Vol. 15, No. 3, Spring 2002

Managing Diabetes Care in California

James Oliver

Tracking health information at a clinic is a big job, but tracking such information for all Indians with diabetes is a monumental task. With funding from The California Endowment and the Indian Health Service (IHS), the Northwest Portland Area Indian Health Board established a project to assist 32 rural and urban Indian health care programs in California. The California Areas Diabetes Surveillance Project mirrors the strategies of the nationally recognized Northwest Tribal Diabetes Surveillance Project, which serves tribes in Idaho, Oregon, and Washington. The primary goal of the California project is to assist California tribes to build sustainable infrastructure for diabetes health information and case management. Recently, these two large programs merged into one, the Western Tribal Diabetes Project (WTDP). Following up on the success of these efforts, we will soon implement a national arm to disseminate the project nationwide.

Much of the work of the project will assist clinics with improving medical care of people with diabetes. Clinics now are required to complete the annual IHS Diabetes Audit. This compares a clinic’s performance against national medical standards of care for people with diabetes. The audit includes about fifty data elements, covering everything from dental and eye exams to lab tests to immunizations. Clinics that actively track this information are better able to identify how patient care can be improved for individuals and are therefore better able to deliver the necessary services to their patients.

It is vital that all people with diabetes play an active and informed role in their own diabetes care. At a minimum, diabetics need to receive the services listed in the "IHS Standard of Care for Patients with Type 2 Diabetes" (available at the IHS web site: http://www.ihs.gov/MedicalPrograms/Diabetes/2001soc.pdf). One of the WTDP’s roles is to help clinics track and manage health care information, so that they are better able to meet the standards of care. Some key components of these standards are included here so that you can be more proactive in your own health or the health of a loved one with diabetes.

Baseline Assessments

Baseline assessments should be conducted as soon as a patient has been diagnosed with diabetes and should include the following:

Height: For adults, height needs to be measured and recorded just once. Heights are frequently missing from medical records. For children, height needs to be measured and recorded at each clinic visit.

Date of diagnosis: An accurate date of diagnosis should be recorded at the first visit, since complications occur more frequently the longer one has had diabetes.

Electrocardiogram (ECG): A baseline ECG is required and should be repeated every one to five years, as clinically indicated. For people over age forty, however, or those who have had diabetes for more than ten years, an ECG is recommended every one to two years.

Tuberculin skin test (PPD): A simple skin test for tuberculosis infection, the PPD should be done and evaluated after the date of diagnosis. This test is frequently not performed or is not documented in medical records.

Checked Each Clinic Visit

These checks are important for monitoring and adjusting care.

Weight: Weight gain can lead to increased blood pressure and increased risk of heart attack. Moderate weight loss, on the other hand, improves blood pressure and blood glucose control in people with diabetes.

Blood pressure: High blood pressure is known to worsen kidney problems, a common complication of diabetes. Many people with type 2 diabetes have high blood pressure when diagnosed. The goal for blood pressure is less than 130/80.

Blood sugar control: Blood glucose, either fasting or random, should be checked at each visit. Glycosylated hemoglobin (or A1c) should be checked every three months. A good A1c range for people with diabetes is less than 7. A high A1c increases the risk of serious complications, such as eye, kidney, and nerve damage.

Foot check: People with diabetes often lose feeling in their feet. For this reason, it is important to have regular foot checks.

Immunizations

Immunizations are important because people with diabetes often have difficulty fighting off infections. We have found that information on immunizations is frequently missing from medical records.

Flu shot: A yearly flu vaccine should be given.

Pneumonia vaccine (pneumovax): A pneumovax helps protect against pneumonia and should be given at the time of diagnosis.

Tetanus and Diphtheria (TD): A TD vaccine should be given every ten years.

Annual Exams

Three specialized examinations are needed each year. These exams are typically either not completed or not documented in medical records.

Dilated eye exam: Eye damage, sometimes leading to severe vision impairment, is a common complication of diabetes. A dilated eye exam is the only way to check for eye damage.

Complete dental exam: Dental problems are also common in people with diabetes. An annual complete dental exam, including X-rays, is needed each year.

Comprehensive foot exam: A comprehensive foot exam, usually administered by a podiatrist or a primary care provider, is different than the foot check that should occur at each clinic visit. It should include checking circulation and evaluating sensation. This helps to protect against foot ulcers and amputations.

Annual Lab Tests

Yearly checks of the following items can help both doctor and patient monitor overall health and diabetes management:

Complete urinalysis (UA): A complete UA, including screening for microalbumin, helps test for kidney damage. Screening positive for microalbumin is a risk factor for heart disease.

Creatinine: Serum creatinine is another test for kidney damage.

Lipid panel: A lipid panel measures the amount of cholesterol and fat in the blood. When the total cholesterol is over 200, or the LDL (bad cholesterol) is over 100, or the HDL (good cholesterol) is under 40, the risk of heart disease increases. The triglycerides, a measure of blood fat, should be less than 150.

Aspirin

All people with diabetes should be prescribed a low dose of aspirin. Aspirin thins the blood, helping to protect against heart attacks. We have found that many people with diabetes are not prescribed low doses of aspirin.

Preventing Diabetes

The recently completed Diabetes Prevention Program (DPP), a major multicenter trial conducted by the National Institutes of Health, showed that diet and exercise can prevent type 2 diabetes in people at the highest risk. Program participants reduced the fat in their diets, received lifestyle counseling, and exercised thirty minutes per day, usually by walking. There is the potential for these findings to have a huge impact in Indian Country, which has the highest rates of diabetes in the nation.

Participants in the DPP all had Impaired Glucose Tolerance (IGT), a condition in which blood sugar is high, but not high enough to diagnose diabetes. It is frequently a precursor to type 2 diabetes. Most people with IGT have no symptoms but do have the highest risk of going on to develop type 2 diabetes. IGT is identified by using a screening test. The WTDP is currently developing a tool kit to assist tribal health care facilities with screening. This will help identify target populations for prevention programs. We plan to work with tribes to help them track health information for screening and prevention programs. As more is learned about preventing diabetes, we will bring forward new prevention strategies. Our ultimate goal is to prevent diabetes throughout all of Indian Country.

James Oliver is the Northwest Regional Project Specialist for the Western Tribal Diabetes Project. A registered dietitian, he is a member of the Lummi Nation.