Diabetes Mellitus (Diabetes)

This set of indicators refers to patients with both type 1 and type 2 diabetes.

Diabetes - Rationale for Inclusion of Indicator Set
Diabetes mellitus is one of the common endocrine diseases affecting all age groups with over one million people in the UK having the condition. Effective control and monitoring can reduce mortality and morbidity. Much of the management and monitoring of diabetic patients, particularly patients with type 2 diabetes is undertaken by the general practitioner and members of the primary care team.

The indicators for diabetes are based on widely recognised approaches to the care of diabetes. Detailed guidelines for health professionals are published by Diabetes UK (see www.diabetes.org.uk/catalogue/reports.htm), and by SIGN - the Scottish Intercollegiate Guidelines Network (see www.sign.ac.uk/guidelines/published/index.html#Diabetes). The SIGN website contains detailed evidence tables, and links to published articles. The English National Service Framework for Diabetes is available at http://www.doh.gov.uk/nsf/diabetes/ - this site also includes details of the evidence behind a range of recommendations. NICE has also published guidance on a number of aspects of diabetic control (www.nice.nhs.uk).

The indicators for diabetes are generally those which would be expected to be done, or checked in an annual review. There is no requirement on the GP practice to carry out all these items (eg retinal screening), but it is the practice's responsibility to ensure that they have been done.

Rather than including a substantial number of individual indicators, there has been discussion about whether a composite indicator such as "the percentage of diabetic patients who have had an annual check" would suffice. The view taken was that this would not make data collection any easier for GPs, since they would still have to satisfy their PCO at periodic visits that annual checks had included those items recommended in national guidance.

This set of indicators relates to both type 1 and type 2 diabetes. Although the care of patients with type 1 diabetes may be shared with specialists, the general practitioner would still be expected to ensure that appropriate annual checks had been carried out.

Diabetes (DM) Indicator 1
The practice can produce a register of all patients with diabetes mellitus

DM 1.1 Rationale
It is not possible to undertake planned systematic care for patients with diabetes without a register which forms the basis of a recall system, and is needed in order to audit care.

The Quality and Outcomes Framework does not specify how the diagnosis should be made, and a record of the diagnosis will, for the purposes of the contract, be regarded as sufficient evidence of diabetes. However, in addition to the substantial number of undiagnosed patients with diabetes who exist, other patients are treated for diabetes when they do not in fact have the disease. Practices are therefore encouraged to adopt a systematic approach to the diagnosis of diabetes.

The World Health Organisation (WHO) 1999 criteria for the diagnosis of patients with diabetes mellitus are:
· random glucose test: a glucose level above 11.1mmol/l taken at a random time on two occasions is a diagnosis of diabetes.
· fasting glucose test: a glucose level above 7.0mmol/l measured without anything to eat and on two different days is also a diagnosis of diabetes.
· glucose tolerance test: a blood glucose test is taken two hours after a glucose drink is given to the patient. A level above 11.1mmol/l is a diagnosis of diabetes, while a level below 7.8 is normal. However, if the level falls between these values you may have a decreased tolerance for glucose (known as impaired glucose tolerance or IGT).

As the care of children with diabetes mellitus is generally under the control of specialists, the register should exclude those patients age 16 and under. Likewise, the indicators are not intended to apply to patients with gestational diabetes.

DM 1.2 Preferred Coding
Diabetes Mellitus C10%

DM 1.3 Reporting and Verification
Practices should report the number of patients on their diabetic register (age 17 and over) and the number of patients on their diabetic register (age 17 and over) as a proportion of their total list size.

Verification - PCOs may compare the expected prevalence with the reported prevalence.

Diabetes (DM) Indicator 2
The percentage of patients with diabetes whose notes record BMI in the previous 15 months

DM 2.1 Rationale
Weight control in overweight subjects with diabetes is associated with improved glycaemic control. There is little evidence to dictate the frequency of recording but it is general clinical practice that BMI is assessed at least annually.

DM 2.2 Preferred Coding
BMI recorded 22K.

DM 2.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic register who have had a BMI recorded in the last 15 months.

Diabetes (DM) Indicator 3
The percentage of patients with diabetes in whom there is a record of smoking status in the previous 15 months, except those who have never smoked where smoking status should be recorded once

DM 3.1 Rationale
The risk of vascular complications in patients with diabetes is substantially increased. Smoking is an established risk factor for cardiovascular and other diseases.

DM 3.2 Preferred Coding
Never Smoked 1371
Ex-Smoker 137L
Smoker 137R

DM 3.3 Reporting and Verification
The aim of this indicator is to ensure that the smoking status of all patients is known in the previous year, making the assumption that patients who have never smoked will continue not to smoke (in order to avoid keeping asking them).

