diabetes
Content
Original article
Performance management in clinical diabetes: are the Diabetes UK ‘15 health care essentials’ a good enough measure of the standard of diabetes care?
Dr Paul Grant
MBBS, MSc, MRCP, Specialist Registrar Diabetes & Endocrinology
Abstract
Dr Masud Haq
BSc, MBBS, MD, FRCP, Consultant Diabetologist
Dr Dennis Barnes
MB, FRCP, Consultant Diabetologist Department of Diabetes & Endocrinology, Tunbridge Wells Hospital,Pembury, Kent, UK
Correspondence to: Dr Paul Grant, Department of Diabetes & Endocrinology, Tunbridge Wells Hospital, Pembury, Kent TN2 4QJ, UK; email: drpaul.grant@doctors. org.uk Received: 2 July 2012 Accepted in revised form: 2 August 2012
Having the right care is essential for the wellbeing of all people with diabetes. There is a minimum level of health care that every person with diabetes should expect. In 2010, Diabetes UK produced a list of 15 essential checks and services that people with diabetes should expect to receive. We wanted to assess whether we were adequately achieving all of these targets in our own diabetes service and assess whether the targets were themselves adequate and appropriate. We retrospectively reviewed the medical records of 200 randomly selected patients attending the diabetes review clinic in a district general hospital. We recorded whether the parameters outlined in the Diabetes UK ‘15 health care essentials’ had been achieved in the last 12 months and then collated the data. The data showed that we scored well in terms of monitoring HbA1c, blood pressure, body mass index, retinal screening and cholesterol. However, we scored sub-optimally in terms of the following parameters: smoking cessation, pregnancy planning, structured education, measurement of waist circumference and psychological assessment. In conclusion, the Diabetes UK ‘essentials’ checklist may be viewed as mechanistic, but it provides a useful starting point to assess the effectiveness of a diabetes service in providing the basics of patient care in much the same way as the WHO surgical checklist reduces adverse outcomes. We have been able to see where the deficiencies in our own service lie and have made amends to ensure that these areas are covered in future. One issue that arose is that there are certain other ‘essentials’ that would be good to include in such a checklist, such as: erectile dysfunction (as suggested by the NICE guidelines), obstructive sleep apnoea, vitamin D deficiency, neuropathy screening and monitoring of liver function to rule out incipient steatohepatitis/fatty liver disease. Copyright © 2012 John Wiley & Sons. Practical Diabetes 2012; 29(7): 275–278
Key words
health care standards; diabetes service; performance management; Diabetes UK essentials
Diabetes UK has developed a checklist of the basic standards of care that a person with diabetes should expect to receive from their health care provider as a minimum on an annual basis (Table 1).1 The diabetes review clinic in secondary care is arguably the best opportunity for providing a holistic assessment of a patient with diabetes, and aims to screen for and reduce the likelihood of the development of diabetesrelated complications. We have previously done some work around the development of a ‘perfect’ diabetes review2,3 and the National Institute for Health and Clinical Excellence (NICE) quality standards,4 and acknowledge that there are many factors that need to be monitored and recorded during
Introduction
each clinical encounter; these include but are not limited to the ‘9 key care processes’ that the Department of Health states should occur for all patients with diabetes.5 Diabetes UK previously undertook a survey of 7134 people with diabetes (32% type 1, 66% type 2) to ask whether they had had these ‘essential’ checks within the last year. The results were very revealing demonstrating that 6% of patients did not have an HbA1c blood test, 11% of patients did not have retinal screening, 25% of patients did not have their feet checked, 35% of people had never been offered any education about their diabetes, and 62% of patients had not developed a care plan with their health care professionals to meet their individual needs.1
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
275
Original article
Performance management in clinical diabetes
We wanted to explore whether our own clinical practice was favourable and if we were we achieving the ‘15 essentials’ the majority of the time in our own patient population. The question that leads on from this is whether the essentials checklist itself is adequate and appropriate, as it may be missing other important diabetesrelated problems such as erectile dysfunction, for example, which is an important diabetes-related cardiovascular risk factor and has been recommended for inclusion into yearly diabetes screening by NICE.6 We developed a score sheet based on the 15 ‘essentials’ and modified it for our own practice to allow us to record data from clinical encounters. The 15 ‘essentials’ include measures that may not be applicable to all patients such as pregnancy planning in females and standards of hospital care in those patients who may have been admitted. Also, this was an adults-only group as we are separate from the paediatric services. We therefore adjusted our data capture accordingly. We then retrospectively reviewed the medical records of 200 patients who had been seen in the diabetes review clinic (prior to our awareness of the Diabetes UK 15 ‘essentials’ list) between October 2011 and March 2012, and marked whether they had documented evidence of the above care processes or investigations taking place. Subsequently we compiled the data to calculate a percentage for how successful we were on meeting each of the parameters. We then compared our results with the results of a national patient survey based on the 15 ‘essentials’ to compare how we fared, and looked for deficiencies in our practice and potential areas for improvement. From a review of 200 patient records attending the diabetes review clinic in a secondary care setting we discovered that we had outperformed all but one of the results from the national survey, as demonstrated in Figure 1. In our population we discovered that we had
Study aims
Methods
1. Get your blood glucose levels measured at least once a year. An HbA1c blood test will measure your overall blood glucose control and help you and your diabetes health care team set your own target 2. Have your blood pressure measured and recorded at least once a year, and set a personal target that is right for you 3. Have your blood fats (cholesterol) measured every year. Like blood glucose levels and blood pressure, you should have your own target that is realistic and achievable 4. Have your eyes screened for signs of retinopathy every year. Using a specialised digital camera, a photo of each eye will be taken and examined by a specialist who will look for any changes to your retina (the seeing part at the back of your eye) 5. Have your feet checked – the skin, circulation and nerve supply of your feet should be examined annually. You should be told if you have any risk of foot problems, how serious they are and if you will be referred to a specialist podiatrist or specialist foot clinic 6. Have your kidney function monitored annually. You should have two tests for your kidneys: urine test for protein (a sign of possible kidney problems) and a blood test to measure kidney function 7. Have your weight checked and have your waist measured to see if you need to lose weight 8. Get support if you are a smoker, including advice and support on how to quit. Having diabetes already puts people at increased risk of heart disease and stroke, and smoking further increases this risk 9. Receive care planning to meet your individual needs – you live with diabetes every day so you should have a say in every aspect of your care. Your yearly care plan should be agreed as a result of a discussion between you and your diabetes health care team, where you talk about your individual needs and set targets 10. Attend an education course to help you understand and manage your diabetes. You should be offered and have the opportunity to attend courses in your local area 11. Receive paediatric care if you are a child or young person. You should receive care from specialist diabetes paediatric health care professionals. When the time comes to leave paediatric care, you should know exactly what to expect so you have a smooth change over to adult health services 12. Receive high-quality care if admitted to hospital. If you have to stay in hospital, you should still continue to receive high-quality diabetes care from specialist diabetes health care professionals, regardless of whether you have been admitted due to your diabetes or not 13. Get information and specialist care if you are planning to have a baby as your diabetes control has to be a lot tighter and monitored very closely. You should expect care and support from specialist health care professionals at every stage from preconception to post-natal care 14. See specialist diabetes health care professionals to help you manage your diabetes. Diabetes affects different parts of the body and you should have the opportunity to see specialist professionals such as an ophthalmologist, podiatrist or dietitian 15. Get emotional and psychological support. Being diagnosed with diabetes and living with a long-term condition can be difficult. You should be able to talk about your issues and concerns with specialist health care professionals
Table 1. The Diabetes UK ‘15 health care essentials’ list
Results
missed the following essentials: 6% of patients did not have a blood pressure check; 10% of patients did not have monitoring of their renal function; 0% of patients had their waist circumference measured – however, only 9% of patients had not had their body weight recorded; 45% of patients did not have recorded documentation of smoking status or a discussion relating to smoking cessation; 70% of patients did not have their psychological issues broached; and 20% of
patients did not appear to have been offered structured education. On the plus side, we scored well in terms of discussing and documenting a clinical plan for the patients, something which appeared to be in stark contrast to the national survey results which was only 38% of patients. This retrospective study was a useful piece of reflective work to assess our practice. It allowed us to recognise
Discussion
276
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
Original article
Performance management in clinical diabetes
and record how we were performing with regard to a series of recommended annual checks for the care of patients with diabetes. For several of the parameters there are good reasons why the success rate was relatively low. These include: patients not having a blood test; unexpected absence of clinical support workers to perform routine observations; lack of cartridges for the DCA HbA1c analyser; lack of necessity to document an essential that may have already been recorded and dealt with in the past – for example, smoking status, previous attendance on an education course, mental health problems. Arguably, one does not need to keep checking some of the essentials on every visit. We appeared to do well in terms of monitoring HbA1c, blood pressure, lipid status, foot checks and body weight/BMI, scoring 90% and over. However, for other factors such as renal monitoring, waist circumference measurement, smoking cessation support and enquiring about pregnancy planning, we appear to be sub-optimal in our performance. This is useful to know as it provides a baseline reference score which we can compare to in future as we attempt to improve the success rates for each of the important variables. We recorded waist circumference in 0% of patients and would argue against the utility of this particular measure in clinical practice, finding BMI rather than weight or waist measurement per se as a better guide to morbidity and prognostication. Even better than BMI is the use of an obesity staging criteria, which would be useful in a significant number of our patients, and represents a much better way of assessing obesity and all of its related co-morbidities. We agree that the use of a checklist in clinical practice may be viewed as terribly reductionist and dehumanising, but checklists are a considerative approach to ensuring that we are not missing out on a vital part of the diabetes MOT. Many will agree that checking is one thing, but doing something about it is another. Look, for example, at the disparities in the provision of specialist diabetes psychologists or the local availability of DAFNE courses.
