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Appendix (1): SNDC standards of services and quality measures for diabetes centers and units 2020)

Table 1: Tertiary Care level (outpatient and inpatient)

Qualification and specialtiesStaffStructure
Physician based service (outpatient and inpatient)At least one Endocrinology  Endocrinology board and certified in Diabetes Training program (SCHS accredited)
Health educator clinicHealth educator specialist /Health coach.Bachelor in health education from medical science applied college with accredited diabetes training (SCHS accredited)
Clinical dietician clinicClinical dietician specialist / Health coach.Bachelor in clinical dietitian from medical science applied college (SCHS accredited)
NursingNurse

Diploma/bachelor

(SCHS accredited)

Retinal fundoscopy camera.Ophthalmology technician /Optometrists /Trained NurseOptometrist certification/ Diploma/bachelor (SCHS accredited) with established system of referral to ophthalmology service
Ophthalmology Clinic (in-hospital referral) Ophthalmology specialist 

Saudi Board in ophthalmology (SCHS accredited)

 

Laboratory service.Lab technician / Trained Nurse.Allies with central lab CAP CIBAHI
Pharmacy (in-hospital)PharmacistBachelor's in pharmacy
Social service Social worker Bachelor's in social science
Accessible medical service (in-hospital referral)Neurology Nephrology Cardiology and psychiatry

Saudi Board (SCHS accredited)

 

Coordinator, Reception and Electronic appointment system Secretary Diploma in secretary (bilingual)

Foot care clinic

Inside the center

 

Podiatrist/orthopedics/ Vascular/ General surgery specialty Saudi Board in specialty (SCHS accredited)
Specialized retina clinic (in hospital referral)Retina specialist Saudi Board in subspecialty (SCHS accredited)
Dental clinic (in hospital referral)Dentist Saudi Board in specialty (SCHS accredited)
Insulin Pump service Endocrinologist, diabetic educator and clinical dietician specialized in pump 

Endocrinologist, educator and clinical dietician with accredited pump training (SCHS accredited)

 


Table 2 Diabetes clinic KPI's

Quality measureADA benchmarkSNDC benchmark
Percentage of patients received an A1C in last 6 months>93%70<%
Percentage of patients who had lipid profile tested in a year time>80%80<%
Percentage of diabetes patients how had retinopathy screening *>61%60<%
percentage of new diabetes cases referred for diabetes education within (≤) 8 weeks from first visit>70%70<%
Percentage of diabetes patients tested for microalbuminuria within 12month>73%70<%
Percentage of patients received visual foot exam or monofilament testing80<%80<%


Assessment:

This should be achieved within 5 years, after 1year, we are going to reassess benchmark locally and international and then you put a plan to reach ADA target.

**KPI well be 60% first year and then 5% annually increase.

*Although ADA recommend dilated eye exam but due to deficiency in personal providing the service we would indorse person with fundus camera service initially instead of dilated eye exam.


Table 3: autoimmune disease screening

ConditionIndications for screeningScreening testFrequency
Autoimmune thyroid diseaseAll children with type 1 diabetesSerum TSH level + thyroid peroxidase antibodiesAt diagnosis and every 2 years thereafter; thyroperoxidase antibodies do not need to be repeated if previously positive
Positive thyroid antibodies, symptoms of thyroid disease or goiterSerum TSH level (+thyroid peroxidase antibodies if previously negative)Every 6–12 months 
Primary adrenal insufficiencyUnexplained recurrent hypoglycemia and decreasing insulin requirements8 AM serum cortisol and serum sodium and potassiumAs clinically indicated
Celiac diseaseRecurrent gastrointestinal symptoms, poor linear growth, poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia or poor metabolic controlTissue transglutaminase + immunoglobulin A levelsAs clinically indicated
TSH, thyroid-stimulating hormone.


Table 4: Long-term complication screening:

Complication/ ComorbidityIndications and intervals for screeningScreening method
Nephropathy
  • Yearly screening commencing at 12 years of age in those with duration of type 1 diabetes >5 years
  • First morning (preferred) or random urine ACR
  • Abnormal ACR requires confirmation at least 1 month later with a first morning ACR and, if abnormal, followed by timed, overnight or 24-hour split urine collections for albumin excretion rate
  • Repeated sampling should be done every 3–4 months over a 6- to 12-month period to demonstrate persistence
Retinopathy
  • Yearly screening commencing at 15 years of age with duration of type 1 diabetes >5 years
  • Screening interval can increase to 2 years if good glycemic control, duration of diabetes <10 years and no retinopathy at initial assessment
  • 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard); or
  • Direct ophthalmoscopy or indirect slit-lamp fundoscopy through dilated pupil; or
  • Digital fundus photography
Neuropathy
  • Children ≥15 years with poor metabolic control should be screened yearly after 5 years of type 1 diabetes
  • Question and examine for symptoms of numbness, pain, cramps and paresthesia, as well as skin sensation, vibration sense, light touch and ankle reflexes
Dyslipidemia
  • Delay screening post-diabetes diagnosis until metabolic control has stabilized
  • Screen at 12 and 17 years of age
  • <12 years of age: screen only those with BMI >97th percentile, family history of hyperlipidemia or premature CVD
  • Fasting or non-fasting TC, HDL-C, TG, calculated LDL-C. Measurement of non-fasting lipids may be considered if TG are not elevated.
Hypertension
  • Screen all children with type 1 diabetes at least twice a year
  • Use appropriate cuff size
ACR, albumin to creatinine ratio; BMI, body mass index; CVD, cardiovascular disease; HDL-C; high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triglycerides.



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