The revised diabetes indicators should help reduce morbidity and mortality in both type 1 and type 2 disease, says Dr Matthew Lockyer


   

As we enter QOF2, it is time to evaluate the new diabetes indicators and see how the changes will affect your practice (Table 1).

Table 1: Clinical indicators for diabetes
       
Disease indicator Clinical indicator Points

Payment stages

Min (%)                    Max (%)

         
DM 19
The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has type 1 or type 2 diabetes
6    
DM 2
% patients with diabetes whose notes record BMI in the previous 15 months
3 40 90
DM 5
% diabetic patients who have a record of HbA1c or equivalent in the previous 15 months
3 40 90
DM 20
% patients with diabetes in whom the last HbA1c is 7.5 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months
17 40 50
DM 7
% patients with diabetes in whom the last HbA1c is 10 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months
11 40 90
DM 21
% patients with diabetes who have a record of retinal screening in the previous 15 months
5 40 90
DM 9
% patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months
3 40 90
DM 10
% patients with diabetes with a record of neuropathy testing in the previous 15 months
3 40 90
DM 11
% patients with diabetes who have a record of the blood pressure in the previous 15 months
3 40 90
DM 12
% patients with diabetes in whom the last blood pressure is 145/85 mmHg or less
18 40 60
DM 13
% patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months (exception reporting for patients with proteinuria)
3 40 90
DM 22
% patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months
3 40 90
DM 15
% patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors (or angiotensin II antagonists)
3 40 80
DM 16
% patients with diabetes who have a record of total cholesterol in the previous 15 months
3 40 90
DM 17
% patients with diabetes whose last measured total cholesterol within previous 15 months is 5 mmol/l or less
6 40 70
DM 18
% patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March
3 40 85

Diagnosis, register and prevalence (DM19)

This year prevalence of the diseases included in QOF2 becomes relevant to payment. Disease prevalence will be compared with an agreed national or local figure. In the case of type 2 diabetes, where area prevalence can vary between 2.4% in a Caucasian population to 3–5 times higher in predominantly Asian communities,1 local rather than national prevalence comparators will be preferred.

Practices should check their prevalence figures against other local practices or a published PCT average. This data will be sent to you by your PCT. If there is a discrepancy first check that your computer data is not at fault. All systems have the capacity to 'lose' patients if data is entered incorrectly. We use the VAMP system and in the past it has been easy to enter diagnoses on disease registers that are missed on searches.

Another area we successfully tackled in our practice was the handling of raised random blood glucose results. A search of patients who had raised blood glucose levels with no diagnosis of diabetes during the previous 5 years yielded about 120 results.

It took me an hour to review the records and come up with a short list of 30 patients who had not had a subsequent fasting glucose test. I wrote to these patients and arranged for them to attend in batches of five over a 6-week period for follow-up testing. This yielded three new diabetes cases and one new case of impaired glucose tolerance – a 1% increase in our number of diabetes patients.

I have subsequently changed the follow-up of raised random glucose tests from passively leaving a message to actively contacting the patient.

My diabetes practice nurse and I still use protected time to review our register and try to keep it as accurate as possible. I recommend keeping a separate register of children and adolescents under 17 years of age, because when they reach 17 they will need to be invited to the clinic. We start when they are 16, usually sharing care with the hospital adolescent clinic.

Patients with gestational diabetes need a separate register and should have an annual fasting glucose measurement. We also keep a separate register of impaired glucose tolerance patients. A substantial number of these will progress to type 2 diabetes.

We offer them a diabetes style review annually because even if not overtly diabetic their risk of cardiovascular disease will already be raised.

For the first time practices need to be able to identify type 1 and type 2 diabetes separately. This should not present a problem – coding can easily be added at annual review, with a register check before April 2007. It is also useful to subdivide the types of treatment which type 2 diabetes patients receive by recording relevant Read codes.

Ongoing management indicators

Diabetes now features in the depression set and there will be overlap with the new obesity and chronic kidney disease sets. DM 3 and DM 4 relating to recording smoking, and advice on smoking cessation have been removed as there are separate smoking indicators in QOF2.

DM 20 has replaced DM 6 with an increase in the HbA1c threshold from 7.4 to 7.5%. DM 21 has replaced DM 8, and to meet this indicator practices must now demonstrate that patients have received retinal screening to the required standard.

DM 22 has replaced DM 14 and adds the estimated glomerular filtration rate to creatinine measurement (see below).

In all of the ongoing management indicators the minimum threshold achievement for payments has been increased from 25% to 40%. In some areas the maximum payment target has also been modestly increased (by 5 or 10%).

This reflects the success that practices achieved in the first year of the system. We await this year's results to compare how practices have fared in the second year.

