Putting Diabetes Canada’s Clinical Practice Guidelines into practice

By Noah Ivers and Dr Catherine Yu

The 2018 Diabetes Canada Clinical Practice Guidelines (Guidelines) represent a monumental accomplishment, involving tens of thousands of hours of volunteer work by 135 health professionals across the country. Importantly, the Guidelines were also developed with the participation of informed people with diabetes on the Expert Committee to ensure that their views and preferences inform the guideline development process and the recommendations, as well as development of key messages using lay terms directed at people living with diabetes. Thus, the Guidelines provide recommendations for management of diabetes of that cover a broad range of situations, informed by rigorous review of the evidence.

Patients with type 2 diabetes underestimate their cardiovascular risk

However, guidelines do not self-implement. The massive contributions by volunteer health professionals across the country will be for naught without a concerted effort toward dissemination and implementation. We now ask for your help, as members of the diabetes community, in this effort.

Who are we and why are we bothering with all this? We are a family physician (Ivers) and endocrinologist (Yu) who act as co-chairs of the Diabetes Canada Guideline Dissemination and Implementation Committee. This committee has over 50 members representing the full range of relevant disciplines, as well as people living with or affected by diabetes, from across the country. We do this because we believe in the potential of all of us working together to find ways to deliver evidence-based care in a patient-centred manner.

We know that change is not easy. It’s not easy for our patients who live with diabetes and it’s not easy for us in our practice when we are used to managing patients in a certain way. It’s one thing to be aware of the Guidelines… it’s quite another to put them into practice. For Guidelines to lead to better outcomes for patients, we need to move from awareness, to agreement, and then on to adoption and adherence. But even the most well-intentioned people may struggle to turn their intentions into action. Can we help them (and each other) as we collectively aim to improve diabetes outcomes?

In this article, we provide an overview of some of the Key Messages in dissemination of the Guidelines. In future articles, we will expand upon this overview, zeroing in on each of the Key Messages and describing some of the relevant tools that we hope will help with implementation.

ABCDES³ of Diabetes Care

Providing care concordant with the Guidelines requires conversations about opportunities to:

Key Message 1: reduce the risk of complications;

Key Message 2: ensure safety; and

Key Message 3: support self-management.

A revised acronym that incorporates the Key Messages above was developed as an aid to facilitate comprehensive assessment and action by any member of the healthcare team, “ABCDES³”:

		GUIDELINE TARGET (or personalized goal)
A	A1C targets	A1C ≤7%; if on insulin or insulin secretagogue, assess for hypoglycemia and ensure driving safety
B	BP targets	BP <130/80 mmHg; if on treatment, assess for risk of falls
C	Cholesterol targets	LDL-C <2.0 mmol/L
D	Drugs for CVD risk reduction	ACEi/ARB (if CVD, age ≥55 with risk factors, OR diabetes complications) Statin (if CVD, age ≥40 for Type 2, OR diabetes complications) ASA (if CVD) SLGT2i/GLP1ra with demonstrated CV benefit (if have type 2 DM with CVD and A1C not at target)
E	Exercise goals and healthy Eating	150 minutes of moderate to vigorous aerobic activity/ week and resistance exercises 2-3 times/week Follow healthy dietary pattern (i.e. Mediterranean diet, low glycemic index)
S	Screening for complications	Cardiac: ECG every 3-5 years if age >40 OR diabetes complications Foot: Monofilament/Vibration yearly or more if abnormal Kidney: Test eGFR and ACR yearly, or more if abnormal Retinopathy: yearly dilated retinal exam
S	Smoking cessation	If smoker: Ask permission to give advice, arrange therapy and provide support
S	Self-management, stress, other barriers	Set personalized goals Assess for stress, mental health, and financial or other concerns that might be barriers to achieving goals

Some guideline tools:

At the Guidelines website (http://guidelines.diabetes.ca/) you can find educational slide kits videos and case studies, a quick reference guide, healthcare provider tools organized by Key Message, as well as resources for people with diabetes in a variety of languages. In addition, both IOS and Android apps are available.

Many healthcare provider tools are available on the Guidelines website and also on the app offer ‘interactive’ clinical decision support. These help you identify ways to use the recommendations for particular patients. For example, the interactive tool entitled Reducing Vascular Risk asks you to input selected information about your patient and then indicates which medication the Guideline would recommend. This tool provides you with a way to implement the ‘D’ in the ABCDES³ above. For the ‘A’, the interactive tool entitled Pharmacotherapy for Type 2 Diabetes provides clinical decision support regarding the Guideline recommendations when considering adding the next antihyperglycemic medication class. If people with diabetes are medications that can cause hypoglycemia (i.e., insulin or insulin secretagogues), the Guidelines recommend counselling regarding safe driving. Now available on the Guidelines website is a handout you can give to such patients to help implement this recommendation:

People with diabetes benefit when they include a range of health professionals in their care team. We need all team members, along with the person with diabetes themselves, to be working ‘on the same page’. This was the impetus for an ABCDES3 tool that we hope people will ‘share to improve their care’ (will provide updated link prior to publication). We hope people with diabetes will take this tool with them when they visit their primary care clinicians, including their pharmacist, nurse, dietician, etcetera to help keep things on track and identify key action items.

Noah Ivers MD PhD CCFP and Catherine Yu FRCPC MHSc Co-Chairs, 2018 Clinical Practice Guidelines Dissemination and Implementation Committee.