The targets set for improving diabetes care are rooted in good practice and many practices should be able to achieve high point scores, says Dr Matthew Lockyer
Diabetes affects an estimated 1.4 million individuals in the UK and absorbs around 9% of NHS expenditure.1 The condition is therefore among the ten clinical areas in the quality framework of the new GMS contract.
Most of the diabetes indicators (Table 1, below) are supported by high grade evidence and complement recently published guidelines on the management of diabetes by NICE and SIGN.2-5 The National Service Framework for Diabetes is supporting the move to digital retinal photography for eye screening.6 Other targets for the NSF are to be agreed locally and the indicators may help to give some structure to local objectives.
|Table 1: Clinical indicators for diabetes|
|Disease/indicator no||Clinical indicator||Points||Qualifier||Preferred Read code||Exception reporting Read codes||Payment stages|
|DM 1||Register of all patients >16 years with diabetes||6||C10%||Gestational diabetes|
|DM 2||% patients with BMI recorded||3||Recorded in past 15 months||22K||25-90%|
|DM 3||% patients with smoking status recorded||3||Recorded in past 15 months||Never smoked: 137I
|DM 4||% smokers advised or referred for smoking cessation advice||5||Recorded in past 15 months||8CAL||25-90%|
|DM 5||% patients with HbA1c recorded||3||Recorded in past 15 months||42W% and value||25-90%|
|DM 6||% patients with HbA1c <=7.4%||16||Recorded in past 15 months||Numeric value Fructosamine||25-50%|
|DM 7||% patients with HbA1c <=10%||11||Recorded in past 15 months||Numeric value||25-85%|
|DM 8||% patients with retinal screening recorded||5||Recorded in past 15 months||68A7||25-90%|
|DM 9||% patients with peripheral pulses recorded||3||Recorded in past 15 months||Right foot: 24E%
Left foot: 24F%
|DM 10||% patients with neuropathy test recorded||3||Recorded in past 15 months||68A1 (new code awaited)||25-90%|
|DM 11||% patients with BP recorded||3||Recorded in past 15 months||246||25-90%|
|DM 12||% patients with BP <=145/85 mmHg||17||Recorded in past 15 months||Numeric value||25-55%|
|DM 13||% patients with microalbuminuria test recorded||3||Recorded in past 15 months||46W%
|DM 14||% patients with serum creatinine recorded||3||Recorded in past 15 months||44J3%||25-90%|
|DM 15||% patients with proteinuria or microalbuminuria on ACE inhibitors or A2 antagonists||3||Recorded in past 15 months||Proteinuria: 4678 Albuminuria: 46W0m||ACEI contraindicated: 8128
A2A contraindicated: 812H
|DM 16||% patients with total cholesterol recorded||3||Recorded in past 15 months||44P%||25-90%|
|DM 17||% patients with total cholesterol <5 mmol>||6||Recorded in past 15 months||Numeric value||25-60%|
|DM 18||% patients with flu vaccination||3||In preceding 1 Sept - 31 March||Flu accination given: 65E||25-85%|
Achieving the clinical indicators
None of us has any experience of the clinical indicator system yet. I believe that practices that are paper-light or paper-free will have advantages over those that are not. Despite the fact that under the new contract responsibility for IT moves to the primary care organisation, immediate review and expansion of practice computer use will pay dividends.
Disease and therapy registers and the ability to enter and search for clinical data will be essential to achieving the clinical indicators. Although they are not compulsory, effectively this will mean using the Read codes specified by the contract. Read codes are searchable by the practice and externally verifiable, by the PCT and Government bodies, to confirm claims.
We, in common with other practices, will need to be more disciplined in our data entry.We will have to refer to the specified Read codes rather than keyword entry (only about 50% of the Read library has a keyword), and avoid making non-searchable ‘free text’ entries of essential information. We will be going paper-free in October 2003 to give ourselves 6 months’ lead time and to enable us to assess our baseline income.
In some areas it may help to make one clinician responsible for data management. In our practice, the diabetes nurse has protected time each week for data entry and audit.
