Vital Diabetes Management

Vital

DIABETES MANAGEMENT Your essential reference for diabetes management in primary care Roger Gadsby MB, ChB, DCH, DRCOG, FRCGP and

Pam Gadsby RGN

Vital

DIABETES MANAGEMENT

Vital

DIABETES MANAGEMENT Your essential reference for managing diabetes in primary care Roger Gadsby MB, ChB, DCH, DRCOG, FRCGP General Practitioner with a Special Interest in Diabetes Associate Professor in Diabetes Care, Warwick University Medical School and

Pam Gadsby RGN Practice Diabetes Nurse

CLASS HEALTH • LONDON

Text © Roger Gadsby, Pam Gadsby 2009 © Class Publishing Ltd 2009 All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (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 the Copyright Designs and Patents Act 1988 to be identified as the authors of this work wherever it is published commercially and whenever any adaptation of this work is published or produced including any sound recordings or films made of or based upon this work. NOTICE The information presented in this book is accurate and current to the best of the authors’ knowledge. The authors and publisher, however, make no guarantee as to, and assume no responsibility for, the correctness, sufficiency or completeness of such information or recommendation. The reader is advised to consult a doctor regarding all aspects of individual health care. Printing history First 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, UK Telephone: 020 7371 2119 Fax: 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

Contents

Introduction Acknowledgements

9 10

1 The context The Quality and Outcomes Framework Exemption reporting Exclusion of individual patients Levels of exemption reporting Income from the Quality and Outcomes Framework Rewards for high-quality care Locally enhanced service payments Prescribing incentive schemes Intermediate diabetes care General Practitioner with a Special Interest Practice-based commissioning Secondary care Relationship with secondary care Handling data from secondary care Indications for referral to secondary care Young people with type 1 diabetes

11 11 12 12 13 13 13 14 14 14 15 15 16 16 16 16 17

2 The practice diabetes register The prevalence of diabetes in your practice The accuracy of your practice diabetes register Labelling with type 1 or type 2 diabetes Teenagers with type 2 diabetes Diagnosing diabetes Diagnosing diabetes from fasting glucose level Diagnosing diabetes from an oral glucose tolerance test Information for practice staff: Registry and recall for people with IGT and IFG

18 18 19 20 20 21 21 22 22 CONTENTS | 5

Information for practice staff: Follow-up of people newly diagnosed with diabetes Information for practice staff: Protocol to be followed at an initial diagnosis of type 2 diabetes Information for practice staff: Suggested frequency of self-monitoring of blood glucose Self-monitoring of blood glucose Prescribing for self-monitoring of blood glucose Self-monitoring of blood glucose in people who are newly diagnosed and on lifestyle management only

23 23 24 24 24 25

3 The practice diabetes service The staffing of diabetes clinics The GP partner The diabetes nurse(s) The healthcare assistant Information for practice staff: The practicalities of running a diabetes clinic Care planning Information for practice staff: Frequency of clinics Information for practice staff: Reducing ‘did-not-attend’ (DNA) rates

26 26 26 26 28

4 Achieving glycaemia targets Information for practice staff: Practical tips for achieving glycaemia targets Reducing the risk of complications Microvascular disease prevention Macrovascular disease prevention Information for practice staff: Initiating insulin therapy Oral anti-obesity therapies Information for practice staff: Management of special cases

33

5 Retinal screening The rationale The method 6 | VITAL DIABETES MANAGEMENT

28 30 31 32

34 35 35 35 36 37 38 39 39 39

Information for practice staff: Preparing for the screening team visit Information for practice staff: Running an efficient retinal screening day at the practice Handling the results from retinal screening programme 6 Foot screening Background Information for practice staff: Practical tips for examining feet to detect the at-risk-foot Risk factors for foot ulceration Causes of foot ulceration Prevention of foot ulceration Information for practice staff: Giving advice to people with normal feet Action to take for new foot ulcers and/or cellulitis of the foot

40 41 42 43 43 44 44 45 45 46 46

7 Good blood pressure control Key components of good blood pressure measurement White coat hypertension Automated blood pressure measuring devices Controlling hypertension Drug therapy Information for practice staff: Pragmatic therapy action plan Blood pressure targets

48 48 49 49 49 50

8 Microalbuminuria and kidney function Kidney disease in diabetes Type 1 diabetes Type 2 diabetes Microalbuminuria in healthy people Points to consider Information for practice staff: Detection of microalbuminuria Non-diabetic causes of microalbuminuria or proteinuria Microalbuminuria and hypertension Creatinine and eGFR

52 53 53 54 54 54

51 51

55 56 56 57

CONTENTS | 7

9 Cholesterol management Practical steps

59 59

10 Influenza immunisation Information for practice staff: Running an influenza immunisation programme

62

11 Depression Screening questions Information for practice staff: Practical steps

63 64 65 65

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

66

Appendix 2 Clinical indicators for diabetes from 1 April 2006

68

Appendix 3 Sample practice letter for booking appointments for diabetes review clinics

71

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

72

Glossary

73

References

75

Resources Useful websites Useful books Useful journals

76 76 77 77

Other titles

78

Priority Order Form

80

8 | VITAL DIABETES MANAGEMENT

Introduction

Dear Colleagues Welcome to this edition of Vital Diabetes Management This book has been written to give practical help to healthcare professionals who work in general practice and are involved in delivering diabetes care. It brings together the expertise of general practice and practice diabetes nursing to help practitioners to deliver high-quality diabetes care and fulfil the requirements of the new GP contract Quality and Outcomes Framework, ensuring that the maximum income for diabetes care is obtained. The book is divided into 11 chapters with topics clearly presented. The detailed contents list will help you find your way around with ease. Within each topic you will find one or more vital points to give you essential information in just a few words. Some chapters also contain sections on Information for Practice Staff that can be photocopied and enlarged for your staff. You will also find useful appendices and other information at the end of the book, including sample practice letters, a glossary, useful addresses, websites and contacts, and references and further reading. We would welcome your comments or suggestions for improvements. Vital Diabetes Management is backed by the wisdom and experience gained by delivering diabetes care in a large 14,500-patient general practice for more than 25 years, and from speaking and writing about diabetes care over a similar period. We hope that you will find this book helpful for your practice.

Roger Gadsby and Pam Gadsby

I NTRODUC TI ON | 9

Acknowledgements

We would like to pay tribute to Mary MacKinnon for all her support and encouragement to us over the years. We would like to thank all the partners and staff of Redroofs surgery and all our colleagues who have worked for Warwick Diabetes Care for their help. We thank Colin Kenny for his helpful introduction and our editor Caroline Taylor for all her help and expertise in getting this book to print.

1 0 | VITAL DIABETES MANAGEMENT

1

The context

Over the past 30 years diabetes care has moved from being seen almost exclusively as the province of secondary care to one in which virtually all routine care for people with diabetes occurs in primary care. The new GP contract that was introduced in April 2004 has provided some financial recompense to support this shift in diabetes care from primary to secondary care. The GP contract lists a series of clinical domains for diabetes covering both process and outcome measures (see appendix 1 on p. 66). They were modified from 2006 onwards to give a possible 93 points for full achievement of the diabetes clinical indicator. From 1 April 2009 the previous two clinical outcome indicators for HbA1c are altered and become three, with an additional seven points being added, giving a total of 100 points available for the diabetes clinical indicator set.These modifications are listed in appendix 2 on p. 68.