National Local (PG) 100 90 80 Percentage of patients 70 60 50 40 30 20 10 0
c A1 ure Hb ress p od Blo
al ol es Ey ster Ren ole Ch
l r y n et ht ke ing ica Fe eig catio nanc mo lann olog g W du S p h E Pre yc re Ps Ca
Figure 1. Graph to compare the percentage of patients who had received the Diabetes UK ‘essentials’ checks while attending the adult diabetes secondary care service (national versus local [PG])
With regard to the ongoing management of our patients, guidelines are helpful, but they are often rigid and are not context specific. Individualised care and treatment to target are important issues. In terms of HbA1c, for example, there has long been an argument for more frequent monitoring (to relate to up-titration of diabetes therapies) as well as the use of ‘longitudinal HbA1c’ to track changes over time and act as a goal for intervention rather than just a simple recording of the occurrence of the test.7 We also feel that there are several other ‘essential’ factors which we consider should be recognised as being important to measure as part of the ongoing care for patients with diabetes. • Erectile dysfunction – hypogonadism is common in type 2 diabetes. It is an important cardiovascular risk factor and has been recommended by NICE for inclusion in the diabetes annual review.6,8 • Liver function tests – the prevalence of abnormal liver function tests in patients with type 2 diabetes is high, with only modest variation between defined patient groups. The prognostic significance is as yet unclear, but many argue that routine monitoring is important in our patient population.9 • Obstructive sleep apnoea – OSA and diabetes are conditions that
frequently co-exist and overlap. Prevalence is high in older and obese patients and, arguably, screening with close questioning or an Epworth sleepiness scale would be appropriate.10 • Classification of diabetes type – a recent Royal College of General Practitioners and NHS Diabetes systematic review on the miscoding and misclassification of patients with type 1 diabetes misdiagnosed as type 2 and vice versa found that as many as 10–15% of patients are not identified correctly and, as such, may be receiving the wrong type of treatment. It is also common for patients with MODY (maturity onset diabetes of the young) to be misdiagnosed (up to 5%) with type 1 diabetes and unnecessarily receiving insulin.11 • Contraceptive advice to women of child bearing age who are not planning pregnancies. The Diabetes UK health care essentials include giving advice to women who are planning a pregnancy, but do not mention the provision of contraceptive advice to those women who do not wish to become pregnant. This is important given the increased risks in unplanned pregnancies in diabetes. If one considers the criteria for appraising the viability, effectiveness and appropriateness of including the above as a part of a screening
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
277
Original article
Performance management in clinical diabetes
programme, then they certainly appear to fulfil the requirements of the UK national screening service.12 Our goal is to repeat our modified ‘essential’ checklist in every diabetes consultation and then continue to analyse the results, but in a prospective manner. We can then use run charts to regularly monitor how we are doing. The extra checks as suggested above will also be included to assess how relevant they may be for our own patient population. A potential danger is that a diabetes review becomes too unwieldy for clinical practice, so maybe it is also time to rethink the way in which we deliver the diabetes review clinic. Is it time to consider the two-stop shop? Integrating more with primary care? Co-creating health? And is there scope for a national consensus or a standardised approach over and above the Diabetes UK model? And a final point is that we have not even started to touch on the subject of outcomes… It is important to monitor, measure and learn from one’s own clinical practice.13 We have shown that the Diabetes UK ‘15 health care essentials’ are a useful starting point to ensure that we are not missing out important screening checks for patients attending our service. Arguably, some essentials are more ‘essential’ than others and some of them may not necessarily need to be CONFERENCE NOTICE
Key points
l The Diabetes UK ‘15 health care essentials’ checklist was designed for patients to ensure that they are receiving all the correct checks, treatment and screening tests to optimise their diabetes care l The secondary care diabetes review clinic has a variety of formats and content and can differ significantly depending on local circumstances. The benefits of using such a checklist would be both to reduce variation in care and to ensure a thorough evaluation of the patient’s diabetes-related issues l We compared our clinical performance with the national data from Diabetes UK and found that, while we were undertaking the majority of the checks well, there were areas for improvement. The checklist has now been modified to include a few extras and has been adopted into routine clinical practice
our data annually to strive for continual improvement in care delivery. Many thanks to the South East Thames Diabetes Consultants’ group and the Young Diabetologists Forum. There are no conflicts of interest declared.
