ADA's New Standards of Care Focus on Individualization

Miriam E Tucker

December 23, 2015

The American Diabetes Association's 2016 Standards of Medical Care contains some hard new recommendations, within an overall shift in focus toward more individualized care and shared decision making.

New in 2016 are evidence-based recommendations advising consideration of: aspirin therapy for women aged 50 and older (a change from women >60 previously); antiplatelet use in patients younger than 50 with multiple risk factors; and the addition of ezetimibe (Zetia, Merck) to moderate-intensity statin therapy in select patients with diabetes, based on the recent IMPROVE-IT trial.

Also newly added are recommendations on tailoring treatment for vulnerable populations with diabetes, such as those with food insecurity, HIV infection, mental illness, and socioeconomic disparities, and encouragement of the use of new technology such as apps and text messaging to enhance lifestyle modification in those at risk for diabetes.

And a new section on obesity — covering lifestyle modification, pharmacologic management, and bariatric surgery — has been added, while the section on older adults was expanded to provide further nuance in terms of treatment individualization, as well as care in nursing facilities and end-of-life considerations.

The annual update, Standards of Medical Care in Diabetes — 2016, was published online December 22, 2015 as a supplement to the January 2016 issue of Diabetes Care, by the ADA's 12-member professional practice committee.

A Fundamental Shift to a Patient-Centered Focus

Throughout the entire document, there is a new emphasis on individual patient circumstances, needs, and desires, ADA chief scientific and medical officer Robert E Ratner, MD told Medscape Medical News.

"The tone we've taken here is moving much more toward patient-centeredness. We focus on shared decision making, vulnerable populations, and setting goals that meet the needs of the individual. That's really a fundamental shift."

To that end, the very first chapter addresses strategies for improving care, including "a patient-centered communication style," with treatment decisions "tailored to individual patient preferences, prognosis, and comorbidities." Care should be aligned with components of the chronic care model, which includes modules such as the patient-centered medical home and incentives for the provision of appropriate and high-quality care.

"We're beginning to move in a direction where we'll be able to analyze the data coming out of patient-centered medical homes and accountable-care organizations on how healthcare delivery is really impacting outcomes. We're setting the groundwork," Dr Ratner commented.

Tailoring HbA1c and BP Targets

As in previous years and in keeping with the focus on individualization, the document continues to state that an HbA1c level less than 7% is "a reasonable HbA1c goal for many nonpregnant adults" but that more stringent goals such as less than 6.5% may be appropriate for selected patients who can achieve it without significant hypoglycemia, while looser targets such as less than 8% many be appropriate for those with severe hypoglycemia or limited life expectancy.

A general target of less than 7.5% is advised for children with type 1 diabetes, first recommended in 2014.

Regarding blood pressure, the ADA continues to advise lowering to less than 140 mm Hg systolic and 90 mm Hg diastolic in people with diabetes.

That guidance, first published in the 2013 Standards to align with the then newly released JNC8, has recently been called into question with new data from the Systolic Blood Pressure Intervention Trial (SPRINT) showing that a systolic target of less than 120 mm Hg might improve cardiovascular outcomes.

The new document mentions SPRINT but also notes that patients with diabetes were excluded. "So, whether those cut-offs are appropriate for diabetes remains to be seen. But we felt it was an important enough trial, and there were some suggestive data in the past that lower levels were important, that we wanted to get that in," Dr Ratner explained.

Other 2016 Changes

There are also some language changes for 2016. The word diabetic will no longer be used by the ADA when referring to people with diabetes, signifying that "We're not treating a disease. We're treating a patient," Dr Ratner said.

"Diabetic" will still be used as an adjective, however, as in the case of another new term, "diabetic kidney disease," which replaces "nephropathy."

This comes from nephrologists, who aim to differentiate diabetes-related kidney disease from other causes of nephropathy. In fact, "DKD" is now a standard term in the nephrology literature, Dr Ratner noted.

Another linguistic shift is the use of "atherosclerotic cardiovascular disease (ASCVD)" as a more specific term than simple "CVD."

Also new for 2016:

  • A revision in the discussion of diagnostic tests to make it clear that no one test is preferred over another.

  • Following the 2015 US Preventive Services Task Force guidance, a recommendation to screen all adults for dysglycemia beginning at age 45 years, regardless of weight.

  • Because of the increasing longevity of adults with type 1 diabetes, the ADA has called for continued access to insulin pumps and continuous glucose monitoring after they turn 65 years of age and become Medicare beneficiaries.

  • Guidance was added on the use of intravitreal anti–vascular endothelial growth factor (VEGF) agents for the treatment of center-involved diabetic macular edema.

  • The scope of the section on children and adolescents was broadened, with new recommendations for obtaining a fasting lipid profile in children starting at age 10 years.

  • For women of childbearing age, there is a new recommendation emphasizing the importance of discussing family planning with those who have preexisting diabetes and specific advice on pregestational diabetes, gestational diabetes, and diabetes management in pregnancy.

  • The section on diabetes care in the hospital was made more focused, with a newly added table on basal and bolus dosing recommendations for enteral and parenteral feedings.

  • Sections on diabetes care in schools and in day care were separated, to reflect significant differences in diabetes care between the two settings.

Dr Ratner is an employee of the American Diabetes Association and has no additional relevant financial relationships. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online December 22, 2015. Article


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