of preventive care services and provide information about the patient’s status to the entire care team.
- Use office prompts (e.g., posters asking patients to remove their shoes and socks prior to the exam) to facilitate care.
- Work with patients and their families to develop comprehensive care plans that include lifestyle changes and medical services needed to control blood glucose, blood pressure, and LDL cholesterol and prevent and manage complications from diabetes. Care plans should include the following: a meal plan, an exercise program to help patients maintain a healthy weight and good cardiovascular health, diabetes education to guide self-management, and a schedule to ensure that patients receive preventive and diagnostic care services, such as HbA1C tests, dilated eye exams, and foot exams in a timely manner.
- Prescribe medications (angiotensin converting enzyme inhibitors or angiotensin receptor blockers) that can slow progression of diabetic kidney disease in patients found to have hypertension and/or elevated urinary microalbumin.
- Ask if patients with diabetes smoke, and help those who smoke to stop smoking.
- Help educate patients’ family members and friends about ways they can help loved ones with diabetes to manage the condition.
- Refer patients with diabetes to various health care specialists and educators as appropriate.
- Refer people with diabetes to community resources that can help them manage their diabetes.
- Facilitate community support groups for people with diabetes and their friends and family to help educate them about the health problems that can be caused by diabetes and the ways they can manage the disease and live healthy and productive lives.
- Talk with community leaders about diabetes and the importance of supporting people with diabetes.
- Translate patient materials into other languages for people in the community when feasible.
- Participate in clinical trials to evaluate new technologies for treating diabetes.
- Become involved in research studies to determine effective approaches for educating and treating patients with diabetes in various populations, such as children, elderly persons, and members of specific racial/ethnic groups.
Table 5. Examples of Items to Include in Flow Chart for Patients with Diabetes
- Weight check
- Blood pressure check
- Foot exam
- Diabetes education and self-management
Twice per year
- HbA1c test (quarterly if not within recommended range)
- Dental exam
- Lipid profile
- Dilated eye exam
- Physical exam for detecting nerve damage
- Serum creatinine and urinalysis for protein, microalbumin to creatinine ratio to detect kidney disease
- Influenza (annual)
- Pneumoccal (usually only once, repeat if over age 64 or immunocompromised and the last vaccice was longer than 5 years ago)
SOURCE: National Diabetes Education Program (NDEP). Guiding principles for diabetes care: for health care providers. HHS Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf. Accessed August 24, 2004.
76 The Diabetes Control and Complications Trial Research Group, op.cit; and Turner, RC, op.cit.
77 The ABCs of Diabetes, op.cit.
78 National Diabetes Education Program (NDEP). Guiding principles for diabetes care: For health care providers. HHS Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf.