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: post@class.co.uk
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
Inormation or practice sta:
Protocol to be ollowed at an initial diagnosis o type 2 diabetes 23
Inormation or practice sta:
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
Inormation or practice sta:
The practicalities o running a diabetes clinic 28
Care planning 30
Inormation or practice sta:
Frequency o clinics 31
Inormation or practice sta:Reducing did-not-attend (DNA) rates 32
4 Achieving glycaemia targets 33
Inormation or practice sta:
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
Inormation or practice sta:
Management o special cases 38
5 Retinal screening 39
The rationale 39The method 39
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Inormation or practice sta:
Preparing or the screening team visit 40
Inormation or practice sta:
Running an efcient retinal screening day at the practice 41
Handling the results rom retinal screening programme 42
6 Foot screening 43
Background 43
Inormation or practice sta:
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
Inormation or practice sta:
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
Inormation or practice sta:
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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8 | V I T A L D I A B E T E S M A N A G E M E N T
9 Cholesterol management 59
Practical steps 59
10 Infuenza immunisation 62
Inormation or practice sta:
Running an inuenza immunisation programme 63
11 Depression 64
Screening questions 65
Inormation or practice sta:
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.
T H E C O N T E X T | 13
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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
T H E C O N T E X T | 15
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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
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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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22 | V I T A L D I A B E T E S M A N A G E M E N T
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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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 | 23
INFORMATION FOR PR ACTICE STAFF
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
INFORMATION FOR PR ACTICE STAFF
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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INFORMATION FOR PR ACTICE STAFF
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
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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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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 | 25
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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26 | V I T A L D I A B E T E S M A N A G E M E N T
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
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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
28 | V I T A L D I A B E T E S M A N A G E M E N T
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
INFORMATION FOR PRACTICE STAFF
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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30 | V I T A L D I A B E T E S M A N A G E M E N T
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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INFORMATION FOR PRACTICE STAFF
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%
Diabetes quality indicator 23 (DM23)
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
Minimum threshold = 40%
Maximum threshold to earn the ull 17 available points = 50%
Diabetes quality indicator 24 (DM24)
The percentage o patients with diabetes in whom the last
HbA1c is 8% or less (or the equivalent test/reerence range
depending on local laboratory) in the previous 15 months
Minimum threshold = 40%
Maximum threshold to earn the ull 8 available points = 70%
Diabetes quality indicator 25 (DM25)
The percentage o patients with diabetes in whom the last
HbA1c is 9 % or less (or the equivalent test/reerence range
depending on local laboratory) in the previous 15 months
Minimum threshold = 40%
Maximum threshold to earn the ull 10 available points = 90%
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INFORMATION FOR PR ACTICE STAFF
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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A C H I E V I N G G L YC A E M I A T A R G E T S | 35
INFORMATION FOR PR ACTICE STAFF
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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A C H I E V I N G G L YC A E M I A T A R G E T S | 37
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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38 | V I T A L D I A B E T E S M A N A G E M E N T
INFORMATION FOR PR ACTICE STAFF
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
Diabetes quality indicator 21 (DM21)
The percentage o patients with diabetes who have a record
o retinal screening in the previous 15 months
Minimum threshold = 40%
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
40 | V I T A L D I A B E T E S M A N A G E M E N T
INFORMATION FOR PR ACTICE STAFF
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
INFORMATION FOR PR ACTICE STAFF
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
Diabetes quality indicator 9 (DM9)
The percentage o patients with diabetes with a record o
the presence or absence o peripheral pulses in the previous
15 months
Minimum threshold = 40%
Maximum threshold to earn ull available 3 points = 90%
Diabetes quality indicator 10 (DM10)
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%
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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
44 | V I T A L D I A B E T E S M A N A G E M E N T
INFORMATION FOR PR ACTICE STAFF
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
46 | V I T A L D I A B E T E S M A N A G E M E N T
INFORMATION FOR PR ACTICE STAFF
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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48 | V I T A L D I A B E T E S M A N A G E M E N T
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
Diabetes quality indicator 11 (DM11)
The percentage o patients with diabetes who have a record
o the blood pressure in the past 15 months
Minimum threshold = 40%
Maximum threshold to learn ull 3 available points = 90%
Diabetes quality indicator 12 (DM12)
The percentage o patients with diabetes in whom the blood
pressure is 145/85 or less
Minimum threshold = 40%
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
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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
52 | V I T A L D I A B E T E S M A N A G E M E N T
Microalbuminuriaand kidney unction
8
Diabetes quality indicator 13 (DM13)
The percentage o patients with diabetes who have a record
o microalbuminuria testing in the previous 15 months
(exemption reporting or patients with proteinuria)
Minimum threshold = 40%
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%
Diabetes quality indicator 22 (DM22)
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
Minimum threshold = 40%
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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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 | 55
INFORMATION FOR PR ACTICE STAFF
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
Diabetes quality indicator (DM16)
The percentage o patients with diabetes who have a record
o total cholesterol level in the previous 15 months
Minimum threshold = 40%
Maximum threshold to earn ull available 3 points = 90%
Diabetes quality indicator (DM17)
The percentage o patients with diabetes whose last measured
total cholesterol within previous 15 months is 5 mmol/l
Minimum threshold = 40%
Maximum threshold to earn ull available 3 points = 70%
C H O L E S T E R O L M A N A G E M E N T | 59
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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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62 | V I T A L D I A B E T E S M A N A G E M E N T
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
Diabetes quality indicator 18 (DM18)
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
INFORMATION FOR PR ACTICE STAFF
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
64 | V I T A L D I A B E T E S M A N A G E M E N T
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)
INFORMATION FOR PR ACTICE STAFF
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
top related