VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

# IN THE PRIMARY CARE SETTING

## Veterans Health Administration

Department of Defense

*Prepared by:*

# THE MANAGEMENT OF **DIABETES MELLITUS**

# Working Group

## *With support from:*

### The Office of Performance and Quality, VHA, Washington, DC

&

Quality Management Directorate, United States Army MEDCOM

&

## The External Peer Review Program

Contractor and Subcontractor:

West Virginia Medical Institute, Inc.

Birch & Davis Associates, Inc.

Contract number: V101(93)P-1633

December, 1999

Version 2.2

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

# IN THE PRIMARY CARE SETTING

# TABLE OF CONTENTS

#### MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING

#### 

#### Table of Contents

*Page*

### INTRODUCTION..........................................................................................................i

PARTICIPANTS

Module Leaders

Working Group

Other Participants

### ALGORITHMS AND ANNOTATIONS 

Module D --
Core.............................................................................................\...1

> Module G -- Glycemic
> Control...............................................................................12

Module H --
Hypertension....................................................................................46

Module E -- Eye
Care.......................................................................................\...59

Module F -- Foot
Care.........................................................................................70

Module L -- Lipid
Control....................................................................................83

Module R -- Renal Disease
...................................................................................97

Module M -- Self-management and
Education...........................................................114

GLOSSARY.............................................................................................................139

BIBLIOGRAPHY......................................................................................................141

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

# IN THE PRIMARY CARE SETTING

# INTRODUCTION

#### MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING

Introduction

**DIABETES IN THE VETERANS HEALTH ADMINISTRATION AND DEPARTMENT OF
DEFENSE**

15.7 million Americans\--5.9 percent of the population, have diabetes
mellitus (1, 2). Total diabetes related costs in 1997 totaled nearly 100
billion dollars (3), or about 14 percent of health care expenditures in
the United States in 1992 (4). The burden of diabetes in the VHA,
documented in a recent series of VHA reports (5, 6, 7) is among the
highest of any national health care system. Despite the high prevalence
and even higher direct and indirect economic costs of diabetes, there is
now incontrovertible scientific evidence that effective
antihyperglycemic, antihypertensive, and hypolipidemic treatment produce
substantial outcomes benefit. To assure that cost-effective treatment of
known efficacy is consistently delivered to all affected health care
beneficiaries, a multidisciplinary panel of experts drawn from the VHA,
DoD, and other Federal agencies has developed this outcomes-oriented,
evidence-based, comprehensive clinical practice guideline, intended for
implementation at to all VHA and DoD health care facilities.

The prevalence of diabetes among all veterans receiving outpatient care
is estimated to be 15 to 20 percent. It is estimated that as many as
500,000 veterans receiving VHA care in FY98 have diabetes, based upon a
combination of at least one outpatient prescription for oral
antihyperglycemic medications and/or insulin; at least two outpatient
250.xx ICD-9CM codes, or an inpatient discharge (PTF file) (8). The
following data relates to FY98:

-   The average demographic profile is that of a 67 year old male who is
    a Category A beneficiary.

-   Over twelve percent of veterans receiving outpatient care were
    prescribed diabetes specific medications (e.g., insulin, oral agents
    or monitoring supplies). The pharmacologic resources used to treat
    these veterans included:

1.  Twenty seven percent of all pharmacy acquisition costs can be
    attributed to veterans with diabetes

2.  Overall annual mean pharmacy cost was \$873 per veteran with
    diabetes; glycemic control expense alone was \$220(8).

3.  Nearly seven cents out of every outpatient pharmacy dollar is spent
    for glycemic control medications and related supplies

4.  The per person average expenditure for blood glucose monitoring
    supplies was \$95, about double the FY94 expenditure of \$48.

-   Diabetes accounted for roughly 40 percent of patients with end-stage
    renal disease receiving dialysis and for over 70 percent of
    amputations performed at VA hospitals (Gerald Hawley, RN, MSN,
    Diabetes Project Manager, National Center for Cost Containment).

-   A 1994 Optometry Service study indicated that 0.9 percent of
    veterans with diabetes sequentially examined in an Optometry Service
    multisite field study had severe visual loss.

Diabetes is a serious public health problem in the Veterans Health
Administration and Department of Defense health care systems, as well as
in the nation at large; hence, timely diagnosis and effective treatment
is an important responsibility of health care providers caring for
beneficiaries. It is incumbent on each health care provider to be aware
of comprehensive preventive care needs for the entire person at time of
each encounter. For example, a podiatrist should be alert as to whether
an eye exam has been performed within the past year; and an optometrist
or ophthalmologist should be concerned whether there is evidence of
clinical nephropathy in a person with retinopathy. Each should be aware
of the symptoms of uncontrolled hyperglycemia and be able to make
appropriate referrals back to the primary care provider or subspecialist
team. Expanded roles for nurse practitioners, nurses, physician
assistants, dietitians and pharmacists should be considered.

This clinical practice guideline on the ambulatory assessment and
treatment of diabetes mellitus is intended to promote evidence-based
management of individuals with diabetes*.* Although veterans with
diabetes have a disproportionate number of hospitalizations relative to
veterans without diabetes, diagnosis, education, preventive screening,
risk factor reduction, and pharmaceutical treatment of diabetes
(including microvascular and macrovascular complications), occurs mostly
in the outpatient primary care setting. This guideline encompasses the
critical decision points in patient management such as glycemic control,
evaluation of the eyes and feet, and early recognition and treatment of
co-morbid conditions including hypertension, hyperlipidemia, and renal
disease. At the same time, it is designed to be flexible so that local
options and policies for implementation such as those regarding
referrals to or consultation with diabetes teams, ophthalmology,
optometry, podiatry, nephrology, and endocrinology (lipids) can be
accommodated. It should be recognized that this series of algorithms, as
is true for most, cannot be used as a linear guideline for the
recognition and management of diabetes mellitus and is not intended to
supersede the clinical judgment of the provider caring for an
individual. Medication usage guidelines have been adapted from the
Pharmacy Benefits Management Strategic Health Group Medical Advisory
Panel Guidelines for Non-Insulin Dependent Diabetes Mellitus (NIDDM),
Hypertension and Cholesterol.

**OVERVIEW OF THE DIABETES GUIDELINES**

The Diabetes Mellitus guideline is organized into eight major modules
with a linkage to the diabetes algorithm providing an overview of the
relationship between the modules:

> **Module D---Core**
>
> **Module G---Glycemic Control**
>
> **Module H---Hypertension Management**
>
> **Module E---Eye Care**
>
> **Module F---Foot Care**
>
> **Module L---Lipid Control**
>
> **Module R---Renal Disease Treatment**
>
> **Module M---Self-management and Education.**

Each module uses a risk stratification approach to identify persons with
diabetes who have a greater probability of developing complications and
who therefore would benefit from more intensive intervention. Despite
the costs and morbidity associated with diabetes these is a general
consensus that preventive care can delay, if not prevent, a significant
percentage of the instances of visual loss, chronic renal failure, foot
ulcers and lower extremity amputations, as well as admissions for
metabolic control. Providers should recognize that the major cause of
morbidity and mortality in persons with diabetes is cardiovascular
disease---myocardial infarction, stroke and peripheral vascular disease.
It accounts for over 70 percent of hospitalizations and deaths.
Therefore, an aggressive approach to evaluating and reducing
cardiovascular risk factors---including smoking cessation, management of
hyperlipidemia, treatment of hypertension, and promotion of a healthy
lifestyle---should reflect the general goal for all providers.

