10 Points to Quality
Dr Lorna Gold continues her series on achieving the necessary standards to meet the quality framework by looking at diabetes
Involve everyone who does diabetes care in the practice in the development of a template for recording information
With so many pieces of information to collect about each patient, and hundreds of Read codes for diabetes, your data will soon become fragmented if everyone does not have a sense of ownership of the information-gathering process. The major IT system providers are developing contract-friendly templates, but transferring information to these will be simpler if it is already being recorded systematically. To avoid unnecessary duplication, ensure the codes you use for smoking, blood pressure, cholesterol and influenza immunisation are standardised across the different indicator sets.
Screen high-risk patients
Your PCT will be alert for those practices (not yours, of course) that 'accidentally' omit to include poorly-controlled patients on their diabetes register, and may compare the prevalence of diabetes in your practice population with the expected prevalence in the area, so it is important to avoid underdiagnosing the condition. Consider offering opportunistic screening to high-risk patients over the age of 40, including those who are overweight, of African, Caribbean or south Asian origin, or who have a strong family history of the condition. Women who have had gestational diabetes or given birth to a baby weighing more than 4kg are also at increased risk of developing type 2
The new contract diabetes indicators only apply to over-16s
It is assumed that children with diabetes will be managed in secondary care. It is also unnecessary to include patients with impaired glucose tolerance or gestational diabetes.
Diagnose diabetes accurately
In patients who present with osmotic symptoms, diagnosis rarely presents a problem. In asymptomatic patients, or those with nonspecific symptoms such as fatigue or recurrent abscesses, use the WHO 1999 criteria. These are a random plasma (not capillary) blood glucose above 11.1mmol/l or fasting plasma glucose above 7.0mmol/l on two separate occasions. If the results are ambiguous
(for example, if the fasting blood glucose is normal but the random blood glucose is raised), a two-hour glucose tolerance test should be performed and a blood glucose of more than 11.1mmol/l regarded as diagnostic of diabetes.
Ensure patients are reviewed annually
Practices can earn up to 37 points if a full annual review is performed on at least 90 per cent of patients on the diabetes register and all the relevant information is entered on the computer. Entering data from the hospital annual review is acceptable but it is much easier to ensure all the necessary information is available if the annual review is done in the practice or PCT clinic. Record the following information at each annual review:
mBody mass index (three points)
mSmoking status (three)
mSmoking cessation advice (five)
mHbA1c or fructosamine (three)
mDate of last retinal screening (five)
mPresence or absence of peripheral pulses
mPresence or absence of diabetic neuropathy (three)
mBlood pressure (three)
mMicro-albuminuria testing (three)
mSerum creatinine (three)
mTotal cholesterol (three)
Know your PCO-approved retinal screening services...
It is no longer acceptable for a GP, or an SHO in the hospital clinic, to point the ophthalmoscope through undilated pupils and call it retinal screening. Ideally, everyone with diabetes should have a visual acuity test and fundoscopy through dilated pupils performed by an appropriately trained clinician annually, and fundal photography at least once every two years. Some PCOs have a contract with local optometrists to provide this service.
...and know your podiatrist
Examination of foot pulses and lower limb neurology are not difficult skills to acquire, but competence improves with experience and podiatrists are the specialists in this field. Most are approachable and will gladly see patients about whom you are in doubt. If you are performing diabetic annual reviews in the practice, consider including a training session with a podiatrist in your personal development plan. Ensure you have a 256Hz tuning-fork and a 10g monofilament in the practice, and know how to use them properly.
Aim for the best possible blood glucose control in every patient
There are two separate indicators for HbA1c . Eleven points are available for practices that can achieve a HbA1c of 10 per cent or less in at least 85 per cent of the patients on their diabetes register, and an additional 16 points can be earned if 50 per cent of patients have a HbA1c of 7.4 per cent or less. Both targets are challenging but not impossible to achieve with appropriate prescribing and judicious use of the exception-reporting system for patients in whom aggressive blood glucose lowering is impossible or inappropriate.
Take note of the blood pressure target and make ACE inhibitors your treatment of choice
Blood pressure features in other indicator sets, but the treatment target in diabetes is lower 145/85mmHg. Practices can earn 17 points for reducing blood pressure to this level or below in 55 per cent of adult patients with diabetes. In non-diabetic patients with hypertension, current evidence supports the firstline use of cheap, established drugs such as ?-blockers and thiazide diuretics. The adverse effects of these agents upon blood glucose are more theoretical than real and they are not contraindicated in diabetes, but the renoprotective effect of ACE inhibitors should make them your first choice in this group. Three points are available for practices in which at least 70 per cent of diabetic patients with microalbuminuria or frank proteinuria are prescribed an ACE inhibitor. Angiotensin-2 antagonists are an acceptable alternative.
Use statins to lower cholesterol
Diabetes is often associated with hyperlipidaemia and the contract specifies that statins should be prescribed and the dose titrated to reduce total cholesterol to 5.0mmol/l or less. Six points are available for achieving this target in at least 60 per cent of your patients. If your laboratory gives a detailed lipid profile it is worth recording this information in case this indicator is revised to take LDL or triglycerides into consideration.