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Practice audits in diabetes
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 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.
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 use the link in 'Further reading & references' at the end of this article.
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 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.
- 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 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.
- When starting basal insulin therapy:
- 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.
- 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 use the link in 'Further reading & references' at the end of this article. The recommended audit criteria can be found in Appendix D at the end of NICE guideline for type 1 diabetes).
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.
- 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.
- 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.
DiabetesE is a web-based, self-assessment tool that enables primary healthcare teams and specialist teams to assess the structures and processes of the diabetes services they provide.
Further reading and references
Standards for diabetes care; National service frameworks and strategies, NHS Choices
Principles for Best Practice in Clinical Audit; NICE, 2002
Diagnosis and management of type 1 diabetes in children, young people and adults; NICE Clinical Guideline (July 2004)