18922470 vital diabetes management

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DIABETESMANAGEMENT

Your essential reference

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

and

Pam Gadsby RGN

Vital


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DIABETESMANAGEMENT

Vital


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DIABETES

MANAGEMENTYour essential reerence

or managing diabetes in primary care

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

Associate Proessor in Diabetes Care, Warwick University Medical School

and

Pam Gadsby RGNPractice Diabetes Nurse

CLASS HEALTH LONDON

Vital


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Text Roger Gadsby, Pam Gadsby 2009

Class Publishing Ltd 2009

All rights reserved. Without limiting the rights under copyright reservedabove, no part o this publication may be reproduced, stored in or

introduced into a retrieval system, or transmitted, in any orm or by any

means (electronic, mechanical, photocopying, recording or otherwise),

without the prior written permission o the above publisher o this book.

The authors assert their rights as set out in Sections 77 and 78 o the

Copyright Designs and Patents Act 1988 to be identifed as the authors

o this work wherever it is published commercially and whenever any

adaptation o this work is published or produced including any sound

recordings or flms made o or based upon this work.

NOTICE

The inormation presented in this book is accurate and current to the

best o the authors knowledge. The authors and publisher, however,

make no guarantee as to, and assume no responsibility or, the

correctness, sufciency or completeness o such inormation or

recommendation. The reader is advised to consult a doctor regarding all

aspects o individual health care.

Printing historyFirst published 2009

The authors and publisher welcome eedback rom the users o 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 or this book is available rom 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 Woodroe

Printed and bound in Slovenia by Delo Tiskarna

by arrangement with Korotan, Ljubljana


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Introduction 9

Acknowledgements 10

1 The context 11

The Quality and Outcomes Framework 11

Exemption reporting 12Exclusion o individual patients 12

Levels o exemption reporting 13

Income rom the Quality and Outcomes Framework 13

Rewards or high-quality care 13

Locally enhanced service payments 14

Prescribing incentive schemes 14

Intermediate diabetes care 14

General Practitioner with a Special Interest 15Practice-based commissioning 15

Secondary care 16

Relationship with secondary care 16

Handling data rom secondary care 16

Indications or reerral to secondary care 16

Young people with type 1 diabetes 17

2 The practice diabetes register 18The prevalence o diabetes in your practice 18

The accuracy o your practice diabetes register 19

Labelling with type 1 or type 2 diabetes 20

Teenagers with type 2 diabetes 20

Diagnosing diabetes 21

Diagnosing diabetes rom asting glucose level 21

Diagnosing diabetes rom an oral glucose tolerance test 22

Inormation or practice sta:Registry and recall or people with IGT and IFG 22

Contents

C O N T E N T S | 5


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Inormation or practice sta:

Follow-up o people newly diagnosed with diabetes 23


Protocol to be ollowed at an initial diagnosis o type 2 diabetes 23


Suggested requency o sel-monitoring o blood glucose 24Sel-monitoring o blood glucose 24

Prescribing or sel-monitoring o blood glucose 24

Sel-monitoring o blood glucose in people who are newly diagnosed

and on liestyle management only 25

3 The practice diabetes service 26

The stafng o diabetes clinics 26

The GP partner 26The diabetes nurse(s) 26

The healthcare assistant 28


The practicalities o running a diabetes clinic 28

Care planning 30


Frequency o clinics 31

Inormation or practice sta:Reducing did-not-attend (DNA) rates 32

4 Achieving glycaemia targets 33


Practical tips or achieving glycaemia targets 34

Reducing the risk o complications 35

Microvascular disease prevention 35

Macrovascular disease prevention 35Inormation or practice sta:

Initiating insulin therapy 36

Oral anti-obesity therapies 37


Management o special cases 38

5 Retinal screening 39

The rationale 39The method 39

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


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Preparing or the screening team visit 40


Running an efcient retinal screening day at the practice 41

Handling the results rom retinal screening programme 42

6 Foot screening 43

Background 43


Practical tips or examining eet to detect the at-risk-oot 44

Risk actors or oot ulceration 44

Causes o oot ulceration 45

Prevention o oot ulceration 45

Inormation or practice sta:Giving advice to people with normal eet 46

Action to take or new oot ulcers and/or cellulitis o the oot 46

7 Good blood pressure control 48

Key components o good blood pressure measurement 48

White coat hypertension 49

Automated blood pressure measuring devices 49

Controlling hypertension 49Drug therapy 50


Pragmatic therapy action plan 51

Blood pressure targets 51

8 Microalbuminuria and kidney unction 52

Kidney disease in diabetes 53

Type 1 diabetes 53Type 2 diabetes 54

Microalbuminuria in healthy people 54

Points to consider 54


Detection o microalbuminuria 55

Non-diabetic causes o microalbuminuria or proteinuria 56

Microalbuminuria and hypertension 56

Creatinine and eGFR 57

C O N T E N T S | 7


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9 Cholesterol management 59

Practical steps 59

10 Infuenza immunisation 62


Running an inuenza immunisation programme 63

11 Depression 64

Screening questions 65


Practical steps 65

Appendix 1

Clinical indicators or diabetes and scores or 2004/5 and 2005/6 66

Appendix 2

Clinical indicators or diabetes rom 1 April 2006 68

Appendix 3

Sample practice letter or booking appointments or diabetes

review clinics 71

Appendix 4

Sample practice letter or ollow-up o a one positive

microalbuminuria result 72

Glossary 73

Reerences 75

Resources 76

Useul websites 76

Useul books 77

Useul journals 77

Other titles 78

Priority Order Form 80


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Dear Colleagues

Welcome to this edition of Vital Diabetes Management

This book has been written to give practical help to healthcare

proessionals who work in general practice and are involved in deliveringdiabetes care. It brings together the expertise o general practice and

practice diabetes nursing to help practitioners to deliver high-quality

diabetes care and ulfl the requirements o the new GP contract Quality

and Outcomes Framework, ensuring that the maximum income or

diabetes care is obtained.

The book is divided into 11 chapters with topics clearly presented. The

detailed contents list will help you fnd your way around with ease.

Within each topic you will fnd one or more vital points to give youessential inormation in just a ew words. Some chapters also contain

sections on Information for Practice Staffthat can be photocopied and

enlarged or your sta. You will also fnd useul appendices and other

inormation at the end o the book, including sample practice letters, a

glossary, useul addresses, websites and contacts, and reerences and

urther reading. We would welcome your comments or suggestions or

improvements.

Vital Diabetes Management is backed by the wisdom and experience gained

by delivering diabetes care in a large 14,500-patient general practice

or more than 25 years, and rom speaking and writing about diabetes

care over a similar period. We hope that you will fnd this book helpul

or your practice.

Roger Gadsby and Pam Gadsby

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

Introduction


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We would like to pay tribute to Mary MacKinnon or all her support and

encouragement to us over the years. We would like to thank all the partners

and sta o Redroos surgery and all our colleagues who have worked or

Warwick Diabetes Care or their help. We thank Colin Kenny or his helpul

introduction and our editor Caroline Taylor or all her help and expertise in

getting this book to print.

Acknowledgements



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1 The context

T H E C O N T E X T | 11

Over the past 30 years diabetes care has moved rom being seen almost

exclusively as the province o secondary care to one in which virtually all

routine care or people with diabetes occurs in primary care. The new GP

contract that was introduced in April 2004 has provided some fnancial

recompense to support this shit in diabetes care rom primary to secondary

care.

The GP contract lists a series o clinical domains or diabetes covering bothprocess and outcome measures (see appendix 1 on p. 66). They were modifed

rom 2006 onwards to give a possible 93 points or ull achievement o the

diabetes clinical indicator. From 1 April 2009 the previous two clinical

outcome indicators or HbA1c are altered and become three, with an

additional seven points being added, giving a total o 100 points available or

the diabetes clinical indicator set.These modifcations are listed in appendix 2

on p. 68.

THE QUALITY AND OUTCOMES FRAMEWORK

The Quality and Outcomes Framework (QOF) is a payment system, so

some o the clinical standards are dierent rom the targets o national

and international guidelines

It may not be medically appropriate or all people with diabetes to

achieve the desired clinical indicator standards o QOF. For example:

For a rail elderly person to achieve a glycated haemoglobin (HbA1c)level o 7.5% or a blood pressure o 140/80 mmHg to ulfl the QOF

may put them at an unacceptable increased risk o hypoglycaemia or

hypotension

These individuals can be exempted rom the ramework


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EX EM P T IO N R EP O R T ING

Exclusion o individual patients

Exemption reporting allows the practice to exclude individual patients rom

the disease indicators in particular circumstances. These are:

Patients exempted rom the whole clinical area

Patients who have been recorded as reusing to attend a review and

who have been invited on at least three occasions during the

preceding 12 months

Patients or whom it is not appropriate to review the chronic disease

parameters due to specifc circumstances, eg extreme railty, terminal

illness or severe dementia

Patients who do not agree to investigation and treatment (and, ater a

reasonable discussion or written advice, have given their inormed

dissent) and this dissent has been recorded in the medical notes

Patients exempted rom one clinical indicator only (i a valid computer

code Read code is used)

Patients on maximum tolerated doses o medication whose level o

outcome remains suboptimal

Patients or whom prescribing a medication is not clinicallyappropriate, 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, ater a

reasonable discussion or written advice, have given their inormed

dissent) and this dissent has been recorded in the medical notes

Patients who have a supervening condition that makes treatment o

their condition inappropriate, eg cholesterol reduction when thepatient has liver disease

Patients or whom an investigative service or secondary care service

is unavailable

Patients exempted automatically rom any o the indicators by

reporting sotware

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 o clinical



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standards within 9 months, eg blood pressure or cholesterol

measurements within target levels

Levels o exemption reporting

There was a concern that there would be excessive levels o exemption

reporting

Published reports or 2004/5 give overall exemption rates that were

generally low, with a median o 6%

In 2005/6 the median was 4.7% (interquartile range 3.37.0%)

In 2006/7 the median was 5.3%

INCOME FROM THE QUALITY

AND OUTCOMES FRAMEWORK

Points mean prizes! The points that can be achieved rom each clinical

indicator are given in appendices 1 and 2 (p. 66 and p. 68, respectively.

Each point earned is worth a certain amount o money to the practice.

The size o the payment is dependent on:

Practice list size and

Prevalence o diabetes in the practice

A square root ormula is used on the prevalence this has the eect o

reducing potential income or practices with high prevalence rates or

diabetes

For an average-sized practice with an average prevalence o diabetes

each point was worth 75 in the frst year and 125 in the year

2005/6. So or the average practice with average prevalence thetotal income or the QOF or 2005/6 was 99 points each worth

125 = 12,375

REWARDS FOR HIGH-QUALITY CARE

Other structural changes have taken place to reward primary care or

delivering high-quality diabetes care.



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Locally enhanced service payments

These are payments agreed locally by an individual PCT or particular

services delivered by practices in their area

Some practices have negotiated agreements or extra payments or

specifc diabetes services over and above QOF

One o the most common extra payments in diabetes is or initiation

onto insulin in type 2 diabetes

Some Primary Care Trusts (PCTs) or example pay a specifc sum o

100 per patient initiated onto insulin

Prescribing incentive schemes

These schemes reward practices or achieving certain prescribingchanges 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 o switching to the prescribing o generic

simvastatin 40 mg once daily rom more expensive branded atorvastatin

10 mg once daily. A practice may be rewarded or achieving 70 people

on simvastatin 40 mg or those needing a statin or primary prevention

Some PCTs have had schemes to try to reduce the inappropriate

prescribing o blood glucose monitoring strips

Some PCTs have tried to introduce incentives to ration the number o

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 specifc more

complex problems, instead o reerring 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 staed by a Community Diabetes Specialist Nurse, a

Community Dietitian who has a special interest in diabetes, and adoctor



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This doctor is sometimes a Consultant Community Diabetologist or a GP

with a Special Interest in diabetes (GPSI; see below)

These clinics see people reerred rom GPs and usually see them only

once or twice to address specifc problems

They are then returned to their GPs care

General Practitioner with a Special Interest

A GPSI is a ull-time GP who works up to 1 day a week as a GPSI in a

specifc clinical feld

Framework documents or the work o GPSIs are available at

www.doh.gov.uk/pricare/gp-specialinterests

GPSIs in diabetes can ulfl a purely management unction, or exampleoverseeing a diabetes network, or can ulfl a clinical unction, or

example running diabetes clinics in the community

New guidance on accreditation and governance o GPSIs was released

in summer 2007 (details are available at www.doh.gov.uk)