T HE Q UALI TY A ND O UTCO M E S FR AME WORK ■ The Quality and Outcomes Framework (QOF) is a payment system, so some of the clinical standards are different from the ‘targets’ of national and international guidelines ■ It may not be medically appropriate for all people with diabetes to achieve 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 QOF may put them at an unacceptable increased risk of hypoglycaemia or hypotension

■ These individuals can be ‘exempted’ from the framework

THE CONTEX T | 1 1

EXEMPTION REPORTING Exclusion of individual patients Exemption reporting allows the practice to exclude individual patients from the 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 the preceding 12 months ◆ Patients for whom it is not appropriate to review the chronic disease parameters due to specific circumstances, eg extreme frailty, terminal illness or severe dementia ◆ Patients who do not agree to investigation and treatment (and, after a reasonable discussion or written advice, have given their informed dissent) and this dissent has been recorded in the medical notes ■ Patients exempted from one clinical indicator only (if a valid computer code – 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 contraindication or 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 informed dissent) and this dissent has been recorded in the medical notes Patients who have a supervening condition that makes treatment of their condition inappropriate, eg cholesterol reduction when the patient has liver disease Patients for whom an investigative service or secondary care service is unavailable

■ Patients exempted automatically from any of the indicators by reporting software ◆ Patients newly diagnosed within the practice with diabetes or who have recently registered with the practice, who should have measurements made within 3 months and delivery of clinical 1 2 | VITAL DIABETES MANAGEMENT

standards within 9 months, eg blood pressure or cholesterol measurements 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 were generally 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 NCOM E F RO M THE Q UA LI TY AND O U TCO M E S F R A M E WO RK ■ Points mean prizes! The points that can be achieved from each clinical indicator 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 of reducing potential income for practices with high prevalence rates for diabetes ■ For an average-sized practice with an average prevalence of diabetes each point was worth £75 in the first year and £125 in the year 2005/6. So for the average practice with average prevalence the total income for the QOF for 2005/6 was 99 points each worth £125 = £12,375

R E WAR D S F O R HI GH- Q UA LI TY C ARE Other structural changes have taken place to reward primary care for delivering high-quality diabetes care. THE CONTEX T | 1 3

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 for specific diabetes services over and above QOF ■ One of the most common extra payments in diabetes is for initiation onto 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 prescribing advisors ■ An example is the rewarding of switching to the prescribing of generic simvastatin 40 mg once daily from more expensive branded atorvastatin 10 mg once daily. A practice may be rewarded for achieving 70 people on 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 of strips 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 more complex problems, instead of referring to secondary care the patient can be seen in an intermediate clinic nearer to their home, rather than having to travel to a hospital outpatient clinic ■ Clinics are usually staffed by a Community Diabetes Specialist Nurse, a Community Dietitian who has a special interest in diabetes, and a doctor 1 4 | VITAL DIABETES MANAGEMENT

■ This doctor is sometimes a Consultant Community Diabetologist or a GP with a Special Interest in diabetes (GPSI; see below) ■ These clinics see people referred from GPs and usually see them only once 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 at www.doh.gov.uk/pricare/gp-specialinterests ■ GPSIs in diabetes can fulfil a purely management function, for example overseeing a diabetes network, or can fulfil a clinical function, for example running diabetes clinics in the community ■ New guidance on accreditation and governance of GPSIs was released in 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 a link to the document in pdf format and this can be downloaded ■ The toolkit provides advice for all commissioners of diabetes services and describes how to carry out a needs assessment for a local diabetes population. It provides a generic specification for diabetes care, signposting recognised quality markers and suggesting key outcomes for the service ■ In some parts of the country practice-based commissioning is being developed, whereas in others it has hardly started. Some commissioning groups have developed services to provide intermediate diabetes care clinics and insulin initiation in type 2 diabetes programmes ■ The National Institute for Health and Clinical Excellence (NICE) has produced a commissioning guideline for diabetes footcare based on the NICE 2004 guideline. It can be found at www.library.nhs.uk/diabetes (using search facility for ‘commissioning footcare’). This gives a link to the document as a pdf

THE CONTEX T | 1 5

S ECONDARY C A RE 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 with diabetes who are stable back to primary care for their continuing routine care. This is to enable secondary care diabetes clinics to become less involved in routine chronic care and more able to provide quick access 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 are needed by primary care to enable them to be entered onto the practice computer system to fulfil QOF requirements ■ It is important to ask secondary care colleagues to include all this QOF relevant information in their clinic letters sent to the practice ■ The practice then needs a protocol to ensure that this data is transferred to the practice computer appropriately ■ In many practices the GP receiving the letter uses a highlighter pen to mark the results that need entering ■ Practice administration staff then enter these data, which are automatically 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 prepregnancy advice and counselling ■ Women with diabetes who are pregnant need early referral to a unit with 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 of their feet 1 6 | VITAL DIABETES MANAGEMENT

■ Nephrology assessment services for people with stage 4 and 5 chronic kidney disease (CKD) and dialysis ■ People requiring retinopathy treatment ■ Anyone with a diabetes problem that the practice does not feel it has the expertise 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 practice will be providing repeat prescriptions for insulin and may be the only place of contact for people failing to attend secondary care. Every attempt needs to be made to try to re-engage them with diabetes care provision

THE CONTEX T | 1 7

2

The practice diabetes register

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

Diabetes quality indicator 19 (DM19) The practice can produce a register of all patients aged ≥17 years with diabetes mellitus that specifies whether the patient has type 1 or type 2 diabetes = 6 points

TH E P R E VAL E NC E O F DI A BE TE S IN YOUR P R AC TI C E ■ The registered prevalence of diabetes from 2007/8 QOF figures for the whole of the UK was 3.86% on 14 February 2008 ■ The registered prevalence was higher than this in Wales and lower than this in Northern Ireland (3.1%) ■ In an ‘average’ practice of 10,000 registered patients, 370 will have diabetes ■ In practices with a higher than average proportion of older people the prevalence of diabetes is likely to be higher than 3.7% as diabetes is more common in older people ■ In practices with a younger than average population, eg student health centre practices and practices on new housing estates with many young families, the prevalence of diabetes is likely to be below 3.7% ■ In practices with large numbers of people from a South Asian ethnic group, prevalence rates are likely to be much greater, even up towards 10% 1 8 | VITAL DIABETES MANAGEMENT

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

V ITA L POINT ✱ If the recorded prevalence of diabetes in your practice is below what would be expected and this cannot be explained by the mix of your practice population, consider where the missing people might be

T HE ACCUR AC Y O F YO UR PR AC T I C E DI A BE TE S RE GI STE 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 diabetes mellitus ■ People with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) wrongly being included in the diabetes register ■ People with a history of gestational diabetes wrongly being included in the register ■ People labelled as having diabetes and included on the register many years ago because they had glycosuria, and when records are checked no proper diagnostic tests for diabetes were ever made ■ People diagnosed as having diabetes whilst an inpatient and the diagnosis not being recorded or not being picked up from a hospital letter, so they are not added to the practice register

V ITA L POINT ✱ Review and update your diabetes register regularly

T H E P R AC 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 to be 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 in their 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 type 2 diabetes and less than 10% will have type 1 diabetes

V ITA L POINT ✱ If your practice has more than 10% of people labelled as having type 1 diabetes consider whether some may have been wrongly labelled – just because someone is on insulin does not mean 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, often from Indo-Asian ethnic backgrounds, who are newly presenting with diabetes ■ In the USA today if someone aged 18 years old newly presents with diabetes they are just as likely to have type 2 as type 1 diabetes ■ There are some rare forms of diabetes that often present in teenagers and young adults, such as maturity onset diabetes of the young (MODY)

2 0 | VITAL DIABETES MANAGEMENT

V ITA L POINT ✱ Best practice is to always refer someone newly diagnosed with diabetes <25 years old for specialist advice on what sort of diabetes they have and to ensure optimal management

D I AGNO S I NG DI A BE TE S ■ In asymptomatic individuals, two abnormal blood glucose levels diagnostic of diabetes are required ■ If someone has symptoms suggestive of diabetes (eg weight loss, thirst, polyuria and polydypsia) only one abnormal blood glucose value diagnostic of diabetes is required ■ HbA1c values cannot be used to diagnose diabetes (but they may give important information at the time of diagnosis about the level of control) ■ The presence of ketonuria with abnormal blood glucose levels at diagnosis suggests type 1 diabetes

Fasting plasma glucose (mmol/l)

Diagnosing diabetes from fasting glucose level

Diabetes diagnosed

If asymptomatic repeat to confirm

Impaired fasting glucose

Proceed to oral glucose tolerance test

Normal

Repeat if screening protocol says so*

7.0

6.0

*In the USA it is repeated every year

Figure 2.1 Diagnosis of diabetes: fasting plasma glucose T H E P R AC T I C E D I A B E T E S R E G I S T E R | 2 1

Diagnosing diabetes from an oral glucose tolerance test

Plasma glucose (mmol/l)

Diabetes diagnosed 11.1 Impaired glucose tolerance diagnosed

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

7.8

Normal

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

I N F O R MAT ION F OR PRACTICE S TAFF Registry and recall for people with IGT and IFG ■ If someone is diagnosed with IGT or IFG the appropriate Read code needs 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

2 2 | VITAL DIABETES MANAGEMENT

I N F O R MAT ION F OR PRACTICE S TAFF Follow-up of people newly diagnosed with diabetes ■ The practice needs a protocol for following-up people newly diagnosed 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