While each module is designed for use by primary care providers (PCP) in
an ambulatory care setting, the modules can also be used to coordinate
and standardize care within subspecialty teams and as teaching tools for
students and house staff.

The majority of the literature supporting the science for these
guidelines are referenced throughout the document and are based upon key
clinical randomized controlled trials and longitudinal studies published
from 1992 through March, 1999. The references listed have undergone a
thorough review and rating based on the scientific rigor of the article,
clinical relevance of the material presented and the ability to
generalize using this data. Where existing literature is ambiguous or
conflicting, or where scientific data are lacking on an issue,
recommendations have been based on the clinical experience of the Expert
Panel's opinion. Annotations indicate whether each recommendation is
based on scientific data or expert opinion. A letter, e.g., A or B
within a box of the algorithm refers the reader to an annotation for
that box. The annotation typically follows the specific page of the
algorithm in the sections labeled Algorithms and Annotations in each
module. Strength of recommendation and level of evidence grading is
based on AHCPR guideline development efforts and a ACC/AHA publication
(9, 10). For a description of each, refer to the following tables:

####### Table 1. Evidence Grading System

**1a. Strength of Recommendation**

  --------- -------------------------------------------------------------
  **Level   Usually indicated, always acceptable and considered useful
  I**       and effective.

  **Level   Acceptable, of uncertain efficacy and may be controversial.
  IIa**     Weight of evidence in favor of usefulness/efficacy.

  **Level   Acceptable, of uncertain efficacy and may be controversial.
  IIb**     May be helpful, not likely to be harmful.

  **Level   Not acceptable, of uncertain efficacy and may be harmful.
  III**     Does not appear in guidelines.
  --------- -------------------------------------------------------------

**1b. Level of Evidence**

+-----------------+------------------+-------------------+------------+
|                 | **A**            | #### B            | **C**      |
+-----------------+------------------+-------------------+------------+
| Primary         | Randomized       | Well designed     | Panel      |
| Evidence        |                  | clinical studies  | consensus  |
+-----------------+------------------+-------------------+------------+
| Secondary       | Other Clinical   | Clinical studies  | Clinical   |
| Evidence        | studies          | related to topic  | studies    |
|                 |                  | but not in a      | Unrelated  |
|                 |                  | population with   | to topic   |
|                 |                  | diabetes          |            |
+-----------------+------------------+-------------------+------------+

The guideline/algorithms are designed to be adapted to the individual
facility's needs and resources. They will also be periodically updated
or when relevant research results become available. It should be used as
an impetus for administrators at each Veterans Integrated Services
Network (VISN), facility, and care access site to develop innovative
plans to break down the barriers preventing primary care providers,
subspecialists and allied health professionals from working together,
and from preventing patients from having prompt access to preventive
care. The ultimate goal is to improve local management of patients with
diabetes and thereby improve patient outcomes.

## **GUIDELINE DEVELOPMENT PROCESS**

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 (11). The use of the algorithm format has been 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) 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 initial guidelines development process was undertaken from August
1996 through March 1997. The list of more than 70
developers/contributors included Veterans Health Administration
professionals, senior representatives from key federal health related
agencies including the Diabetes Division of the National Institutes for
Diabetes (DDNID), Digestive and Kidney Diseases (DKD); Division of
Diabetes Translation, Centers for Disease Control and Prevention (CDCP);
Office of Managed Care, Health Care Financing Administration (HCFA); and
the Pharmacoeconomic Center (PEC) of the Department of Defense, as well
as private sector experts provided by the VHA External Peer Review
Program contractor. Many participants held senior leadership positions
in the American Diabetes Association (ADA), the National Institutes of
Health (NIH)/Center for Disease Control and Prevention, and the National
Diabetes Education Program (NDEP).

The guideline and algorithm drew heavily from existing American Diabetes
Association, National Cholesterol Education Program, and National Kidney
Foundation practice guidelines for diabetes mellitus. This Guideline
integrates the recommendations developed by VHA's Medical Advisory Panel
(MAP) to the Pharmacy Benefits Management Strategic Health Group
examining the pharmacological management of persons with diabetes,
hypertension and hyperlipidemia. Consumer input was also included in
revision of this guideline. The perspective of beneficiaries and their
family members sensitized panelists to patient needs.

The VHA Diabetes Guidelines represented the first comprehensive
guidelines for this disease by a federal agency or national health care
system in which risk stratification is both explicit and evidence based.
Version 1.0 of the VHA Guidelines was reviewed at a joint meeting of the
National Diabetes Education Program (NDEP) Steering Committee and the
Diabetes Mellitus Federal Interagency Coordinating Committee (DMICC) on
October 21, 1997. The DMICC report acknowledged the flexibility of the
VHA guidelines in that they explicitly indicate the need for individual
provider assessments and patient preferences, and authorized the use of
the NDEP logo to reflect the collaboration with the NDEP executive
steering committee members.

The original 1997 VHA guidelines represented a \"seed document\" that
was updated and adapted by the joint VHA/DoD Diabetes Guideline
Development Group over a six-month period from January-June, 1999. As
with the original workgroup, the charge of the VHA/DoD group was to
provide evidence-based action recommendations whenever possible; hence,
major clinical randomized controlled trials and observational studies
published from March 1997 through March 1999 in the areas of diabetes,
hypertension, lipid management, renal disease, foot and eye care, and
diabetes education. These were identified by Medline literature search
and reviewed by the expert panel. Each reference cited was critically
appraised for scientific merit, clinical relevance, and applicability to
the populations served by the Federal health care system.
Recommendations were based on the expert panels' opinion and clinical
experience only when scientific evidence was unavailable from the
current literature. Annotations to the guidelines indicate whether the
recommendation is based on published scientific information or expert
opinion (vide supra).

This version was compared with the most recent guidelines published by
other professional organizations, notably those of the American Diabetes
Association, National Kidney Foundation (NKF), Joint National Council VI
on Hypertension (JNC-VI), and National Cholesterol Education Program
(NCEP). A summary comparing recommendations from VHA/DoD Diabetes
Clinical Guidelines with other currently published guidelines is
included in Table 2.

