CLINICAL AUDIT TOOL: Type 2 Diabetes and Glycaemic Control

Transcription

1 CLINICAL AUDIT TOOL: Type 2 Diabetes and Glycaemic Control

2 Introduction This clinical audit tool addresses glycaemic control for people with type 2 diabetes. It draws on best practice guidance reproduced in the New Zealand Primary Care Handbook 2102 from the source document Guidance on the Management of Type 2 Diabetes (2011). See for further content from the Handbook. TOPIC Type 2 Diabetes and Glycaemic Control Why is this topic of interest? Good glycaemic control has a clear benefit on microvascular outcomes and if started early enough, on long-term macrovascular outcomes. Key information from the guidance: Risk for diabetes-related complications increases incrementally with increasing HbA1c. Any reduction in HbA1c is beneficial. In younger people, tighter control should be considered given their higher lifetime risk of diabetes-related complications. is important as both initial treatment and an ongoing component of treatment. strategies use the FAB approach - a combination of changes to food/diet, increased physical activity, and behavioural strategies (problem-solving and goal setting). For glycaemic control, the value of using proven agents, such as metformin, sulphonylureas and insulin is emphasised. For details of recommended drug therapy for management of glycaemic control see Figure 5 page 57 of the Handbook. PLAN Indicators (elements of practice performance to be measured) The practice effectively manages patients with type 2 diabetes with respect to glycaemic control, using target HbA1c to guide clinical management. 1. (using the FAB approach) is provided as initial and ongoing treatment. 2. Drug therapy for glycaemic control is instigated as appropriate. 3. for glycaemic control is consistent with recommended stepped drug therapy. 4. optimisation is reviewed when treatment response to an agent(s) is inadequate. 2

3 Criteria (how the indicator will be measured) 1. Patient records indicate patient has had brief counselling and an appropriate action plan for lifestyle modification has been initiated, monitored and altered as appropriate. 2. Drug therapy for glycaemic control is commenced after inadequate response (measured HbA1c does not closely approach target) within 3 months lifestyle modification. Earlier initiation of drug therapy is considered in a symptomatic patient. 3. Drug therapy prescribed is consistent with recommended use of first-line (metformin/sulfonylurea/acarbose), second-line (metformin plus sulfonylurea or pioglitazone; DPP-IV in selected patients) and third-line (insulin) agents. See Fig 5 for further details (note Medsafe updates regarding adverse effects of pioglitazone). Changes in drug therapy reflect measured HbA1c and individual patient response to drug therapy. 4. optimisation is reviewed prior to a change from first-line to second-line or second-line to third-line agents. Standards (the standards to be achieved) Note that the focus is on improving standards of clinical practice, with 80% achievement identified by the RNZCGP as an appropriate target and 100% as an ideal. Individual GPs and practices may choose to set a differing target for a first or subsequent audit/s, with a view to increasing standards over time. 1. Patients newly diagnosed with type 2 diabetes have received lifestyle modification brief counselling (standard: 80%). Patient records indicate planned lifestyle modification (80% of records). Other patients: 80% of patient records indicate lifestyle modification addressed in a recent review % of patient notes indicate initiation of drug therapy for glycaemic control meets criteria % of patient records indicate patient receiving a recommended treatment regimen for glycaemic control % of patient records indicate medication adherence and dose optimisation considered prior to change from first-line to second-line or second-line to third-line agent/s (most recent change noted for standard). DO Discover what you are doing now (collect data) Retrieve records for 15 patients with type 2 diabetes. Review patient records using Patient Records Review Sheet (following page). 3

4 STUDY Next steps: what do the results tell you (interpret the data) Collate the data according to the standards set and compile a brief summary for each indicator. What are you doing well? What needs improving? What gaps between standards and performance do you want to close? Identify possible solutions ACT Make changes what changes can be made to improve patient care? Write an action plan Choose one or two achievable goals. Identify any barriers and enablers to change e.g. resources, skills, IT. Decide what needs to be done and by when. Plan a review date to follow up on changes. Implement changes Monitor change and progress Review your action plan to see if you are keeping to timeline for implementing change. Monitor to see if actions are taking place. Solve problems as they arise. Obtain qualitative feedback from staff and patient about the improvement/s. Consider if you need to develop new strategies to achieve the goals you have set? 4

5 Clinical Audit Tool: Type 2 Diabetes and Glycaemic Control Patient Record Review Sheet Date: Patient 1 (add initials/nhi): If on metformin, egfr>30 ml/min/1.73 m2 Lifestyle modification Current drug therapy regimen appropriate (standards 3 & 4 and see change to current regimen /Don t know /Don t know Patient 2 (add initials/nhi): If on metformin, egfr>30 ml/min/1.73 m2 /Don t know /Don t know 5

6 Patient 3 (add initials/nhi): If on metformin, egfr>30 ml/min/1.73 m2 /Don t know /Don t know Patient 4 (add initials/nhi): /Don t know /Don t know Patient 5 (add initials/nhi): /Don t know 6 /Don t know

7 Patient 6 (add initials/nhi): /Don t know /Don t know Patient 7 (add initials/nhi): /Don t know /Don t know Patient 8 (add initials/nhi): /Don t know 7 /Don t know

8 Patient 9 (add initials/nhi): /Don t know /Don t know Patient 10 (add initials/nhi): /Don t know /Don t know Patient 11 (add initials/nhi): /Don t know 8 /Don t know

9 Patient 12 (add initials/nhi): /Don t know /Don t know Patient 13 (add initials/nhi): /Don t know /Don t know Patient 14 (add initials/nhi): /Don t know 9 /Don t know

10 Patient 15 (add initials/nhi): /Don t know /Don t know 10

11 RNZCGP Summary Sheet Continuous Quality Improvement (CQI) Activity Topic: Type 2 diabetes and glycaemic control Doctor's name: First cycle Data: Date of data collection: Check: Describe any areas targeted for improvement as a result of analysing the data collected. Action: Describe how these improvements will be implemented Monitor: Describe how well the process is working. When will you undertake a second cycle?

12 Second cycle Data: Date of data collection: Check: Describe any areas targeted for improvement as a result of analysing the data collected. Action: Describe how these improvements will be implemented. Monitor: Describe how well the process is working. Comments: 12