• Wisconsin Diabetes Advisory Group. Wisconsin diabetes mellitus essential care guidelines. Madison (WI): Wisconsin Diabetes Prevention and Control Program; 2008. Various p. [17 references]

This is the current release of the guideline.

This guideline updates a previous version: Wisconsin Diabetes Advisory Group. Wisconsin essential diabetes mellitus care guidelines. Madison (WI): Wisconsin Diabetes Prevention and Control Program; 2004. Various p. [246 references]

• Pre-diabetes
• Diabetes mellitus (type 1, type 2, gestational)
• Diabetes-related complications (diabetic foot ulceration, diabetic foot infection, Charcot foot, diabetic neuropathy, diabetic retinopathy, diabetic kidney disease, periodontal disease)

Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment

Cardiology
Dentistry
Dermatology
Emergency Medicine
Endocrinology
Family Practice
Gastroenterology
Geriatrics
Infectious Diseases
Internal Medicine
Nephrology
Neurology
Nursing
Nutrition
Obstetrics and Gynecology
Ophthalmology
Optometry
Pediatrics
Pharmacology
Physical Medicine and Rehabilitation
Podiatry
Preventive Medicine
Psychiatry
Psychology
Urology

Advanced Practice Nurses
Allied Health Personnel
Dentists
Dietitians
Emergency Medical Technicians/Paramedics
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Podiatrists
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Students

• To update the 2004 Wisconsin Diabetes Mellitus Essential Care Guidelines by incorporating the latest scientific evidence regarding good diabetes care
• To provide recommendations, which serve as a guide for the prevention and management of diabetes mellitus
• To provide a concise, general framework for the care of diabetes and prevention of diabetes-related complications
• To improve care and enhance quality of life for people with diabetes

Patients with type 1 and type 2 diabetes mellitus, pre-diabetes, and pre-gestational or gestational diabetes

General Care

1. Diabetes-focused visit including assessment of physical activity, diet, weight, body mass index (BMI), growth, and review of management plan
2. Self-management education
3. Medical nutrition therapy (MNT)
4. Glycemic control including:
   • A1c testing
   • Review of self-monitoring of blood glucose (SMBC)
   • Review of medication management monitoring, side effects, and hypoglycemic episodes
   • Glucose-lowering agents alone or in combination with one or more oral agents and/or insulin
5. Referral to specialists, as appropriate
6. Essential patient education

Cardiovascular Care

1. Lifestyle modification
2. Tobacco cessation
3. Lipid assessment and monitoring
4. Statin therapy combined with lifestyle changes
5. Blood pressure control
6. Aspirin prophylaxis

Kidney Care

1. Obtaining albumin/creatinine ratio, serum creatinine for estimated glomerular filtration rate (eGFR), and routine urinalysis, as appropriate
2. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) and aggressive blood pressure therapy

Eye Care

1. Dilated eye exams
2. Anti-vascular endothelial growth factor (anti-VEGF) treatment
3. Referral to ophthalmologist or optometrist and coordination of care

Neuropathies and Foot Care

1. Classification of diabetic neuropathy
2. Routine and comprehensive foot exams
3. Risk categorization
4. Management of foot ulceration and infection
5. Management of Charcot foot

Oral Care

1. Oral screening
2. Dental exam
3. Medical-dental collaboration

Emotional and Sexual Health Care

1. Assessment of emotional health, depression screening and recommendations, including postpartum depression
2. Assessment of sexual health concerns

Influenza and Pneumococcal Immunizations

Providing influenza and pneumococcal immunizations

Preconception and Pregnancy Care

1. Preconception counseling
2. Assessment of contraception/discuss family panning
3. Screening for gestational diabetes and type 2 diabetes post-gestational diabetes mellitus
4. Treatment of gestational diabetes
5. Postpartum screening, breastfeeding, and lactation counseling

Identification and Diagnosis of Pre-Diabetes and Type 2 Diabetes

1. Opportunistic and community screening
2. Fasting plasma glucose or oral glucose tolerance test

• Efficacy of management strategies at preventing, delaying, or reducing the risk of diabetes-related complications
• Glycemic control
• Quality of life
• Cost-effectiveness of care

Searches of Electronic Databases

Not stated

Not stated

Not stated

Not applicable

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

The Guidelines, originally published in 1998 and revised in 2001 and 2004, were again revised in 2008 to incorporate the latest scientific evidence regarding good diabetes care. The Wisconsin Diabetes Advisory Group and other health care professionals collaborated with the Wisconsin Diabetes Prevention and Control Program staff to update the Guidelines.

The following national and international studies were instrumental in shaping previous versions of the Guidelines and continue to shape the current Guidelines version for Wisconsin:

• Diabetes Control and Complications Trial
• United Kingdom Prospective Diabetes Study
• Diabetes Prevention Program

Not applicable

Optimal glycemic control is cost-effective and improves quality of life as well as reduces microvascular, and possible macrovascular, disease. It is estimated that for every one percent decrease in A1c, there is a 14-20% decrease in hospitalizations, resulting in $4-5 billion savings in direct health care costs alone.

Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review

The authors of these Guidelines, the Wisconsin Diabetes Advisory Group, and many other individuals were involved in the review and revision of various drafts and the final document.

The following table presents a brief summary of the diabetes mellitus essential care guidelines. For details and references for each specific area, please refer to the full text guideline.

*Consider more often if A1c >7.0% and/or complications exist.
**Consider referring to provider experienced in care of women with diabetes during pregnancy.

Clinical algorithms are provided in the original guideline document for:

• Type 2 Diabetes: Glycemic Control Pathway
• Treatment of Hypertension
• Screening and Initial Recommendations for Diabetic Kidney Disease (Microalbuminuria, Macroalbuminuria, and estimated glomerular filtration rate [eGFR])
• Diabetic Foot Ulceration
• Diabetic Foot Infection
• Charcot Foot
• Screening Adults for Pre-Diabetes and Type 2 Diabetes

The recommendations are based on results of clinical trials, accepted science, and expert opinions.

Overall Potential Benefits

• Prevention, early detection, and aggressive treatment can have a significant impact on the quality of life for people who have diabetes.
• The management goal for diabetes is to achieve optimal glycemic control to prevent acute and chronic complications.

Specific Potential Benefits

Self-Management Education

The primary goal of diabetes self-management education (DSME) is to provide knowledge and skill training, facilitate problem solving, help people identify barriers to change, and nurture the development of coping skills with the goal of achieving effective self-management and behavior change.

Medical Nutrition Therapy (MNT)

MNT can assist with the prevention of Type 2 diabetes, management of existing diabetes, and preventing (or at least slowing) the development of costly diabetes-related complications and hospitalizations. MNT can assist people at risk for or with diabetes to make informed and beneficial dietary changes to assist in reducing the amount of oral medication(s)/insulin needed to optimize glycemic control.

Cardiovascular Care

Aggressive assessment, prevention and treatment of cardiovascular disease through lifestyle modifications and medical interventions can lead to preventing the development of cardiovascular complications, and the prevention or reduction of occurrences or recurrences of events, enabling people with diabetes to lead healthier and longer lives.

Kidney Care

Early detection and intervention, along with improved glycemic and blood pressure control, can help reduce the risk of the development and progression of nephropathy. Screening for, and treatment of, early kidney disease resulting from diabetes adds years to life and is proven cost-effective.

Eye Care

Studies show that early detection and proper treatment reduces the risk of diabetic retinopathy and blindness by 50-60%. In addition, proper glycemic control can reduce the risk of progression of retinopathy by 34-76%. For each two unit decrease in A1c (e.g., A1c of 8.5% to 6.5%) there is a 50-75% reduction in complications. Retinal screening exams and early can result in increased years of sight and also assist with cost savings. Diabetic retinopathy is preventable; and, optimal glycemic control and blood pressure control can reduce its severity.

