D iabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. Specifically titled sections of the standards address children with diabetes, pregnant women, and people with prediabetes. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A large number of these interventions have been shown to be cost-effective (4). A grading system (Table 1), developed by the American Diabetes Association (ADA) andmodeled after existingmethods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence. For the current revision, committee members systematically searched Medline for human studies related to each subsection and published since 1 January 2010. Recommendations (bulleted at the beginning of each subsection and also listed in the “Executive Summary: Standards of Medical Care in Diabetesd2012”) were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strength of the wording to the strength of the evidence. A table linking the changes in recommendations to new evidence can be reviewed at http:// professional.diabetes.org/CPR_Search. aspx. Subsequently, as is the case for all Position Statements, the standards of care were reviewed and approved by the ExecutiveCommittee of ADA’s Board ofDirectors, which includes health care professionals, scientists, and lay people. Feedback from the larger clinical community was valuable for the 2012 revision of the standards. Readers who wish to comment on the “Standards of Medical Care in Diabetesd2012” are invited to do so at http://professional.diabetes.org/ CPR_Search.aspx. Members of the Professional Practice Committee disclose all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the standards revisionmeeting. Members of the committee, their employer, and their disclosed conflicts of interest are listed in the “Professional PracticeCommitteeMembers” table (see pg. S109). The AmericanDiabetes Association funds development of the standards and all its position statements out of its general revenues and does not utilize industry support for these purposes.

https://www.science-open.com/document_file/bb04d9d0-b3df-4133-9494-e71e300f4279/PubMedCentral/bb04d9d0-b3df-4133-9494-e71e300f4279.pdf

Standards of Medical Care in Diabetes—2012

D iabetes is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was used to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA multidisciplinary Professional Practice Committee, and new evidence is incorporated. Members of the Professional Practice Committee and their disclosed conflicts of interest are listed in the Introduction. Subsequently, as with all position statements, the standards of care are reviewed and approved by the Executive Committee of ADA’s Board of Directors.

Standards of Medical Care in Diabetes—2010

https://www.scienceopen.com/document_file/57689460-a74a-45be-b1a0-a3e9cd0c5d62/PubMedCentral/57689460-a74a-45be-b1a0-a3e9cd0c5d62.pdf

Standards of Medical Care in Diabetes—2013

I. CLASSIFICATION AND DIAGNOSIS OF DIABETES, p. S12 A. Classification of diabetes B. Diagnosis of diabetes C. Categories of increased risk for diabetes (prediabetes) II. TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS, p. S13 A. Testing for type 2 diabetes and risk of future diabetes in adults B. Testing for type 2 diabetes in children C. Screening for type 1 diabetes III. DETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS, p. S15 IV. PREVENTION/DELAY OF TYPE 2 DIABETES, p. S16 V. DIABETES CARE, p. S16 A. Initial evaluation B. Management C. Glycemic control 1. Assessment of glycemic control a. Glucose monitoring b. A1C 2. Glycemic goals in adults D. Pharmacologic and overall approaches to treatment 1. Therapy for type 1 diabetes 2. Therapy for type 2 diabetes E. Diabetes self-management education F. Medical nutrition therapy G. Physical activity H. Psychosocial assessment and care I. When treatment goals are not met J. Hypoglycemia K. Intercurrent illness L. Bariatric surgery M. Immunization VI. PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS, p. S27 A. Cardiovascular disease 1. Hypertension/blood pressure control 2. Dyslipidemia/lipid management 3. Antiplatelet agents 4. Smoking cessation 5. Coronary heart disease screening and treatment B. Nephropathy screening and treatment C. Retinopathy screening and treatment D. Neuropathy screening and treatment E. Foot care VII. DIABETES CARE IN SPECIFIC POPULATIONS, p. S38 A. Children and adolescents 1. Type 1 diabetes Glycemic control a. Screening and management of chronic complications in children and adolescents with type 1 diabetes i. Nephropathy ii. Hypertension iii. Dyslipidemia iv. Retinopathy v. Celiac disease vi. Hypothyroidism b. Self-management c. School and day care d. Transition from pediatric to adult care 2. Type 2 diabetes 3. Monogenic diabetes syndromes B. Preconception care C. Older adults D. Cystic fibrosis–related diabetes VIII. DIABETES CARE IN SPECIFIC SETTINGS, p. S43 A. Diabetes care in the hospital 1. Glycemic targets in hospitalized patients 2. Anti-hyperglycemic agents in hospitalized patients 3. Preventing hypoglycemia 4. Diabetes care providers in the hospital 5. Self-management in the hospital 6. Diabetes self-management education in the hospital 7. Medical nutrition therapy in the hospital 8. Bedside blood glucose monitoring 9. Discharge planning IX. STRATEGIES FOR IMPROVING DIABETES CARE, p. S46

Standards of Medical Care in Diabetes—2011

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

OBJECTIVE —The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. RESEARCH DESIGN AND METHODS —In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic ( n = 200), waiting room at a diabetes specialty clinic ( n = 179), a diabetes management study program ( n = 167), and an ongoing diabetes management program ( n = 158). RESULTS —Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high ( r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high ( r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (α > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas diet-controlled subjects displayed the lowest scores ( P CONCLUSIONS —The DDS has a consistent, generalizable factor structure and good internal reliability and validity across four different clinical sites. The new instrument may serve as a valuable measure of diabetes-related emotional distress for use in research and clinical practice.

https://care.diabetesjournals.org/content/diacare/28/3/626.full.pdf

Assessing psychosocial distress in diabetes: development of the diabetes distress scale.

