Vital Diabetes Management

Vital

DIABETES MANAGEMENT Your essential reference for diabetes management in primary care Roger Gadsby MB, ChB, DCH, DRCOG, FRCGP and

Pam Gadsby RGN

Vital

DIABETES MANAGEMENT

Vital

DIABETES MANAGEMENT Your essential reference for managing diabetes in primary care Roger Gadsby MB, ChB, DCH, DRCOG, FRCGP General Practitioner with a Special Interest in Diabetes Associate Professor in Diabetes Care, Warwick University Medical School and

Pam Gadsby RGN Practice Diabetes Nurse

CLASS HEALTH • LONDON

Text © Roger Gadsby, Pam Gadsby 2009 © Class Publishing Ltd 2009 All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of the above publisher of this book. The authors assert their rights as set out in Sections 77 and 78 of the Copyright Designs and Patents Act 1988 to be identified as the authors of this work wherever it is published commercially and whenever any adaptation of this work is published or produced including any sound recordings or films made of or based upon this work. NOTICE The information presented in this book is accurate and current to the best of the authors’ knowledge. The authors and publisher, however, make no guarantee as to, and assume no responsibility for, the correctness, sufficiency or completeness of such information or recommendation. The reader is advised to consult a doctor regarding all aspects of individual health care. Printing history First published 2009 The authors and publisher welcome feedback from the users of 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 for this book is available from 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 Woodroffe Printed and bound in Slovenia by Delo Tiskarna by arrangement with Korotan, Ljubljana

Contents

Introduction Acknowledgements

9 10

1 The context The Quality and Outcomes Framework Exemption reporting Exclusion of individual patients Levels of exemption reporting Income from the Quality and Outcomes Framework Rewards for high-quality care Locally enhanced service payments Prescribing incentive schemes Intermediate diabetes care General Practitioner with a Special Interest Practice-based commissioning Secondary care Relationship with secondary care Handling data from secondary care Indications for referral to secondary care Young people with type 1 diabetes

11 11 12 12 13 13 13 14 14 14 15 15 16 16 16 16 17

2 The practice diabetes register The prevalence of diabetes in your practice The accuracy of your practice diabetes register Labelling with type 1 or type 2 diabetes Teenagers with type 2 diabetes Diagnosing diabetes Diagnosing diabetes from fasting glucose level Diagnosing diabetes from an oral glucose tolerance test Information for practice staff: Registry and recall for people with IGT and IFG

18 18 19 20 20 21 21 22 22 CONTENTS | 5

Information for practice staff: Follow-up of people newly diagnosed with diabetes Information for practice staff: Protocol to be followed at an initial diagnosis of type 2 diabetes Information for practice staff: Suggested frequency of self-monitoring of blood glucose Self-monitoring of blood glucose Prescribing for self-monitoring of blood glucose Self-monitoring of blood glucose in people who are newly diagnosed and on lifestyle management only

23 23 24 24 24 25

3 The practice diabetes service The staffing of diabetes clinics The GP partner The diabetes nurse(s) The healthcare assistant Information for practice staff: The practicalities of running a diabetes clinic Care planning Information for practice staff: Frequency of clinics Information for practice staff: Reducing ‘did-not-attend’ (DNA) rates

26 26 26 26 28

4 Achieving glycaemia targets Information for practice staff: Practical tips for achieving glycaemia targets Reducing the risk of complications Microvascular disease prevention Macrovascular disease prevention Information for practice staff: Initiating insulin therapy Oral anti-obesity therapies Information for practice staff: Management of special cases

33

5 Retinal screening The rationale The method 6 | VITAL DIABETES MANAGEMENT

28 30 31 32

34 35 35 35 36 37 38 39 39 39

Information for practice staff: Preparing for the screening team visit Information for practice staff: Running an efficient retinal screening day at the practice Handling the results from retinal screening programme 6 Foot screening Background Information for practice staff: Practical tips for examining feet to detect the at-risk-foot Risk factors for foot ulceration Causes of foot ulceration Prevention of foot ulceration Information for practice staff: Giving advice to people with normal feet Action to take for new foot ulcers and/or cellulitis of the foot

