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糖尿病医学实践指南

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糖尿病医学实践指南Diabetes Diabetes MEDICAL PRACTICE GUIDELINES State of Florida Agency for Health Care Administration These guidelines are endorsed under the authority of the Florida Health Care and Insurance Reform Act of 1993, Section 408.02, Chapter 93-129, Laws of Florida. Endor...
糖尿病医学实践指南
Diabetes Diabetes MEDICAL PRACTICE GUIDELINES State of Florida Agency for Health Care Administration These guidelines are endorsed under the authority of the Florida Health Care and Insurance Reform Act of 1993, Section 408.02, Chapter 93-129, Laws of Florida. Endorsed on October 19, 2001 Permission to duplicate and distribute granted. Table of Contents —————————— Table of Contents........................................................ ......................................................1 State of Florida Agency for Health Care Administration Notice on Practice Parameters........ .................................... .............. .................................... ............. …......3 Florida Diabetes Practice Guideline Advisory Committee.................................. ....... ....... ....... ....... ....... ....... ....... ................................4 Introduction....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... . ....... ......5 Definitions.. ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... 6 Minimum Standards of Care for Children with Diabetes............ ................ ... ..........8 Assessment of Need for Hospitalization for Stabilization of Newly Diagnosed Children with Diabetes........ ............ .... .. .. ............. .................................. 8 Indications for Hospitalization for Diabetic Ketoacidosis (DKA)..............................................8 After Medical Stabilization (One to Three Days) ............................ ........ ......... ..........................8 Ongoing Disease Management – First Year . ........................... ....... ....... .................................... 8 .Office Visits........... ....... ....... ....... ....... ....... ....... ...... . ...... .. ..... ........ ....... ....... ....... ....... ......... 9 Annual Assessment ....... ....... ....... ....... ....... ....... ....... ........ ....... ....... ....... ....... ....... ....... .......9 Second Year and Beyond. ....... ....... ....... ....... .... ....... ....... ....... ....... ....... ....... ....... ....... ....... ... 9 Criteria that Suggest Children or Adolescents have Type 2 Diabetes.. . ...... . ...... . .................. 9 Treatment Goals for Children with Type 2 Diabetes................ .... ................ .... ................ ....10 Treatment Components for Type 2 Diabete ........................ ............ ............ ............................. 11 Education.......... ............ ............ ............ ............ ............ ............ ............ ............ ............ ............11 Monitoring............. ............ ............ ............ ............ ............ ............ ............ ............ ............ .......11 Nutrition herapy. ............ ............ ............ ............ ............ ............ ............ .......... ............ ...........11 Exercis.............. ............ ............ ............ ............ ............ ............ ............ ............ ............ .............11 Follow-Up Visit ...... ............ ............ ............ ............ ............ ............ ....... ........... ............ ..........11 Drug Therapy........ ............ ............ ............ ............ ............ ............ ............ ............ ............ .. ....11 Additional Medication ......................................................................................................................12 Monitoring for Complication ..........................................................................................................12 Treatment of Complications .......................................... .... ............ .. ............................................12 Hypertension...... ............ ............ ............ ............ ............ ............ ............ ............ .... .... .. .. ......12 Hyperdipidemia.. ............ ............ ............ ............ ............ ............ ............ ............ ............ .... ....12 Minimum Standards of Care for Adults..................................... .............. ... ...............13 Hospital Admission Guidelines for Adults ............. ........ ... ... .. ..............................................14 Initial Assessment ..... ............ ............ ............ ............ ............ ............ ............ ............ .............14 Assess Patient’s Disease Status and Risk Factor.............. ... ......................................................14 Follow-up Assessments (Three-Month Intervals) ........... ........ ........ ......................................16 Prevention/Assessment of Complications.............................. ... ... .. .... .... ..............................17 Glucose Control .. ............ ............ ............ ............ ............ ............ ............ ............ ............ .....17 Retinal Evaluation ............ ............ ............ ............ ............ ............ ............ .... ......... ............ .... 17 Cardiac Peripheral Vascular Evaluation ........... ............ ............ .. ................. .............................17 Aspirin Therapy ... ............ ............ ............ ............ ............ .......... .... ............ ............ .... .. .. .. ...18 Tobacco Cessation ....................... .... .... .........................................................................................18 Renal Evaluation... ............ ............ ............ ............ ............ ............ ............ ............ ............ .... ..18 Neuropathy Evaluation ............ ............ ............ ............ ............ ............ ............ ............ ............18 Immunization Evaluation.................................... ............ ...............................................................19 Preconception Counseling ..............................................................................................20 Gestational Diabetes ...................................................................................................... 22 Detection and Diagnosis......... ............ ........... ......... ............ ............ ............ ............ .... .... .... ..22 Therapeutic Strategies .......................................................................................................................23 Maternal Strategies ................................................... ............ ............ .... ........................................ 23 Fetal Strategies...... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..23 Nutritional Counseling ..................................................................................................................... 23 Insulin Therapy ... ............ ............ ............ ............ ............ ............ ............ ............ ............ ........23 Postpartum Follow-up Care ............................................................................................................ 24 Diabetes Self-Management Training............................................................................. 25 Diabetes Overview ... ............ ............ ............ ............ ............ ............ ............ ............ ............. 26 Medication .......... ............ ............ ............ ............ ............ ............ ............ ............ ............ ........ 26 Monitoring and Use of Results......................... .. .. ........................................................................ 27 Nutrition ........... ............ ............ ............ ............ ............ ............ ............ ............ ............ .......... 27 Immunizations ........... ............ ............ ............ ............ ............ ............ ............ ............ ............ .28 Prevention, Detection and Treatment of Acute and Chronic Complications...... .. .. ............ 29 Exercise and Activity ............ ............ ............ ............ ............ ............ ............ .. .. .. .. .. .. .. .. 29 Importance of An Individualized Exercise Plan .......................................................................... 30 Reducing Exercise Risk..................................................................................................................... 30 Guidelines for Safe Exercise Including Preparing for Exercise (Adjustment of Food and Insulin).................................................................................................. 30 Benefits of Exercise .......................................................................................................................... 30 Glycemic Response to Exercise....................................................................................................... 30 Stress and Psycho-Social Adjustment............................................................................................. 30 Children ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ .. ....... 31 Adolescents ...... ............ ............ ............ ............ ............ ............ ............ ............ ............ .. .. .... 31 Young Adults..... ............ ............ ............ ............ ............ ............ ............ ............ ............ .. .. ... 31 Older Adult ........... ............ ............ ............ ............ ............ ............ .............. ............ ............ ....31 Foot, Skin and Dental Care............................................................................................................. 32 Use of Health Care Systems and Community Resources............................................................ 32 Reference .................................. .................................. . .. .. .. .. ................................. 33 Appendices .................................. .................................. ...... .. .. .. ............................. 35 State of Florida Agency for Health Care Administration Notice on Practice Parameters —————————— These practice guidelines, produced in consultation with the Diabetes Practice Guideline Advisory Committee, are endorsed by the Florida Agency for Health Care Administration (AHCA) pursuant to the Florida Health Care and Insurance Reform Act of 1993, Chapter 93-129, section 408.02, Laws of Florida. These guidelines are endorsed for information, education and review by the medical community, other professionals, and the public. These guidelines are not to be used as fixed protocols. They merely identify typical courses of intervention. There may be patients who require more or less treatment. However, those cases that exceed or fall below the guidelines may be subject to more careful scrutiny and may require documentation of the special circumstances. Treatment must be based on patient need as well as professional judgment. In summary, medical guidelines are patient management strategies, which are not entirely inclusive or exclusive of all methods of reasonable care that can obtain the same results, or of those which consider the particular needs of the patient and available resources. While standards are intended to be rigid and mandatory — making exceptions rare and difficult to justify — guidelines are more flexible, although they should be followed in most cases. Guidelines can be tailored to fit individual needs that are influenced by the patient, setting, resources and other factors. Deviations can be justified by individual circumstances. Options are intended to be neutral. They merely note the interventions available to practitioners. Guidelines are revisited every three years or less. Review is based on valid scientific update. These guidelines were initially endorsed on January 16, 1998. Revisions have been made to the original guidelines and endorsed on October 19, 2001. Practice Parameter Subject: Diabetes Guideline Review Comments a Guideline Review Conmments and Information Order from: Cost Diabetes Medical Practice Guidelines For technical information on these guidelines, and to submit your scientifically-valid review comments, please contact: Debby Walters Division of Health Policy AHCA Address at right Agency for Health Care Administration Call Center Toll Free: (888) 419-3456 Free Copy Order From: Cost Florida Diabetes Medical Practice Guideline Advisory Committee —————————— Pauline Ellis Director Programs and Government Relations American Diabetes Association Florida Affiliate, Inc. Maitland, Florida Gigi Foster, RN Community Health Nurse Diabetes Control Program Department of Health Tallahassee, Florida Bonnie Gaughan-Bailey Health Care Coordinator Diabetes Control Program Department of Health Tallahassee, Florida Barbara Joswick, RN, MS, CDE Florida Hospital Medical Center Diabetes Center Orlando, Florida John I. Malone, MD University of South