|Diabetes: Clinical Indicators|
|Register of patients aged 17 years and over with diabetes mellitus, specifying Type 1 or Type 2 diabetes||Register||6|
|Record of BMI in past 15 months||90||3|
|Record of HbA1c in past 15 months||90||3|
|Last HbA1c 7.5 or less in past 15 months||50||17|
|Last HbA1c 10 or less in past 15 months||90||11|
|Record of retinal screening in past 15 months||90||5|
|Record of peripheral pulses in past 15 months||90||3|
|Record of neuropathy test in past 15 months||90||3|
|BP recorded in past 15 months||90||3|
|Last BP 145/85mmHg or less||60||18|
|Record of micro-albuminuria testing in past 15 months (exception reporting for proteinuria||90||3|
|Record of estimated glomerular filtration rate or serum creatinine in past 15 months||90||3|
|Patients with proteinuria or micro-albuminuria on ACE inhibitor or angiotensin II antagonist||80||3|
|Total cholesterol recorded in past 15 months||90||3|
|Last cholesterol 5mmol/l or less in past 15 months||70||6|
|Influenza immunisation in preceding September to March||85||3|
- National prevalence of diabetes mellitus was 3.6 per cent in England and 3.1 per cent in Northern Ireland in 2006/7 and prevalence rates for Wales and Scotland in 2005/6 were 4.1 per cent and 3.4 per cent respectively. Rates will vary depending on your practice profile. In some black and ethnic minority groups, prevalence could be three to five times higher. There is no cap on payments for those with the highest prevalence. The current estimate is that there are one million undiagnosed cases in the UK.
- Average exception reporting rates for diabetes in England in 2005/6 were 6.01 per cent.
- The changes to the requirements for diabetes from 2006/7 included extra information to record on the register, the addition of estimated glomerular filtration rate (eGFR) as an alternative to serum creatinine testing and two extra points for reaching targets on blood sugars and blood pressure levels.
- Minimum threshold levels to trigger payment were raised in all cases to 40 per cent and maximum threshold levels were also raised for some individual indicators.
- Liaison groups between GPs and secondary care could prove essential to cover issues such as retinal screening, transfer of results, chiropody and dietetic care. Lack of good data from secondary care could affect your ability to reach the higher thresholds.
- The timescale for most of the diabetes indicators is 15 months from 1 January 2007 to 31 March 2008. Work carried out before January 2007 will not count. Influenza vaccinations must be given between 1 September 2007 and 31 March 2008.
Step 1: Setting up the register
- Begin by setting up your diabetes register or assessing the state of it. If you already use Read codes, you can identify patients with diabetes mellitus by searching for relevant codes. You can also search for repeat prescription drugs used for diabetes, such as insulin and oral hypoglycaemic agents. Searching for blood or urine testing may be particularly useful for patients being managed by dietary modification alone.
- The guidance now states that the register should specify whether the patient has Type 1 or Type 2 diabetes. If this is unclear from the records, the code for Type 1 should be used for patients under 30 or requiring insulin within a year of diagnosis. Otherwise, the code for Type 2 should be used. Separate coding is designed to align the indicators more closely with NICE guidance. Note that Read codes for this indicator have been changed to reflect the need for all patients to be recorded as having Type 1 or Type 2.
- Further names may be added by the primary care team and the register can be updated by adding patients as they consult and by adding information from hospital letters.
- Note that the allowable Read codes for the diabetes register were significantly cutback in the new business rules and that C10E and C10F chapters are now the only two permitted for inclusion in the register.
- There is no requirement to justify your diagnosis of diabetes, although practices are encouraged to adopt a systematic approach. A written policy on diagnosis and treatment, agreed with the multidisciplinary diabetes care team, will help to produce such an approach (see recommended guidance).
- All patients under 17 are excluded because children are usually under specialist care. However, be aware that some patients will reach 17 before 1 April 2008, the cut-off date.
- Patients with gestational diabetes are also excluded from the indicators but need to be kept under review.
Step 2: From now onwards
- The indicators include 10 annual checks. The majority, with the exception of retinal screening, can be carried out in general practice. Work should begin immediately.
- Decide on your system for call and recall of patients and follow up of non-attenders. If you are planning to delegate this to nurses, investment in training is desirable.
