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VA/DoD Clinical Practice Guidelines

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VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care

Citation: Management of Diabetes Mellitus Update Working Group. (2010). VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus. Version 4.0. Washington, DC: Veterans Health Administration and Department of Defense.
Completion Date: 2010
Release Date: 2010
Source(s): Washington (DC): The VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus was developed by and for clinicians from the Department of Veterans Affairs (VA) and the Department of Defense (DoD); 2010.
Adaptation:

The guideline was an update of the January, 2003 VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus.

Evidence-based guidelines referenced in this updated version of the VA/DoD Clinical Practice Guideline include:

Guideline Status: This is the current version of the guideline. An update is targeted for 2015.
Developer(s): Veterans Health Administration (VHA), Department of Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [US]
Funding Source: United States Government
Committee: Management of Diabetes Mellitus Update Working Group
Group Composition: Primary care providers (physicians and nurse practitioners), endocrinologist, pharmacists, registered nurses, registered dietitians, and diabetes educators.
Disease Condition: Diabetes Mellitus (DM)
Category: Assessment, Diagnosis, Treatment, Management
Intended Users: The guideline is relevant to all healthcare professionals who have direct contact with patients with DM, and make decisions about their care. While the guideline is designed for primary care providers in an ambulatory care setting, the modules can also be used to coordinate and standardize care within subspecialty teams and as a teaching tool for students and house staff.
Target Population: Adult patients (18 years or older) with DM receiving treatment in the VA or DoD health care system. This guideline applies to Type 1 and Type 2 patients presenting for the first time with DM and to patients already being followed for DM. This guideline does not apply to gestational diabetes mellitus (GDM).
Contact Person(s):
M. Eric Rodgers, PhD, FNP, BC
Acting Director, Evidence-Based Practice Program
Office of Quality, Safety & Value (10A4B)
Department of Veterans Affairs
Veterans Health Administration - Virtual
4100 E. Mississippi Ave., Suite 510
Glendale, CO 80246
Office: 303-603-3298
Eric.Rodgers@va.gov
Ernest Degenhardt, COL USA (Ret.)
Chief, Evidence-Based Practice
Quality Management Division
U.S. Army MEDCOM
Office: 210-221-6527 or DSN 471-6527
ernest.degenhardt@us.army.mil 
Goals/Objectives: The intent of the guideline is to:
  • Reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes.
  • Provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with DM.
  • Identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines.
Scope: Offers best practice advice on the care of adults who have a clinical working diagnosis of DM.
  • Covers diagnostic criteria for DM.
  • Focuses on identification of susceptibility factors (i.e., adult patients at increased risk for developing DM).
  • Specifies key elements in the evaluation of patients with DM (including assessment of disease progression).
  • Emphasizes principles of risk stratification and shared decision-making regarding glycemic control.
  • Focuses on identification of risk factors for progression of DM.
  • Addresses approaches to slowing the progression of DM.
  • Addresses pharmacotherapy, nutrition, and management of comorbidities in patients with DM.
  • Addresses indications for consultation and referral to an endocrinologist.
Interventions And Practices: The Guideline consists of six modules, with annotations:
  • Algorithm D- Core Module (including hypertension, dyslipidemia and chronic kidney disease)
  • Algorithm S- Screening and Prevention
  • Algorithm G- Glycemic Control
  • Algorithm E- Eye Screening
  • Algorithm F- Foot Screening
  • Algorithm M- Self-Management and Education
Evidence tables, recommendations, and appendices are incorporated within each module.
Outcomes Considered:
  1. Achieve individualized HbA1c target through diet, exercise, medication, and patient self-management diabetes education.
  2. Reduce and control blood pressure to improve quality and length of life, and prevent micro- and macrovascular complications.
  3. Control cholesterol to reduce risk for cardiovascular disease.
  4. Annual or periodic screening for kidney disease, retinopathy, and lower extremity complications and risk stratification.
  5. Empower patients to make informed decisions about their self care of diabetes.
Major Recommendations: Presentation of the algorithms is intended to assist the clinician in reviewing and identifying key points that are comprehensively discussed in the guideline document.
Clinical Algorithms:
  • Algorithm D- Core Module (including hypertension, dyslipidemia and chronic kidney disease)
  • Algorithm S- Screening and Prevention
  • Algorithm G- Glycemic Control
  • Algorithm E- Eye Screening
  • Algorithm F- Foot Screening
  • Algorithm M- Self-Management and Education
Type Of Evidence: The guideline is supported by the literature in a majority of areas, with evidence-based tables and references throughout the document. The evidence consists of key clinical randomized controlled trials and longitudinal studies in the area of DM. Where existing literature is ambiguous or conflicting, or where scientific data are lacking on an issue, recommendations are based on the expert panel's opinion and clinical experience. The guideline contains a bibliography and discussion of the evidence supporting each recommendation.
Guideline Development Process: The development process of this guideline follows a systematic approach described in "Guidelines-for-Guidelines." In addition Appendix A clearly describes the guideline development process. The literature was critically analyzed and evidence was graded using a standardized format. The evidence rating system for this document is based on the system used by the U.S. Preventative Services Task Force.
Review
Methods:
Peer Review
Qualifying Statements: Clinical practice guidelines, which are increasingly being used in health care, are seen by many as potential solutions to inefficiency and inappropriate variations in care. Guidelines should be evidenced-based as well as based upon explicit criteria to ensure consensus regarding their internal validity. However, it must be remembered that the use of guidelines must always be in the context of a health care provider's clinical judgment in the care of a particular patient. For that reason, the guidelines may be viewed as an educational tool analogous to textbooks and journals, but in a more user-friendly format.
Guideline Availability: Electronic copies available from the OQS website
Copyright Statement: No copyright restrictions apply.