What challenges have the diabetes indicators presented during the first year of the nGMS contract? Dr Matthew Lockyer takes stock of his practice’s achievements
Some 1.4 million individuals in England have diabetes, and this figure is expected to double by 2010. The Audit Commission’s review of diabetes services in 2000 reported that diabetes care consumed 9% of hospital funding, although total costs were much greater.1
The quality and outcomes framework of the nGMS contract recognises the importance of good management of patients with diabetes by offering a total of 99 points for achieving the targets it sets (Table 1, below).
|Table 1: Clinical indicators for diabetes|
|Disease indicator||Clinical indicator||Points||Payment stages|
|Min (%)||Max (%)|
A register of diabetes patients
% diabetes patients whose notes record BMI in the past 15 months
% diabetes patients with a record of smoking status in the past 15 months
% smokers offered or referred for smoking cessation advicein the past 15 months
% diabetes patients with a record of HbA1c in the past 15 months
% diabetes patients in whom the last HbA1c is 7.4 or less in the past 15 months
% diabetes patients in whom the last HbA1c is 10 or less in the past 15 months
% diabetes patients with a record of retinal screening in the past 15 months
% diabetes patients with a record of the presence or absence of peripheral
% diabetes patients with a record of neuropathy testing in the past 15 months
% diabetes patients with a blood pressure record in the past 15 months
% diabetes patients in whom the last blood pressure is145/85 mmHg or less
% diabetes patients with a record of microalbuminuria testing in the past 15 months
% diabetes patients with a record of serum creatinine testing in the past 15 months
% diabetes patients with a diagnosis of proteinuria or microalbuminuria treated with ACE inhibitors
% diabetes patients with a record of total cholesterol in the past 15 months
% diabetes patients whose last measured total cholesterol in the past 15 months is 5 mmol/l or less
% diabetes patients who have had influenza immunisationin the preceding 1 September to 31 March
I first wrote about achieving the clinical indicators for diabetes in October 2003, when practices were beginning to get to grips with the nGMS contract. 2 Now, at the end of the first year, practices have been able to see how many points they have achieved. A good score for the past year predicts the finances for the coming year, when the value of the points will increase. Our next challenge will be to sustain the achievements we have made.
The quality and outcomes framework
The quality and outcomes framework has brought about some substantial changes in practice working methods.
First, it has encouraged the practice to become paper-free or ‘paper-light’ to make the best use of the computer system. New practice software has shifted us away from the notion of annual audit to one of continual evaluation of our progress in reaching clinical targets. Data entry must be accurate to show a true picture of a practice’s clinical achievement, and a growing number of computer programs offer support with this.
Second, the type of staff employed by practices has changed. There has been a reduction in reception staff and a move to employing more computer-literate staff as well as healthcare assistants who gather the simple clinical data required by the new contract.
Third, we have had to learn how to use exception reporting effectively (Box 1, below). Although it is a mechanism to ensure fairness, if used to excess it will affect the denominator for the target population and may prompt investigation to ensure that claims are appropriate. The requirement to re-register exemptions annually may need careful administration.
|Box 1: Exception Read codes for the diabetes indicators|
Maximum tolerated anti-hypertensive therapy
History of allergy to ACE
ACE inhibitor adverse effect
ACE inhibitor contraindicated
ACE inhibitor refused
ACE inhibitor not indicated
ACE inhibitor not tolerated
History of allergy to A2 antagonist
A2 antagonist adverse effect
A2 antagonist refused
A2 antagonist not indicated
A2 antagonist not tolerated
Statin adverse effect
Maximum tolerated lipid lowering therapy
Statin not indicated
Statin not tolerated
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Last, the contract has thrown up some difficult questions relating to specific clinical directives and how they should be applied to the elderly, infirm patients who make up a substantial proportion of the target populations.
Disease register (DM 1)
Most practice prevalence rates are between 2 and 3%, but may be as high as 5% or more in practices with large numbers of Asian patients, who have a genetic predisposition to diabetes.
My recommendation is to enter diabetes patients of all ages in the practice register and to include patients with impaired glucose tolerance and gestational diabetes as a separately reviewed subset.
The diabetes practice nurse and I comb through our register at least once a year to keep it up to date. We know the patients and can always identify those who have died or moved away as well as the non-attenders.
It is important to be aware of your practice prevalence. External assessment will check prevalence to verify this indicator. Next year, practice prevalence will be compared with expected prevalence, and target payments will be adjusted to ensure that those with the lowest prevalences are not financially disadvantaged.
