The annual diabetes review: how can we improve?

Despite a continued increase in the percentage of patients receiving all of the nine NICE recommended care processes (the core annual review 'bundle'), around half of people with type 2 diabetes and two thirds of people with type 1 diabetes still do not achieve this basic standard of care. So what should we be doing?

The most recent figures from Diabetes UK indicate that the number of people diagnosed with diabetes has more than doubled, from 1.4 million in 1996 to 3 million this year. By 2025, it is estimated that the number will have increased to approximately 5 million, with the majority of these affected by Type 2 diabetes.¹ Recent Government reports have expressed grave concern at the standard of care received by patients with diabetes, which is contributing to the development of preventable complications, more hospital admissions and a growing burden on resources in an already overstretched NHS. In this context, new targets have been announced to improve the proportion of patients receiving all nine basic checks, from 49% to 80% by 2018. (See Government sets new targets to control diabetes risk factors, in 'News') So how can practice nurses improve the review process for their patients? This article aims to look at structuring a review appointment, key areas of care and follow up, and areas for concern.

PATIENT CALL AND RECALL

The minimum requirement is for an annual review of patients with diabetes, but the actual frequency of patients' reviews should be tailored to each individual: in my own practice, patients with an HbA1c above the recommended target are seen every three months, while those who are on target are reviewed at six-monthly intervals, in line with guidance from the American Diabetes Association.² At the time of sending the invitation, the patient's recall date is reset so that if they fail to attend, a reminder will be sent so they will not be missed. Before the appointment, patients are sent forms for the necessary blood tests so that their results will be available in time for their review.

KEY AREAS FOR REVIEW

The main area to be addressed at the review is — first and foremost — HbA1c, as this is the key determinant of diabetic control, and poor control is the underlying cause of both macro- and microvascular complications, including cardiovascular disease, retinopathy, nephropathy and neuropathy.³ The review should also therefore encompass the patient's individual risk status of these particular areas of concern — that is, assessment of kidney function, blood pressure and lipids, eyes, feet and smoking status. It is unfortunate that many people with diabetes either have not reached their treatment goal, or have not been screened for these risks. (Table 1) Additional areas for consideration include sexual function and depression.

STRUCTURE OF REVIEW

It is important not to lose sight of the 'whole patient' when structuring a review appointment, but a basic format would comprise:⁴

• Welcome — ask how your patient is, if they are experiencing any problems, and confirm smoking status
• Educate — make sure your patient has been referred to a structured education programme, and that they have attended; update their education on a one-to-one basis
• Measure — weight, blood pressure, urine. Check feet and give foot education (Box 1) and ask about attendance for eye screening.
• Record — the results of all of the above onto the clinic template
• Discuss — results of tests for glycaemic control, blood pressure control and lipid control; any modification of treatment that may be needed; and targets for the individual patient.

Most practices have access to a diabetes clinic template that covers the key areas for inclusion in a review. Table 3 shows the basics included.

Looking at the whole picture

When assessing the patient, remember that many of the elements for review are interlinked and that they can have a cumulative impact on the development of complications, or can lead to the development of more than one complication.

BLOOD GLUCOSE CONTROL

Despite the plethora of drug treatments available to control blood glucose, only around 60% of people with diabetes are achieving the recommended target range for HbA1c.⁵ The aim should be to optimise treatment to achieve as close to normoglycaemia as is practical — and safe — in line with NICE guidelines.⁶

MICROALBUMINURIA

Microalbuminuria is defined by the persistent elevation of albumin:creatinine ratio (ACR) >2.5mg/mmol in men, and >3.5mg/mmol in women or an albumin concentration of >20mg/l.⁷ The presence of microalbuminuria in people with type 2 diabetes is associated with an increased risk for all-cause and cardiovascular mortality, cardiac abnormalities, cerebrovascular disease, and peripheral arterial disease.⁸

In the event of an elevated test result, it is important to determine whether there may be an alternative cause for the finding. Elevated results may also be caused by vigorous exercise, blood in the urine, urinary tract infection, dehydration, and some drugs (e.g.corticosteroids and aspirin).⁷ It may therefore be sensible to exclude urinary tract infection and other possible causes before repeating the test. The National Kidney Foundation suggests that two positive tests, taken 3-6 months apart, indicate the need to commence treatment.⁹ Do not use reagent strips to identify proteinuria unless they are capable of specifically measuring albumin at low concentrations, and expressing the result as an ACR.

NICE recommends an ACE inhibitor (or ARB if an ACE inhibitor is not tolerated).¹⁰ These agents have been shown to be effective in slowing the progression of diabetic nephropathy in patients with hypertension, and that even in normotensive patients, ace inhibitor treatment may arrest the progression of microalbuminuria and reduce mortality rates.¹⁰

Monitoring renal function

Chronic kidney disease (CKD) is common in patients with diabetes, and when advanced, carries a high risk of mortality.⁹ Diabetes can cause progressive declining kidney function,and without intervention, estimates suggest that approximately 20-40% of people with diabetes develop diabetic nephropathy.¹⁰ However, with good diabetes care, kidney damage can be prevented. Monitoring kidney function should therefore be included in the diabetic review.

