Table 1:

Definitions of visit types to diabetes specialists with a clear indication*

DescriptionDefinitionWhy the referral was clearly indicated
Poorly controlled HbA1CHbA1C ≥ 8.5%. The HbA1C test reflects the percentage of hemoglobin (protein in red blood cells) coated in sugar. Higher HbA1C values indicate poorer blood glucose control and higher risk of complications.Diabetes control is sufficiently poor that improvement is unlikely without substantial changes to therapy, which often requires a diabetes specialist and multidisciplinary team.
Elevated HbA1C and taking 3 or more non-insulin antihyperglycemic agentsHbA1C ≥ 7.5% and taking 3 or more antihyperglycemic agentsPatients who fit this description have type 2 diabetes and need to start insulin. Traditionally, initiation of insulin in type 2 diabetes has been an activity for specialists. While this can be done safely and effectively in primary care it is not yet standard of care in all places.
Elevated HbA1C and on insulin Hospital admission or ED visit for a diabetes-specific ambulatory care sensitive condition in prior yearHbA1C ≥ 7.5% and taking insulin (regardless of use of antihyperglycemic agents) A hospital admission or ED visit with 1 of the following ICD-10 codes indicating hyperglycemic or hypoglycemic events for type 1, type 2 and other diabetes in the year before specialist visit:
  • E10.0 (type 1 with coma)

  • E10.63 (type 1 with hypoglycemia)

  • E11.0 (type 2 with coma)

  • E11.63 (type 2 with hypoglycemia)

  • E13.0 (other specified with coma)

  • E13.63 (other specified with hypoglycemia)

  • E14.0 (unspecified with coma)

  • E14.63 (unspecified with hypoglycemia)

Patients who fit this description have type 1 diabetes or type 2 diabetes requiring further intensification of therapy. These represent potentially life-threatening events because of significant gaps in, or adverse effects of, diabetes therapy that may require substantial changes to therapy by a specialist and multidisciplinary team.
  • Note: ED = emergency department, HbAIC = hemoglobin A1C, ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision.

  • * Definitions supported by the Canadian Diabetes Association’s 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada21 and expert committee opinion.