One of the main measures adopted by the Ministry of Health is the model of care. It was introduced as part of the new vision of our country (2030) in 2017. The model represents a method for restructuring health care through interactions between health systems and communities . It focuses on the patient's journey through health system and help to provide an organized, coordinated, and patient centered healthcare services. The outcomes of this model will be reflected on cost reduction, decrease in morbidity and mortality from chronic diseases as well as increase the satisfaction of patients and their caregiver.

We in the chronic care team are working together to improve chronic diseases care in the region that integrate the available resources with the best practices worldwide. We will also engage the healthcare workers at different healthcare levels to activate the role of multidisciplinary team in the management of chronic diseases.

• T1DM and gestational DM (GDM) shall be managed at the secondary care, tertiary care- DM clinic.
•  Newly diagnosed T2DM patient or T2DM patient under 1 or 2 DM medications and HbA1C less than 9% categorized Level 0 and should be seen at PHC level.
• T2DM patient under 1 or 2 DM medications and HbA1C more than 9% considered as Level 2 moderate risk patient with possibility to adjust the treatment and initiation of insulin at the primary care centers only, except if the patient still uncontrolled for more than 1 year then will fall under Level 3 and need referral to secondary care - tertiary Hospital - DM clinic.
• T2DM Patient on 3 or more DM medications and HbA1C less than 9% categorized Level 1 controlled patient, visit primary care facilities only.
•   T2DM patient on 3 or more DM medications and HbA1C more than 9% labeled as Level 3 uncontrolled patient with no successful treatment at the PHC. Visit PHC & Secondary Care, including DM Clinic.
•  T2DM patient with comorbidities e.g. (Past history of obesity, heart disease or renal disease) and HbA1C less than or more than 9% labeled as Level 3 uncontrolled patient with no successful treatment at the PHC visit PHC & secondary care, including DM clinic.
• T2DM patient with one or more complications e.g. (Retinopathy, neuropathy, nephropathy, IHD or foot problem e.g. ulcer, amputation and charcot foot, sever hypoglycemia characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia, DKA and HHS) and HbA1C less than or more than 9% categorized Level 4 acute episode visit PHC & acute care in specialized centers for patients with comorbidities and urgent cases.

DM Pathway undergo Standers of Care in Diabetes - 2023    

Screening for Diabetes Complications:

1.Chronic Kidney Disease:

 At least once a year, assess urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes with duration of ≥5 years and in all patients with type 2 diabetes regardless of treatment.

 Patients with urinary albumin >30 mg/g creatinine and/or an eGFR <60 mL/min/1.73 m2 should be monitored twice annually to guide therapy.

 2. Diabetic Retinopathy:

Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes

Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then screening every 1-2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist.

 If retinopathy is progressing or sight-threatening, then examinations will be required more frequently Eye examinations should occur before pregnancy or in the first trimester in patients with preexisting type 1 or type 2 diabetes, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy.

 3. Neuropathy Screening:

 All patients should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter Neuropathy screening: Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function).

 All patients should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation Symptoms and signs of autonomic neuropathy should be assessed in patients with microvascular complications

4. Foot Care Screening: Perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations Foot Care Screening: Patients with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit

PHC Referral Guidelines:

Refer patient to 2^nd or 3^rd care if:

• Uncontrolled patient with A1C > 9% and without successful treatment at the PHC for one year.
• Patients with comorbidities.
• A1C levels are above 9% and patient has been uncontrolled for one year.
• Refer patient to acute care centers if either one or more complications have been diagnosed.

Criteria for Referral to Tertiary DM Center:

• DM type 1.
• DM1 for insulin pump.
• DM1 for pancreatic or islet cell transplantation.
• DM1 or 2 during pregnancy - GDM.
• DM1 or 2 with CKD.
• Steroid induced DM.
• New onset DM post transplantation.

Case Management Guidelines:

• Case Coordinators should play an active role in persuading patients to stay in PHCs if controlled.
• Patients should be followed-on and brought back to PHCs even after treatment has been delivered in secondary care.

       Referral back of Diabetic patients from 2ry-3ry Care to PHCs (after the patient is controlled or end the Requested Service) through Case Coordinators should accompanied with Discharge Summary and plan of care (If unified EHR is not available).

Criteria for screening for diabetes or prediabetes in asymptomatic adults

1.Testing should be considered in adults with overweight or obesity (BMI 25 kg/m2 or =23 kg/m2 in Asian Americans) who have one or more of the following risk factors:

 • First-degree relative with diabetes

 • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

• History of CVD

• Hypertension (140/90 mmHg or on therapy for hypertension)

 • HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

• Women with polycystic ovary syndrome

• Physical inactivity

• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

2. Patients with prediabetes (A1C ==5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly. 3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. 4. For all other patients, testing should begin at age 35 years.

5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.

6. People with HIV

 CVD, cardiovascular disease; GDM, gestational diabetes mellitus; IFG, impaired fasting glu- cose; IGT, impaired glucose tolerance.

Screening for and diagnosis of GDM

One-step strategy

Perform a 75-g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2 h, at 24-28 weeks of gestation in women not previously diagnosed with diabetes.

The OGTT should be performed in the morning after an overnight fast of at least 8 h.

The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded:

• Fasting: 92 mg/dL (5.1 mmol/L)

1 h: 180 mg/dL (10.0 mmol/L)

2 h: 153 mg/dL (8.5 mmol/L)

Two-step strategy

Step 1: Perform a 50-g GLT (nonfasting), with plasma glucose measurement at 1 h, at 24-28 weeks of gestation in women not previously diagnosed with diabetes.

If the plasma glucose level measured 1 h after the load is 130, 135, or 140 mg/dL (7.2, 7.5, or 7.8 mmol/L, respectively), proceed to a 100-g OGTT.

Step 2: The 100-g OGTT should be performed when the patient is fasting.

The diagnosis of GDM is made when at least two* of the following four plasma glucose levels (measured fasting and at 1, 2, and 3 h during OGTT) are met or exceeded (Carpenter-Coustan criteria [244]):

Fasting: 95 mg/dL (5.3 mmol/L)

1 h: 180 mg/dL (10.0 mmol/L)

2 h: 155 mg/dL (8.6 mmol/L)

3 h: 140 mg/dL (7.8 mmol/L)

 GLT, glucose load test; OGTT, oral glucose tolerance and Gynecologists notes that one elevated value GDM, gestational diabetes mellitus; test. *American College of Obstetricians can be used for diagnosis (240).

•  AIC
• Lipid profile, including total cholesterol, LDL, and HDL cholesterol and triglycerides#
• Liver function tests: AST & ALT#
• Serum urea and creatinine and estimated glomerular filtration rate*
• Spot urinary albumin-to-creatinine ratio
• Thyroid-stimulating hormone (when indicated)
• Vitamin B12 if on metformin (when indicated)
• Serum potassium levels in patients on ACE inhibitors, ARBs, or Diuretics*
• Urine analysis (when indicated)

# May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes, blood pressure, cholesterol, or thyroid medications).

* May be needed more frequently in patients with known CKD or with changes in medications that affect kidney function and serum potassium. 

PHC Referral Guidelines:

Refer patient to 2nd or 3rd care if:

Refer patient to acute care centers if either:

Criteria for Referral to Tertiary DM Center:

Case Management Guidelines: