Diabetic Audit

Well planned audit can lead to beneficial change for both patients and clinicians. A positive attitude to completing and repeating the audit cycle provides an opportunity for the practice to improve patient care, improve work satisfaction for practice health professionals and staff and, especially in terms of the GMS contract Quality and Outcomes Framework, an opportunity to boost practice income.

Since the higher profile of systematic audit since the late 1980's and early 1990's, diabetes care has been seen as a very suitable disease for audit and patient care has benefitted greatly as a consequence.

Computer audits have made the process of audit much less onerous but this does then present the temptation for insufficient thought and discussion to follow the results of the audit. Audit results should always lead to team discussion and, where indicated, plans for improvements in patient care.

• Identify problem or issue
• Set criteria and standards
• Observe practice, collect data
• Compare performance with criteria and standards
• Implement change
• Re-audit after implementation of change

• Structures: e.g. practice register (is the known and registered prevalence in line with expectations in terms of local prevalence, adjusted for age and ethnic patient profile).
• Processes; e.g. DNA rates for diabetes clinic, reviews up to date (e.g. annual practice clinic review, retinal screening, other specific aspects such as blood pressure, HbA1c or full foot review).
• Outcomes; e.g. levels of blood pressure, HbA1c, frequency of hypoglycaemic episodes.
• Criteria:
  • Criteria which are specific and directly related to the process of patient care (such as those in the New GMS contract) are much easier to interpret and act upon.
  • More qualitative aspects such as patient knowledge and confidence are much harder to define and assess.
  • Less common outcomes such as amputations and renal failure cannot be interpreted in the practice setting as numbers are far too small, but these outcomes are very important for evaluation at district and regional level in order to plan and provide effective diabetes services locally and nationally.

Diabetes forms a part of the quality framework of the new GMS contract. The Quality Management and Analysis System (QMAS) is a national system that is being developed to support the quality and outcomes framework detailed in the GMS Contract.¹

The NICE guidelines for Type 1 and Type 2 diabetes provide audit recommendations for a detailed range of clinical aspects of care for people with diabetes, e.g.

• CHD risk: greater detail of patient clinical care, e.g. those with higher CHD risk who have been offered anti-platelet therapy (aspirin), in those who have microalbuminuria or proteinuria, the percentage of patients whose BP is equal to or below 135/75 mmHg.
• Glycaemic control: percentage of patients who have received education about self-monitoring of blood glucose, received lifestyle advice or received patient education.
• Renal: percentage of people with type 2 diabetes who have had albumin:creatinine ratio or albumin concentration measured in the last 12 months, percentage of patients with microalbuminuria or proteinuria who are receiving an ACE inhibitor.
• Eyes: for those with severe retinopathy on examination, the percentage of people who receive a specialist opinion within 4 weeks or for those with new vessels found on examination, the percentage of people who are seen by an ophthalmologist within 1 week.
• Feet: percentage of patients who have a record of an agreed management plan (including patient education) in the previous 15 months; percentage of patients with recorded diabetes with feet at high risk of ulceration who attend a podiatry service, percentage of patients with a new below ankle (and, separately, those with above ankle) amputation in the previous 12 months.

• The aim of the National Clinical Audit Support Programme (NCASP) Diabetes Project is to support the implementation of the Diabetes National Service Framework.²
• The audit recommendations within the NSF take a broader look at general patient care, including patient empowerment and support for carers and cover all the standards of the diabetes NSF. Examples of recommended audit criteria in the NSF:
  • Percentage with diabetes who have retinopathy and/or maculopathy at time of diagnosis.
  • Patient/carer experience: psychological well-being, knowledge of diabetes and its management; satisfaction with services.
  • Empowering adults with diabetes and clinical care of adults with diabetes.
  • Management of diabetic emergencies: annual incidence rates and hospital admission rates for hypoglycaemia; annual incidence rates and hospital admission rates for diabetic ketoacidosis.
  • Care of people with diabetes during hospital admission: average length of stay in hospital for hospital admissions in people with diabetes.
  • Diabetes and pregnancy: stillbirth and perinatal mortality rates and incidence of congenital malformations for both pre-existing and gestational diabetes.
  • Management of long-term complications: those who develop end-stage renal failure and are accepted for renal replacement therapy each year; angioplasty and coronary artery bypass graft rates in people known to have diabetes.
  • Health outcomes of NHS care, e.g. annual incidence of severe visual impairment, end-stage renal failure, amputation, symptomatic angina, myocardial infarction and stroke.

DiabetesE is a web-based, self-assessment tool that enables PCTs, primary care teams and specialist teams to assess the structures and processes of the diabetes services they provide.