I N F O R MAT ION F OR PRACTICE S TAFF Protocol to be followed at an initial diagnosis of a person with type 2 diabetes ■ Confirm diagnosis in accordance with the WHO criteria. Arrange further blood tests if needed ■ Ask about the person’s knowledge of diabetes and how the diagnosis has affected them ■ Give some initial education about the condition, but don’t overload them at this first consultation ■ Give written information to consolidate the information given verbally with a care plan ■ Encourage them to attend a community group education programme being run in your PCT locally ■ Discuss appropriate changes in diet and set an appropriate target for weight reduction if they are obese or overweight ■ Discuss increasing physical activity to a level appropriate for their age and physical abilities. The aim is 20–30 min of physical activity per day. Consider referral to local ‘fitness on prescription’ programme if available ■ Discuss whether they would find self-monitoring of blood glucose helpful. Arrange for them to be taught how to do this if they want to ■ Agree a follow-up consultation and appropriate blood tests to be done before that visit

T H E P R AC T I C E D I A B E T E S R E G I S T E R | 2 3

I N F O R MAT ION F OR PRACTICE S TAFF Suggested frequency of self-monitoring of 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 of hypoglycaemia 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 are suspected ■ For people who are stable on metformin, thiazolidinediones or dipeptidyl peptidase-4 (DPP4) inhibitors or combinations of these agents: ◆ These agents do not cause hypoglycaemia and so no routine testing is necessary

S ELF-M O N I TO RI NG O F BLO O D GLU COSE Prescribing for self-monitoring of blood glucose Self-monitoring of blood glucose (SMBG) costs the NHS a significant amount of money each year. It is an area where prescribing advisors are keen to see appropriate 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 2 4 | VITAL DIABETES MANAGEMENT

■ Prescribe the appropriate lancets in the appropriate quantity ■ Prescribe the appropriate lancing device ■ Prescribe a sharps box to put the used lancets in, and explain appropriate 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 with type 2 diabetes learn to self-monitor blood glucose and check their own levels after eating and before and after exercise, they will learn the benefits 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 is no additional benefit of SMBG, and it can be stopped

V I TA L POI NTS ✱ Ensure that SMBG is being used appropriately by all people who have diabetes ✱ If SMBG is being done out of habit and has no clinical relevance consider stopping it ✱ SMBG is expensive and any appropriate reduction in its use will reduce the practice prescribing costs significantly

T H E P R AC T I C E D I A B E T E S R E G I S T E R | 2 5

3

The practice diabetes service

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

TH E S TA FFI NG O F DI A BE TE S C LI N ICS ■ Most practice diabetes services are now nurse-run and GP-managed ■ Healthcare assistants (HCAs) are increasingly employed to do some of the 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 a certificate/diploma course in diabetes care, such as the Certificate in Diabetes Care from the University of Warwick, is one way of demonstrating this ■ Keeps up-to-date with diabetes developments through continuing professional development (CPD). Being a member of the Primary Care Diabetes 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 the clinics ■ Ensures that all staff work to keep the practice diabetes register up-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 2 6 | VITAL DIABETES MANAGEMENT

in Diabetes Care from the University of Warwick, is one way of demonstrating this (see p. 76) ■ Keeps up-to date with diabetes developments through CPD. Being a member of the Primary Care Diabetes Society is a good way of helping to achieve this (see p. 76) ■ Oversees the practice call and recall system to ensure that people with diabetes receive the appropriate appointments and follow-up in the diabetes clinic (see appendix 3 on p. 71 for sample practice letter for follow-up appointments) ■ Ensures that appropriate numbers of appointments are available each month 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 clinical computer system diabetes template ■ Ensures that people receive their blood test request form at least 2 weeks before their appointment in order that the results can be available in clinic ■ Ensures that blood results have been received from the laboratory and have been entered on the diabetes template ■ Ensures that the practice has access to a retinal screening programme that fulfils national standards and that people with diabetes registered at the practice receive an annual invitation for screening ■ Ensures that people with diabetes are asked to bring a first morning sample of urine for testing for proteinuria and microalbuminuria ■ Ensures that results of microalbuminuria testing are recorded properly and acted upon (see p. 55) ■ Ensures that arrangements are in place for group structured education for newly diagnosed people with diabetes ■ Ensures that appropriate one-to-one education is available for people not wanting group education ■ Ensures that there is a structure for on-going education of people with diabetes ■ Liaises with hospital- and community-based diabetes nurses T H E P R AC T I C E D I A B E T E S S E R V I C E | 2 7

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

V I TA L POI NT S ✱ 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 and this may be supported by specific local training programmes ■ HCAs can help the practice diabetes nurse in the diabetes clinic by doing a number of the routine measurements and recording information on the clinical computer system ■ These tasks could include measurement of weight, height and blood pressure, urine dipstick testing, and checking feet

I N F O R MAT ION F OR PRACTICE S TAFF The practicalities of running a diabetes clinic ■ Welcome the patient, and give them opportunity to express any particular concerns about their diabetes and its impact on their lives ■ Do specific measurements of weight and height (if not recorded on computer, so that the body mass index (BMI) can be calculated). Enter the results on the computerised template and share them with the patient ■ Discuss lifestyle issues such as healthy eating, weight reduction and physical activity

2 8 | VITAL DIABETES MANAGEMENT

I N F O RM AT ION F OR PRACTICE S TAFF The practicalities of running a diabetes clinic (cont’d) ■ Measure blood pressure (for details see p. 48) and enter the result on the computer ■ Review blood test results and discuss their implications with the person with diabetes ■ Review all medications and any possible side effects. Discuss compliance with therapy ■ Discuss alterations and up-titrations of medications needed in the light of blood test results, weight and blood pressure ■ Ask about any foot problems and examine as necessary. Examine foot pulses annually and test for neuropathy (see p. 44) ■ Refer anyone found to have ‘foot-at-risk’ to local podiatry foot protection clinic (see p. 46) ■ Ask about any eye problems. Ensure that the person has received annual retinopathy screening by digital retinal photography ■ Ask about current smoking status and offer smoking cessation advice as necessary ■ Check the urine sample for protein using the appropriate dipstick and act on the result if positive (see p. 54) ■ Ensure that a urine sample is sent to the laboratory annually for an ACR to detect microalbuminuria (see p. 54) ■ Make a sensitive enquiry about whether any erectile dysfunction issues are bothering the person with diabetes or their partner and prescribe as necessary ■ Ask the two specific questions to screen for depression and record the answers on the computer (p. 65). Refer for psychological support if indicated ■ Give influenza and pneumococcal immunisation as necessary (see p. 63) ■ Update regular prescriptions ■ Agree the time of the next follow-up appointment and set the goals to be achieved by then

T H E P R AC T I C E D I A B E T E S S E R V I C E | 2 9

■ HCAs can also assist in retinal screening clinics (see p. 41) ■ Using an HCA to do some of this routine work can enable the practice diabetes nurse to have more time to spend reviewing the impact of diabetes on lifestyle, concordance and medication issues ■ This may then enable the patient to take more control of their diabetes

V I TA L POI NT S ✱ Accurate recording of date for follow-up appointments and those who did-not-attend (DNA) on the computer template is necessary 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 prescribing qualifications 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 NG There is a renewed emphasis on care plans and care planning in chronic disease management consultations. The aim of these plans is to enable the person with diabetes to set the agenda for their review appointment. Pilot initiatives are being undertaken in ‘The Year of Care’ project supported by the National Diabetes Support Team (NDST) and Diabetes UK (see www.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 to deal with and talk about Goal-setting and action-planning. The person with diabetes and healthcare professional decide what needs to happen and who does what. This should be written down

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I N F O RM AT ION F OR PRACTICE S TAFF Frequency of clinics ■ Most people with diabetes who are well controlled can be seen every 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 are usual ■ If an HCA is used, a 10-minute appointment with them may precede the practice nurse appointment, which may then be reduced to 10 minutes ■ The number of clinics needed per week then needs to be calculated, depending on the practice diabetes list size and the number of people needing to be seen every 3 and 6 months ■ The number of clinics each month may need to vary slightly depending on the above calculation

◆

◆

Joint review. This involves checking back at the next visit to see if the points agreed have been put into action Writing a care plan. This can facilitate the process. Examples may be found in the document entitled Partners in Care from the NDST

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

V I TA L POI NTS ✱ Ensure that diabetes review consultations are patient-centred ✱ Giving patients the results of their blood tests and asking them to consider the results before the clinic can help in focusing the consultation on their needs

T H E P R AC T I C E D I A B E T E S S E R V I C E | 3 1

I N F O R MAT ION F OR PRACTICE S TAFF Reducing ‘did-not-attend’ (DNA) rates If people book their clinic appointment 6 months in advance you will often find that they forget to attend. DNA rates can be significantly reduced 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 months before 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 that their appointment is due ■ Having a system to note those who fail to phone in to make a booking ■ Having a practice procedure to contact those who DNA to ensure that they make an appropriate appointment