BMI (DM 2)

The BMI indicator (DM 2) remains unaltered. However, the overall distribution of clinical points in QOF2 has been altered such that there is a new obesity indicator OB1 requiring a register of all patients with a body mass index ? 30. Although I remain sceptical about 'managing' all obesity as a medical problem, I try very hard to motivate my diabetes patients to adopt a healthy lifestyle.

A behavioural programme called DESMOND is currently being introduced nationally to help newly diagnosed patients with type 2 diabetes make positive changes in diet and exercise.2 This intervention has an evidence base of proven success.The DAFNE (Dose Adjustment For Normal Eating) programme allows patients with type 1 diabetes more flexibility with their diet.3

As increasing numbers of younger patients present with type 2 diabetes, it is vital that we are able to help them use lifestyle changes effectively as part of their treatment.

Glycaemic control (DM 7, DM 5)

These indicators remain unaltered and therefore should still be achievable. HbA1c is a fundamental part of any annual diabetes check. The large number of older diet-controlled diabetes patients in general practice weight the figures towards better control.

We have found it possible to achieve consistently good results on this indicator, as have our neighbouring practices.

Retinal screening (DM 21)

It is important to remember that most areas do not have a regional diabetes register, so the practice register is the basis of retinal screening recall. The uptake for this service has been excellent, even better than the annual recall to the practice clinic. It is sensible to capitalise on this flow of your diabetes patients through the practice.

We are lucky enough to have the mobile screening unit visit in October. We place them at the end of a corridor and to get there the patients must first pass the nurse who will administer a flu jab, and then the healthcare assistant with her scales, clipboard and blood letting gear. There are even some reserved appointments for me, the GP, to offer immediate review to the odd recidivist!

Foot pulses and neuropathy testing (DM 9 and DM 10)

There is no change for these indicators. These examinations remain an integral part of annual general practice review. Sensation should be tested with a 10g filament for light touch, neurotip tester for pinprick sensation and C0 tuning fork for vibration sense. It should be possible to perform ankle/brachial pressures using Doppler ultrasound if pulses are reduced. Record 'at risk' feet and try to ensure that these patients have regular chiropody.

All secondary care providers should now have a rapid access diabetes foot care service.We are arranging education sessions both within our practice and PCT-wide to try to ensure optimal use of this service.

Blood pressure (DM 11, DM 12)

Blood pressure control in type 2 diabetes remains the most effective evidence-based intervention.4 The results of good blood pressure control are superior to those achieved by attaining normoglycaemia. Unfortunately, for reasons that are as yet not understood, diabetes patients are often the most difficult to treat to target levels.

Triple or even quadruple antihypertensive therapy is common in diabetes patients. This produces all the problems of compliance, side-effects and interactions that come from polypharmacy. This difficulty continues to be reflected in the relatively low percentage required to achieve full payment (60% of target population).

When I see patients on multiple antihypertensive regimens at the diabetes clinic I often book a 24-hour blood pressure monitor for them. This gives valuable information and frequently shows improved BP control compared with that measured in the clinic.

Those patients who are truly hypertensive on therapy or lack diurnal variation may benefit from an increased effort to reduce other risk factors, compliance checking, or revision of their treatment.

In our district GPs do not have direct access to 24-hour BP monitoring and I have long felt it might be a useful, if expensive, purchase. Contractually patients who fail to achieve target blood pressure on multiple drug regimens may be exempt from the denominator population on the grounds of 'maximum tolerated treatment'.

The selection of treatment for hypertension has been the subject of debate following the publication of the ASCOT trial in which newer drug regimens were shown to be superior to the older thiazide diuretics and beta-blockers.5 In diabetes patients with no contraindications an angiotensin converting enzyme (ACE) inhibitor or angiotensin II antagonist should be the first drug prescribed, with a long-acting calcium channel blocker the second.5

Microalbuminuria and renal function (DM 13, DM 22, DM 15)

Detection of microalbuminuria is important in both type 1 and type 2 diabetes. In type 1 it predicts the inexorable decline to end-stage renal failure. In type 2 it reflects increased mortality risk from heart attack or stroke.6,7 Intensive management of cardiovascular risk factors means we are seeing increased numbers of type 2 diabetes patients progressing to severe renal impairment or even dialysis for end-stage renal failure.

Improving our management of renally impaired patients is on the list of priorities for our practice clinic. Do not forget that some diabetes patients will now also fall into the new chronic kidney disease indicator set. These patients will be checked as part of a register and also for blood pressure control and use of ACE inhibitors.

We continue to check microalbuminuria annually. The population weighting to the elderly that helped our HbA1c results acts against us here. Older people often produce urine that cannot be read for an albumin:creatinine ratio, yet they cannot be exempt from the target group. They are frequently already on ACE inhibitors or angiotensin II antagonists.

