ADA Releases Revised Clinical Practice Guidelines

By Brian McCurdy

The American Diabetes Association (ADA) recently released its revisions of the 2002 Clinical Practice Recommendations. Will these revisions lead to improved clarity, better outcomes and a heightened awareness of diagnostic indicators among all health care professionals? Those in the know seem to have a favorable impression. “Two of the association’s most critical position statements have been completely revised and several others have been updated, using the ADA’s system for grading scientific evidence to support clinical practice recommendations,” says Lee Sanders, DPM, the Former President of Health Care and Education for the ADA. The rewritten position statements are the “Standards of Medical Care for Patients with Diabetes” and “Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Complications.” Dr. Sanders says the “Standards of Medical Care” detail specific goals of treatment, at diagnosis and in continuing care, and offers recommendations concerning complications and particular patient groups, such as the elderly, children and pregnant women. He adds that the “Nutrition Principles” outline the ADA’s goals and recommendations for nutrient composition, energy balance, alcohol and micronutrients in patients who have type 1 or type 2 diabetes. “I feel the position statements by the ADA are right on the money in that they target the essential points of managing the diabetic foot,” says Tamara Fishman, DPM. “From a practical standpoint, most, if not all, podiatrists are aware of the risk diabetic patients have for infections and amputations. However, I feel many other specialists will benefit tremendously from this information, especially primary care physicians.” Dr. Fishman, the Chairman of the Wound Care Institute in Florida, says most primary care doctors never ask patients about their feet or examine them. Other changes from the ADA include the unveiling of a new position statement on “Treatment of Hypertension in Adult Patients with Diabetes Mellitus,” and a terminology change that replaced “HbA1C” with the simpler “A1C” to denote the test for long-term glycemic control. However, ADA’s position statement on “Preventive Foot Care in People With Diabetes” (based on a 1998 Diabetes Care paper) remains unchanged. As Dr. Sanders notes, these foot care guidelines have been adopted by the American Podiatric Medical Association and the American Orthopedic Foot and Ankle Society. “Fundamental to preventive management of the foot in people with diabetes is risk identification,” says Dr. Sanders. “There is an increased risk of foot ulcers and amputations in people who have diabetes for 10 years or longer, are male, have poor glucose control, or who have cardiovascular, retinal or renal complications.” Given the heightened risk of foot ulcers and amputations, Dr. Sanders says DPMs should be particularly vigilant when they see patients who have peripheral neuropathy with loss of protective sensation; altered biomechanics (with neuropathy); increased plantar pressure; and/or peripheral vascular disease. For more information on the 2002 Clinical Practice Recommendations, see the ADA Web site, Can A1c Screening Improve Early Detection Of Diabetes? Roughly five million Americans have undiagnosed diabetes, according to a recent study published in the January issue of the Journal of General Internal Medicine. This highly undiagnosed population prompted the study’s researchers to conduct hemoglobin A1c (HbA1c) testing on 1,200 men and women patients between the ages of 45 and 64. The patients had not been diagnosed with diabetes but were under a doctor’s care. Researchers found that nearly 5 percent of those tested had type 2 diabetes. The study’s results suggested the A1c test catches more cases of diabetes than other well-known tests such as the fasting plasma glucose test. While the A1c test has been used to test for type 2 diabetes for some time, the study indicated that targeting certain patients with routine screening, using this test, may lead to an early diagnosis. Clearly, there is a strong need for early diagnosis as statistics on the potential prevalence of Type 2 diabetes continue to rise. Researchers from the Centers for Disease Control and Prevention (CDC) estimate 47 million Americans are at risk for type 2 diabetes. The estimated number of those diagnosed with the disease is around 16 million but medical researchers believe that number is much higher. In a study published in the January edition of The Journal of the American Medical Association, CDC researchers observed almost 9,000 U.S. men and women between 1988 and 1994. They noted that 22 percent of adults between the ages of 20 to 79 exhibited some warning signs linked to type 2 diabetes, such as obesity, high blood pressure and high blood sugar. “I’m not surprised by the high numbers, based on the increased obesity and sedentary lifestyle of the American population …,” says Terence Albright, DPM, the Dean of the Dr. William M. Scholl College of Podiatric Medicine at Finch University. Dr. Albright says other warning signs of diabetes include family history, rapid changes in weight loss/gain, patients having an excessive desire for water and/or food and an increase in urination. Administering the A1c test to patients who fit the profile of having type 2 diabetes may help detect the disease in its early stages. With early detection, patients may be able to make lifestyle changes such as monitoring their sugar intake and engaging in physical activity. Dr. Albright advocates the A1c test as the “best method” for detection. — Gina DiGironimo Production Editor Changes In The Wind For HIPAA The Administrative Simplification Compliance Act, signed into law in December by President Bush, has some changes for the Health Insurance Portability and Accountability Act (HIPAA). The new law provides a one-year extension (to Oct. 16, 2003) for compliance with the HIPAA standard transactions and code set requirements. To qualify for the extension, providers must submit a comprehensive plan detailing their budget, schedule, work plan, implementation strategy and other info by October 16, 2002. The law requires the Department of Health and Human Services to promulgate a model compliance form for the plan by March 31. The act requires all healthcare providers to submit claims electronically to Medicare and cease filing forms on paper, according to Billie Bradford, Director of the Department of Socioeconomics and Practice Management with the American College of Foot and Ankle Surgeons (ACFAS). She says the HIPAA covers standard electronic formats for enrollment, eligibility, referral authorization and certification, payment and remittance advice, claims, health plan premium payments and claims status. “One of your most important responsibilities will be ensuring that your billing systems or billing companies and claims clearinghouses are compliant with HIPAA standards and that you have written such a requirement into any of your contracts,” points out Bradford. The Administrative Simplification Compliance Act maintains the compliance deadlines for the privacy rule. The deadline is still April 14, 2003 for all covered entities and April 14, 2004 for small health plans. For more info on HIPAA, you may check out the ACFAS’s HIPAA Privacy Manual, which should be available soon on the Web site, It is $99 for ACFAS members and $199 for non-members. — B.M. Enbrel Clears FDA Hurdle For Psoriatic Arthritis Close to 1 million people suffer from psoriatic arthritis, which can cause swelling, severe pain and permanent joint damage. Fortunately, the FDA has just approved Enbrel as the first drug for treating psoriatic arthritis. Enbrel, a genetically engineered protein, attacks the overactive immune system cells which cause the condition. “This new drug, since it so specifically targets immune cells that are causing the problem, it goes right to where the heart of the problem is and does not cause as much trouble for the rest of the body,” says Philip Mease, M.D., of Seattle Rheumatoid Associates. Manufactured by Immunex, Enbrel previously was approved to treat patients with symptoms of moderate to severe rheumatoid arthritis who have not responded well to other treatments. The company says Enbrel can significantly reduce pain and swollen joints in those who have rheumatoid arthritis, which affects over 2 million Americans. A previous FDA report warned Enbrel has been associated with a small number of serious nervous system problems. The FDA recommends physicians monitor those taking Enbrel for symptoms like numbness, confusion, difficulty walking and changes in vision. — B.M.

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