Stepping up treatment in people with poorly controlled diabetes
In this article 
Background
Type 2 diabetes is a progressive disease characterised by insulin resistance, progressive loss of β-cell function and
reduced insulin production, leading to hyperglycaemia. The mainstay of treatment for patients with type 2 diabetes is individualised
lifestyle modification, e.g. focusing on improving diet and increasing exercise. Oral hypoglycaemic medcines are often
initiated at the time of diagnosis; metformin is first-line, followed by a sulphonylurea, and sometimes additional oral
anti-diabetes medicines, such as arcabose or pioglitazone. For many people, glycaemic control is less able to be achieved
using oral medicines alone as their diabetes progresses over time. Many of these people will eventually require insulin
to control glycaemic levels. New Zealand guidelines recommend that insulin initiation for people with type 2 diabetes can
be managed in primary care where possible, with additional support as required.
In most people with type 2 diabetes, management follows a defined pathway:
- Lifestyle modification – physical activity, dietary changes and smoking cessation advice
- Initiation of metformin
- Addition of a sulphonylurea
- Initiation of insulin, usually with the cessation of the sulphonylurea
Each step is taken when there is a lack of control despite good adherence with the previous steps. For some patients,
steps may overlap or be skipped altogether, e.g. some patients with very high HbA1c levels at diagnosis may progress straight
to insulin. In addition, other oral medicines, such as pioglitazone or acarbose, may be used as alternatives to or alongside
the more conventional medicines in some patients. New Zealand guidelines recommend that initiation of insulin should be
considered for any person with type 2 diabetes if their HbA1c level is > 64 mmol/mol, or symptoms of hyperglycaemia are
present despite appropriate treatment
Ideally, a target HbA1c level should be individually agreed upon after a discussion with the patient at the
time of their diagnosis or soon after, and then regularly revisited. Keeping HbA1c levels below this target
is a measure of good control. An HbA1c > 64 mmol/mol is considered a marker of poor control. The decision to
step up treatment, particularly to initiate insulin, needs to be balanced with other factors, such as the patient’s
age and therefore their long-term risk of complications, the patient’s ability to manage a more complex treatment
regimen, appropriate family/whānau support and the patient’s acceptance of the need for insulin.
For further information, see: “Improving
glycaemic control in people with type 2 diabetes: Expanding the primary care toolbox”, BPJ 53 (Jun, 2013)
and “Initiating
insulin in people with type 2 diabetes”, BPJ 42 (Feb, 2012).
Recommendations for this audit
The aim of this audit is to identify people with type 2 diabetes enrolled in the practice who would benefit from more
intensive management, such as the initiation of insulin.
The recommendation for the audit is that all patients with type 2 diabetes should have a predefined HbA1c target recorded
in their notes, and be undergoing lifestyle interventions and prescribed appropriate medicines, so that their HbA1c is
under their target level. Any patient who is not meeting their target HbA1c requires further assessment and should have
their treatment stepped-up as per New Zealand guidelines.
Audit Plan
Summary
Identify patients in the practice with type 2 diabetes who have an HbA1c result > 64 mmol/mol in the previous twelve
months. Assess whether they have a target HbA1c recorded in their notes. The patient’s notes should indicate that the clinician
reiterated and discussed the importance of diet and lifestyle measures and the need for proper compliance with medicines.
The clinician should also have intensified the patient’s treatment in order to reduce their glycaemic levels; this may
have involved initiation of insulin.
Criteria for a positive outcome
The patient has type 2 diabetes, has had an HbA1c result > 64 mmol/mol in the previous twelve months, and:
- Has a target HbA1c recorded in their notes, AND;
- The clinician has investigated the reason for increasing HbA1c and attempted to gain better glycaemic control by:
- Reiterating the need for adherence or diet control/ exercise, AND;
- Intensifying the patient’s treatment in order to gain better glycaemic control
Recommended audit standards
As the long-term outcomes associated with poorly controlled diabetes are severe, the standard for this audit should be
high. A recommended standard would be for 90% of patients with HbA1c > 64 mmol/mol to have had their treatment reviewed
and intensified. There should ideally be an improvement in the achieved percentage between the first and second audit cycles.
Data
Eligible people
All patients with type 2 diabetes who had an HbA1c > 64 mmol/mol at some point in the past 12 months are eligible
for this audit.
Identifying patients
You will need to have a system in place that allows you to identify these eligible patients. Many practices will be able
use their PMS reporting system, such as best practice intelligence or a similar product, to find all patients with an HbA1c > 64
mmol/mol. Alternatively, if a reporting system is not used, patients can be identified by running a ‘query’ through their
PMS system for HbA1c results > 65 mmol/mol.
Sample size
The number of eligible patients will vary according to your practice demographic. If a large number of patients are be
identified, a random sample of 20-30 patients should be taken (the first 20-30 results returned is sufficiently random
for the purposes of this audit).
Data analysis
Use the data sheet to record your data. A positive
result is any patient that has a tick in column A, B and C. Any patient without a tick in column A, B or C is a negative
outcome.
Calculate your percentage achievement by adding up the number of audited patients with a “positive result” (all those
with a tick in column D) and dividing this by the total number of patients audited.
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.
Decide on a set of priorities for change and develop an action plan to implement any changes.
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).
- Change it to an aim.
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote 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.
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
and behavior.
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:
- Is 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 practices complete the first part of the
CQI
activity summary sheet.
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, 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 practices complete
the remainder of the CQI activity summary sheet.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.