Disease register (DM 1)
The first requirement is a register of diabetes patients aged 16 years or over. Most practices will already have a register, but if starting afresh, searches may be made on diagnosis and therapy to generate a list.
The most difficult diabetes patients to identify are those whose condition is controlled by diet, especially if they are housebound or in a nursing home, as they have no therapy record and may not have any computer data generated by surgery visits. One way to find these ‘hidden’ patients is to ask nursing home staff to list their residents with diabetes and to talk to the district nurses who often visit the housebound.
Patients on the diabetes register should equate to 2-3% of the practice list, increasing to 5% or more if there is a large Asian population. Prevalence of diabetes will provide the means of checking this indicator externally.
Most registers will include one or two patients who do not have diabetes but are identified as having the condition, usually because a glucose tolerance test has been misread in the past.
Patients with impaired glucose tolerance should be offered formal diabetes follow up. Diabetes risk is a continuum, so patients with impaired glucose tolerance will already have a greater cardiovascular risk than individuals with normal glucose tolerance; a proportion of these patients will go on to develop diabetes.
Most of the requirements to record data about diabetes patients will work on a 15-month cycle.We have recently extended our clinic to accommodate the increase in numbers of diabetes patients, yet we have been hard pressed to achieve a yearly check for all.
The hardest patients to reach are at the extremes of the age range.Young patients frequently do not attend clinic appointments and the housebound elderly and those in nursing homes need to be visited individually.
Body mass index (DM 2)
This clinical indicator relates to the percentage of the diabetes population whose BMI has been recorded within the past 15 months. Obesity is strongly associated with type 2 diabetes, and weight loss can help diabetes control.
In practice, many diabetes patients find it very hard to lose weight.This is partly caused by poor lifestyle but may also result from co-morbidity and the tendency of all diabetes therapies, except for metformin, to cause weight gain. BMI measurement can help assess those patients who may benefit from additional anti-obesity drugs.
Smoking status (DM 3, 4)
The first of these two indicators relates to the percentage of diabetes patients with a record of smoking status. Lifelong non-smokers need only a single computer entry, but smokers and ex-smokers must have their entry updated within the 15-month cycle. For smokers, the percentage offered smoking cessation advice or intervention should also be recorded.
With this indicator – as with others – it is important to ensure that computer records of this activity automatically update on other relevant screens. For example, if the smoking status is updated in the diabetes clinic it should also appear in the ischaemic heart disease or COPD screens, if relevant. Smoking is probably the single most important risk factor for heart disease and in high risk populations such as diabetes patients it is hard to dispute its importance.
Blood glucose (DM 5, 6, 7)
As the main yardstick by which the adequacy of glycaemic control is assessed, it is important that all diabetes patients have a review of HbA1c. Well controlled patients should have an HbA1c test every 6 months,3,5 and the test should be performed more frequently in those with problems.
Fructosamine level is an acceptable measure of glycaemia in some patients, for example those with haemoglobinopathies.
The fact of recording is entered by Read code Read coding cannot record numerical values. In existing computer systems the disease recording screens will record an HbA1c value but the Read code to confirm ‘HbA1c taken’may require a separate entry to qualify in the clinical indicator search.
At present, we record values on to an Excel spreadsheet and use a simple programme to band HbA1c values. We shall continue to do this because it will not only provide the required evidence but it also gives a more useful picture of our diabetes population. We subdivide the HbA1c results into ‘diet’, ‘tablet treated’, ‘type 2 on insulin’ and ‘type 1’, which makes the results more meaningful.
The percentage of diabetes patients with an HbA1c of 7.4% or lower (equating to tight control in diabetes outcome studies) and the percentage with an HbA1c of 10% or lower are both required. This will be validated by production of a computer record or inspection of a sample of records.
Trial data from the DCCT study for type 1 diabetes and the UKPDS study for type 2 diabetes showed that achieving better control, as defined by HbA1c below 7.4%, equates with fewer new microvascular complications and slower progression of existing complications.7,8 Macrovascular complications in type 2 diabetes were improved but to a lesser degree.
The upper band of control recognises another finding from the UKPDS trial. Glycaemic control in type 2 diabetes tends to worsen over time. More treatment is needed, but even when insulin is used it may be difficult to achieve the optimum target HbA1c value.9 Some patients will also find it difficult to make the lifestyle choices necessary for good control.
The thresholds to achieve maximum points for good control of HbA1c are set at 50% of diabetes patients achieving HbA1c of 7.4% or lower, and 85% being below 10%. Among most general practice diabetes populations are a substantial number of patients whose glycaemia is controlled by diet alone in addition to those in whom control is achieved by treatment. Most practices will achieve quality points and the maximum levels are not impossible.
Retinal screening (DM 8)
Information on retinal screening may be provided by a local screening programme. Digital retinal photography is being supported financially by the NSF for Diabetes.
Our local trust already operates a successful system which works from a register of diabetes patients, and a summary of screening results is sent to each practice. Last year, 87% of our practice’s patients were screened during a week’s visit by the mobile unit. This is very close to the top clinical indicator level of 90%.
Foot pulses and neuropathy (DM 9, 10)
The clinical examination recordings, foot pulses and neuropathy testing, are important parts of an annual diabetes examination. Neuropathy can be assessed with a device that measures neurological sensitivity through consistent 15g pressure with a light touch filament and a reproducible sharp touch. A tuning fork should be used to detect vibration. Using the specified Read code to record the results should be easy as most computer systems are already preset to the specified codes.
Blood pressure (DM 11, 12)
Blood pressure, with renal function and lipids, will probably be the most difficult areas to record and achieve high targets. Blood pressure is of great importance in improving cardiovascular outcomes especially in type 2 diabetes. In the UKPDS trial, controlling blood pressure was shown to be more effective in this respect than maintaining tight glycaemic control.10 The target blood pressure in diabetes patients is 140/80 mmHg or below, although the HOT study suggested that in diabetes there was continuing benefit as blood pressures fell provided the patient was not symptomatically hypotensive.11
Unfortunately, blood pressure in diabetes patients is frequently refractory to treatment and multiple drug regimens are common. Even with effective treatment in place, many patients fail to achieve target blood pressure.
Clinical indicator 11 offers maximum points for recording blood pressure in 90% of diabetes patients. The points for the percentage of patients with blood pressure under 145/85 mmHg (no points below 25%, as with all the clinical indicators; maximum points at 55% of population) will be harder to achieve; this indicator offers the greatest number of points of any diabetes indicator, reflecting the importance of aggressive treatment in this area of diabetes management.
Diabetic renal disease (DM 13, 14, 15)
These three indicators reflect screening and management of diabetic renal disease. Microalbuminuria (a 24-hour urinary protein loss of 30-300 micrograms, not detectable at routine urinalysis) and established diabetic nephropathy (dipstick positive proteinuria 300 micrograms/24 hrs or more) are markers for end-stage renal failure in type 1 diabetes and predictive of imminent vascular disease in type 2 diabetes.12,13
Treatment with ACE inhibitors and A2 antagonists has been shown to be protective. The HOPE and MICROHOPE studies showed that ramipril protects against overt nephropathy in diabetes patients as well as being cardioprotective and independent of its antihypertensive effect.14 The treatment arm of this study showed an overall reduction in mortality of 24%. Irbesartan has also been shown to reduce the progression of microalbuminuria, but without data on mortality outcomes.15
This seems to me an area where there may need to be some review or local agreement. Indicator 13 offers maximum points for recording microalbuminuria screening annually in 90% of patients.
We do not routinely test patients over 70 years. Once microalbuminuria is established, by two abnormal albumin: creatinine ratios,we treat with ACE inhibitors or A2 antagonists and do not repeat the test. If a further assessment of renal function is needed, a 24-hour urinary protein or creatinine clearance is superior for charting changes.
