Diabetes Preventive Care

The diabetes preventive care state consists of three substates: screening, preventive care, and initial diagnosis.

Screening

The screening state contains two substates: Regular, aimed at low-risk patients - as indicated by the guard {Risk = Low}; and Targeted {Risk = High}, aimed at high-risk patients. The risk level is determined by the criteria described in the Sect. 2 dedicated to diabetes mellitus. Inside both states similar actions are performed.

Upon entering the regular - and the targeted - state, a series of tests are ordered, as indicated by the entry event entry/orderTests(). If applicable preventive care is recommended/recommend(PrevCare). The session is documented on exiting the state.

Both states converge at a dynamic choice pseudostate. If a patient has no symptoms and preventive care of some sort is recommended (transition with guard [Symptoms = F AND PrevCare = T]), the patient will leave the current state and will enter the preventive care state. However, if the patient presents any symptoms consistent with diabetes ([Symptoms = T]), she/he will enter the initial diagnosis state, where she/he will be diagnosed and will move into long-term management. Note that when exiting the screening state two actions are carried out: the session is documented, and if the patient has no symptoms, a follow-up is scheduled. This action is indicated by [Symptoms = F]/scheduleFollowUp(). scheduleFollowUp() sets up a timer that eventually will trigger the event TimeToCheck(), recalling the patient for another screening procedure.

Preventive Care

The preventive care state consists of six concurrent substates: BP for blood pressure management, lipid management, antiplatets, smoking, CHD, and immunization. These states will be described in detail in the following sections.

There are two actions that are executed while leaving the preventive care state: exit/DocumentSession(), and /scheduleFollowUp(), the latter sets up a timer for a future screening session.

Initial Diagnosis

The Initial Diagnosis state consists of four concurrent substates aimed at reviewing the medical history of the patient, performing a physical exam, laboratory evaluation, and scheduling the appropriate referrals. Upon exiting the state the session is documented and the guard PatientHas(Diabetes) is set to T. This guard will trigger the transition event from the diabetes preventive care state to the diabetes long-term management state.

5.1.2 Diabetes Long-Term Management

The diabetes long-term management state consists of three substates: management, surveillance, and intercurrent illnesses. A patient will enter, and remain in this state when the guard PatientHas(Diabetes) becomes true.

Management

The management state consists of six concurrent substates: self blood glucose monitoring, diet, physical activity, hyperglycemia, blood pressure management, and lipid management. These states will be described in detail in the following sections. The management state has two exit actions, both setting up timers for upcoming management and surveillance visits: exit/SetManage-mentFollowUp(), and /SetSurveillance().

Surveillance

The surveillance state consists of six concurrent substates: nephropathy, eye exam, foot care, antiplatelets - aspirin, BP management, and immunization. These states are described in detail in the upcoming sections. exit/ SurveillanceFollowUp() sets up a timer for a future surveillance visit. This action is executed upon exiting the Surveillance state. There are also two guards that, if true, will trigger two different transition events: [NewIllness() = T]/EVT (IntercurrentIllness) triggers a transition event to the intercurrent illnesses state if there is a new illness that needs to be treated. Note that the transition to the Intercurrent Illnesses state is guarded by {EVT(IntercurrentIllness)}, which has to be true so the transition can take place. Similarly, [NewIllness() = F]/EVT(Management) triggers a transition event back to the management state, since there are no new illnesses detected. The transition from Surveillance back to management is guarded by {EVT(Management)}.

Intercurrent Illnesses

The Intercurrent Illnesses state consists of four substates: screening, diagnose, treatment, and follow-up. They are described below. Upon exiting this state, two actions take place: exit/DocumentSession(), and EVT(Management). The latter triggers a transition event from this state back to the management state. The transition is guarded by {EVT(Management)} which has to be true for the transition to take place.

5.2 Preventive Care Substates

5.2.1 BP State

The BP state in Fig. 4 monitors and manages hypertension. This state is part of the preventive care, diabetes/management, and diabetes/surveillance substates. The criteria for monitoring and managing high blood pressure are the same in all three states. We will describe the BP state in detail in this section and will refer the reader back here where appropriate.

The BP overdue state is triggered if a patient's blood pressure has not been checked. Upon entering the state, the patient's blood pressure is measured by the action entry/takeBP() and the reading is recorded exit/record(BP). Abnormal BP values systolic > 130 or diastolic > 80, will trigger a transition to the BP > Goal state, guarded by {Systolic BP > 130 or diastolic BP > 80}.

Upon entering the BP > Goal state, several actions take place, all aimed at regulating the patient's blood pressure. These actions include lifestyle modifications, laboratory tests to evaluate specific markers, drug therapies, and referrals to specialists for further treatment. The session is documented on exiting the state.

State: Hypertension management

State: BP overdue entry/takeBP(); exit/record(BP)

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