Neuropathies and Foot Care

Improved glycemic control and reduced variations in blood glucose excursions can slow the progression of neuropathy. Simple prevention strategies may reduce the rate of lower extremity complications in people with diabetes.

Oral Care

Individuals can avoid the negative outcomes of periodontitis through early screening, referral, and treatment.

Emotional/Sexual Health Care

Early recognition of depression symptoms, prompt treatment, and referral may lead to improved diabetes self-care and quality of life.

Influenza and Pneumococcal Immunizations

Immunizations can prevent serious illness, complications, hospitalizations, and death associated with influenza and pneumococcal disease.

Preconception and Pregnancy Care

Preconception counseling, intensive management to optimize glycemic control before pregnancy and during pregnancy, and utilizing a team of providers experienced in caring for women with diabetes can help at-risk women achieve health outcomes similar to those of women without diabetes.

Identification and Diagnosis of Pre-diabetes and Type 2 Diabetes

Without lifestyle changes, most people with pre-diabetes will develop Type 2 diabetes within ten years. Lifestyle modifications, such as dietary changes, a 5-10% weight loss, and increased physical activity (recommended 30 minutes a day, at least 5 days a week) can help return blood glucose levels to a normal range for many people.

For information on side effects of diabetes medications, see "Medication Update for Diabetes Mellitus - 2008" at the end of Section 4 in the original guideline document.

For information on side effects of lipid medications, see "Lipid Medication Update" at the end of Section 5 in the original guideline document.

For information on side effects of smoking cessation products, see "Quite Tobacco Series: Medication Chart" at the end of Section 5 in the original guideline document.

For information on contraindications of diabetes medications, see "Medication Update for Diabetes Mellitus - 2008" at the end of Section 4 in the original guideline document.

For information on contraindications of lipid medications, see "Lipid Medication Update" at the end of Section 5 in the original guideline document.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are contraindicated in pregnancy.

The Guidelines are population-based and therefore intended to be appropriate for most people with diabetes, but not intended to define the optimal level of care that an individual person may need. Clinical judgment may indicate the need for adjustments appropriate to the needs of each particular person (e.g., age, medical condition, or individual glycemic control goal).

Quality Improvement

Quality improvement is important in assuring optimal care for people with diabetes. Implementing evidence-based guidelines such as the Wisconsin Diabetes Mellitus Essential Care Guidelines is an example of improving quality care for people with diabetes in a health system or organization. In addition, the Guidelines set a standard of care for which to measure an organization's quality improvement in care. Possible data sources to audit care in a patient population include medical records (paper or electronic), patient registries, administrative claims data, pharmacy records, lab records, or patient surveys.

Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• Wisconsin Diabetes Advisory Group. Wisconsin diabetes mellitus essential care guidelines. Madison (WI): Wisconsin Diabetes Prevention and Control Program; 2008. Various p. [17 references]

Not applicable: The guideline was not adapted from another source.

2004 Dec (revised 2008)

Wisconsin Diabetes Prevention and Control Program - State/Local Government Agency [U.S.]

Centers for Disease Control and Prevention (CDC), Division of Diabetes Translation

