Diabetes Care Volume 42, Supplement 1, January 2019 S7

1. Improving Care and Promoting American Diabetes Association

Health in Populations: Standards

of Medical Care in Diabetesd2019
Diabetes Care 2019;42(Suppl. 1):S7–S12 | https://doi.org/10.2337/dc19-S001

1. IMPROVING CARE AND PROMOTING HEALTH

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care. Members of the ADA Professional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for
ADA’s clinical practice recommendations, please refer to the Standards of Care
Introduction. Readers who wish to comment on the Standards of Care are invited
to do so at professional.diabetes.org/SOC.

DIABETES AND POPULATION HEALTH

Recommendations
1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines, and
are made collaboratively with patients based on individual preferences, prog-
noses, and comorbidities. B
1.2 Align approaches to diabetes management with the Chronic Care Model,
emphasizing productive interactions between a prepared proactive care team
and an informed activated patient. A
1.3 Care systems should facilitate team-based care, patient registries, decision
support tools, and community involvement to meet patient needs. B
1.4 Efforts to assess the quality of diabetes care and create quality improvement
strategies should incorporate reliable data metrics, to promote improved pro-
cesses of care and health outcomes, with simultaneous emphasis on costs. E

Population health is defined as “the health outcomes of a group of individuals,

including the distribution of health outcomes within the group”; these outcomes can
be measured in terms of health outcomes (mortality, morbidity, health, and functional
status), disease burden (incidence and prevalence), and behavioral and metabolic
Suggested citation: American Diabetes Associa-
factors (exercise, diet, A1C, etc.) (1). Clinical practice recommendations for health care tion. 1. Improving care and promoting health
providers are tools that can ultimately improve health across populations; however, in populations: Standards of Medical Care in
for optimal outcomes, diabetes care must also be individualized for each patient. Thus, Diabetesd2019. Diabetes Care 2019;42(Suppl. 1):
efforts to improve population health will require a combination of system-level and S7–S12
patient-level approaches. With such an integrated approach in mind, the American © 2018 by the American Diabetes Association.
Diabetes Association (ADA) highlights the importance of patient-centered care, Readers may use this article as long as the work
is properly cited, the use is educational and not
defined as care that is respectful of and responsive to individual patient preferences, for profit, and the work is not altered. More infor-
needs, and values and that ensures that patient values guide all clinical decisions (2). mation is available at http://www.diabetesjournals
Clinical practice recommendations, whether based on evidence or expert opinion, are .org/content/license.
S8 Improving Care and Promoting Health Diabetes Care Volume 42, Supplement 1, January 2019

