Detecting type 2 diabetes

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Background

Based on both local and international recommendations, HbA1c is now the recommended first-line test for the diagnosis of, and routine testing for, type 2 diabetes. This is a change in practice for most clinicians, who previously used glucose tests. There are only a limited number of situations when HbA1c is not appropriate, and fasting glucose or oral glucose tolerance testing should be used instead.

Recommendations

This audit addresses the use of laboratory testing in the diagnosis of type 2 diabetes. It will allow practitioners to assess their use of testing and to determine the appropriateness of tests for individual patients.

HbA1c is the recommended test for diagnosing diabetes in most people. Fasting glucose testing is indicated where the patient has a specific condition that increases the likelihood of HbA1c results being inaccurate.

HbA1c is the recommended test for diagnosing diabetes in most people. Fasting glucose testing is indicated where the patient has a specific condition that increases the likelihood of HbA1c results being inaccurate.

HbA1c may be falsely high in people:

  • With reduced red blood cell production
    • Iron, B12 deficiency
    • Renal failure
    • Bone marrow suppression (e.g. alcoholism)
  • With reduced red blood cell destruction
    • Splenectomy

HbA1c may be falsely low in people:

  • With increased red blood cell production
    • Iron or erythropoietin treatment
    • Recent transfusion (previous three months)
  • With increased red blood cell destruction
    • Haemolytic anaemias, haemoglobinopathies, e.g. sickle cell anaemia, methaemoglobinaemia
    • Thalassaemia
    • Splenomegaly
    • Chronic liver disease

Plan

Indications

Males aged over 45 years and females aged over 55 years should be tested for diabetes as part of a joint diabetes/ cardiovascular risk assessment, at least every three to five years, depending on risk. An HbA1c test should be requested for most people, and only those with a specific contraindication (to an HbA1c test) should have a fasting glucose test, without first being assessed with HbA1c.

N.B. Testing for diabetes at a younger age is recommended for people with risk factors, e.g. Maori or Pacific ethnicity, obesity; however, for the purposes of this audit, only the above group should be included in the audit population.

For full recommendations on who should be screened, see “The new role of HbA1c in diagnosing type 2 diabetes”, BPJ 42 (Feb, 2012).

Criteria for a positive outcome

  • The patient was tested for type 2 diabetes using HbA1c (Tested with HbA1c = Yes)
  • The patient was tested for type 2 diabetes using fasting glucose (Tested with HbA1c = No; Tested with fasting glucose = Yes) and:

The use of HbA1c was contraindicated for that patient (Tested with fasting glucose = Yes; Contraindication to HbA1c = Yes + Identified contraindication)

Recommended audit standards

Of the patients tested for type 2 diabetes in the last 12 months, 90% will have been tested with HbA1c or will have been tested with fasting glucose and have an appropriated contraindication to HbA1c.

Data

Eligible people

Males aged over 45 years or females aged over 55 years enrolled with the practice who have had a diabetes/ cardiovascular assessment in the previous 12 months.

Identifying patients

You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to identify patients by running a ‘query’ through their practice management software for patients who have had a CVD risk assessment in the previous twelve months. Depending on recording practices, the tests that were requested at that time can be then be found either within the query or from the patient notes.

Sample size

The number of eligible patients will vary according to your practice demographic. If you identify a large number of patients, take a random sample of 30 patients whose notes you will audit (or the first 30 results returned).

Data analysis

Use the data sheet to record your data. Calculate your percentages by taking the number of people who are a “positive result” as per the above criteria, divided by the total number of people audited (i.e. the 30 patients whose test choice was reviewed), multiplied by 100.

Identifying opportunities for CQI

Taking action

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

The plan should assign responsibility for any actions to the doctor and should include realistic timelines.

The plan should also include steps to identify any patients on citalopram not directly included in the audit but who may still benefit from review.

It may be useful to consider the following points when developing a plan for action:

Problem solving process

  • What is the problem or underlying problem(s)?
  • hange it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers

  • Identifying barriers can provide a basis for change
  • What is achievable – find out what the external
  • pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • nterventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan against the timeline at regular intervals. It may be helpful to consider the following questions:

  • s the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that the doctor completes the first part of the CQI activity summary sheet.

Undertaking a second cycle

In addition to regular reviews of progress, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that doctors complete the remainder of the CQI activity summary sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).