DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
differences overall in hypoglycemic episodes, hyperglycemic incidents, or hospital admissions. Quality of life was
not shown to be affected by input from a diabetes specialist nurse/nurse case manager.
Norris et al. (2002b) performed a systematic review of the effectiveness and economic efficiency of disease
management and case management for people with diabetes in managed care organizations and community clinics
in the United States and Europe. The evidence supported the effectiveness of disease management on glycemic
control, screening for diabetic retinopathy, foot lesions and peripheral neuropathy, and proteinuria, and on lipid
monitoring. The use of case management in managed care setting for adults with type 2 diabetes in the United
States improved both glycemic control and provider monitoring of glycemic control. Moreover, case management
was shown to be effective when delivered in conjunction with disease management, and with one or more additional
educational, reminder, or support interventions.
EVIDENCE
Recommendation Sources LE QE SR
1 Provision of specialized referrals
when necessary.
3 Use of case manager to improve
outcomes
Aubert et al., 1998
Franz et al., 1995
Sikka et al., 1999
Loveman et al., 2003 §
Machado et al., 2007 §
Norris et al., 2002b §
II-1
II-2
II-2
Fair
Fair
Fair
B
A
I Good A
LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation §=Systematic Review (see Appendix A)
G. Reassess and Follow-Up as Indicated
OBJECTIVE
Identify the frequency of patient appointments needed to evaluate educational effectiveness or reinforce
education/self-management skills.
RECOMMENDATIONS
1. When knowledge deficits continue to exist or a large number of lifestyle changes are necessary, frequent
follow-up may be indicated.
2. Recently learned diabetes skills or information should be re-evaluated no longer than 3 months after initial
instruction. One possible method involves follow-up at earlier time points, e.g., 1 month.
3. When appropriate, single behavioral goals should be identified and prioritized to increase the likelihood of
the patient adopting lifestyle changes necessary to achieve treatment goals.
DISCUSSION
The importance of individualization and tailoring sessions to participants’ needs has been amply documented
(Colagiuri et al., 2009; Duke et al., 2009), but there is no definitive evidence to support specific frequencies of
follow-up. Frequency of appointments has been reported from weekly to annually. Frequency of re-assessment
should be based on the patient’s and provider’s perceptions of need. Panel experts recommend that recently learned
diabetes skills or information should be reassessed within 3 months of the initial instruction. When appropriate,
single behavioral goals should be identified and prioritized to increase the likelihood of the patient adopting lifestyle
changes that are necessary to achieve the treatment goals.
H. Does The Patient Want More Information?
OBJECTIVE
Address the patient’s desire (motivation) for additional information.
Module M: Self-management Page 113