1.
Acknowledgments
Declaration of interests
References
2. 3. 4. 5. 6. 7.
Conclusion
enquired about at every annual review. For example, we do not need to ask someone every time they attend if they are still a non-smoker, or to ask about structured education if they are already a DAFNE graduate, or to ask about pregnancy planning if they are a man, or how their hospital inpatient diabetes care was if they were not admitted etc. It is also important to recognise that there are some new essentials that fulfil the criteria for valid inclusion into our diabetes screening service and we hope to re-analyse
8.
9. 10. 11. 12. 13.
Diabetes UK 15 Healthcare Essentials. www. diabetes.org.uk/15-essentials [accessed 1 May 2012]. Grant P. The perfect Diabetes Review. Prim Care Diabetes 2010;4(2):69–72. Grant P, Lipscomb D. Pursuing perfection in the diabetes review clinic. Diabet Med 2012;29(Suppl s1):497. Grant P. The NICE quality standards for diabetes care: a critical analysis. Pract Diabetes 2011;28(5):208. National Diabetes Audit Executive Summary. Department of Health Gateway reference 14327. NICE Clinical Guideline 66. The management of type 2 diabetes. 2008. www.nice.org.uk/nicemedia/pdf/ CG66NICEGuideline.pdf [accessed 10 May 2012]. Rathmann W, et al. Longitudinal change in HbA1c after insulin initiation in primary care patients with type 2 diabetes: a database analysis in UK and Germany. Prim Care Diabetes 2012;6(1):47–52. Grant P, Lipscomb D. How often do we ask about erectile dysfunction in the diabetes review clinic? Development of a neuropathy screening tool. Acta Diabetol 2009;46(4):285–90. Morling JR, et al. Prevalence of abnormal plasma liver enzymes in older people with type 2 diabetes. Diabet Med 2012;29(4):488–91. Boyer S, Kapur V. Obstructive sleep apnoea: its relevance in the care of diabetic patients. Clin Diabetes 2002;20(3):126–32. Royal College of General Practitioners, NHS Diabetes. Diagnosis, classification and treatment of diabetes. BMJ 2011;342:597–8. UK National Screening Committee. www.screening. nhs.uk/criteria [accessed 14 May 2012]. Grant P. Performance management in medical outpatients: the clinical endocrinology experience. Int J Clin Leadership 2011;17(2):83–85(3).
Association of British Clinical Diabetologists (ABCD) Autumn Meeting
8–9 November 2012, The Royal College of Physicians, London
Programme details include: • New models of care for long-term conditions – Sir John Oldham • What have we learnt over the last decade about managing T1 diabetes and sport? – Dr Ian Gallen • Complementary and alternative medicine for diabetes – Professor Edzard Ernst • Results of the ABCD sponsored hypoglycaemia audit – Dr Adrian Scott • Investigation and management of severe disorders of insulin sensitivity – Dr Robert Semple • The ABCD debate: this house believes that surrogate markers are of no use in evaluating treatments in diabetes – Professor John Yudkin v Dr M Angelyn Bethel For further information and to register please contact Elise Harvey email: [email protected] or visit www.diabetologists.org.uk
278
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
Performance management in clinical diabetes: are the Diabetes UK ‘15 health care essentials’ a good enough measure of the standard of diabetes care?
