Preventive and clinical practice guidelines are based on the health needs and opportunities for improvement identified as part of the Quality Assurance Program Improvement (QAPI) program. Whenever possible, Bridgeway Health Solutions adopts preventive and clinical practice guidelines that are published by nationally recognized organizations or government institutions as well as state-wide collaborative and/or a consensus of healthcare professionals in the applicable field.
To help provide our members with consistent, high-quality care that utilizes services and resources effectively, we have chosen certain clinical guidelines to help our providers. These are treatment protocols for specific conditions as well as preventive health guidelines.
These guidelines are intended to clarify standards and expectations for providers. They should not:
- Come before the providers’ responsibility to provide treatment based on the member’s individual needs.
- Substitute as orders for treatment of a member.
- Guarantee coverage or payment for the type or level of care proposed or provided.
Bridgeway Health Solutions has adopted the evidence based guidelines published by the National Guideline Clearinghouse.
The following are guidelines that have been adopted by the Medical Management Committee:
Congestive Heart Failure
- 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
- AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update A Guideline From the American Heart Association and American College of Cardiology Foundation
American Diabetes Association
Diabetes Care Supplement 1 was previously called Clinical Practice Recommendationsand included the “Standards of Medical Care in Diabetes” and key American Diabetes Association (ADA) position statements. The supplement has been renamed Standards of Medical Care in Diabetes (“Standards”) and contains a single ADA position statement that provides evidence-based clinical practice recommendations for diabetes care.
Whereas the “Standards of Medical Care in Diabetes—2015” should still be viewed as a single document, it has been divided into 14 sections, each individually referenced, to highlight important topic areas and to facilitate navigation.
The supplement now includes an index to help readers find information on particular topics.
Although the levels of evidence for several recommendations have been updated, these changes are not included below as the clinical recommendations have remained the same. Changes in evidence level from, for example, C to E are not noted below. The “Standards of Medical Care in Diabetes—2015” contains, in addition to many minor changes that clarify recommendations or reflect new evidence, the following more substantive revisions.
Section 2. Classification and Diagnosis of Diabetes
The BMI cut point for screening overweight or obese Asian Americans for prediabetes and type 2 diabetes was changed to 23 kg/m2 (vs. 25 kg/m2) to reflect the evidence that this population is at an increased risk for diabetes at lower BMI levels relative to the general population.
Section 4. Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization
The physical activity section was revised to reflect evidence that all individuals, including those with diabetes, should be encouraged to limit the amount of time they spend being sedentary by breaking up extended amounts of time (>90 min) spent sitting.
Due to the increasing use of e-cigarettes, the Standards were updated to make clear that e-cigarettes are not supported as an alternative to smoking or to facilitate smoking cessation.
Immunization recommendations were revised to reflect recent Centers for Disease Control and Prevention guidelines regarding PCV13 and PPSV23 vaccinations in older adults.
Section 6. Glycemic Targets
The ADA now recommends a premeal blood glucose target of 80–130 mg/dL, rather than 70–130 mg/dL, to better reflect new data comparing actual average glucose levels with A1C targets.
To provide additional guidance on the successful implementation of continuous glucose monitoring (CGM), the Standards include new recommendations on assessing a patient’s readiness for CGM and on providing ongoing CGM support.
Section 7. Approaches to Glycemic Treatment
The type 2 diabetes management algorithm was updated to reflect all of the currently available therapies for diabetes management.
Section 8. Cardiovascular Disease and Risk Management
The recommended goal for diastolic blood pressure was changed from 80 mmHg to 90 mmHg for most people with diabetes and hypertension to better reflect evidence from randomized clinical trials. Lower diastolic targets may still be appropriate for certain individuals.
Recommendations for statin treatment and lipid monitoring were revised after consideration of 2013 American College of Cardiology/American Heart Association guidelines on the treatment of blood cholesterol. Treatment initiation (and initial statin dose) is now driven primarily by risk status rather than LDL cholesterol level.
With consideration for the new statin treatment recommendations, the Standards now provide the following lipid monitoring guidance: a screening lipid profile is reasonable at diabetes diagnosis, at an initial medical evaluation and/or at age 40 years, and periodically thereafter.
Section 9. Microvascular Complications and Foot Care
To better target those at high risk for foot complications, the Standards emphasize that all patients with insensate feet, foot deformities, or a history of foot ulcers have their feet examined at every visit.
Section 11. Children and Adolescents
To reflect new evidence regarding the risks and benefits of tight glycemic control in children and adolescents with diabetes, the Standards now recommend a target A1C of <7.5% for all pediatric age-groups; however, individualization is still encouraged.
Section 12. Management of Diabetes in Pregnancy
This new section was added to the Standards to provide recommendations related to pregnancy and diabetes, including recommendations regarding preconception counseling, medications, blood glucose targets, and monitoring.
- © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
National Heart, Lung and Blood Institute (NHLBI)
Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Offering information on HIV/AIDS Treatment, Prevention and Research
High Blood Pressure
US Department of Health & Human Services / National Institute of Health / National Heart Lung and Blood Institute
- Pocket Guide to Blood Pressure Measurement in Children
- The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
The following are AHCCCS approved Guidelines:
National Institutes of Health / National Heart, Lung, and Blood Institute
Centers for Disease Control and Prevention
Pain Management Toolkit
Bridgeway developed a pain management tool kit that includes information that may assist you in managing members with pain management concerns. These guidelines are distributed under Bridgeway Health Solutions' Quality Improvement/Utilization Management Program in order to identify criteria for appropriate and effective use of health care services and consistency in the care provided to plan participants.
Guidelines for the Use of Narcotics in Non-cancer Pain
The US Department of Health and Human Services has published a set of guidelines for the use of narcotics in non-cancer pain. The information is useful and comprehensive. The guidelines can be found on the National Guideline Clearinghouse website at http://www.guideline.gov/index.aspx. The guideline is titled “Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve safety with opioid therapy”.
Bridgeway encourages you to review these guidelines so that you can help us to improve the quality of care we provide to our members.
Thank you for your continued partnership.
These guidelines are distributed under Bridgeway Health Solutions Quality Improvement/Utilization Management Program in order to identify criteria for appropriate and effective use of health care services and consistency in the care provided to plan participants.