**Table 2: COMPARISON OF VHA/DoD DIABETES CLINICAL GUIDELINES TO
EXISTING NATIONAL GUIDELINES RELEVANT TO DIABETES**

+----------+----------------------------+------------------------------+
| ## **S   | **EXISTING**               | **VHA/DoD GUIDELINE**        |
| UBJECT** |                            |                              |
|          | **GUIDELINE**              |                              |
+==========+============================+==============================+
| > **     | **American Diabetes        | HbA~1c~ target goals should  |
| Glycemic | Association (ADA) (1999)** | be individualized and        |
| > C      | (12):                      | primarily based upon both    |
| ontrol** |                            | life expectancy and presence |
|          | Recommended HbA~1c~ target | or absence of microvascular  |
|          | ranges, with upper limit   | complications.               |
|          | of normal 6%:              |                              |
|          |                            | **Target**: ≤ 7% (≤ 1% above |
|          | **Optimal:** \< 7% (\<1%   | high normal range) IF        |
|          | above high normal range)   |                              |
|          |                            | expectancy \> 15 years AND   |
|          | **Action Suggested:** \>8% | microvascular complications  |
|          | (\>2% above high normal    | absent                       |
|          | range).                    |                              |
|          |                            | OR                           |
|          | (exception: diminished     |                              |
|          | life expectancy)           | Life expectancy \>10 years   |
|          |                            | WITH early to moderate       |
|          |                            | microvascular disease.       |
|          |                            |                              |
|          |                            | **Target:** ≤ 8.0% (≤2%      |
|          |                            | above high normal range) IF  |
|          |                            | life expectancy 5-15 years   |
|          |                            | AND no microvascular disease |
|          |                            |                              |
|          |                            | OR                           |
|          |                            |                              |
|          |                            | Life Expectancy 5-10 years   |
|          |                            | WITH moderate microvascular  |
|          |                            | disease.                     |
|          |                            |                              |
|          |                            | **Target:** ≤ 9.0% (≤ 3%     |
|          |                            | above high normal range) IF  |
|          |                            | life expectancy \< 5 years   |
|          |                            | (with or without             |
|          |                            | microvascular disease).      |
+----------+----------------------------+------------------------------+
| **Self   | **ADA Consensus Statement  | Frequency of SMBG should be  |
| Mo       | (1994)**                   | individualized according to  |
| nitoring |                            | clinical circumstances and   |
| of Blood | Frequency of SMBG should   | response to treatment. Urine |
| G        | be individualized          | testing may be considered as |
| lucose** | according to clinical      | an alternative if the goal   |
|          | circumstances and response | is avoidance of symptomatic  |
|          | to treatment. Urine        | hyperglycemia. Explicitly    |
|          | testing may be considered  | recommends validation and    |
|          | as an alternative if the   | documentation of user        |
|          | only goal is avoidance of  | technique with prior to      |
|          | symptomatic hyperglycemia. | initial justification, and   |
|          |                            | recommends assessment of     |
|          |                            | whether individualized       |
|          |                            | health outcome goals are met |
|          |                            | as part of ongoing interval  |
|          |                            | justification.               |
+----------+----------------------------+------------------------------+
| **Chole  | **National Cholesterol     | No upper age limit but does  |
| sterol** | Education Program          | not recommend screening if   |
|          | (1993)**: Primary CVD      | life expectancy \<5 years.   |
|          | prevention goal is         | Target LDL-C \<130 mg/dl for |
|          | LDL-C\<130 mg/dl for all   | all persons with diabetes.   |
|          | persons with diabetes and  | Consider Target LDL-C\<100   |
|          | other CVD risk factors;    | mg/dl for persons with prior |
|          | secondary CVD prevention   | coronary artery bypass       |
|          | goal is LDL-C \< 100       | surgery.                     |
|          | mg/dl. Goal of LDL-C \<    |                              |
|          | 100 mg/dl can be           |                              |
|          | considered for patients    |                              |
|          | with type 2 diabetes who   |                              |
|          | have dyslipidemia (low     |                              |
|          | HDL-C and                  |                              |
|          | hypertriglyceridemia)      |                              |
|          | (13).                      |                              |
|          |                            |                              |
|          | **American Diabetes        |                              |
|          | Association (1999):**      |                              |
|          | Optimal LDL-C \<100 mg/dl  |                              |
|          | for all patients with      |                              |
|          | diabetes; Action           |                              |
|          | Recommended for LDL-C \>   |                              |
|          | 130 mg/dl if CVD absent    |                              |
|          | and for LDL-C \> 100 mg/dl |                              |
|          | if CVD present (14).       |                              |
|          |                            |                              |
|          | **American College of      |                              |
|          | Physicians (1996):**       |                              |
|          |                            |                              |
|          | Screening for primary      |                              |
|          | prevention is neither      |                              |
|          | recommended nor            |                              |
|          | discouraged between ages   |                              |
|          | 65-75, and not recommended |                              |
|          | for individuals \>75 (15). |                              |
+----------+----------------------------+------------------------------+
| **Prote  | **National Kidney          | No upper age limit but no    |
| inuria** | Foundation (1995): No**    | screening for                |
|          | screening after age 70;    | microalbuminuria if life     |
|          | annual random urine        | expectancy \<5 years: timed  |
|          | specimen tested for        | urine specimen preferred (24 |
|          | albumin to creatinine      | hour or overnight) but       |
|          | ratio; scope of            | random urine for albumin to  |
|          | recommendations limited to | creatinine ratio is          |
|          | screening for              | acceptable. Scope of         |
|          | microalbuminuria;          | recommendations deals with   |
|          | nephrology referral if     | elevated creatinine,         |
|          | albumin/creatinine ratio   | proteinuria and              |
|          | \>300 mg/g or adverse      | microalbuminuria. Nephrology |
|          | effect of ACE inhibitor    | referral for creatinine      |
|          | (16).                      | \>2.5 mg or 24 hour urine    |
|          |                            | specimen for proteinuria     |
|          | **American Diabetes        | \>150 mg/L in the absence of |
|          | Association (1999):** No   | any retinopathy (to evaluate |
|          | upper age limit for        | for non-diabetic renal       |
|          | screening; timed urine     | disease).                    |
|          | collection; urine specimen |                              |
|          | for albumin to creatinine  |                              |
|          | ratio; or 24-hour          |                              |
|          | specimen. Scope of         |                              |
|          | recommendation includes    |                              |
|          | proteinuria as well as     |                              |
|          | microalbuminuria. Consider |                              |
|          | nephrology referral when   |                              |
|          | GFR begins to decline      |                              |
|          | substantially or           |                              |
|          | creatinine \>2.0 (17).     |                              |
+----------+----------------------------+------------------------------+
| ## *     | **American Diabetes        | Initial eye exam after 3 to  |
| *Eye Scr | Association,**             | 5 years duration for type I  |
| eening** |                            | diabetes (onset \<30 years). |
|          | (in cooperation with       | Annual eye screening if      |
|          | American College of        | baseline or subsequent exam  |
|          | Physicians, American       | normal EXCEPT for persons    |
|          | Optometric Association and | with type II diabetes with   |
|          | American Academy of        | HbA~l~c \<8.0% treated with  |
|          | Ophthalmology) (1999)**:** | oral agents who would be     |
|          | Annual eye screening for   | seen within 2 years if       |
|          | persons with type I (Onset | baseline or prior            |
|          | \<30 years) diabetes       | examination was normal.      |
|          | mellitus of duration \>5   | Individuals at "high risk"   |
|          | years; annually for        | for visual loss are          |
|          | individuals with type II   | explicitly referred to eye   |
|          | diabetes. Acknowledges     | specialists.                 |
|          | necessity for more         |                              |
|          | frequent follow-up for     |                              |
|          | retinal pathology(18).     |                              |
+----------+----------------------------+------------------------------+
| **Foot   | **American Diabetes        | Same                         |
| Scr      | Association:**             |                              |
| eening** |                            |                              |
|          | Annual foot risk           |                              |
|          | assessment for all         |                              |
|          | patients with diabetes;    |                              |
|          | more frequent foot         |                              |
|          | examinations for patients  |                              |
|          | at high risk for lower     |                              |
|          | extremity amputations      |                              |
|          | (19).                      |                              |
+----------+----------------------------+------------------------------+
| **Hypert | **JNC-VI (1997)** (20):    | Hypertension defined as BP   |
| ension** |                            | \>140/90. Treatment target:  |
|          | **Systolic Diastolic**     | \< 140/85 mm Hg as usual     |
|          |                            | goal; guideline empowers     |
|          | ## **Normal \<130 \<85**   | targeting to \<130/85 for    |
|          |                            | appropriate individual       |
|          | ## **H                     | factors                      |
|          | igh Norma1 130-139 85-89** |                              |
|          |                            |                              |
|          | ## *                       |                              |
|          | *Hypertension \>140 \>90** |                              |
|          |                            |                              |
|          | **American Diabetes        |                              |
|          | Association (1999)** (21): |                              |
|          | Defines hypertension as    |                              |
|          | 140/90; however, the       |                              |
|          | primary goal of therapy    |                              |
|          | should be to decrease BP   |                              |
|          | to \<130/85.               |                              |
+----------+----------------------------+------------------------------+

