Audit of diabetes care

See also the separate articles Audit and Audit Cycle, Management of Type 1 Diabetes and Management of Type 2 Diabetes.

National Diabetes Audit^{1 2}

The National Diabetes Audit (NDA) is a major national clinical audit, which measures the effectiveness of diabetes healthcare against the NICE Clinical Guidelines and NICE Quality Standards in England and Wales.

The NDA is delivered by NHS England, in partnership with Diabetes UK. It collects and analyses data and produces reports for a range of stakeholders to use to drive changes and improve the quality of services and health outcomes for people with diabetes.

Practice audits in diabetes

Diabetes audits have been shown to improve diabetes care in the primary care setting.³ Audits of diabetes care can include:

• Structures: eg, practice register (is the known and registered prevalence in line with expectations in terms of local prevalence, adjusted for age and ethnic patient profile).

• Patient satisfaction surveys.

• Processes: eg, failure to attend rates for diabetes clinic, reviews up to date (eg, annual practice clinic review, retinal screening, other specific aspects such as blood pressure, HbA1c or full foot review).

• Outcomes: eg, levels of blood pressure, HbA1c, frequency of hypoglycaemic episodes.

Criteria:

• Criteria which are specific and directly related to the process of patient care (such as those in the GMS contract) are much easier to interpret and act upon.

• More qualitative aspects such as patient knowledge and confidence are much harder to define and assess.

• Less common outcomes such as amputations and renal failure cannot be interpreted in the practice setting as numbers are far too small, but these outcomes are very important for evaluation at district and regional level in order to plan and provide effective diabetes services locally and nationally.

Quality and Outcomes Framework guidance for 2023/24

The NHS England QOF indicators for 2023/24 for diabetes are:

• DM017. The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed. 6 points.

• DM006. The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs). 3 points; threshold 57–97%.

• DM012. The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months. 4 points; threshold 50–90%.

• DM014. The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register. 11 points; threshold 40–90%.

• DM033. The percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less (or equivalent home blood pressure reading). 10 points; threshold 38-78%.

• DM020. The percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months. 17 points; threshold 35-75%.

• DM021. The percentage of patients with diabetes, on the register, with moderate or severe frailty in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months. 10 points; threshold 52-92%.

• DM022. The percentage of patients with diabetes aged 40 years and over, with no history of cardiovascular disease and without moderate or severe frailty, who are currently treated with a statin (excluding patients with type 2 diabetes and a CVD risk score of <10% recorded in the preceding 3 years). 4 points; threshold 50-90%.

• DM023. The percentage of patients with diabetes and a history of cardiovascular disease (excluding haemorrhagic stroke) who are currently treated with a statin. 2 points; threshold 50-90%.

NICE audit guidance for type 2 diabetes

The following are examples of the audit criteria for type 2 diabetes recommended by the National Institute for Health and Care Excellence (NICE). For further details, see the 'Tools and resources' section of the NICE guideline for type 2 diabetes.⁴

Blood glucose control

• The individual's HbA1c levels should be measured at:
  

  • 2-6-monthly intervals until the blood glucose level is stable on unchanging therapy.

  • 6-monthly intervals once the blood glucose level and blood glucose-lowering therapy are stable.

• Metformin:
  

  • Metformin treatment should be started in a person who is overweight or obese, and whose blood glucose is inadequately controlled by lifestyle interventions (nutrition and exercise) alone.

  • Metformin should be stopped if the serum creatinine exceeds 150 μmol/L or the estimated glomerular filtration rate (eGFR) is below 30 ml/minute/1.73-m².

• Sulfonylureas:
  

  • A sulfonylurea should be added as second-line therapy when blood glucose control remains or becomes inadequate with metformin.

• Thiazolidinediones should not be prescribed to people who have evidence of heart failure or who are at higher risk of fracture.

• Exenatide:
  

  • Exenatide should not be used routinely in type 2 diabetes.

• Acarbose should only be prescribed for people unable to use other glucose-lowering medications.

• Insulin therapy:
  

  • When starting basal insulin therapy:
    

    • Continue with metformin and the sulfonylurea (and acarbose, if used).