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4

Achieving glycaemia targets 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 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) 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) 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%

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I N F O R MAT ION F OR PRACTICE S TAFF Practical tips for achieving glycaemia targets ■ Review people who are not reaching their agreed HbA1c target every 3 months ■ At each consultation agree and document the plans to try to reach that 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 6 months ■ Negotiate realistic targets for weight loss with each individual. An agreed plan to lose 1 stone (6.5 kg) in 3 months in someone who is 16 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 people can realistically agree to try to walk a mile (1.5 km) a day initially. The aim is for 30 min of brisk physical activity on five days a week ■ Metformin is the initial monotherapy of choice for the majority of people with type 2 diabetes, with the exception of thin, very symptomatic people newly diagnosed with type 2 diabetes, who should be managed differently (p. 38) ■ Use 500 mg tablets of metformin twice a day but suggest the person just takes 500 mg daily for the first 2 weeks to minimise the risk of abdominal pain and diarrhoea. Warn about side effects and reassure patients 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 gastrointestinal tolerability prevents continuation of metformin therapy ■ When maximally tolerated dose of metformin does not give optimal glycaemic control, a sulphonylurea should be the second therapy to be added for most people ■ The most commonly prescribed sulphonylurea in the UK is generic gliclazide, 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 splitting an 80 mg tablet in two ■ The next up-titration is to one 80 mg tablet twice a day, then to two tablets, ie 160 mg twice a day

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I N F O R MAT ION F OR PRACTICE S TAFF Practical tips for achieving glycaemia targets (cont’d) ■ When optimal glycaemic control is not obtained with maximal tolerated doses of metformin plus a sulphonylurea there are a number of 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 the glitazone with the best evidence of cardiovascular protection although 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 diabetes care. This is reflected in the number of points given to these three clinical indicators in the QOF. There is good evidence that controlling glycaemia is associated with reduced risks of complications in both type 1 and type 2 diabetes from the Diabetes Control and Complications Trial (DCCT) study and the UK Prospective Diabetes Study (UKPDS) respectively (see p. 75).

R E D U C I N G THE RI SK O F CO M PLIC AT ION 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 developing microvascular disease for people with type 1 diabetes and is likely to do so in people with type 2 diabetes

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

AC HI E VI NG G LYC A EM I A TA RG ETS | 3 5

■ In the epidemiological analysis of the UKPDS in newly diagnosed people with type 2 diabetes, a 1% reduction in HbA1c was associated with a 21% reduction in death related to diabetes and a 14% reduction in myocardial infarction. There was a threefold increase over the HbA1c range from 6% to 10% in any diabetes-related macrovascular endpoint with no evidence of a threshold ■ There is no level of HbA1c below which macrovascular disease is prevented ■ An HbA1c target of 6.5% has been stated as the goal in all major guidelines, as this is a level that will prevent microvascular complications and reduce the risk of macrovascular complications ■ Reducing HbA1c from 12% to 9.1% is likely to be of significant clinical benefit but it will not earn QOF points ■ Reducing HbA1c from 7.2% to 6.9% does earn QOF points but is unlikely to be of significant clinical benefit

I N F O R MAT ION F OR PRACTICE S TAFF Initiating insulin therapy ■ There are training programmes for GPs and practice nurses to teach insulin initiation in primary care. One example is a short course from Warwick University (Intensive management of type 2 diabetes) (www.warwick.ac.uk/go/studydiabetes) ■ The most appropriate insulin regimen for many people with type 2 diabetes is adding once daily long-acting insulin whilst continuing on oral metformin and sulphonylurea tablets ■ A usual starting dose is 10 units, which can be up-titrated by the person with diabetes according to their fasting glucose levels determined by SMBG ■ Close contact with the initiating nurse by telephone is maintained during this titration process ■ For practices who do not have the skill and experience to initiate insulin, referral for this to intermediate or secondary diabetes care will be required

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■ The target HbA1c for any individual needs to be the subject of a discussion between the healthcare professional and the individual, but most people can safely aim to get their HbA1c to 7.5% ■ Where attaining a tight HbA1c target is felt, in discussion with the patient, to be unattainable without significant risk of adverse side effects of glucose-lowering treatments (mainly the risk of hypoglycaemia), consider accepting a HbA1c level >7.5% and exempting them from the QOF target (see p. 12) ■ There is little evidence for the benefit of tight glycaemic control above the age of 80 years, and there is a significant increased risk of falling and developing increased confusion from hypoglycaemia in the frail elderly person with diabetes. Higher HbA1c targets may be therefore appropriate in the frail elderly, and exemption reporting needed

OR AL A N T I - O BE SI TY THE R A P IES ■ The anti-obesity agent orlistat can be used in obese people with diabetes controlled on diet, on one, two or three oral agents, or with insulin, and can be considered as additional treatment where it is deemed necessary ■ Sibutramine is an effective anti-obesity agent but it can cause hypertension and tachycardia. This reduces its usefulness in people with diabetes ■ Rimonabant is an anti-obesity agent that may be associated with mood changes and depression. Its role in people with type 2 diabetes has yet to be ascertained

V ITA L POINT ✱ Evaluate glycaemic control at each review appointment, set appropriate goals and up-titrate medications as necessary

AC HI E VI NG G LYC A EM I A TA RG ETS | 3 7

I N F O R MAT ION F OR PRACTICE S TAFF Management of special cases The newly diagnosed person with type 2 diabetes who is thin and very symptomatic ■ The concern is that these individuals have significant beta cell dysfunction 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

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5

Retinal screening

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%

T HE R AT I ONA LE ■ Diabetic retinopathy is the leading cause of blindness in people of working age in many countries in the developed world ■ It is possible to have severe sight-threatening diabetic retinopathy and have normal vision ■ Good glycaemic control with an HbA1c below 7.5% helps to prevent retinopathy ■ Laser therapy is effective treatment for diabetic retinopathy ■ Laser therapy for the treatment of diabetic retinopathy has been shown to be effective in reducing blindness ■ Screening for retinopathy is therefore essential, as people may not know they have it ■ Cataracts are more common in people with diabetes. They need to be detected and treated. Referral for consideration of urgent cataract extraction is needed when the cataract stops a good view of the retina

T HE M E T H O D ■ Screening by digital retinal photography is the only approved method for retinal screening RETI NA L SC REENI NG | 3 9

■ Digital retinal screening must be carried out by an approved screening service that uses skilled staff, has appropriate internal quality assurance mechanisms, and conforms to the national specifications (see www.nscretinopathy.org.uk). Programmes ideally are of a size to screen 15,000–20,000 people with diabetes each year. Each programme therefore covers more than one PCT. There are at present just over 100 retinal screening programmes in the UK ■ In some areas this service is provided by optometrists

I N F O R MAT ION F OR PRACTICE S TAFF Preparing for the screening team visit ■ Most screening programmes now run their own call and recall system that has been developed from names and addresses of people with diabetes given to the programme by the practice. Electronic transfer is now being developed and trialled in some practices ■ The practice needs to have a reliable way of informing the screening programme of the names and contact details of people newly diagnosed with diabetes so that they can be called up for screening at the appropriate time ■ People are informed by letter of the dates that the screening programme is visiting the practice and phone in to book their appointment at a time convenient to themselves ■ This letter also contains information about the screening and advice about the effects of the eye drops. It advises people not to drive until their sight returns to normal, so they need to make appropriate transport arrangements ■ To ensure that the visit of the screening team is used most efficiently, practice administration staff can phone people who have not already booked in to try to fill any spare appointments ■ Ensure that those people already attending hospital retinal services are excluded from the invitation list

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■ In some areas the service is provided by a fixed camera system so all people with diabetes from a specific geographical area travel to have screening done at a specific location, often at a diabetes centre or hospital outpatient suite ■ In some areas the service is provided by a mobile camera-based screening programme that visits each practice in an area to do the screening on practice premises

I N F O R MAT ION F OR PRACTICE S TAFF 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 with reception staff, and are given written information about how they will receive their results and about the follow-up procedure ■ A practice nurse or HCA calls the person into a room where they will check the person’s details, including a brief history of any eye problems ■ Visual acuity is checked using a Snellen chart and is recorded for the screener ■ 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 report sent to them and the practice ■ The practice nurse or HCA records that retinal screening has taken place on the practice clinical computer

