vital diabetes management

DIABETESMANAGEMENT

Your essential reference for diabetes management in primary careRoger Gadsby MB, ChB, DCH, DRCOG, FRCGP

andPam Gadsby RGN

Vital

DIABETESMANAGEMENT

Vital

DIABETESMANAGEMENT

Your essential reference for managing diabetes in primary care

Roger Gadsby MB, ChB, DCH, DRCOG, FRCGPGeneral Practitioner with a Special Interest in Diabetes

Associate Professor in Diabetes Care, Warwick University Medical School

and

Pam Gadsby RGNPractice Diabetes Nurse

CLASS HEALTH • LONDON

Vital

Text © Roger Gadsby, Pam Gadsby 2009

© Class Publishing Ltd 2009

All rights reserved. Without limiting the rights under copyright reservedabove, no part of this publication may be reproduced, stored in orintroduced into a retrieval system, or transmitted, in any form or by anymeans (electronic, mechanical, photocopying, recording or otherwise),without the prior written permission of the above publisher of this book.

The authors assert their rights as set out in Sections 77 and 78 of theCopyright Designs and Patents Act 1988 to be identified as the authorsof this work wherever it is published commercially and whenever anyadaptation of this work is published or produced including any soundrecordings or films made of or based upon this work.

NOTICEThe information presented in this book is accurate and current to thebest of the authors’ knowledge. The authors and publisher, however,make no guarantee as to, and assume no responsibility for, thecorrectness, sufficiency or completeness of such information orrecommendation. The reader is advised to consult a doctor regarding allaspects of individual health care.

Printing historyFirst published 2009

The authors and publisher welcome feedback from the users of this book.Please contact the publisher:Class Publishing, Barb House, Barb Mews, London W6 7PA, UKTelephone: 020 7371 2119Fax: 020 7371 2878 [International +4420]Email: [email protected]

A CIP catalogue for this book is available from the British Library

ISBN 978 1 85959 202 1

10 9 8 7 6 5 4 3 2 1

Edited by Caroline Taylor

Designed and typeset by Martin Bristow

Diagrams by David Woodroffe

Printed and bound in Slovenia by Delo Tiskarna by arrangement with Korotan, Ljubljana

Introduction 9

Acknowledgements 10

1 The context 11The Quality and Outcomes Framework 11Exemption reporting 12

Exclusion of individual patients 12Levels of exemption reporting 13

Income from the Quality and Outcomes Framework 13Rewards for high-quality care 13

Locally enhanced service payments 14Prescribing incentive schemes 14Intermediate diabetes care 14General Practitioner with a Special Interest 15Practice-based commissioning 15

Secondary care 16Relationship with secondary care 16Handling data from secondary care 16Indications for referral to secondary care 16Young people with type 1 diabetes 17

2 The practice diabetes register 18The prevalence of diabetes in your practice 18The accuracy of your practice diabetes register 19

Labelling with type 1 or type 2 diabetes 20Teenagers with type 2 diabetes 20

Diagnosing diabetes 21Diagnosing diabetes from fasting glucose level 21Diagnosing diabetes from an oral glucose tolerance test 22

Information for practice staff: Registry and recall for people with IGT and IFG 22

Contents

C O N T E N T S | 5

Information for practice staff:Follow-up of people newly diagnosed with diabetes 23

Information for practice staff: Protocol to be followed at an initial diagnosis of type 2 diabetes 23

Information for practice staff: Suggested frequency of self-monitoring of blood glucose 24

Self-monitoring of blood glucose 24Prescribing for self-monitoring of blood glucose 24Self-monitoring of blood glucose in people who are newly diagnosed

and on lifestyle management only 25

3 The practice diabetes service 26The staffing of diabetes clinics 26

The GP partner 26The diabetes nurse(s) 26The healthcare assistant 28

Information for practice staff:The practicalities of running a diabetes clinic 28

Care planning 30Information for practice staff:

Frequency of clinics 31Information for practice staff:

Reducing ‘did-not-attend’ (DNA) rates 32

4 Achieving glycaemia targets 33Information for practice staff:

Practical tips for achieving glycaemia targets 34Reducing the risk of complications 35

Microvascular disease prevention 35Macrovascular disease prevention 35

Information for practice staff:Initiating insulin therapy 36

Oral anti-obesity therapies 37Information for practice staff:

Management of special cases 38

5 Retinal screening 39The rationale 39The method 39

6 | V I TA L D I A B E T E S M A N A G E M E N T

Information for practice staff:Preparing for the screening team visit 40

Information for practice staff:Running an efficient retinal screening day at the practice 41

Handling the results from retinal screening programme 42

6 Foot screening 43Background 43Information for practice staff:

Practical tips for examining feet to detect the at-risk-foot 44Risk factors for foot ulceration 44Causes of foot ulceration 45Prevention of foot ulceration 45Information for practice staff:

Giving advice to people with normal feet 46Action to take for new foot ulcers and/or cellulitis of the foot 46

7 Good blood pressure control 48Key components of good blood pressure measurement 48White coat hypertension 49Automated blood pressure measuring devices 49Controlling hypertension 49Drug therapy 50Information for practice staff:

Pragmatic therapy action plan 51Blood pressure targets 51

8 Microalbuminuria and kidney function 52Kidney disease in diabetes 53

Type 1 diabetes 53Type 2 diabetes 54

Microalbuminuria in healthy people 54Points to consider 54

Information for practice staff:Detection of microalbuminuria 55

Non-diabetic causes of microalbuminuria or proteinuria 56Microalbuminuria and hypertension 56Creatinine and eGFR 57

C O N T E N T S | 7

8 | V I TA L D I A B E T E S M A N A G E M E N T

9 Cholesterol management 59Practical steps 59

10 Influenza immunisation 62Information for practice staff:

Running an influenza immunisation programme 63

11 Depression 64Screening questions 65Information for practice staff:

Practical steps 65

Appendix 1Clinical indicators for diabetes and scores for 2004/5 and 2005/6 66

Appendix 2Clinical indicators for diabetes from 1 April 2006 68

Appendix 3Sample practice letter for booking appointments for diabetes

review clinics 71

Appendix 4Sample practice letter for follow-up of a one positive

microalbuminuria result 72

Glossary 73

References 75

Resources 76Useful websites 76Useful books 77Useful journals 77

Other titles 78

Priority Order Form 80

Dear Colleagues

Welcome to this edition of Vital Diabetes Management

This book has been written to give practical help to healthcareprofessionals who work in general practice and are involved in deliveringdiabetes care. It brings together the expertise of general practice andpractice diabetes nursing to help practitioners to deliver high-qualitydiabetes care and fulfil the requirements of the new GP contract Qualityand Outcomes Framework, ensuring that the maximum income fordiabetes care is obtained.

The book is divided into 11 chapters with topics clearly presented. Thedetailed contents list will help you find your way around with ease.Within each topic you will find one or more vital points to give youessential information in just a few words. Some chapters also containsections on Information for Practice Staff that can be photocopied andenlarged for your staff. You will also find useful appendices and otherinformation at the end of the book, including sample practice letters, aglossary, useful addresses, websites and contacts, and references andfurther reading. We would welcome your comments or suggestions forimprovements.

Vital Diabetes Management is backed by the wisdom and experience gainedby delivering diabetes care in a large 14,500-patient general practicefor more than 25 years, and from speaking and writing about diabetescare over a similar period. We hope that you will find this book helpfulfor your practice.

Roger Gadsby and Pam Gadsby

I N T R O D U C T I O N | 9

Introduction

We would like to pay tribute to Mary MacKinnon for all her support andencouragement to us over the years. We would like to thank all the partnersand staff of Redroofs surgery and all our colleagues who have worked forWarwick Diabetes Care for their help. We thank Colin Kenny for his helpfulintroduction and our editor Caroline Taylor for all her help and expertise ingetting this book to print.

Acknowledgements

1 0 | V I TA L D I A B E T E S M A N A G E M E N T

1 The context

T H E C O N T E X T | 1 1

Over the past 30 years diabetes care has moved from being seen almostexclusively as the province of secondary care to one in which virtually allroutine care for people with diabetes occurs in primary care. The new GPcontract that was introduced in April 2004 has provided some financialrecompense to support this shift in diabetes care from primary to secondarycare.

The GP contract lists a series of clinical domains for diabetes covering bothprocess and outcome measures (see appendix 1 on p. 66). They were modifiedfrom 2006 onwards to give a possible 93 points for full achievement of thediabetes clinical indicator. From 1 April 2009 the previous two clinicaloutcome indicators for HbA1c are altered and become three, with anadditional seven points being added, giving a total of 100 points available forthe diabetes clinical indicator set.These modifications are listed in appendix 2on p. 68.

T H E Q UA L I T Y A N D O U TCO M E S F R A M E WO R K

■ The Quality and Outcomes Framework (QOF) is a payment system, sosome of the clinical standards are different from the ‘targets’ of nationaland international guidelines

■ It may not be medically appropriate for all people with diabetes toachieve the desired clinical indicator standards of QOF. For example: ◆ For a frail elderly person to achieve a glycated haemoglobin (HbA1c)

level of 7.5% or a blood pressure of 140/80 mmHg to fulfil the QOFmay put them at an unacceptable increased risk of hypoglycaemia orhypotension

■ These individuals can be ‘exempted’ from the framework

E X E M P T I O N R E P O R T I N G

Exclusion of individual patientsExemption reporting allows the practice to exclude individual patients fromthe disease indicators in particular circumstances. These are:

■ Patients exempted from the whole clinical area◆ Patients who have been recorded as refusing to attend a review and

who have been invited on at least three occasions during thepreceding 12 months

◆ Patients for whom it is not appropriate to review the chronic diseaseparameters due to specific circumstances, eg extreme frailty, terminalillness or severe dementia

◆ Patients who do not agree to investigation and treatment (and, after areasonable discussion or written advice, have given their informeddissent) and this dissent has been recorded in the medical notes

■ Patients exempted from one clinical indicator only (if a valid computercode – Read code – is used)◆ Patients on maximum tolerated doses of medication whose level of

outcome remains suboptimal◆ Patients for whom prescribing a medication is not clinically

appropriate, eg those who have an allergy, another contraindicationor have experienced an adverse reaction

◆ Patients who have not tolerated a medication◆ Patients who do not agree to investigation and treatment (and, after a

reasonable discussion or written advice, have given their informeddissent) and this dissent has been recorded in the medical notes

◆ Patients who have a supervening condition that makes treatment oftheir condition inappropriate, eg cholesterol reduction when thepatient has liver disease

◆ Patients for whom an investigative service or secondary care serviceis unavailable

■ Patients exempted automatically from any of the indicators byreporting software◆ Patients newly diagnosed within the practice with diabetes or who

have recently registered with the practice, who should havemeasurements made within 3 months and delivery of clinical


standards within 9 months, eg blood pressure or cholesterolmeasurements within target levels

Levels of exemption reporting■ There was a concern that there would be excessive levels of exemption

reporting

■ Published reports for 2004/5 give overall exemption rates that weregenerally low, with a median of 6%

■ In 2005/6 the median was 4.7% (interquartile range 3.3–7.0%)

■ In 2006/7 the median was 5.3%

I N CO M E F RO M T H E Q UA L I T Y

A N D O U TCO M E S F R A M E WO R K

■ Points mean prizes! The points that can be achieved from each clinicalindicator are given in appendices 1 and 2 (p. 66 and p. 68, respectively.Each point earned is worth a certain amount of money to the practice.The size of the payment is dependent on: ◆ Practice list size and◆ Prevalence of diabetes in the practice

■ A square root formula is used on the prevalence – this has the effect ofreducing potential income for practices with high prevalence rates fordiabetes

■ For an average-sized practice with an average prevalence of diabeteseach point was worth £75 in the first year and £125 in the year2005/6. So for the average practice with average prevalence thetotal income for the QOF for 2005/6 was 99 points each worth£125 = £12,375

R E WA R D S F O R H I G H - Q UA L I T Y C A R E

Other structural changes have taken place to reward primary care fordelivering high-quality diabetes care.


