HAAD Standards for diagnosis, management - هيئة الصحة

Health Authority – Abu Dhabi

Title: HAAD Standards for diagnosis, management and Issue Date: data reporting for diabetes. Reference: PHP/PHPr/DC/02

‫ أبوظبي‬- ‫هــيئـــــة الصحة‬

July 2009

1. Purpose 1.1 The Health Authority Abu Dhabi is the authority responsible for regulating all aspects of health care service, including quality of care and patient safety. In order to achieve this, HAAD mandates regulations and develops standards. This may include developing and/or adopting international best-practice and standardised clinical care pathways. 1.2 This standard mandates the clinical service specifications and data reporting requirements (in Annex III) for patients with diabetes mellitus. 1.3 The clinical care pathways provided at Annex I and II in this Standard provide additional advisory guidance to healthcare professionals to support quality, evidence-based clinical services to diabetes patients. 2. Scope 2.1 This standard applies to all Healthcare Facilities and Professionals licensed by HAAD in the Emirate of Abu Dhabi. 2.2 This standard refers to type I and type II diabetes mellitus in adults (18 years and above). 2.3 This standard is intended to ensure that patients with diabetes mellitus receive quality and safe standard of treatment and supportive care; to do this it: 2.3.1 Sets out the clinical care and service specifications for patients with diabetes mellitus. 2.4 Clinical services and patient care and data reporting must be delivered in accordance with the laws and regulations of the Emirate of Abu Dhabi and consistent with HAAD policies and standards. This Standard is related to, and has effect together with, the HAAD Reporting of Health Statistics Policy and the HAAD Data Standards and Procedures (found online at www.haad.ae/datadictionary). 3. Duties for Healthcare Facilities and Professionals All licensed healthcare facilities and professionals engaging in Diabetes care: 3.1 Must report and submit data to HAAD via e-claims and in accordance with the HAAD Reporting of Health Statistics Policy and as set out in the HAAD Data Standards and Procedures. 3.2 Must manage Diabetes patients as per internationally accepted best practice; HAAD Public Health Protocols (Annex I and II) are advisory in this regard. 4. Enforcement and Sanctions 4.1 HAAD may impose sanctions in relation to any breach of duties under this standard consistent with the HAAD Reporting of Health Statistics Policy and in accordance with the [HAAD Policy on Enforcement and Sanctions]. 5. Data reporting 5.1 HAAD requires all licensed healthcare facilities to submit data on healthcare delivery and health statistics. Reporting of data under this standard must comply with the HAAD Reporting of Page 1 of 11

Health Statistics Policy, the HAAD Data Standards and Procedures (found online at www.haad.ae/datadictionary). 6 Standards 6.1 All HAAD licensed healthcare providers in Abu Dhabi are authorized to diagnose and manage diabetes patients provided they meet this Standard. 6.2 The diagnosis and management of diabetes patients in Abu Dhabi: 6.2.1 Must be a service that is supervised by a HAAD licensed physician; although the initial testing may be substantively provided by a HAAD licensed nurse, all cases confirmed to have diabetes must be assessed by a HAAD licensed physician, who will also be responsible for communicating a diagnosis of established risk factors (e.g. diabetes) and discussing the management options. 6.2.2 Should be in line with the HAAD care pathway for diabetes mellitus designed for diagnosis and initial management (Annex I) and consistent with International best practice for continuation of diabetes care (Annex II). The diagnosis and initial management care pathway in Annex I has been customized from International evidence-base so as to take into account local needs and care models. Annex II management care pathway is adopted from International best practice as it is available and has not undergone local customization as it fulfills the local management and care models. 6.3 The diagnosis of those suspected of being diabetic (including those identified through Weqaya screening) involves an initial visit (initial encounter) for screening for symptoms and blood testing as outlined in 7.1. 6.4 The initial encounter should be followed up for those individuals meeting the criteria for diabetes or pre-diabetes (in Annex I) by a consultation with a HAAD licensed physician, including examination, assessment for complications and risk factors and a personalised plan for diabetes care in line with International best practice (Annex II); it is recommended that this should be offered within 2 days of the initial consultation. 6.5 If a definitive diagnosis of diabetes is made, the patient must be referred for specialist care in the presence of: 6.5.1 Gestational diabetes 6.5.2 Diabetic complications 6.5.3 Persistent poor control of glucose or glycosylated haemoglobin (HbA1c) 6.6 If the initial consultation for screening for symptoms and blood testing identifies pre-diabetes, as defined by the HAAD care pathway (Annex I), a consultation by a HAAD licensed physician and plan of care for pre-diabetes should take place as per the care pathway (Annex I).

7.

Standard 1: Diagnosis of diabetes

7.1 Following a symptom check as per Annex I, data recording as specified in advisory care pathway to include laboratory results for HbA1c and oral glucose tolerance testing (fasting and 2-hour post glucose load).

8.

Standard 2: Management of diabetes and data reporting

8.1 Clinical examination and assessment should be performed by a HAAD licensed physician on those who have diabetes mellitus confirmed by the tests specified in the care pathway (Annex I), using the tests outlined in Standard 1 above.

