Early diagnosis and treatment can significantly reduce the risk of chronic complications of diabetes. Clinic and managed care surveys identified several gaps in diabetes preventive care practices.


Eye Care

Clinical practice guidelines recommends all people with diabetes have a dilated eye examinations. Juvenile-onset diabetics need to be assessed for eye disease within five years after diagnosis or generally not until after puberty. People with Type II diabetes should have an eye evaluation shortly after diagnosis. If seven field photography is available and no eye disease is present at diagnosis then follow-up annual eye exams should begin four years after diagnosis. Women with diabetes should be assessed for diabetic eye disease before conception and during pregnancy, especially during the first trimester.

However, patients with persistent elevated levels of blood glucose or proteinuria should have annual eye disease examinations. These assessments should be conducted on a more frequent basis when eye disease is present.

  • 35% of diabetics screened were identified with one or more forms of eye disease including; diabetic retinopathy, macular edema, degeneration, cataracts or increased ocular pressure.
  • 20% of physicians do not refer patients for dilated eye exams.
  • 29% of patients do not get a dilated eye exam annually.
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Foot Care

The clinical practice recommendations indicate that all people with diabetes have their feet visually inspected for amputation risk factors at every visit. Each clinical visit should include an assessment of corns, calluses, pre-ulcers, ulcers, and skin integrity. At least once per year the foot should be inspected for neuropathy, vascular changes, musculoskeletal, and skin and nail deformities. Early diagnosis and treatment of these conditions reduces the risk of infection, gangrene and amputations by up to 85%.

  • 47% of diabetics screened were identified with one or more amputation risk factors including:
  • 43% with loss of protective sensation
  • 20% with loss of circulation
  • 20% with foot deformities.
  • 67% of patients surveyed reported foot problems.
  • 17-25% of physicians check foot pulses and nerve sensation at every visit.
  • 45% of patients have not ever had their feet examined by a nurse or physician
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Kidney and Cardiovascular Care

Assessments of kidney function should be conducted within five years of diagnosis for people with Type I diabetes. People with Type II diabetes should have annual kidney disease function assessments for microproteinuria. Early diagnosis and treatment reduce the risk of end stage renal disease.

  • 33-55% of physicians do not test for microproteinuria.
  • 62% of screened patients had blood pressure levels exceeding recommended levels (140/90 mm Hg).
  • 66% of patients were obese (body mass index >27).
  • 25% had total blood cholesterol levels over 240 mg/dl.
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Study Conclusion

The information from these studies and clinics have now identified several factors contributing to the high rate of diabetes complications and mortality in North Dakota. New methods need to be identified to improve utilization and referral to diabetes preventive care services and education. Poor compliance to the standards of care appears to be caused by a lack of understanding of the importance glycemic control and new care and treatment guidelines. One factor contributing this problem is a lack of education on available reimbursement for preventive care services.

The Phico Insurance Company recently alerted providers that they can be successfully sued if there has been no documentation that the person with diabetes has been referred to preventive care services including early diagnosis, treatment, self care education, and medical nutrition therapy. Phico recommends providers utilize available preventive care services and reimbursement by identifying ways to incorporate the American Diabetes Association's Clinical Practice Recommendations into their daily practice.

The North Dakota Hospital Association, in cooperation with the Diabetes Control Project, has developed care flow sheets for monitoring the frequency of clinical assessments, treatment and education. The North Dakota Department of Health Diabetes Control Project is available to assist care facilities develop new ways to improve the service and delivery of care to people with diabetes. This includes patient and professional education materials on diabetes care, treatment.

For additional information on resources available contact the Diabetes Control Project Director Darian Schaubert at 1-800-472-2180.

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