Guideline Revision Workgroups
Wisconsin Diabetes Advisory Group

Revision Workgroup Members: Sue Backes, RN, BS, AE-C, CCM, Physicians Plus Insurance Corporation; Dory Blobner, RN, MS, CDE, Diabetes Educators International; Erika Brown, CSW, Wisconsin Dental Association, Inc.; Mary Bruskewitz, RN, BC-ADM, UW Health Diabetes Clinic; Jenny Camponeschi, MS, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Pat Celek, RN, CDE, Aurora Medical Group, Wisconsin Association for Perinatal Care Preconception and Prenatal Care Committee; April Eddy, RN, CNS, CDE (APNP) Meriter Center for Perinatal Care; Diane Elson, MD,  University of Wisconsin Hospital and Clinics; Edwin Ferguson, MD, Section of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health; Joan Fisher, RN, CCM, CDE, MercyCare Health Plans; Pamela Geis, BA, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Irene Golembiewski, MA, Media Solutions, University of Wisconsin School of Medicine and Public Health; Dee Helgeson, RN, BSN, CDE, Reedsburg Physicians Group; Thomas Haupt, MS, Communicable Disease Epidemiology Section, Wisconsin Department of Health Services; Sue Hugl, RN, BSN, CDE, Diabetes & Endocrine Center, Froedtert & Medical College of Wisconsin; Anthony M. Iacopino, DMD, PhD, University of Manitoba Faculty of Dentistry; Jonathan B. Jaffery, MD, Department of Medicine, Section of Nephrology, University of Wisconsin School of Medicine and Public Health; Audrey Johnson, RN, MSN, CDE, Aurora Health Care; Bob Johnson, MD, Wisconsin Academy of Family Physicians, Western Wisconsin Medical Associates – River Falls Medical Clinic; Virginia Jordan, MS, RD, CDE, West Central Wisconsin Area Association of Diabetes Educators; Judith Kozminski, Media Solutions, University of Wisconsin School of Medicine and Public Health; Jennifer Keeley, MS, RD, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Pamela Kittleson, RPh, UW Medical Foundation; Christy Kreul, BS, CCP, Physicians Plus Insurance Corporation; Scott Krueger, RD, CD, CDE, Wisconsin Dietetic Association and Menominee Tribal Clinic; Leah Ludlum, RN, BSN, CDE, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Steven B. Magill, MD, PhD, Midwest Endocrinology Associates and Aurora Diabetes Care Initiative, St. Luke's Medical Center; Jason Mailhot, DMD, MS, Marquette University of School of Dentistry; Melissa Meredith, MD, University of Wisconsin Hospital and Clinics; Mary Jane Mihajlovic, RN, BSN, HN-BC, CHTP, Unity Health Plans Insurance Corporation, Nutrition and Physical Activity Program, Department of Health Services; Pamela Myhre, RN, BSN, CDE, University of Wisconsin School of Nursing; Jane Nelson Worel, MS, APNP, Women's Cardiovascular Wellness Program, Meriter Heart Hospital; Angela Nimsgern, MPH, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Roxanne Radich, APNP, CNS, CDE, Fox Valley Nephrology Partners, Inc., The Diabetes Management Center; Paul M. Reber, DO, Division of Endocrinology, Dean Health Systems; Thomas Repas, DO, FACP, FACE, CDE, Regional Medical Clinic – Endocrinology, Rapid City, SD; Kathleen Rickerl, BA, RN, Mental Health Center of Dane County; Tim Ringhand, RN, MPH, Diabetes Prevention and Control Program, Wisconsin Department of Health Services; Elaine Rosenblatt, MSN, FNP-BC, UW Medical Foundation; David A. Scheidt, OD, Wisconsin Optometric Association; Thomas S. Stevens, MD, Wisconsin Academy of Ophthalmology; Alisa Sunness, RD, CDE, UW Health and Nutrition Education; Gail Underbakke, MS, RD, CD, Preventive Cardiology Program, University of Wisconsin Hospital and Clinics; Denise Walbrandt Pigarelli, PharmD, BC-ADM, University of Wisconsin School of Pharmacy, William S. Middleton VA Memorial Hospital; Naomi Wedel, MS, RD, CDE, BC-ADM, Capitol Area and Surrounding Communities Association of Diabetes Educators; William Weis, DPM, FACFAS, CWS, Wisconsin Society of Podiatric Medicine; Susan Williams, RN, CDE, Wheaton Franciscan Healthcare – St. Francis Hospital; Deborah Patrick Wubben, MD, MPH, University of Wisconsin School of Medicine and Public Health and Physicians Plus Insurance Corporation; Kara Yaeger, RN, BSN, CDE, UW Health – West Diabetes Clinic