intended to guide an overall approach to health strategies are needed in order to suboptimal (3). Efforts to increase the
care. The science and art of medicine reduce costs and provide optimized care. quality of diabetes care include provid-
come together when the clinician is faced ing care that is concordant with
with making treatment recommenda- Chronic Care Model evidence-based guidelines (16); expand-
tions for a patient who may not meet Numerous interventions to improve ad- ing the role of teams to implement more
the eligibility criteria used in the studies herence to the recommended standards intensive disease management strate-
on which guidelines are based. Recog- have been implemented. However, a gies (7,17,18); tracking medication-
nizing that one size does not fit all, the major barrier to optimal care is a delivery taking behavior at a systems level (19);
standards presented here provide guid- system that is often fragmented, lacks redesigning the organization of the care
ance for when and how to adapt rec- clinical information capabilities, dupli- process (20); implementing electronic
ommendations for an individual. cates services, and is poorly designed health record tools (21,22); empowering
for the coordinated delivery of chronic and educating patients (23,24); removing
Care Delivery Systems care. The Chronic Care Model (CCM) financial barriers and reducing patient
The proportion of patients with diabetes takes these factors into consideration out-of-pocket costs for diabetes educa-
who achieve recommended A1C, blood and is an effective framework for im- tion, eye exams, diabetes technology, and
pressure, and LDL cholesterol levels has proving the quality of diabetes care (9). necessary medications (7); assessing and
increased in recent years (3). The mean Six Core Elements.The CCM includes six addressing psychosocial issues (25,26);
A1C nationally among people with diabe- core elements to optimize the care of and identifying, developing, and engaging
tes declined from 7.6% (60 mmol/mol) patients with chronic disease: community resources and public policies
in 1999–2002 to 7.2% (55 mmol/mol) that support healthy lifestyles (27). The
in 2007–2010 based on the National 1. Delivery system design (moving from National Diabetes Education Program
Health and Nutrition Examination Survey a reactive to a proactive care delivery maintains an online resource (www
(NHANES), with younger adults less likely system where planned visits are .betterdiabetescare.nih.gov) to help health
to meet treatment targets than older coordinated through a team-based care professionals design and implement
adults (3). This has been accompanied approach) more effective health care delivery systems
by improvements in cardiovascular out- 2. Self-management support for those with diabetes.
comes and has led to substantial re- 3. Decision support (basing care on The care team, which centers around
ductions in end-stage microvascular evidence-based, effective care the patient, should avoid therapeutic
complications. guidelines) inertia and prioritize timely and appro-
Nevertheless, 33–49% of patients still 4. Clinical information systems (using priate intensification of lifestyle and/or
did not meet general targets for glyce- registries that can provide patient- pharmacologic therapy for patients who
mic, blood pressure, or cholesterol con- specific and population-based sup- have not achieved the recommended
trol, and only 14% met targets for all port to the care team) metabolic targets (28–30). Strategies
three measures while also avoiding smok- 5. Community resources and policies shown to improve care team behavior
ing (3). Evidence suggests that progress in (identifying or developing resources and thereby catalyze reductions in A1C,
cardiovascular risk factor control (partic- to support healthy lifestyles) blood pressure, and/or LDL cholesterol
ularly tobacco use) may be slowing (3,4). 6. Health systems (to create a quality- include engaging in explicit and collab-
Certain segments of the population, such oriented culture) orative goal setting with patients (31,32);
as young adults and patients with complex identifying and addressing language,
comorbidities, financial or other social Redefining the roles of the health care numeracy, or cultural barriers to care
hardships, and/or limited English pro- delivery team and empowering patient (33–35); integrating evidence-based guide-
ficiency, face particular challenges to self-management are fundamental to lines and clinical information tools
goal-based care (5–7). Even after adjust- the successful implementation of the into the process of care (16,36,37);
ing for these patient factors, the persis- CCM (10). Collaborative, multidisciplinary soliciting performance feedback, setting
tent variability in the quality of diabetes teams are best suited to provide care reminders, and providing structured care
care across providers and practice set- for people with chronic conditions such (e.g., guidelines, formal case manage-
tings indicates that substantial system- as diabetes and to facilitate patients’ ment, and patient education resources)
level improvements are still needed. self-management (11–13). (7); and incorporating care management
Diabetes poses a significant financial teams including nurses, dietitians, phar-
burden to individuals and society. It is Strategies for System-Level Improvement macists, and other providers (17,38).
estimated that the annual cost of di- Optimal diabetes management requires Initiatives such as the Patient-Centered
agnosed diabetes in 2017 was $327 an organized, systematic approach and Medical Home show promise for im-
billion, including $237 billion in direct the involvement of a coordinated team of proving health outcomes by fostering
medical costs and $90 billion in reduced dedicated health care professionals work- comprehensive primary care and offer-
productivity. After adjusting for inflation, ing in an environment where patient- ing new opportunities for team-based
economic costs of diabetes increased centered high-quality care is a priority chronic disease management (39).
by 26% from 2012 to 2017 (8). This is (7,14,15). While many diabetes pro- Telemedicine is a growing field that
attributed to the increased prevalence cesses of care have improved nationally may increase access to care for patients
of diabetes and the increased cost per in the past decade, the overall quality of with diabetes. Telemedicine is defined
person with diabetes. Ongoing population care for patients with diabetes remains as the use of telecommunications to
care.diabetesjournals.org Improving Care and Promoting Health S9