Locally enhanced service payments■ These are payments agreed locally by an individual PCT for particular

services delivered by practices in their area

■ Some practices have negotiated agreements for extra payments forspecific diabetes services over and above QOF

■ One of the most common extra payments in diabetes is for initiationonto insulin in type 2 diabetes

■ Some Primary Care Trusts (PCTs) for example pay a specific sum of£100 per patient initiated onto insulin

Prescribing incentive schemes■ These schemes reward practices for achieving certain prescribing

changes in a particular year in accordance with local priorities

■ The schemes are usually developed in association with PCT prescribingadvisors

■ An example is the rewarding of switching to the prescribing of genericsimvastatin 40 mg once daily from more expensive branded atorvastatin10 mg once daily. A practice may be rewarded for achieving 70 peopleon simvastatin 40 mg for those needing a statin for primary prevention

■ Some PCTs have had schemes to try to reduce the ‘inappropriate’prescribing of blood glucose monitoring strips

■ Some PCTs have tried to introduce incentives to ‘ration’ the number ofstrips prescribed to an individual

Intermediate diabetes care ■ Intermediate diabetes care has developed in some PCTs

■ Most routine diabetes care is given at practice level under the QOF

■ Where the practice does not have the skills to deal with specific morecomplex problems, instead of referring to secondary care the patientcan be seen in an intermediate clinic nearer to their home, rather thanhaving to travel to a hospital outpatient clinic

■ Clinics are usually staffed by a Community Diabetes Specialist Nurse, aCommunity Dietitian who has a special interest in diabetes, and adoctor


■ This doctor is sometimes a Consultant Community Diabetologist or a GPwith a Special Interest in diabetes (GPSI; see below)

■ These clinics see people referred from GPs and usually see them onlyonce or twice to address specific problems

■ They are then returned to their GP’s care

General Practitioner with a Special Interest■ A GPSI is a full-time GP who works up to 1 day a week as a GPSI in a

specific clinical field

■ Framework documents for the work of GPSIs are available atwww.doh.gov.uk/pricare/gp-specialinterests

■ GPSIs in diabetes can fulfil a purely management function, for exampleoverseeing a diabetes network, or can fulfil a clinical function, forexample running diabetes clinics in the community

■ New guidance on accreditation and governance of GPSIs was releasedin summer 2007 (details are available at www.doh.gov.uk)

Practice-based commissioning■ A diabetes commissioning toolkit can be found at www.library.nhs.uk/diabetes

using the search facility to look for ‘commissioning toolkit’. This gives alink to the document in pdf format and this can be downloaded

■ The toolkit provides advice for all commissioners of diabetes servicesand describes how to carry out a needs assessment for a local diabetespopulation. It provides a generic specification for diabetes care,signposting recognised quality markers and suggesting key outcomesfor the service

■ In some parts of the country practice-based commissioning is beingdeveloped, whereas in others it has hardly started. Some commissioninggroups have developed services to provide intermediate diabetes careclinics and insulin initiation in type 2 diabetes programmes

■ The National Institute for Health and Clinical Excellence (NICE) hasproduced a commissioning guideline for diabetes footcare based on theNICE 2004 guideline. It can be found at www.library.nhs.uk/diabetes (usingsearch facility for ‘commissioning footcare’). This gives a link to thedocument as a pdf


S E CO N DA RY C A R E

Relationship with secondary care■ Many practices provide routine care for the majority of people in the

practice who have diabetes

■ Many secondary care services are trying to discharge people withdiabetes who are stable back to primary care for their continuingroutine care. This is to enable secondary care diabetes clinics to becomeless involved in routine chronic care and more able to provide quickaccess for those with specific problems

Handling data from secondary care■ People with diabetes seen in secondary care will have blood test and

clinic examination results in their hospital records. These data areneeded by primary care to enable them to be entered onto the practicecomputer system to fulfil QOF requirements

■ It is important to ask secondary care colleagues to include all this QOFrelevant information in their clinic letters sent to the practice

■ The practice then needs a protocol to ensure that this data is transferredto the practice computer appropriately

■ In many practices the GP receiving the letter uses a highlighter pen tomark the results that need entering

■ Practice administration staff then enter these data, which areautomatically coded to comply with the QOF

Indications for referral to secondary care■ Children and people under the age of 25 years newly diagnosed with

diabetes

■ Women with diabetes who are contemplating pregnancy for pre-pregnancy advice and counselling

■ Women with diabetes who are pregnant need early referral to a unitwith expertise in managing diabetic pregnancy

■ People who need to be considered for insulin pump therapy

■ People newly presenting with diabetic foot ulcers and/or cellulitis oftheir feet


■ Nephrology assessment services for people with stage 4 and 5 chronickidney disease (CKD) and dialysis

■ People requiring retinopathy treatment

■ Anyone with a diabetes problem that the practice does not feel it has theexpertise to manage. If the area has an intermediate diabetes service,these people may be referred to that service

Young people with type 1 diabetes■ Young people with type 1 diabetes will be cared for in secondary care.

Some may default from follow-up during teenage years. The practicewill be providing repeat prescriptions for insulin and may be the onlyplace of contact for people failing to attend secondary care. Everyattempt needs to be made to try to re-engage them with diabetes careprovision


An accurate register of everyone with diabetes is the basis for any structuredcare for people with diabetes in the practice. From 2006/7 practices wererequired to indicate whether a person had type 1 or type 2 diabetes. This isnow diabetes quality indicator 19.


The practice diabetes register2

Diabetes quality indicator 19 (DM19)The practice can produce a register of all patients aged

≥17 years with diabetes mellitus that specifies whether thepatient has type 1 or type 2 diabetes = 6 points

T H E P R E VA L E N C E O F D I A B E T E S

I N YO U R P R AC T I C E

■ The registered prevalence of diabetes from 2007/8 QOF figures for thewhole of the UK was 3.86% on 14 February 2008

■ The registered prevalence was higher than this in Wales and lower thanthis in Northern Ireland (3.1%)

■ In an ‘average’ practice of 10,000 registered patients, 370 will havediabetes

■ In practices with a higher than average proportion of older people theprevalence of diabetes is likely to be higher than 3.7% as diabetes ismore common in older people

■ In practices with a younger than average population, eg student healthcentre practices and practices on new housing estates with many youngfamilies, the prevalence of diabetes is likely to be below 3.7%

■ In practices with large numbers of people from a South Asian ethnicgroup, prevalence rates are likely to be much greater, even up towards10%

■ Diabetes is more common in lower socio-economic groups, so if yourpractice has many patients from lower socio-economic groups thepractice prevalence is likely to be higher than 3.7%

VITAL POINT

✱ If the recorded prevalence of diabetes in your practice isbelow what would be expected and this cannot be explained by

the mix of your practice population, consider where themissing people might be

T H E ACC U R AC Y O F YO U R

P R AC T I C E D I A B E T E S R E G I S T E R

There may be instances of incorrect diagnosis or coding in your register.These problems include:

■ People with diabetes insipidus being wrongly labelled as having diabetesmellitus

■ People with impaired glucose tolerance (IGT) or impaired fastingglucose (IFG) wrongly being included in the diabetes register

■ People with a history of gestational diabetes wrongly being included inthe register

■ People labelled as having diabetes and included on the register manyyears ago because they had glycosuria, and when records are checkedno proper diagnostic tests for diabetes were ever made

■ People diagnosed as having diabetes whilst an inpatient and thediagnosis not being recorded or not being picked up from a hospitalletter, so they are not added to the practice register

VITAL POINT

✱ Review and update your diabetes register regularly

T H E P R A C T I C E D I A B E T E S R E G I S T E R | 1 9

Labelling with type 1 or type 2 diabetes■ For the first 2 years of the QOF the register simply had to list all people

with diabetes in the practice. From 2006/7 people with diabetes need tobe labelled as having type 1 or type 2◆ Record people as having type 1 diabetes using the correct Read code

if their notes clearly say they have type 1 diabetes◆ Record people as having type 2 diabetes using the Read code if their

notes clearly state they have type 2 diabetes

■ If a patient does not have a clear label of type 1 or type 2 diabetes intheir notes, use the label type 2 unless:◆ The patient was diagnosed before the age of 30 years, then label

them as type 1◆ The patient required insulin within 1 year of diagnosis, then label

them as type 1

■ In most practices, more than 90% of people with diabetes will have type2 diabetes and less than 10% will have type 1 diabetes

VITAL POINT

✱ If your practice has more than 10% of people labelled ashaving type 1 diabetes consider whether some may have been

wrongly labelled – just because someone is on insulin does notmean they have type 1 diabetes!

Teenagers with type 2 diabetes■ Ten or more years ago the vast majority of teenagers diagnosed with

diabetes had type 1 diabetes

■ Type 2 diabetes is now being diagnosed in very obese children, oftenfrom Indo-Asian ethnic backgrounds, who are newly presenting withdiabetes

■ In the USA today if someone aged 18 years old newly presents withdiabetes they are just as likely to have type 2 as type 1 diabetes

■ There are some rare forms of diabetes that often present in teenagersand young adults, such as maturity onset diabetes of the young (MODY)


VITAL POINT

✱ Best practice is to always refer someone newly diagnosedwith diabetes <25 years old for specialist advice on what sort

of diabetes they have and to ensure optimal management

D I AG N O S I N G D I A B E T E S

■ In asymptomatic individuals, two abnormal blood glucose levelsdiagnostic of diabetes are required

■ If someone has symptoms suggestive of diabetes (eg weight loss, thirst,polyuria and polydypsia) only one abnormal blood glucose valuediagnostic of diabetes is required

■ HbA1c values cannot be used to diagnose diabetes (but they may giveimportant information at the time of diagnosis about the level of control)

■ The presence of ketonuria with abnormal blood glucose levels atdiagnosis suggests type 1 diabetes

Diagnosing diabetes from fasting glucose level


Fast

ing

plas

ma

gluc

ose

(mm

ol/l)

7.0

6.0

Diabetes diagnosed

If asymptomaticrepeat to confirm

Impairedfastingglucose

Proceed to oral glucosetolerance test

Normal Repeat if screening protocol says so*

*In the USA it is repeated every year

Figure 2.1 Diagnosis of diabetes: fasting plasma glucose


Plas

ma

gluc

ose

(mm

ol/l)

11.1

7.8

Diabetes diagnosed

Impaired glucose tolerance diagnosed

Follow-up advice on healthy eating and lifestyle Repeat in 1 year

Normal

Figure 2.2 Diagnosis of diabetes: plasma glucose 2 hours after a 75 g glucose load

Diagnosing diabetes from an oral glucose tolerance test

INFORMATION FOR PRACTICE STAFF

Registry and recall for people with IGT and IFG

■ If someone is diagnosed with IGT or IFG the appropriate Read codeneeds to e used

■ Make a register of these people ■ Women who have had a diagnosis of gestational diabetes can be

added■ Recall them all for an annual fasting blood glucose estimation as up

to 50% will develop type 2 diabetes in the next 10 years■ Some practices do this recall in the month of the patient’s birthday



Follow-up of people newly diagnosed with diabetes

■ The practice needs a protocol for following-up people newlydiagnosed with diabetes◆ Refer them to the partner in charge of diabetes who can perform

the initial assessment, or◆ Give them a new-patient appointment in the nurse-managed

diabetes clinic


Protocol to be followed at an initial diagnosisof a person with type 2 diabetes

■ Confirm diagnosis in accordance with the WHO criteria. Arrangefurther blood tests if needed

■ Ask about the person’s knowledge of diabetes and how thediagnosis has affected them

■ Give some initial education about the condition, but don’t overloadthem at this first consultation

■ Give written information to consolidate the information givenverbally with a care plan

■ Encourage them to attend a community group educationprogramme being run in your PCT locally

■ Discuss appropriate changes in diet and set an appropriate target forweight reduction if they are obese or overweight

■ Discuss increasing physical activity to a level appropriate for theirage and physical abilities. The aim is 20–30 min of physical activityper day. Consider referral to local ‘fitness on prescription’ programmeif available

■ Discuss whether they would find self-monitoring of blood glucosehelpful. Arrange for them to be taught how to do this if they want to

■ Agree a follow-up consultation and appropriate blood tests to bedone before that visit


Suggested frequency of self-monitoringof blood glucose

■ For people on once daily long-acting insulin:◆ When up-titrating the dose of insulin one fasting test daily before

breakfast is needed◆ Once the insulin dose is stabilised and the HbA1c optimally

controlled, tests will only need to be done when symptoms ofhypoglycaemia are suspected or if patients become ill

■ For people on twice daily mixed insulin:◆ People with stable control should check two or three times a week

■ For people on basal bolus insulin:◆ Tests are usually done at least before each meal to help determine

what dose of rapid acting insulin needs to be taken with that meal◆ Tests need to be done when symptoms of hypoglycaemia are

suspected■ For people on sulphonylurea medications:

◆ Tests need to be done if symptoms of hypoglycaemia aresuspected

■ For people who are stable on metformin, thiazolidinediones ordipeptidyl peptidase-4 (DPP4) inhibitors or combinations of theseagents:◆ These agents do not cause hypoglycaemia and so no routine

testing is necessary


S E L F - M O N I TO R I N G O F B LO O D G LU CO S E

Prescribing for self-monitoring of blood glucose Self-monitoring of blood glucose (SMBG) costs the NHS a significant amountof money each year. It is an area where prescribing advisors are keen to seeappropriate prescribing, and may be the subject of a local prescribing initiative.