40 41 42 43 43 44 44 45 45 46 46

7 Good blood pressure control Key components of good blood pressure measurement White coat hypertension Automated blood pressure measuring devices Controlling hypertension Drug therapy Information for practice staff: Pragmatic therapy action plan Blood pressure targets

48 48 49 49 49 50

8 Microalbuminuria and kidney function Kidney disease in diabetes Type 1 diabetes Type 2 diabetes Microalbuminuria in healthy people Points to consider Information for practice staff: Detection of microalbuminuria Non-diabetic causes of microalbuminuria or proteinuria Microalbuminuria and hypertension Creatinine and eGFR

52 53 53 54 54 54

51 51

55 56 56 57

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9 Cholesterol management Practical steps

59 59

10 Influenza immunisation Information for practice staff: Running an influenza immunisation programme

62

11 Depression Screening questions Information for practice staff: Practical steps

63 64 65 65

Appendix 1 Clinical indicators for diabetes and scores for 2004/5 and 2005/6

66

Appendix 2 Clinical indicators for diabetes from 1 April 2006

68

Appendix 3 Sample practice letter for booking appointments for diabetes review clinics

71

Appendix 4 Sample practice letter for follow-up of a one positive microalbuminuria result

72

Glossary

73

References

75

Resources Useful websites Useful books Useful journals

76 76 77 77

Other titles

78

Priority Order Form

80

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Introduction

Dear Colleagues Welcome to this edition of Vital Diabetes Management This book has been written to give practical help to healthcare professionals who work in general practice and are involved in delivering diabetes care. It brings together the expertise of general practice and practice diabetes nursing to help practitioners to deliver high-quality diabetes care and fulfil the requirements of the new GP contract Quality and Outcomes Framework, ensuring that the maximum income for diabetes care is obtained. The book is divided into 11 chapters with topics clearly presented. The detailed contents list will help you find your way around with ease. Within each topic you will find one or more vital points to give you essential information in just a few words. Some chapters also contain sections on Information for Practice Staff that can be photocopied and enlarged for your staff. You will also find useful appendices and other information at the end of the book, including sample practice letters, a glossary, useful addresses, websites and contacts, and references and further reading. We would welcome your comments or suggestions for improvements. Vital Diabetes Management is backed by the wisdom and experience gained by delivering diabetes care in a large 14,500-patient general practice for more than 25 years, and from speaking and writing about diabetes care over a similar period. We hope that you will find this book helpful for your practice.

Roger Gadsby and Pam Gadsby

I NTRODUC TI ON | 9

Acknowledgements

We would like to pay tribute to Mary MacKinnon for all her support and encouragement to us over the years. We would like to thank all the partners and staff of Redroofs surgery and all our colleagues who have worked for Warwick Diabetes Care for their help. We thank Colin Kenny for his helpful introduction and our editor Caroline Taylor for all her help and expertise in getting this book to print.

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1

The context

Over the past 30 years diabetes care has moved from being seen almost exclusively as the province of secondary care to one in which virtually all routine care for people with diabetes occurs in primary care. The new GP contract that was introduced in April 2004 has provided some financial recompense to support this shift in diabetes care from primary to secondary care. The GP contract lists a series of clinical domains for diabetes covering both process and outcome measures (see appendix 1 on p. 66). They were modified from 2006 onwards to give a possible 93 points for full achievement of the diabetes clinical indicator. From 1 April 2009 the previous two clinical outcome indicators for HbA1c are altered and become three, with an additional seven points being added, giving a total of 100 points available for the diabetes clinical indicator set.These modifications are listed in appendix 2 on p. 68.

T HE Q UALI TY A ND O UTCO M E S FR AME WORK ■ The Quality and Outcomes Framework (QOF) is a payment system, so some of the clinical standards are different from the ‘targets’ of national and international guidelines ■ It may not be medically appropriate for all people with diabetes to achieve the desired clinical indicator standards of QOF. For example: ◆

For a frail elderly person to achieve a glycated haemoglobin (HbA1c) level of 7.5% or a blood pressure of 140/80 mmHg to fulfil the QOF may put them at an unacceptable increased risk of hypoglycaemia or hypotension

