using audit support.doc

Audit support: Clinical (NICE clinical guideline 87) Type 2 diabetes (2009) of 29

Audit supportIssue date: [Year]Short title of guidelineNICE clinical guideline [XX]

Type 2 diabetes

Audit support(clinical criteria)

Implementing NICE guidance

2009

NICE clinical guideline 87

This audit support accompanies the clinical guideline: ‘Type 2 diabetes’

(available online at www.nice.org.uk/CG87).

Issue date: 2009

This is a support tool for clinical audit based on the NICE guidance.

It is not NICE guidance.

Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.

National Institute for Health and Clinical Excellence

MidCity Place, 71 High Holborn, London WC1V 6NA; www.nice.org.uk

© National Institute for Health and Clinical Excellence, 2009. All rights reserved. This

material may be freely reproduced for educational and not-for-profit purposes. No

reproduction by or for commercial organisations, or for commercial purposes, is

allowed without the express written permission of the Institute.


Using audit supportThe audit support document can be used to measure current practice in type

2 diabetes against the recommendations in the NICE guideline. Use it for a

local audit project, by either using the whole tool or cutting and pasting the

relevant parts into a local audit template.

Audit criteria and standards are based on the guideline’s recommendations.

The standards given are typically 100% or 0%. If these are not achievable in

the short term, set a more realistic standard based on discussions with local

clinicians. However, the standards given remain the ultimate objective.

The data collection tool can be used or adapted for the data collection part of

the clinical audit cycle by the trust, service or practice. The tool is based on

the recommendations relating to clinical criteria Organisational criteria are

covered in a separate document. Data may be required from a range of

sources, including policy documents and patient records. Suggestions for

these are indicated on the tools, although this is not an exhaustive list and

they may differ in your organisation.

The relevant group for this audit is adults with type 2 diabetes. Select an

appropriate sample in line with your local clinical audit strategy.

Whether or not the audit results meet the standard, re-auditing is a key part of

the audit cycle. If your first data collection shows room for improvement, re-

run it once changes to the service have had time to make an impact. Continue

with this process until the results of the audit meet the standards.

Links with other national prioritiesThe audit based on this guideline should be considered in conjunction with

other national priorities:

It is suggested that the audit based on this guideline is considered in

conjunction with other national priorities such as the National Diabetes Audit

and the audit criteria developed from ‘Depression: management of depression

in primary and secondary care’ (NICE clinical guideline 23)


http://www.nice.org.uk/cg023

Clinical criteria for ‘Type 2 diabetes’

Patient education

Criterion 1 Patients should receive patient education.

Exceptions None

Standard 100%

Definitions Structured education should be offered to every person and/or their carer at and around the time of diagnosis with annual reinforcement and review. Patient education programmes should meet the criteria laid down by the Department of Health and Diabetes UK Patient Education Working Group.

According to the Department of Health and Diabetes UK, structured patient education means that there is a planned course that:

has a structured, written curriculum

has trained educators

is quality assured

is audited.

See organisational criterion 1 for more details.

Dietary advice

Criterion 2Patients should receive nutritional advice from a healthcare professional with expertise and competencies in nutrition.

Exceptions None

Standard 100%

Definitions None

Glucose control levels

Criterion 3

The individual’s HbA1c levels should be measured at:

2–6-monthly intervals until the blood glucose level is stable on unchanging therapy

6-monthly intervals once the blood glucose level and blood glucose-lowering therapy are stable.

Exceptions None

Standard 100%

Definitions A measurement made at an interval of less than 3 months should be used as an indicator of direction of change, rather than as a new steady state.


http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4113213

Criterion 4

Unexplained discrepancies between HbA1c and other glucose measurements should be investigated.

Advice should be sought from a team with specialist expertise in diabetes or clinical biochemistry.

Exceptions None

Standard 100%

Definitions None

Self-monitoring of plasma glucose

Criterion 5

Assess at least annually:

self-monitoring skills

the quality and appropriate frequency of testing

the use made of the results obtained

the impact on quality of life

the continued benefit

the equipment used.