■ Agree the appropriate frequency of SMBG with that individual

■ Prescribe the appropriate SMBG stix in the appropriate quantity


■ Prescribe the appropriate lancets in the appropriate quantity

■ Prescribe the appropriate lancing device

■ Prescribe a sharps box to put the used lancets in, and explainappropriate disposal procedure when full

SMBG in people who are newly diagnosed and on lifestyle management only

■ Many healthcare professionals feel that if people newly diagnosed withtype 2 diabetes learn to self-monitor blood glucose and check their ownlevels after eating and before and after exercise, they will learn thebenefits of physical activity and dietary control and become more‘empowered’ than if they did not do SMBG

■ Once glycaemic control is optimised and their HbA1c is on target there isno additional benefit of SMBG, and it can be stopped

VITAL POINTS

✱ Ensure that SMBG is being used appropriately by all peoplewho have diabetes

✱ If SMBG is being done out of habit and has no clinicalrelevance consider stopping it

✱ SMBG is expensive and any appropriate reduction in its usewill reduce the practice prescribing costs significantly


In order to run an efficient chronic disease management diabetes service, andto maximise the number of QOF points the practice earns for diabetes, mostpractices now run dedicated diabetes clinics.

T H E S TA F F I N G O F D I A B E T E S C L I N I C S

■ Most practice diabetes services are now nurse-run and GP-managed

■ Healthcare assistants (HCAs) are increasingly employed to do some ofthe routine measurements

The GP partner■ Has a responsibility to the whole partnership for providing an excellent

service and achieving full QOF points for diabetes

■ Has a special interest and skill in diabetes care. Completion of acertificate/diploma course in diabetes care, such as the Certificate inDiabetes Care from the University of Warwick, is one way ofdemonstrating this

■ Keeps up-to-date with diabetes developments through continuingprofessional development (CPD). Being a member of the Primary CareDiabetes Society is a good way of helping to achieve this (see p. 76)

■ Demonstrates diabetes CPD undertaken for annual appraisal

■ Agrees protocols with diabetes clinic staff for smooth running of theclinics

■ Ensures that all staff work to keep the practice diabetes registerup-to-date

The diabetes nurse(s)■ Has a special interest and skill in diabetes care. Completion of a

certificate/diploma course in diabetes care, such as the Certificate

The practice diabetes service3

T H E P R A C T I C E D I A B E T E S S E R V I C E | 2 7

in Diabetes Care from the University of Warwick, is one way ofdemonstrating this (see p. 76)

■ Keeps up-to date with diabetes developments through CPD. Being amember of the Primary Care Diabetes Society is a good way of helpingto achieve this (see p. 76)

■ Oversees the practice call and recall system to ensure that people withdiabetes receive the appropriate appointments and follow-up in thediabetes clinic (see appendix 3 on p. 71 for sample practice letter forfollow-up appointments)

■ Ensures that appropriate numbers of appointments are available eachmonth for the number of people with diabetes who need to be seen

■ Supervises the work, support and education of any healthcare assistant(HCA) working in the diabetes clinic

■ Liaises with the partner who has responsibility for diabetes care

■ Ensures that all data are recorded accurately on the practice clinicalcomputer system diabetes template

■ Ensures that people receive their blood test request form at least 2 weeksbefore their appointment in order that the results can be available inclinic

■ Ensures that blood results have been received from the laboratory andhave been entered on the diabetes template

■ Ensures that the practice has access to a retinal screening programmethat fulfils national standards and that people with diabetes registeredat the practice receive an annual invitation for screening

■ Ensures that people with diabetes are asked to bring a first morningsample of urine for testing for proteinuria and microalbuminuria

■ Ensures that results of microalbuminuria testing are recorded properlyand acted upon (see p. 55)

■ Ensures that arrangements are in place for group structured educationfor newly diagnosed people with diabetes

■ Ensures that appropriate one-to-one education is available for peoplenot wanting group education

■ Ensures that there is a structure for on-going education of people withdiabetes

■ Liaises with hospital- and community-based diabetes nurses

■ Supplies letters for people with diabetes travelling abroad who need totake ‘sharps’ for SMBG and insulin administration through customsand airport security

VITAL POINTS

✱ All healthcare professionals undertaking diabetes work in the practice need to have had appropriate training

and updating

✱ The practice needs to make provision for this

The healthcare assistant■ Some practices now employ HCAs to help with diabetes care

■ Training should be given to newly appointed HCAs in the practice andthis may be supported by specific local training programmes

■ HCAs can help the practice diabetes nurse in the diabetes clinic by doinga number of the routine measurements and recording information onthe clinical computer system

■ These tasks could include measurement of weight, height and bloodpressure, urine dipstick testing, and checking feet



The practicalities of running a diabetes clinic

■ Welcome the patient, and give them opportunity to express anyparticular concerns about their diabetes and its impact on their lives

■ Do specific measurements of weight and height (if not recorded oncomputer, so that the body mass index (BMI) can be calculated).Enter the results on the computerised template and share them withthe patient

■ Discuss lifestyle issues such as healthy eating, weight reduction andphysical activity



The practicalities of running a diabetes clinic(cont’d)

■ Measure blood pressure (for details see p. 48) and enter the result onthe computer

■ Review blood test results and discuss their implications with theperson with diabetes

■ Review all medications and any possible side effects. Discusscompliance with therapy

■ Discuss alterations and up-titrations of medications needed in thelight of blood test results, weight and blood pressure

■ Ask about any foot problems and examine as necessary. Examinefoot pulses annually and test for neuropathy (see p. 44)

■ Refer anyone found to have ‘foot-at-risk’ to local podiatry footprotection clinic (see p. 46)

■ Ask about any eye problems. Ensure that the person has receivedannual retinopathy screening by digital retinal photography

■ Ask about current smoking status and offer smoking cessationadvice as necessary

■ Check the urine sample for protein using the appropriate dipstickand act on the result if positive (see p. 54)

■ Ensure that a urine sample is sent to the laboratory annually for anACR to detect microalbuminuria (see p. 54)

■ Make a sensitive enquiry about whether any erectile dysfunctionissues are bothering the person with diabetes or their partner andprescribe as necessary

■ Ask the two specific questions to screen for depression and recordthe answers on the computer (p. 65). Refer for psychological supportif indicated

■ Give influenza and pneumococcal immunisation as necessary (seep. 63)

■ Update regular prescriptions■ Agree the time of the next follow-up appointment and set the goals

to be achieved by then


■ HCAs can also assist in retinal screening clinics (see p. 41)

■ Using an HCA to do some of this routine work can enable the practicediabetes nurse to have more time to spend reviewing the impact ofdiabetes on lifestyle, concordance and medication issues

■ This may then enable the patient to take more control of their diabetes

VITAL POINTS

✱ Accurate recording of date for follow-up appointments andthose who did-not-attend (DNA) on the computer template isnecessary to ensure that people do not ‘fall through the net’

✱ Practices need to have a system to recall and ‘chase-up’those who do not attend

Note that in some practices the practice nurse will have the prescribingqualifications and expertise to alter and update therapy within guidelines. In others a doctor may be called in for this work.

C A R E P L A N N I N G

There is a renewed emphasis on care plans and care planning in chronicdisease management consultations. The aim of these plans is to enable theperson with diabetes to set the agenda for their review appointment.

Pilot initiatives are being undertaken in ‘The Year of Care’ project supportedby the National Diabetes Support Team (NDST) and Diabetes UK (seewww.diabetes.org.uk/professionals/year-of-care). The aim is to make consultations more‘patient-centred’.

■ The stages of care planning are:◆ Agenda setting. The person with diabetes discussing progress with

the healthcare professional◆ Shared decision-making. The person with diabetes and the

healthcare professional decide what are the most important things todeal with and talk about

◆ Goal-setting and action-planning. The person with diabetes andhealthcare professional decide what needs to happen and who doeswhat. This should be written down



Frequency of clinics

■ Most people with diabetes who are well controlled can be seenevery 6 months

■ When people are not optimally controlled and treatment is changed,they need to be seen in 3 months

■ Twenty-minute appointments with the practice diabetes nurse areusual

■ If an HCA is used, a 10-minute appointment with them may precedethe practice nurse appointment, which may then be reduced to10 minutes

■ The number of clinics needed per week then needs to be calculated,depending on the practice diabetes list size and the number ofpeople needing to be seen every 3 and 6 months

■ The number of clinics each month may need to vary slightlydepending on the above calculation

◆ Joint review. This involves checking back at the next visit to see if thepoints agreed have been put into action

◆ Writing a care plan. This can facilitate the process. Examples may befound in the document entitled Partners in Care from the NDST

Care planning can help by enabling people with diabetes to have access totheir blood tests results prior to their review appointment. Prompts andquestions can be given to encourage the person with diabetes to consider theresults and other aspects of their diabetes before the review consultation, sothat this forms the agenda for the review appointment.