■ These individuals can be ‘exempted’ from the framework

THE CONTEX T | 1 1

EXEMPTION REPORTING Exclusion of individual patients Exemption reporting allows the practice to exclude individual patients from the disease indicators in particular circumstances. These are: ■ Patients exempted from the whole clinical area ◆ Patients who have been recorded as refusing to attend a review and who have been invited on at least three occasions during the preceding 12 months ◆ Patients for whom it is not appropriate to review the chronic disease parameters due to specific circumstances, eg extreme frailty, terminal illness or severe dementia ◆ Patients who do not agree to investigation and treatment (and, after a reasonable discussion or written advice, have given their informed dissent) and this dissent has been recorded in the medical notes ■ Patients exempted from one clinical indicator only (if a valid computer code – Read code – is used) ◆ Patients on maximum tolerated doses of medication whose level of outcome remains suboptimal ◆ Patients for whom prescribing a medication is not clinically appropriate, 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, after a reasonable discussion or written advice, have given their informed dissent) and this dissent has been recorded in the medical notes Patients who have a supervening condition that makes treatment of their condition inappropriate, eg cholesterol reduction when the patient has liver disease Patients for whom an investigative service or secondary care service is unavailable

■ Patients exempted automatically from any of the indicators by reporting software ◆ 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 of clinical 1 2 | VITAL DIABETES MANAGEMENT

standards within 9 months, eg blood pressure or cholesterol measurements within target levels

Levels of exemption reporting ■ There was a concern that there would be excessive levels of exemption reporting ■ Published reports for 2004/5 give overall exemption rates that were generally low, with a median of 6% ■ In 2005/6 the median was 4.7% (interquartile range 3.3–7.0%) ■ In 2006/7 the median was 5.3%

I NCOM E F RO M THE Q UA LI TY AND O U TCO M E S F R A M E WO RK ■ Points mean prizes! The points that can be achieved from each clinical indicator are given in appendices 1 and 2 (p. 66 and p. 68, respectively. Each point earned is worth a certain amount of money to the practice. The size of the payment is dependent on: ◆ Practice list size and ◆ Prevalence of diabetes in the practice ■ A square root formula is used on the prevalence – this has the effect of reducing potential income for practices with high prevalence rates for diabetes ■ For an average-sized practice with an average prevalence of diabetes each point was worth £75 in the first year and £125 in the year 2005/6. So for the average practice with average prevalence the total income for the QOF for 2005/6 was 99 points each worth £125 = £12,375

R E WAR D S F O R HI GH- Q UA LI TY C ARE Other structural changes have taken place to reward primary care for delivering high-quality diabetes care. THE CONTEX T | 1 3

Locally enhanced service payments ■ These are payments agreed locally by an individual PCT for particular services delivered by practices in their area ■ Some practices have negotiated agreements for extra payments for specific diabetes services over and above QOF ■ One of the most common extra payments in diabetes is for initiation onto insulin in type 2 diabetes ■ Some Primary Care Trusts (PCTs) for example pay a specific sum of £100 per patient initiated onto insulin

Prescribing incentive schemes ■ These schemes reward practices for achieving certain prescribing changes 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 of switching to the prescribing of generic simvastatin 40 mg once daily from more expensive branded atorvastatin 10 mg once daily. A practice may be rewarded for achieving 70 people on simvastatin 40 mg for those needing a statin for primary prevention ■ Some PCTs have had schemes to try to reduce the ‘inappropriate’ prescribing of blood glucose monitoring strips ■ Some PCTs have tried to introduce incentives to ‘ration’ the number of 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 specific more complex problems, instead of referring 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 staffed by a Community Diabetes Specialist Nurse, a Community Dietitian who has a special interest in diabetes, and a doctor 1 4 | VITAL DIABETES MANAGEMENT

■ This doctor is sometimes a Consultant Community Diabetologist or a GP with a Special Interest in diabetes (GPSI; see below) ■ These clinics see people referred from GPs and usually see them only once or twice to address specific problems ■ They are then returned to their GP’s care

General Practitioner with a Special Interest ■ A GPSI is a full-time GP who works up to 1 day a week as a GPSI in a specific clinical field ■ Framework documents for the work of GPSIs are available at www.doh.gov.uk/pricare/gp-specialinterests ■ GPSIs in diabetes can fulfil a purely management function, for example overseeing a diabetes network, or can fulfil a clinical function, for example running diabetes clinics in the community ■ New guidance on accreditation and governance of GPSIs was released in summer 2007 (details are available at www.doh.gov.uk)