The text of the VHA/DoD guidelines differ from the current ADA, NCEP,
and JNC-VI guidelines in two significant respects: (1) VHA/DoD
guidelines emphasize absolute rather than relative risk reduction
derived from randomized controlled trials of treatment of hyperglycemia,
hyperlipidemia, and hypertension in setting population-based target
goals; and (2) VHA/DoD explicitly advocates that risk stratification be
based upon absolute rather than relative risk reduction in negotiating
individual target goals. When available evidence has not established
efficacy of a therapeutic intervention, effectiveness cannot be
determined on a probabilistic basis. Consequently, the VHA/DoD
guidelines encourage clinicians to appraise individual risks and
benefits of therapeutic targets, rather than advocating a single
"optimal" or "ideal" target value that purports to be appropriate for
all patients with diabetes.

PERFORMANCE MEASUREMENT

The inability of consumers and health care purchasers to determine if
medical care is appropriate and effective has given rise to the concept
that the health care system should be held accountable for what is done
and the outcomes achieved. This principle of accountability has resulted
in the development of so-called "performance and outcome measures,"
administered through "report card" systems. Measures must be seen as
fair and reasonable, and able to be achieved in various practice
settings, and when carried out either by diabetes experts and/or
generalists.

Performance measures are indicators or tools to assess the level of care
provided within systems of care to populations of patients with
diabetes. The measures are constructed to make the best use of the
evidence available for assessing care or outcomes of care in systems
where test reliability, patient characteristics, (co-morbidity), and
compliance can not be easily determined and taken fully into
consideration (i.e., the measures are not case-mix adjusted). This
decision was made since the current state of the art does not allow full
adjustment for factors outside the control of the health care system.

The VHA instituted performance measures for diabetes in FY97 based upon
the recommendations of the VHA Diabetes Advisory Field Group. Subsequent
to the publication of the first version of the VHA Guidelines in March,
1997, the VHA hosted a conference at the NIH attended by representatives
of the NIDDK, CDCP, DoD, Rand, HCFA and private sector experts to
recommend performance measures to the agency. The recommended measures
were to be derived from the guidelines, and be evidence based. In this
context, the VHA Chronic Disease Performance Measures for Diabetes
foreshadowed, and are very similar to, the Diabetes Quality Improvement
Project (DQIP) both in content areas and recommended target values.

Results of performance monitoring by VHA's External Peer Review (EPRP)
are presented, both for diabetes specific measures ,Table 3, and general
preventive measures pertinent for persons with diabetes, Table 4. The
cohort was defined as veterans with at least three primary care or
selected subspeciality visits during the year. The significance level
was determined by calculating the correlation coefficient between the
year and intervention status. When two years of data were available, the
significance of any difference was determined by a standard chi square
test for 2x2 tables. There was significant improvement (P\<0.001) in all
measures whether determined over two or three sampling years.

**Table 3. VHA's External Peer Review Specific Measures for Diabetes
Mellitus**

+-------------------------------+------------+-----------+------------+
| **MEASURE**                   | **1995**   | **1997**  | **1998**   |
|                               |            |           |            |
|                               | **(n=      | **(n=13   | **(n=      |
|                               | 9578)(%)** | 557)(%)** | 8513)(%)** |
+-------------------------------+------------+-----------+------------+
| H[b]{.                        | 59         | 85        | 91         |
| smallcaps}A~1~[c]{.smallcaps} |            |           |            |
| performed                     |            |           |            |
+-------------------------------+------------+-----------+------------+
| H[b]{.                        | 72         | 82        | 87         |
| smallcaps}A~1~[c]{.smallcaps} |            |           |            |
| \<10%                         |            |           |            |
+-------------------------------+------------+-----------+------------+
| Dilated retinal examination   | 44         | 55        | 62         |
| by eye specialist             |            |           |            |
+-------------------------------+------------+-----------+------------+
| Foot visual examination       | 77         | 90        | 95         |
+-------------------------------+------------+-----------+------------+
| Foot sensation checked        | 38         | 69        | 78         |
+-------------------------------+------------+-----------+------------+
| Foot pulses checked           | 51         | 74        | 84         |
+-------------------------------+------------+-----------+------------+
| BP \<140/90 if hypertension   | N/A        | 40        | 44         |
| diagnosed                     |            |           |            |
+-------------------------------+------------+-----------+------------+
| LDL-C measured                | N/A        | 47        | 64         |
+-------------------------------+------------+-----------+------------+
| LDL-C \<130 mg/dL             | N/A        | 62        | 68         |
+-------------------------------+------------+-----------+------------+
| Urine protein evaluated       | N/A        | 23        | 36         |
+-------------------------------+------------+-----------+------------+