Practices using the VAMP computer system should be aware that patients entered on the diabetes register may not have diabetes Read codes recorded. If your target payments do not reflect your patient register, search on diabetes Read codes to check.
Body mass index (DM 2)
This clinical indicator rewards recording BMI in diabetes patients during the preceding 15 months. It should be possible to gather baseline data with any formal annual recall system, and most practices will collect points for this indicator.
Diabetes patients are often on treatments that cause weight gain. Referral to a dietician and diabetes support groups as well as judicious use of drug therapy, such as orlistat and sibutramine, should all be considered.
Smoking (DM 3, 4)
Smoking is probably the single most important risk factor for heart disease, and when a smoker has diabetes the risk of damage to the vascular system may be increased by 20 times or more.
DM 3 rewards recording smoking status. The smoking status of lifelong non-smokers need only be recorded once, but all other entries relating to smoking status must be updated annually.
DM 4 awards points for recording the offer of smoking cessation services to diabetes patients who smoke. This indicator may cover quite a small number of patients – our population of 305 adult diabetes patients yielded 26 smokers. While this makes intervention easy, it also means that missing any eligible patients can have a disproportionate effect on target outcomes.
Recording smoking status also earns points under the records and information organisational indicator as well as under other clinical areas, so a single record can contribute to several indicators.
Blood glucose measurement and results (DM 5, 6, 7)
The large number of points available here reflects the importance of good glycaemic control to patients’ general wellbeing and to preventing complications. Using glycosylated haemoglobin as a measurement of control, the DCCT trial and the UKPDS trial showed in type 1 and type 2 diabetes respectively that tighter diabetes control improved outcomes with respect to microvascular complications.3,4 UKPDS also found a small improvement in macrovascular outcomes but this finding was not statistically significant.
The contract’s target HbA1c level is less than 7.4%. The lower the level, the lower the incidence of new complications, and the slower the progression of existing complications. Patients are advised to have an HbA1c measurement twice a year if their diabetes is well controlled and more frequently if control is poor or there are complicating factors such as intercurrent illness or pregnancy.
DM 5 rewards practices if more than 25% of the target population have had an HbA1c check in the preceding 15 months, with maximum points gained if 90% have been tested.
DM 6 awards points for patients with HbA1c of 7.4% or below. Maximum points are gained for 50% of the target population achieving this level. This recognises the difficulty of maintaining good glycaemic control, especially in type 2 diabetes in which UKPDS showed the need to increase treatment over time to keep pace with the disease.
DM 7 also recognises this difficulty and awards points for the percentage of patients with an HbA1c at or below 10%. This is important as each practice has a number of elderly patients in whom it is inappropriate, or even dangerous, to strive for tight glycaemic control. Some individuals also make lifestyle choices that do not include tight adherence to a diabetes regimen. It is impractical to remove all these patients from the population denominator.
To attain maximum points, 85% of the target population must achieve this level. We have achieved maximum points for these indicators, and I suspect many other practices have too, perhaps because of the many elderly diabetes patients who are stable on diet alone or on low doses of oral hypoglycaemics, who counterbalance the patients whose condition is more complex.
Retinal screening (DM 8)
The National Service Framework for Diabetes commits the NHS to providing a systematic programme of retinal screening for diabetic retinopathy.5 Most areas have static units and mobile units that visit individual surgeries.
Do not forget that you may need to provide the unit with an updated register. Few areas have local registers and there is no national register in England and Wales, so check the recall list for changes before it is sent. Scottish readers can disregard this advice, because Scotland, wisely, has instituted a national eye screening programme with a central database.
If you are fortunate enough to have a visiting unit, take advantage of the fact that most of your diabetes patients will attend the practice in a short period of time. Our unit visits annually in late October, so we arrange for our healthcare assistant to measure the height, weight and blood pressure of every diabetes patient who comes for eye screening. Patients are also offered a flu vaccination.
This also helps us achieve DM 18, which offers 3 points for a maximum of 85% of diabetes patients receiving a flu vaccination.
Our practice nurse had a list of outstanding blood tests and persistent non-attenders at clinic and took the opportunity to take blood and try to persuade these patients back to regular care. Several trusts now employ assistants to take measurements at the fixed site screening units and feed the information back with the clinic letter.
Foot pulses and neuropathy (DM 9, 10)
In my previous article I said I thought these indicators would be easy to achieve because it is recording the finding of a simple clinical examination. In practice, getting the Read codes to behave proved most difficult for these parameters – our computer system did not offer the right Read codes in the diabetes recording screen. We think the problems are now sorted out, but it illustrates the importance of accurate recording in assessing practice performance.
