The Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE), a nationally endorsed guideline process that targets primary health care practitioners, has updated a Diabetes Outpatient Care Flow Sheet for clinicians. The information on the flow sheet is all evidence-based and published in the clinical practice guidelines from Diabetes Canada and C-CHANGE.
Last revised in 2009, the flow sheet has since been updated to align with current leading practices, including Diabetes Canada’s updated clinical practice guidelines, and now includes a billing incentive for primary care.
The updated flow sheet is currently integrated and available for Accuro® EMR users to access directly from their EMR. If you use another certified EMR, please ask your EMR vendor about obtaining this updated version in your EMR.
Updates to the Diabetes Outpatient Care Flow Sheet – Details
The format of this flow sheet has been kept similar to improve ease of use among clinicians who are familiar with using the currently available flow sheet from 2009.
The flow sheet is organized using the 2020 “ABCDES” of diabetes management from Diabetes Canada, which reflects the landmark STENO-2 trial (2008) noting the importance of a multimodal approach to diabetes care (including pharmacotherapy and health behaviours change) to prevent cardiovascular complications and death. This flow sheet is consistent with the most up-to-date clinical practice guidelines in Canada.
List of Updates:
- Expanded glycemic control section to reflect both laboratory values and home readings (including capillary blood glucose and intermittently scanned/real-time continuous glucose monitoring (including concept of time in range) using terminology consistent with current guidelines
- Added hypoglycemic episodes “CBG <4” for clarity/education
- Clarified indications for ASA and ACE inhibitor/ARBs based on most recent guidelines
- Added “mental health and memory” to self-management/motivational counselling given the importance to screen for depression, anxiety, and cognitive decline which may co-exist with diabetes; a variety of mood scales exist for depression and anxiety and have been noted
- Simplified lipid control with most updated 2021 lipid guidelines
- Added an important Diabetes Canada 2020 update related to adjusting and advancing therapy if there are changes in clinical status, which may necessitate addition/switching to evidence-based therapy (e.g., SGLT2i and/or GLP1RA) based on clinical conditions/risk factors (i.e., ASCVD, CKD, HF or age >60 years with 2 CV risk factors), reassessing glycemic targets, medication dosing, de-prescribing, and side effects of therapy
- Added dilated eye exam screening intervals recommended for DM1 (annually) and DM2 (q1-2 years) or as per eyecare provider recommendations for clarity/education
- Corrected urine ACR cut-offs which are now the same for both male and female (i.e., urine ACR <2) and consideration of ECG screening interval of q3-5 years if age > 40 or diabetes complications
- Expanded patient education to include topics such as referral to diabetes education centre, as well as considerations for driving safety, pregnancy, sick day medication management (SADMANS), hypoglycemia, etc.
- Added ‘Plan’ and follow-up section
The top of the flow sheet has a reminder re: K030 and Q040 billing codes if criteria is met annually.
This flow sheet has been endorsed by C-CHANGE and Diabetes Canada as a credible resource for primary care providers.
- Lead for update: Dr. Rahul Jain (Co-chair, C-CHANGE Guidelines; Family Physician and Hospitalist, Ontario)
- Dr. Harpreet Bajaj (Chair, Clinical Practice Guidelines, Diabetes Canada; Endocrinologist, Ontario)
- Dr. Sheldon Tobe (Co-chair, C-CHANGE Guidelines; Nephrologist, Ontario)
- Dr. James Kim (Steering Committee Member, Clinical Practice Guidelines, Diabetes Canada; Family Physician, Alberta)