Dr Paul Grant
MBBS, MSc, MRCP, Specialist Registrar Diabetes & Endocrinology
Abstract
Dr Masud Haq
BSc, MBBS, MD, FRCP, Consultant Diabetologist
Dr Dennis Barnes
MB, FRCP, Consultant Diabetologist Department of Diabetes & Endocrinology, Tunbridge Wells Hospital,Pembury, Kent, UK
Correspondence to: Dr Paul Grant, Department of Diabetes & Endocrinology, Tunbridge Wells Hospital, Pembury, Kent TN2 4QJ, UK; email: drpaul.grant@doctors. org.uk Received: 2 July 2012 Accepted in revised form: 2 August 2012
Having the right care is essential for the wellbeing of all people with diabetes. There is a minimum level of health care that every person with diabetes should expect. In 2010, Diabetes UK produced a list of 15 essential checks and services that people with diabetes should expect to receive. We wanted to assess whether we were adequately achieving all of these targets in our own diabetes service and assess whether the targets were themselves adequate and appropriate. We retrospectively reviewed the medical records of 200 randomly selected patients attending the diabetes review clinic in a district general hospital. We recorded whether the parameters outlined in the Diabetes UK ‘15 health care essentials’ had been achieved in the last 12 months and then collated the data. The data showed that we scored well in terms of monitoring HbA1c, blood pressure, body mass index, retinal screening and cholesterol. However, we scored sub-optimally in terms of the following parameters: smoking cessation, pregnancy planning, structured education, measurement of waist circumference and psychological assessment. In conclusion, the Diabetes UK ‘essentials’ checklist may be viewed as mechanistic, but it provides a useful starting point to assess the effectiveness of a diabetes service in providing the basics of patient care in much the same way as the WHO surgical checklist reduces adverse outcomes. We have been able to see where the deficiencies in our own service lie and have made amends to ensure that these areas are covered in future. One issue that arose is that there are certain other ‘essentials’ that would be good to include in such a checklist, such as: erectile dysfunction (as suggested by the NICE guidelines), obstructive sleep apnoea, vitamin D deficiency, neuropathy screening and monitoring of liver function to rule out incipient steatohepatitis/fatty liver disease. Copyright © 2012 John Wiley & Sons. Practical Diabetes 2012; 29(7): 275–278
Key words
health care standards; diabetes service; performance management; Diabetes UK essentials
Diabetes UK has developed a checklist of the basic standards of care that a person with diabetes should expect to receive from their health care provider as a minimum on an annual basis (Table 1).1 The diabetes review clinic in secondary care is arguably the best opportunity for providing a holistic assessment of a patient with diabetes, and aims to screen for and reduce the likelihood of the development of diabetesrelated complications. We have previously done some work around the development of a ‘perfect’ diabetes review2,3 and the National Institute for Health and Clinical Excellence (NICE) quality standards,4 and acknowledge that there are many factors that need to be monitored and recorded during
Introduction
each clinical encounter; these include but are not limited to the ‘9 key care processes’ that the Department of Health states should occur for all patients with diabetes.5 Diabetes UK previously undertook a survey of 7134 people with diabetes (32% type 1, 66% type 2) to ask whether they had had these ‘essential’ checks within the last year. The results were very revealing demonstrating that 6% of patients did not have an HbA1c blood test, 11% of patients did not have retinal screening, 25% of patients did not have their feet checked, 35% of people had never been offered any education about their diabetes, and 62% of patients had not developed a care plan with their health care professionals to meet their individual needs.1
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
275
Original article
Performance management in clinical diabetes
We wanted to explore whether our own clinical practice was favourable and if we were we achieving the ‘15 essentials’ the majority of the time in our own patient population. The question that leads on from this is whether the essentials checklist itself is adequate and appropriate, as it may be missing other important diabetesrelated problems such as erectile dysfunction, for example, which is an important diabetes-related cardiovascular risk factor and has been recommended for inclusion into yearly diabetes screening by NICE.6 We developed a score sheet based on the 15 ‘essentials’ and modified it for our own practice to allow us to record data from clinical encounters. The 15 ‘essentials’ include measures that may not be applicable to all patients such as pregnancy planning in females and standards of hospital care in those patients who may have been admitted. Also, this was an adults-only group as we are separate from the paediatric services. We therefore adjusted our data capture accordingly. We then retrospectively reviewed the medical records of 200 patients who had been seen in the diabetes review clinic (prior to our awareness of the Diabetes UK 15 ‘essentials’ list) between October 2011 and March 2012, and marked whether they had documented evidence of the above care processes or investigations taking place. Subsequently we compiled the data to calculate a percentage for how successful we were on meeting each of the parameters. We then compared our results with the results of a national patient survey based on the 15 ‘essentials’ to compare how we fared, and looked for deficiencies in our practice and potential areas for improvement. From a review of 200 patient records attending the diabetes review clinic in a secondary care setting we discovered that we had outperformed all but one of the results from the national survey, as demonstrated in Figure 1. In our population we discovered that we had
Study aims
Methods
1. Get your blood glucose levels measured at least once a year. An HbA1c blood test will measure your overall blood glucose control and help you and your diabetes health care team set your own target 2. Have your blood pressure measured and recorded at least once a year, and set a personal target that is right for you 3. Have your blood fats (cholesterol) measured every year. Like blood glucose levels and blood pressure, you should have your own target that is realistic and achievable 4. Have your eyes screened for signs of retinopathy every year. Using a specialised digital camera, a photo of each eye will be taken and examined by a specialist who will look for any changes to your retina (the seeing part at the back of your eye) 5. Have your feet checked – the skin, circulation and nerve supply of your feet should be examined annually. You should be told if you have any risk of foot problems, how serious they are and if you will be referred to a specialist podiatrist or specialist foot clinic 6. Have your kidney function monitored annually. You should have two tests for your kidneys: urine test for protein (a sign of possible kidney problems) and a blood test to measure kidney function 7. Have your weight checked and have your waist measured to see if you need to lose weight 8. Get support if you are a smoker, including advice and support on how to quit. Having diabetes already puts people at increased risk of heart disease and stroke, and smoking further increases this risk 9. Receive care planning to meet your individual needs – you live with diabetes every day so you should have a say in every aspect of your care. Your yearly care plan should be agreed as a result of a discussion between you and your diabetes health care team, where you talk about your individual needs and set targets 10. Attend an education course to help you understand and manage your diabetes. You should be offered and have the opportunity to attend courses in your local area 11. Receive paediatric care if you are a child or young person. You should receive care from specialist diabetes paediatric health care professionals. When the time comes to leave paediatric care, you should know exactly what to expect so you have a smooth change over to adult health services 12. Receive high-quality care if admitted to hospital. If you have to stay in hospital, you should still continue to receive high-quality diabetes care from specialist diabetes health care professionals, regardless of whether you have been admitted due to your diabetes or not 13. Get information and specialist care if you are planning to have a baby as your diabetes control has to be a lot tighter and monitored very closely. You should expect care and support from specialist health care professionals at every stage from preconception to post-natal care 14. See specialist diabetes health care professionals to help you manage your diabetes. Diabetes affects different parts of the body and you should have the opportunity to see specialist professionals such as an ophthalmologist, podiatrist or dietitian 15. Get emotional and psychological support. Being diagnosed with diabetes and living with a long-term condition can be difficult. You should be able to talk about your issues and concerns with specialist health care professionals
Table 1. The Diabetes UK ‘15 health care essentials’ list
Results
missed the following essentials: 6% of patients did not have a blood pressure check; 10% of patients did not have monitoring of their renal function; 0% of patients had their waist circumference measured – however, only 9% of patients had not had their body weight recorded; 45% of patients did not have recorded documentation of smoking status or a discussion relating to smoking cessation; 70% of patients did not have their psychological issues broached; and 20% of
patients did not appear to have been offered structured education. On the plus side, we scored well in terms of discussing and documenting a clinical plan for the patients, something which appeared to be in stark contrast to the national survey results which was only 38% of patients. This retrospective study was a useful piece of reflective work to assess our practice. It allowed us to recognise
Discussion
276
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
Original article
Performance management in clinical diabetes
and record how we were performing with regard to a series of recommended annual checks for the care of patients with diabetes. For several of the parameters there are good reasons why the success rate was relatively low. These include: patients not having a blood test; unexpected absence of clinical support workers to perform routine observations; lack of cartridges for the DCA HbA1c analyser; lack of necessity to document an essential that may have already been recorded and dealt with in the past – for example, smoking status, previous attendance on an education course, mental health problems. Arguably, one does not need to keep checking some of the essentials on every visit. We appeared to do well in terms of monitoring HbA1c, blood pressure, lipid status, foot checks and body weight/BMI, scoring 90% and over. However, for other factors such as renal monitoring, waist circumference measurement, smoking cessation support and enquiring about pregnancy planning, we appear to be sub-optimal in our performance. This is useful to know as it provides a baseline reference score which we can compare to in future as we attempt to improve the success rates for each of the important variables. We recorded waist circumference in 0% of patients and would argue against the utility of this particular measure in clinical practice, finding BMI rather than weight or waist measurement per se as a better guide to morbidity and prognostication. Even better than BMI is the use of an obesity staging criteria, which would be useful in a significant number of our patients, and represents a much better way of assessing obesity and all of its related co-morbidities. We agree that the use of a checklist in clinical practice may be viewed as terribly reductionist and dehumanising, but checklists are a considerative approach to ensuring that we are not missing out on a vital part of the diabetes MOT. Many will agree that checking is one thing, but doing something about it is another. Look, for example, at the disparities in the provision of specialist diabetes psychologists or the local availability of DAFNE courses.