Rapid and far-reaching technological advances are revolutionizing the ways in which people relate, communicate, and live their daily lives. Technologies that were hardly used a few years ago, such as the Internet, e-mail, and video teleconferencing, are becoming familiar methods for modern communication. Telecommunications will continue to evolve quickly, spawning telehealth applications for research and the provision of clinical care in communities, university settings, clinics, and medical facilities. The impact on psychology will be significant. This article examines the application of developing technologies as they relate to psychology and discusses implications for professional research and practice.

http://psycnet.apa.org/journals/amp/55/4/407.pdf

The coming of age of telecommunications in psychological research and practice.

OBJECTIVE —This study evaluated the Diabetes Outpatient Intensive Treatment (DOIT) program, a multiday group education and skills training experience combined with daily medical management, followed by case management over 6 months. Using a randomized control design, the study explored how DOIT affected glycemic control and self-care behaviors over a short term. The impact of two additional factors on clinical outcomes were also examined (frequency of case management contacts and whether or not insulin was started during the program). RESEARCH DESIGN AND METHODS —Patients with type 1 and type 2 diabetes in poor glycemic control (A1c >8.5%) were randomly assigned to DOIT or a second condition, entitled EDUPOST, which was standard diabetes care with the addition of quarterly educational mailings. A total of 167 patients (78 EDUPOST, 89 DOIT) completed all baseline measures, including A1c and a questionnaire assessing diabetes-related self-care behaviors. At 6 months, 117 patients (52 EDUPOST, 65 DOIT) returned to complete a follow-up A1c and the identical self-care questionnaire. RESULTS —At follow-up, DOIT evidenced a significantly greater drop in A1c than EDUPOST. DOIT patients also reported significantly more frequent blood glucose monitoring and greater attention to carbohydrate and fat contents (ACFC) of food compared with EDUPOST patients. An increase in ACFC over the 6-month period was associated with improved glycemic control among DOIT patients. Also, the frequency of nurse case manager follow-up contacts was positively linked to better A1c outcomes. The addition of insulin did not appear to be a significant contributor to glycemic change. CONCLUSIONS —DOIT appears to be effective in promoting better diabetes care and positively influencing glycemia and diabetes-related self-care behaviors. However, it demands significant time, commitment, and careful coordination with many health care professionals. The role of the nurse case manager in providing ongoing follow-up contact seems important.

https://care.diabetesjournals.org/content/diacare/26/11/3048.full.pdf

Integrating Medical Management With Diabetes Self-Management Training: A randomized control trial of the Diabetes Outpatient Intensive Treatment program

Background Vocal cord dysfunction (VCD) is an obstructive upper airway syndrome that frequently mimics asthma and for which there is no empirical treatment of choice. Objective To describe two military service members experiencing VCD who were treated with psychophysiologic self-regulation training. Methods Both cases were active-duty military members with VCD confirmed by laryngoscopy They each received biofeedback self-regulation training to decrease tension in the extrinsic laryngeal musculature. Results Both patients responded to the treatment, denied the presence of dsypnea, and had resumed military physical training. Conclusions Psychophysiologic self-regulation strategies both with and without concurrent speech therapy positively impacted VCD symptoms.

Psychophysiologic treatment of vocal cord dysfunction.

Psychophysiological diagnostic and therapeutic methods, to include biofeedback, have been found to be empirically effective in the treatment of a variety of physical disorders. In many areas of the country, however, certified biofeedback practitioners are not well distributed, limiting patient access to this treatment modality. Psychologists at Tripler Army Medical Center have pioneered efforts to develop and provide these needed services via a telehealth venue. Such capability significantly improves access to care, particularly for patient's located at considerable distance from the provider. As the telecommunications infrastructure in rural and remote areas is often quite basic, such a system must be capable of operating within these limited parameters. The system developed by the authors provides real-time video and audio interactivity and allows the therapist to monitor and control biofeedback equipment located at the remote site. The authors discuss the clinical applications, the technology, and relevant practical and ethical issues.

/pdf/biofeedback-via-telehealth-a-new-frontier-for-applied-54dr36k7ps.pdf

Jay Edward Earles

Papers

Assessing psychosocial distress in diabetes: development of the diabetes distress scale.

The coming of age of telecommunications in psychological research and practice.

Integrating Medical Management With Diabetes Self-Management Training: A randomized control trial of the Diabetes Outpatient Intensive Treatment program

Psychophysiologic treatment of vocal cord dysfunction.

Biofeedback via telehealth: a new frontier for applied psychophysiology.