Medicine

The purpose of this assignment is to identify a clinical practice guideline in your specialty area. You will be challenged to evaluate this guideline and discuss its use in clinical practice. This assignment is due at the end of Week 8 but can be completed anytime during this course. This assignment requires a considerable amount of time for completion. Do not wait until week 8 to begin this assignment.

Choose a health problem that you may commonly see in primary care nurse practitioner practice. Describe the health problem and recommended medical management for it. Research published clinical practice guidelines and evaluate the practice guideline you have selected based on the components listed in the Clinical Practice Guideline Template below.

Clinical Practice Guideline Prompts:

HEALTHCARE PROBLEM IDENTIFIED: Briefly describe the health problem you have identified. Include a discussion of morbidity, mortality, epidemiology and pathophysiology related to this health problem

PRACTICE GUIDELINE: Describe the clinical practice guideline used for this problem. Reflect on the questions included. Expand on your answer using support from evidence

Does the clinical practice guideline adequately address the health problem? Describe.
Is this practice guideline based on current evidence (within 5 years)? What is the strength of this evidence?
Does this clinical practice guideline adequately direct the healthcare provider in the management of a patient with this problem?
How effective is this clinical guideline in the management of patients with this healthcare problem? Think about how you would assess the effectiveness of patient management.
ANALYSIS: Think about future healthcare needs of patients with this problem, changing demographics, and changes in healthcare policies. Address these questions.

Does this clinical practice guideline need revision(s)? Please explain your answer in detail.
If you were going to revise this clinical practice guideline, what would you change? What evidence would you use to base your changes on?
How might changes in US demographics and healthcare reform affect this clinical practice guideline?
What strategies would you use to increase the likelihood that a new or modified clinical practice guideline would be adopted and used in clinical practice?
EVALUATION How would you determine its effectiveness of this revised clinical practice guideline in directing care for patients with the identified health problem? Outline the steps you might employ.

LEARNING POINTS (3-5 bullet points outlining key learning in this case.)

REFERENCES (APA formatting, current within past 5 years.)

ANSWER

Clinical Practice Guideline

Introduction

The primary care nurse practitioners play an essential role in primary care by assessing patients’ health, administering preventive care, and helping to manage and treat general conditions. They are educated, licensed and certified to offer chronic, comprehensive and continuous care characterized by long term connection with the patient. Therefore, this paper will focus on primary care nurse practitioner practice for type 2 diabetes health problem and the significance of clinical practice guidelines in providing primary care for type 2 diabetic individuals.

Type 2 Diabetes

Type 2 diabetes is a lingering health state that affects how the body transforms nutrients into energy. Considerably, type two diabetes leads to impairment in how the body uses and regulates insulin. In type 2 diabetes, there are two primary interrelated problems. The pancreas fails to produce enough insulin, and the cells poorly respond to insulin intake (Khan et al., 2020). The chronic health condition can go for long without being recognized since there are no noticeable symptoms. Type 2 diabetes is a major source of kidney failure, stroke, blindness heart attack and lower limb amputation. Type 2 diabetes affects both young and old people and is highly linked with mortality, morbidity and high health costs to the patient and their families.

Type 2 diabetes has been increasingly a global public health issue. Recent statistics indicate that Type 2 diabetes has had new epidemiological characteristics. Diabetes has steadily increased in developed nations such as the United States. It’s predicted that the rate of diabetes will continue rising, with the majority of the patients being between 45 and 64 years. Rapid urbanization and economic development have led to a high burden of diabetes in various parts of the world (Tinajero and Malik, 2021). Diabetes impacts a person’s functional abilities and life quality, which leads to premature mortality and weighty morbidity. According to CDC, more than thirty-four million Americans have diabetes, with the highest percentage having type 2 diabetes. This disease is predominant in the United States among people over 45 and young adults. Sedentary lifestyles and consumption of unhealthy diets have led to high BMI, which have been blamed for the rising trends of type 2 diabetes.