RETI NA L SC REENI NG | 4 1

H AND L I N G THE R E SULTS F ROM T HE R ETI NA L SC R E E NI NG PROG R AMME ■ Any abnormalities seen on the photograph are graded in accordance with national standards ■ Any people with abnormalities that require laser therapy are referred to the diabetic retinal clinic by the screening service, and information is sent to the practice. In Northern Ireland the onus may be left on the GP to refer as appropriate ■ Those who have no abnormalities on their retinal photographs or those with simple background retinopathy are informed by letter of their results, as is the practice. This information is then recorded and coded by the practice administration staff on the computer. They are informed that they will be recalled for a further screen in 1 year. In Northern Ireland the 1-year interval may be replaced by ‘an agreed time’ ■ Many screening programmes send written information about the results of the screening to the patients themselves and copy this to the practice. They also send copies of referral letters to the practice

V I TA L POI NT S ✱ 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

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6

Foot screening

Diabetes quality indicator 9 (DM9) The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months Minimum threshold = 40% Maximum threshold to earn full available 3 points = 90%

Diabetes quality indicator 10 (DM10) The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months Minimum threshold = 40% Maximum threshold to earn full available 3 points = 90%

BACKGROUND ■ Foot problems in diabetes result from complications such as peripheral vascular disease and neuropathy, which lead to ischaemia and loss of protective pain sensation in the feet ■ Relative ischaemia of the feet may be symptomless, and so people may be at risk without knowing it ■ Diabetic peripheral neuropathy is often symptomless. People often don’t notice the gradual loss of protective pain sensation as neuropathy develops ■ Thus, there are people with diabetes who have risk factors for foot ulceration and amputation of which they are not aware FOOT SC REENI NG | 4 3

■ Unless screening is carried out people may be at risk without knowing it ■ For some people presentation with a foot problem is the first indication of diabetes

I N F O R MAT ION F OR PRACTICE S TAFF Practical tips for examining feet to detect the at-risk-foot ■ Ensure that people with diabetes realise that they will be having an annual foot examination. Tell them to be prepared to take their shoes and socks off ■ Examine the foot for bony abnormalities. The most common are bunions, overriding toes, hallux rigidus and hallux valgus ■ Palpate for the posterior tibial and dorsalis pedis pulses. If they are absent the foot is at-risk ■ Detect the loss of protective pain sensation by using a 10 g nylon monofilament 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 it buckles, which occurs at 10 g of linear pressure when the patient is asked to detect its presence ◆ If it cannot be felt, protective pain sensation is lost and neuropathy is present ■ Record the findings from the foot examination on the diabetes template in the practice clinical computer system to ensure appropriate coding

R ISK FAC TO RS F O R FOOT ULC E R ATI O N ■ Absent foot pulses, indicating ischaemia ■ Loss of protective pain sensation in the feet due to diabetic peripheral neuropathy

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■ The presence of bony abnormalities in the feet ■ The presence of any one of the above risk factors puts a foot ‘at risk’ of ulceration ■ 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 high risk

C AUS E S O F F O OT ULC E R ATI O N ■ Feet that are at-risk due to neuropathy or ischaemia or bony abnormality do not spontaneously ulcerate ■ Minor trauma is usually the additional factor that precipitates ulceration ■ The person with loss of protective pain sensation due to neuropathy may 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

PR E V E NT IO N OF FOOT ULC E R ATI O N There are several ways in which the risk of foot ulceration can be reduced in someone 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 clinic staffed by podiatrists who have a special interest in diabetes.

FOOT SC REENI NG | 4 5

V ITA L POINT ✱ Those who are found to have a foot at risk through screening in primary care should be referred to the local ‘foot-at-risk clinic’ for extra education, assessment, management and follow-up

I N F O R MAT ION F OR PRACTICE S TAFF 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 care of them ■ Advise people to regularly wash and dry their feet and use moisturising cream on areas of dry skin. The use of a foot spa is not usually advised ■ The presence of callus (thickened dead skin) implies that there is excessive pressure in that area, and may indicate that the foot is developing ‘at-risk’ features ■ Nails should be trimmed regularly

AC T I O N TO TA KE F O R NE W F O OT U LCERS A N D /OR C E LLULI TI S O F THE F O OT Most people with diabetes who have to have a limb amputation have a preceding 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

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■ Blood glucose needs to be optimised ■ Appropriate dressings are needed All of these interventions need to be managed by a multidisciplinary footcare team.

V ITA L POINT ✱ All people with diabetes who newly present with a foot ulcer or signs of cellulitis in the foot should be referred immediately to the local multidisciplinary footcare team for assessment and treatment

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7

Good blood pressure control

Diabetes quality indicator 11 (DM11) The percentage of patients with diabetes who have a record 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% Blood pressure control to agreed targets is important in people with diabetes as there is good evidence from the UKPDS study that it reduces the risk of adverse outcomes, particularly stroke and heart attacks. This is reflected in the fact that 21 points are available for this clinical area.

KE Y COM PO N E NTS O F GO O D BLO OD P R E SSUR E M E A SURE M E NT ■ 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 4 8 | VITAL DIABETES MANAGEMENT

WHITE COAT HYPERTENSION ■ Some people have falsely elevated blood pressure readings when they attend hospital (white coat hypertension). The risks of this are probably much less in the practice as this is a more familiar place where their blood pressure is taken by someone they know ■ Where blood pressure readings may be falsely elevated, it is possible for the person to be taught to use an automatic blood pressure recording machine and given one on loan to record blood pressure measurements at home, say two times each day for a couple of weeks ■ These readings can then be compared with surgery-recorded levels and decisions about treatment taken

AU TO M ATE D BLO O D P RE SSURE M E AS U R I NG DE 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 is good practice to check it with a properly calibrated and quality assured mercury device. These mercury devices are the ones that have been used in the vast majority of clinical trials that form the evidence-base for good blood pressure control. There was fear that mercurycontaining devices would be banned under EU health and safety legislation, but this is now no longer the case

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

GO O D BLOOD PRESSURE CONTROL | 4 9

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

DRUG T H E R APY ■ Evidence from trials including the UKPDS suggest that achieving blood pressure reduction to target levels is more important than which individual drug therapy is used ■ After 9 years of follow-up in the UKPDS blood pressure study, 29% of people in the tight control group needed three or more therapies to meet target blood pressure ■ In practice, therefore, many people with type 2 diabetes will not have their blood pressure controlled to target on one therapy alone. This means that the controversy over which is the best agent to use as initial monotherapy is largely irrelevant ■ Angiotensin converting enzyme (ACE) inhibitor drugs (or if not tolerated because of cough, angiotensin receptor blocker (ARB) – sometimes called A2 drugs) should be used first in anyone with microalbuminuria or proteinuria ■ Certain ethnic groups, eg African/Caribbeans, may not respond to ACE inhibitor drugs. Calcium channel blocker agents may be more useful in this population ■ It is known that concordance with therapy decreases with increasing numbers of tablets and increasing dose frequency ■ Combination tablets are therefore helpful to reduce the number of tablets that people need to take ■ Low-dose diuretics augment the antihypertensive effects of other major classes and so diuretic plus ACE inhibitor combinations may help

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I N F O RM AT ION F OR PRACTICE S TAFF: 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

B LOO D P R E SSUR E TA RGE TS Blood pressure targets are given in the NICE type 2 diabetes guidelines (May 2008): ■ Treat blood pressure if lifestyle advice does not reduce blood pressure to below 140/80 mmHg or below 130/80 mmHg in a person with evidence of kidney or eye damage or cerebrovascular disease ■ Monitor blood pressure every 1 or 2 months and intensify therapy if on medication until blood pressure is consistently below 140/80 or 130/80 mmHg in a person with evidence of kidney or eye damage, or cerebrovascular disease ■ In women in whom, after an informed discussion, it is agreed that there is a possibility of pregnancy, first line blood pressure-lowering therapy should be with a calcium channel blocker. This is because ACE inhibitors and ARB2 drugs are thought to cause fetal abnormalities in early pregnancy

V ITA L POINT ✱ Measure blood pressure at each review appointment and if not controlled well treat to agreed goals

GO O D BLOOD PRESSURE CONTROL | 5 1

8

Microalbuminuria and kidney function Diabetes quality indicator 13 (DM13) The percentage of patients with diabetes who have a record 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-converting enzyme (ACE) inhibitors (or ARB (A2) antagonists) Minimum threshold = 40% Maximum threshold to earn maximum 3 points = 80%

Diabetes quality indicator 22 (DM22) The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months Minimum threshold = 40% Maximum threshold to earn maximum 3 points = 90%