Indicator 14 relates to the record of serum creatinine. This test is helpful in diabetes patients with established nephropathy, to detect non-diabetic renal disease, in those on ACE inhibitors, and to ensure safe use of oral hypoglycaemics. As with HbA1c, a record of taking the test will need to be entered as well as the numerical value.
Indicator 15 sets a target of 70% of patients on ACE inhibitors or A2 antagonists. Exception reporting is allowed in the case of patient refusal or contraindication.
Lipids (DM 16, 17)
The lipids indicators reflect the increasingly widely held view that treating diabetes patients to the same standards as for secondary prevention of cardiovascular disease is cost effective. Major studies of primary and secondary prevention of cardiovascular disease using statins show benefit in diabetes sub-group analysis.16-18
The NICE guideline currently suggests initiating primary prevention at a threshold coronary risk of 15% per annum in diabetes patients. There is no indicator for aspirin, but it is worth remembering that 75 mg aspirin, if not contraindicated, is recommended at the same threshold risk.19
It may be that all diabetes patients should be offered cholesterol-lowering treatment irrespective of their starting lipid levels, but this has not yet been supported by national guidelines. Points are on offer for recording total cholesterol (the same recording checks as for HbA1c and creatinine probably apply) and achieving levels below 5 mmol/l maximum payment is for 60% at this target. I suspect the high level may be difficult to achieve.
The final indicator is the percentage of diabetes population receiving a flu vaccination. This may be the longawaited reward for vaccinating an at-risk group other than the elderly. However, the target for maximum points is high and the number of available points small – 85% coverage for 3 points.
Diabetes patients should probably be given their flu immunisation and then also checked for weight, blood pressure, smoking, HbA1c and lipids, thus improving the cover in all clinical indicators.
The new contract’s clinical indicators for diabetes are an unknown quantity. Many seem rooted in good practice and potentially achievable. Some areas need to be clarified to prevent unnecessary duplication of work. All target areas will demand careful data entry.
- Audit Commission. Testing Times: A Review of Diabetes Services in England and Wales. London: Audit Commission, 2000.
- National Institute for Clinical Excellence. Management of type 2 diabetes, renal disease prevention and early management. NICE Inherited Clinical Guideline F. London: NICE, 2002.
- National Institute for Clinical Excellence. Management of type 2 diabetes management of blood glucose. NICE Inherited Clinical Guideline G.London: NICE, 2002.
- National Institute for Clinical Excellence. Management of type 2 diabetes management of blood pressure and blood lipids. NICE Inherited Clinical Guideline H. London: NICE, 2002.
- Scottish Intercollegiate Guidelines Network. SIGN 55. Management of Diabetes. Edinburgh: SIGN, 2001.
- Department of Health. National Service Framework for Diabetes: Delivery strategy. London: DoH, 2002.
- The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329: 977-86.
- Stratton IM,Adler AI,Neil HA et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. Br Med J 2000; 321: 405-12.
- Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999; 281: 2005-12.
- UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: Br Med J 1998; 317: 703-13.
- Hansson L, Zanchetti A, Carruthers SG et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial.HOT Study Group. Lancet 1998; 351: 1755-62.
- Mogenson CE, Keane WF, Bennett PH et al. Prevention of diabetic renal disease with special reference to microalbuminuria. Lancet 1995; 346: 1080-4.
- Dinneen SF, Gerstein HC.The association of microalbuminuria and mortality in non-insulin dependent diabetes mellitus.A systematic overview of the literature. Arch Intern Med 1997; 4: 1413-18.
- Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000; 355: 253-9.
- Parving HH, Lehnert H, Brochner-Mortensen J et al. Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001; 345: 870-8.
- Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383-9.
- Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998; 339: 1349-57.
- Shepherd J, Cobbe SM, Ford I et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia.West of Scotland Coronary Prevention Study Group. N Engl J Med 1995; 333: 1301-7.
- Collaborative overview of randomised trials of antiplatelet therapy-I: Prevention of death,myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. Br Med J 1994; 308: 81-106.