Practice-based commissioning ■ A diabetes commissioning toolkit can be found at www.library.nhs.uk/diabetes using the search facility to look for ‘commissioning toolkit’. This gives a link to the document in pdf format and this can be downloaded ■ The toolkit provides advice for all commissioners of diabetes services and describes how to carry out a needs assessment for a local diabetes population. It provides a generic specification for diabetes care, signposting recognised quality markers and suggesting key outcomes for the service ■ In some parts of the country practice-based commissioning is being developed, 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 for Health and Clinical Excellence (NICE) has produced a commissioning guideline for diabetes footcare based on the NICE 2004 guideline. It can be found at www.library.nhs.uk/diabetes (using search facility for ‘commissioning footcare’). This gives a link to the document as a pdf

THE CONTEX T | 1 5

S ECONDARY C A RE Relationship with secondary care ■ Many practices provide routine care for the majority of 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 for 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 for those with specific problems

Handling data from 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 fulfil QOF requirements ■ It is important to ask secondary care colleagues to include all this QOF relevant information in their clinic letters sent to the practice ■ The practice then needs a protocol to ensure that this data is transferred 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 staff then enter these data, which are automatically coded to comply with the QOF

Indications for referral to secondary care ■ Children and people under the age of 25 years newly diagnosed with diabetes ■ Women with diabetes who are contemplating pregnancy for prepregnancy advice and counselling ■ Women with diabetes who are pregnant need early referral to a unit with expertise in managing diabetic pregnancy ■ People who need to be considered for insulin pump therapy ■ People newly presenting with diabetic foot ulcers and/or cellulitis of their feet 1 6 | VITAL DIABETES MANAGEMENT

■ Nephrology assessment services for 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 feel it has the expertise to manage. If the area has an intermediate diabetes service, these people may be referred to that service

Young people with type 1 diabetes ■ Young people with type 1 diabetes will be cared for in secondary care. Some may default from follow-up during teenage years. The practice will be providing repeat prescriptions for insulin and may be the only place of contact for people failing to attend secondary care. Every attempt needs to be made to try to re-engage them with diabetes care provision

THE CONTEX T | 1 7

2

The practice diabetes register

An accurate register of everyone with diabetes is the basis for any structured care for people with diabetes in the practice. From 2006/7 practices were required to indicate whether a person had type 1 or type 2 diabetes. This is now diabetes quality indicator 19.

Diabetes quality indicator 19 (DM19) The practice can produce a register of all patients aged ≥17 years with diabetes mellitus that specifies whether the patient has type 1 or type 2 diabetes = 6 points

TH E P R E VAL E NC E O F DI A BE TE S IN YOUR P R AC TI C E ■ The registered prevalence of diabetes from 2007/8 QOF figures for the whole of the UK was 3.86% on 14 February 2008 ■ The registered prevalence was higher than this in Wales and lower than this in Northern Ireland (3.1%) ■ In an ‘average’ practice of 10,000 registered patients, 370 will have diabetes ■ In practices with a higher than average proportion of older people the prevalence of diabetes is likely to be higher than 3.7% as diabetes is more common in older people ■ In practices with a younger than average population, eg student health centre practices and practices on new housing estates with many young families, the prevalence of diabetes is likely to be below 3.7% ■ In practices with large numbers of people from a South Asian ethnic group, prevalence rates are likely to be much greater, even up towards 10% 1 8 | VITAL DIABETES MANAGEMENT

■ Diabetes is more common in lower socio-economic groups, so if your practice has many patients from lower socio-economic groups the practice prevalence is likely to be higher than 3.7%

V ITA L POINT ✱ If the recorded prevalence of diabetes in your practice is below what would be expected and this cannot be explained by the mix of your practice population, consider where the missing people might be

T HE ACCUR AC Y O F YO UR PR AC T I C E DI A BE TE S RE GI STE R There may be instances of 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 fasting glucose (IFG) wrongly being included in the diabetes register ■ People with a history of 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 for diabetes were ever made ■ People diagnosed as having diabetes whilst an inpatient and the diagnosis not being recorded or not being picked up from a hospital letter, so they are not added to the practice register