Practice-based commissioning

A diabetes commissioning toolkit can be ound at www.library.nhs.uk/diabetesusing the search acility to look or commissioning toolkit. This gives a

link to the document in pd ormat and this can be downloaded

The toolkit provides advice or all commissioners o diabetes services

and describes how to carry out a needs assessment or a local diabetes

population. It provides a generic specifcation or diabetes care,

signposting recognised quality markers and suggesting key outcomes

or the service

In some parts o the country practice-based commissioning is beingdeveloped, 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 or Health and Clinical Excellence (NICE) has

produced a commissioning guideline or diabetes ootcare based on the

NICE 2004 guideline. It can be ound at www.library.nhs.uk/diabetes (using

search acility or commissioning ootcare). This gives a link to the

document as a pd



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SECONDARY CARE

Relationship with secondary care

Many practices provide routine care or the majority o 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 or 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 or those with specifc problems

Handling data rom 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 ulfl QOF requirements

It is important to ask secondary care colleagues to include all this QOF

relevant inormation in their clinic letters sent to the practice

The practice then needs a protocol to ensure that this data is transerred

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 sta then enter these data, which are

automatically coded to comply with the QOF

Indications or reerral to secondary care

Children and people under the age o 25 years newly diagnosed withdiabetes

Women with diabetes who are contemplating pregnancy or pre-

pregnancy advice and counselling

Women with diabetes who are pregnant need early reerral to a unit

with expertise in managing diabetic pregnancy

People who need to be considered or insulin pump therapy

People newly presenting with diabetic oot ulcers and/or cellulitis otheir eet



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Nephrology assessment services or 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 eel it has the

expertise to manage. I the area has an intermediate diabetes service,these people may be reerred to that service

Young people with type 1 diabetes

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

Some may deault rom ollow-up during teenage years. The practice

will be providing repeat prescriptions or insulin and may be the only

place o contact or people ailing to attend secondary care. Every

attempt needs to be made to try to re-engage them with diabetes careprovision



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Diabetes is more common in lower socio-economic groups, so i your

practice has many patients rom lower socio-economic groups the

practice prevalence is likely to be higher than 3.7%

VITAL P OINT

I the recorded prevalence o diabetes in your practice is

below what would be expected and this cannot be explained by

the mix o your practice population, consider where the

missing people might be

THE ACCURACY OF YOUR

P R AC T IC E D IAB ET ES R EG IS T ER

There may be instances o 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 astingglucose (IFG) wrongly being included in the diabetes register

People with a history o 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 or diabetes were ever made

People diagnosed as having diabetes whilst an inpatient and thediagnosis not being recorded or not being picked up rom a hospital

letter, so they are not added to the practice register

VITAL P OINT

Review and update your diabetes register regularly

T H E P R A C T I C E D I A B E T E S R E G I S T E R | 19


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Labelling with type 1 or type 2 diabetes

For the frst 2 years o 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 codei their notes clearly say they have type 1 diabetes

Record people as having type 2 diabetes using the Read code i their

notes clearly state they have type 2 diabetes

I a patient does not have a clear label o type 1 or type 2 diabetes in

their notes, use the label type 2 unless:

The patient was diagnosed beore the age o 30 years, then label

them as type 1

The patient required insulin within 1 year o diagnosis, then labelthem as type 1

In most practices, more than 90% o people with diabetes will have type

2 diabetes and less than 10% will have type 1 diabetes

VITAL P OINT

I your practice has more than 10% o people labelled ashaving 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 o teenagers diagnosed with

diabetes had type 1 diabetes

Type 2 diabetes is now being diagnosed in very obese children, oten

rom Indo-Asian ethnic backgrounds, who are newly presenting with

diabetes

In the USA today i 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 orms o diabetes that oten present in teenagers

and young adults, such as maturity onset diabetes o the young (MODY)



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VITAL P OINT

Best practice is to always reer someone newly diagnosed

with diabetes


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Plasmaglucose(mmol/l)

11.1

7.8

Diabetesdiagnosed

Impairedglucosetolerancediagnosed

Follow-up advice on healthy eatingand liestyleRepeat in 1 year

Normal

Figure 2.2 Diagnosis o diabetes: plasma glucose 2 hours ater a 75 g glucose load

Diagnosing diabetes rom an oral glucose tolerance test

INFORMATION FOR PR ACTICE STAFF

Registry and recall for people with IGT and IFG

I someone is diagnosed with IGT or IFG the appropriate Read code

needs to e used

Make a register o these people

Women who have had a diagnosis o gestational diabetes can be

added

Recall them all or an annual asting 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 o the patients birthday


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Follow-up of people newly diagnosed with diabetes

The practice needs a protocol or ollowing-up people newly

diagnosed with diabetes Reer them to the partner in charge o diabetes who can perorm

the initial assessment, or

Give them a new-patient appointment in the nurse-managed

diabetes clinic


Protocol to be ollowed at an initial diagnosiso a person with type 2 diabetes

Confrm diagnosis in accordance with the WHO criteria. Arrange

urther blood tests i needed

Ask about the persons knowledge o diabetes and how the

diagnosis has aected them

Give some initial education about the condition, but dont overloadthem at this frst consultation

Give written inormation to consolidate the inormation 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 or

weight reduction i they are obese or overweight

Discuss increasing physical activity to a level appropriate or their

age and physical abilities. The aim is 2030 min o physical activity

per day. Consider reerral to local ftness on prescription programme

i available

Discuss whether they would fnd sel-monitoring o blood glucose

helpul. Arrange or them to be taught how to do this i they want to

Agree a ollow-up consultation and appropriate blood tests to be

done beore that visit


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Suggested requency o sel-monitoringo blood glucose

For people on once daily long-acting insulin: When up-titrating the dose o insulin one asting test daily beore

breakast is needed

Once the insulin dose is stabilised and the HbA1c optimally

controlled, tests will only need to be done when symptoms o

hypoglycaemia are suspected or i 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 beore each meal to help determine

what dose o rapid acting insulin needs to be taken with that meal

Tests need to be done when symptoms o hypoglycaemia are

suspected

For people on sulphonylurea medications:

Tests need to be done i symptoms o hypoglycaemia are

suspected For people who are stable on metormin, thiazolidinediones or

dipeptidyl peptidase-4 (DPP4) inhibitors or combinations o these

agents:

These agents do not cause hypoglycaemia and so no routine

testing is necessary


SELF-MONI TORING OF BLOOD GLUCOSE

Prescribing or sel-monitoring o blood glucose

Sel-monitoring o blood glucose (SMBG) costs the NHS a signifcant amount

o money each year. It is an area where prescribing advisors are keen to see

appropriate prescribing, and may be the subject o a local prescribing initiative.