Florida, College of Medicine Tampa, Florida State of Florida Diabetes Advisory Council Members Samuel Crockett, MD Chairperson Florida Diabetes Implementation Work Group Members Larry Deeb, MD Primary Facilitator Diabetes Medical Practice Guideline Advisory Committee Chairperson Larry Deeb, MD Pediatric Endocrinology Consultant Agency for Health Care Administration and Children's Clinic Tallahassee, Florida Diabetes Medical Practice Guideline Advisory Committee Vice Chairperson Louis Chaykin, MD Endocrinology 21110 Biscayne Boulevard Aventura, Florida Diabetes Medical Practice Guideline Advisory Committee Technical Advisor and Coordinator Debby Walters Senior Health Policy Analyst Agency for Health Care Administration Tallahassee, Florida Introduction —————————— Diabetes is a chronic illness requiring continual medical care and education in order to prevent acute complications and reduce the risk of long-term medical problems. In Florida, over 1,000,000 individuals have been diagnosed as having diabetes. It is estimated that over 300,000 additional adults have diabetes but will not know it until confronted with one of its serious complications. Recognizing the devastating effects of this disease without a comprehensive approach to treatment, the Florida Legislature passed legislation in 1996 that requires all insurance policies and HMO plans to provide coverage for all medically appropriate equipment and supplies in addition to diabetes outpatient self-management training and educational services used to treat diabetes. The legislation directed the Florida Agency for Health Care Administration to develop standards for self-management training. In 1997 the agency, in conjunction with the Department of Health, Florida affiliate of the American Diabetes Association, endocrinologists, internists, dietitians, diabetes self-management educators and other experts in the delivery of treatment services for individuals with diabetes, developed the initial practice guidelines to address the complex needs of patients with this illness. In 2001 revisions were made to the original guidelines to reflect the most current medical standards used in the treatment of children and adults having Type 1 and Type 2 diabetes. It is important for members of the health care team to consider the following: ◆Each patient is an individual and requires care that addresses their individual specific medical and psychosocial needs. It is imperative that the intensity and level of medical and psycho-social support necessary to accomplish treatment goals meet ongoing changes in the patient’s needs, care and lifestyle. ◆A critical element for the successful treatment of all patients with diabetes is participation in a comprehensive self-management care and education program. Ongoing support, maintenance, and modifications in treatment regimes and lifestyle changes, all require continued patient and caregiver participation. Self-management education is necessary to accomplish these goals. These guidelines were developed using the American Diabetes Association (ADA) “Standards of Medical Care for Patients With Diabetes Mellitus,” ADA National Standards for Diabetes Self-Management Education, current World Health Organization Diagnostic Criteria, the American Association of Clinical Endocrinologists Diabetes Care Guideline, and the Lawson Wilkens Pediatric Endocrine Society Diabetes Guideline. The guidelines are organized into the following areas: Definitions, Minimum Standards of Care for Children and Adults (which includes guidelines for hospital admission, initial and follow-up assessments), Strategies for Treatment of Gestational Diabetes, Guidelines for a Comprehensive Diabetes Self-Management Treatment Program, References, and Appendices. Definitions —————————— (AACE) American Association of Clinical Endocrinologists. (ADA) American Diabetes Association - is the not-for-profit national voluntary health agency concerned with diabetes. Board-Certified Adult Endocrinologist - refers to a physician who has completed a residency program in internal medicine and a fellowship program in endocrinology, diabetes and metabolism and passed the certification examinations of the American Board of Internal Medicine to become board certified in endocrinology, diabetes and metabolism. Board-Certified Pediatric Endocrinologist - refers to a physician who has completed a residency program in pediatrics and a fellowship program in pediatric endocrinology, diabetes, and metabolism and has passed the certification examinations of the American Board of Pediatrics to become board-certified in Pediatric Endocrinology. Certified Diabetes Educator - refers to a health care professional who has passed the certification exam of, and is currently certified by, the National Certification Board for Diabetes Educators and meets the criteria set forth by the American Association of Diabetes Educators (AADE) and has passed the national exam established by the AADE. Diabetes - is a chronic disorder characterized by abnormalities in the metabolism of carbohydrate, protein and fat. Types of diabetes include: Type 1 Diabetes - Beta-cell destruction usually leading to absolute insulin deficiency. This form of diabetes is usually immune mediated. Type 2 Diabetes - Ranges from predominantly insulin resistance with relative insulin deficiency to a predominately secretory defect with insulin resistance. Diabetes Outpatient Self-Management Training - is a program designed to help individuals to learn to manage their diabetes in an outpatient setting. They learn self-management skills and making lifestyle changes to effectively manage their diabetes and to avoid or delay the complications associated with this illness. The diagnosis of diabetes is made with test results of: ◆random plasma glucose greater than 200 mg/dl (11.1 mmol) plus classic symptoms (polyuria, polydipsia, unexplained weight loss, etc.), ◆fasting plasma glucose (8-14 hours) greater than or equal to 126 mg/dl (7.0 mmol) on two occasions, and/or ◆two-hour plasma glucose greater than 200 mg/dl (11.1 mmol) after 75 gm glucose challenge (World Health Organization definition). In the absence of unequivocal hyperglycemia with acute metabolic decompensation confirmation should be made by repeat testing on a different day. Fasting plasma glucose is the recommended method for clinical diagnosis of diabetes. It is easier for the patient and much less expensive to perform. Gestational Diabetes - occurs in women who manifest glucose intolerance during pregnancy. Impaired Fasting Glucose - occurs when a person’s fasting blood glucose level is above normal but fails to meet current diagn
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