V ITA L POINT ✱ Review and update your diabetes register regularly

T H E P R AC T I C E D I A B E T E S R E G I S T E R | 1 9

Labelling with type 1 or type 2 diabetes ■ For the first 2 years of 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 code if their notes clearly say they have type 1 diabetes ◆ Record people as having type 2 diabetes using the Read code if their notes clearly state they have type 2 diabetes ■ If a patient does not have a clear label of type 1 or type 2 diabetes in their notes, use the label type 2 unless: ◆

◆

The patient was diagnosed before the age of 30 years, then label them as type 1 The patient required insulin within 1 year of diagnosis, then label them as type 1

■ In most practices, more than 90% of people with diabetes will have type 2 diabetes and less than 10% will have type 1 diabetes

V ITA L POINT ✱ If your practice has more than 10% of people labelled as having 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 of teenagers diagnosed with diabetes had type 1 diabetes ■ Type 2 diabetes is now being diagnosed in very obese children, often from Indo-Asian ethnic backgrounds, who are newly presenting with diabetes ■ In the USA today if 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 forms of diabetes that often present in teenagers and young adults, such as maturity onset diabetes of the young (MODY)

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V ITA L POINT ✱ Best practice is to always refer someone newly diagnosed with diabetes 7.5% and exempting them from the QOF target (see p. 12) ■ There is little evidence for the benefit of tight glycaemic control above the age of 80 years, and there is a significant increased risk of falling and developing increased confusion from hypoglycaemia in the frail elderly person with diabetes. Higher HbA1c targets may be therefore appropriate in the frail elderly, and exemption reporting needed

OR AL A N T I - O BE SI TY THE R A P 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 effective anti-obesity agent but it can cause hypertension and tachycardia. This reduces its usefulness in people with diabetes ■ 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

V ITA L POINT ✱ Evaluate glycaemic control at each review appointment, set appropriate goals and up-titrate medications as necessary

AC HI E VI NG G LYC A EM I A TA RG ETS | 3 7

I N F O R MAT ION F OR PRACTICE S TAFF Management of special cases The newly diagnosed person with type 2 diabetes who is thin and very symptomatic ■ The concern is that these individuals have significant beta cell dysfunction and could even have slow-onset type 1 diabetes ■ They often are active and are eating healthily ■ They may present with a short history of weight loss, tiredness, thirst and polyuria ■ They do not have ketonuria, as if 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 of sulphonylurea every 2 weeks as indicated by their SMBG readings ■ Add in metformin if sulphonylurea alone doesn’t control their glycaemia ■ If glycaemia still is not controlled, consider insulin early ■ If insulin is required within the first year from diagnosis, they can be relabelled as having type 1 diabetes

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5

Retinal screening

Diabetes quality indicator 21 (DM21) The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months Minimum threshold = 40% Maximum threshold to earn full available 5 points = 90%

T HE R AT I ONA LE ■ Diabetic retinopathy is the leading cause of blindness in people of 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 effective treatment for diabetic retinopathy ■ Laser therapy for the treatment of diabetic retinopathy has been shown to be effective in reducing blindness ■ Screening for retinopathy is therefore essential, as people may not know they have it ■ Cataracts are more common in people with diabetes. They need to be detected and treated. Referral for consideration of urgent cataract extraction is needed when the cataract stops a good view of the retina

T HE M E T H O D ■ Screening by digital retinal photography is the only approved method for retinal screening RETI NA L SC REENI NG | 3 9

■ Digital retinal screening must be carried out by an approved screening service that uses skilled staff, has appropriate internal quality assurance mechanisms, and conforms to the national specifications (see www.nscretinopathy.org.uk). Programmes ideally are of a size to screen 15,000–20,000 people with diabetes each year. Each programme therefore covers more than one PCT. There are at present just over 100 retinal screening programmes in the UK ■ In some areas this service is provided by optometrists

I N F O R MAT ION F OR PRACTICE S TAFF Preparing for the screening team visit ■ Most screening programmes now run their own call and recall system that has been developed from names and addresses of people with diabetes given to the programme by the practice. Electronic transfer is now being developed and trialled in some practices ■ The practice needs to have a reliable way of informing the screening programme of the names and contact details of people newly diagnosed with diabetes so that they can be called up for screening at the appropriate time ■ People are informed by letter of 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 information about the screening and advice about the effects of 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 of the screening team is used most efficiently, practice administration staff can phone people who have not already booked in to try to fill any spare appointments ■ Ensure that those people already attending hospital retinal services are excluded from the invitation list