Agree the appropriate requency o SMBG with that individual

Prescribe the appropriate SMBG stix in the appropriate quantity


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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 ull

SMBG in people who are newly diagnosedand on liestyle management only

Many healthcare proessionals eel that i people newly diagnosed with

type 2 diabetes learn to sel-monitor blood glucose and check their own

levels ater eating and beore and ater exercise, they will learn the

benefts o physical activity and dietary control and become more

empowered than i they did not do SMBG

Once glycaemic control is optimised and their HbA1c is on target there is

no additional beneft o SMBG, and it can be stopped

VITAL POINT S

Ensure that SMBG is being used appropriately by all people

who have diabetes

I SMBG is being done out o 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 signifcantly


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In order to run an efcient chronic disease management diabetes service, and

to maximise the number o QOF points the practice earns or diabetes, most

practices now run dedicated diabetes clinics.

THE STAFFING OF DIABE TES CLINICS

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

Healthcare assistants (HCAs) are increasingly employed to do some o

the routine measurements

The GP partner

Has a responsibility to the whole partnership or providing an excellent

service and achieving ull QOF points or diabetes

Has a special interest and skill in diabetes care. Completion o a

certifcate/diploma course in diabetes care, such as the Certifcate in

Diabetes Care rom the University o Warwick, is one way o

demonstrating this

Keeps up-to-date with diabetes developments through continuing

proessional development (CPD). Being a member o the Primary Care

Diabetes Society is a good way o helping to achieve this (see p. 76)

Demonstrates diabetes CPD undertaken or annual appraisal

Agrees protocols with diabetes clinic sta or smooth running o the

clinics

Ensures that all sta work to keep the practice diabetes register

up-to-date

The diabetes nurse(s)

Has a special interest and skill in diabetes care. Completion o acertifcate/diploma course in diabetes care, such as the Certifcate

The practicediabetes service

3


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T H E P R A C T I C E D I A B E T E S S E R V I C E | 27

in Diabetes Care rom the University o Warwick, is one way o

demonstrating this (see p. 76)

Keeps up-to date with diabetes developments through CPD. Being a

member o the Primary Care Diabetes Society is a good way o 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 ollow-up in the

diabetes clinic (see appendix 3 on p. 71 or sample practice letter or

ollow-up appointments)

Ensures that appropriate numbers o appointments are available each

month or the number o people with diabetes who need to be seen

Supervises the work, support and education o any healthcare assistant

(HCA) working in the diabetes clinic

Liaises with the partner who has responsibility or 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 orm at least 2 weeks

beore their appointment in order that the results can be available in

clinic

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

Ensures that the practice has access to a retinal screening programme

that ulfls national standards and that people with diabetes registered

at the practice receive an annual invitation or screening

Ensures that people with diabetes are asked to bring a frst morning

sample o urine or testing or proteinuria and microalbuminuria

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

Ensures that arrangements are in place or group structured education

or newly diagnosed people with diabetes

Ensures that appropriate one-to-one education is available or people

not wanting group education

Ensures that there is a structure or on-going education o people with

diabetes

Liaises with hospital- and community-based diabetes nurses


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Supplies letters or people with diabetes travelling abroad who need to

take sharps or SMBG and insulin administration through customs

and airport security

VITAL POIN TS

All healthcare proessionals undertaking diabetes work

in the practice need to have had appropriate training

and updating

The practice needs to make provision or 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 specifc local training programmes

HCAs can help the practice diabetes nurse in the diabetes clinic by doing

a number o the routine measurements and recording inormation on

the clinical computer system

These tasks could include measurement o weight, height and bloodpressure, urine dipstick testing, and checking eet


INFORMATION FOR PRACTICE STAFF

The practicalities o running a diabetes clinic

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

Do specifc measurements o weight and height (i 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 liestyle issues such as healthy eating, weight reduction and

physical activity


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T H E P R A C T I C E D I A B E T E S S E R V I C E | 29


The practicalities o running a diabetes clinic(contd)

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

Review blood test results and discuss their implications with the

person with diabetes

Review all medications and any possible side eects. Discuss

compliance with therapy

Discuss alterations and up-titrations o medications needed in the

light o blood test results, weight and blood pressure

Ask about any oot problems and examine as necessary. Examineoot pulses annually and test or neuropathy (see p. 44)

Reer anyone ound to have oot-at-risk to local podiatry oot

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 oer smoking cessation

advice as necessary

Check the urine sample or protein using the appropriate dipstick

and act on the result i positive (see p. 54)

Ensure that a urine sample is sent to the laboratory annually or an

ACR to detect microalbuminuria (see p. 54)

Make a sensitive enquiry about whether any erectile dysunction

issues are bothering the person with diabetes or their partner and

prescribe as necessary

Ask the two specifc questions to screen or depression and recordthe answers on the computer (p. 65). Reer or psychological support

i indicated

Give inuenza and pneumococcal immunisation as necessary (see

p. 63)

Update regular prescriptions

Agree the time o the next ollow-up appointment and set the goals

to be achieved by then


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

Using an HCA to do some o this routine work can enable the practice

diabetes nurse to have more time to spend reviewing the impact o

diabetes on liestyle, concordance and medication issues

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

VITAL POIN TS

Accurate recording o date or ollow-up appointments and

those who did-not-attend (DNA) on the computer template is

necessary to ensure that people do not all 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

qualifcations and expertise to alter and update therapy within guidelines.

In others a doctor may be called in or this work.

C AR E P LANNING

There is a renewed emphasis on care plans and care planning in chronic

disease management consultations. The aim o these plans is to enable the

person with diabetes to set the agenda or their review appointment.