**Table 4. General Preventive Measures Pertinent for Persons with
Diabetes Preventive Measures**

+---------------------------+-------------+-------------+------------+
| ##### MEASURE             | **1995      | **1997      | **1998     |
|                           | (n          | (n=         | (n         |
|                           | =9578)(%)** | 13557)(%)** | =8513(%)** |
+---------------------------+-------------+-------------+------------+
| Influenza immunization    | 34          | 58          | 70         |
+---------------------------+-------------+-------------+------------+
| Pneumococcal vaccine      | 29          | 56          | 68         |
+---------------------------+-------------+-------------+------------+
| Nutritional counseling if | 68          | 92          | 95         |
| BMI \>27                  |             |             |            |
+---------------------------+-------------+-------------+------------+
| Smoking cessation         | 39          | 78          | 90         |
| intervention              |             |             |            |
+---------------------------+-------------+-------------+------------+

DISEASE MANAGEMENT

Disease state management can be defined as the continuous process of
identifying and delivering, within selected patient populations, the
most efficient combination of resources for the treatment of or
prevention of disease. The rationale assumes that there are systematic
ways health care delivery can be provided to a population that will be
more efficient than the status quo. The guideline is appropriate for
population based medicine. There is no intent to prevent practitioners
from using their best judgement in the care of an individual patient.
Rather, the intent is to establish verifiable treatment objectives for
veterans with diabetes that will lead to a reduction in limb loss,
visual loss, chronic renal insufficiency, and cardiovascular disease.
The Pharmacy Benefits Management Strategic Health Group/Medical Advisory
Panel Guidelines and Headquarters External Peer Review Program
Performance Measures collaboration has resulted in reaching for these
goals in this clinical guideline which should be viewed as the
cornerstone for Diabetes Chronic Disease State Management Program in the
VHA and DOD. Templates for the elements of a diabetes management program
were published by the Employee Education System in January, 1999.

**MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING**

**References for Introduction**

(1) National Diabetes Fact Sheet., 1998

(2) Weinstock et al., (in press)

(3) American Diabetes Association. 1997, 1998

(4) Rubin RJ; et al., 1994

(5) Veterans Administration National Center for Cost Containment
    Publications. 1998, <http://vaww.va.gov.health/nccc>

(6) VHA Directive 96-053, August 29, 1996

(7) Wolfson M; et al., 1994

(8) Weinstock et al., (in press)

(9) ACC/AHA Task Force Report 1993

(10) AHCPR Clinical Practice Guideline, 1993

(11) Woolf SH 1992, 1993

(12) National Cholesterol Education Program. 1994

(13) American Diabetes Association. 1999

(14) American Diabetes Association. 1999

(15) American College of Physicians. 1996

(16) Bennett PH, et al., 1995

(17) American Diabetes Association. 1999

(18) American Diabetes Association. 1999

(19) American Diabetes Association. 1999

(20) Joint National Committee on Prevention, Detection, Evaluation and
     Treatment of High Blood Pressure. 1997

**MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING**

**Bibliography for Introduction**

ACC/AHA Task Force Report 1993

AHCPR Clinical Practice Guideline, Number 5, Rockville, MD. US
Department of Health and Human Services, Public Health Service, Agency
for Health Care Policy and Research. AHCPR publication No. 93-0550,
March 1993

American College of Physicians: Guidelines for using serum cholesterol,
high-density lipoprotein cholesterol, and triglyceride levels as
screening tests for preventing coronary heart disease in adults (part
1). *Ann Int Med* 124:515-517, 1996

American Diabetes Association: Diabetic retinopathy (Position
Statement). *Diab Care* 22 (Supp 1): S70-S73, 1999

American Diabetes Association. Economic Consequences of diabetes
mellitus in the US in 1997. 296-309, 1998

Bennett PH, Haffner S, Kasiske BL, Keane WF et al. Screening and
management of microalbuminuria in patients with diabetes mellitus:
recommendations to the scientific advisory board of the National Kidney
Foundation from an ad hoc Committee of the Council on Diabetes Mellitus
of the National Kidney Foundation. Am *J Kidney Dis* 25:107-112, 1995

Joint National Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure: The sixth report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure. *Arch Intern Med* 157:2413-2446, 1997

National Cholesterol Education Program: Second report of the Expert
Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol
in Adults (Adult Treatment Panel II). *Circulation* 89:1333-1445, 1994

National Diabetes Fact Sheet. National estimates and general information
of diabetes in the United States. revised edition. Atlanta, GA. U.S.
Department of Health and Human Services, Centers for Disease Control and
Prevention, 1998

Optometry Service: Briefing to the Under Secretary for Health, 1995

Rubin RJ; Altman WM; Mendelson DN. Health Care Expenditures for People
with Diabetes Mellitus in 1992. *JCEM* 1994; 78:80-90A-F

VA 1996 External Peer Review Program, Contract No. V101(93) P-1369

Veterans Administration National Center for Cost Containment
Publications Diabetes Costs and Health Outcomes in the VHA in FY94
(November, 1996)

Veterans Administration National Center for Cost Containment
Publications. Diabetes costs and health outcomes in the VHA in FY98.
June 1998, <http://vaww.va.gov.health/nccc>

VHA Directive 96-053, August 29, 1996. Roles and Definitions for
Clinical Practice Guidelines and Clinical Pathways

Weinstock et al., Pharmacy costs and glycemic control in the Veterans
Health Administration: 1994-1998, *Diab Care* (in press)

Wolfson M; Mundt D; Hawley G. Human Erythropoietin Utilization in the
Department of Veterans Affairs. *Am J* *Kidney Disease* 1994; 24:184-91

Woolf SH. Practice guidelines, a new reality in medicine II. Methods of
developing guidelines. *Arch Int Med* 1992 May; 152:947-48

Woolf SH. Practice guidelines, a new reality in medicine III. Impact on
patient care. *Arch Int Med* 1993 Dec; 153:2647.

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

# IN THE PRIMARY CARE SETTING

# PARTICIPANTS

**MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING**

#### Module Leaders

##### DIABETES MELLITUS GUIDELINE DEVELOPMENT LEADERS

**Leonard Pogach, MD**

National Program Director, Diabetes, VA New Jersey Health Care System,

East Orange, NJ 07018

**Stephen Brietzke,** **Col, MC, USAF**

Consultant for Endocrinology, Dept. of Medicine, Uniformed Services
University of Health Science (USUHS), Bethesda, MD 20889

######## EDUCATIONAL SPECIALIST/FACILITATOR

######## Oded Susskind, MPH

Boston, MA

######## SPECIAL MODULE LEADERS

MODULE D -- CORE

**Leonard Pogach, MD**

> National Program Director, Diabetes, VA New Jersey Health Care System,
>
> East Orange, NJ 07018
>
> **Stephen Brietzke,** **Col, MC, USAF**
>
> Consultant for Endocrinology, Dept. of Medicine, Uniformed Services
> University of Health Science (USUHS), Bethesda, MD 20889

MODULE G -- GLYCEMIC CONTROL

**Leonard Pogach, MD**

> National Program Director, Diabetes, VA New Jersey Health Care System,
>
> East Orange, NJ 07018
>
> **Stephen Brietzke,** **Col, MC, USAF**
>
> Consultant for Endocrinology, Dept. of Medicine, Uniformed Services
> University of Health Science (USUHS), Bethesda, MD 20889