National Local (PG) 100 90 80 Percentage of patients 70 60 50 40 30 20 10 0
c A1 ure Hb ress p od Blo
al ol es Ey ster Ren ole Ch
l r y n et ht ke ing ica Fe eig catio nanc mo lann olog g W du S p h E Pre yc re Ps Ca
Figure 1. Graph to compare the percentage of patients who had received the Diabetes UK ‘essentials’ checks while attending the adult diabetes secondary care service (national versus local [PG])
With regard to the ongoing management of our patients, guidelines are helpful, but they are often rigid and are not context specific. Individualised care and treatment to target are important issues. In terms of HbA1c, for example, there has long been an argument for more frequent monitoring (to relate to up-titration of diabetes therapies) as well as the use of ‘longitudinal HbA1c’ to track changes over time and act as a goal for intervention rather than just a simple recording of the occurrence of the test.7 We also feel that there are several other ‘essential’ factors which we consider should be recognised as being important to measure as part of the ongoing care for patients with diabetes. • Erectile dysfunction – hypogonadism is common in type 2 diabetes. It is an important cardiovascular risk factor and has been recommended by NICE for inclusion in the diabetes annual review.6,8 • Liver function tests – the prevalence of abnormal liver function tests in patients with type 2 diabetes is high, with only modest variation between defined patient groups. The prognostic significance is as yet unclear, but many argue that routine monitoring is important in our patient population.9 • Obstructive sleep apnoea – OSA and diabetes are conditions that
frequently co-exist and overlap. Prevalence is high in older and obese patients and, arguably, screening with close questioning or an Epworth sleepiness scale would be appropriate.10 • Classification of diabetes type – a recent Royal College of General Practitioners and NHS Diabetes systematic review on the miscoding and misclassification of patients with type 1 diabetes misdiagnosed as type 2 and vice versa found that as many as 10–15% of patients are not identified correctly and, as such, may be receiving the wrong type of treatment. It is also common for patients with MODY (maturity onset diabetes of the young) to be misdiagnosed (up to 5%) with type 1 diabetes and unnecessarily receiving insulin.11 • Contraceptive advice to women of child bearing age who are not planning pregnancies. The Diabetes UK health care essentials include giving advice to women who are planning a pregnancy, but do not mention the provision of contraceptive advice to those women who do not wish to become pregnant. This is important given the increased risks in unplanned pregnancies in diabetes. If one considers the criteria for appraising the viability, effectiveness and appropriateness of including the above as a part of a screening
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
277
Original article
Performance management in clinical diabetes
programme, then they certainly appear to fulfil the requirements of the UK national screening service.12 Our goal is to repeat our modified ‘essential’ checklist in every diabetes consultation and then continue to analyse the results, but in a prospective manner. We can then use run charts to regularly monitor how we are doing. The extra checks as suggested above will also be included to assess how relevant they may be for our own patient population. A potential danger is that a diabetes review becomes too unwieldy for clinical practice, so maybe it is also time to rethink the way in which we deliver the diabetes review clinic. Is it time to consider the two-stop shop? Integrating more with primary care? Co-creating health? And is there scope for a national consensus or a standardised approach over and above the Diabetes UK model? And a final point is that we have not even started to touch on the subject of outcomes… It is important to monitor, measure and learn from one’s own clinical practice.13 We have shown that the Diabetes UK ‘15 health care essentials’ are a useful starting point to ensure that we are not missing out important screening checks for patients attending our service. Arguably, some essentials are more ‘essential’ than others and some of them may not necessarily need to be CONFERENCE NOTICE
Key points
l The Diabetes UK ‘15 health care essentials’ checklist was designed for patients to ensure that they are receiving all the correct checks, treatment and screening tests to optimise their diabetes care l The secondary care diabetes review clinic has a variety of formats and content and can differ significantly depending on local circumstances. The benefits of using such a checklist would be both to reduce variation in care and to ensure a thorough evaluation of the patient’s diabetes-related issues l We compared our clinical performance with the national data from Diabetes UK and found that, while we were undertaking the majority of the checks well, there were areas for improvement. The checklist has now been modified to include a few extras and has been adopted into routine clinical practice
our data annually to strive for continual improvement in care delivery. Many thanks to the South East Thames Diabetes Consultants’ group and the Young Diabetologists Forum. There are no conflicts of interest declared.