There are several risk aspects for type 2 diabetes. Two of the strongest ones are heredity and obesity. There is a strong genetic component to developing the disease. For instance, the risk of developing is much higher for an individual with diabetic relatives than other people in the general population. It’s estimated that if one identical twin has type 2 diabetes, then there is about a 75% chance that their sibling will also develop the disease at some point in their life (Weisman et al., 2018). Therefore, adults with a family history of type 2 diabetes have a higher risk of having the disease than individuals with no family history.

Being obese or overweight is another risk aspect for type 2 diabetes. Excess weight is a major contributor to insulin resistance, which happens when the body can’t accurately use the insulin it produces. Cells need sugar, and lean muscle tissue needs glucose to function; if cells can’t get enough sugar and glucose doesn’t reach muscles, the pancreas releases more and more insulin to make up the difference. Over time, excess fat in the liver may interfere with this process by disrupting the way insulin works in the body (Weisman et al., 2018). As a result, people who are overweight or obese tend to have higher than normal blood glucose levels.

Type 2 diabetes pathophysiology is described by damaged control of hepatic glucose production, peripheral insulin resistance and deteriorating cell function of insulin-producing pancreatic beta cells (Galicia-Garcia et al., 2020). The first physiological process that is known to be associated with a diabetes diagnosis is pancreatic beta-cell dysfunction, which can be identified by the low first phase insulin secretion of an intravenous glucose tolerance test. In the early stage of obesity-induced type 2 diabetes, non-diabetic patients have already lost almost half their beta-cell volume and percentage of function. This suggests that a beta-cell defect precedes obesity and type 2 diabetes; however, the underlying cause is unclear. It is hypothesized that there may be an interaction between genetics and environment in developing type 2 diabetes, as those with a family history are more likely to develop the disease.

The second process that has been concerned in developing type 2 diabetes is insulin resistance. This occurs when the cells of muscle, liver and adipose tissue do not respond to the normal actions of insulin in transporting glucose across the cell membrane. As a result, the pancreas produces more insulin to try and overcome this resistance, but eventually, it can no longer keep up with the increased demand and type 2 diabetes develops (Galicia-Garcia et al., 2020). In muscle, for example, insulin resistance results in a decreased ability of the hormone to stimulate glucose uptake and utilization. This increases blood sugar levels as the body tries to compensate by producing more insulin. Over time, if the pancreas can no longer keep up with this increased demand for insulin, type 2 diabetes can be diagnosed.

The third process involved in developing type 2 diabetes is an abnormality in lipid metabolism that leads to impaired glucose and fatty acid metabolism after a meal. This hepatic abnormality is also thought to play a role in the progression from pre-diabetes to diabetes. Together, these three pathophysiological processes are known as metabolic syndrome, and they often occur together in people who eventually develop type 2 diabetes.

Medical Management

Antidiabetic medications have played a great role in diabetes treatment and management. Medical Management of type 2 diabetes can be divided into weight loss, physical exercise, and dietary regulation. Pharmacological treatment of type two diabetes includes several agents, including biguanides (metformin), sulphonylureas, meglitinides, thiazolidinediones, and DPP-4 inhibitors. The choice of pharmacologic treatment for type 2 diabetes is based on the individual’s clinical situation and patient preferences. Metformin is first-line oral drug therapy for the type 2 diabetes treatment. Metformin lowers hepatic glucose output, increases tissue sensitivity to insulin, and reduces intestinal absorption of glucose, resulting in increased insulin sensitivity.

Sulphonylureas stimulates insulin secretion from the pancreatic beta cells, thus bringing down the level of blood glucose. Sulphonylureas are used as second-line agents in treating type 2 diabetes after metformin when lifestyle interventions have not resulted in inadequate glycemic control.

Meglitinides stimulate the secretion of insulin from pancreatic beta cells. It is accepted for use in type 2 diabetes persons that fail to achieve desired glycemic control on these agents. DPP-4 inhibitors increase the action of the incretin hormones, GLP-1 and GIP. Thiazolidinedione reduces glucose production and stimulates insulin release. They increase insulin sensitivity by acting on muscle and adipose.