- Practices can now report eGFR as an alternative to serum creatinine testing. The guidance says eGFR is a better means of detecting and monitoring early renal disease and in the longer term, should be easier for patients to understand. The eGFR should be routinely reported data but if it is not yet routine in your area, check if your system supplier has a program to go through your notes, find creatinine levels, calculate eGFRs and highlight abnormal ones. Alternatively, you could use an online calculator (http://www.renal.org/eGFRcalc/GFR.pl)
- Patients with a diagnosis of proteinuria or micro-albuminuria need to be treated with ACE inhibitors or angiotensin II antagonists.
- Patients without established proteinuria must have their urine checked annually for micro-albuminuria. The cost of testing strips may be an issue. Possible alternatives are to obtain funding for test strips from pharmaceutical companies, to send urine samples to the pathology laboratory, or to get the PCO to fund it as a laboratory test.
- Note that on retinal screening, practices face a new requirement to demonstrate that patients have received retinal screening to the required standard. Make sure there is a system in place to add information about retinal screening to patients’ records because this may come from various sources.
- Provide patients and/or carers with literature and contacts for support groups. Consider introducing personalised diabetic care plans. Regular checks need to be made on patients’ techniques for testing urine or blood. Do not attempt to cover everything in one visit.
- Set up a system to ensure all relevant information is transferred from hospital letters to patients’ electronic records.
Step 3: September
- Optimal glycaemic control is probably one of the toughest targets and GP and nurse follow-up will be essential. The contract sets two indicators, so there is the potential to earn 27 points if you can deliver 50 per cent of those on the register with an HbA1c of 7.5 or less and 90 per cent with an HbA1c of 10 or less. Three-monthly checks will be appropriate for those with an HbA1c of 7.5 or more.
- PCOs are allowed to set different figures for these levels to account for test availability and variations in normal ranges in different parts of the UK.
- The upper threshold of the first target for HbA1c changed to 7.5 in 2006/7. This is based on the Diabetes Control and Complications Trial in Type 1 diabetes and NICE guidance on Type 2 diabetes. This indicator is worth an extra point from 2006/7, up from 16 to 17, because it was identified as one of six across the clinical domain that practices had difficulty achieving. Achievement level for full points for the second indicator (HbA1c levels, specifying a maximum level of 10), was raised from 85 to 90 per cent in 2006/7.
- Tight blood pressure control is also difficult to achieve in diabetic patients and in 2006/7 the indicator increased the top target from 55 to 60 per cent of patients with a last measurement of 145/85 or less. A point was added to this indicator, now worth 18, as a mark of the difficulty practices have faced in achieving it.
- Note that the blood pressure target for diabetes is more demanding than that for stroke or CHD (150/90), although the percentage needed to generate the highest payment is lower. Reduce the interval of repeat prescriptions for patients whose blood pressure is above the target.
- Cholesterol control with statin therapy, where appropriate, will help to meet the target of 70 per cent of patients with a last cholesterol measurement of 5mmol/l or less.
- If cholesterol is checked by nurses or healthcare assistants, a protocol can be written to generate a prescription for the GP to sign where appropriate.
- The age when a statin should be initiated is unclear. The contract guidance suggests that patients over 40 with a cholesterol of greater than 5mmol/l should be treated with a statin. Below 40, a decision needs to be reached between the doctor and the patient and may involve assessment of other risk factors and the actual age of the patient. The 2006/7 guidance removed the previous blanket advice that when a statin is not prescribed, the patient can be exception reported.
- Make sure all patients with diabetes are invited for influenza vaccination and exception report all those who refuse. Although it is not included in the indicators, patients with diabetes should also receive a pneumococcal vaccination.
- Consider inviting patients in secondary care for an annual review, to ensure all the necessary checks have been carried out.
Step 4: January 2007 onwards
- Re-audit progress on indicators and develop an action plan to target those areas still requiring work before April 2008.
- Recall patients who have not had an annual review.
- Newly diagnosed and poorly controlled patients should be seen every three months.
Useful Resources for Diabetes
1. Diabetes Control and Complications Trial (DCCT)
N Engl J Med 1993; 329 (14): 977-86
2. Diabetes UK
3. English National Service Framework for Diabetes
4. National Institute for Health and Clinical Excellence (NICE)
Type 1 Diabetes
Type 2 Diabetes
6. Scottish Intercollegiate Guidelines Network (SIGN)