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8.2 Further assessment of complications and cardiovascular risk (including reporting of observations) should be as indicated in Annex I and II. 8.3 Further continuation of management for diabetes should be in accordance with International best practice as outlined in Annex II. 8.4 The data set-out in 7.1 must be submitted via e-claims within 3 days of the visit for the clinical consultation, examination and assessment using the standard process. 9

Communication

9.1 All communication regarding the diabetes care must be in accordance with HAAD Policies and Standards, including general confidentiality and consent policies available at www.haad.ae.

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Annex I: HAAD care pathway for diagnosis and initial management of diabetes mellitus

Suspected Diabetes Mellitus Definitive Diagnostic Testing Presence of symptoms# & random blood glucose > 11.1 mmol/l Or -fasting plasma glucose > 7.0 mmol/L Or -2 Hour plasma glucose following oral glucose tolerance test§ > 11.1 mmol/l

No

HbA1c > 6.1% ? Yes No

No

Other testing to be undertaken -HbA1c -fasting triglyceride level

Type 1 Consider in presence of: -young adults -ketonuria -marked weight loss -no other risk factors or features of metabolic syndrome -Follow diabetes mellitus treatment protocol -follow steps for prevention and early detection of complications$$

Pre-Diabetes Present? Either: -fasting plasma glucose 5.6– 6.9 mmol/l (impaired fasting glucose) or; -oral glucose tolerance testing 7.8 – 11.0 mmol/l (impaired glucose tolerance)

Review after 1 year

Yes

Offer help with lifestyle modification** -weight loss -dietary advice -exercise

Diabetes Mellitus Confirmed

Presence of alarming symptoms * (Suspected Diabetic Emergency) Yes

Review as for normal population

Yes

Formal assessment of cardiovascular risk ## (see algorithm for high cardiovascular risk if > 20%) Type 2 (adult onset) Consider in presence of: -older adults (although can also be seen in children) -milder symptoms -other features of metabolic syndrome$

Treat as a Hyperglycaemic emergency

Referral to diabetes specialist in presence of: -pregnancy -any diabetic complications -persistent poor control of glucose or HbA1c Urgent (same-day) referral to diabetes specialist

* Alarming Symptoms ,Hyperglycaemic conditions: ketoacidosis (common in type 1 diabetes, rare in type 2 diabetes): O increased concentration of glucose in blood O ketone bodies accumulate in tissues and fluid O fluids become more acidic (increase in hydrogen ion concentration) O thirst or dry mouth O frequent urination O high ketone levels in urine O tiredness O dry, flushed skin O gastrointestinal symptoms O short, deep breaths O breath smells fruity O difficulty concentration or confusion O leads to coma and death non-ketotic hyperosmolar state (more common in type 2 diabetes): O increased concentration of glucose in blood O hyperosmolarity of extracellular fluid and dehydration of intracellular fluid O thirst or dry mouth O warm, dry skin that does not sweat O high fever (above 38.5°C) O confusion or drowsiness O vision loss O hallucinations O weakness on one side of body O leads to coma and death if untreated # Symptoms of Diabetes mellitus symptoms of hyperglycaemia (generally more severe in type 1 diabetes than in type 2 diabetes): O thirst O polyuria O blurred vision O weight loss O recurrent infections O tiredness symptoms of long-term complications: O type 2 diabetes may not be diagnosed until complications are present increased screening of patients at high risk of diabetes may lead to earlier diagnosis before onset of complications if symptoms are present, only one elevated glucose measurement is needed to confirm diagnosis § Oral glucose tolerance testing: plasma glucose 2 hours following a glucose load of 75gms anhydrous glucose dissolved in water ** Lifestyle Modification : For those who meet the criteria for overweight (BMI 25-29.9 Kg/m2 and no other cardiovascular risk factors), encourage behavioural changes to achieve a healthy lifestyle, including: O modest weight loss - 5-7% of bodyweight in people who are overweight O regular physical activity - 30minutes/day on most days of the week or more if possible at around 50% intensity (this should make the individual breathless and sweat by the end of 30 mins). O follow-up counselling For those who are obese (BMI > 30 Kg/m2), or with BMI 25-29.9 Kg/m2 and raised waist circumference (>88 in women, >102cm in men) and other two or more cardiovascular risk factors, the algorithm for weight management for obesity should be followed. ## Cardiovascular Risk Factor Score : Assess Cardiovascular Risk using the Framingham 10-year risk equations (Anderson et al 1991). Ten year CVD risk should be calculated as: CVD risk=10 year risk of coronary heart disease (CHD)+10 year risk of fatal and non-fatal stroke, including transient ischaemic attack $Features of metabolic syndrome: I.waist circumference >102cm in males, >88cm in females II. serum triglycerides 1.7mmol/l (150mg/dl) III. HDLcholesterol 20%

Treated with # aspirin

There is unequivocal evidence for the treatment of those at high risk of CVD such as diabetics in preventing cardiovascular events and reducing all cause mortality.

Data reporting on prevention of hospitalisation Diabetic patient

#

Patient received follow up every 3 months and no inpatient admissions (for overnight stay or more) in last 12 months

Unless contra-indicated or not tolerated by the patient. If not tolerated, replace with clopidogrel.

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