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

Version 4.0
Algorithm Format
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
The goal in developing the guideline for diabetes mellitus was not to repeat the guideline development process, but
rather, to incorporate the information from several existing, national consensus, evidence-based guidelines into a
format which would maximally facilitate clinical decision-making. The use of the algorithm format was chosen
because of the evidence that such a format improves data collection, diagnostic and therapeutic decision-making and
changes patterns of resource use. However, few guidelines are published in such a format. To enhance continuity
of care, the Diabetes Guidelines (version 1.0 and 2.0 and 3.0) were designed to encompass a broad spectrum of
outpatient care of persons with diabetes. This required incorporating multiple published guidelines into a single,
unified document.
The algorithmic format allows the provider to follow a linear approach to critical information needed at the major
decision points in the clinical process, and includes:
• An ordered sequence of steps of care
• Recommended observations
• Decisions to be considered
• Actions to be taken.
A clinical algorithm diagrams a guideline into a step-by-step decision tree. Standardized symbols are used to
display each step in the algorithm (Society for Medical Decision-Making Committee, 1992). Arrows connect the
numbered boxes indicating the order in which the steps should be followed.
Rounded rectangles represent a clinical state or condition.
Hexagons represent a decision point in the guideline, formulated as a question that
can be answered Yes or No. A horizontal arrow points to the next step if the
answer is YES. A vertical arrow continues to the next step for a negative answer.
Rectangles represent an action in the process of care.
Ovals represent a link to another section within the guideline.
A letter within a box of an algorithm refers the reader to the corresponding annotation. The annotations elaborate on
the recommendations and statements that are found within each box of the algorithm. Included in the annotations
are brief discussions that provide the underlying rationale and specific evidence tables. Annotations indicate
whether each recommendation is based on scientific data or expert opinion. A complete bibliography is included in
the guideline.
REFERENCES
Agency for Health Care Policy and Research (AHCPR). Manual for Conducting Systematic Review. Draft. August
1996. Prepared by Steven H. Woolf.
Cochrane Reviews, Cochrane Controlled Trials Register at http://www.update-software.com/cochrane.
Harris RP, Helfand M, Woolf SH. Current methods of the U.S. Preventive Services Task Force. A review of the
process. Am J Prev Med 2001.
Society for Medical Decision-Making Committee (SMDMC). Proposal for clinical algorithm standards, SMDMC on
Standardization of Clinical Algorithms. In: Medical Decision Making 1992; 12(2):149-54.
United States Preventive Service Task Force (USPSTF). Guide to Clinical Preventive Services. 2 nd edition.
Baltimore: Williams and Wilkins, 1996.
Woolf SH. Practice guidelines, a new reality in medicine II. Methods of developing guidelines. Archives of Intern
Med 1992; 152:947-948.
Appendices Page 125