Introduction

Standards of Medical Care in Diabetes

Standards of Care: ADA position statement that provides key clinical practice recommendations. The PPC performs an extensive literature search and updates the Standards annually based on the quality of new evidence.

ADA Position Statement

A position statement is an official ADA point of view or belief that contains clinical or research recommendations. Position statements are issued on scientific or medical issues related to diabetes. They are published in ADA journals and other scientific/medical publications. ADA position statements are typically based on a systematic review or other review of published literature. Position statements undergo a formal review process. They are updated annually or as needed. Key ADA position statements: These are select position statements that represent official ADA opinion on topics not adequately covered in the Standards of Care but that are necessary to provide additional information on quality diabetes management. These position statements also undergo a formal review process. A list of recent position statements is included on p. e3 of this supplement.

ADA Scientific Statement

A scientific statement is an official ADA point of view or belief that may or may not contain clinical or research recommendations. Scientific statements contain scholarly synopsis of a topic related to diabetes. Work group reports fall into this category. Scientific statements are published in the ADA journals and other scientific/medical publications, as appropriate. Scientific statements also undergo a formal review process. A list of recent scientific statements is included on p. e4 of this supplement.

Systematic Review

A systematic review is a balanced review and analysis of the literature on a scientific or medical topic related to diabetes. A systematic review provides the scientific rationale for a position statement and undergoes critical peer review prior to PPC approval. A list of past systematic reviews is included on p. e1 of this supplement.

Consensus Report

A consensus report contains a comprehensive examination by an expert panel (i.e., consensus panel) of a scientific or medical issue related to diabetes. A consensus report is not an ADA position and represents expert opinion only. The category may also include task force and expert committee reports. The need for a consensus report arises when clinicians or scientists desire guidance on a subject for which the evidence is contradictory or incomplete. A consensus report is typically developed immediately following a consensus conference where the controversial issue is extensively discussed. The report represents the panel's collective analysis, evaluation, and opinion at that point in time based in part on the conference proceedings. A consensus report does not undergo a formal ADA review process. A list of recent consensus reports is included on p. e2 of this supplement.

Grading of Scientific Evidence

Since the ADA first began publishing practice guidelines, there has been considerable evolution in the evaluation of scientific evidence and in the development of evidence-based guidelines. Accordingly, in 2002 we developed a classification system to grade the quality of scientific evidence supporting ADA recommendations for all new and revised ADA position statements.

Recommendations are assigned ratings of A, B, or C, depending on the quality of evidence. Expert opinion E is a separate category for recommendations in which there is as yet no evidence from clinical trials, in which clinical trials may be impractical, or in which there is conflicting evidence. Recommendations with an A rating are based on large well-designed clinical trials or well-done meta-analyses. Generally, these recommendations have the best chance of improving outcomes when applied to the population to which they are appropriate. Recommendations with lower levels of evidence may be equally important but are not as well supported.

Of course, evidence is only one component of clinical decision making. Clinicians care for patients, not populations; guidelines must always be interpreted with the individual patient in mind. Individual circumstances, such as comorbid and coexisting diseases, age, education, disability, and, above all, patients' values and preferences, must be considered and may lead to different treatment targets and strategies. Also, conventional evidence hierarchies, such as the one adapted by the ADA, may miss nuances important in diabetes care. For example, while there is excellent evidence from clinical trials supporting the importance of achieving multiple risk factor control, the optimal way to achieve this result is less clear. It is difficult to assess each component of such a complex intervention.

The ADA strives to improve and update the Clinical Practice Recommendations to ensure that clinicians, health plans, and policymakers can continue to rely on them as the most authoritative and current guidelines for diabetes care. Our Clinical Practice Recommendations are also available on the Association's website at www.diabetes.org/diabetescare.

ADA Response to 2013 American College of Cardiology/American Heart Association Guideline

The ADA recognizes the release of the new revised 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the treatment of blood cholesterol. The PPC plans to review the revised 2013 ACC/AHA guideline as it relates to patients with diabetes and prediabetes and will determine if changes to the ADA cholesterol management guidelines are warranted, but such a review could not have been incorporated, in a timely manner, into the 2014 ADA Standards of Care.