screening for diabetes and prediabetes a1c order …...at a recent visit to (clinic name), your...

SCREENING FOR DIABETES and PREDIABETESA1C ORDER ALERT and SCREENING

QUESTIONNAIREeCW Standard Diabetes Management Screening

(SDMS)

TRAINING MODULE

FOR

MEDICAL PROVIDERS

Continuum Health Partners2012

©2017 American Diabetes Association. Published online at http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc16-2133/-/DC1

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Background information

In 2010 the ADA recommended Hb A1c be used for screening and diagnosing diabetes (A1c ≥6.5%)

The ADA also recommended screening for Pre-Diabetes using A1c ranges from 5.7 to 6.4 (included)

One aspect of this research study is to standardize the screening process and increase the number of patients screened

The next slide will show the ADA criteria for pre-diabetes screening

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ADA criteria for Diabetes screening (who is at risk)

Criteria for testing for diabetes in asymptomatic adult individuals (ADA 2010)

1) Testing should be considered in all adults who are overweight (BMI: 25 kg/m2) AND have additional risk factors: Physical inactivity First-degree relative with diabetes Members of a high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific

Islanders Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension (≥140/90 mmHg or on therapy for hypertension) HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l) Women with polycystic ovary syndrome (PCOS) A1C ≥5.7%, IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD

2) In the absence of the above criteria, testing for diabetes should begin AT age 45 years 3) If results are normal, testing should be repeated at least at 3-year intervals, with consideration of

more frequent testing depending on initial results and risk status.

Adapted from: American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care. 34 (suppl 1): S11-61, 2011.

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A1C ORDER ALERTScreening for Diabetes and Pre-

diabetes:

An A1C ORDER ALERT will be triggered based on the patient’s AGE from data already in eCW

If the patient is over 45 years old: An alert will appear in the registry alert box.Clicking on the alert will trigger an A1C lab order*.Established Diabetic patients will be automatically

excluded.

*at present the A1C lab has to be ordered manually (the Medical Assistant will be trained to do it)

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A1C ORDER ALERT Location of the Registry Alert: Click on “CDSS” box on the right hand side of the screen when eCW is

opened on the patient’s “progress note” page (see below) If patient meets age criteria, the A1c alert will appear under the “Registry

Alerts” heading (see below)

Click on the CDSS box

A1c Alert

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AT RISK for DIABETES SCREENING QUESTIONNAIRE:

DM RISK Screening Questionnaire: Gives additional information, useful for pt less than 45

year old or if provider is unsure of the need to screen for an A1C

Identifies Diabetes risk factors other than age: BMI, family Hx., HTN/CVD, PCOS, GDM, physical inactivity

These are yes or no answers provided by the patient or per the patient’s medical history, medication list, and/or diagnosis codes.

The screening questionnaire should be entered for all patients

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“AT RISK for DIABETES” SCREENING QUESTIONNAIRE:

1) Diabetes in First Degree relatives includes parents, siblings and offspring, DOES NOT include grand-parents, aunts or uncles, nieces or nephews

2) HTN or CVD as defined by medical history, medication list or diagnosis codes. Includes HTN, MI, PCI, CABG, Stroke, PVD

3) PCOS as defined by medical history or diagnosis code4) Gestational Diabetes mellitus5) “Physically Inactive” is defined as less than 150 minutes per week of moderate intensity aerobic physical activity

(40% to 60% of maximal aerobic capacity such as brisk walking)

Yes No

BMI >= 25

Diabetes in First Degree Relative(s)*

Hypertension / Cardiovascular Disease*

Polycystic Ovary Syndrome

Gestational Diabetes MellitusPhysically Inactive: Less than 150 minutes/week of moderate intensity aerobic physical activity (40% -60% of maximal aerobic capacity such as brisk walking)

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AT RISK for DIABETES SCREENING QUESTIONNAIRE:

The screening questionnaire

Questionnaire is selected

from HPI list

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WHEN (and how) TO ORDER AN A1CWHEN to order an A1C? If AGE >45 year old: patient is at risk for diabetes.

A1c screening alert is triggered automatically and will stay on until an A1c is ordered

If AGE <45 year old but has a BMI equal or higher than 25: A1c needs to be ordered manually at present.

Other risk factors may apply (as per the American Diabetes Association criteria)

The V77.1 ICD9 code should be usedAt all times providers should use clinical

judgment when ordering an A1C

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Patient registers at the front desk

Front Staff confirms the patient’s demographics, especially AGE, RACE and ETHNICITY

Gives out paper version of screening questionnaire for patient to fill out

Front Staff prints A1c requisition if ordered(please no DC analyzer)

Patient Visit starts

MA/Nurse takes patient’s vitals including BMI

MA brings Questionnaire from HPI choices

MA enters the BMI, Family Hx. and Physical Activity answers in the questionnaire

MA will bring up an A1C order If an age alert is present and/or BMI>25

Practitioner checks that questionnaire has been answered and processes A1C order

if appropriate.

Proceed with regular portion of visit

BASIC FLOW OF AN OFFICE VISIT

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POST-VISIT ENCOUNTERMD checks HgbA1c result in 24 to 48 hours as per institutions policy

Post Visit/Subsequent Encounter

HgbA1cresult

A1C ≥ 6.5%DIABETES

• DM management• A1C 3 – 4x a year

A1C < 5.7%NORMAL

• Repeat A1C in 3 years

5.7% ≤ A1C ≤ 6.4%PRE-DIABETES

• Pre-DM management• A1C 1 – 2x a year

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A1c results

Normal A1C (<5.7) Pre-Diabetes (5.7 ≤ A1c ≤ 6.4) Diabetes A1c ≥ 6.5

Post Visit/ Subsequent Encounter

•The lab result shouldbe reviewed at the next scheduled visit but no further action is required

•Please re-orderHbA1c in three years unless patient's status changes (New risk factors such as weight gain, CVD…)

•Patient will be contacted andinformed of A1C result, either by a phone call or a letter (see English and Spanish copies of letter)

•Recommendation for dietand exercise will be provided as per standard protocol (see English and Spanish copies of letter)

•Patient will need to have arepeat A1C within 1 year of the first test or SOONER if medically indicated

•Patient will be told ofA1C result, either by a phone call or a letter.

•Follow-up visit will bescheduled within 1-2 weeks

•Interventions as percurrent DM standards of care and Patient-Centered Medical Home (PCMH) approach will be provided to the patient on subsequent visits

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EXTRA TRAINING SLIDESFOR

OFFICE STAFF

Continuum Health Partners

2011

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Patient registers at the front desk

Front Staff1) Enters the patient’s demographics, especially AGE, RACE and ETHNICITY (please use drop down

menu)2) Enters the primary care provider information

Front StaffAt the end of visit, make sure that the alert was acted upon by MD and when appropriate, give patients their laboratory requisitions.

Patient Visit starts

Medical Assistant/Nurse1) Enters the answers to the questionnaire in ecW and reminds physician of the screening

2) Measure and weight the patient:When measuring Height and Weight the patients need to be barefoot and in light

weight attire (when not limited by a physical impairment such as being wheelchair bound).

BASIC FLOW OF AN OFFICE VISIT

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DIABETES SCREENING QUESTIONNAIRE and A1C ORDER ALERT

During Post visit / Subsequent EncounterFront OfficeGive patient lab requisition if labs are done off site

Medical Assistant/ NurseDo labs if done on siteCall patients or send letter with lab results as per

institution policyReview that questionnaire and registry alert have been

done at previous visit

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Dear Patient,

At a recent visit to (clinic name), your blood was tested for diabetes. This blood test is known as “Hemoglobin A1C.” This test is different than home blood sugar monitoring (fingerstick testing). Your level (5.7-6.4) is elevated.

Hemoglobin A1C Interpretation Less than 5.7 Normal 5.7-6.4 – Your level. High Risk / Pre Diabetes 6.5 or greater Diabetes

What does this mean? Diabetes is a medical problem of high levels of blood sugar, which can lead to potentially dangerous conditions such as heart attacks and strokes. Over 20 million people in this country are affected. Many more are estimated to be at high risk of developing diabetes. Your test indicates you are in this high risk category, also known as pre diabetes. If pre diabetes is untreated, it can develop into diabetes.