1.
Acknowledgments
Declaration of interests
References
2. 3. 4. 5. 6. 7.
Conclusion
enquired about at every annual review. For example, we do not need to ask someone every time they attend if they are still a non-smoker, or to ask about structured education if they are already a DAFNE graduate, or to ask about pregnancy planning if they are a man, or how their hospital inpatient diabetes care was if they were not admitted etc. It is also important to recognise that there are some new essentials that fulfil the criteria for valid inclusion into our diabetes screening service and we hope to re-analyse
8.
9. 10. 11. 12. 13.
Diabetes UK 15 Healthcare Essentials. www. diabetes.org.uk/15-essentials [accessed 1 May 2012]. Grant P. The perfect Diabetes Review. Prim Care Diabetes 2010;4(2):69–72. Grant P, Lipscomb D. Pursuing perfection in the diabetes review clinic. Diabet Med 2012;29(Suppl s1):497. Grant P. The NICE quality standards for diabetes care: a critical analysis. Pract Diabetes 2011;28(5):208. National Diabetes Audit Executive Summary. Department of Health Gateway reference 14327. NICE Clinical Guideline 66. The management of type 2 diabetes. 2008. www.nice.org.uk/nicemedia/pdf/ CG66NICEGuideline.pdf [accessed 10 May 2012]. Rathmann W, et al. Longitudinal change in HbA1c after insulin initiation in primary care patients with type 2 diabetes: a database analysis in UK and Germany. Prim Care Diabetes 2012;6(1):47–52. Grant P, Lipscomb D. How often do we ask about erectile dysfunction in the diabetes review clinic? Development of a neuropathy screening tool. Acta Diabetol 2009;46(4):285–90. Morling JR, et al. Prevalence of abnormal plasma liver enzymes in older people with type 2 diabetes. Diabet Med 2012;29(4):488–91. Boyer S, Kapur V. Obstructive sleep apnoea: its relevance in the care of diabetic patients. Clin Diabetes 2002;20(3):126–32. Royal College of General Practitioners, NHS Diabetes. Diagnosis, classification and treatment of diabetes. BMJ 2011;342:597–8. UK National Screening Committee. www.screening. nhs.uk/criteria [accessed 14 May 2012]. Grant P. Performance management in medical outpatients: the clinical endocrinology experience. Int J Clin Leadership 2011;17(2):83–85(3).
Association of British Clinical Diabetologists (ABCD) Autumn Meeting
8–9 November 2012, The Royal College of Physicians, London
Programme details include: • New models of care for long-term conditions – Sir John Oldham • What have we learnt over the last decade about managing T1 diabetes and sport? – Dr Ian Gallen • Complementary and alternative medicine for diabetes – Professor Edzard Ernst • Results of the ABCD sponsored hypoglycaemia audit – Dr Adrian Scott • Investigation and management of severe disorders of insulin sensitivity – Dr Robert Semple • The ABCD debate: this house believes that surrogate markers are of no use in evaluating treatments in diabetes – Professor John Yudkin v Dr M Angelyn Bethel For further information and to register please contact Elise Harvey email: [email protected] or visit www.diabetologists.org.uk
278
PRACTICAL DIABETES VOL. 29 NO. 7
COPYRIGHT © 2012 JOHN WILEY & SONS
