Diabetes Care

In late December, the American Diabetes Association (ADA) released the 2019 Standards of Medical Care in Diabetes. The standards, which were first introduced in 1989, have been updated every year to reflect the current state of diabetes practice.

While multiple changes have been made to clarify recommendations and align with new evidence in the 2019 edition, here’s a high-level overview of the relevant changes impacting inpatient glycemic management:

  1. In the inpatient section, Section 15. Diabetes Care in the Hospital, a new recommendation was added calling for providers to consider consulting with a specialized diabetes or glucose management team, where possible, when caring for hospitalized patients with diabetes. This emphasizes the need to form a multidisciplinary glycemic optimization committee to ensure all components of inpatient glycemic management—medication, nutrition, and the general care plan, both while in the hospital and post-discharge—are being coordinated and managed appropriately.
  2. In the population health section, Section 1. Improving Care and Promoting Health in Populations, the recommendations again call for collaboration and standardization. The section highlights that, “optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated healthcare professionals working in an environment where patient-centered high-quality care is a priority.” The following two new guidelines were added in support of improving coordination and quality of diabetes care:
    1. Care systems should facilitate team-based care, patient registries, decision support tools, and community involvement to meet patient needs.
    2. Efforts to assess the quality of diabetes care and create quality improvement strategies should incorporate reliable data metrics to promote improved processes of care and health outcomes, with simultaneous emphasis on costs.
  3. Section 4. Comprehensive Medical Evaluation and Assessment of Comorbidities now includes direction on the appropriate language to use when communicating with people with diabetes and professional audiences. Referencing the American Diabetes Association (ADA) and American Association of Diabetes Educators consensus report, “The Use of Language in Diabetes Care and Education,” the standards advise healthcare professionals to:
    1. Use language that is neutral, nonjudgmental, and based on facts, actions, or physiology/biology (e.g., “manage” is preferred over “control”).
    2. Use language that is free from stigma.
    3. Use language that is strength-based, respectful, and inclusive and that imparts hope.
    4. Use language that fosters collaboration between patients and providers ( e.g., “engagement” is preferred over “compliant” or “adherent”).
    5. Use language that is person-centered (e.g., “person with diabetes” is preferred over “diabetic”).
  4. This year, for the first time, the American College of Cardiology has endorsed the ADA Standards of Care and guidelines for persons with cardiac disease, Section 10. Cardiovascular Disease and Risk Management. Cardiovascular disease is the leading cause of death and disability for people with diabetes. The section includes recommendations that aim to reduce the risk of heart attacks, strokes, heart failure, and other manifestations of cardiovascular disease.
  5. Also new this year is a section on Diabetes Technology, Section 7, which contains preexisting material that was previously in other sections, as well as new recommendations. For this first iteration, the standards focus only on insulin delivery and glucose monitoring with guidelines for use of insulin syringes, pens, insulin pumps, glucose meters, continuous glucose monitors and automated insulin delivery devices. In the future, they anticipate that the section will be expanded to include software as a medical device, technology-enabled diabetes education and support, telemedicine, and other use of technology in modern diabetes care.

Despite not including Electronic Glucose Management Systems (eGMS) in this section, Section 15 on inpatient diabetes care continues to support use of the technology, stating:

“A Cochrane review of randomized controlled trials using computerized advice to improve glucose control in the hospital found significant improvement in the percentage of time patients spent in the target glucose range, lower mean blood glucose levels, and no increase in hypoglycemia. Thus, where feasible, there should be structured order sets that provide computerized advice for glucose control.”

6. Throughout all sections, personalization of care was emphasized. Although this is not a new concept that was introduced to the 2019 Standards of Care, the ADA made patient-centered      care a priority throughout all guidelines, calling for healthcare providers to avoid “therapeutic inertia” and adapt the recommendations to each individual, customizing each patient’s regime based on their individual factors, preferences, values, and goals.

See the full summary of revisions for the 2019 Standards in Diabetes Care