VITAL POINTS

✱ Ensure that diabetes review consultations arepatient-centred

✱ Giving patients the results of their blood tests and askingthem to consider the results before the clinic can help in

focusing the consultation on their needs



Reducing ‘did-not-attend’ (DNA) rates

If people book their clinic appointment 6 months in advance you willoften find that they forget to attend. DNA rates can be significantlyreduced by:■ Telling people how long it will be until they will need to be seen

again before they leave their clinic appointment■ Putting that recall interval on the practice clinical computer system■ Sending out letters advising people when the diabetes clinics are

being held for the month in which they need to be seen, 2 monthsbefore the appointment

■ Enclosing a repeat blood test form with that clinic letter■ Asking people to telephone the surgery to book themselves into a

clinic at a date and time convenient for them during the month thattheir appointment is due

■ Having a system to note those who fail to phone in to make abooking

■ Having a practice procedure to contact those who DNA to ensurethat they make an appropriate appointment

A C H I E V I N G G LY C A E M I A TA R G E T S | 3 3

Achieving glycaemia targets4

Diabetes quality indicator 5 (DM5)The percentage of patient with diabetes who have a record

of HbA1c or equivalent in the previous 15 months

Minimum threshold = 40%Maximum threshold to earn full 3 available points = 90%

Diabetes quality indicator 23 (DM23)The percentage of patients with diabetes in whom the last HbA1c is 7% or less (or the equivalent test/reference rangedepending on local laboratory) in the previous 15 months

Minimum threshold = 40%Maximum threshold to earn the full 17 available points = 50%

Diabetes quality indicator 24 (DM24)The percentage of patients with diabetes in whom the last HbA1c is 8% or less (or the equivalent test/reference rangedepending on local laboratory) in the previous 15 months

Minimum threshold = 40% Maximum threshold to earn the full 8 available points = 70%

Diabetes quality indicator 25 (DM25)The percentage of patients with diabetes in whom the last HbA1c is 9 % or less (or the equivalent test/reference rangedepending on local laboratory) in the previous 15 months

Minimum threshold = 40% Maximum threshold to earn the full 10 available points = 90%


Practical tips for achieving glycaemia targets

■ Review people who are not reaching their agreed HbA1c targetevery 3 months

■ At each consultation agree and document the plans to try to reachthat target within the next 3 months

■ Up-titrate or add medications as necessary every 3 months

■ When agreed HbA1c targets have been achieved review every 6months

■ Negotiate realistic targets for weight loss with each individual. Anagreed plan to lose 1 stone (6.5 kg) in 3 months in someone who is16 stone (100 kg) is possible. Aim for 1 lb (0.5 kg) weight loss per week

■ Remember to stress the importance of physical activity. Most peoplecan realistically agree to try to walk a mile (1.5 km) a day initially. Theaim is for 30 min of brisk physical activity on five days a week

■ Metformin is the initial monotherapy of choice for the majority ofpeople with type 2 diabetes, with the exception of thin, verysymptomatic people newly diagnosed with type 2 diabetes, whoshould be managed differently (p. 38)

■ Use 500 mg tablets of metformin twice a day but suggest the personjust takes 500 mg daily for the first 2 weeks to minimise the risk ofabdominal pain and diarrhoea. Warn about side effects and reassurepatients that they will usually settle

■ Up-titrate to two 500 mg tablets twice a day if and when necessary

■ Consider a trial of extended absorption metformin where gastro -intestinal tolerability prevents continuation of metformin therapy

■ When maximally tolerated dose of metformin does not give optimalglycaemic control, a sulphonylurea should be the second therapy tobe added for most people

■ The most commonly prescribed sulphonylurea in the UK is genericgliclazide, which has over 80% of the sulphonylurea market in the UK

■ The initial dose is often 40 mg twice a day. This is done by splittingan 80 mg tablet in two

■ The next up-titration is to one 80 mg tablet twice a day, then totwo tablets, ie 160 mg twice a day




Practical tips for achieving glycaemia targets (cont’d)

■ When optimal glycaemic control is not obtained with maximaltolerated doses of metformin plus a sulphonylurea there are a numberof options. Each option may be appropriate for some individuals: ◆ Option 1: a glitazone can be added to give triple oral therapy.

Pioglitazone 30 mg daily up-titrating to 45 mg daily is theglitazone with the best evidence of cardiovascular protectionalthough rosiglitazone is as effective at lowering glycaemia

◆ Option 2: basal insulin can be added◆ Option 3: exenatide can be added◆ Option 4: a DPP4 oral agent can be started in triple oral therapy

Optimising glycaemic control is one of the most important aspects of diabetescare. This is reflected in the number of points given to these three clinicalindicators in the QOF. There is good evidence that controlling glycaemia isassociated with reduced risks of complications in both type 1 and type 2diabetes from the Diabetes Control and Complications Trial (DCCT) study andthe UK Prospective Diabetes Study (UKPDS) respectively (see p. 75).

R E D U C I N G T H E R I S K O F CO M P L I C AT I O N S

Microvascular disease prevention■ Good glycaemic control is important to reduce microvascular disease in

both type 1 and type 2 diabetes

■ Keeping HbA1c below 7.5% will minimise the risk of developingmicrovascular disease for people with type 1 diabetes and is likely to doso in people with type 2 diabetes

Macrovascular disease prevention■ Good glycaemic control reduces the risk of developing macrovascular

disease


■ In the epidemiological analysis of the UKPDS in newly diagnosed peoplewith type 2 diabetes, a 1% reduction in HbA1c was associated with a21% reduction in death related to diabetes and a 14% reduction inmyocardial infarction. There was a threefold increase over the HbA1crange from 6% to 10% in any diabetes-related macrovascular endpointwith no evidence of a threshold

■ There is no level of HbA1c below which macrovascular disease isprevented

■ An HbA1c target of 6.5% has been stated as the goal in all majorguidelines, as this is a level that will prevent microvascularcomplications and reduce the risk of macrovascular complications

■ Reducing HbA1c from 12% to 9.1% is likely to be of significant clinicalbenefit but it will not earn QOF points

■ Reducing HbA1c from 7.2% to 6.9% does earn QOF points but isunlikely to be of significant clinical benefit


Initiating insulin therapy

■ There are training programmes for GPs and practice nurses to teachinsulin initiation in primary care. One example is a short course fromWarwick University (Intensive management of type 2 diabetes)(www.warwick.ac.uk/go/studydiabetes)

■ The most appropriate insulin regimen for many people with type 2diabetes is adding once daily long-acting insulin whilst continuingon oral metformin and sulphonylurea tablets

■ A usual starting dose is 10 units, which can be up-titrated by theperson with diabetes according to their fasting glucose levelsdetermined by SMBG

■ Close contact with the initiating nurse by telephone is maintainedduring this titration process

■ For practices who do not have the skill and experience to initiateinsulin, referral for this to intermediate or secondary diabetes carewill be required


■ The target HbA1c for any individual needs to be the subject of adiscussion between the healthcare professional and the individual, butmost people can safely aim to get their HbA1c to 7.5%

■ Where attaining a tight HbA1c target is felt, in discussion with thepatient, to be unattainable without significant risk of adverse sideeffects of glucose-lowering treatments (mainly the risk ofhypoglycaemia), consider accepting a HbA1c level >7.5% andexempting them from the QOF target (see p. 12)

■ There is little evidence for the benefit of tight glycaemic control abovethe age of 80 years, and there is a significant increased risk of fallingand developing increased confusion from hypoglycaemia in the frailelderly person with diabetes. Higher HbA1c targets may be thereforeappropriate in the frail elderly, and exemption reporting needed

O R A L A N T I - O B E S I T Y T H E R A P I E S

■ The anti-obesity agent orlistat can be used in obese people with diabetescontrolled on diet, on one, two or three oral agents, or with insulin, andcan be considered as additional treatment where it is deemed necessary

■ Sibutramine is an effective anti-obesity agent but it can causehypertension and tachycardia. This reduces its usefulness in people withdiabetes

■ Rimonabant is an anti-obesity agent that may be associated with moodchanges and depression. Its role in people with type 2 diabetes has yet tobe ascertained

VITAL POINT

✱ Evaluate glycaemic control at each review appointment, setappropriate goals and up-titrate medications as necessary



Management of special casesThe newly diagnosed person with type 2 diabetes

who is thin and very symptomatic

■ The concern is that these individuals have significant beta celldysfunction and could even have slow-onset type 1 diabetes

■ They often are active and are eating healthily■ They may present with a short history of weight loss, tiredness, thirst

and polyuria■ They do not have ketonuria, as if they did they would be diagnosed

as having type 1 diabetes■ See them every 2 weeks■ Encourage them to start SMBG straightaway■ Begin with sulphonylurea therapy■ Up-titrate the dose of sulphonylurea every 2 weeks as indicated by

their SMBG readings■ Add in metformin if sulphonylurea alone doesn’t control their

glycaemia■ If glycaemia still is not controlled, consider insulin early■ If insulin is required within the first year from diagnosis, they can be

relabelled as having type 1 diabetes

T H E R AT I O N A L E

■ Diabetic retinopathy is the leading cause of blindness in people ofworking age in many countries in the developed world

■ It is possible to have severe sight-threatening diabetic retinopathy andhave normal vision

■ Good glycaemic control with an HbA1c below 7.5% helps to preventretinopathy

■ Laser therapy is effective treatment for diabetic retinopathy

■ Laser therapy for the treatment of diabetic retinopathy has been shownto be effective in reducing blindness

■ Screening for retinopathy is therefore essential, as people may not knowthey have it

■ Cataracts are more common in people with diabetes. They need to bedetected and treated. Referral for consideration of urgent cataractextraction is needed when the cataract stops a good view of the retina

T H E M E T H O D

■ Screening by digital retinal photography is the only approved methodfor retinal screening

R E T I N A L S C R E E N I N G | 3 9

Retinal screening5

Diabetes quality indicator 21 (DM21)The percentage of patients with diabetes who have a record

of retinal screening in the previous 15 months

Minimum threshold = 40%Maximum threshold to earn full available 5 points = 90%

■ Digital retinal screening must be carried out by an approved screeningservice that uses skilled staff, has appropriate internal quality assurancemechanisms, and conforms to the national specifications (seewww.nscretinopathy.org.uk). Programmes ideally are of a size to screen15,000–20,000 people with diabetes each year. Each programmetherefore covers more than one PCT. There are at present just over 100retinal screening programmes in the UK

■ In some areas this service is provided by optometrists



Preparing for the screening team visit

■ Most screening programmes now run their own call and recallsystem that has been developed from names and addresses ofpeople with diabetes given to the programme by the practice.Electronic transfer is now being developed and trialled in somepractices

■ The practice needs to have a reliable way of informing the screeningprogramme of the names and contact details of people newlydiagnosed with diabetes so that they can be called up for screeningat the appropriate time

■ People are informed by letter of the dates that the screeningprogramme is visiting the practice and phone in to book theirappointment at a time convenient to themselves

■ This letter also contains information about the screening and adviceabout the effects of the eye drops. It advises people not to drive untiltheir sight returns to normal, so they need to make appropriatetransport arrangements

■ To ensure that the visit of the screening team is used most efficiently,practice administration staff can phone people who have notalready booked in to try to fill any spare appointments

■ Ensure that those people already attending hospital retinal servicesare excluded from the invitation list

R E T I N A L S C R E E N I N G | 4 1


Running an efficient retinal screening day at the practice

■ Most screening programmes book people at 10-minute intervals,screening about 40 people per day

■ On arrival at the practice people to be screened book in withreception staff, and are given written information about how theywill receive their results and about the follow-up procedure

■ A practice nurse or HCA calls the person into a room where they willcheck the person’s details, including a brief history of any eyeproblems

■ Visual acuity is checked using a Snellen chart and is recorded for thescreener

■ Mydriatric eye drops (tropicamide 0.5%) are inserted into each eye■ The person is asked to wait in the waiting room for about 20 minutes

to ensure that their pupils are fully dilated■ The screener calls the people through and takes a digital retinal

photograph of each eye■ The screener will usually tell the person if the image appears normal,

but will say that the photographs will be checked and a full reportsent to them and the practice

■ The practice nurse or HCA records that retinal screening has takenplace on the practice clinical computer

■ In some areas the service is provided by a fixed camera system so allpeople with diabetes from a specific geographical area travel to havescreening done at a specific location, often at a diabetes centre orhospital outpatient suite

■ In some areas the service is provided by a mobile camera-basedscreening programme that visits each practice in an area to do thescreening on practice premises

H A N D L I N G T H E R E S U LTS

F RO M T H E R E T I N A L S C R E E N I N G P RO G R A M M E

■ Any abnormalities seen on the photograph are graded in accordancewith national standards

■ Any people with abnormalities that require laser therapy are referred tothe diabetic retinal clinic by the screening service, and information issent to the practice. In Northern Ireland the onus may be left on the GPto refer as appropriate

■ Those who have no abnormalities on their retinal photographs or thosewith simple background retinopathy are informed by letter of theirresults, as is the practice. This information is then recorded and codedby the practice administration staff on the computer. They are informedthat they will be recalled for a further screen in 1 year. In NorthernIreland the 1-year interval may be replaced by ‘an agreed time’

■ Many screening programmes send written information about theresults of the screening to the patients themselves and copy this to thepractice. They also send copies of referral letters to the practice