Advisory Group Members: Della Alvarez, MS, FNP, APNP SC Johnson, Inc.; Diane Anderson, MS, RN, BC-FNP, APNP, CDE Gateway Technical College; Lori Arnoldussen, RN ThedaCare Health System; Sue Backes, RN, BS, AE-C, CCM, Physicians Plus Insurance Corporation; Jill Ballard, MPH, CHES, Evidence-Based Prevention Programs; Erika Brown, CSW Wisconsin Dental Association, Inc.; Catheryn Brue, MA, Heart Disease and Stroke Prevention Program, Wisconsin Department of Health Services; Mary Bruskewitz, RN, BC-ADM, UW Health Diabetes Clinic; Mary Carlson, WPS Health Insurance; Mariaelena Chang Calhoun, MSN, Children's Speciality Group, Medical College of Wisconsin; Isa Chase, RN, MSN, CPNP, Wisconsin Association of School Nurses; Wendy Countryman, RN, CCM, COHN-S, CVE WEA Trust; Pam Crouse, MS, RN, Wisconsin Primary Health Care Association; Diane Elson, MD, University of Wisconsin Hospital and Clinics; Elizabeth Fayram, PhD, RN, UW-Milwaukee College of Nursing; Joan Fisher, RN, CCM, CDE, MercyCare Health Plans; Charlanne FitzGerald, MPH, University of Wisconsin Population Health Institute; Susan Garman, Wisconsin Institute for Public Health; Gary Goyke, Wisconsin Council of the Blind and Visually Impaired; Sharon Gray, RN, BSN, Aurora Health Care; Yvonne D. Greer, MPH, RD, CD, Adolescent Community Health Program, City of Milwaukee Health Department; Dean Groth, MS, Pfizer, Inc., Linda Guddie, RPh, Diabetes Assessment and Resource Team, Froedtert Hospital Pharmacy; Peter Hanson, MD, Peter Christensen Health Clinic; Kristin Hill, Great Lakes Inter-Tribal Council, Inc.; Kate Holzum, RN, BSN, CDE, Diabetes Program, Children's Hospital of Wisconsin; Cindy Huber, National Kidney Foundation of Wisconsin; Todd Hughes, Novo Nordisk, Inc.; Sue Hugl, RN, BSN, CDE, Diabetes & Endocrine Center, Froedtert & Medical College of Wisconsin; Bob Johnson, MD, Wisconsin Academy of Family Physicians, Western Wisconsin Medical Associates – River Falls Medical Clinic; Virginia Jordan, MS, RD, CD, CDE, West Central Wisconsin Area Association of Diabetes Educators; Penny Kasprzak, American Diabetes Association, Wisconsin Area; Gwen Klinkner, MS, RN, ADMCNS-BC, CDE, University of Wisconsin Hospital and Clinics; Stephen R. Knapp, ProMark Communications, Inc.; Joy Kobiske, RN, MSN, FNP, CDE, Northeast Wisconsin Association of Diabetes Educators; Kevin Kortsch, DPM, Wisconsin Society of Podiatric Medicine, Inc.; Christy Kreul, BS, CCP, Physicians Plus Insurance Corporation; Scott Krueger, RD, CD, CDE, Wisconsin Dietetic Association, Menominee Tribal Clinic; Jim Lazarz, Juvenile Diabetes Research Foundation; Rob London, Independent Private Practitioner; Jason Mailhot, DMD, MS; Marquette University of School of Dentistry; W. Curtis Marshall, Southeast Regional Office, Wisconsin Division of Public Health; Suzanne Matthew, PhD, Northern Wisconsin Area Health Education Center; Patricia McManus, PhD, Black Health Coalition of Wisconsin; Melissa Meredith, MD, University of Wisconsin Hospital and Clinics; Traci Meyer, MS, Froedtert & Community Health; Mary Jane Mihajlovic, RN, BSN, HN-BC, CHTP, Unity Health Plans Insurance Corporation; Christine Miller, RN, PhD, Ruth S. Coleman College of