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■ In some areas the service is provided by a fixed camera system so all people with diabetes from a specific geographical area travel to have screening done at a specific location, often 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 the screening on practice premises

I N F O R MAT ION F OR PRACTICE S TAFF Running an efficient 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 staff, and are given written information about how they will receive their results and about the follow-up procedure ■ A practice nurse or HCA calls the person into a room where they will check the person’s details, including a brief history of any eye problems ■ Visual acuity is checked using a Snellen chart and is recorded for the screener ■ Mydriatric eye drops (tropicamide 0.5%) are inserted into each eye ■ The person is asked to wait in the waiting room for about 20 minutes to ensure that their pupils are fully dilated ■ The screener calls the people through and takes a digital retinal photograph of each eye ■ The screener will usually tell the person if the image appears normal, but will say that the photographs will be checked and a full report sent to them and the practice ■ The practice nurse or HCA records that retinal screening has taken place on the practice clinical computer

RETI NA L SC REENI NG | 4 1

H AND L I N G THE R E SULTS F ROM T HE R ETI NA L SC R E E NI NG PROG R AMME ■ Any abnormalities seen on the photograph are graded in accordance with national standards ■ Any people with abnormalities that require laser therapy are referred to the diabetic retinal clinic by the screening service, and information is sent to the practice. In Northern Ireland the onus may be left on the GP to refer as appropriate ■ Those who have no abnormalities on their retinal photographs or those with simple background retinopathy are informed by letter of their results, as is the practice. This information is then recorded and coded by the practice administration staff on the computer. They are informed that they will be recalled for a further screen in 1 year. In Northern Ireland the 1-year interval may be replaced by ‘an agreed time’ ■ Many screening programmes send written information about the results of the screening to the patients themselves and copy this to the practice. They also send copies of referral letters to the practice

V I TA L POI NT S ✱ Retinal screening is vitally important for 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 offered a retinal screening appointment

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6

Foot screening

Diabetes quality indicator 9 (DM9) The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months Minimum threshold = 40% Maximum threshold to earn full available 3 points = 90%

Diabetes quality indicator 10 (DM10) The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months Minimum threshold = 40% Maximum threshold to earn full available 3 points = 90%

BACKGROUND ■ Foot problems in diabetes result from complications such as peripheral vascular disease and neuropathy, which lead to ischaemia and loss of protective pain sensation in the feet ■ Relative ischaemia of the feet may be symptomless, and so people may be at risk without knowing it ■ Diabetic peripheral neuropathy is often symptomless. People often don’t notice the gradual loss of protective pain sensation as neuropathy develops ■ Thus, there are people with diabetes who have risk factors for foot ulceration and amputation of which they are not aware FOOT SC REENI NG | 4 3

■ Unless screening is carried out people may be at risk without knowing it ■ For some people presentation with a foot problem is the first indication of diabetes

I N F O R MAT ION F OR PRACTICE S TAFF Practical tips for examining feet to detect the at-risk-foot ■ Ensure that people with diabetes realise that they will be having an annual foot examination. Tell them to be prepared to take their shoes and socks off ■ Examine the foot for bony abnormalities. The most common are bunions, overriding toes, hallux rigidus and hallux valgus ■ Palpate for the posterior tibial and dorsalis pedis pulses. If they are absent the foot is at-risk ■ Detect the loss of protective pain sensation by using a 10 g nylon monofilament as follows: ◆ The filament is applied to at least five sites on the foot (but not over callus, which is an area of dry, hard, often fissured skin) until it buckles, which occurs at 10 g of linear pressure when the patient is asked to detect its presence ◆ If it cannot be felt, protective pain sensation is lost and neuropathy is present ■ Record the findings from the foot examination on the diabetes template in the practice clinical computer system to ensure appropriate coding

R ISK FAC TO RS F O R FOOT ULC E R ATI O N ■ Absent foot pulses, indicating ischaemia ■ Loss of protective pain sensation in the feet due to diabetic peripheral neuropathy