VITAL POINTS

✱ Retinal screening is vitally important for all people with diabetes

✱ Retinal screening programmes are being rolled out across the UK

✱ The practice needs to work with its screening programme to ensure that all people registered with diabetes

are offered a retinal screening appointment


BACKGROUND

■ Foot problems in diabetes result from complications such as peripheralvascular disease and neuropathy, which lead to ischaemia and loss ofprotective pain sensation in the feet

■ Relative ischaemia of the feet may be symptomless, and so people maybe at risk without knowing it

■ Diabetic peripheral neuropathy is often symptomless. People often don’tnotice the gradual loss of protective pain sensation as neuropathydevelops

■ Thus, there are people with diabetes who have risk factors for footulceration and amputation of which they are not aware

F O O T S C R E E N I N G | 4 3

Foot screening6

Diabetes quality indicator 9 (DM9)The percentage of patients with diabetes with a record of

the presence or absence of peripheral pulses in the previous15 months


Diabetes quality indicator 10 (DM10)The percentage of patients with diabetes with a record of

neuropathy testing in the previous 15 months


■ Unless screening is carried out people may be at risk without knowing it

■ For some people presentation with a foot problem is the first indicationof diabetes



Practical tips for examining feet to detect the at-risk -foot

■ Ensure that people with diabetes realise that they will be having anannual foot examination. Tell them to be prepared to take theirshoes and socks off

■ Examine the foot for bony abnormalities. The most common arebunions, overriding toes, hallux rigidus and hallux valgus

■ Palpate for the posterior tibial and dorsalis pedis pulses. If they areabsent the foot is at-risk

■ Detect the loss of protective pain sensation by using a 10 g nylonmonofilament as follows:◆ The filament is applied to at least five sites on the foot (but not

over callus, which is an area of dry, hard, often fissured skin) until itbuckles, which occurs at 10 g of linear pressure when the patient isasked to detect its presence

◆ If it cannot be felt, protective pain sensation is lost andneuropathy is present

■ Record the findings from the foot examination on the diabetestemplate in the practice clinical computer system to ensureappropriate coding

R I S K FAC TO R S

F O R F O OT U LC E R AT I O N

■ Absent foot pulses, indicating ischaemia

■ Loss of protective pain sensation in the feet due to diabetic peripheralneuropathy

■ The presence of bony abnormalities in the feet

■ The presence of any one of the above risk factors puts a foot ‘at risk’ ofulceration

■ The presence of two of the above risk factors puts the foot at greater risk

■ The presence of all three of the above risk factors puts the foot at highrisk

C AU S E S O F F O OT U LC E R AT I O N

■ Feet that are at-risk due to neuropathy or ischaemia or bonyabnormality do not spontaneously ulcerate

■ Minor trauma is usually the additional factor that precipitatesulceration

■ The person with loss of protective pain sensation due to neuropathymay get trauma through:◆ Thermal damage, eg walking on hot sand on holiday, getting into a

bath that is too hot◆ Chemical damage, eg use of corn-cures ◆ Mechanical trauma, eg tight-fitting shoes, standing on a stone or

sharp object, eg a drawing pin

P R E V E N T I O N

O F F O OT U LC E R AT I O N

There are several ways in which the risk of foot ulceration can be reduced insomeone with an at-risk-foot:

■ Specific education about care of the at-risk-foot

■ Appropriate further investigation to define the level of risk more clearly

■ Provision of appropriate footwear if needed

■ Close follow-up

This package of care is ideally provided at a ‘foot-at-risk’ community clinicstaffed by podiatrists who have a special interest in diabetes.


AC T I O N TO TA K E F O R N E W F O OT U LC E R S

A N D / O R C E L LU L I T I S O F T H E F O OT

Most people with diabetes who have to have a limb amputation have apreceding foot ulcer. Foot ulcers do not inevitably lead to an amputation.They can be healed. To heal an ulcer:

■ The ulcer needs to be ‘off-loaded’ to reduce pressure on it

■ The ulcer needs to be debrided regularly to remove dead tissue

■ Infection must be treated

VITAL POINT

✱ Those who are found to have a foot at risk through screeningin primary care should be referred to the local ‘foot-at-risk

clinic’ for extra education, assessment, management and follow-up



Giving advice to people with normal feet

■ Even when there are no ‘at-risk’ features it is helpful to encourage all people with diabetes to inspect their feet regularly and take careof them

■ Advise people to regularly wash and dry their feet and usemoisturising cream on areas of dry skin. The use of a foot spa is notusually advised

■ The presence of callus (thickened dead skin) implies that there isexcessive pressure in that area, and may indicate that the foot isdeveloping ‘at-risk’ features

■ Nails should be trimmed regularly

■ Blood glucose needs to be optimised

■ Appropriate dressings are needed

All of these interventions need to be managed by a multidisciplinary footcareteam.

VITAL POINT

✱ All people with diabetes who newly present with a foot ulceror signs of cellulitis in the foot should be referred immediately

to the local multidisciplinary footcare team for assessment and treatment



Blood pressure control to agreed targets is important in people with diabetesas there is good evidence from the UKPDS study that it reduces the risk ofadverse outcomes, particularly stroke and heart attacks. This is reflected inthe fact that 21 points are available for this clinical area.

K E Y CO M P O N E N TS O F G O O D

B LO O D P R E S S U R E M E A S U R E M E N T

■ The person sits at rest for 5 min in quiet surroundings

■ The dominant arm is supported at heart level

■ Use an appropriate-sized cuff

■ Use an appropriately calibrated device

■ Take two separate readings

■ Record these (and average) to nearest 2 mmHg

Good blood pressurecontrol7


of the blood pressure in the past 15 months

Minimum threshold = 40% Maximum threshold to learn full 3 available points = 90%

Diabetes quality indicator 12 (DM12)The percentage of patients with diabetes in whom the blood

pressure is 145/85 or less

Minimum threshold = 40%Maximum threshold to gain the full 18 available points = 60%

G O O D B LO O D P R E S S U R E C O N T R O L | 4 9

W H I T E COAT HYP E R T E N S I O N

■ Some people have falsely elevated blood pressure readings when theyattend hospital (white coat hypertension). The risks of this are probablymuch less in the practice as this is a more familiar place where theirblood pressure is taken by someone they know

■ Where blood pressure readings may be falsely elevated, it is possible forthe person to be taught to use an automatic blood pressure recordingmachine and given one on loan to record blood pressure measurementsat home, say two times each day for a couple of weeks

■ These readings can then be compared with surgery-recorded levels anddecisions about treatment taken

AU TO M AT E D B LO O D P R E S S U R E

M E A S U R I N G D E V I C E S

■ Many people now use automated blood pressure measuring devices.There are a number of possible problems with these including:◆ Inaccuracy in the presence of any irregularity in the pulse◆ False high readings when people are aware that the cuff is about to

inflate and then tense themselves up in anticipation

■ If a high reading is obtained with an automatic recording device it isgood practice to check it with a properly calibrated and quality assuredmercury device. These mercury devices are the ones that have beenused in the vast majority of clinical trials that form the evidence-basefor good blood pressure control. There was fear that mercury-containing devices would be banned under EU health and safetylegislation, but this is now no longer the case

CO N T RO L L I N G HYP E R T E N S I O N

■ Weight loss and increasing physical activity both reduce blood pressure,so it is important to allow a trial of lifestyle change before rushing intoblood pressure-lowering drugs when the person’s blood pressure is onlyslightly raised

■ If lifestyle change doesn’t reduce blood pressure to target or it is so farabove target that lifestyle change will not normalise it, then drugtherapy needs to be started

D RU G T H E R A PY

■ Evidence from trials including the UKPDS suggest that achieving bloodpressure reduction to target levels is more important than whichindividual drug therapy is used

■ After 9 years of follow-up in the UKPDS blood pressure study, 29% ofpeople in the tight control group needed three or more therapies to meettarget blood pressure

■ In practice, therefore, many people with type 2 diabetes will not havetheir blood pressure controlled to target on one therapy alone. Thismeans that the controversy over which is the best agent to use as initialmonotherapy is largely irrelevant

■ Angiotensin converting enzyme (ACE) inhibitor drugs (or if nottolerated because of cough, angiotensin receptor blocker (ARB) –sometimes called A2 drugs) should be used first in anyone withmicroalbuminuria or proteinuria

■ Certain ethnic groups, eg African/Caribbeans, may not respond to ACEinhibitor drugs. Calcium channel blocker agents may be more useful inthis population

■ It is known that concordance with therapy decreases with increasingnumbers of tablets and increasing dose frequency

■ Combination tablets are therefore helpful to reduce the number oftablets that people need to take

■ Low-dose diuretics augment the antihypertensive effects of other majorclasses and so diuretic plus ACE inhibitor combinations may help


B LO O D P R E S S U R E TA RG E TS

Blood pressure targets are given in the NICE type 2 diabetes guidelines (May2008):

■ Treat blood pressure if lifestyle advice does not reduce blood pressure tobelow 140/80 mmHg or below 130/80 mmHg in a person withevidence of kidney or eye damage or cerebrovascular disease

■ Monitor blood pressure every 1 or 2 months and intensify therapy if onmedication until blood pressure is consistently below 140/80 or130/80 mmHg in a person with evidence of kidney or eye damage, orcerebrovascular disease

■ In women in whom, after an informed discussion, it is agreed that thereis a possibility of pregnancy, first line blood pressure-lowering therapyshould be with a calcium channel blocker. This is because ACEinhibitors and ARB2 drugs are thought to cause fetal abnormalities inearly pregnancy

VITAL POINT

✱ Measure blood pressure at each review appointment and ifnot controlled well treat to agreed goals

G O O D B LO O D P R E S S U R E C O N T R O L | 5 1

INFORMATION FOR PRACTICE STAFF:

Pragmatic therapy action plan

■ Step 1: ACE inhibitor (or if not tolerated ARB) or thiazide■ Step 2: Add in the agent not used in step 1■ Step 3: Add long-acting dihydropyridone or non-dihydropyridone

calcium channel blocker■ Step 4: Add beta-blocker■ Step 5: Add alpha-blocker or other agent

■ Microalbuminuria is defined as:◆ The leakage into the urine of small amounts of protein in the range

30–300 mg in 24 hours◆ It can be detected by specific test strip (Micral-Test) that is dipped into

the urine. The urine will be negative to normal protein dipsticks


Microalbuminuria and kidney function8


of microalbuminuria testing in the previous 15 months(exemption reporting for patients with proteinuria)

Minimum threshold = 40%Maximum threshold to earn maximum 3 points = 90%

Diabetes quality indicator (DM15)The percentage of patients with diabetes with proteinuria or

microalbuminuria who are treated with angiotensin-convertingenzyme (ACE) inhibitors (or ARB (A2) antagonists)


Diabetes quality indicator 22 (DM22)The percentage of patients with diabetes who have a record ofestimated glomerular filtration rate (eGFR) or serum creatinine

testing in the previous 15 months


M I C R O A L B U M I N U R I A A N D K I D N E Y F U N C T I O N | 5 3

◆ It can be detected in a urine sample sent to a laboratory for thedetection of the albumin:creatinine ratio (ACR). A ratio>2.5 mg/mmol for men and >3.5 mg/mmol for women indicatesmicroalbuminuria

■ Proteinuria is defined as:◆ The leakage into the urine of protein of greater than 300 mg in

24 hours ◆ The urine is positive to proteinuria urine testing stick

■ Proteinuria is sometimes labelled as dipstick-positive proteinuria orfrank proteinuria

■ Albustix and Medi-Test Protein 2 are two protein-testing strips that areavailable in the UK

■ Proteinuria testing is found as part of various branded combinationsticks, eg Uristix, Multistix, etc

K I D N E Y D I S E A S E I N D I A B E T E S

Type 1 diabetes■ Not everyone with type 1 diabetes will develop nephropathy, but in

those that do a progressive natural history has been described

■ In the first few years of living with diabetes, kidney function is normaland there is variable excretion of only tiny amounts of protein: <30 mgin 24 hours

■ Later, often after 8–10 years of living with diabetes, microalbuminuriamay develop. This stage may last for 10 years. People at this stageusually have a normal blood pressure

