The importance of regular structured review in diabetes care
Good organisation and accurate record keeping are essential to help improve the delivery of diabetes care. As part of the Diabetes Initiative Take Control, Dr Roger Gadsby discusses the key considerations, along with the requirements for quality payments in the new contract
There is clear evidence that regular structured review in the management of people with diabetes is vital to achieving targets and optimising care. More people achieve HbA1c and blood pressure targets in primary care systems where there is regular recall and review.1
Structured care and regular review in primary care are central parts of the diabetes national service framework, and are supported by NICE recommendations and Diabetes UK.2,3
Tips to help regular structured review
Consider staff training
Many practices in the UK run diabetes clinics where practice nurses with special training and expertise in diabetes care recall and review people with diabetes. Such clinics are supervised by the GP partner who has an interest in diabetes care. Suitable staff education and training programmes are widely available and include the Certificate in Diabetes Care (CIDC) course from Warwick Diabetes Care. More than 3,000 students, mainly practice nurses and GPs, have used this to develop their skills in diabetes management.
Build a diabetes register
One of the basic building blocks for running a clinic is an electronic/computerised diabetes register. There is evidence that clinical outcomes are best when computerised recall systems based on registers of people with diabetes are used.4 The diabetes quality payment framework in the new GMS contract allocates six points out of a total of 99 for such a register. It is vital to ensure all people with diabetes are diagnosed and recorded accurately. It is also important that the practice agrees a common Read code to specify a diagnosis of diabetes. Most use the C10 code.
Make your own clinic template
Many practice clinical computer systems contain a diabetes clinic template that automatically uses the appropriate Read codes for recording care. These need to be modified to ensure they record care information in a form that will fit the quality indicators from the new contract. A diabetes dataset has been developed and is being modified to allow accurate recording of the various items of clinical care that need to be recorded to document care for the contract quality payments.
In most GP diabetes programmes, blood tests are requested two weeks before clinic attendance so this information is available on the clinic day.
Many systems receive test results from the local laboratory by electronic download. These test results are then posted into the diabetes clinical template.
Think about frequency of review
This clearly depends on the needs of the particular individual. When someone is newly diagnosed their clinical condition may mean they need reviewing very frequently until their glycaemic control is optimised. Once a person is stabilised and targets for glycaemia and blood pressure have been achieved, routine review every two to six months is usual.
Documenting clinical information
Specific clinical information needs to be documented at the clinic attendance and includes:
· Weight and BMI, blood pressure, smoking status, record of influenza immunisation
· Urine test for proteinuria
· Urine test for microalbuminuria
· Results from most recent retinal screening
· Results of foot screening examination for signs of a foot at risk these are presence of bony abnormality and callus, absence of foot pulses and inability to feel a 10g nylon monofilament
· Recent HbA1c, creatinine and total cholesterol results from blood tests.
In addition, there will be the need for further records and documentation for quality payments in the new contract (see box).
Good evidence supports the fact that regular review and recall is essential to achieve
targets and optimise care for people with diabetes. Such review will help the practice achieve the diabetes quality payments in
Additional records for quality payments in the new GMS contract
in the new GMS contract
Total points available
Diabetes process measurements in past 15 months
· Recording of BMI 3
· Recording of smoking status with record of smokers 8
being offered cessation advice
· HbA1c recording 3
· Record of retinal screening 5
· Record of presence or absence of peripheral pulses 3
· Record of neuropathy testing 3
· Record of blood pressure 3
· Record of microalbuminuria testing 3
· Record of serum creatinine 3
· Record of total cholesterol 3
· Record of influenza immunisation in the preceding 3
September 1 to March 31
Points awarded accordingly for the proportion of
patients achieving targets in the past 15 months
· HbA1c Ã 7.4 per cent 16
· BP Ã 145/85mmHg 17
· Total cholesterol Ã 5mmol/L 6
Diabetes quality targets
· To have at least 70 per cent of those with proteinuria 3
or microalbuminuria treated with an ACE inhibitor
or an A2 antagonist
· To have at least 85 per cent of people on register with 11
HbA1c at or below 10 per cent
References 1. Olivarius N de Fine, Beck-Nielsen H, Andreasen AH et al. Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ 2001; 323: 1-9. 2. Diabetes UK. Recommendations for the management of diabetes in primary care. 2nd ed. London, October 2000. 3. National Institute for Clinical Excellence. Inherited Clinical Guideline G. Management of type 2 diabetes. Management of blood glucose. London: NICE, September 2002. 4. Griffin S, Kinmonth AL. Systems for routine surveillance for people with diabetes mellitus (Cochrane Review). Cochrane Library 2002; 2: Oxford: Update Software. Information about Warwick Diabetes Care courses can be found at www.diabetescare.warwick.ac.uk
1. Olivarius N de Fine, Beck-Nielsen H, Andreasen AH et al. Randomised controlled trial of structured personal care of
type 2 diabetes mellitus.
BMJ 2001; 323: 1-9.
2. Diabetes UK. Recommendations for the management of diabetes in primary care. 2nd ed. London, October 2000.
3. National Institute for Clinical Excellence. Inherited Clinical Guideline G. Management of
type 2 diabetes. Management of blood glucose. London: NICE, September 2002.
4. Griffin S, Kinmonth AL. Systems for routine surveillance for people with diabetes mellitus (Cochrane Review). Cochrane Library 2002; 2: Oxford: Update Software.
Information about Warwick Diabetes Care courses
can be found at www.diabetescare.warwick.ac.uk
Roger Gadsby is a GP in Nuneaton and senior lecturer in primary care at the University of Warwick. He was also a member of the guideline development group for NICE guidelines on type 1 diabetes and diabetes foot diseases.