Exceptions A.Person has been in contact with the service for less than 1 year.

Standard 100%

Definitions None

Blood-glucose-lowering therapy

Metformin

Criterion 6Metformin treatment should be started in a person who is overweight or obese, and whose blood glucose is inadequately controlled by lifestyle interventions (nutrition and exercise) alone.

Exceptions None

Standard 100%

Definitions The assessment should be tailored according to ethnic group.


Criterion 7Metformin should be continued if blood glucose control remains or becomes inadequate and another oral glucose-lowering medication (usually a sulfonylurea) is added.

Exceptions None

Standard 100%

Definitions None

Criterion 8Metformin therapy should be stepped up gradually over weeks to minimise risk of gastrointestinal side effects.

Exceptions None

Standard 100%

Definitions Local clinical advice should be sought as to an appropriate timescale for this.

Criterion 9

The dose of metformin should be reviewed if the serum creatinine exceeds 130 micromol/litre or the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73-m2.

Metformin should be stopped if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30 ml/minute/1.73-m2.

Exceptions None

Standard 100%

Definitions None

Sulfonylureas

Criterion 10A sulfonylurea should be added as second-line therapy when blood glucose control remains or becomes inadequate with metformin.

Exceptions None

Standard 100%

Definitions None

Criterion 11A sulfonylurea should be continued if blood glucose control remains or becomes inadequate and another oral glucose-lowering medication is added.

Exceptions None

Standard 100%

Definitions None


Criterion 12A once-daily, long-acting sulfonylurea should only be offered if drug concordance is a problem.

Exceptions None

Standard 100%

Definitions None

Criterion 13People being treated with an insulin secretagogue should be educated about the risk of hypoglycaemia.

Exceptions None

Standard 100%

Definitions None

DPP-4 inhibitors (sitagliptin, vildagliptin)

Criterion 14

NEW

DPP-4 inhibitor therapy should only be continued if the person has had a reduction of at least 0.5 percentage points in HbA1c in 6 months.

Exceptions None

Standard 100%

Definitions None

Thiazolidinediones (glitazones)

Criterion 15

NEW

Thiazolidinediones should not be commenced or continued in people who have heart failure, or who are at higher risk of fracture.

Exceptions None

Standard 100%

Definitions None

Criterion 16

NEW

Thiazolidinedione therapy should only be continued if the person has had a reduction of at least 0.5 percentage points in HbA1c in 6 months.

Exceptions None

Standard 100%

Definitions None


Exenatide

Criterion 17

NEW

GLP-1 mimetic (exenatide) therapy should be continued if the person has had a reduction of at least 1.0 percentage point in HbA1c and a weight loss of at least 3% of initial body weight at 6 months.

Exceptions None

Standard 100%

Definitions The BMI advice should be tailored for other ethnic groups.

Acarbose

Criterion 18Acarbose should only be prescribed for people unable to use other glucose-lowering medications.

Exceptions None

Standard 100%

Definitions None

Insulin therapy

Criterion 19

When starting basal insulin therapy:

continue with metformin and the sulfonylurea (and acarbose, if used)

review the use of the sulfonylurea if hypoglycaemia occurs.

Exceptions None

Standard 100%

Definitions When other measures no longer achieve adequate blood glucose control (to HbA1c < 7.5% or other higher level agreed with the individual) discuss the benefits and risks of insulin therapy.

Criterion 20

When starting pre-mixed insulin therapy or mealtime plus basal insulin regimens:

continue with metformin

continue the sulfonylurea initially, but review and discontinue if hypoglycaemia occurs.

Exceptions None

Standard 100%

Definitions When other measures no longer achieve adequate blood glucose control (to HbA1c < 7.5% or other higher level agreed with the individual) discuss the benefits and risks of insulin therapy.


Criterion 21Insulin therapy should begin with human NPH insulin, taken at bed-time or twice daily according to need.