ADA Clinical Practice Guidelines for Managing Type 2 diabetes

The ADA “Standards of Medical Care in Diabetes 2020” have offered clinical guidelines for managing diabetic patients. The Standards provide a solid foundation of clinical management strategies that healthcare professionals can use to provide high-quality patient care (Doyle-Delgado et al., 2020). For instance, they recommend that the initial step in treating most cases of type 2 diabetes is lifestyle modifications, they recommend weight loss if a person with type 2 diabetes is overweight or obese, they encourage healthy eating patterns focused on vegetables, fruits, whole grains, lean protein and dairy products while limiting saturated fat, they suggest people with type 2 diabetes limit their consumption of sugar-sweetened beverages to lower the risk of weight increase, and they recommend regular physical activity.

The clinical practice guidelines provide evidence-based recommendations to help practitioners provide quality care to their patients. The American Diabetes Association (ADA) publishes clinical practice guidelines for diabetes every few years. The most recent set of guidelines, “Standards of Medical Care in Diabetes 2020,” was published in 2020. The Standards of Medical Care in Diabetes 2020 provide comprehensive guidance on the diagnosis and management of diabetes and its impediments (American Diabetes Association, 2020). They are based on the latest scientific evidence and are designed to enable healthcare professionals offer high-quality care for individuals with diabetes.

The clinical practice guideline has been effective in managing type 2 diabetes. The “Standards of Medical Care” are designed to be dynamic tools that help practitioners make appropriate treatment decisions for individual patients who have diabetes or may develop it. The “Standards” provide a solid foundation of clinical management strategies but should not be interpreted as dictating an exclusive course of action or substituting for clinician judgment. The clinical practice guideline allows for flexibility in the standards based on the needs of individual patients. Many aspects of diabetes care are complex and require ongoing patient-clinician communication to achieve optimal results.

The “Standards of Medical Care” are intended to outline appropriate approaches for treating people with diabetes, not to be inflexible requirements or limitations. Clinicians must consider additional factors that may impact their patients, including age, coexisting conditions, life expectancy, functional status, preferences related to the quality of life and health economics issues, when deciding whether a standard applies or should be departed from in clinical practice.

Clinical practices have changed since previous ADA guidelines were published in 2010. Technology advancements have provided new therapies for managing blood glucose levels and modifying cardiovascular risk factors, while at the same time, new evidence has emerged on glucose control, glycemic thresholds for hypoglycemia, cardiovascular risk reduction and medical nutrition therapy that require careful consideration in making clinical decisions.

Analysis

The clinical practice guideline, ADA standards of medical care in diabetes, does not account for all individuals with diabetes. The clinical practice guidelines need to be revised since they fail to account for the changing health care environment and challenges presented by comorbidities in type 2 diabetes patients. The changing demographics of diabetic people, metabolic syndrome and comorbidities at diagnosis should be considered in the clinical practice guidelines. For instance, people with type 2 diabetes are living longer, probably have underlying medical conditions commonly associated with older age, including obesity, cardiovascular disease, hypertension and renal impairment. As a result of this increasing prevalence of age-related conditions, there is an increased burden on the health care system to provide care for these individuals.

An increase in life expectancy also has implications for public health policy since many people will require long term care which may lead to a reduced quality of life and financial difficulties, especially if they do not have adequate insurance coverage. The clinical practice guidelines also need to consider the changing demographics of persons with type 2 diabetes. There is a growing predominance of type 2 diabetes in minority groups, so it is important to establish whether ethnic factors contribute to variation in glycemic control when delving into the causes of differences between population subgroups (Tinajero and Malik, 2021). Only when these factors are taken into account can health care providers better understand how they affect glycemic control.