##### Thomas Taylor, COL, MC, USA

> Chief, Endocrinology Service, Tripler Army Medical Center
>
> Tripler [AMC, HI 96859]{.smallcaps}
>
> **Debbie Khachikian**
>
> Clinical Pharmacy Specialist, PBM/VA, Hines VA Hospital (119D)
>
> Hines, IL 60141

MODULE H -- HYPERTENSION MANAGEMENT

### **Ruth S. Weinstock, MD, PhD**

> Professor of Medicine and Chief, Endocrinology, Syracuse VAMC
>
> Endocrinology, SUNY HSC, Syracuse, NY 13210

MODULE E -- EYE CARE

**Claude Cowan, MD**

Chief, Ophthalmology, VAMC, Washington, D. C. 20422

MODULE F -- FOOT CARE

> **Terry D. Weaver**, **DPM**
>
> Podiatrist, Lebanon VAMC, Lebanon, PA 17042

######## MODULE L -- LIPIDS CONTROL

**John R. Downs**, **Lt Col, MC, USAF**

Director, Internal Medicine, Residency Program, Lackland AFB, TX 78236

MODULE R -- RENAL DISEASE TREATMENT

> **Jacqueline Pugh**, **MD**
>
> Audie L. Murphy VAMC, Ambulatory Care, San Antonio, TX 78284

MODULE M -- SELF-MANAGEMENT AND EDUCATION

> **Laura Leune, RN, CS, MPH, CDE**
>
> Patient Educator, Central TX Veterans Healthcare System, Temple TX
> 76504

**Esther F. Myers, Col, MC, USAF**

> AF/SG Consultant for Nutritional Medicine

60 MDTS\\SGQD, Travis AFB, CA 94535

**MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING**

**Working Group**

Kevin Abbott, LTC, MC, USA

Staff Nephrologist

Walter Reed Army Medical Center

6900 Georgia avenue

Washington, D.C. 20307

202-782-6462

202-782-0185 (fax)

[kabbott@vs.wramc.amedd.arm.mil](mailto:kabbott@us.wramc.amedd.army.mil)

Cheryl Berman, RD, DE

Diabetic Educator Coordinator

Ambulatory Care

VAMC 4101 Woolworth Avenue

Omaha, NE 68105

402-346-8800, ext 4900

402-977-5657 (fax)

<bermancheryl@omaha.va.gov>

Patricia Biagi, MS, ANP, CDE

Diabetes Nurse Practitioner

Minneapolis VAMC

1 Veterans Drive (111G)

Minneapolis, MN 55417

62-725-2000, ext 4424

612-725-2273 (fax)

[biagi.patricia@minneapolis.va.gov](mailto:biagipatricia@minneapolis.va.gov)

Elizabeth Bonometti, RD, CDE

Dietitian, Certified Diabetes Educator

Chief, Inpatient Medical Nutrition Therapy

DeWitt Health Care System

Ft. Belvoir, VA 22060

703-805-0604

703-805-0904 (fax)

<lizbono@aol.com>

Dana Bradshaw, MD, MPH

Chief, Prevention Medicine

Air Force Medical Operations Agency, OTSG

110 Luke Avenue, Room 405

Bolling AFB, DC 20332

202-767-4286

202-404-8089 (fax)

<dana.bradshaw@usafsg.bolling.af.mil>

**Stephen Brietzke, Col, MC, USAF**

Consultant for Endocrinology

Dept. of Medicine USUHS

4301 Jones Bridge Rd.

Bethesda, MD 20814

301-295-3609

301-295-3557 (fax)

<sbrietzke@mxa.usuhs.mil>

Alan N. Brown, Capt., MC, USA

Internal Medicine

1126 Village Court

Evans, GA 30809

706-787-0001/8880

706-787-8131 (fax)

<alan_n.brown@ddeamc-a.chcs>.amedd.army.mil

BethAnn Cameron, MS

Health Educator

US Army Center for Health Promotion and Preventive Medicine (CHPPM)

MCHB-TS-HET

5158 Blackhawk Rd.

Aberdeen Proving Ground, MD 21010

410-436-4656

410-436-7381 (fax)

[bethann.cameron@apg.amedd.army.mil](mailto:bethann.cameron@apg.%0Damedd.army.mil)

**Claude Cowan, MD**

Chief, Ophthalmology

VAMC

50 Irving Street NW (112)

Washington, D. C., 20422

202-745-8295

202-745-8293 (fax)

Dee Deakins, RN, MS, CDE

Diabetes Educator

Lexington VAMC (118-CDD)

2250 Leestown Road

Lexington, KY 40511

606-233-4511, ext. 4230

606-281-4804 (fax)

Lois Dickinson, COL, ANC, USA

Nurse Practitioner

US Army Medical Command MCHO-CL-C

2050 Worth Road, Suite 102

Fort Sam Houston, TX 78234-6010

210-221-7885

210-221-6896 (fax)

<col_lois_dickinson@smtplink.medcom>.

amedd.army.mil

Laura Donegan, Capt., MC, USAF

Staff Internist

1050 W. Perimeter Rd.

Andrews AFB, MD 20762

240-857-0617

240-857-2463 (fax)

<donegl@mgmc.af.mil>

**John R. Downs, Lt Col, MC, USAF**

Director, Internal Medicine

Residency Program

759 MDOS/MMIRM

2200 Bergquist Drive, Suite 1

Lackland AFB, TX 78236

210-292-5336

210-292-7868 (fax)

<john.downs@59mdw.whmc.af.mil>

Walter Elias, III, CDR, MC, USN

Family Practice Faculty

Naval Hospital, Camp Pendleton, CA

Oceanside, CA 92056

760-725-1179

760-725-1101 (fax)

<weliasiii@pol.net>

Gary L. Francis, COL, MC, USA

Professor of Pediatrics & Fellowhip Program Director , Pediatric
Endocrinology

USUHS

4301 Jones Bridge Rd.

Bethesda, MD 20814

301-295-6770

<gfrancis@usuhs.mil>

######## Bernie Good, MD

Professor of Medicine

University of Pittsburgh

Pittsburgh VAMC

University Drive C

Pittsburgh, PA 15240

412-688-6113

412-688-6916 (fax)

<chester.good@med.va.gov>

Marsha H. Graham

Chief, Clinical Quality Services

Tripler Army Medical Center

MCHK-QS, Quality Services Div.

1 Jarrett White Road

Tripler AMC, Hawaii 96859

808-433-6864

808-433-1558 (fax)

[graham_marsha@smtplink.tamc.amedd.army.mi](mailto:graham_marsha@smtplink.tamc.amedd.army.mil)l

Linda B. Haas

Endocrinology Clinical Nurse Specialist

VA Puget Sound HCS, Seattle Division

1660 S. Columbian Way (118)

Seattle, WA 98108

206-764-2721

<linda.haas@med.va.gov>

Dorothy Hale, RNC, MS, CDE

Nurse Educator

Dept of Diabetes & Metabolism

National Naval Medical Center

8901Wisconsin Ave.