Exceptions B. Where a long-acting insulin analogue (insulin glargine) is used for a person who falls into one of the following categories:

- those who require assistance from a carer or healthcare professional to administer their insulin injections

- those whose lifestyle is significantly restricted by recurrent symptomatic hypoglycaemic episodes

- those who would otherwise need twice-daily basal insulin injections in combination with oral glucose-lowering medications.

C. Where twice-daily biphasic human insulin (pre-mix) regimens are used (once daily may be an option when initiating this therapy).

D. Where pre-mixed preparations of insulin analogues rather than pre-mixed human insulin preparations are used when:

- immediate injection before a meal is preferred

- hypoglycaemia is a problem

- there are marked postprandial blood glucose excursions.

Standard 100%

Definitions None

Criterion 22

NEW

People on a basal insulin regimen* should be monitored for the need for short-acting insulin before meals (or a pre-mixed insulin preparation).

Exceptions None

Standard 100%

Definitions *NPH insulin or a long-acting insulin analogue (insulin detemir, insulin glargine)

Criterion 23

NEW

People who are using pre-mixed insulin once or twice daily should be monitored for the need for a further injection of short-acting insulin before meals or for a change to a regimen of mealtime plus basal insulin, based on NPH insulin or long-acting insulin analogues (insulin detemir, insulin glargine), if blood glucose control remains inadequate.

Exceptions None

Standard 100%

Definitions None


Blood pressure management

Criterion 24Blood pressure should be measured at least annually in a person without previously diagnosed hypertension or renal disease.

Exceptions None

Standard 100%

Definitions None

Criterion 25

If a person is on antihypertensive therapy at diagnosis:

blood pressure control and medication use should be reviewed

changes should be made only if the blood pressure is poorly controlled or current medications are inappropriate because of microvascular complications or metabolic problems.

Exceptions None

Standard 100%

Definitions None

Criterion 26

If a person is not hypertensive, does not have renal disease and their blood pressure is over the target, the measurement should be repeated at the following intervals:

within 1 month if > 150/90 mmHg

within 2 months if > 140/80 mmHg

within 2 months if > 130/80 mmHg and kidney, eye or cerebrovascular damage.

Exceptions None

Standard 100%

Definitions None

Criterion 27 A blood pressure target of < 140/80 mmHg should be set.

Exceptions E. Where the person has kidney, eye or cerebrovascular damage a target of < 130/80 mmHg should be set.

Standard 100%

Definitions None


Criterion 28

If a person’s blood pressure reaches and consistently remains at, the target they should be:

monitored every 4–6 months

checked for possible adverse effects of antihypertensive therapy.

Exceptions F. Person has been in contact with health services for less than 4 months.

Standard 100%

Definitions None

Cardiovascular risk estimation

Criterion 29

People should be considered to be at high premature cardiovascular risk for their age unless they:

are not overweight, tailoring this assessment according to ethnic group

are normotensive (< 140/80 mmHg in the absence of antihypertensive therapy)

do not have microalbuminuria

do not smoke

do not have a high-risk lipid profile

have no history of cardiovascular disease and

have no family history of cardiovascular disease.

Exceptions None

Standard 100%

Definitions None

Criterion 30People not considered to be at high cardiovascular risk should have their cardiovascular risk estimated annually using the UK Prospective Diabetes Study (UKPDS) risk engine.

Exceptions A. Person has been in contact with the service for less than 1 year.

Standard 100%

Definitions See: UKPDS risk engine. Available from: www.dtu.ox.ac.uk/index.php?maindoc=/riskengine/


Criterion 31

A full lipid profile, including high-density lipoprotein (HDL) cholesterol and triglyceride estimations, should be performed:

when assessing cardiovascular risk after diagnosis

annually

before starting lipid-modifying therapy.

Exceptions None

Standard 100%

Definitions None

Management of blood lipids

Statins and ezetimibe

Criterion 32

Cardiovascular risk status should be reviewed annually by assessment of cardiovascular risk factors, including features of the metabolic syndrome and waist circumference, and change in personal or family cardiovascular history.