■ After about 20 or more years of living with diabetes, frank proteinuriamay develop

■ This continues on with progressive renal impairment, a rising serumcreatinine level, a falling eGFR and hypertension

■ This results in the need for renal replacement therapy (dialysis ortransplantation), perhaps after 25–35 years of living with diabetes

Type 2 diabetes■ The natural history is thought in general to be similar to that in type 1

diabetes

■ However, in type 2 diabetes most people with microalbuminuria willalso have hypertension

■ The presence of microalbuminuria is a marker for increasedcardiovascular risk

■ Many people with type 2 diabetes and microalbuminuria will die ofcoronary heart disease before they have time to develop end stage renaldisease

■ A lower blood pressure target of 130/80 mmHg is often recommendedin guidelines for people with diabetes and microalbuminuria

M I C ROA L B U M I N U R I A I N H E A LT HY P E O P L E

■ Microalbuminuria can occur in healthy people after they have beenstanding for a while – this is why tests are done after a period ofrecumbency, usually after sleep

■ Microalbuminuria can occur after exercise or during a febrile illness

Points to consider■ One positive test for microalbuminuria does not mean

microalbuminuria has been confirmed as two positive tests are required(see appendix 4 on p. 72 for standard practice letter to recall people afterone positive test)

■ Some clinical computer systems may label someone as havingmicroalbuminuria when a single positive test arrives from thelaboratory

■ If the person with diabetes forgets to bring an early morning urinespecimen with them they should be given a completed form and urinebottle and asked to drop the specimen in at the surgery as soon aspossible

■ Urine tests for microalbuminuria do not need refrigerating as they arestable at room temperature for up to 14 days




Detection of microalbuminuria

Ask the person with diabetes to bring to their clinic appointment thefirst urine sample of the day, after they have got up after sleeping■ Use a dipstick to check for proteinuria■ If positive, check for leucocytes and other signs of infection, send off

a mid-stream urine specimen if indicated, and treat any urinary tractinfection

■ If negative, send urine to laboratory for determination of ACR■ An ACR >2.5 mg/mmol for men and >3.5 mg/mmol for women

indicates microalbuminuria■ If the ACR is <2.5 mg/mmol for men and <3.5 mg/mmol for women,

the person does not have microalbuminuria and the test will need tobe repeated in 1 year

■ If an ACR diagnostic of microalbuminuria is found on one occasion itmust be repeated within a month

■ If a second test is positive the person is confirmed as havingmicroalbuminuria and should be coded as such on the computer

■ If a second test is negative, a third must be sent within a month■ If the third test is negative the person does not have

microalbuminuria and the test is repeated after a year■ If the third test is positive the person is confirmed as having

microalbuminuria and should be coded as such on the computer■ When microalbuminuria has been properly diagnosed the person’s

computer records need to be checked to ensure that they are on anACE inhibitor (or ARB2 if ACE are not tolerated). If they are not onone of these agents they need to be contacted and advised to makean appointment for one to be started

N O N - D I A B E T I C C AU S E S O F

M I C ROA L B U M I N U R I A O R P ROT E I N U R I A

■ The microvascular complications of diabetes tend to occur together

■ If microalbuminuria or proteinuria is detected and the person does nothave retinopathy, non-diabetic causes of the abnormal proteinexcretion need to be investigated

■ Such investigations might need to include renal ultrasound and/orreferral to nephrology

M I C ROA L B U M I N U R I A

A N D HYP E R T E N S I O N

■ People with type 1 diabetes who are found to have microalbuminuriaoften do not have hypertension

■ People with type 2 diabetes who have microalbuminuria often havehypertension

■ There is good evidence that giving an ACE inhibitor to people with type1 or type 2 diabetes and microalbuminuria can delay or arrest theprogression to proteinuria and end stage renal disease

■ An ACE inhibitor is one of the first line agents used to treathypertension in people with diabetes so many people with type 2diabetes and microalbuminuria will already be on an ACE inhibitor

■ Where an ACE inhibitor is not tolerated (usually because of cough) anARB2 or sartan drug should be used. There is evidence of theireffectiveness in reducing progression to end stage renal disease inpeople with diabetes

■ Giving full-dose ACE (or if not tolerated an ARB2) therapy to peoplewith diabetes and microalbuminuria who do not have hypertensiondoes not seem to result in significant hypotension, so it can be safelygiven


C R E AT I N I N E A N D e G F R

■ Laboratories now report eGFR at the same time as a creatinine level

■ eGFR is calculated from the age, sex and serum creatinine level

■ It was introduced because the serum creatinine level alone may give aninaccurate picture of renal function

■ It is possible to have a fairly normal serum creatinine but to havesignificantly reduced renal function

■ The new measure of eGFR brings added precision to the measurementof renal function

■ eGFR is used to classify CKD into five stages as follows:

eGFR (ml/min per 1.73 m2) CKD stage

≥90 1

60–89 2

30–59 3

15–29 4

<15 5

■ If there is no proteinuria or haematuria CKD stages 1 and 2 are normal

■ CKD level 3 indicates someone at increased cardiovascular risk. Theyshould have this risk assessed and treated in the practice, and not bereferred

■ Referral to nephrology services should normally be considered forpeople with stage 4 CKD who may need preparation for end stage renalfailure treatment

■ People found to have CKD stage 5 should be referred as they are likely toneed treatment for end stage renal disease in the near future

■ eGFR measurements in those aged >70 years may have less utility.Some older people may have low but stable renal function (eg witheGFR of 20 ml/min per 1.73 m2), which does not decline significantlyyear-on-year. Such people may never need treatment for end-stage renalfailure and may therefore not need referring to nephrology


■ The presence of CKD stage 3, 4 or 5 indicates someone at increasedvascular risk

■ It is important for people with CKD stages 3, 4 or 5 to have good controlof blood pressure, and blood glucose and cholesterol levels to reducethis vascular risk

VITAL POINTS

✱ Ensure that microalbuminuria is diagnosed properly

✱ Two separate urine samples with ACR diagnostic formicroalbuminuria are required


■ Cardiovascular risk (CVD) is increased two- to fourfold in type 2diabetes. Seventy-five per cent of people with type 2 diabetes will dieof cardiovascular disease, and life expectancy is reduced by about10 years by type 2 diabetes

■ There is good evidence that therapy with a statin that reduces totalserum cholesterol levels will reduce adverse cardiovascular events

P R AC T I C A L S T E P S

■ Measurement of total cholesterol level does not need to be done on afasting blood test, so it can be ordered together with the other routineblood tests and done 2 weeks before attending the practice diabetesclinic

■ Request a fasting lipid profile test if LDL-cholesterol, HDL-cholesteroland triglyceride levels are needed

Cholesterol management9

Diabetes quality indicator (DM16)The percentage of patients with diabetes who have a record

of total cholesterol level in the previous 15 months


Diabetes quality indicator (DM17)The percentage of patients with diabetes whose last measured

total cholesterol within previous 15 months is ≤5 mmol/l


C H O L E S T E R O L M A N A G E M E N T | 5 9

■ There is a good evidence base for the use of either simvastatin 40 mgonce daily or atorvastatin 10 mg daily given for primary prevention ofcardiovascular disease for people with type 2 diabetes

■ Simvastatin has come off-patent so is much cheaper than atorvastatin

■ Many PCTs have a prescribing incentive scheme in operation toencourage the transfer of people who are on atorvastatin 10 mg tosimvastatin 40 mg, as this can save a significant amount of money forthe PCT

■ People on atorvastatin 10 mg can be ‘flagged up’ on the practice clinicalcomputer system. After discussion and agreement with the person withdiabetes, consideration can be given to changing them to simvastatin40 mg daily at their next diabetes clinic appointment

■ If simvastatin 40 mg taken once daily does not reduce the totalcholesterol to ≤5 mmol/l:◆ the dose of simvastatin can be doubled to 80 mg, or ◆ simvastatin can be stopped and a more potent statin prescribed

(eg atorvastatin 20 mg one daily or rosuvastatin 10 mg one daily), or ◆ the cholesterol absorption inhibitor ezetimibe 10 mg daily can be

added to simvastatin 40 mg daily

■ If the total cholesterol level is not ≤5 mmol/l on maximum tolerateddose of potent statin plus ezetimibe 10 mg daily, referral for furtheradvice may be appropriate

■ People with diabetes who have cardiovascular disease or those at veryhigh risk of cardiovascular disease (eg those with microalbuminuria)should have more aggressive cholesterol-lowering targets to a totalcholesterol level ≤4 mmol/l and an LDL-cholesterol level ≤2 mmol/l

■ The NICE 2008 guidelines for type 2 diabetes contains detailedguidance on lipid management (May 2008). It recommends treatmentwith a statin at a 10-year 20% risk◆ For most people, the recommended treatment will be simvastatin

40 mg daily with an aim of achieving a total cholesterol level of≤4 mmol and an LDL-cholesterol level of ≤2 mmol/l

◆ If simvastatin 40 mg daily does nt achieve these targets, simvastatin80 mg daily is recommended, or intensifying treatment with a moreeffective statin

◆ This recommendation is more intensive than the QOF target


VITAL POINTS

✱ Monitor total cholesterol regularly

✱ Consider giving simvastatin to everyone with type 2diabetes unless there is a good reason not to

✱ Alter statin medication if the cholesterol target of ≤5mmol/l is not obtained

C H O L E S T E R O L M A N A G E M E N T | 6 1


■ Influenza immunisation is offered annually to groups considered to beat increased risk. This includes people with diabetes

■ The vaccine is manufactured to try to cover the strains of influenzavirus that are likely to be prevalent in the next winter period

■ Consider joining with other practices to buy influenza vaccine in orderto obtain bulk purchase discounts

■ Ensure that some of the vaccine is ordered on a sale or return basis justin case all is not used

■ Ensure that the vaccine is ordered early in each year for delivery in theautumn

■ The vaccine should arrive in the practice in early October. It can thenbe given opportunistically to everyone attending the practice diabetesclinics and normal surgeries in October through to December

■ Unfortunately this will only cover a small proportion of those at risk.The practice therefore needs to develop a strategy to invite peopleconsidered to be at increased risk to the practice to be vaccinated

■ Assess the need for pneumococcal vaccine and give if necessary

Diabetes quality indicator 18 (DM18)The percentage of patients with diabetes who have had

an influenza immunisation in the preceding 1 September to 31 March

Minimum threshold = 40%Maximum threshold to achieve the full 3 points = 85%

Influenza immunisation10

I N F LU E N Z A I M M U N I S AT I O N | 6 3


Running an influenza immunisation programme

■ Develop a register for call and recall on the practice clinicalcomputer of all people on the practice register considered to be atrisk and who should be offered immunisation

■ Send a letter to these individuals from September inviting them toattend for an influenza immunisation

■ Immunisations may be done by practice nurses and other healthcareprofessionals in special clinics or in normal practice nurse surgerysessions

■ Some practices, especially in areas where many people commute towork, arrange special influenza immunisation clinics in evenings oron Saturday mornings to give more opportunities for people toattend

■ Special arrangements are usually made to immunise those who arehousebound or who live in residential or nursing homes. This mayinvolve the community nursing team or immunisation as part of aGP home visit

■ Posters in the waiting room can be used to alert people consideredto be at risk to book an appointment

■ Telephone contact may need to be made towards the end of theprogramme to ensure that as many people as possible who areeligible get invited to attend

■ Once the immunisation is given details need to be recorded on thepractice computer system

■ If anyone doesn’t want to have the immunisation this needs to berecorded on the practice computer system using the appropriateRead code

■ There may be a few people with diabetes who have specific allergiesthat prevent them safely receiving the immunisation. This needs tobe recorded on the practice computer system

■ Influenza vaccination clinics at the surgery can be used to gatherother data from people with diabetes (eg weight, blood pressure,foot examination or urine test for microalbuminuria) that are missingfrom their records. Some practices feel that it is a cost-effective useof resources to ensure that sufficient staff time is available to do this

■ The overall prevalence of depression in type 2 diabetes is similar to thatobserved in other chronic diseases, and is greater than matchedpopulations without diabetes

■ Being diagnosed with diabetes imposes a life-long psychological burdenon the person and their family

■ Poor psychological functioning causes suffering, can seriously interferewith daily diabetes self-management, and is associated with poormedical outcomes and high healthcare costs

■ From 2006, as part of the QOF, two screening questions need to beasked annually to everyone with diabetes

■ If oral antidepressant therapy is needed, there is an evidence-base forusing fluoxetine 20 mg once daily in people with diabetes

■ Depression and psychiatric morbidity are risk factors for diabetes

■ Some atypical anti-psychotic medications cause an increase in weightand increase the risk of developing diabetes


Quality indicator DEP1The percentage of patients on the diabetes register and/or the

coronary heart disease register for whom case finding fordepression has been undertaken on one occasion during theprevious 15 months using two standard screening questions


Depression11

D E P R E S S I O N | 6 5

S C R E E N I N G Q U E S T I O N S

■ The two standard screening questions for depression 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?