Pilot initiatives are being undertaken in The Year o 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 o care planning are:

Agenda setting. The person with diabetes discussing progress with

the healthcare proessional

Shared decision-making. The person with diabetes and the

healthcare proessional decide what are the most important things to

deal with and talk about

Goal-setting and action-planning. The person with diabetes and

healthcare proessional decide what needs to happen and who does

what. This should be written down


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Reducing did-not-attend (DNA) rates

I people book their clinic appointment 6 months in advance you will

oten fnd that they orget to attend. DNA rates can be signifcantlyreduced by:

Telling people how long it will be until they will need to be seen

again beore 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 or the month in which they need to be seen, 2 months

beore the appointment

Enclosing a repeat blood test orm with that clinic letter

Asking people to telephone the surgery to book themselves into a

clinic at a date and time convenient or them during the month that

their appointment is due

Having a system to note those who ail 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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A C H I E V I N G G L YC A E M I A T A R G E T S | 33

Achievingglycaemia targets

4

Diabetes quality indicator 5 (DM5)

The percentage o patient with diabetes who have a record

o HbA1c or equivalent in the previous 15 months

Minimum threshold = 40%

Maximum threshold to earn ull 3 available points = 90%


The percentage o patients with diabetes in whom the last

HbA1c is 7% or less (or the equivalent test/reerence range

depending on local laboratory) in the previous 15 months


Maximum threshold to earn the ull 17 available points = 50%



HbA1c is 8% or less (or the equivalent test/reerence range






HbA1c is 9 % or less (or the equivalent test/reerence range





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Practical tips or 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 or 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 or 1 lb (0.5 kg) weight loss per week

Remember to stress the importance o physical activity. Most people

can realistically agree to try to walk a mile (1.5 km) a day initially. The

aim is or 30 min o brisk physical activity on fve days a week

Metormin is the initial monotherapy o choice or the majority o

people with type 2 diabetes, with the exception o thin, very

symptomatic people newly diagnosed with type 2 diabetes, who

should be managed dierently (p. 38)

Use 500 mg tablets o metormin twice a day but suggest the person

just takes 500 mg daily or the frst 2 weeks to minimise the risk o

abdominal pain and diarrhoea. Warn about side eects and reassure

patients that they will usually settle

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

Consider a trial o extended absorption metormin where gastro-

intestinal tolerability prevents continuation o metormin therapy

When maximally tolerated dose o metormin does not give optimal

glycaemic control, a sulphonylurea should be the second therapy to

be added or most people

The most commonly prescribed sulphonylurea in the UK is generic

gliclazide, which has over 80% o the sulphonylurea market in the UK

The initial dose is oten 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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Practical tips or achieving glycaemia targets (contd)

When optimal glycaemic control is not obtained with maximal

tolerated doses o metormin plus a sulphonylurea there are a numbero options. Each option may be appropriate or 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 o cardiovascular protection

although rosiglitazone is as eective 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 o the most important aspects o diabetes

care. This is reected in the number o points given to these three clinical

indicators in the QOF. There is good evidence that controlling glycaemia is

associated with reduced risks o complications in both type 1 and type 2

diabetes rom the Diabetes Control and Complications Trial (DCCT) study and

the UK Prospective Diabetes Study (UKPDS) respectively (see p. 75).

REDUCIN G THE RISK OF COMPLICATIONS

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 o developing

microvascular disease or 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 o developing macrovascular

disease


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The target HbA1c or any individual needs to be the subject o a

discussion between the healthcare proessional and the individual, but

most people can saely aim to get their HbA1c to 7.5%

Where attaining a tight HbA1c target is elt, in discussion with the

patient, to be unattainable without signifcant risk o adverse side

eects o glucose-lowering treatments (mainly the risk ohypoglycaemia), consider accepting a HbA1c level >7.5% and

exempting them rom the QOF target (see p. 12)

There is little evidence or the beneft o tight glycaemic control above

the age o 80 years, and there is a signifcant increased risk o alling

and developing increased conusion rom hypoglycaemia in the rail

elderly person with diabetes. Higher HbA1c targets may be thereore

appropriate in the rail elderly, and exemption reporting needed

O R AL ANT I-O B ES IT Y T HER AP 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 eective anti-obesity agent but it can cause

hypertension and tachycardia. This reduces its useulness in people withdiabetes

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

VITAL P OINT

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


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Management o special casesThe newly diagnosed person with type 2 diabetes

who is thin and very symptomatic

The concern is that these individuals have signifcant beta cell

dysunction and could even have slow-onset type 1 diabetes

They oten are active and are eating healthily

They may present with a short history o weight loss, tiredness, thirst

and polyuria

They do not have ketonuria, as i 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 o sulphonylurea every 2 weeks as indicated by

their SMBG readings

Add in metormin i sulphonylurea alone doesnt control their

glycaemia

I glycaemia still is not controlled, consider insulin early I insulin is required within the frst year rom diagnosis, they can be

relabelled as having type 1 diabetes


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THE R ATIONALE

Diabetic retinopathy is the leading cause o blindness in people o

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 eective treatment or diabetic retinopathy

Laser therapy or the treatment o diabetic retinopathy has been shown

to be eective in reducing blindness

Screening or retinopathy is thereore essential, as people may not know

they have it

Cataracts are more common in people with diabetes. They need to be

detected and treated. Reerral or consideration o urgent cataract

extraction is needed when the cataract stops a good view o the retina

T HE M ET HO D

Screening by digital retinal photography is the only approved methodor retinal screening

R E T I N A L S C R E E N I N G | 39

Retinal screening5


The percentage o patients with diabetes who have a record

o retinal screening in the previous 15 months


Maximum threshold to earn ull available 5 points = 90%


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Digital retinal screening must be carried out by an approved screening

service that uses skilled sta, has appropriate internal quality assurance

mechanisms, and conorms to the national specifcations (see

www.nscretinopathy.org.uk). Programmes ideally are o a size to screen

15,00020,000 people with diabetes each year. Each programme

thereore covers more than one PCT. There are at present just over 100retinal screening programmes in the UK

In some areas this service is provided by optometrists



Preparing or the screening team visit

Most screening programmes now run their own call and recall

system that has been developed rom names and addresses o

people with diabetes given to the programme by the practice.

Electronic transer is now being developed and trialled in some

practices

The practice needs to have a reliable way o inorming the screening

programme o the names and contact details o people newly

diagnosed with diabetes so that they can be called up or screening

at the appropriate time

People are inormed by letter o 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 inormation about the screening and advice

about the eects o 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 o the screening team is used most efciently,practice administration sta can phone people who have not

already booked in to try to fll any spare appointments

Ensure that those people already attending hospital retinal services

are excluded rom the invitation list


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R E T I N A L S C R E E N I N G | 41


Running an efcient 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 sta, and are given written inormation about how they

will receive their results and about the ollow-up procedure

A practice nurse or HCA calls the person into a room where they will

check the persons details, including a brie history o any eye

problems

Visual acuity is checked using a Snellen chart and is recorded or the

screener

Mydriatric eye drops (tropicamide 0.5%) are inserted into each eye

The person is asked to wait in the waiting room or about 20 minutes

to ensure that their pupils are ully dilated

The screener calls the people through and takes a digital retinal

photograph o each eye

The screener will usually tell the person i the image appears normal,but will say that the photographs will be checked and a ull report

sent to them and the practice

The practice nurse or HCA records that retinal screening has taken

place on the practice clinical computer

In some areas the service is provided by a fxed camera system so all

people with diabetes rom a specifc geographical area travel to have

screening done at a specifc location, oten 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 thescreening on practice premises