Exceptions A. Person has been in contact with service for less than 1 year.

Standard 100%

Definitions None

Criterion 33

For people aged 40 or older:

therapy should be initiated with:

generic simvastatin (to 40 mg) or

a statin of similar efficacy and cost.

Exceptions G. Where cardiovascular risk from non-hyperglycaemia-related factors is low.

Standard 100%

Definitions None

Criterion 34

For people aged 40 or older:

if the cardiovascular risk from non-hyperglycaemia-related factors is low, cardiovascular risk should be assessed using the UKPDS risk engine

simvastatin therapy (to 40 mg), or a statin of similar efficacy and cost, should be initiated if the cardiovascular risk exceeds 20% over 10 years.

Exceptions None

Standard 100%

Definitions None


Criterion 35

People on cholesterol-lowering therapy should have their lipid profile, together with other modifiable risk factors and any new diagnosis of cardiovascular disease, assessed 1–3 months after starting treatment, and annually thereafter.

Exceptions None

Standard 100%

Definitions None

Criterion 36 In anyone on simvastatin the dose should be increased to 80 mg daily.

Exceptions H. Total cholesterol level is below 4.0 mmol/litre.

I. Low-density lipoprotein cholesterol level is below 2.0 mmol/litre.

J. People who have not had an assessment 1–3 months after initiating treatment.

Standard 100%

Definitions None

Criterion 37If there is a possibility of a woman becoming pregnant, statins should not be used unless the issues have been discussed with the woman and agreement has been reached.

Exceptions None

Standard 100%

Definitions None

Fibrates

Criterion 38If there is a history of elevated serum triglycerides, annual cardiovascular risk assessments should include a full fasting lipid profile (including HDL cholesterol and triglyceride estimations).

Exceptions None

Standard 100%

Definitions None

Criterion 39Possible secondary causes of high serum triglyceride levels should be assessed.

Exceptions None

Standard 100%

Definitions Causes could include poor blood glucose control (others include hypothyroidism, renal impairment and liver inflammation, particularly from alcohol).


Criterion 40A fibrate should be prescribed if triglyceride levels remain above 4.5 mmol/litre. Fenofibrate should be the first-line fibrate.

Exceptions None

Standard 100%

DefinitionsIn some circumstances, this will be before a statin has been started because of acute need (that is, risk of pancreatitis) and because of the undesirability of initiating two drugs at the same time.

Anti-thrombotic therapy

Criterion 41 People should be receiving low-dose daily aspirin if they are:

aged 50 or over with blood pressure (BP) under 145/90 mmHg or

aged under 50 with significant cardiovascular risk factors.

Exceptions K. People who declined to take low-dose daily aspirin.

Standard 100%

Definitions Low-dose daily aspirin: 75 mg.

Significant cardiovascular risk factors: features of the metabolic syndrome, strong early family history of cardiovascular disease, smoking, hypertension, extant cardiovascular disease, microalbuminuria.

Criterion 42 Clopidogrel should only be prescribed to people with a clear aspirin intolerance.

Exceptions None

Standard 100%

Definitions None

Kidney damage

Criterion 43 The following should be carried out annually:

albumin:creatinine ratio (ACR) estimation on first-pass urine sample or spot sample if necessary

serum creatinine measurement

GFR estimate.

Exceptions A. People who have been in contact with the service for less than 1 year.

Standard 100%

Definitions None


Criterion 44 If ACR is abnormal:

the test should be repeated at the next two clinic visits and within 3–4 months

microalbuminuria should be confirmed if at least one of the further tests is also abnormal.

Exceptions None

Standard 100%

Definitions Abnormal ACR = ACR > 2.5 mg/mmol for men and > 3.5 mg/mmol for women.

Eye damage

Criterion 45 Eye screening should be performed at or around the time of diagnosis.

Exceptions None

Standard 100%

Definitions None

Criterion 46 Eye screening should be repeated at least annually.

Exceptions A. People who have been in contact with the service for less than 1 year.

Standard 100%

Definitions None

Criterion 47 A person should be referred1 to an ophthalmologist if any of the following features are present.

Referable maculopathy:

- exudate or retinal thickening within one disc diameter of the centre of the fovea

- circinate or group of exudates within the macula2

- any microaneurysm or haemorrhage within one disc diameter of the centre of the fovea if associated with a best visual acuity of 6/12 or worse.

Referable pre-profilerative retinopathy:

- venous beading

- venous loop or reduplication

- intraretinal microvascular abnormalities

- multiple deep, round or blot haemorrhages.

Unexplained drop in visual acuity.

Exceptions None

Standard 100%

Definitions1 Patients should be referred in accordance with the National Screening Committee criteria and timelines.


2 The macula is defined here as a circle centred on the fovea, with a diameter the distance between the temporal border of the optic disc and the fovea.

Neuropathic pain

Criterion 48 Neuropathic symptoms should be recorded annually.

Exceptions None

Standard 100%

Definitions None

Person-centred care

Criterion 49 People should be offered:

written information about their illness or condition

written information about the treatment and care they should be offered, including the ‘Understanding NICE guidance’ booklet

written information about the service providing their treatment and care

structured education at and around the time of diagnosis with annual reinforcement and review (they should be informed that this is an integral part of diabetes care).

Exceptions None

Standard 100%

Definitions Patients should be offered written information to help them make informed decisions about their healthcare. This should cover the condition, treatments and the health service providing care. Information should be available in formats appropriate to the individual, taking into account language, age, and physical, sensory or learning disabilities.

Number of criterion replaced:

Local alternatives to above criteria (to be used where other data addressing the same issue are more readily available).

Exceptions

Standard

Definitions


http://www.nice.org.uk/Guidance/CG66/PublicInfo/pdf/English

Complete one form for each patient.

Patient identifier: Sex: M / F Age: Ethnicity:

Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Patient education

1 1.1 Is the person receiving patient education?

(Data source: patient record)

1.1

Dietary advice

2 2.1 Has the person received nutritional advice? 1.2.1

2.2 Did the healthcare professional giving the advice have expertise and competencies in nutrition?


1.2.1.1

Glucose control levels

3 3.1Is the person’s blood glucose level stable?

(Data source: patient record)1.3.2

3.2 The person’s levels were measured at:

……………………… …………………………… ………………………….(Data source: patient record)

4 4.1Are there any unexplained discrepancies between HbA1c and other glucose measurements?

1.3.6

4.2

If yes, was advice sought from a team with specialist expertise in diabetes or clinical biochemistry?


Self-monitoring of plasma glucose

5Have the following been assessed in the last 12 months:

A1.4.3

5.1 self-monitoring skills?

5.2 the quality and appropriate frequency of

testing?

5.3 the use made of the results obtained?

5.4 the impact on quality of life?

5.5 the continued benefit?

5.6 the equipment used?



Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Blood-glucose-lowering therapyMetformin

6 6.1 Is the person receiving metformin treatment? 1.5.1

6.2 Is the person overweight or obese? 1.5.1.1/1.5.1.2

6.3Has the person’s blood glucose been controlled by lifestyle interventions?

(Data source: patient record)1.5.1.1

7 7.1Has blood glucose remained or become inadequate while the person has been receiving metformin?

1.5.1.37.2Has another oral glucose-lowering medication been added?

7.3If yes to either, has metformin been continued?


8 8.1Has metformin therapy been gradually stepped up over weeks?


9 Has:

1.5.1.5

Serum creatinine exceeded:

9.1 - 130 micromol/litre?

9.2 - 150 micromol/litre?

Estimated glomerular filtration rate (eGFR) dropped below:

9.3 - 45 ml/minute/1.73-m2?

9.4- 30 ml/minute/1.73-m2?

(Data source: patient record)Has the metformin:

9.5 been stopped?

9.5 been reduced in dosage?

(Data source: patient record/drug chart)

Sulfonylureas

10 10.1Has blood glucose control stayed or become inadequate while on metformin?

1.5.2.210.2

Has another oral glucose-lowering medication been added to the metformin treatment?


11 11.1Is the person’s blood glucose control inadequate?

1.5.2.3

11.2Has another oral glucose-lowering `medication been added?

11.3Has the sulfonylurea been continued?


12 12.1Is drug concordance a problem for the person?

1.5.2.512.2

If yes, have they been offered a daily, long-acting sulfonylurea?


13 13.1Has the person been educated about the risk of hypoglycaemia?



DPP-4 inhibitors (sitagliptin, vildagliptin)

14Is the person receiving DPP-4 inhibitor therapy?

1.6.1.4

If yes, have they had a reduction of at least 0.5 percentage points in HbA1c in 6 months?

Thiazolidinediones (glitazones)

15 15.1Is the person being prescribed a thiazolidinedione?

1.6.2.4

15.2 Does the person have heart failure?

15.3Has the person’s fracture risk been assessed?

15.4Is the person at higher risk of fracture?


16 16.1

Are they receiving thiazolidinedione?

Has the person has had a reduction of at least 0.5 percentage points in HbA1c in 6 months)?

1.6.2.6

Exenatide Is exenatide being prescribed?

(Data source: drug chart)1.6.3.2

17 17.1

If yes, has the person has had: a reduction of at least 1.0 percentage

points in HbA1c in 6 months weight loss of at least 3% of initial

body weight at 6 months?

Acarbose

18 18.1Is acarbose being prescribed?

(Data source: drug chart)1.5.4.1

18.2If yes, is the person unable to use other glucose-lowering medications?


Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Insulin therapy

19 19.1Has the person been started on basal insulin therapy?

1.7.1

Is the person receiving:

1.7.1.1/1.7.1.2/1.7.1.3

19.2 metformin?

19.3 sulfonylurea?

19.4 an alpha-glucosidase inhibitor?

19.5.1Did hypoglycaemia occur after the basal insulin therapy started?

1.7.1.119.5.2

If yes, was there a change in the use of the sulfonylurea?

20 Has the person recently started:

1.7.1.220.1 pre-mixed insulin therapy?

20.2 mealtime plus basal insulin regimens?

21 21.1Did insulin therapy begin with human NPH insulin taken:

B / C / D1.7.2.3

at bed time?

twice daily?

2222.122.1

If the person is on a basal insulin regimen, have they been monitored for the need for:

short-acting insulin before meals pre-mixed insulin preparation?

1.7.2.6

23 23.1If the person is using pre-mixed insulin once or twice daily, are they being monitored for the need for:

1.7.2.7

a further injection of short-acting insuling before meals

a change to a regimen of mealtime plus basal insulin based on NPH insulin analogues if blood glucose remains inadequate


Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Blood pressure management

24 24.1 Has the person’s blood pressure been measured within the last year?

1.8.124.2 Has the person been diagnosed with

hypertension or renal disease?

25

25.1

25.2

25.3

If the person was on antihypertensive therapy at diagnosis:

was blood pressure control and medication use reviewed?

If yes:

- was the blood pressure poorly controlled?

- are current medications inappropriate because of microvascular complications or metabolic problems?


1.8.2

26 If the person is not hypertensive, were subsequent measurements repeated at the following intervals:

1.8.3

26.1 within 1 month if > 150/90 mmHg?

26.2 within 2 months if > 140/80 mmHg?

26.3 within 2 months if > 130/80 mmHg and kidney, eye or cerebrovascular damage?


27 27.1If the person has kidney, eye or cerebrovascular damage, was a target < 130/80 mmHg set?

E

1.8.627.2 If no, was a target of < 140/80 mmHg set?


28

28.1

28.2

If the person’s blood pressure reached and consistently remained at the target were they:

monitored every 4–6 months?

checked for possible adverse effects of antihypertensive therapy?


F

1.8.13


Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Cardiovascular risk estimation

29 29.1 Do the following apply to the person(if none apply, they should not be considered to be at high premature cardiovascular risk for their age):

1.9.1

29.1.1 overweight?