■ A record that the questions have been asked needs to be made on thepractice computer system

■ A ‘yes’ answer to either question is considered a positive result

■ The concept of screening high-risk groups which include people withdiabetes and people with coronary heart disease for depression is fromthe NICE Clinical Guideline for the management of depression (2004)


Practical steps

■ Ask the two screening questions annually in the practice■ It is likely that in most practices the practice nurse running the

diabetes clinic will be the most appropriate person to ask them aspart of the annual diabetes review

■ If a positive response is given to either or both questions it isnecessary to consider further assessment and appropriatemanagement. Individual practices need to develop a protocol forthis. In some it will require the person booking an appointment tosee their usual GP

VITAL POINTS

✱ Make sure that the two screening questions for depressionare asked and the answers recorded on the practice clinical

computer system

✱ If someone is on an atypical anti-psychotic agent and putson a lot of weight, they should be screened for diabetes


Clinical quality indicators for diabetes and scores for 2004/5 and 2005/6

Quality indicator 2005/6 2004/5

Denom– Numer- Score Score Difference inator ator (%) (%) (%)

DM2 The percentage of patients with diabetes with a record of BMI in the previous 15 months 1,835,480 1,726,599 94.1 90.6 3.5

DM3 The percentage of patients with diabetes 1,870,940 1,821,376 97.4 95.9 1.5with a record of smoking status in the previous 15 months, except for those who have never smoked where smoking status should be recorded once

DM4 The percentage of patients with diabetes 277,317 265,623 95.8 93.2 2.6who smoke and with a record that smoking cessation advice has been offered in the last 15 months

DM5 The percentage of patients with diabetes 1,841,571 1,776,415 96.5 94.4 2.1with a record of HbA1c or equivalent in the previous 15 months

DM6 The percentage of patients with diabetes 1,674,231 1,034,294 61.8 58.8 3.0 in whom the last HbA1c is ≤7.5% (or the equivalent test/reference range depending on the local laboratory) in the last 15 months

DM7 The percentage of patients with diabetes 1,786,114 1,633,8981 91.5 89.4 2.1in whom the last HbA1c is ≤10% (or the equivalent test/reference range dependingon the local laboratory) in the last 15 months

DM8 The percentage of patients with diabetes 1,781,716 1,580,830 88.7 83.4 5.3who have a record of retinal screening inthe previous15 months

Appendix 1

A P P E N D I X 1 | 6 7

Clinical quality indicators for diabetes and scores (cont’d)

Quality indicator 2005/6 2004/5

Denom– Numer- Score Score Difference inator ator (%) (%) (%)

DM9 The percentage of patients with diabetes 1,785,322 1,574,374 88.2 78.9 9.3with a record of the presence or absence of peripheral pulses in the previous 15 months

DM10 The percentage of patients with diabetes 1,782,667 1,558,411 87.4 77.6 9.8with a record of neuropathy testing in the previous 15 months

DM11 The percentage of patients with diabetes 1,874,529 1,840,954 98.2 97.0 1.2who have a record of blood pressure in the past 15 months

DM12 The percentage of patients with diabetes 1,753,856 1,313,760 74.9 70.3 4.6in whom the last recorded blood pressure is 145/85 mmHg or less

DM13 The percentage of patients with diabetes 1,684,327 1,396,760 82.9 70.9 12.0with a record of microalbuminuria testing in the previous 15 months (exception reporting for patients with proteinuria)

DM14 The percentage of patients with diabetes 1,857,309 1,777,422 95.7 93.0 2.7with a record of serum creatinine testing in the previous 15 months

DM15 The percentage of patients with diabetes 161,211 138,292 85.8 82.1 3.7with proteinuria or microalbuminuria who are treated with ACE inhibitors (or A2 agonists)

DM16 The percentage of patients with diabetes 1,849,405 1,764,280 95.4 92.7 2.7with a record of total cholesterol level in the previous 15 months

DM17 The percentage of patients with diabetes 1,703,389 1,345,409 79.0 71.8 7.2 whose last measured total cholesterol level within the previous 15 months is ≤5 mmol/l

DM18 The percentage of patients with diabetes 1,651,515 1,477,561 89.5 85.2 4.3who have had influenza immunisation inthe preceding 1 September to 31 March

Diabetes prevalence (registered) 53,211,253 1,890,663 3.6 3.4 0.2

Appendix 2


Clinical quality indicators for diabetes from 1 April 2006

Indicator Points Threshold Points Threshold(%) (%)

Diabetes:

Records

DM1 The practice can produce a register of all patients with 6 Moved to DM19diabetes mellitus

DM19 The practice can produce a register of all patients Moved from DM1 6aged ≥17 years with diabetes mellitus that specifieswhether the patient has type 1 or type 2 diabetes

Ongoing management

DM2 The percentage of patients with diabetes with a record 3 25–90 3 40–90of BMI in the previous 15 months

DM3 The percentage of patients with diabetes with a record 3 25–90 Moved to SMOKINGof smoking status in the previous 15 months, except for those who have never smoked where smoking status should be recorded once

DM4 The percentage of patients with diabetes who smoke 5 25–90 Moved to SMOKINGand with a record that smoking cessation advice has been offered in the last 15 months

DM5 The percentage of patients with diabetes with a record 3 25–90 3 40–90of HbA1c or equivalent in the previous 15 months

DM6 The percentage of patients with diabetes in whom the 16 25–50 Moved to DM20last HbA1c is ≤7.5% (or the equivalent test/reference range depending on the local laboratory) in the last 15 months

DM20 The percentage of patients with diabetes in whom the Moved from DM6 17 40–50last HbA1c is ≤7.5% (or the equivalent test/reference rangedepending on the local laboratory) in the last 15 months

DM7 The percentage of patients with diabetes in whom the 11 25–85 11 40–90 last HbA1c is ≤10% (or the equivalent test/reference range depending on the local laboratory) in the last 15 months

A P P E N D I X 2 | 6 9

Clinical quality indicators for diabetes from 1 April 2006 (cont’d)


DM8 The percentage of patients with diabetes who have 5 25–90 Moved to DM21 a record of retinal screening in the previous 15 months

DM21 The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months Moved from DM8 5 40–90

DM9 The percentage of patients with diabetes with a record 3 25–90 3 40–90 of the presence or absence of peripheral pulses in the previous 15 months

DM10 The percentage of patients with diabetes with a record 3 25–90 3 40–90of neuropathy testing in the previous 15 months

DM11 The percentage of patients with diabetes who have 3 25–90 3 40–90a record of blood pressure in the past 15 months

DM12 The percentage of patients with diabetes in whom 17 25–55 18 40–60the last recorded blood pressure is 145/85 mmHg or less

DM13 The percentage of patients with diabetes with a record 3 25–90 3 40–90 of microalbuminuria testing in the previous 15 months (exception reporting for patients with proteinuria)

DM14 The percentage of patients with diabetes with a record 3 25–90 Moved to DM22 of serum creatinine testing in the previous 15 months

DM22 The percentage of patients with diabetes who have Moved from DM14 3 40–90a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months

DM15 The percentage of patients with diabetes with 3 25–70 3 40–80proteinuria or microalbuminuria who are treated with ACE inhibitors (or A2 agonists)

DM16 The percentage of patients with diabetes with a record 3 25–90 3 40–90 of total cholesterol level in the previous 15 months

DM17 The percentage of patients with diabetes whose last 6 25–60 6 40–70measured total cholesterol level within the previous 15 months is ≤5 mmol/l

DM18 The percentage of patients with diabetes who have 3 25–85 3 40–85had influenza immunisation in the preceding 1 September to 31 March

Clinical quality indicators for diabetes from 1 April 2006 (cont’d)


Depression:

Diagnosis and initial management

DEP1 The percentage of patients in the diabetes register and/or 8 40–90the coronary heart disease register for whom case-finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions*

*For screening questions, see p. 65

From 1 April 2009 DM20 is replaced by DM23, a new DM24 is introduced,and DM25 replaces DM7 as follows:

■ Diabetes quality indicator 23 (DM23) (replaces DM20) The percentage of patients with diabetes in whom the last HbA1c is 7% or less (or the equivalent test/reference range depending on local laboratory) in the previous 15 months Minimum threshold = 40% Maximum threshold to earn the full 17 available points = 50%

■ Diabetes quality indicator 24 (DM24) (new indicator) The percentage of patients with diabetes in whom the last HbA1c is 8% or less (or the equivalent test/reference range depending on local laboratory) in the previous 15 months Minimum threshold = 40% Maximum threshold to earn the full 8 available points = 70%

■ Diabetes quality indicator 25 (DM25) (replaces DM7) The percentage of patients with diabetes in whom the last HbA1c is 9% or less (or the equivalent test/reference range depending on local laboratory) in the previous 15 months Minimum threshold = 40% Maximum threshold to earn the full 10 available points = 90%


A P P E N D I X 3 | 7 1

Appendix 3

Sample practice letter for booking appointments for diabetes review clinics

PRIVATE & CONFIDENTIAL

Date

NameAddress

Dear ——

Your next diabetes review is due in April 2008. We are holding clinicson the following dates and would be grateful if you could phone thesurgery to book a convenient time for you to attend.

Friday 25 April AMMonday 28 April PMFriday 9 May AMMonday 12 May PMFriday 16 May AMMonday 19 May PMFriday 23 May AMFriday 30 May AM

To book your diabetes appointment please ring at 9.30–11.30 am or 2.00–5.00 pm, Tuesday to Friday and ask for a diabetes clinicappointment on one of the above dates.

Please remember to bring with you a urine sample (collected firstthing on the morning of your appointment, if possible).

I enclose a form for you to have your blood test carried out at least afortnight before your appointment. This test can be performed eitherhere at the surgery by appointment, or by drop-in at the HospitalPathology Lab.

Yours sincerely,

Practice Diabetes Nurses

Sample practice letter for follow-up of a one positive microalbuminuriaresult

PRIVATE & CONFIDENTIAL

Date

NameAddress

Dear ——

The result of the urine sample sent to the laboratory recently to testyour kidney function has come back raised.

As a result, we would like to repeat this test. Enclosed is a form andurine bottle for you to provide an early morning urine sample andeither take it to the path lab at the hospital or drop it in our ‘samplesbox’ at the surgery.

If the repeat result is raised again, we will contact you and ask you tomake an appointment to see Dr ———.