The numerator of the indicator is the number of patients with diabetes who have never smoked plus the number who have been recorded as ex- or current smokers in the past 15 months. The denominator is the total number of patients with diabetes. Thus:

Diabetes (DM) Indicator 4
The percentage of patients with diabetes who smoke and whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered in the last 15 months

DM 4.1 Rationale
Because vascular risks are so high, regular reminders to patients about smoking are justified. Simple advice to stop smoking given by a doctor, a nurse or a counsellor has a small but significant effect on helping smokers to quit. Health professionals involved in caring for patients with diabetes should advise them not to smoke.

Grade A Recommendation SIGN 55

Further information: http://www.sign.ac.uk/guidelines/fulltext/55/index.html

Smoking cessation services will also help diabetic smokers to quit. A number of studies have recently shown benefits from the prescription of nicotine replacement therapy or buproprion in patients who have indicated a wish to quit smoking. Further guidance is available from NICE.

Further information: http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf

In a significant number of PCOs across the UK specialist smoking cessation clinics are now available. Referral to such clinics, where they are available can be discussed with patients. This should also be recorded as smoking cessation advice.

DM 4.2 Preferred Coding
Smoking Cessation Advice 8CAL

DM 4.3 Reporting and Verification
The practice should report the percentage of patients on the diabetic register who are current smokers who have been offered smoking cessation advice in the last 15 months.

Diabetes Indicator (DM) 5
The percentage of diabetic patients who have a record of HbA1c or equivalent in the previous 15 months

DM 5.1 Rationale
HbA1c is a marker of long-term control of diabetes. Better control leads to fewer complications in both insulin dependent and non-insulin dependent patients with diabetes. There is no trial evidence to support the frequency of HbA1c measurement.

Fructosamine may be used in some areas as an alternative to HbA1c or, for example, in some patients with haemoglobinopathies.

In stable patients with diabetes measurements should be made at six monthly intervals. Measurement should occur more frequently if control is poor or there has been a change in therapy.

Grade D Recommendation NICE Inherited Guideline G

For the purposes of contract monitoring the indicator has been set at a minimal level assuming an HbA1c measurement at least annually.

DM 5.2 Preferred Coding
HbA1c 42W%

DM 5.3 Reporting and Verification
The practice should report the percentage of diabetic patients who have had an HbA1c or equivalent in the previous 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:
1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients with diabetes to look at the proportion with recorded HbA1c in last 15 months
3. Inspection of a sample of records of patients for whom a record of HbA1c is claimed, to see if there is evidence of this in the medical records.

Diabetes (DM) Indicator 6
The percentage of patients with diabetes in whom the last HbA1C is 7.4 or less (or equivalent test/reference range depending on local laboratory) in last 15 months

DM 6.1 Rationale
For each individual a target HbA1c should be set between 6.5% and 7.5% based on the risk of macrovascular and microvascular complications.

Grade B Recommendation NICE Inherited Guideline G

For the purposes of the contract 7.4 (or equivalent) has been selected as an optimal level of control for the purposes of audit and reporting. Where fructosamine is used, for example in patients with haemoglobinopathies, local standards may need to be developed for this indicator.

It is recognised that there may be variations in test availability and in normal ranges in different parts of the UK. If this is the case, the PCO may stipulate a different but equivalent range for this indicator. This issue is discussed in the English NSF (http://www.doh.gov.uk/nsf/diabetes/) under Standards: Supplementary information: Clinical care of adults with diabetes: Monitoring blood glucose control.

DM 6.2 Preferred Coding
HbA1c level numeric value

DM 6.3 Reporting and Verification
The practice should report the percentage of patients on the diabetic register in which the last HbA1c measurement was 7.4 or less. The test must have been carried out in the last 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:
1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of record of patients with diabetes to look at the proportion with last recorded HbA1c 7.4 or less
3. Inspection of a sample of records of patients for whom a record of HbA1c 7.4 or less is claimed, to see if there is evidence of this in the medical records.

Diabetes (DM) Indicator 7
The percentage of patients with diabetes in whom the last HbA1C is 10 or less (or equivalent test/reference range depending on local laboratory) in last 15 months

DM 7.1 Rationale
Reaching optimal levels of control in diabetic patients is difficult. For this reason a second outcome indicator has been introduced to encourage working with patients with high HbA1c to bring the level to 10 or less. Where fructosamine is used, for example in patients with haemoglobinopathies, local standards may need to be developed for this indicator.

It is recognised that there may be variations in test availability and in normal ranges in different parts of the UK. If this is the case, the PCO may stipulate a different but equivalent range for this indicator. This issue is discussed in the English NSF (http://www.doh.gov.uk/nsf/diabetes/) under Standards: Supplementary information: Clinical care of adults with diabetes: Monitoring blood glucose control.