29.1.2 not normotensive?

- hypertensive?

- hypotensive?

29.1.3 has macroalbuminuria?

29.1.4 smokes?

29.1.5 has high-risk lipid profile?

29.1.6 has history of cardiovascular disease?

29.1.7 has family history of cardiovascular disease?


30 30.1 Is the person indicated as being at high cardiovascular risk?


1.9.230.2.1 If not, have they had their risk estimated using

the UKPDS1 risk engine?


30.2.2 Dates of the last two estimates?


A

31 31.1 Has a full lipid profile been performed:

1.9.4

31.1.1 after diagnosis when cardiovascular risk was assessed?

31.1.2 annually?

31.1.3 before starting lipid-modifying therapy?


1 UK Prospective Diabetes StudyAudit support: Clinical (NICE clinical guideline 87) Type 2 diabetes (2009) of

29

Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Management of blood lipidsStatins and ezetimibe

32

32.1.1

32.1.2

32.1.3

32.1.4

Was cardiovascular risk status reviewed by assessment of cardiovascular risk factors, including:

features of the metabolic syndrome?

waist circumference?

a change in personal or family

cardiovascular history?


1.10.1.1

Dates of the last two reviews:

32.2.2 1. A

32.2.3 2.

33

33.1

If the person is aged 40 or over, was therapy initiated with a generic simvastatin?

G 1.10.1.2/

1.10.1.3

33.2 If yes, was the dose up to 40 mg?

If no, was a statin used of

33.3

33.4

- similar efficacy

- similar cost



Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

34 If the person is aged 40 or over: 1.10.1.3

34.1 Is the cardiovascular risk from non-hyperglycaemia-related factors low?

34.2 If yes, has risk been assessed using the UKPDS risk engine?


34.3 Does the cardiovascular risk exceed 20% over 10 years?

34.4 If yes, have either of the following been initiated:

34.4.1

34.4.2

simvastatin therapy?

- if yes, was the dose up to 40 mg?

33.4.3

33.4.4

A statin of

- similar efficacy

- similar cost

used?


35 35.1 Is the person on cholesterol-lowering therapy?

1.10.1.4

35.2 Have the following been assessed:1–3 months

after diagnosisAnnually

35.2.1 lipid profile?

35.2.2 other modifiable risk factors?

35.2.3 new diagnosis of cardiovascular disease?


36 36.1 Is the person on simvastatin?

1.10.1.5

36.1.1 If yes, has the dose been increased to 80 mg daily?


H / I / J

37 37.1.1 If the person is female, is there a possibility of her becoming pregnant?

37.1.2 Is she receiving a statin?

37.1.3 If yes, is there evidence that the statin was started following discussion with the person?



Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Fibrates

38 38.1Is there a history of elevated serum triglycerides?

1.10.2.1

If yes, is there evidence of annual cardiovascular risk assessments, including:

38.1.1 full fasting lipid profile?

38.1.2 HDL cholesterol?

38.1.3 triglyceride estimations?


39 39.1 Have possible secondary causes of high serum triglyceride levels been assessed?


1.10.2.2

40 40.1Are the person’s triglyceride levels above 4.5 mmol/litre?

1.10.2.340.2 If yes, has a fibrate been prescribed?

40.3

Was fenofibrate the first or only fibrate prescribed?


Anti-thrombotic therapy

41

41.1

41.2

If the person is taking low-dose daily aspirin, are they:

aged 50 or over with BP under 145/90 mmHg?

aged under 50 with significant cardiovascular risk factors?


K

1.11.1/1.11.2

42 42.1 If the person is prescribed clopidogrel, do they have an intolerance to aspirin?


1.11.3


Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Kidney damage

43Have the following been carried out in the last year:

A

1.12.343.1

ACR estimation on first-pass urine sample or spot sample if necessary?

43.2 serum creatinine measurement?

43.3 GFR estimate?

4444.1 If ACR is abnormal:

1.12.4

was the test repeated:

44.2 - at the following two clinic visits?

