Detecting type 2 diabetes
In this Audit 
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
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 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.