COMMENTARY

Type 2 Diabetes: The Case for Using the ADA Standards in Primary Care

Jay H. Shubrook, DO; Hope Feldman, CRNP

Disclosures

May 01, 2018

Jay H. Shubrook, DO: Hi. I'm Jay Shubrook, DO. I am a professor in the primary care department of Touro University. We are going to continue our program on Everyday Diabetes: Practical Management for Primary Care.

Today I am speaking with Hope Feldman, a family nurse practitioner in Philadelphia, Pennsylvania, and a member of the American Diabetes Association (ADA) Primary Care Advisory Group and Professional Practice Committee, which developed the 2018 Standards of Medical Care in Diabetes. Welcome, Hope.

Hope Feldman, CRNP: Thanks for inviting me, Jay.

Shubrook, DO: Let's talk about the ADA Standards of Care. How is the committee that authors these standards determined and how does it come up with the guidelines?

Feldman: The Professional Practice Committee is a multidisciplinary committee comprising clinicians throughout the spectrum of diabetes care. The committee members undertake a literature search to determine emerging research and publications and then engage in a dialogue about how best to set guidelines for clinicians involved in diabetes care.

It is a 2-year assignment. The committee rotates members off yearly. Members include anyone you would think of who would be involved in diabetes care: pediatric endocrinologists, geriatricians, obstetricians, public health professionals, nutritionists, diabetic educators, psychiatrists, psychologists, and so on.

Shubrook: The Standards is really an amazing document and quite comprehensive. How do committee members integrate new information and make decisions?

Feldman: An impressive amount of work goes into this. As a primary care provider, I have the big-picture view.

Writing teams comprise professionals tasked with performing a comprehensive literature search, examining new literature published within the past year, and making sense within each of the sections of the standards of care. Writing group members examine the data, the research methods (randomized controlled trials; observational trials), grade of evidence, and relevance to the population.

We then determine what impact that particular research study has on the Standards. Face-to-face meetings take place several times a year, and in between we communicate via email. A lot of very strong clinical expertise comes to the table to look objectively at the studies. Additionally, the group determines what gaps continue to be present in the literature. The workings of the group are very transparent.

Shubrook: Sounds like a very active group and one that certainly has its work cut out for it. I appreciate the work you are doing.

Feldman: Thanks. It involves hundreds of hours of work. I respect that everyone on the committee takes this very seriously. We really want to be able to give good guidance based on the best available evidence.

For example, there was a lot of conversation about one standard, where the evidence did not support all pieces of that standard. The result was that that standard was broken up so that we could assign a grade of evidence independently to each component.

You will note that some of the standards speak about specific age ranges to which that recommendation applies. That is because there are a lot of data for persons 65 years and under that allows us to assign one grade. The same outcome might have a lesser grade, a Grade B or C, for older adults because the data aren't there yet.

Some standards do rely on expert opinion because there are not sufficient data to support it and this is the best information we have.

Shubrook: I think that is important. Both the ADA Standards of Care and the abridged standards of care not only provide some guidance but also provide a ranking of the strength of the support for that guidance. That is something that I find to be of great value.

One of the recommendations included in the Standards is an A1c goal. This has been a hot topic right now. How did the Professional Practice Committee come up with the A1c target of less than 7%?

Feldman: This relied on a number of studies, including the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial, the Veterans Affairs Diabetes Trial (VADT), the United Kingdom Prospective Diabetes Study (UKPDS), and others. These studies provide the gold standard for evidence supporting target treatment goals that prevent long-term damage and the legacy benefits of early control.

There was a lot of discussion among committee members about individualization, which has always been part of that target goal. The Standards include a figure by Silvio Inzucchi and his team, which emphasizes the need to look at A1c target across social determinants of health, duration of disease, comorbidities, and hypoglycemia risk.

With the Standards, we want to provide enough structure so that a clinician is able to treat with the best guidance that allows for optimization of care. They are not meant to be a road map for the patient in front of you. You are going to individualize that treatment. But the Standards provide a guide in how you approach the target goal and a rationale for when to intensify care.

Shubrook: That individualization of patient care is really critical. I love that you, as a primary care provider serving on this committee, have this voice.

What would be the single most important message you can give to other primary care providers about the ADA Standards of Care?

Feldman: I think the best advice that I can give is to look at the Standards periodically throughout the course of your [career] and reexamine what seems familiar. Often in clinical practice, we have solid knowledge of where the data are [at a point in time] but it changes. As new information emerges and changes, we need to change our practice. So be flexible.

The Standards provide guidance about what is staying the same and what's changing annually. For me as a generalist, as I read the Standards of Care, my [use of them] changes with my practice. There are things that make more sense as I see more patients or work with different medications.

I think the hardest part of practice is to avoid care fatigue. It is avoiding the [mindset] that now that my patient is at goal, I'm going to move on to something else because there will always be something else in clinical practice. There will always be another patient with another set of stuff to navigate. At least for me, in the practice where I work, we are never done with this. Patients who are meeting their goals, we get to cheer them on, we get to encourage them and reevaluate them, but we are not done with them and they're not done with us. Remember to be really engaged in this journey with them and alongside them.

Shubrook: What a really important point—that this is not a single point in time. This is an ongoing relationship, not only with the patient as the patient evolves in their progression of whatever condition they have; the knowledge around the way we treat things evolves as well.

Thank you so much for your time today. We really appreciate your work, representing primary care on the Professional Practice Committee at the American Diabetes Association.

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