Most secondary care diabetes teams are now creating separate teams dedicated to rapid assessment of diabetes patients at risk of foot complications. Diabetic foot ulcers are a costly problem when patients need in-patient treatment. Early detection and referral to a specialised service will be cost effective and greatly improve the patient’s quality of life.
Blood pressure (DM 11, 12)
Blood pressure recording and control are accorded a large number of points. This is because, especially in type 2 diabetes, good control of blood pressure is even more significant than glycaemic control in preventing macrovascular events.
Unfortunately, for reasons that are not understood, hypertension in diabetes patients is often the most difficult to control. They often need multiple drug regimens to try to achieve target blood pressure and even then not all patients will reach the target.6
The target for the contract is set at 145/85 mmHg or less. Maximum points are awarded if 55% or more of the patient population achieve this target in the preceding months, reflecting the difficulty in achieving it.
The target reflects older research such as UKPDS,6 and the HOT study,7 which suggested an optimum blood pressure of 140/80 mmHg, with greater reductions bringing further benefits in diabetes patients. These findings inform the NICE guideline for the management of hypertension in diabetes.8 More recent guidelines have recommended reduced blood pressure targets and changes in therapy for hypertension, all of which have made navigating this area of patient care more complicated.9
Renal disease (DM 13, 14, 15)
These indicators reward the measurement of serum creatinine, screening for microalbuminuria (most commonly by measuring urinary albumin: creatinine ratio) and the treatment of microalbuminuria or nephropathy with an ACE inhibitor.
Microalbuminuria (a 24-hour urinary protein loss of 30-300 mcg, not detectable at routine urinalysis) and established diabetic nephropathy (dipstick-positive proteinuria,300 mcg per 24 hours or more) are markers for progression to end-stage renal disease in type 1 diabetes and imminent vascular disease in type 2 diabetes.10,11 Treatment with ACE inhibitors and some angiotensin receptor blockers has been shown to be protective.12,13
An annual creatinine check is a sensible requirement. Microalbuminuria screening is of particular importance in type 1 diabetes and in type 2 diabetes patients who are not on ACE inhibitors.
Lipids (DM 16, 17)
Treating diabetes patients to the same standards as secondary prevention for coronary heart disease had already been shown to be of benefit before the new contract was introduced. Since then, a powerful further study has suggested the benefit of lipid lowering in every diabetes patient.14
Even with this new evidence, however, it is sometimes difficult to decide whether to offer statin treatment to the increasing numbers of diabetes patients in their 80s and to older patients with multiple pathologies. Once committed to statin treatment, the patient will undergo cholesterol tests and alterations in treatment to achieve target lipid levels.
At present, the trend seems to be to treat these patients, and the National Service Framework for Older People supports this,15 but we must be careful not to lose sight of the patient’s quality of life in our desire to collect points.
We have recently reviewed our statins policy to get the most from our drug budget. There is an evidence base for many approaches and each practice will decide how it will use these drugs.
We have reached our target of more than 60% of our diabetes patients achieving a cholesterol level of 5 mmol/l or less in the past 15 months.
Influenza immunisation (DM 18)
As I have explained, we capitalise on any opportunity that draws our diabetes patients en masse to the surgery. Although the flu vaccination targets are worth only a few points they can help to improve other clinical data entries.
Many practices have scored well in the diabetes indicators this year, but work is still needed in organising patient care to ensure good outcomes.
- Audit Commission: Testing Times: A Review of Diabetes Services in England and Wales. London: Audit Commission, 2000.
- Lockyer MJ.Achieving the clinical indicators for diabetes.Guidelines in Practice 2003;6(10): 48-55.
- The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.
- 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.
- Department of Health. National Service Framework for Diabetes: Delivery strategy. London: DoH, 2002.
- Tight blood pressure control and risk of microvascular and macrovascular complications in type 2 diabetes. UKPDS 38. UK Prospective Diabetes Study Group.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.
- National Institute for Clinical Excellence. Management of type 2 diabetes: management of blood pressure and blood lipids. Inherited Clinical Guideline H. London: NICE, 2002.
- Williams B, Poulter NR, Brown MJ et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18: 139-85.
- Morgensen CE, Keane WF, Bennett 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-insulindependent 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.
- Colhoun HM,Thomason MJ, Mackness MI et al. Design of the Collaborative AtoRvastatin Diabetes Study (CARDS) in patients with type 2 diabetes. Diabet Med 2002, 19: 201-11.
- Department of Health. National Service Framework for Older People.London:DoH,2001.