Yours sincerely,

Practice Diabetes Nurses


Appendix 4

Glossary

ACE inhibitor angiotensin converting enzyme inhibitor. A class of drugs thatlowers blood pressure and protect kidneys. Members of the class havenames ending in ‘-pril’

ARB/A2 angiotensin receptor blocker or angiotensin 2 blocker. A class ofdrugs that lowers blood pressure and protects the kidney. Members of theclass all have names ending in ‘-sartan’

body mass index (BMI) body weight corrected for height expressed as weight inkilograms/(height in metres)2

CPD continuing professional development

diabetes quality indicator (DQI) a process or outcome measure, one of theclinical indicators for diabetes in the Quality and Outcomes Framework(QOF)

estimated glomerular filtration rate (eGFR) a measure of kidney function derivedfrom a serum creatinine measurement related to age and sex expressed asml/min per 1.73 m2

glycated haemoglobin (HbA1c) the part of haemoglobin molecule that hasglucose attached to it. It is a test of diabetes control, reflecting the level ofglycaemia in the previous 2 or 3 months

general practitioner with a special interest (GPSI) a full-time general practitionerwho spends up to 1 day a week working outside their practice in a definedarea of clinical practice

healthcare assistant (HCA) a person who has been trained to assist a healthcareprofessional

impaired fasting glucose (IFG) a fasting glucose >6 mmol/l and <7 mmol/l

impaired glucose tolerance (IGT) a blood glucose level 2 hours after a 75 gglucose load >7.8 mmol/l and <11.1 mmol/l

microalbuminuria the excretion of small amounts of protein in the urine in therange 30–300 mg/24 hours. It is an indicator of early renal disease

G LO S S A R Y | 7 3

National Service Framework (NSF) a government initiative designed to improvethe quality of care for people with diabetes. Published in two documents:Part 1 Standards in December 2001 and Part 2 Delivery Strategy inDecember 2002

NICE National Institute for Health and Clinical Excellence

oral glucose tolerance test blood glucose measured fasting and 2 hours after a75 g glucose load

proteincreatinine ratio (ACR) the test done on urine measuring the albumin and creatinine content of the urine and expressing this as a ratio. In menthe normal ratio is less than 2.5 mg/mmol and for women it is less than3.5 mg/mmol. Ratios greater than these indicate the presence ofmicroalbuminuria

proteinuria the excretion of significant amounts of protein in the urine above300 mg in 24 hours

Read code the computer code for diagnosis, treatment and medical processthat underpins GP clinical computing systems

self-monitoring of blood glucose (SMBG) testing blood glucose using a meterand special reagent strips

Quality and Outcomes Framework (QOF) the series of clinical indicatorsintroduced in the new GP contract from April 2004


References

NICE guideline on management of depression in primary and secondary care.London, December 2004 (www.nice.org.uk)

NICE guideline on management of type 2 diabetes. London, May 2008(www.nice.org.uk)

Diabetes Control and Complications Trial Research Group (1993) The effectof intensive treatment on the development and progression of long-termcomplications in insulin dependent diabetes mellitus. New England Journal ofMedicine 329: 977–86

This is the randomised controlled trial that shows that good glycaemic controlimproves microvascular outcomes in type 1 diabetes

United Kingdom Prospective Diabetes Study UKPDS 33 (1998) Intensiveblood glucose control with sulphonylureas or insulin compared withconventional treatment and risk of complications in patients with type 2diabetes. Lancet 352: 837–53

This is the randomised controlled trial that shows that good glycaemic controlimproves outcomes in type 2 diabetes

United Kingdom Prospective Diabetes Study UKPDS 34 (1998) Effect ofintensive blood glucose control with metformin on complications inoverweight patients with type 2 diabetes. Lancet 352: 854–65

This is a sub-study of UKPDS that shows that initial treatment withmetformin in overweight individuals reduces their cardiovascular risk

UKPDS Group (1998) Tight blood pressure control and risk of macrovascularand microvascular complications in type 2 diabetes (UKPDS 38) (1998)British Medical Journal 317: 703–13

This reports the UKPDS blood pressure sub-study results showing that goodblood pressure control reduces the risk of adverse outcomes in type 2 diabetes

R E F E R E N C E S | 7 5

Useful websites www.library.nhs.uk/diabetesThe diabetes library of the National Library for Health. This is the NHS web-based library containing high-quality knowledge (mainly guidelines andsystematic reviews) about all aspects of diabetes

www.diabetes.org.ukThe website of Diabetes UK with lots of information for health professionalsand people living with diabetes

www.diabetes.nhs.ukThe website of the National Diabetes Support Team. Information forhealthcare professionals about diabetes, especially delivery of care, examplesof good care and care planning

www.pcdsociety.orgThe website of the Primary Care Diabetes Society. The aim of the society is tosupport primary care professionals to deliver high-quality effective care inorder to improve the lives of those living with diabetes. Open to all membersof primary care, and membership is free

www.warwick.ac.uk/go/studydiabetesThis site gives details of the healthcare professional training programmes indiabetes provided by Warwick University, including the Certificate in DiabetesCare, Intensive Management in Type 2 Diabetes (insulin initiationprogramme) and Masters programmes in Diabetes

www.nscretinopathy.org.ukThis is the website of the national diabetes retinopathy screening committeeand contains all the guidance, documents and advice for commissioning andmanaging retinopathy screening programmes

www.dur.ac.uk/ccmd/yocThis is the ‘Year of Care’ website with information about care planning andcare plans for people with chronic illness


Resources

R E S O U R C E S | 7 7

www.yhpho.org.ukThe website of the Yorkshire and Humberside Public Health Observatory, thelead observatory for diabetes. It contains a lot of information, including aprevalence model

www.ic.nhs.uk/services/qofThis website contains all the information and results for the Quality andOutcomes Framework for the UK

Useful booksFox C & MacKinnon M (2007) Vital Diabetes, 4th edition. London: Class Publishing

Gadsby R (2005) Delivering Quality Diabetes Care in General Practice. London: RCGP

Hall G (2007) Providing Diabetes Care in General Practice, 5th edition. London: Class Publishing

Useful journalsDiabetes in Primary Care (www.diabetesandprimarycare.co.uk)The house journal of the Primary Care Diabetes Society

Diabetes Digest (www.diabetesdigest.com)This journal contains reviews of all the important papers on diabetes in theprevious 3 months

Journal of Diabetes Nursing (www.thejournalofdiabetesnursing.co.uk)

Practical Diabetes International (http://eu.wiley.com/WileyCDA/WileyTitle/productCd-PDI.html)

British Journal of Diabetes and Vascular Disease (www.bjdvd.co.uk)

Diabetes Care (http://care.diabetesjournals.org)

Primary Care Diabetes (www.primary-care-diabetes.com)

Have you found Vital Diabetes Management useful and practical? If so, you may be interested in other books from Class Publishing.

Vital Diabetes £14.99Dr Charles Fox and Mary MacKinnonThis handy reference guide gives you all thebackup you need for best practice indiabetes care, and includes all the vital factsand figures about diabetes for yourinformation and regular use, as well asproviding patient and carer informationsheets that you can photocopy for patientsto take away with them.

‘Full of the kind of essential and up-to-dateinformation you need to deliver the bestpractice in diabetes care.’

M. Carpenter, Diabetes Grapevine

Providing Diabetes Care in General Practice £29.99Gwen HallMary MacKinnon’s classic textbook for thePractice Diabetes Team has been completelyrevised and updated by one of the leadingnames in diabetes care today. This newedition takes into account recent develop -ments in service structure and healthcarepolicy, research, education and much,much more.

‘Gwen Hall is to be congratulated inretaining the spirit of the original, butimbuing it with her own personality. Thebest just got better. Treasure it.’

Dr Eugene Hughes, Chairman, Primary Care Diabetes Europe

Type 1 Diabetes: Answers at your fingertips £14.99Type 2 Diabetes: Answers at your fingertips £14.99Both by Dr Charles Fox and Dr Anne KilvertFor your patients, and for you. The latestedition of our bestselling reference guide ondiabetes has now been split into two bookscovering the two distinct forms of thedisease. These books maintain the popularquestion and answer format to providepractical advice for patients on every aspectof living with the condition.

Chronic Obstructive PulmonaryDisease in Primary Care £29.99Dr David Bellamy and Rachel BookerThis clear and helpful resource manualaddresses the management requirements ofGPs and practice nurses. In this book, youwill find guidance, protocols, plans andtests – all appropriate to the primary caresituation – that will streamline yourdiagnosis and management of COPD.

‘I am sure it will become a classic in thehistory of COPD Care.’

Duncan Geddes, Professor ofRespiratory Medicine

and Consultant Physician, RoyalBrompton Hospital

Heart Health: Answers at your fingertips £14.99Dr Graham JacksonThis practical handbook, written by aleading cardiologist, answers many of yourpatients’ questions about heart conditions.It gives the reader information about theirown health and their heart; how to keep theheart healthy, or – if it has been affected byheart disease – how to make it as strong aspossible.

‘Those readers who want to know moreabout the various treatments for heartdisease will be much enlightened.’

Dr James Le Fanu, The Daily Telegraph

Stroke: Answers at your fingertips £17.99Dr Anthony Rudd, Penny Irwin and Bridget PenhaleThis essential guidebook tells you all aboutstrokes – most importantly how to recoverfrom them.

As well as providing clear explanationsof the medical processes, tests, andtreatments, the book is full of practicaladvice, including recuperation plans. Youwill find it inspiring.

V I TA L B O O K S F O R YO U R P R AC T I C E T E A M

The definitive quick reference manuals for all health professionalsArmed with these straightforward handbooks, you can treat patients

with speed and confidence. Ideal for GPs, practice nurses, specialistnurses, community pharmacists and students.

This series provides you with:

■ Clear and concise information at a glance

■ All the essential medical background you need for daily practice

■ Patient information sections to help you explain complex subjects

■ ‘Vital Points’ highlighted throughout the text for easy reference

■ Up-to-date information to help you structure treatment in primarycare

V I TA L D I A B E T E S

Dr Charles Fox and Mary MacKinnon

V I TA L D I A B E T E S M A N AG E M E N T

Dr Roger Gadsby and Pam Gadsby

V I TA L A S T H M A

Sue Cross and Dave Burns

V I TA L C K D

Dr Rob Higgins

V I TA L N E P H RO LO G Y

Dr Andy Stein, Janet Wild and Dr Paul Cook

V I TA L CO P D

Rachel Booker

V I TA L LU N G F U N C T I O N

Rachel Booker

✃

Cut out or photocopy this form and send it (post-free in the UK) to: Class Publishing, FREEPOST 16705, Macmillan Distribution, Basingstoke RG21 6ZZ

Tel: 01256 302 699 / Fax: 01256 812 558Please send me urgently

No. of Post included price copies per copy (UK only)

□ Vital Diabetes Management (ISBN 978 1 85959 202 1) £17.99□ Vital Diabetes (ISBN 978 1 85959 174 1) £17.99□ Vital Asthma (ISBN 978 1 85959 107 9) £17.99□ Vital CKD (ISBN 978 1 85959 195 6) £17.99□ Vital Nephrology (ISBN 978 1 85959 180 2) £17.99□ Vital COPD (ISBN 978 1 85959 114 7) £17.99□ Vital Lung Function (ISBN 978 1 85959 161 1) £17.99□ Providing Diabetes Care in General Practice (ISBN 978 1 85959 154 3) £32.99□ Chronic Obstructive Pulmonary Disease in Primary Care (ISBN 978 1 85959 104 8) £32.99□ Type 1 Diabetes: Answers at your fingertips (ISBN 978 1 85959 175 8) £17.99□ Type 2 Diabetes: Answers at your fingertips (ISBN 978 1 85959 176 5) £17.99□ Heart Health: Answers at your fingertips (ISBN 978 1 85959 097 3) £17.99□ Stroke: Answers at your fingertips (ISBN 978 1 85959 113 0) £20.99

TOTAL £______

Easy ways to pay

I enclose a cheque made payable to Class Publishing for £_________

Please charge my Mastercard □ Visa □ Amex □

CARD NUMBER EXPIRY DATE

NAME

MY ADDRESS FOR DELIVERY IS

TOWN COUNTY POSTCODE

TELEPHONE NUMBER (in case of query)

CREDIT CARD BILLING ADDRESS (if different from above)

TOWN COUNTY POSTCODE

Class Publishing’s guarantee: remember that if, for any reason, you are not satisfied with these books, we will refund allyour money, without any questions asked. Prices and VAT rates may be altered for reasons beyond our control.

Priority Order Form

vital diabetes management

Documents