  • Pioglitazone should be combined with insulin therapy only for:
    

    • A person who has previously had a marked glucose-lowering response to thiazolidinedione therapy.

    • A person on high-dose insulin therapy whose blood glucose is inadequately controlled.

Cardiovascular risk

• Blood pressure should be measured at least annually in a person without previously diagnosed hypertension or renal disease.

• If a person is not hypertensive, does not have renal disease and their blood pressure is over the target, the measurement should be repeated at the following intervals:
  

  • Within 1 month if >150/90 mm Hg.

  • Within 2 months if >140/80 mm Hg.

  • Within 2 months if >130/80 mm Hg and kidney, eye or cerebrovascular damage.

• A blood pressure target of <140/80 mm Hg should be set.

• A full lipid profile, including high-density lipoprotein (HDL) cholesterol and triglyceride estimations, should be performed:
  

  • When assessing cardiovascular risk after diagnosis.

  • Annually.

  • Before starting lipid-modifying therapy.

• People should be receiving low-dose daily aspirin if they are:
  

  • Aged 50 or over with blood pressure under 145/90 mm Hg; or

  • Aged under 50 with significant cardiovascular risk factors.

• Clopidogrel should only be prescribed to people with a clear aspirin intolerance.

Other diabetes complications

• The following should be carried out annually:
  

  • Albumin:creatinine ratio (ACR) estimation on first-pass urine sample or spot sample if necessary.

  • Serum creatinine measurement.

  • Estimated glomerular filtration rate.

• Eye screening should be performed at or around the time of diagnosis.

• Eye screening should be repeated at least annually.

• Neuropathic symptoms should be recorded annually.

NICE audit guidance for type 1 diabetes

The following are examples of the audit criteria for type 1 diabetes recommended by NICE. For further details, see the 'Tools and resources' section of the NICE guideline for type 2 diabetes.⁵

Children and young people

• A child or young person with type 1 diabetes has it documented in their notes that they have been offered testing of their HbA1c levels two to four times per year.

• A child or young person with type 1 diabetes has it documented in their notes that an offer of a coeliac disease test at diagnosis and at least every 3 years has been made.

• A child or young person with type 1 diabetes has it documented in their notes that an offer of a thyroid disease test at diagnosis and every year subsequently has been made.

• A child or young person with type 1 diabetes has it documented in their notes that an offer of a retinopathy test every year from the age of 12 years has been made.

• A child or young person with type 1 diabetes has it documented in their notes that an offer of a microalbuminuria test every year from the age of 12 years has been made.

• A child or young person with type 1 diabetes has it documented in their notes that an offer of blood pressure measurement every year from the age of 12 years has been made.

Adults

• The medical record should note those with type 1 diabetes diagnosed longer than 1 year who have HbA1c 7.5% or above recorded at last annual review or if no annual review within 12 months.

• Patient records should note episodes of severe hypoglycaemia.

• The medical record should give a structured record of assessment of arterial risk factors (including microalbuminuria, metabolic syndrome, abnormal lipid profile, raised blood pressure, smoking.

• The medical records should demonstrate a plan for management, where microalbuminuria diagnosed, smoker, low-density lipoprotein (LDL) cholesterol >2.6 mmol/L, triglycerides >2.3 mmol/L, systolic or diastolic blood pressure >135/85 mm Hg, and change in first-degree family history of arterial events, or any previous personal arterial event or history.

• Medical record of adults with type 1 diabetes should record assessments of eye, kidney, nerve, foot and arterial damage (all these) within the past 14 months.

• Where evidence of eye, nerve, kidney or arterial damage is found, evidence of a plan for management of the condition within the medical record.

Outcome measures

• Prevalence of diabetes retinal damage in adults with type 1 diabetes.

• Prevalence of abnormality of monofilament sensory detection in adults with type 1 diabetes.

• Prevalence of abnormality of albumin excretion rate or serum creatinine.

• Prevalence of absence of both pulses in at least one foot in adults with type 1 diabetes.

• Prevalence of symptomatic angina in adults with type 1 diabetes.

• Prevalence of claudication in adults with type 1 diabetes.