In a younger patient the value of screening is more obvious, and a rising albumin:creatinine ratio may be an early indicator to refer for specialist review. Patients who progress to overt proteinuria are exempt from the need to check microalbumin levels.

The new indicator DM22 requires GPs to record the percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the past 15 months. The guidance to the revised QOF states that eGFR based on serum creatinine is a better method to detect and monitor early renal disease. Over the next year all linked practices should receive eGFR values without having to request them, i.e. as routinely reported data.

Cholesterol (DM 16, DM 17)

The ASCOT-LLA and the CARDS trials have both demonstrated the reduction of risk in diabetes patients from reducing their cholesterol whatever their starting value.8,9 It is sometimes difficult to know how to apply this evidence.

The Joint British Societies' guidelines (JBS 2) recommend that all patients with diabetes aged 40 years or more should be offered statin therapy.10 Our policy (which is not offered as a gold standard) has been to offer all patients with diabetes over 50 a statin. For younger patients I calculate a cardiovascular risk. The JBS 2 guidelines state that the presence of diabetes automatically puts the patient into a high-risk category. However, I find a lot of younger patients are less enthusiastic about starting long-term medication and the risk calculation allows me to focus on those who are at greatest risk.

The JBS 2 guidelines suggest a revision of target lipid values to total cholesterol < 4.0 mmol/l and low-density lipoprotein cholesterol < 2.0 mmol/l. The recently published trial of rosuvastatin suggests these targets may become attainable.11 However, at present the target in QOF2 is a total cholesterol of ? 5 mmol/l.

Flu vaccination (DM 18)

The flu vaccination indicator remains unchanged. Flu vaccinations are another time when most of the diabetes population of your practice will pass through the doors – use the opportunity to conduct their annual reviews.

Depression (DEP 1)

For the first time another disease indicator set requires intervention specifically for diabetes patients. The new depression indicators include DEP1 'the percentage of patients on the diabetes register and/or the CHD register for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions'. The two questions referred to are:

  • During the last month have you often been bothered by feeling down, depressed or hopeless?
  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

The evidence for this type of screening is sound. The problem is the practicality of including it in a diabetes review. These can already be medically complex consultations and a formidable amount of information must be recorded. Consultations to diagnose and initiate treatment for depression are often long and involved. Yet, if we can detect depression not only will our patients benefit from treatment, but we may also make more impact with their diabetes care.

I have always argued for practice diabetes care being structured around a practice nurse supported by a lead GP. My suggestion will be to include the questions in the invitation letter sent out to diabetes patients to encourage them to attend the clinic. Positive responders will get an appointment with the lead GP to discuss the possibility of depression separately from the diabetes clinic.

Conclusion

Diabetes remains one of the central components of QOF2. Changes are being made to reflect a rapidly evolving field of medicine. A well-structured practice clinic should be able to cope with these changes and additions and continue to achieve points in many of the indicators.

 

Guidelines in Practice, May 2006, Volume 9(5)
© 2006 MGP Ltd
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  1. Diabetes UK:www.diabetes.org.uk
  2. Diabetes Education & Self Management for Ongoing & Newly Diagnosed: www.desmond-project.org.uk/
  3. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomisd controlled trial. Br Med J 2002; 325 (7367): 746.
  4. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. Br Med J 1998; 317 (7160): 703-13.
  5. Dahlöf B, Sever PS, Poulter NR et al; ASCOT Investigators. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005; 366 (9489): 895-906.
  6. Mogensen CE, Keane WF, Bennett PH et al. Prevention of diabetic renal disease with special reference to microalbuminuria. Lancet 1995; 346 (8982): 1080-84.
  7. Dinneen SF, Derstein HC. The association of microalbuminuria and mortality in non-insulin-dependent diabetes mellitus. A systematic overview of the literature. Arch Intern Med 1997; 157 (13): 1413-18.
  8. Sever PS, Poulter NR, Dahlöf B et al. Reduction in cardiovascular events with atorvastatin in 2,532 patients with type 2 diabetes: Anglo- Scandinavian Cardiac Outcomes Trial--lipid-lowering arm (ASCOT-LLA). Diabetes Care 2005; 28 (5): 1151-57.
  9. Colhoun HM, Thomason MJ, Mackness MI et al. Design of the Collaborative AtoRvastatin Diabetes Study (CARDS) in patients with type 2 diabetes. Diabetic Med 2002; 19 (3): 201-11.
  10. JBS 2: Joint British Societies' Guidelines on Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; 91 (suppl v): v1-v52.
  11. Nissen SE, Nicholls SJ, Sipahi I et al. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA 2006; 295 (13): 1556-65.