What can be done? With intervention, the risk of developing diabetes can be reduced. There are steps you can take to reduce your risk of developing diabetes: Step 1: See your doctor- Schedule a follow up appointment with your doctor by calling (clinic phone number) to discuss pre-diabetes. This should be arranged as soon as possible. Your blood test will eventually be repeated to monitor your progress. Step 2: Exercise – Increase your amount of physical activity to at least 150 minutes of exercise weekly (e.g. walking 30 minutes daily). Step 3: Changing your diet : -Increase dietary fiber intake to 14grams/1000 calories total food intake -Switching bread/pasta/starch products to whole grain products -Reducing your amount of saturated fat intake

-Avoiding foods containing trans fats -Limiting alcohol intake to 1 drink per day -Attain weight loss of 7% of your current body weight if overweight or obese

Step 4: Medications: In certain cases, medication may be appropriate for people with pre-diabetes. You should only begin using medications after discussion with your doctor. Step 5. Habits: If you currently smoke or engage in recreational drug use, quitting immediately is recommended. Please mention this to your doctor at your visit.

If you have been told by your doctor that you have diabetes previously, please disregard this message and follow with your doctor. For all others, this message intends to educate you about the potential hazards and steps you can take to reduce your risk of becoming diabetic. Any questions you have should be discussed with your doctor. We look forward to working with you in minimizing your risk of developing diabetes.

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Estimado Paciente,

Recientemente en la clínica (clinic name) se le tomó una muestra de sangre para identificar la presencia de diabetes. Esta prueba se le conoce como hemoglobina glucosilada o “hemoglobina A1C”. Esta prueba es diferente a la glucosa que se mide en casa (pinchando el dedo). El resultado para usted fue entre 5.7 y 6.4, esta elevado.

Hemoglobina A1C Interpretación Menor a 5.7 Normal Entre 5.7 y 6.4 – El resultado de usted. Riesgo Elevado / Pre-diabetes 6.5 o mas Diabetes

¿Que significa este resultado? La diabetes es una condición medica que se caracteriza por tener glucosa (azúcar) elevada en la sangre,

tener diabetes puede llevar a enfermedades cardiovasculares potencialmente peligrosas (incluyendo embolia cerebral o stroke y ataque al corazón). La diabetes es un gran problema de salud, afecta a mas de 20 millones de personas en Estados Unidos. Además hay muchas otras personas que están en riesgo de desarrollar diabetes en el futuro. El resultado de su prueba nos indica que usted esta en este grupo de personas, también conocido como pre-diabetes, que sin tratamiento pueden desarrollar diabetes. ¿Que se puede hacer?

Tener pre-diabetes significa que usted esta en riesgo de desarrollar diabetes. Pero este riesgo se puede disminuir si se toman las medidas necesarias. Aquí están los pasos que usted tiene que seguir para reducir su riesgo de desarrollar diabetes: 1. Acudir a su medico -

Haga una cita con su doctor llamando a (clinic phone number) para hablar acerca de la pre-diabetes y de sus resultados. Esta cita tiene que ser lo antes posible. Su examen de la sangre se repetirá eventualmente para evaluar su progreso. 2. Ejercicio –

Tiene que aumentar el tiempo que hace de ejercicio a por lo menos 150 minutos a la semana, por ejemplo camiar 30 minutos a día. 3. Cambiar su dieta -

- Aumetnar la ingesta de fibra a 14 gramos por cada 1000 calorías. - Cambiar el pan, la pasta y harinas por productos integrales (whole grain). - Reducir la cantidad de grasa saturada que ingiere (que menos del 7% de las calorías totales provengan de grasa saturada) - Evitar por completo alimentos con grasas trans (trans fats) - Limitar la ingesta de alcohol a una bebida al día. - Bajar de peso, 7% de su peso actual.

4. Medicamentos-En algunos casos los pacientes con pre-diabetes pueden requerir medicamentos. Discuta el tema con su

doctor en su próxima visita. 5. Otros

Si usted fuma o utiliza alguna droga de recreación, se recomienda que pare. Mencione esta información a su doctor en la próxima visita.

Si a usted ya lo habían diagnosticado con diabetes, no haga caso a este mensaje y continúe tomando sus medicamentos como de costumbre y continúe acudiendo a su doctor regularmente. Si usted nunca ha sido diagnosticado con diabetes, este mensaje esta enfocado en educarlo acerca de los posibles riesgos y enseñarle los pasos que debe de seguir para reducir su riesgo. Esperamos trabajar con usted para reducir su riesgo de desarrollar diabetes.

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screening for diabetes and prediabetes a1c order …...at a recent visit to (clinic name), your...

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