There is a hierarchy of evidence used to rank the strength and validity of the evidence from expert opinion to systematic reviews and meta-analyses (see table 1). Background. found an increase in events per patient year among MDI patients, however, all of the other RCTs showed no difference between the patient groups in this aspect. In brief, more than 734,000 patients with diabetes were identified in the Ontario Diabetes Database (ODD) and followed for up to 10 years. CSII pumps also confer a statistically significant reduction in glucose variability as compared to MDI in adults with type 1 diabetes (>19 years) however the clinical significance is unknown. Over 70 experts representing diverse VA health care professionals, federal agencies, and experts from clinical and academic settings participated in the initial guideline development process. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. The VA/DoD Guidelines do not propose single “optimal” or “ideal” target values to be applied to most or all patients. In the development of the VA/DoD Guidelines, life expectancy was considered to be a proxy for the effect of comorbid conditions on the benefit of glycemic control. primary care vs. hospital outpatient clinic vs. community clinic). observed a higher number of events per patient week in the CSII pump group than the MDI group, while Hoogma et al. Duration of follow up of the studies ranged from 6 months to 8 years with a median follow-up duration of 12 months, but whether the follow up was measured from participant entry into study or from the end of intervention was unclear in some of the studies. Ontario Health Technology Assessment Series 2009;9(19). The GRADE quality of evidence for the use of CSII in adults with type 2 diabetes is, therefore, low and any estimate of effect is uncertain. Furthermore, household and even neighbourhood socioeconomic status were indentified as influencing both the access of diabetes care and the use of available care. Only 18% ( n = 136) were based on Level I evidence (or equivalent); 25% ( n = 185) were based on Level II evidence, 29% ( n = 218) on Level III, and 9% ( n = 66) on Level IV. The global burden of disease and disability is now mainly caused by non-communicable diseases (NCDs), notably heart disease, stroke, dementia, diabetes and cancer.1,2 NCD prevention strategies are now prioritizing four major risk factors: tobacco, poor diet, physical inactivity and alcohol.1–3 However, there is debate about the most … diet, behaviour modification, increased physical activity, and drugs therapy) but who have not lost weight permanently. Hypertension is common in diabetes and is associated with the onset and progression of both microvascular and macrovascular complications. A comprehensive literature search was performed in OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, The Cochrane Library, and INAHTA for studies published between January 1, 2007 and January 31, 2009. The strongest predictor of diabetes complications is glycaemic control and achieving HbA1c ≤ 7.0% is the primary management target. rates of intervention uptake or trends in current programs in place in the Province), and estimates on funding and prices. Thank you for your interest in spreading the word about Diabetes Care. The incidence of microvascular complications in such patients is estimated to be quite low, and attainment of this target goal should prevent symptoms of uncontrolled hyperglycemia. Policy considerations and available funds may dictate shifts in care at a local level, but evidence-based guidelines provide strategic direction. There are, however, still risks associated with the use of CSII pumps. Most studies reported gender with a mean percentage of females of 67%. Where possible, economic analyses were performed using an Ontario-specific economic model for type 2 diabetes. Q2B.1.a. Reference lists were also checked for relevant studies. reported no difference in treatment satisfaction between CSII pump users and MDI users while Brutomesso et al. At the request of the MAS, the Institute for Clinical Evaluative Sciences (ICES) undertook a study of barriers to diabetes care as experienced by patients in Ontario. Studies varied considerably on characteristics of design, population, and intervention/control. published in the Canadian Journal of Diabetes in 2008. Several meta-analyses and systematic reviews have demonstrated improved health outcomes with self-management support programs in type 2 diabetics. Meta-analysis of seven trials identified a moderate but significant reduction in HbA1c levels (~0.5% reduction) in favour blood glucose home telemonitoring compared to usual care for adults with type 2 diabetes). Cholesterol levels were examined in three studies and blood pressure reduction in two studies. David Aron, MD, MS; John Brehm, MD, FACP; Stephen Brietzke, Col. (ret), MC, USAF; Paul R. Conlin, MD; Susan Davis, CPT MS, USA; Kathryn J. Dolter, RN, PhD, LTC, ANC; Jeffrey M. Hardin, CDR, MD, USN; Rodney Hayward, MD; Debbie