Bethesda, MD 20814

301-295-1565

301-295-1939 (fax)

<dmhale@bth12.med.navy.mil>

David W. Hudgel, MD

Professor of Medicine, Case Western

Pulmonary Div., Metro Health Med. Ctr.

2500 Metro Health Drive

Cleveland, OH 44109

216-778-8393

216-779-8215 (fax)

<dhudgel@metrohealth.org>

Theresa Klose, MAJ, RN, RD, CDE

Chief, Nutritional Medicine Clinic

89 MDTS/SGQD

1050 W. Perimeter Rd. #BB-2

Andrews Air Force Base, MD 20720

240-857-8065

240-857-6858 (fax)

[kloset@mgmc.af.mil](mailto:kloset@mgmc.af.mil%0D)

**Debbie Khachikian**

Clinical Pharmacy Specialist

PBM/VA

Hines VA Hospital (119D)

P. O. Box 126

Hines, IL 60141

708-216-2079, ext. 3592

708-216-2136 (fax)

<debbie.khachikian@med.va.gov>

Michael Krafczyk, CPT, MC, USA

DeWitt Army Community Hospital

13600 South Springs Court

Clifton, VA 20124

703-805-9037

703-805-0284 (fax)

<mkrafczyk@pol.net>

**Laura Leune, RN, CS, MPH, CDE**

Patient Educator

Central TX Veterans Healthcare System

1901 South First Street

Temple TX 76504

254-778-4811, ext. 5438

254-771-4537 (fax)

<leune.laura_s@temple.va.gov>

<laura.leune@med.va.gov>

Mavourneen Mangan, RN, MS, CDE

Dir., Diabetes Education

VAMC

385 Tremont Avenue

East Orange, NJ 07018

201-676-3332

973-677-4408 (f)

Charles Miller, COL, MC

USA Medcom MCHO-CL-C

2050 Worth Road -- Suite 10

Andrews AFB, MD 78234-6010

210-221-6616

**Esther F. Myers, Col, MC, USAF**

AF/SG Consultant for Nutritional Medicine

60 MDTS\\SGQD

101 Bodin

Travis AFB, CA 94535

707-423-3665

707-423-3627 (fax)

[esther.myers@60MDG.travis.af.mil](mailto:esther.myers@60mdg.travis.af.mil%0Dand)

Peter Nielsen, MD

Director Maternal-Fetal Medicine

Chief Obstetric service

Madigan Army Medical Center

MCHJ-OG

Tacoma, WA 98431

253-968-1710

<maj_peter_nielsen_at_medcen7-mamc@smtplink.mamc.amedd.army.mil>

Thakor G. Patel, MD

Chief, Renal Diseases

Veterans Health Administration (111A)

810 Vermont Avenue, NW

Washington, DC 20420

202-273-8491

202-273-9142 (fax)

<tgpatel@mail.va.gov>

**Leonard Pogach, MD**

National Program Director, Diabetes

VA New Jersey Health Care System

Room 9-160 (111)

385 Tremont Avenue

East Orange, NJ 07018

973-676-1000 ext. 1693

973-677-4408 (fax)

<leonard.pogach@med.va.gov>

**Jacqueline Pugh, MD**

Audie L. Murphy VAMC

Ambulatory Care (11C-6)

7400 Merton Minters

San Antonio, TX 78284

210-617-531-5314

210-567-4423 (fax)

<pugh@uthscsa.edu>

Clark Sawin, MD

Professor of Medicine

VA Headquarters (10Q)

810 Vermont Avenue, NW

Washington, DC 20420

202-273-8342

202-273-9102 (fax)

<sawinct@mail.va.gov>

K. M. M. Shakir, CAPT, MC, USN

Program Director, NNMC

8901 Wisconsin Avenue

Bethesda, MD 20814

301-295-5165

301-295-5170 (fax)

**Thomas Taylor, COL, MC, USA**

Chief, Endocrinology Service, MCHK-DM

Tripler Army Medical Center

1 Jarrett White Road

Tripler AMC, HI 96859

808-433-6933

808-433-2631 (fax)

<rathmines2@yahoo.com>

Major Cheryl L. Thieschafer, RD

Chief, Community Nutrition

Brooke Army Medical Center

MCHE-DFE

3851 Rogers Brooke Drive

Ft. Sam Houston, TX 78234

210-916-2629

210-916-1991 (fax)

<maj_cheryl_thieschafer@medcom2>.

smtplink.amedd.army.mil

Major Javier Torrens, MD

Endocrinologist, Dir., Diabetes Education

Walter Reed Army Medical Center

6900 Georgia Avenue

Washington, D.C. 20307

202-782-6770

202-782-0187 (fax)

Lorraine Valdez, RN, MPA, CDE

Nurse Consultant, PHS Indian Health Service

Diabetes Program, HQ

5300 Homestead Rd. NE

Albuquerque, NM 87110

505-248-4182

505-248-4188 (fax)

<s.lorraine.valdez@mail.his.gov>

Janis Ward, Ltjg, MSC, USNR

Clinical Dietitian

National Naval Medical Center

8901 Wisconsin Avenue

Bethesda, MD 20889

301-295-0697

301-295-0559 (fax)

Thomas P. Ward, LTC, MC, USA

Ophthalmology

Walter Reed Army Medical Center

6900 Georgia Avenue

Washington, D.C. 20307

202-782-7852

202-782-6156 (fax)

<LTC_THOMAS_WARD@wramc1-amedd.army.mil>

Annette Warricks

Endocrine Nurse

VA Maryland Health care System

HEU-2c 10 N. Greene Street

Baltimore, MD 21201

410-605-7000 ext. 6365

410-605-7930 (fax)

warrick,annette@baltimore.va.gov

**Terry D. Weaver, DPM**

Podiatrist

Lebanon VAMC (112A)

1700 South Lincoln Avenue

Lebanon, PA 17042

717-228-5952

717-228-5955 (fax)

<terry.weaver@med.va.gov>

### **Ruth S. Weinstock, MD, PhD**

### Professor of Medicine and

Chief, Endocrinology

Syracuse VAMC

Endocrinology, SUNY HSC

750 E. Adams Street (CWB 353)

Syracuse, NY 13210

315-464-5740

315-464-5718 (fax)

<weinstor@vax-cs.hscsyr.edu>

**MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING**

**Other Participants**

Sid Atkinson, COL, MC, USA

Chief, Quality Management Division

Commander MCHO-CL-Q

2050 Worth Rd. Suite 10

Ft. Sam Houston, TX 78234

210-221-6195

210-221-6160 (fax)

col_sid_atkinson@smtplink.medcom.

amedd.army.mil

Marsha Beaugrand, CDR, MSC, USN

Clinical Plans and Management Division

Bureau of Medicine & Surgery

2300 E Street NW

Washington, DC 20372

202-762-3110

202-762-3133 (fax)