The changes in the clinical practice guideline will focus on age-related changes in type 2 diabetes. The guidelines need to include diabetes management among different demographics. The most effective strategy in implementing change in the clinical practice guideline is the use of opinion leader intervention. Opinion leadership (OL) is a powerful influence on behaviour and has been identified as an avenue for healthcare professionals to support quality of life improvements in patients’ lives. Opinion leadership (OL) help in the implementation of change in the guideline through shared decision making by the diabetes care team. Considerably, primary care nurse practitioners work within groups that share common assumptions and beliefs. Opinion leadership intervention will influence other people’s attitudes in the desired way. Therefore, opinion leader driven intervention will improve the clinical practice guideline since they act as internal change agents.

Evaluation

There are a few ways to determine the effectiveness of a clinical practice guideline in directing care for persons with type 2 diabetes. One way is to look at how well healthcare professionals followed the guideline. If the guideline is not being followed, then it is not effective in directing care. Another way to measure the effectiveness of a guideline is to look at how the patient care for type 2 diabetes has changed since the guideline was implemented. Finally, patient outcomes can be used to measure the effectiveness of a guideline. Suppose patients are seeing improvements in their blood sugar levels and overall health after following a particular guideline. In that case, it can be said that the guideline is effective in directing care.

Evaluation indicators will provide specific data on whether the revised clinical practice guideline is achieving its goals in directing care for patients with type 2 diabetes. The evaluation indicators will focus on changes in BMI, weight, blood glucose level and cholesterol levels. The Healthcare effectiveness data and information set will be used to measure the performance of the changes in the clinical practice guideline.

The HEDIS performance data helps monitor the success of the quality improvement initiatives and track changes in diabetes management (Gray et al., 2018). HEDIS will offer a comprehensive picture of the management of type 2 diabetes. The HEDIS performance measure for diabetes will be useful in determining the effectiveness of this guideline in directing care. Looking at how many patients have had their blood sugar levels measured over a certain period, along with other recommended measures, will show improvement since the implementation of the guideline.

Conclusion

Type 2 diabetes has been considered a serious public health concern. An advancing risk factor for type 2 diabetes is the rate of childhood obesity which has led to an increased rate of Type 2 diabetes among adolescents, teenagers and children. The clinical practice guideline by American Diabetes Association is aimed at improving the lives of those affected by type 2 diabetes. The revised clinical practice guideline will improve the quality of care and treatment among type 2 diabetes patients.

References

American Diabetes Association. (2020). Introduction: standards of medical care in diabetes—2020. Diabetes care, 43(Supplement 1), S1-S2.

Doyle-Delgado, K., Chamberlain, J. J., Shubrook, J. H., Skolnik, N., & Trujillo, J. (2020). Pharmacologic approaches to the glycemic treatment of type 2 diabetes: synopsis of the 2020 American Diabetes Association’s Standards of Medical Care in Diabetes clinical guideline. Annals of Internal Medicine, 173(10), 813-821.

Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., … & Martín, C. (2020). Pathophysiology of type 2 diabetes mellitus. International journal of molecular sciences, 21(17), 6275.

Gray, B., Vandergrift, J., Landon, B., Reschovsky, J., & Lipner, R. (2018). Associations between American Board of Internal Medicine Maintenance of certification status and performance on a set of Healthcare Effectiveness Data and Information Set (HEDIS) process measures. Annals of internal medicine, 169(2), 97-105.

Khan, M. A. B., Hashim, M. J., King, J. K., Govender, R. D., Mustafa, H., & Al Kaabi, J. (2020). Epidemiology of type 2 diabetes–global burden of disease and forecasted trends. Journal of epidemiology and global health, 10(1), 107.

Tinajero, M. G., & Malik, V. S. (2021). An update on the epidemiology of type 2 diabetes: a global perspective. Endocrinology and Metabolism Clinics, 50(3), 337-355.

Weisman, A., Fazli, G. S., Johns, A., & Booth, G. L. (2018). Evolving trends in the epidemiology, risk factors, and prevention of type 2 diabetes: a review. Canadian Journal of Cardiology, 34(5), 552-564.