Khachikian, PharmD; Juan Esteban Palacio, CPT, MD, USA; Laura Pistey, LCDR, RN, MSN, CDE, USN; Jacqueline A. Pugh, MD; Donna Schoonover, RN, EdD; Capt. Hanaire-Broutin et al. Efficacy is the capacity or power to produce an effect. Mixed populations with respect to insulin therapy. To apply the model to other geographic areas (such as Ontario), however, it requires needs adaptation. In addition, since prior treatment regimens varied between participants (no requirement for patients to be on MDI), study findings may not be generalizable to the population eligible for a pump in Ontario. The primary outcomes for this review were glycosylated hemoglobin (HbA1c) levels and systolic blood pressure (SBP). Based on examination of an Ontario-specific multidisciplinary care program, specialized multidisciplinary community care for the management of type 2 diabetes is a cost-effective strategy. Studies (7,8) estimate that the incidence of end-stage microvascular complications is low when diabetes develops at age ≥65 years, primarily because life expectancy is <10 years. All three studies found an improvement in QoL for CSII users compared to those using MDI, although various instruments were used among the studies and possible reporting bias was evident as non-positive outcomes were not consistently reported. The ePub format uses eBook readers, which have several "ease of reading" features The systolic blood pressure (SBP) and diastolic blood pressure (DBP) treatment targets recommended by the VA/DoD Group were derived from the results of the HOT and UKPDS trials. CSII pumps for the treatment of adults with type 2 diabetes. The Group adopted the concept that individual risk-benefit appraisal and stratification is of prime importance in a value-oriented health care system. Based on moderate quality evidence, bariatric surgery is highly effective for the improvement and resolution of diabetes in patients who are morbidly obese (BMI >35 kg/m2). The aim is to ensure that residents of Ontario have access to the best available new health technologies that will improve patient outcomes. Small sample sizes for web entry studies increase the chance that findings are false positive. Diabetes (i.e. In cases where a deviation from this standard is used, an explanation is offered as to the reasons, the assumptions, and the revised approach. Funding for this supplement was provided by The Seattle Epidemiologic Research and Information Center and the VA Cooperative Studies Program. Both studies demonstrated that both CSII pumps and MDI reduce HbA1c, but neither treatment modality was found to be superior to the other. referred to as levels of evidence. Glargine has no peak action time and instead acts consistently over a twenty-four hour period, helping reduce the frequency of hypoglycemic episodes. The majority (90%) of diabetes patients have type 2 diabetes and in 2005, an estimated 8.8% of Ontario’s population had diabetes, representing more than 816,000 Ontarians. The absolute risk reduction in diabetes-related clinical end points was about 5 per 1,000 patient-years (41 vs. 46 events/1,000 patient-years, P = 0.03). The American Association of Diabetes Educators (AADE) has identified problem solving as one of seven core diabetes self-management behaviors (AADE-7). All studies reported that there were no differences in the number of mild hypoglycemic events in patients on CSII pumps versus MDI. Diabetes is a highly prevalent chronic metabolic disorder that interferes with the body’s ability to produce or effectively use insulin. A literature search was conducted from January 1996 to December 2004 that included OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, The Cochrane Library, and the INAHTA and CRD databases. Lower quality evidence suggests malabsorptive techniques are the superior alternative for diabetes improvement and resolution. Evidence-based information on Diabetes from hundreds of trustworthy sources for health and social care. Until such modeling is ready for everyday use, clinicians and their patients should continue to consider individual circumstances, events, and preferences within the context of the strength of available evidence. There is indirect evidence that the use of newer long-acting insulins (e.g. Several systematic reviews and meta-analyses have examined multidisciplinary care programs, but these have either been limited to a specific component of multidisciplinary care (e.g. Trials reported consistent results for the outcomes HbA1c, mean blood glucose and glucose variability, but the directness or generalizability of studies, particularly with respect to the generalizability of the diabetic population, was questionable as most trials used highly motivated populations with fairly good glycemic control. For the outcome of hypoglycaemic events the evidence was further downgraded to very low since there was conflicting evidence between studies with respect to the frequency of mild and severe hypoglycaemic events in patients using CSII pumps as compared to CSII (see Table 