■ 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 5 2 | VITAL DIABETES MANAGEMENT

◆

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

■ 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 or frank proteinuria ■ Albustix and Medi-Test Protein 2 are two protein-testing strips that are available in the UK ■ Proteinuria testing is found as part of various branded combination sticks, eg Uristix, Multistix, etc

K I D NE Y D I SE A SE I N DI A BE TE 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 normal and there is variable excretion of only tiny amounts of protein: <30 mg in 24 hours ■ Later, often after 8–10 years of living with diabetes, microalbuminuria may develop. This stage may last for 10 years. People at this stage usually have a normal blood pressure ■ After about 20 or more years of living with diabetes, frank proteinuria may develop ■ This continues on with progressive renal impairment, a rising serum creatinine level, a falling eGFR and hypertension ■ This results in the need for renal replacement therapy (dialysis or transplantation), perhaps after 25–35 years of living with diabetes

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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 will also have hypertension ■ The presence of microalbuminuria is a marker for increased cardiovascular risk ■ Many people with type 2 diabetes and microalbuminuria will die of coronary heart disease before they have time to develop end stage renal disease ■ A lower blood pressure target of 130/80 mmHg is often recommended in guidelines for people with diabetes and microalbuminuria

MI CROAL B U M I NURI A I N HE A LTHY PEOPLE ■ Microalbuminuria can occur in healthy people after they have been standing for a while – this is why tests are done after a period of recumbency, 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 after one positive test) ■ Some clinical computer systems may label someone as having microalbuminuria when a single positive test arrives from the laboratory ■ If the person with diabetes forgets to bring an early morning urine specimen with them they should be given a completed form and urine bottle and asked to drop the specimen in at the surgery as soon as possible ■ Urine tests for microalbuminuria do not need refrigerating as they are stable at room temperature for up to 14 days

5 4 | VITAL DIABETES MANAGEMENT

I N F O R MAT ION F OR PRACTICE S TAFF Detection of microalbuminuria Ask the person with diabetes to bring to their clinic appointment the first 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 tract infection ■ 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 to be repeated in 1 year ■ If an ACR diagnostic of microalbuminuria is found on one occasion it must be repeated within a month ■ If a second test is positive the person is confirmed as having microalbuminuria 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 an ACE inhibitor (or ARB2 if ACE are not tolerated). If they are not on one of these agents they need to be contacted and advised to make an appointment for one to be started

MI C R OALB UMI NURI A A ND KI DNE Y FUNC TI ON | 5 5

N ON-D I AB E TI C C AUSE S O F MI CROAL B U M I NURI A O R P ROTE IN U RIA ■ The microvascular complications of diabetes tend to occur together ■ If microalbuminuria or proteinuria is detected and the person does not have retinopathy, non-diabetic causes of the abnormal protein excretion need to be investigated ■ Such investigations might need to include renal ultrasound and/or referral to nephrology

MI CROAL B U M I NURI A AND HYPERTENSION ■ People with type 1 diabetes who are found to have microalbuminuria often do not have hypertension ■ People with type 2 diabetes who have microalbuminuria often have hypertension ■ There is good evidence that giving an ACE inhibitor to people with type 1 or type 2 diabetes and microalbuminuria can delay or arrest the progression to proteinuria and end stage renal disease ■ An ACE inhibitor is one of the first line agents used to treat hypertension in people with diabetes so many people with type 2 diabetes and microalbuminuria will already be on an ACE inhibitor ■ Where an ACE inhibitor is not tolerated (usually because of cough) an ARB2 or sartan drug should be used. There is evidence of their effectiveness in reducing progression to end stage renal disease in people with diabetes ■ Giving full-dose ACE (or if not tolerated an ARB2) therapy to people with diabetes and microalbuminuria who do not have hypertension does not seem to result in significant hypotension, so it can be safely given

5 6 | VITAL DIABETES MANAGEMENT

CR E AT I NI N E A ND e GF 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 an inaccurate picture of renal function ■ It is possible to have a fairly normal serum creatinine but to have significantly reduced renal function ■ The new measure of eGFR brings added precision to the measurement of 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. They should have this risk assessed and treated in the practice, and not be referred ■ Referral to nephrology services should normally be considered for people with stage 4 CKD who may need preparation for end stage renal failure treatment ■ People found to have CKD stage 5 should be referred as they are likely to need 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 with eGFR of 20 ml/min per 1.73 m2), which does not decline significantly year-on-year. Such people may never need treatment for end-stage renal failure and may therefore not need referring to nephrology

MI C R OALB UMI NURI A A ND KI DNE Y FUNC TI ON | 5 7

■ The presence of CKD stage 3, 4 or 5 indicates someone at increased vascular risk ■ It is important for people with CKD stages 3, 4 or 5 to have good control of blood pressure, and blood glucose and cholesterol levels to reduce this vascular risk

V I TA L POI NT S ✱ Ensure that microalbuminuria is diagnosed properly ✱ Two separate urine samples with ACR diagnostic for microalbuminuria are required

5 8 | VITAL DIABETES MANAGEMENT

9

Cholesterol management

Diabetes quality indicator (DM16) The percentage of patients with diabetes who have a record of total cholesterol level in the previous 15 months Minimum threshold = 40% Maximum threshold to earn full available 3 points = 90%

Diabetes quality indicator (DM17) The percentage of patients with diabetes whose last measured total cholesterol within previous 15 months is ≤5 mmol/l Minimum threshold = 40% Maximum threshold to earn full available 3 points = 70%

■ Cardiovascular risk (CVD) is increased two- to fourfold in type 2 diabetes. Seventy-five per cent of people with type 2 diabetes will die of cardiovascular disease, and life expectancy is reduced by about 10 years by type 2 diabetes ■ There is good evidence that therapy with a statin that reduces total serum cholesterol levels will reduce adverse cardiovascular events

PR AC T I C A L STE P S ■ Measurement of total cholesterol level does not need to be done on a fasting blood test, so it can be ordered together with the other routine blood tests and done 2 weeks before attending the practice diabetes clinic ■ Request a fasting lipid profile test if LDL-cholesterol, HDL-cholesterol and triglyceride levels are needed CHOLESTEROL MANAGEMENT | 5 9

■ There is a good evidence base for the use of either simvastatin 40 mg once daily or atorvastatin 10 mg daily given for primary prevention of cardiovascular 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 to encourage the transfer of people who are on atorvastatin 10 mg to simvastatin 40 mg, as this can save a significant amount of money for the PCT ■ People on atorvastatin 10 mg can be ‘flagged up’ on the practice clinical computer system. After discussion and agreement with the person with diabetes, consideration can be given to changing them to simvastatin 40 mg daily at their next diabetes clinic appointment ■ If simvastatin 40 mg taken once daily does not reduce the total cholesterol 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 tolerated dose of potent statin plus ezetimibe 10 mg daily, referral for further advice may be appropriate ■ People with diabetes who have cardiovascular disease or those at very high risk of cardiovascular disease (eg those with microalbuminuria) should have more aggressive cholesterol-lowering targets to a total cholesterol level ≤4 mmol/l and an LDL-cholesterol level ≤2 mmol/l ■ The NICE 2008 guidelines for type 2 diabetes contains detailed guidance on lipid management (May 2008). It recommends treatment with 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, simvastatin 80 mg daily is recommended, or intensifying treatment with a more effective statin This recommendation is more intensive than the QOF target

6 0 | VITAL DIABETES MANAGEMENT

V I TA L POI NTS ✱ Monitor total cholesterol regularly ✱ Consider giving simvastatin to everyone with type 2 diabetes unless there is a good reason not to ✱ Alter statin medication if the cholesterol target of ≤5 mmol/l is not obtained

CHOLESTEROL MANAGEMENT | 6 1

10

Influenza immunisation

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 immunisation is offered annually to groups considered to be at increased risk. This includes people with diabetes ■ The vaccine is manufactured to try to cover the strains of influenza virus that are likely to be prevalent in the next winter period ■ Consider joining with other practices to buy influenza vaccine in order to obtain bulk purchase discounts ■ Ensure that some of the vaccine is ordered on a sale or return basis just in case all is not used ■ Ensure that the vaccine is ordered early in each year for delivery in the autumn ■ The vaccine should arrive in the practice in early October. It can then be given opportunistically to everyone attending the practice diabetes clinics 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 people considered to be at increased risk to the practice to be vaccinated ■ Assess the need for pneumococcal vaccine and give if necessary