facilitate remote delivery of health-re- barriers to medication taking may be accommodate personalized care goals
lated services and clinical information achieved if the patient and provider (7,57).
(40). A growing body of evidence sug- agree on a targeted approach for a spe-
gests that various telemedicine modali- cific barrier (12). TAILORING TREATMENT FOR
ties may be effective at reducing A1C in SOCIAL CONTEXT
The Affordable Care Act has resulted
patients with type 2 diabetes compared in increased access to care for many Recommendations
with usual care or in addition to usual individuals with diabetes with an empha- 1.5 Providers should assess social
care (41). For rural populations or those sis on the protection of people with context, including potential
with limited physical access to health preexisting conditions, health promotion, food insecurity, housing stabil-
care, telemedicine has a growing body of and disease prevention (45). In fact, health ity, and financial barriers, and
evidence for its effectiveness, particularly insurance coverage increased from apply that information to treat-
with regard to glycemic control as mea- 84.7% in 2009 to 90.1% in 2016 for ment decisions. A
sured by A1C (42–44). Interactive strat- adults with diabetes aged 18–64 years. 1.6 Refer patients to local commu-
egies that facilitate communication Coverage for those $65 years remained nity resources when available. B
between providers and patients, including near universal (46). Patients who have 1.7 Provide patients with self-
the use of web-based portals or text either private or public insurance coverage management support from lay
messaging and those that incorporate are more likely to meet quality indicators health coaches, navigators, or
medication adjustment, appear more for diabetes care (47). As mandated community health workers
effective. There is limited data avail- by the Affordable Care Act, the Agency when available. A
able on the cost-effectiveness of these for Healthcare Research and Quality
strategies. developed a National Quality Strategy
Successful diabetes care also requires based on the triple aims that include Health inequities related to diabetes
a systematic approach to supporting improving the health of a population, and its complications are well docu-
patients’ behavior change efforts. overall quality and patient experience of mented and are heavily influenced by
High-quality diabetes self-management care, and per capita cost (48,49). As social determinants of health (58–62).
education and support (DSMES) has health care systems and practices adapt Social determinants of health are defined
been shown to improve patient self- to the changing landscape of health as the economic, environmental, politi-
management, satisfaction, and glucose care, it will be important to integrate cal, and social conditions in which people
outcomes. National DSMES standards traditional disease-specific metrics with live and are responsible for a major part
call for an integrated approach that in- measures of patient experience, as well of health inequality worldwide (63). The
cludes clinical content and skills, behav- as cost, in assessing the quality of diabe- ADA recognizes the association between
ioral strategies (goal setting, problem tes care (50,51). Information and guid- social and environmental factors and the
solving), and engagement with psycho- ance specific to quality improvement and prevention and treatment of diabetes
social concerns (26). For more informa- practice transformation for diabetes care and has issued a call for research that
tion on DSMES, see Section 5 “Lifestyle is available from the National Diabetes seeks to better understand how these
Management.” Education Program practice transforma- social determinants influence behaviors
In devising approaches to support tion website and the National Institute of and how the relationships between these
disease self-management, it is notable Diabetes and Digestive and Kidney Dis- variables might be modified for the pre-
that in 23% of cases, uncontrolled A1C, eases report on diabetes care and quality vention and management of diabetes
blood pressure, or lipids were associated (52,53). Using patient registries and elec- (64). While a comprehensive strategy to
with poor medication-taking behaviors tronic health records, health systems reduce diabetes-related health inequi-
(“medication adherence”) (19). At a sys- can evaluate the quality of diabetes care ties in populations has not been for-
tem level, “adequate” medication taking being delivered and perform interven- mally studied, general recommendations
is defined as 80% (calculated as the tion cycles as part of quality improve- from other chronic disease models can
number of pills taken by the patient ment strategies (54). Critical to these be drawn upon to inform systems-level
in a given time period divided by the efforts is provider adherence to clinical strategies in diabetes. For example, the
number of pills prescribed by the physi- practice recommendations and accu- National Academy of Medicine has
cian in that same time period) (19). rate, reliable data metrics that include published a framework for educating
If medication taking is 80% or above sociodemographic variables to examine health care professionals on the impor-
and treatment goals are not met, then health equity within and across popula- tance of social determinants of health
treatment intensification should be tions (55). (65). Furthermore, there are resources
considered (e.g., uptitration). Barriers In addition to quality improvement available for the inclusion of standard-
to medication taking may include efforts, other strategies that simulta- ized sociodemographic variables in elec-
patient factors (financial limitations, neously improve the quality of care tronic medical records to facilitate the
remembering to obtain or take medica- and potentially reduce costs are gaining measurement of health inequities as
tions, fear, depression, or health beliefs), momentum and include reimbursement well as the impact of interventions de-
medication factors (complexity, multiple structures that, in contrast to visit-based signed to reduce those inequities (66–68).
daily dosing, cost, or side effects), and billing, reward the provision of appro- Social determinants of health are not
system factors (inadequate follow- priate and high-quality care to achieve always recognized and often go undis-
up or support). Success in overcoming metabolic goals (56) and incentives that cussed in the clinical encounter (61). A
S10 Improving Care and Promoting Health Diabetes Care Volume 42, Supplement 1, January 2019