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HANDLIN G THE RE SULTS

F R O M T HE R ET INAL S C R EENING P R O G R AM M E

Any abnormalities seen on the photograph are graded in accordance

with national standards

Any people with abnormalities that require laser therapy are reerred to

the diabetic retinal clinic by the screening service, and inormation is

sent to the practice. In Northern Ireland the onus may be let on the GP

to reer as appropriate

Those who have no abnormalities on their retinal photographs or those

with simple background retinopathy are inormed by letter o their

results, as is the practice. This inormation is then recorded and coded

by the practice administration sta on the computer. They are inormed

that they will be recalled or a urther screen in 1 year. In Northern

Ireland the 1-year interval may be replaced by an agreed time

Many screening programmes send written inormation about the

results o the screening to the patients themselves and copy this to the

practice. They also send copies o reerral letters to the practice

VITAL POIN TS

Retinal screening is vitally important or 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 oered a retinal screening appointment



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BACKGROUND

Foot problems in diabetes result rom complications such as peripheral

vascular disease and neuropathy, which lead to ischaemia and loss o

protective pain sensation in the eet

Relative ischaemia o the eet may be symptomless, and so people may

be at risk without knowing it

Diabetic peripheral neuropathy is oten symptomless. People oten dont

notice the gradual loss o protective pain sensation as neuropathy

develops

Thus, there are people with diabetes who have risk actors or oot

ulceration and amputation o which they are not aware

F O O T S C R E E N I N G | 43

Foot screening6


The percentage o patients with diabetes with a record o

the presence or absence o peripheral pulses in the previous

15 months




The percentage o patients with diabetes with a record o

neuropathy testing in the previous 15 months

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


45/81

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

For some people presentation with a oot problem is the frst indication

o diabetes



Practical tips or examining eet to detect the at-risk-oot

Ensure that people with diabetes realise that they will be having an

annual oot examination. Tell them to be prepared to take their

shoes and socks o

Examine the oot or bony abnormalities. The most common are

bunions, overriding toes, hallux rigidus and hallux valgus

Palpate or the posterior tibial and dorsalis pedis pulses. I they are

absent the oot is at-risk

Detect the loss o protective pain sensation by using a 10 g nylon

monoflament as ollows:

The flament is applied to at least fve sites on the oot (but not

over callus, which is an area o dry, hard, oten fssured skin) until it

buckles, which occurs at 10 g o linear pressure when the patient is

asked to detect its presence I it cannot be elt, protective pain sensation is lost and

neuropathy is present

Record the fndings rom the oot examination on the diabetes

template in the practice clinical computer system to ensure

appropriate coding

RISK FACTORS

FOR FOOT ULCERATION

Absent oot pulses, indicating ischaemia

Loss o protective pain sensation in the eet due to diabetic peripheral

neuropathy


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ACTION TO TAKE FOR NE W FOOT ULCERS

AND/OR CEL LULITIS OF THE FOOT

Most people with diabetes who have to have a limb amputation have a

preceding oot ulcer. Foot ulcers do not inevitably lead to an amputation.

They can be healed. To heal an ulcer:

The ulcer needs to be o-loaded to reduce pressure on it

The ulcer needs to be debrided regularly to remove dead tissue

Inection must be treated

VITAL P OINT

Those who are ound to have a oot at risk through screening

in primary care should be reerred to the local oot-at-risk

clinic or extra education, assessment, management

and ollow-up



Giving advice to people with normal eet

Even when there are no at-risk eatures it is helpul to encourageall people with diabetes to inspect their eet regularly and take care

o them

Advise people to regularly wash and dry their eet and use

moisturising cream on areas o dry skin. The use o a oot spa is not

usually advised

The presence o callus (thickened dead skin) implies that there is

excessive pressure in that area, and may indicate that the oot is

developing at-risk eatures Nails should be trimmed regularly


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Blood glucose needs to be optimised

Appropriate dressings are needed

All o these interventions need to be managed by a multidisciplinary ootcare

team.

VITAL P OINT

All people with diabetes who newly present with a oot ulcer

or signs o cellulitis in the oot should be reerred immediately

to the local multidisciplinary ootcare team or assessment

and treatment

F O O T S C R E E N I N G | 47


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Blood pressure control to agreed targets is important in people with diabetes

as there is good evidence rom the UKPDS study that it reduces the risk o

adverse outcomes, particularly stroke and heart attacks. This is reected in

the act that 21 points are available or this clinical area.

KEY COMPONENTS OF GOOD

BLOOD PRESSURE MEASUREMENT

The person sits at rest or 5 min in quiet surroundings

The dominant arm is supported at heart level

Use an appropriate-sized cu

Use an appropriately calibrated device

Take two separate readings

Record these (and average) to nearest 2 mmHg

Good blood pressurecontrol

7



o the blood pressure in the past 15 months


Maximum threshold to learn ull 3 available points = 90%


The percentage o patients with diabetes in whom the blood

pressure is 145/85 or less


Maximum threshold to gain the ull 18 available points = 60%


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G O O D B L O O D P R E S S U R E C O N T R O L | 49

WHITE COAT HYPERTEN SION

Some people have alsely elevated blood pressure readings when they

attend hospital (white coat hypertension). The risks o this are probably

much less in the practice as this is a more amiliar place where their

blood pressure is taken by someone they know

Where blood pressure readings may be alsely elevated, it is possible or

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 or a couple o weeks

These readings can then be compared with surgery-recorded levels and

decisions about treatment taken

AUTOMATED BLOOD PRESSURE

M EAS U R ING D EV IC ES

Many people now use automated blood pressure measuring devices.