44.3 - within 3–4 months?

44.4 was microalbuminuria confirmed if at least

one of the further tests was also abnormal?


Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Eye screening

45 45.1Was eye screening performed at or around the time of diagnosis? 1.13.1

46 46.1 Was the eye screening repeated annually? A

47 47.1Were there features of referable maculopathy including:

1.13.9

47.1.1 exudate or retinal thickening within one disc diameter of the centre of the fovea?

47.1.2 circinate or group of exudates within the

macula?

47.1.3

any microaneurysm or haemorrhage within one disc diameter of the centre of the fovea if associated with a best visual acuity of 6/12 or worse?

47.2Were there features of referable pre-profilerative retinopathy, including:

47.2.1 venous bleeding?

47.2.2 venous loop or reduplication?

47.2.3 intraretinal microvascular abnormalities?

47.2.4 multiple deep, round or blot

haemorrhages?

47.3Was there an unexplained drop in visual acuity?

47.4If yes to any of the above, was the person referred to an ophthalmologist?

(Data source: patient record/referral form)

Neuropathic pain

48 48.1Have neuropathic symptoms been recorded annually?

1.14.2.1


Crite-rionno.

Dataitemno.

Criterion Yes NoNA/

exceptions

NICE guideline

ref.

Person-centred care

49 Was the person offered written information about:

their illness or condition

the treatment and care they should be offered

including the ‘Understanding NICE guidance’ booklet

the service providing their treatment and care

Was the person offered structured education at and around the time of diagnosis with annual reinforcement and review.

(Data source: patient records)

Patient-centred care

49.1

49.2

49.3

49.4

Data collection completed

Exception codes:

A – Person has been in contact with health service for less than 1 year.B – Where a long-acting insulin analogue (insulin glargine) is used for a person who falls into one of the following categories:

those who require assistance from a carer or healthcare professional to administer their insulin injections

those whose lifestyle is significantly restricted by recurrent symptomatic hypoglycaemic episodes

those who would otherwise need twice-daily basal insulin injections in combination with oral glucose-lowering medications.

C – Where twice-daily biphasic human insulin (pre-mix) regimens are used (once daily may be an option when initiating this therapy).D – Where pre-mixed preparations of insulin analogues rather than pre-mixed human insulin preparations are used when:

– immediate injection before a meal is preferred– hypoglycaemia is a problem– there are marked postprandial blood glucose excursions.

E – Person has kidney, eye or cerebrovascular damage and a target of < 130/80 mmHg was set.F – Person has been in contact with health service for less than 4 months.G – Cardiovascular risk from non-hyperglycaemia-related factors is low.H – Total cholesterol level is below 4.0 mmol/litre.I – Low-density lipoprotein cholesterol is below 2.0 mmol/litre.J – Person has not had an assessment 1–3 months after initiating treatment.K – Person declined to take low-dose daily aspirin.


Further informationClick here for further information on reporting and monitoring the audit of

NICE guidance in your organisation.

Supporting implementation NICE has developed tools to help organisations implement the clinical

guideline on Type 2 diabetes (listed below). These are available on our

website (www.nice.org.uk/CG87).

Costing tools

Slides highlighting key messages for local discussion.

Audit support for monitoring local practice (this document).

A practical guide to implementation, ‘How to put NICE guidance into practice:

a guide to implementation for organisations’, is also available on our website

(www.nice.org.uk/usingguidance/implementationtools).

The guidanceYou can download the guidance documents from www.nice.org.uk/CG87. For

printed copies of the quick reference guide or ‘Understanding NICE guidance’,

phone NICE publications on 0845 003 7783 or email

[email protected] and quote N1863 (quick reference guide) and/or

N1864 (‘Understanding NICE guidance’).


mailto:[email protected]

http://www.nice.org.uk/usingguidance/implementationtools

http://www.nice.org.uk/usingguidance/implementationtools/auditadvice/audit_advice.jsp

using audit support.doc

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