Using clinical data systems to make a real difference

Using a quality improvement tool can help practices optimise the management of patients with diabetes and reduce their risk of developing complications

Practices hold a wealth of data about their patients with diabetes – and using quality improvement tools, such as GRASP-DM, can help improve outcomes, reduce costs, avoid inappropriate treatment, and even boost QOF achievement.

Dr Dai Evans, PRIMIS Lead Clinical Adviser, is a GP and clinical lead for diabetes in a practice in Staffordshire. His practice uses the GRASP-DM tool to manage the care of its patients with diabetes and to case-find those potentially at risk of developing type 2 diabetes.

The GRASP-DM tool is run on a quarterly basis and the results are reviewed by the practice’s diabetes team, comprising two GPs, advanced nurse practitioner Mel Gibson, two health care assistants, a dedicated chronic disease management administrator and an internal visiting nurse. The summary screens and reporting interfaces provided by the tool are used to present findings at practice educational meetings.

As well as supporting the practice to help people manage their diabetes more effectively, the tool, which has been used by over 3,200 GP practices, also helps to inform workload planning.

REGULAR REVIEWS: CASE FINDING

The team runs the case finder element once a year in order to identify patients with a potential missing diagnosis code, and to build a picture of the numbers at high risk of developing diabetes within the practice population. This process helps the practice to keep its 5-to-10-year plan for diabetes care under review. The practice shares its data with other clinical leads in the PCN, enabling system-wide discussion to take place.

By using the tool, it’s been possible for the diabetes team to predict that around 20% of the practice population either has or is at high risk of developing diabetes. The team has established that its diabetic population is growing at a rate of approximately two patients per month. The GRASP-DM case finder enables practices to build a profile of BMI across the practice population (obesity is a particular concern in Stoke-on-Trent, with higher-than-average levels). The practice can then focus on providing those at high risk with an effective and appropriate behaviour change programme to prevent or delay the onset of type 2 diabetes.

Dr Evans estimates that there is at least one patient per year presenting with a gangrenous toe, who is only then being diagnosed with diabetes. The team’s ambition is to reduce the number of such ‘missing patients’ to zero, and using the tool is key to realising this aspiration.

EFFECTIVE MANAGEMENT OF PATIENTS

The management element of the tool enables the practice to ascertain how many people with diabetes have received structured education soon after diagnosis and a measurement of the care processes which people with diabetes should be able to access. This part of the tool is run on an annual basis and over the last year it proved particularly useful to help prioritise patient care during the COVID-19 pandemic.

The practice focused specifically on its older population who have been reluctant to engage with the health service, using GRASP-DM to easily identify these individuals and quickly assessing the numbers involved.

Mel Robinson said: ‘We needed to quickly see which of our housebound patients with diabetes had not been reviewed in the last year. Using GRASP-DM, it took just seconds to produce a list of patients for us. It also showed which housebound patients had not had a foot check in the past year, which as a foot check must be done face-to-face, mean they had not had a personal consultation. This gave us the names of the patients we needed to see and saved us a lot of laborious manual record-combing.’

The practice has identified 39 people that have been diagnosed with diabetes in the last 12-24 months, however, largely due to the pandemic, only 26 had been offered structured education. Alerts have been added to their records so that the next health care professional who has contact with them can discuss the options.

The tool has revealed that 369 people have atherosclerotic cardiovascular disease (ASCVD), of which the tool suggests that a significant proportion may benefit from a review to optimise their medication. This is a large group to explore, however, filters within the GRASP-DM tool have helped the practice to prioritise people for review, making the job more manageable. An alert can be added to the patient record, or a text sent inviting patients for a discussion about their treatment pathway.

Use of the GRASP-DM tool has enabled the practice to assess what they need to do and size up the scale of the problem.

IDENTIFICATION OF PATIENTS

The practice is particularly vigilant in ensuring patients with diabetes have been ‘typed’ and has recorded major improvements in this objective over the last 24 months. Two years ago the practice had 30 patients with untyped diagnoses, but by October 2021 this had been reduced to just five. The GRASP-DM tool enables the diabetes team to keep a watching brief on this situation and provides a way to measure these improvements. Further discussion of the situation at practice meetings enables a degree of root cause analysis to take place.

The diabetes team also focused their attention on people with a comorbidity. Of particular concern are people with dementia, due to the special attention they need, as well as people who are obese/morbidly obese, since dietary management can have such a positive impact.

Close attention is given to patients without fluent English, to ensure they understand their care, treatment, diet and exercise. The practice generates a list from GRASP-DM tool and, together with AcuRx, sends text messages and simple templates to capture more data from this group.

WORKLOAD PLANNING

The GRASP-DM calculates the proportion of the practice diabetic population who have received the eight care processes, and, where appropriate, if the targets have been achieved. It also looks at the ninth care process, eye screening, where data are available. The practice has used the tool to monitor achievements throughout the COVID pandemic and by careful targeting of resources, has recently returned to pre-pandemic levels.

In terms of workload planning, the practice has used GRASP-DM to count and identify people with diabetes who are housebound, of which there are 55. Knowing this number has enabled the practice to ensure that there are adequate resources for each of these patients to have a home visit at least twice a year.

FIND OUT MORE

Visit https://www.nottingham.ac.uk/primis/documents/audit-docs/grasp-dm-quickguide-2022-v-1.3-.pdf.

For more information on how your practice can begin using the GRASP-DM tool and for further advice, contact enquiries@primis.nottingham.ac.uk