6 2 | VITAL DIABETES MANAGEMENT

I N F O R MAT ION F OR PRACTICE S TAFF Running an influenza immunisation programme ■ Develop a register for call and recall on the practice clinical computer of all people on the practice register considered to be at risk and who should be offered immunisation ■ Send a letter to these individuals from September inviting them to attend for an influenza immunisation ■ Immunisations may be done by practice nurses and other healthcare professionals in special clinics or in normal practice nurse surgery sessions ■ Some practices, especially in areas where many people commute to work, arrange special influenza immunisation clinics in evenings or on Saturday mornings to give more opportunities for people to attend ■ Special arrangements are usually made to immunise those who are housebound or who live in residential or nursing homes. This may involve the community nursing team or immunisation as part of a GP home visit ■ Posters in the waiting room can be used to alert people considered to be at risk to book an appointment ■ Telephone contact may need to be made towards the end of the programme to ensure that as many people as possible who are eligible get invited to attend ■ Once the immunisation is given details need to be recorded on the practice computer system ■ If anyone doesn’t want to have the immunisation this needs to be recorded on the practice computer system using the appropriate Read code ■ There may be a few people with diabetes who have specific allergies that prevent them safely receiving the immunisation. This needs to be recorded on the practice computer system ■ Influenza vaccination clinics at the surgery can be used to gather other data from people with diabetes (eg weight, blood pressure, foot examination or urine test for microalbuminuria) that are missing from their records. Some practices feel that it is a cost-effective use of resources to ensure that sufficient staff time is available to do this

I NFLUENZ A I M M UNI SATI ON | 6 3

11

Depression

Quality indicator DEP1 The percentage of patients on the diabetes register and/or the 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 Minimum threshold = 40% Maximum threshold to earn full available 8 points = 90%

■ The overall prevalence of depression in type 2 diabetes is similar to that observed in other chronic diseases, and is greater than matched populations without diabetes ■ Being diagnosed with diabetes imposes a life-long psychological burden on the person and their family ■ Poor psychological functioning causes suffering, can seriously interfere with daily diabetes self-management, and is associated with poor medical outcomes and high healthcare costs ■ From 2006, as part of the QOF, two screening questions need to be asked annually to everyone with diabetes ■ If oral antidepressant therapy is needed, there is an evidence-base for using 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 weight and increase the risk of developing diabetes

6 4 | VITAL DIABETES MANAGEMENT

S C R E E N I NG Q UE STI O NS ■ 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 the practice computer system ■ A ‘yes’ answer to either question is considered a positive result ■ The concept of screening high-risk groups which include people with diabetes and people with coronary heart disease for depression is from the NICE Clinical Guideline for the management of depression (2004)

I N F O R MAT ION F OR PRACTICE S TAFF 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 as part of the annual diabetes review ■ If a positive response is given to either or both questions it is necessary to consider further assessment and appropriate management. Individual practices need to develop a protocol for this. In some it will require the person booking an appointment to see their usual GP

V I TA L POI NTS ✱ Make sure that the two screening questions for depression are asked and the answers recorded on the practice clinical computer system ✱ If someone is on an atypical anti-psychotic agent and puts on a lot of weight, they should be screened for diabetes

DEPRESSI ON | 6 5

Appendix 1

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

2005/6

2004/5

Denom– inator

Numerator

1,835,480

1,726,599

94.1

90.6

3.5

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

1,870,940

1,821,376

97.4

95.9

1.5

DM4 The percentage of patients with diabetes who smoke and with a record that smoking cessation advice has been offered in the last 15 months

277,317

265,623

95.8

93.2

2.6

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

1,776,415

96.5

94.4

2.1

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

1,034,294

61.8

58.8

3.0

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

1,633,8981

91.5

89.4

2.1

DM8 The percentage of patients with diabetes who have a record of retinal screening in the previous15 months

1,580,830

88.7

83.4

5.3

DM2 The percentage of patients with diabetes with a record of BMI in the previous 15 months

6 6 | VITAL DIABETES MANAGEMENT

1,781,716

Score Score Difference (%) (%) (%)

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

2005/6 Denom– inator

Numerator

2004/5 Score Score Difference (%) (%) (%)

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

1,574,374

88.2

78.9

9.3

DM10 The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months

1,782,667

1,558,411

87.4

77.6

9.8

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

1,840,954

98.2

97.0

1.2

DM12 The percentage of patients with diabetes in whom the last recorded blood pressure is 145/85 mmHg or less

1,753,856

1,313,760

74.9

70.3

4.6

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

1,684,327

1,396,760

82.9

70.9

12.0

DM14 The percentage of patients with diabetes with a record of serum creatinine testing in the previous 15 months

1,857,309

1,777,422

95.7

93.0

2.7

138,292

85.8

82.1

3.7

1,849,405

1,764,280

95.4

92.7

2.7

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

1,345,409

79.0

71.8

7.2

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

1,651,515

1,477,561

89.5

85.2

4.3

Diabetes prevalence (registered)

53,211,253

1,890,663

3.6

3.4

0.2

DM15 The percentage of patients with diabetes 161,211 with proteinuria or microalbuminuria who are treated with ACE inhibitors (or A2 agonists) DM16 The percentage of patients with diabetes with a record of total cholesterol level in the previous 15 months

A PPENDI X 1 | 6 7

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 diabetes mellitus DM19 The practice can produce a register of all patients aged ≥17 years with diabetes mellitus that specifies whether the patient has type 1 or type 2 diabetes

6

Moved to DM19

Moved from DM1

6

Ongoing management DM2 The percentage of patients with diabetes with a record of BMI in the previous 15 months

3

25–90

3

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

3

25–90

Moved to SMOKING

DM4 The percentage of patients with diabetes who smoke and with a record that smoking cessation advice has been offered in the last 15 months

5

25–90

Moved to SMOKING

DM5 The percentage of patients with diabetes with a record of HbA1c or equivalent in the previous 15 months

3

25–90

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

16

25–50

3

40–90

40–90

Moved to DM20

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

17

40–50

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

11

40–90

6 8 | VITAL DIABETES MANAGEMENT

11

25–85

Clinical quality indicators for diabetes from 1 April 2006 (cont’d) Indicator DM8 The percentage of patients with diabetes who have 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

Points Threshold Points Threshold (%) (%) 5

25–90

Moved to DM21

Moved from DM8

5

40–90

DM9 The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months

3

25–90

3

40–90

DM10 The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months

3

25–90

3

40–90

DM11 The percentage of patients with diabetes who have a record of blood pressure in the past 15 months

3

25–90

3

40–90

DM12 The percentage of patients with diabetes in whom the last recorded blood pressure is 145/85 mmHg or less

17

25–55

18

40–60

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

3

25–90

3

40–90

DM14 The percentage of patients with diabetes with a record of serum creatinine testing in the previous 15 months

3

25–90

DM22 The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months

Moved to DM22

Moved from DM14

3

40–90

DM15 The percentage of patients with diabetes with proteinuria or microalbuminuria who are treated with ACE inhibitors (or A2 agonists)

3

25–70

3

40–80

DM16 The percentage of patients with diabetes with a record of total cholesterol level in the previous 15 months

3

25–90

3

40–90

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

6

25–60

6

40–70

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

3

25–85

3

40–85

A PPENDI X 2 | 6 9

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

Points Threshold Points Threshold (%) (%)

Depression: Diagnosis and initial management DEP1 The percentage of patients in the diabetes register and/or the 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*

8

40–90

*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%

7 0 | VITAL DIABETES MANAGEMENT

Appendix 3

Sample practice letter for booking appointments for diabetes review clinics PRIVATE & CONFIDENTIAL Date Name Address Dear —— Your next diabetes review is due in April 2008. We are holding clinics on the following dates and would be grateful if you could phone the surgery to book a convenient time for you to attend. Friday 25 April Monday 28 April Friday 9 May Monday 12 May Friday 16 May Monday 19 May Friday 23 May Friday 30 May

AM PM AM PM AM PM AM 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 clinic appointment on one of the above dates. Please remember to bring with you a urine sample (collected first thing on the morning of your appointment, if possible). I enclose a form for you to have your blood test carried out at least a fortnight before your appointment. This test can be performed either here at the surgery by appointment, or by drop-in at the Hospital Pathology Lab. Yours sincerely, Practice Diabetes Nurses A PPENDI X 3 | 7 1

Appendix 4

Sample practice letter for follow-up of a one positive microalbuminuria result PRIVATE & CONFIDENTIAL Date Name Address Dear —— The result of the urine sample sent to the laboratory recently to test your kidney function has come back raised. As a result, we would like to repeat this test. Enclosed is a form and urine bottle for you to provide an early morning urine sample and either take it to the path lab at the hospital or drop it in our ‘samples box’ at the surgery. If the repeat result is raised again, we will contact you and ask you to make an appointment to see Dr ———. Yours sincerely,

