Quality Standards for Diabetes Care Toolkit

Southern PHO

Southern PHO has developed an insulin initiation programme for people with type 2 diabetes. It is based on the New Zealand Guidelines Group (2011) document pertaining to the management of type 2 diabetes. Details can be found here: (http://southernpho.health.nz/downloads/complete_insulin_initiation_info_to_medtech_practices_27-09-11.pdf).

Assessment tools

Best Practice Advocacy Centre (BPAC) NZ provides a clinical audit for the initiation of insulin for people with type 2 diabetes who are on oral agents and have poor glycaemic control.
The audit is in two parts. Part 1 is designed to audit the trigger point for initiation of insulin in people using it, part 2 is designed to audit the escalation of treatment for people with type 2. Forms for recording data are provided.

Part 1

Auditing the current ‘trigger point’ for the initiation of insulin in patients with type 2 diabetes in your practice:

Identify patients to audit

Step 1: Using the query builder in your Practice Management System (PMS), identify patients with type 2 diabetes who are already on insulin.

Work out your ‘current trigger point’ for initiating insulin

Step 2: From the patient’s notes record the HbA1c level at which treatment with insulin was initiated. (Use the data sheet to record your data).

Identify any gaps in your practice

Step 3: Based on current evidence, identify an HbA1c level at which patients with type 2 diabetes in your practice should be initiated on insulin, this is your target ‘trigger point’.

Step 4: Using data from Step 2 above, calculate the average HbA1c at which treatment with insulin was initiated. What is the gap between this and your target ‘trigger point’?

Part 2

Auditing the escalation of treatment for patients with type 2 diabetes in your practice:

Identify patients to audit

Step 1: Using the query builder in your PMS, identify 20 patients with type 2 diabetes on metformin.

Identify any gaps in your practice

Step 2: Identify patients from your sample with an HbA1c greater than or equal to 64 mmol/mol.

Step 3: Using the patient’s notes, establish whether the patient’s dose of metformin has been titrated to the maximum tolerated dose. (Use the data sheet in Appendix One to record your data)

Step 4: Use this data to:

a. calculate the proportion of these patients that are not on a maximum tolerated metformin dose

b. calculate the proportion of these patients that have an HbA1c greater than or equal to your target ‘trigger point’ for initiating insulin from Part 1 above.
Patients identified in step four above represent the gap between ‘ideal’ practice and your current practice. These patients should be reviewed with a view to escalating treatment or initiating insulin (www.bpac.org.nz/resources/other/audits/bpac_insulin_audit_wv.pdf).
The National Institute for Health and Care Excellence (NICE 2011) provides the following quality measures.

Process

The proportion of people with diabetes starting insulin therapy that is initiated by a trained health care professional.

Numerator	The number of people in the denominator starting insulin therapy initiated by a trained health care professional
Denominator	The number of people with diabetes requiring insulin therapy

The proportion of health care professionals initiating insulin therapy who have documented appropriate training for starting and managing insulin.

Numerator	The number of health care professionals in the denominator having documented appropriate training for starting and managing insulin
Denominator	The number of health care professionals initiating and managing insulin therapy

The proportion of people with diabetes who receive ongoing structured support to initiate and manage insulin therapy.

Numerator	The number of people in the denominator receiving ongoing support to initiate and manage insulin therapy
Denominator	The number of people with diabetes starting insulin therapy