DM 7.2 Preferred Coding
HbA1c level numeric value

DM 7.3 Reporting and Verification
The practice should report the percentage of patients on the diabetic register in which the last HbA1c measurement was ten or less. The test must have been carried out in the last 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:
1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients with diabetes to look at the proportion with last recorded HbA1c 10 or less
3. Inspection of a sample of records of patients for whom a record of HbA1c 10 or less is claimed, to see if there is evidence of this in the medical records.

Diabetes (DM) Indicator 8
The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months

DM 8.1 Rationale
Screening for diabetic retinal disease is effective at detecting unrecognised sight-threatening retinopathy. Systematic annual screening should be provided for all people with diabetes.

Grade B Recommendation SIGN 55

Further information: http://www.sign.ac.uk/guidelines/fulltext/55/index.html

In order to be effective, screening must be carried out by a skilled professional as part of a formal and systematic screening programme to detect sight-threatening diabetic retinopathy. Practices should ensure that the screening received by patients meets national standards (where they exist) or PCO standards otherwise.

DM 8.2 Preferred Coding
Diabetic Retinal Screening 68A7

DM 8.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic register who have had retinal screening performed in the last 15 months.

The PCO may ask for verification of attendance at an approved retinal screening service.

Diabetes (DM) Indicator 9
The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months

DM 9.1 Rationale
Patients with diabetes are at high risk of foot complications. Inspection for vasculopathy and neuropathy is needed to detect problems. Patients with diabetes with foot problems are likely to benefit from referral to specialist diabetic chiropody services. These checks should be carried out at an annual review.

DM 9.2 Preferred Coding
Pulses Right 24E%
Pulses Left 24F%

DM 9.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic register who have a record of the presence or absence of peripheral pulses in the last 15 months.

Diabetes (DM) Indicator 10
The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months

DM 10.1 Rationale
See DM 9.1

The measurement of foot sensation should be carried out as recommended in the SIGN guideline 55 on the Management of Diabetes. Foot sensation should be considered abnormal if monofilament and/or vibration sensation are impaired.

DM 10.2 Preferred Coding
Neurological screening* 68A1

*there is no specific Read code for neuropathy testing.

DM 10.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic register with a record of neuropathy testing in the last 15 months.

Diabetes (DM) Indicator 11
The percentage of patients with diabetes who have a record of the blood pressure in the past 15 months

DM 11.1 Rationale

Cardiovascular disease is the major cause of morbidity and mortality in people with diabetes, and coronary heart disease is the most common cause of death among people with type 2 diabetes. Many people with type 2 diabetes have an increased coronary event risk even if they do not have manifest cardiovascular disease.

Hypertension is associated with an increased risk of many complications of diabetes including cardiovascular disease. Blood pressure should be measured at least annually in patients with diabetes.

Grade D Recommendation NICE Inherited Guideline H

Further information: http://www.nice.org.uk/cat.asp?c=38551

DM 11.2 Preferred Coding
Examination of BP 246.

DM 11.3 Reporting and Verification
Practices should report the percentage of patients on their diabetic register who have a blood pressure recorded in the last 15 months.

Diabetes (DM) Indicator 12
The percentage of patients with diabetes in whom the last blood pressure is 145/85 or less

DM 12.1 Rationale
Blood pressure lowering in people with diabetes reduces the risk of macrovascular and microvascular disease. Hypertension in people with diabetes should be treated aggressively with lifestyle modification and drug therapy.

Grade A Recommendation SIGN 55

Target diastolic in patients with diabetes is less than or equal to 80 mmHg.

Grade A Recommendation SIGN 55

Recommendation British Hypertension Society Guideline 1999

Target systolic in patients with diabetes is less than or equal to 140 mmHg.

Grade D Recommendation SIGN 55

Recommendation British Hypertension Society Guideline 1999

The most commonly identified target level for blood pressure in diabetics is 140/80. This is the level which GPs should aim for. A slightly higher level (145/85) is used as the audit standard in common with other indicators.

Further information: http://www.sign.ac.uk/guidelines/fulltext/55/index.html
Further information: http://www.wellclosesquare.co.uk/protocol/bhsgui/bhsgui.htm

DM 12.2 Preferred Coding
Blood Pressure numeric value

DM 12.3 Reporting and Verification
The practice should report the percentage of patients on the diabetic register in which the last blood pressure measurement was 145/85 or less. The pressure must have been measured in the last 15 months.

Diabetes (DM) Indicator 13
The percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months (exception reporting for patients with proteinuria)

DM 13.1 Rationale
Diabetic patients are at risk of developing nephropathy. Measurements of urinary albumin loss and serum creatinine are the best screening tests for diabetic nephropathy. All patients with diabetes should have their urinary albumin concentration and serum creatinine measured at diagnosis and at regular intervals, usually annually.