2). Reference lists of selected articles were also checked for relevant studies. Conflicting results were reported regarding injection site reactions between the two studies. There is evidence from a meta-analysis of indirect, prospective studies, retrospective studies and case series that malabsorptive techniques are better than other banding techniques in terms of improvement and resolution of diabetes. Guidelines are meant to be applicable to large and complex health care systems and yet to empower the process of individual patient-practitioner counseling and goal setting based on individual risk stratification. Most events were related to severe hypoglycemia and diabetic ketoacidosis. Glucose variability was not examined in either study and the authors reported no difference in weight gain between the CSII pump group and MDI groups at the end of study. Significant limitations of the literature exist specifically: All studies sponsored by insulin pump manufacturers, Types of insulins used in study varied (NPH vs. glargine), Generalizability of studies in question as populations were highly motivated and half of studies used insulin pens as the mode of delivery for MDI. These devices attempt to closely mimic the behaviour of the pancreas, continuously providing a basal level insulin to the body with additional boluses at meal times. The Institute for Social Research at York University conducted the survey for this study. A search for “Evidence pyramid” generates many different diagrams. This suggests that patients were highly motivated. Of 2,316 patients with no retinopathy at baseline, only 0.2% required any photocoagulation within 3 years and only 1.1% needed treatment within 6 years, despite this cohort having many patients with poor glycemic and blood pressure control. The results of the ODEM model using data on clinical efficacy obtained from the above MAS systematic reviews can be used in order to prioritize funding. 2002) did not report study data on mean blood glucose but noted that the differences were not statistically significant. The benefit of glycemic control in type 2 diabetes was convincingly demonstrated in the U.K. MAS has, therefore, conducted a review of the available evidence on blood glucose home telemonitoring and management technologies for type 2 diabetes. Despite differences in individual needs for coping with diabetes, there is general agreement for the necessity of supportive programs for patient self-management. The following interventionists were reported (categories not mutually exclusive): nurse (36%), dietician (18%), physician (9%), pharmacist (9%), peer leader/community worker (18%), and other (36%). Furthermore, specialized multidisciplinary community care provided by at least a pharmacist and primary care physician is an effective model of care for the improvement of both glycemic control (based on high quality evidence) and SBP (based on moderate quality evidence). Unit costs were collected and assigned to each of the different health care sectors. Regarding Subgroup analyses, exploratory analysis seems to suggest differences in effect sizes for the primary outcome when analyzing by subgroup; however, subgroup analyses should only be viewed as exploratory or hypothesis-generating. For mild hypoglycemic events, DeVries et al. Prevention of type 2 diabetes evidence-based nutrition practice guideline Published by Academy of Nutrition and Dietetics, 01 August 2014 The focus of this guideline is on medical nutrition therapy (MNT) for individuals who are at high risk for type 2 diabetes, such as individuals with prediabetes and adults with metabolic syndrome. Leonard Pogach, MD, and Curtis Hobbs, LTC (P), MD, USA. There are conflicting findings with respect to an improved quality of life for patients using CSII pumps as compared to MDI. The authors confirmed that early retinopathy on previous examinations was the main risk factor for requiring photocoagulation within the next 3–6 years. Ontario Health Technology Assessment Series, Presented to the Ontario Health Technology Advisory Committee in June 2009. Periodic screening for diabetic retinopathy is well established as a cost-effective strategy for preventing vision loss (17–19) when accomplished as fundoscopy through dilated pupils (20) or multifield fundus photography interpreted by an experienced reader (21). Randomized controlled trials (RCT) assess the efficacy of an intervention. 2) CSII pumps versus MDI of insulin in insulin-dependent adults with type 2 diabetes, 3) Behavioural interventions versus no intervention in adults with type 2 diabetes, 4) Bariatric surgery versus no surgery in morbidly obese adults with type 2 diabetes. Proposed treatment will produce benefit compared with the display of certain parts of an intervention DBP is > mmHg! Mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the use of risk. Interventions effective in improving glycemic control targets with their patients is also available individuals... 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