There are a number o possible problems with these including:

Inaccuracy in the presence o any irregularity in the pulse

False high readings when people are aware that the cu is about toinate and then tense themselves up in anticipation

I 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 o clinical trials that orm the evidence-base

or good blood pressure control. There was ear that mercury-

containing devices would be banned under EU health and saety

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 o liestyle change beore rushing into

blood pressure-lowering drugs when the persons blood pressure is only

slightly raised


51/81

I liestyle change doesnt reduce blood pressure to target or it is so ar

above target that liestyle change will not normalise it, then drug

therapy needs to be started

DRUG THERAPY

Evidence rom trials including the UKPDS suggest that achieving blood

pressure reduction to target levels is more important than which

individual drug therapy is used

Ater 9 years o ollow-up in the UKPDS blood pressure study, 29% o

people in the tight control group needed three or more therapies to meet

target blood pressure

In practice, thereore, many people with type 2 diabetes will not havetheir 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 i not

tolerated because o cough, angiotensin receptor blocker (ARB)

sometimes called A2 drugs) should be used frst in anyone with

microalbuminuria or proteinuria

Certain ethnic groups, eg Arican/Caribbeans, may not respond to ACEinhibitor drugs. Calcium channel blocker agents may be more useul in

this population

It is known that concordance with therapy decreases with increasing

numbers o tablets and increasing dose requency

Combination tablets are thereore helpul to reduce the number o

tablets that people need to take

Low-dose diuretics augment the antihypertensive eects o other majorclasses and so diuretic plus ACE inhibitor combinations may help



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BLOOD PRESS URE TARGETS

Blood pressure targets are given in the NICE type 2 diabetes guidelines (May

2008):

Treat blood pressure i liestyle advice does not reduce blood pressure to

below 140/80 mmHg or below 130/80 mmHg in a person with

evidence o kidney or eye damage or cerebrovascular disease

Monitor blood pressure every 1 or 2 months and intensiy therapy i onmedication until blood pressure is consistently below 140/80 or

130/80 mmHg in a person with evidence o kidney or eye damage, or

cerebrovascular disease

In women in whom, ater an inormed discussion, it is agreed that there

is a possibility o pregnancy, frst line blood pressure-lowering therapy

should be with a calcium channel blocker. This is because ACE

inhibitors and ARB2 drugs are thought to cause etal abnormalities in

early pregnancy

VITAL P OINT

Measure blood pressure at each review appointment and i

not controlled well treat to agreed goals

G O O D B L O O D P R E S S U R E C O N T R O L | 51

INFORMATION FOR PRACTICE STAFF:

Pragmatic therapy action plan

Step 1: ACE inhibitor (or i 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


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Microalbuminuria is defned as:

The leakage into the urine o small amounts o protein in the range

30300 mg in 24 hours

It can be detected by specifc test strip (Micral-Test) that is dipped intothe urine. The urine will be negative to normal protein dipsticks


Microalbuminuriaand kidney unction

8



o microalbuminuria testing in the previous 15 months

(exemption reporting or patients with proteinuria)


Maximum threshold to earn maximum 3 points = 90%

Diabetes quality indicator (DM15)

The percentage o 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%


The percentage o patients with diabetes who have a record o

estimated glomerular fltration rate (eGFR) or serum creatinine

testing in the previous 15 months


Maximum threshold to earn maximum 3 points = 90%


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M I C R O A L B U M I N U R I A A N D K I D N E Y F U N C T I O N | 53

It can be detected in a urine sample sent to a laboratory or the

detection o the albumin:creatinine ratio (ACR). A ratio

>2.5 mg/mmol or men and >3.5 mg/mmol or women indicates

microalbuminuria

Proteinuria is defned as:

The leakage into the urine o protein o 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

rank proteinuria

Albustix and Medi-Test Protein 2 are two protein-testing strips that are

available in the UK

Proteinuria testing is ound as part o various branded combination

sticks, eg Uristix, Multistix, etc

K ID NEY D IS EAS E IN D IAB ET ES

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 frst ew years o living with diabetes, kidney unction is normal

and there is variable excretion o only tiny amounts o protein:


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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 o microalbuminuria is a marker or increased

cardiovascular risk

Many people with type 2 diabetes and microalbuminuria will die o

coronary heart disease beore they have time to develop end stage renal

disease

A lower blood pressure target o 130/80 mmHg is oten recommended

in guidelines or people with diabetes and microalbuminuria

MICROALBUMINU RIA IN HEA LTHY PEOPLE

Microalbuminuria can occur in healthy people ater they have been

standing or a while this is why tests are done ater a period o

recumbency, usually ater sleep

Microalbuminuria can occur ater exercise or during a ebrile illness

Points to consider

One positive test or microalbuminuria does not mean

microalbuminuria has been confrmed as two positive tests are required

(see appendix 4 on p. 72 or standard practice letter to recall people ater

one positive test)

Some clinical computer systems may label someone as having

microalbuminuria when a single positive test arrives rom thelaboratory

I the person with diabetes orgets to bring an early morning urine

specimen with them they should be given a completed orm and urine

bottle and asked to drop the specimen in at the surgery as soon as

possible

Urine tests or microalbuminuria do not need rerigerating as they are

stable at room temperature or up to 14 days



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Detection o microalbuminuria

Ask the person with diabetes to bring to their clinic appointment the

frst urine sample o the day, ater they have got up ater sleeping Use a dipstick to check or proteinuria

I positive, check or leucocytes and other signs o inection, send o

a mid-stream urine specimen i indicated, and treat any urinary tract

inection

I negative, send urine to laboratory or determination o ACR

An ACR >2.5 mg/mmol or men and >3.5 mg/mmol or women

indicates microalbuminuria

I the ACR is


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NO N-D IAB ET IC C AU S ES O F

MICROALBUMINURIA OR PROTEINURIA

The microvascular complications o diabetes tend to occur together

I microalbuminuria or proteinuria is detected and the person does not

have retinopathy, non-diabetic causes o the abnormal protein

excretion need to be investigated

Such investigations might need to include renal ultrasound and/or

reerral to nephrology

M IC R O ALB U M INU R IA

AND HYPERTENSION

People with type 1 diabetes who are ound to have microalbuminuria

oten do not have hypertension

People with type 2 diabetes who have microalbuminuria oten have

hypertension

There is good evidence that giving an ACE inhibitor to people with type1 or type 2 diabetes and microalbuminuria can delay or arrest the

progression to proteinuria and end stage renal disease

An ACE inhibitor is one o the frst 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 o cough) an

ARB2 or sartan drug should be used. There is evidence o their

eectiveness in reducing progression to end stage renal disease inpeople with diabetes

Giving ull-dose ACE (or i not tolerated an ARB2) therapy to people

with diabetes and microalbuminuria who do not have hypertension

does not seem to result in signifcant hypotension, so it can be saely

given



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CREATININE AND eGFR

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

eGFR is calculated rom the age, sex and serum creatinine level

It was introduced because the serum creatinine level alone may give aninaccurate picture o renal unction

It is possible to have a airly normal serum creatinine but to have

signifcantly reduced renal unction

The new measure o eGFR brings added precision to the measurement

o renal unction

eGFR is used to classiy CKD into fve stages as ollows:

eGFR (ml/min per 1.73m2) CKD stage

90 1

6089 2

3059 3

1529 4

70 years may have less utility.

