1998 clinical practice guidelines for the management of diabetes in Canada

Supplement to CMAJ 1998;159 (8 Suppl)

© 1998 Canadian Medical Association

Diabetes is a complex chronic disorder with major short- and long-term health implications. Diabetes care hinges on the daily commitment of the person with diabetes to self-management, balancing appropriate lifestyle choices and pharmacologic therapy.^16,17 To learn and use the varied, complex skills required to achieve this balance, people with diabetes need the support of an interdisciplinary team of health and other professionals who are expert in total care for diabetes. The diabetes health care (DHC) team provides this support.^18,19,20

Central to the DHC team is the person with diabetes and his or her family. Also at the core are the primary care physician (who may be a diabetes specialist), the diabetes medical specialist/endocrinologist/internist and diabetes educators (nurses and dietitians). If required, other professional and lay caregivers may be included in an expanded DHC team. These may be medical specialists (ophthalmologists, cardiologists, neurologists, nephrologists and obstetricians), other health professionals (other nurses and dietitians, social workers, psychologists and other mental health workers, pharmacists, chiropodists, podiatrists and optometrists), community and public health agencies and other health organizations.²¹

The central recommendation for diabetes care is that it be organized around the DHC team, which is interdisciplinary and provides comprehensive, shared care. The model of shared care that entails ongoing communication among, and participation of, all members of the DHC team increases the commitment and participation of the person with diabetes. ^22,23,24 Care is most effective when delivered in a structured manner^{25,26,27,28,29,30} and when it includes ongoing education and comprehensive care as essential components.^18,31

One of the key properties of the DHC team is flexibility in its organization, which will allow for identification of members of the core and expanded team according to the characteristics of the community in question. Thus, the DHC team can be structured to meet the demands of urban, rural and even remote settings.^24,26 Indeed, models of regional DHC teams exist in a number of Canadian provinces, including Manitoba, Nova Scotia and northern Ontario. Incumbent on any DHC team is the need to maintain current standards of diabetes care.

The primary care physician has an important role as the first, and at times the principal, medical contact for the person with diabetes.^32,33 In this capacity, primary care physicians have an obligation to incorporate and evaluate clinical practice guidelines for the care of their patients with diabetes.^{28, 34}

Recommendations

1. Diabetes care should be organized around an interdisciplinary diabetes health care (DHC) team. [Grade B, Level 2+^18,19,22]
2. As an essential member of the DHC team, the primary care physician (who may be a diabetes specialist), in consultation with the other members of the team, has the responsibility to
   1. incorporate current clinical practice guidelines for diabetes care into daily management practices^23,24
   2. coordinate and facilitate the care of the person with diabetes and use a system of timely reminders for diabetes assessment and management^{23,24, 35}
   3. assure communication among all members of the DHC team.^23,24,35 [Grade B, Level 2^23,24,35]
3. Initial and ongoing education of the person with diabetes should be an integral part of diabetes management and not merely an adjunct to treatment. [Grade B, Level 2+^17,18,36]

Rights and responsibilities

Diabetes touches all aspects of a person's life. It may affect a person's ability to function successfully in both personal and work settings.^37,38 Improved tools and self-management systems now allow many people with diabetes to function well and to achieve near-normal glucose levels. Therefore, previous blanket discrimination 3 in the workplace, in motor vehicle licensing and in vocational training and counselling -- should now be replaced with a case-by-case review. Education and advocacy should focus on awareness of the rights and responsibilities of people with diabetes. ³⁹ Primary care physicians and other health professionals should ensure that they are knowledgeable about provincial and national laws related to people with diabetes.⁴⁰

Recommendations

4. The health care system, governments and society as a whole should recognize the rights of people with diabetes by striving to
   1. include them in the planning of health care delivery
   2. provide equitable access to diabetes care and education that adheres to the Clinical Practice Guidelines for the Management of Diabetes in Canada and the Standards for Diabetes Education in Canada
   3. eliminate diabetes as an unnecessary cause of workplace injury, illness and disability
   4. eliminate diabetes as a source of blanket discrimination with respect to health care services, employment, insurance and other related individual rights
   5. develop a comprehensive information system to support interdisciplinary delivery of diabetes care. [Grade D, consensus]
5. Further, people with diabetes should strive to
   1. become full participants in the DHC team, participate actively in planning and take responsibility for their personal health care delivery
   2. adhere to recommended guidelines where the public interest is at stake (e.g., motor vehicle licensing). [Grade D, consensus]