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■ The presence of bony abnormalities in the feet ■ The presence of any one of the above risk factors puts a foot ‘at risk’ of ulceration ■ The presence of two of the above risk factors puts the foot at greater risk ■ The presence of all three of the above risk factors puts the foot at high risk

C AUS E S O F F O OT ULC E R ATI O N ■ Feet that are at-risk due to neuropathy or ischaemia or bony abnormality do not spontaneously ulcerate ■ Minor trauma is usually the additional factor that precipitates ulceration ■ The person with loss of protective pain sensation due to neuropathy may get trauma through: ◆

◆ ◆

Thermal damage, eg walking on hot sand on holiday, getting into a bath that is too hot Chemical damage, eg use of corn-cures Mechanical trauma, eg tight-fitting shoes, standing on a stone or sharp object, eg a drawing pin

PR E V E NT IO N OF FOOT ULC E R ATI O N There are several ways in which the risk of foot ulceration can be reduced in someone with an at-risk-foot: ■ Specific education about care of the at-risk-foot ■ Appropriate further investigation to define the level of risk more clearly ■ Provision of appropriate footwear if needed ■ Close follow-up This package of care is ideally provided at a ‘foot-at-risk’ community clinic staffed by podiatrists who have a special interest in diabetes.

FOOT SC REENI NG | 4 5

V ITA L POINT ✱ Those who are found to have a foot at risk through screening in primary care should be referred to the local ‘foot-at-risk clinic’ for extra education, assessment, management and follow-up

I N F O R MAT ION F OR PRACTICE S TAFF Giving advice to people with normal feet ■ Even when there are no ‘at-risk’ features it is helpful to encourage all people with diabetes to inspect their feet regularly and take care of them ■ Advise people to regularly wash and dry their feet and use moisturising cream on areas of dry skin. The use of a foot spa is not usually advised ■ The presence of callus (thickened dead skin) implies that there is excessive pressure in that area, and may indicate that the foot is developing ‘at-risk’ features ■ Nails should be trimmed regularly

AC T I O N TO TA KE F O R NE W F O OT U LCERS A N D /OR C E LLULI TI S O F THE F O OT Most people with diabetes who have to have a limb amputation have a preceding foot ulcer. Foot ulcers do not inevitably lead to an amputation. They can be healed. To heal an ulcer: ■ The ulcer needs to be ‘off-loaded’ to reduce pressure on it ■ The ulcer needs to be debrided regularly to remove dead tissue ■ Infection must be treated

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■ Blood glucose needs to be optimised ■ Appropriate dressings are needed All of these interventions need to be managed by a multidisciplinary footcare team.

V ITA L POINT ✱ All people with diabetes who newly present with a foot ulcer or signs of cellulitis in the foot should be referred immediately to the local multidisciplinary footcare team for assessment and treatment

FOOT SC REENI NG | 4 7

7

Good blood pressure control

Diabetes quality indicator 11 (DM11) The percentage of patients with diabetes who have a record of the blood pressure in the past 15 months Minimum threshold = 40% Maximum threshold to learn full 3 available points = 90%

Diabetes quality indicator 12 (DM12) The percentage of patients with diabetes in whom the blood pressure is 145/85 or less Minimum threshold = 40% Maximum threshold to gain the full 18 available points = 60% Blood pressure control to agreed targets is important in people with diabetes as there is good evidence from the UKPDS study that it reduces the risk of adverse outcomes, particularly stroke and heart attacks. This is reflected in the fact that 21 points are available for this clinical area.

KE Y COM PO N E NTS O F GO O D BLO OD P R E SSUR E M E A SURE M E NT ■ The person sits at rest for 5 min in quiet surroundings ■ The dominant arm is supported at heart level ■ Use an appropriate-sized cuff ■ Use an appropriately calibrated device ■ Take two separate readings ■ Record these (and average) to nearest 2 mmHg 4 8 | VITAL DIABETES MANAGEMENT

WHITE COAT HYPERTENSION ■ Some people have falsely elevated blood pressure readings when they attend hospital (white coat hypertension). The risks of this are probably much less in the practice as this is a more familiar place where their blood pressure is taken by someone they know ■ Where blood pressure readings may be falsely elevated, it is possible for 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 for a couple of weeks ■ These readings can then be compared with surgery-recorded levels and decisions about treatment taken

