Following up people with diabetes

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Regular health checks are essential for people with diabetes in order to reduce the frequency and long-term impact of complications. Previously, monitoring of diabetes was supported by the “Get Checked” programme, which offered free annual health reviews to people with diabetes. This has been replaced by the Diabetes Care Improvement Package. This change has meant that the provision of care for people with diabetes is determined by individual DHBs and is less standardised across the country. The needs of individual patients have not changed, however, and every person with diabetes should still receive regular testing and monitoring to ensure that the progression of the disease and its complications is halted or slowed.

The annual follow-up of individuals with diabetes is also currently a PHO Performance Programme (PPP) indicator. The PPP goal as of Oct 2013 (check for updates) is for at least 80% of all people with diabetes enrolled in a practice to have had a full review once per year, and this includes both laboratory testing and clinical examination.

This audit aims to aid clinicians in their follow-up of their patient population with diabetes, by assessing appropriate laboratory testing, which is one part of the recommended annual review.

For further information on performing a diabetes follow-up, see: “Diabetes follow-up: what are the PHO performance indicators and how are they best achieved?”, BPJ 39 (Oct, 2011).

Recommendations for this audit

The regular follow-up of people with diabetes should include the laboratory assessment of:

  • Glycaemic control – using HbA1c
  • Lipid levels
  • Renal health – using urinary albumin/creatinine ratio and serum creatinine

Glycaemic control

HbA1c is used to monitor glycaemic control in people with diabetes. People with diabetes should be tested at least annually. If the patient has unstable glycaemic control or there are changes in treatment, testing should be more frequent, but no more often than three monthly.

Monitoring HbA1c should be based on the following recommendations:

  • For most people with type 2 diabetes, a target HbA1c of 50 – 55 mmol/mol is recommended
  • HbA1c > 64 mmol/mol is a sign of suboptimal control
  • HbA1c targets should be individualised, taking into consideration the patient’s age and co-morbidities, e.g. a higher HbA1c level may be acceptable in an older person

N.B. Occasionally interpretation of HbA1c is unreliable. Conditions that alter erythrocyte survival, production or duration, such as ongoing blood loss or frequent venesection, will reduce the accuracy of HbA1c. For more information see: “When to use fasting glucose to diagnose people with type 2 diabetes”, Best Test December, 2012.

Lipid levels

Macrovascular complications in people with diabetes are associated with high mortality and morbidity. Lipid levels are good measure of the likelihood of developing macrovascular complications, particularly cardiovascular disease.

In general, fasting lipid levels are measured three-monthly until the patient reaches their target level and then, once stable, annually. Targets vary, and should be individualised to each patient, but ideally should be < 4.0 mmol/L for total cholesterol and < 2.0 mmol/L for LDL-cholesterol.

Renal disease

Nephropathy is a common complication of poorly controlled diabetes, and diabetes is the most common cause of kidney disease in the developed world. Regular assessment of renal function can indicate where damage is occurring as a result of poor glycaemic control.

Urinary albumin:creatinine ratio (ACR) and a serum creatinine, with estimated glomerular filtration rate (eGFR), are the best tests for assessing renal disease in people with diabetes.

The recommendations for renal testing in people with diabetes are:

  • Tests should repeated at least annually
  • ACR ≥ 2.5 mg/mmol in males or ≥ 3.5 mg/mmol in females indicates microalbuminuria (in people with diabetes)
  • If the eGFR is > 90 mL/min/1.73m2, no further action is required unless there is suspicion of kidney disease
  • Testing should be more frequent if microalbuminuria or reduced eGFR is present, e.g. six-monthly

Audit Plan


All patients within the practice that have diabetes can be audited to see whether they are receiving appropriate testing for glycaemic control, lipid levels and renal function.

Criteria for a positive outcome

The patient has a diagnosis of diabetes and, in the previous twelve months has received:

  • At least one HbA1c tests, AND;
  • At least one fasting lipid test, AND;
  • At least one urinary ACR test, AND;
  • At least one serum creatinine test

Audit standards

This audit does not have a specified percentage achievement rate. Rather, at the end of the second audit cycle, the practitioner or practice should see an increase in the number of patients who have reached the target follow-up compared with the first cycle. Practitioners are encouraged to set their own goal level, based on their patient population.

Alternatively, the PHO Performance indicator of 80% may also be used.


Eligible people

All patients enrolled in the practice with a previous diagnosis of diabetes are eligible for this audit.

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 PMS system. We suggest you identify all patients who have been coded for a diagnosis of diabetes.

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 sheets provided to record your data (one for now, and one for in one year’s time). Calculate your percentage of patients “at target” by taking the number of patients with a tick in each of the test columns (i.e. they have a tick in the final column) and dividing this number by the total number of people audited, times 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.

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

  • 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
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour


Monitoring change and progress

It is important to review the action plan against the timeline at regular intervals with the practice team. It may be helpful to discuss 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 you complete the first part of the Continuous Quality Improvement (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 Continuing Professional Development (CPD)

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 CPD 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 CPD programme.

To claim points go to the RNZCGP website:

Record your completion of the audit on the CPD Online Dashboard, under the Audit of Medical Practice section. From the drop down menu select “Approved practice/PHO audit” and record the audit name.

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).