study by Piette et al. (69) found that to get more.” An affirmative response Standards for Culturally and Linguisti-
among patients with chronic illnesses, to either statement had a sensitivity of cally Appropriate Services in Health
two-thirds of those who reported not 97% and specificity of 83%. and Health Care provide guidance on
taking medications as prescribed due to Treatment Considerations how health care providers can reduce
cost never shared this with their physi- In those with diabetes and FI, the priority language barriers by improving their
cian. In a more recent study using data is mitigating the increased risk for un- cultural competency, addressing health
from the National Health Interview controlled hyperglycemia and severe hy- literacy, and ensuring communication
Survey (NHIS), Patel et al. (61) found poglycemia. Reasons for the increased with language assistance (76). The site
that half of adults with diabetes reported risk of hyperglycemia include the steady offers a number of resources and materi-
financial stress and one-fifth reported consumption of inexpensive carbohy- als that can be used to improve the quality
food insecurity (FI). One population in drate-rich processed foods, binge eat- of care delivery to non-English–speaking
which such issues must be considered is ing, financial constraints to the filling patients.
older adults, where social difficulties may of diabetes medication prescriptions, Community Support
impair their quality of life and increase and anxiety/depression leading to poor Identification or development of com-
their risk of functional dependency (70) diabetes self-care behaviors. Hypoglyce- munity resources to support healthy
(see Section 12 “Older Adults” for a de- mia can occur as a result of inadequate lifestyles is a core element of the CCM
tailed discussion of social considerations or erratic carbohydrate consumption (9). Health care community linkages
in older adults). Creating systems-level following the administration of sul- are receiving increasing attention from
mechanisms to screen for social deter- fonylureas or insulin. See Table 9.1 for the American Medical Association, the
minants of health may help overcome drug-specific and patient factors, includ- Agency for Healthcare Research and
structural barriers and communication ing cost and risk of hypoglycemia, for Quality, and others as a means of pro-
gaps between patients and providers treatment options for adults with FI and moting translation of clinical recommen-
(61). In addition, brief, validated screen- type 2 diabetes. Providers should con- dations for lifestyle modification in real-
ing tools for some social determinants of sider these factors when making treat- world settings (77). Community health
health exist and could facilitate discus- ment decisions in people with FI and workers (CHWs) (78), peer supporters
sion around factors that significantly seek local resources that might help (79–81), and lay leaders (82) may assist
impact treatment during the clinical en- patients with diabetes and their family in the delivery of DSMES services (66),
counter. Below is a discussion of assess- members to more regularly obtain particularly in underserved communi-
ment and treatment considerations in nutritious food (74). ties. A CHW is defined by the American
the context of FI, homelessness, and
Public Health Association as a “frontline
limited English proficiency/low literacy. Homelessness public health worker who is a trusted
Homelessness often accompanies many member of and/or has an unusually close
Food Insecurity additional barriers to diabetes self- understanding of the community served”
FI is the unreliable availability of nutri- management, including FI, literacy and (83). CHWs can be part of a cost-effective,
tious food and the inability to consis- numeracy deficiencies, lack of insurance, evidence-based strategy to improve
tently obtain food without resorting to cognitive dysfunction, and mental health the management of diabetes and car-
socially unacceptable practices. Over issues. Additionally, patients with diabe- diovascular risk factors in underserved
14% (or one of every seven people) tes who are homeless need secure places communities and health care systems
of the U.S. population is food insecure. to keep their diabetes supplies and re- (84).
The rate is higher in some racial/ethnic frigerator access to properly store their
minority groups, including African insulin and take it on a regular schedule.
American and Latino populations, in References
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