Some older people may have low but stable renal unction (eg with

eGFR o 20 ml/min per 1.73 m2), which does not decline signifcantly

year-on-year. Such people may never need treatment or end-stage renal

ailure and may thereore not need reerring to nephrology



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Cardiovascular risk (CVD) is increased two- to ourold in type 2

diabetes. Seventy-fve per cent o people with type 2 diabetes will die

o cardiovascular disease, and lie 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

P R AC T IC AL S T EP S

Measurement o total cholesterol level does not need to be done on a

asting blood test, so it can be ordered together with the other routine

blood tests and done 2 weeks beore attending the practice diabetes

clinic

Request a asting lipid profle test i LDL-cholesterol, HDL-cholesteroland triglyceride levels are needed

Cholesterol management9



o total cholesterol level in the previous 15 months




The percentage o patients with diabetes whose last measured

total cholesterol within previous 15 months is 5 mmol/l



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There is a good evidence base or the use o either simvastatin 40 mg

once daily or atorvastatin 10 mg daily given or primary prevention o

cardiovascular disease or people with type 2 diabetes

Simvastatin has come o-patent so is much cheaper than atorvastatin

Many PCTs have a prescribing incentive scheme in operation toencourage the transer o people who are on atorvastatin 10 mg to

simvastatin 40 mg, as this can save a signifcant amount o money or

the PCT

People on atorvastatin 10 mg can be agged up on the practice clinical

computer system. Ater 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

I simvastatin 40 mg taken once daily does not reduce the totalcholesterol to 5 mmol/l:

the dose o 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

I the total cholesterol level is not 5 mmol/l on maximum tolerated

dose o potent statin plus ezetimibe 10 mg daily, reerral or urther

advice may be appropriate

People with diabetes who have cardiovascular disease or those at very

high risk o 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 or 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 o achieving a total cholesterol level o

4 mmol and an LDL-cholesterol level o 2 mmol/l

I simvastatin 40 mg daily does nt achieve these targets, simvastatin

80 mg daily is recommended, or intensiying treatment with a more

eective statin

This recommendation is more intensive than the QOF target



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VITAL POINT S

Monitor total cholesterol regularly

Consider giving simvastatin to everyone with type 2

diabetes unless there is a good reason not to

Alter statin medication i the cholesterol target o 5

mmol/l is not obtained

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Inuenza immunisation is oered annually to groups considered to be

at increased risk. This includes people with diabetes

The vaccine is manuactured to try to cover the strains o inuenza

virus that are likely to be prevalent in the next winter period

Consider joining with other practices to buy inuenza vaccine in order

to obtain bulk purchase discounts

Ensure that some o 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 or 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 diabetesclinics and normal surgeries in October through to December

Unortunately this will only cover a small proportion o those at risk.

The practice thereore needs to develop a strategy to invite people

considered to be at increased risk to the practice to be vaccinated

Assess the need or pneumococcal vaccine and give i necessary


The percentage o patients with diabetes who have had

an inuenza immunisation in the preceding 1 September

to 31 March

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

Infuenza immunisation10


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I N F L U E N Z A I M M U N I S A T I O N | 63


Running an inluenza immunisation programme

Develop a register or call and recall on the practice clinical

computer o all people on the practice register considered to be atrisk and who should be oered immunisation

Send a letter to these individuals rom September inviting them to

attend or an inuenza immunisation

Immunisations may be done by practice nurses and other healthcare

proessionals in special clinics or in normal practice nurse surgery

sessions

Some practices, especially in areas where many people commute to

work, arrange special inuenza immunisation clinics in evenings oron Saturday mornings to give more opportunities or 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 o 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 o 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

I anyone doesnt want to have the immunisation this needs to be

recorded on the practice computer system using the appropriate

Read code There may be a ew people with diabetes who have specifc allergies

that prevent them saely receiving the immunisation. This needs to

be recorded on the practice computer system

Inuenza vaccination clinics at the surgery can be used to gather

other data rom people with diabetes (eg weight, blood pressure,

oot examination or urine test or microalbuminuria) that are missing

rom their records. Some practices eel that it is a cost-eective use

o resources to ensure that sufcient sta time is available to do this


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The overall prevalence o 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 lie-long psychological burden

on the person and their amily Poor psychological unctioning causes suering, can seriously interere

with daily diabetes sel-management, and is associated with poor

medical outcomes and high healthcare costs

From 2006, as part o the QOF, two screening questions need to be

asked annually to everyone with diabetes

I oral antidepressant therapy is needed, there is an evidence-base or

using uoxetine 20 mg once daily in people with diabetes

Depression and psychiatric morbidity are risk actors or diabetes

Some atypical anti-psychotic medications cause an increase in weight

and increase the risk o developing diabetes


Quality indicator DEP1

The percentage o patients on the diabetes register and/or the

coronary heart disease register or whom case fnding or

depression has been undertaken on one occasion during the

previous 15 months using two standard screening questions

Minimum threshold = 40%Maximum threshold to earn ull available 8 points = 90%

Depression11


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D E P R E S S I O N | 65

S C R EENING Q U ES T IO NS

The two standard screening questions or depression are:

During the last month, have you oten been bothered by eeling

down, depressed or hopeless?

During the last month have you oten 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 o screening high-risk groups which include people with

diabetes and people with coronary heart disease or depression is rom

the NICE Clinical Guideline or the management o depression (2004)


Practical steps

Ask the two screening questions annually in the practice

It is likely that in most practices the practice nurse running thediabetes clinic will be the most appropriate person to ask them as

part o the annual diabetes review

I a positive response is given to either or both questions it is

necessary to consider urther assessment and appropriate

management. Individual practices need to develop a protocol or

this. In some it will require the person booking an appointment to

see their usual GP

VITAL POINT S

Make sure that the two screening questions or depression

are asked and the answers recorded on the practice clinical

computer system

I someone is on an atypical anti-psychotic agent and puts

on a lot o weight, they should be screened or diabetes


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A P P E N D I X 1 | 67

Clinical quality indicators or diabetes and scores (contd)

Quality indicator 2005/6 2004/5

Denom Numer- Score Score Difference

inator ator (%) (%) (%)

DM9 The percentage of patients with diabetes 1,785,322 1,574,374 88.2 78.9 9.3with a record of the presence or absence of

peripheral pulses in the previous 15 months

DM10 The percentage of patients with dia

18922470 vital diabetes management

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