AU TO M ATE D BLO O D P RE SSURE M E AS U R I NG DE V I C E S ■ Many people now use automated blood pressure measuring devices. There are a number of possible problems with these including: ◆ Inaccuracy in the presence of any irregularity in the pulse ◆ False high readings when people are aware that the cuff is about to inflate and then tense themselves up in anticipation ■ If 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 of clinical trials that form the evidence-base for good blood pressure control. There was fear that mercurycontaining devices would be banned under EU health and safety 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 of lifestyle change before rushing into blood pressure-lowering drugs when the person’s blood pressure is only slightly raised

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■ If lifestyle change doesn’t reduce blood pressure to target or it is so far above target that lifestyle change will not normalise it, then drug therapy needs to be started

DRUG T H E R APY ■ Evidence from trials including the UKPDS suggest that achieving blood pressure reduction to target levels is more important than which individual drug therapy is used ■ After 9 years of follow-up in the UKPDS blood pressure study, 29% of people in the tight control group needed three or more therapies to meet target blood pressure ■ In practice, therefore, many people with type 2 diabetes will not have their 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 if not tolerated because of cough, angiotensin receptor blocker (ARB) – sometimes called A2 drugs) should be used first in anyone with microalbuminuria or proteinuria ■ Certain ethnic groups, eg African/Caribbeans, may not respond to ACE inhibitor drugs. Calcium channel blocker agents may be more useful in this population ■ It is known that concordance with therapy decreases with increasing numbers of tablets and increasing dose frequency ■ Combination tablets are therefore helpful to reduce the number of tablets that people need to take ■ Low-dose diuretics augment the antihypertensive effects of other major classes and so diuretic plus ACE inhibitor combinations may help

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I N F O RM AT ION F OR PRACTICE S TAFF: Pragmatic therapy action plan ■ Step 1: ACE inhibitor (or if 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

B LOO D P R E SSUR E TA RGE TS Blood pressure targets are given in the NICE type 2 diabetes guidelines (May 2008): ■ Treat blood pressure if lifestyle advice does not reduce blood pressure to below 140/80 mmHg or below 130/80 mmHg in a person with evidence of kidney or eye damage or cerebrovascular disease ■ Monitor blood pressure every 1 or 2 months and intensify therapy if on medication until blood pressure is consistently below 140/80 or 130/80 mmHg in a person with evidence of kidney or eye damage, or cerebrovascular disease ■ In women in whom, after an informed discussion, it is agreed that there is a possibility of pregnancy, first line blood pressure-lowering therapy should be with a calcium channel blocker. This is because ACE inhibitors and ARB2 drugs are thought to cause fetal abnormalities in early pregnancy

V ITA L POINT ✱ Measure blood pressure at each review appointment and if not controlled well treat to agreed goals

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Microalbuminuria and kidney function Diabetes quality indicator 13 (DM13) The percentage of patients with diabetes who have a record of microalbuminuria testing in the previous 15 months (exemption reporting for patients with proteinuria) Minimum threshold = 40% Maximum threshold to earn maximum 3 points = 90%

Diabetes quality indicator (DM15) The percentage of 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 of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months Minimum threshold = 40% Maximum threshold to earn maximum 3 points = 90%

■ Microalbuminuria is defined as: ◆ The leakage into the urine of small amounts of protein in the range 30–300 mg in 24 hours ◆ It can be detected by specific test strip (Micral-Test) that is dipped into the urine. The urine will be negative to normal protein dipsticks 5 2 | VITAL DIABETES MANAGEMENT

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It can be detected in a urine sample sent to a laboratory for the detection of the albumin:creatinine ratio (ACR). A ratio >2.5 mg/mmol for men and >3.5 mg/mmol for women indicates microalbuminuria

■ Proteinuria is defined as: ◆

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The leakage into the urine of protein of 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 frank proteinuria ■ Albustix and Medi-Test Protein 2 are two protein-testing strips that are available in the UK ■ Proteinuria testing is found as part of various branded combination sticks, eg Uristix, Multistix, etc

K I D NE Y D I SE A SE I N DI A BE TE S 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 first few years of living with diabetes, kidney function is normal and there is variable excretion of only tiny amounts of protein: 2.5 mg/mmol for men and >3.5 mg/mmol for women indicates microalbuminuria ■ If the ACR is