Grade D Recommendation SIGN 55

Grade C Recommendation NICE Inherited Guideline F

Further Information: http://www.sign.ac.uk/guidelines/fulltext/55/index.html
Further Information: http://www.nice.org.uk/article.asp?a=27964

Diabetic nephropathy is defined by a raised urinary albumin excretion of greater than 300mg/day (indicating clinical proteinuria). Patients with proteinuria should be separately recorded after urinary tract infection has been excluded.

DM 13.2 Preferred Coding
Micro-albuminuria testing 46W%
Proteinuria 4678

DM 13.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic register who have a record of microalbuminuria testing in the last 15 months and the percentage of patients on the diabetic register who have proteinuria who have not therefore been tested for microalbuminuria.

Diabetes (DM) Indicator 14
The percentage of patients with diabetes who have a record of serum creatinine testing in the previous 15 months

DM 14.1 Rationale
See DM 13.1

DM 14.2 Preferred Coding
Serum Creatinine 44J3%

DM 14.3 Reporting and Verification
The practice should report the percentage of patients on the diabetic register who have a record of serum creatinine in the last 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:
1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients with diabetes to look at the proportion with recorded serum creatinine
3. Inspection of a sample of records of patients for whom a record of serum creatinine is claimed, to see if there is evidence of this in the medical records.

Diabetes (DM) Indicator 15
The percentage of patients with diabetes with proteinuria or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists)

DM 15.1 Rationale
The progression of renal disease in patients with diabetes is slowed by treatment with ACE inhibitors, and trial evidence suggests that these are most effective when given in the maximum dose quoted in the BNF. Although trial evidence is based largely on ACE inhibitors, it is believed that similar benefits occur from treatment with angiotensin II antagonists (A2) in patients who are intolerant of ACE inhibitors.

Patients with microalbuminuria or proteinuria should be commenced on an ACE inhibitor or considered for angiotensin II antagonist therapy.

Grade A Recommendation SIGN 55

Further Information: http://www.sign.ac.uk/guidelines/fulltext/55/index.html

DM 15.2 Preferred Coding
Proteinuria 4678
Micro-albuminuria present 46W0
Prescribed drugs will be picked upon drug search

ACE inhibitors contra indicated 8I28.
A.11 antagonists contraindicated 812H

DM 15.3 Reporting and Verification
Practices should report the number of patients with a prescription for ACE inhibitor or A2 antagonist in last six months as a percentage of patients on the diabetic register who have microalbuminuria or proteinuria.

Diabetes (DM) Indicator 16
The percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months

DM 16.1 Rationale
Vascular disease commonly complicates diabetes. Control of risk factors including serum cholesterol is associated with a reduction in vascular risk.

Grade C Recommendation SIGN Guideline 51

Further Information: http://www.sign.ac.uk/guidelines/fulltext/51/section2.html

It is unclear from the literature how frequently this should be undertaken, but the English NSF recommends annually.

DM 16.2 Preferred Coding
Serum cholesterol 44P%

DM 16.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic register who have had a total cholesterol measured in the last 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:
1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients with diabetes to look at the proportion with recorded serum cholesterol
3. Inspection of a sample of records of patients for whom a record of serum cholesterol is claimed, to see if there is evidence of this in the medical records.

Diabetes (DM) Indicator 17
The percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less

DM 17.1 Rationale
If total cholesterol is greater than 5.0 mmol/l, statin therapy to reduce cholesterol should be initiated and titrated as necessary to reduce total cholesterol to less than 5 mmol/l.

Grade B Recommendation SIGN 55

Further Information: http://www.sign.ac.uk/guidelines/fulltext/55/index.html

DM 17.2 Preferred Coding
Cholesterol Level numeric value

DM 17.3 Reporting and Verification
Practices should report the percentage of patients on the diabetic disease register whose last measured cholesterol was 5mmol/l or less. The measurement should have been carried out in the last 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:
1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients with diabetes to look at the proportion with recorded serum cholesterol less than 5 mmol/l
3. Inspection of a sample of records of patients for whom a record of serum cholesterol is less than 5 mmol/l is claimed, to see if there is evidence of this in the medical records.

Diabetes (DM) Indicator 18
The percentage of patients with diabetes who have a record of influenza immunisation in the preceding 1 September to 31 March

DM 18.1 Rationale
This is a current recommendation from the Departments of Health and the Joint Committee on Vaccination and Immunisation (www.doh.gov.uk/greenbook/).

DM 18.2 Preferred Coding
Flu Vaccination given 65E

Flu vac contra-indicated 8I2F.

DM 18.3 Reporting and Verification
The percentage of patients on the diabetic register who have had an influenza vaccination administered in the preceding 1 September to 31 March.