The gold standard for assessing kidney function is the estimated glomerular filtration rate (eGFR), which should be performed annually. Treatment with an ACE inhibitor (or ARB if intolerant) should be offered to patients with an eGFR ≥ 60 ml/min/1.73m2.10

In people with confirmed CKD, the aim should be to keep the systolic BP below 140mmHg (target range 120—139mmHg) and diastolic BP below 90 mmHg.¹⁰ Particular care is needed in patients who are taking metformin — the dose should be reviewed if serum creatinine exceeds 130 micromol/l or the eGFR is below 45 ml/minute/1.73m2, and should be stopped completely if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30 ml/minute/1.73-m2.11

LIPIDS

Hyperlipidaemia is a common finding in patients with type 2 diabetes and practice nurses are well aware of the need for dietary advice in an attempt to modify lipid levels. Dyslipidaemia is a major risk factor for cardiovascular disease and is particularly important in diabetes care because atherosclerosis accounts for approximately 80% of all diabetes-related mortality. People with diabetes have a 2- to 3-fold increased risk of cardiovascular disease compared with the risk in individuals without diabetes.¹²

RETINAL SCREENING

Retinopathy is a sight-threatening complication of diabetes, and despite an established screening programme, approximately 4,200 people in England are blind as a result of this complication — a figure that is predicted to increase by some 1,280 cases each year.¹³ If detected early, prompt treatment can limit the significant loss of sight which would otherwise occur. All patients with diabetes should be referred to the retinopathy screening service for annual review.

However, the 2011 National Diabetes Audit found that only 79% of patients with type 2 diabetes, and 68% of those with type 1 diabetes had been screened for retinopathy. Among the reasons patients give for non-attendance are that they are too busy, were on holiday or that they were unwell.¹⁴ It is therefore essential that practice nurses conducting an annual diabetes review check that their patient has attended their screening appointment, and that they ensure that the patient understands the importance of attending for this vital test.

FOOT EXAMINATION

Examination of feet in patients with diabetes is a task requiring specific training and expertise, and how to perform a foot examination will discussed in more detail in a future article. However, at the very least, practice nurses should ask about any pain, or previous ulceration, and know how to refer patients to their local multidisciplinary foot team for a full assessment.

HOW CAN WE IMPROVE?

Primary care provides the main source of diabetes care for the majority of patients with type 2 diabetes, and much of the routine care for those with type 1 diabetes. People with diabetes often have complex medical and educational needs difficult, and meeting these needs can be difficult. Long intervals between patient visits, and limited time with patients can lead to 'clinical inertia,' resulting in a lack of timely treatment or intensification of therapy.¹⁵ It is therefore important to allow enough time to conduct an annual review, and to ensure that patients are followed up appropriately so that multiple problems can be addressed. The importance of providing individualised diabetes education, to help patients to make choices and decisions about how to manage their life and their diabetes, cannot be overestimated. Some strategies to encourage self-management are summarised in Box 2.

CONCLUSION

Practice nurses are under intense pressure to meet targets for diabetes care, pressure that can only be expected to increase in the light of the Government's new, tougher targets. Not only that, but patients themselves may be resistant to advice or non-compliant with suggested treatment.

The annual review offers an opportunity to improve the care given to patients with diabetes, to assess and, where possible reduce, the risk of developing the complications of diabetes, to modify or intensify treatment where necessary, and to reinforce educational messages and lifestyle advice. Together, these measures should improve outcomes — the ultimate goal of diabetes management.

REFERENCES

1. Diabetes UK. Diabetes in the UK 2012: Key statistics on diabetes. http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf

2. American Diabetes Association. Executive summary: standards of medical care in diabetes: 2011. Diabetes Care. 2010;34(suppl 1): S4-S10.

3. Liebl A, Mata M, Eschwege E. Evaluation of risk factors for development of complications in type II diabetes in Europe. Diabetologia 2002; 45: S23-8.

4. Gadsby R. The annual diabetes review. InnovAIT 2008;1(12):784-7

5. Diabetes UK. State of the Nation 2012. http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf

6. NICE. Type 2 diabetes. NICE clinical guideline 87. http://www.nice.org.uk/nicemedia/pdf/CG87QuickRefGuide.pdf

7. GP Notebook. Microalbuminuria. Available at http://www.gpnotebook.co.uk/simplepage.cfm?ID=-670695375&linkID=22512]

8. Weir MR. Microalbuminuria and cardiovascular disease. Clin J Am Soc Nephrol 2007;2(3):581-90

9. National kidney Foundation. Screening for microalbuminuria in patients with diabetes. 2007. http://www.kidney.org/professionals/kls/pdf/tool12-10-2089.pdf

10. NICE. Chronic kidney disease (CG73) Quick reference guide. http://www.nice.org.uk/nicemedia/live/12069/42119/42119.pdf

11. British National formulary. 2012. BNF www.bnf.org/

12. Goldberg RM. Hyperlipidemia and cardiovascular risk factors in patients with type 2 diabetes. Am J Manag Care 2000;6(13 Suppl):S682-91

13. Scanlon PH. The English national screening programme for sight threatening diabetic retinopathy. J Med Screen 2008;15(1):1—4

14. Sachdeva A, Stratton I, Unwin J. Diabetic retinopathy screening: Study to determine risk factors for non-attendance. Diabetes & Primary Care 2012; 14 (5): 308—316

15. Brown JB, Nichols GA. Slow response to loss of glycaemic control in type 2 diabetes mellitus. Am J Manag Care 2003;9:213—217, 2003

16. Diabetes U.K. 2009. Improving supported self-management for people with diabetes. http://www.diabetes.org.uk/Documents/Reports/Supported_self-management.pdf