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It is not possible to undertake planned systematic care for patients with diabetes without a register which forms the basis of a recall system, and is needed in order to audit care.
The QOF does not specify how the diagnosis should be made, and a record of the diagnosis will, for the purposes of the QOF, be regarded as sufficient evidence of diabetes. However, in addition to the substantial number of undiagnosed patients with diabetes who exist, other patients are treated for diabetes when they do not in fact have the disease. Practices are therefore encouraged to adopt a systematic approach to the diagnosis of diabetes.
The World Health Organisation (WHO) 1999 criteria for the diagnosis of patients with diabetes mellitus are:
• random glucose test: a glucose level above 11.1 mmol/l
taken at a random time on two occasions is a diagnosis of diabetes
• fasting glucose test: a glucose level above 7.0 mmol/l measured without
anything to eat and on two different days is also a diagnosis of diabetes
• glucose tolerance test: a blood glucose test is taken two hours after
a glucose drink is given to the patient. A level above 11.1 mmol/l is a diagnosis
of diabetes, while a level below 7.8 is normal. However, if the level falls
between these values the patient may have a decreased tolerance for glucose
(known as impaired glucose tolerance or IGT).
Distinguishing Type 1 and Type 2 diabetes clinically may not always be easy in primary care. If this is unclear from the patients’ paper or electronic records, the code for Type 1 diabetes should be used if the person is diagnosed with diabetes before the age of 30 or requires insulin within one year of diagnosis, and otherwise, the code for Type 2 should be used.
Separate coding of Type 1 and Type 2 diabetes allows the development of QOF indicators that are more closely aligned to NICE guidance.
As the care of children with diabetes mellitus is generally under the control of specialists, the register should exclude those patients age 16 and under. Likewise, the indicators are not intended to apply to patients with gestational diabetes.
Practices should separately report the numbers of patients on their diabetic register (age 17 and over) with Type 1 and Type 2 diabetes and the number of patients on their diabetic register (age 17 and over) with Type 1 and Type 2 diabetes as a proportion of their total list size.
Practices should note that there has been a change to the acceptable read codes for this indicator to reflect the need for all patients to be recorded as having either Type 1 or Type 2 diabetes.
Verification – in order to ensure that patients with diabetes are not ‘lost’ due to the change in read codes, PCOs may wish to compare reported practice prevalence not only with national prevalence but with the practice prevalence for 2004/05.
Prepared By Jean Keenan