<mjbeaugrand@us.med.navy.mil>

Gerard Cox, CDR, MC, USN

Health Care Operations (MED-32)

Director, Clinical Management & Plans

Bureau of Medicine & Surgery

2300 E Street, NW

Washington, DC 20372

202-76703138

202-762-2133 (fax)

<ercox@us.med.navy.mil>

Kathryn J. Dolter RN, PhD, LTC, ANC

Chief, Outcomes Management

Quality Management

US Army Medical Command

2050 Worth Road, Suite 10

Ft. Sam Houston, TX 78234

210-221-6195

210-221-7118 (fax)

<kathryn.dolter@cen.amedd.army.mil>

Rosalie Fishman, RN, MSN, CPHQ

Clinical Coordinator

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

301-650-0218

<rfishman@birchdavis.com>

Barbara Fleming, MD, PhD

Clinical Advisor

Health Care Financing Administration

12703 Theresa Drive

Silver Spring, MD 20904

410-786-6863

410-786-1873 (fax)

[bfleming@hcfa.gov](mailto:Bfleming@hcfa.gov)

Jennifer Garrett, RRA

Network Coordinator

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

Verna Hightower

Administrative Coordinator

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

301-650-0357

301-650-0398 (fax)

<vhightower@birchdavis.com>

Sarah Ingersoll, RN

Network Coordinator

Birch & Davis Associates, Inc.

1263 S. El Molino Avenue

Pasadena, CA 91106

626-796-4745

626-564-0245 (fax)

<singerso@hsu.usc.edu>

Arthur Kaufman, MD

Medical Director

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

301-650-0268

301-650-0398 (fax)

<akaufman@birchdavis.com>

Lorenzo Kennedy

Administrative Assistant

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

301-650-0291

301-650-0398

<tkennedy@birchdavis.com>

Genny Krackau

Health System Specialist

US Army Medical Command

2050 Worth Road, Suite 10

Ft. Sam Houston, TX 78234

210-221-6195

210-221-7118 (fax)

<genny.krakau@cen.amedd.army.mil>

Louise H. Nelson, RN, BSN

Education and CQI Coordinator

West Virginia Medical Institute, Inc.

3001 Chesterfield Place

Charleston, WV 25304

304-346-9864

304-342-3352 (fax)

<lnelson@wvmi.org>

Linda Ogle, RN

Network Coordinator

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

<Ogle1@knight-hub.com>

George Pickett, MD, MPH

Clinical Project Director

West Virginia Medical Institute, Inc.

3001 Chesterfield Place

Charleston, WV 25304

304-346-4590, ext. 270

304-346-9863 (fax)

<gpickett@charleston.wvmi.org>

Arnyce R. Pock, LtCol., MC, USAF

AF/SG Consultant for Internal Medicine

Office of the Air Force Surgeon General

110 Luke Avenue, Rm. 405

Bolling AFB, DC 20332

202-767-4073

202-404-4043 (fax)

<arnyce.pock@usafsg.bolling.af.mil>

Janet Spinks, BSN, MS, CPHQ

Senior Consultant

Birch & Davis Associates, Inc.

8905 Fairview Road

Silver Spring, MD 20910

301-650-0285

301-650-0398

jspinks[\@birchdavis.com](mailto:@birchdavis.com%0E)

Jan Spoden, RRA

Network Coordinator

Birch & Davis Associaes, Inc.

8905 Fairview Road

Silver Spring, MD 20910

<Janrra@aol.com>

Oded Susskind, MPH

45 Longwood Avenue

Suite 411

Brookline, MA 02146

617-232-3558

617-713-4431 (fax)

<oded@tiac.net>

Debby Walder, RN, MSN

Performance Mgmt. Facilitator

Department of Veterans Affairs

810 Vermont Avenue, NW

Washington, DC 20420

202-273-8336

202-273-9030 (fax)

<debby.walder@mail.va.gov>

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

IN THE PRIMARY CARE SETTING

ALGORITHMS AND ANNOTATIONS

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

IN THE PRIMARY CARE SETTING

GLOSSARY

M**ANAGEMENT OF DIABETES MELLITUS IN PRIMARY CARE**

**Glossary**

ACE angiotensin converting enzyme

ADA American Diabetes Association

AUDIT Alcohol Use Disorders Identification Test

BCF basic care formulary

BIDS bedtime insulin daytime sulfonylurea

BMI body mass index

BP blood pressure

BPH benign prostatic hyperplasia

CAGE screening pneumonic for determining drunkenness

CVA cerebral vascular accident

CHD coronary heart disease

CHF congestive heart failure

COPD chronic obstructive pulmonary disease

CVD cardiovascular disease

DCCT diabetic control and complication trial

DM diabetes mellitus

DQIP Diabetes Quality Indicator Project

DTR deep tendon reflex

ESRD end stage renal disease

ETOH ethanol

FBS fasting blood glucose

FPG fasting plasma glucose

g gram

GDM gestational diabetes mellitus

GFR glomerular filtration rate

GHb glycosylated hemoglobin

GU genitourinary

HbA~1~c hemoglobin marker (A~1~c)

HCTZ hydrochlorthiazide

HDL high density lipoproteins

HMG CoA Hydromethylglutaryl coenzyme A

HOT Hypertension Optimal Treatment study

HPLC high pressure (liquid chromatography)

HTN hypertension

IFG impaired fasting glucose

IGT impaired glucose tolerance

IRMA intraretinal microvascular anomalies

JNC VI Sixth Report of the Joint National Committee on Detection,
Evaluation and Treatment of High Blood Pressure

LDL low density lipoproteins

LDL-C cholesterol low density lipoproteins

LE lower extremity

LE = level of evidence

MAST Michigan Alcohol Screening Test

MI myocardial infarction

MNT medical nutrition therapy

NCEP National Cholesterol Education Program

NGSP National Glycohemoglobin Standardization Program

NVD neurovascular disc disease

NVE neurovascular disease elsewhere or new vessels elsewhere

OGTT oral glucose tolerance test

mg/dL milligrams per deciliter

mmols/dL millimoles per deciliter

MNP medical nutritional therapy

MI myocardial infarction

MNT medical nutrition therapy

NIDDM non-insulin dependent diabetes mellitus

PDR proliferative diabetic retinopathy

PTH parathyroid hormone

RD registered dietitian

SLE Systemic Lupus Erythematosis

SMBG self-monitoring blood glucose

SR= strength of recommendation

TC= total cholesterol

TDD total daily dose

TG= triglycerides

TIA transient ischemic attack

TSH thyroid stimulating hormone

UKPDS United Kingdom Prospective Diabetes Study

UTI urinary tract infection

WESDR Wisconsin Epidemiological Study of Diabetic Retinopathy

VHA Veterans Health Administration

VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF **DIABETES
MELLITUS**

# IN THE PRIMARY CARE SETTING

# BIBLIOGRAPHY

MANAGEMENT OF DIABETES MELLITUS IN THE PRIMARY CARE SETTING

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