Nursing, Cardinal Stritch University; Paula J. Miller, RN, BA, Wisconsin Lions Foundation; Gail Morgan American Heart Association, Midwest Affiliate; Timothy A. Moureau, APRN, BC-GNP, BC-ADM, CDE, Oneida Nation Community Health Center; Pam Myhre, RN, BSN, CDE, University of Wisconsin School of Nursing; Michael Nelipovich, RhD, Office for the Blind and Visually Impaired, Wisconsin Department of Health Services; Victoria O'Brien, American Heart Association, Greater Midwest Affiliate; Daniel Patterson, RN, BSN, Managed Health Services Network Health Plan; Mary Pesik, RD, CD, Nutrition and Physical Activity Program, Wisconsin Department of Health Services; John Quinette, American Diabetes Association, Wisconsin Area; Dana Richardson, MHA, RN, Wisconsin Hospital Association; Ray Ropers, Wisconsin Lions Diabetes Focus Group, Wisconsin Lions Foundation; David A. Scheidt, OD, Wisconsin Optometric Association; Joie Scheuer, BSN, RN, CDE, Southeastern Wisconsin Association of Diabetes Educators; Cynthia Schlough, Wisconsin Collaborative for Healthcare Quality; Susan Schmitz, BSN, GlaxoSmithKline; Debbie Scullin, RN, Fort Health Care; Shirley Sharp, BS, MA, Milwaukee Urban League, Inc.; Liz Shelley, Wisconsin Lions Foundation; Sonya Sidky, Wisconsin Department of Employee Trust Funds; Kay Simmons, MA, MetaStar, Inc.; Terry Spears Barnett, MD, Cream City Medical Society; Elizabeth Spencer, RD, MS, CDE, West Central Wisconsin Area Association of Diabetes Educators; Thomas S. Stevens, MD, Wisconsin Academy of Ophthalmology and Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health; Jacqueline Terry, National Black Nurses Association, Milwaukee Chapter; Julie Thiel, RPh, Pharmacy Society of Wisconsin; Melissa Tobler, RN, BSN, Wachovia Insurance Services; Anne Trinh, Great Lakes Inter-Tribal Council, Inc.; Fanaye Turner, Milwaukee Area Health Education Center; Vaughn Vance WEA Trust; Kathy Verstegen, RN, Wisconsin Association of School Nurses, Denise Walbrandt Pigarelli, PharmD, BC-ADM, Pharmacy Society of Wisconsin, University of Wisconsin School of Pharmacy; Katie Walsh, RN, CDE Innovex; Naomi Wedel, MS, RD, CDE, BC-ADM, Capitol Area and Surrounding Communities Association of Diabetes Educators; Mark Wegner, MD, MPH, Bureau of Community Health Promotion, Wisconsin Department of Health Services; Debbie Woelfel, Northeast Wisconsin Association of Diabetes Educators, Deborah Patrick Wubben, MD, MPH, University of Wisconsin School of Medicine and Public Health and Physicians Plus Insurance Corporation; Chua Xiong, Brown County Health Department; Kara Yaeger, RN, BSN, CDE, UW Health – West Diabetes Clinic; Jessica Zuercher, RN, BSN, Gerald L. Ignace Indian Health Center

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Wisconsin Diabetes Advisory Group. Wisconsin essential diabetes mellitus care guidelines. Madison (WI): Wisconsin Diabetes Prevention and Control Program; 2004. Various p. [246 references]

This NGC summary was completed by ECRI on July 22, 2005. This NGC summary was updated by ECRI Institute on February 16, 2009. The updated information was verified by the guideline developer on April 7, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.