Practice Diabetes Nurses

7 2 | VITAL DIABETES MANAGEMENT

Glossary

ACE inhibitor angiotensin converting enzyme inhibitor. A class of drugs that

lowers blood pressure and protect kidneys. Members of the class have names ending in ‘-pril’ ARB/A2 angiotensin receptor blocker or angiotensin 2 blocker. A class of

drugs that lowers blood pressure and protects the kidney. Members of the class all have names ending in ‘-sartan’ body mass index (BMI) body weight corrected for height expressed as weight in

kilograms/(height in metres)2 CPD continuing professional development diabetes quality indicator (DQI) a process or outcome measure, one of the

clinical indicators for diabetes in the Quality and Outcomes Framework (QOF) estimated glomerular filtration rate (eGFR) a measure of kidney function derived

from a serum creatinine measurement related to age and sex expressed as ml/min per 1.73 m2 glycated haemoglobin (HbA1c) the part of haemoglobin molecule that has

glucose attached to it. It is a test of diabetes control, reflecting the level of glycaemia in the previous 2 or 3 months general practitioner with a special interest (GPSI) a full-time general practitioner

who spends up to 1 day a week working outside their practice in a defined area of clinical practice healthcare assistant (HCA) a person who has been trained to assist a healthcare

professional 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 g

glucose load >7.8 mmol/l and <11.1 mmol/l microalbuminuria the excretion of small amounts of protein in the urine in the

range 30–300 mg/24 hours. It is an indicator of early renal disease G LOSSA RY | 7 3

National Service Framework (NSF) a government initiative designed to improve

the quality of care for people with diabetes. Published in two documents: Part 1 Standards in December 2001 and Part 2 Delivery Strategy in December 2002 NICE National Institute for Health and Clinical Excellence oral glucose tolerance test blood glucose measured fasting and 2 hours after a

75 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 men the normal ratio is less than 2.5 mg/mmol and for women it is less than 3.5 mg/mmol. Ratios greater than these indicate the presence of microalbuminuria proteinuria the excretion of significant amounts of protein in the urine above

300 mg in 24 hours Read code the computer code for diagnosis, treatment and medical process

that underpins GP clinical computing systems self-monitoring of blood glucose (SMBG) testing blood glucose using a meter

and special reagent strips Quality and Outcomes Framework (QOF) the series of clinical indicators

introduced in the new GP contract from April 2004

7 4 | VITAL DIABETES MANAGEMENT

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 effect of intensive treatment on the development and progression of long-term complications in insulin dependent diabetes mellitus. New England Journal of Medicine 329: 977–86 This is the randomised controlled trial that shows that good glycaemic control improves microvascular outcomes in type 1 diabetes United Kingdom Prospective Diabetes Study UKPDS 33 (1998) Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 352: 837–53 This is the randomised controlled trial that shows that good glycaemic control improves outcomes in type 2 diabetes United Kingdom Prospective Diabetes Study UKPDS 34 (1998) Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes. Lancet 352: 854–65 This is a sub-study of UKPDS that shows that initial treatment with metformin in overweight individuals reduces their cardiovascular risk UKPDS Group (1998) Tight blood pressure control and risk of macrovascular and 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 good blood pressure control reduces the risk of adverse outcomes in type 2 diabetes

REFERENC ES | 7 5

Resources

Useful websites www.library.nhs.uk/diabetes The diabetes library of the National Library for Health. This is the NHS webbased library containing high-quality knowledge (mainly guidelines and systematic reviews) about all aspects of diabetes www.diabetes.org.uk The website of Diabetes UK with lots of information for health professionals and people living with diabetes www.diabetes.nhs.uk The website of the National Diabetes Support Team. Information for healthcare professionals about diabetes, especially delivery of care, examples of good care and care planning www.pcdsociety.org The website of the Primary Care Diabetes Society. The aim of the society is to support primary care professionals to deliver high-quality effective care in order to improve the lives of those living with diabetes. Open to all members of primary care, and membership is free www.warwick.ac.uk/go/studydiabetes This site gives details of the healthcare professional training programmes in diabetes provided by Warwick University, including the Certificate in Diabetes Care, Intensive Management in Type 2 Diabetes (insulin initiation programme) and Masters programmes in Diabetes www.nscretinopathy.org.uk This is the website of the national diabetes retinopathy screening committee and contains all the guidance, documents and advice for commissioning and managing retinopathy screening programmes www.dur.ac.uk/ccmd/yoc This is the ‘Year of Care’ website with information about care planning and care plans for people with chronic illness

7 6 | VITAL DIABETES MANAGEMENT

www.yhpho.org.uk The website of the Yorkshire and Humberside Public Health Observatory, the lead observatory for diabetes. It contains a lot of information, including a prevalence model www.ic.nhs.uk/services/qof This website contains all the information and results for the Quality and Outcomes Framework for the UK

Useful books Fox 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 journals Diabetes 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 the previous 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)

RESOURC ES | 7 7

Have you found Vital Diabetes Management useful and practical? If so, you may be interested in other books from Class Publishing. Vital Diabetes £14.99 Dr Charles Fox and Mary MacKinnon This handy reference guide gives you all the backup you need for best practice in diabetes care, and includes all the vital facts and figures about diabetes for your information and regular use, as well as providing patient and carer information sheets that you can photocopy for patients to take away with them. ‘Full of the kind of essential and up-to-date information you need to deliver the best practice in diabetes care.’ M. Carpenter, Diabetes Grapevine Providing Diabetes Care in General Practice

£29.99 Gwen Hall Mary MacKinnon’s classic textbook for the Practice Diabetes Team has been completely revised and updated by one of the leading names in diabetes care today. This new edition takes into account recent developments in service structure and healthcare policy, research, education and much, much more. ‘Gwen Hall is to be congratulated in retaining the spirit of the original, but imbuing it with her own personality. The best just got better. Treasure it.’ Dr Eugene Hughes, Chairman, Primary Care Diabetes Europe

Type 1 Diabetes: Answers at your fingertips Type 2 Diabetes: Answers at your fingertips

£14.99

£14.99 Both by Dr Charles Fox and Dr Anne Kilvert For your patients, and for you. The latest edition of our bestselling reference guide on diabetes has now been split into two books covering the two distinct forms of the disease. These books maintain the popular question and answer format to provide practical advice for patients on every aspect of living with the condition.

Chronic Obstructive Pulmonary Disease in Primary Care £29.99 Dr David Bellamy and Rachel Booker This clear and helpful resource manual addresses the management requirements of GPs and practice nurses. In this book, you will find guidance, protocols, plans and tests – all appropriate to the primary care situation – that will streamline your diagnosis and management of COPD. ‘I am sure it will become a classic in the history of COPD Care.’ Duncan Geddes, Professor of Respiratory Medicine and Consultant Physician, Royal Brompton Hospital

Heart Health: Answers at your fingertips

£14.99 Dr Graham Jackson This practical handbook, written by a leading cardiologist, answers many of your patients’ questions about heart conditions. It gives the reader information about their own health and their heart; how to keep the heart healthy, or – if it has been affected by heart disease – how to make it as strong as possible. ‘Those readers who want to know more about the various treatments for heart disease will be much enlightened.’ Dr James Le Fanu, The Daily Telegraph

Stroke: Answers at your fingertips

£17.99 Dr Anthony Rudd, Penny Irwin and Bridget Penhale This essential guidebook tells you all about strokes – most importantly how to recover from them. As well as providing clear explanations of the medical processes, tests, and treatments, the book is full of practical advice, including recuperation plans. You will find it inspiring.

VITAL BOOK S FOR YOUR P R AC TI CE TE A M The definitive quick reference manuals for all health professionals Armed with these straightforward handbooks, you can treat patients with speed and confidence. Ideal for GPs, practice nurses, specialist nurses, 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 primary care

VI TAL DI ABETE S Dr Charles Fox and Mary MacKinnon

V I TAL DI ABETES MANAG E M E N T Dr Roger Gadsby and Pam Gadsby

VI TAL AS THMA Sue Cross and Dave Burns

VI TAL CKD Dr Rob Higgins

VI TAL NEPHROLO GY Dr Andy Stein, Janet Wild and Dr Paul Cook

VI TAL COPD Rachel Booker

VI TAL LUNG FUNC T IO N Rachel Booker

Priority Order Form 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 812 558 Please 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

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