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8BL2. Patient on maximal tolerated therapy for diabetes
For each individual a target HbA1c should be set between 6.5% and 7.5% based on the risk of macrovascular and microvascular complications.
Grade B Recommendation NICE Inherited Guideline G (2002)
For the purposes of the QOF 7.5 (or equivalent) has been selected as an optimal level of control for the purposes of audit and reporting. Where fructosamine is used, for example in patients with haemoglobinopathies, local standards may need to be developed for this indicator. The fructosamine value is derived as follows:
Fructosamine = (HbA1c – 1.61)/0.017 = 346 umol/l
The evidence for the targets for HbA1c are based on the DCCT study in Type 1 diabetes, which found few microvascular complications in those with HbA1c below 7.5 (N Engl J Med. 1993; 329 (14): 977-86). The authors of the NICE guidelines for Type 2 diabetes (2002) use this to argue for HbA1c levels below 7.5 in Type 2 diabetics.
www.nice.org.uk/search/guidancesearchresults.jsp?keywords=diabetes&search Type=guidance
Although there is less direct evidence to support a specific threshold for risk of macrovascular disease in Type 2 diabetes, the 7.5% threshold seems reasonable as a quality indicator for the purposes of QOF, and should play a role in shifting the overall distribution of blood glucose downwards in those with diabetes.
It is recognised that there may be variations in test availability and in normal ranges in different parts of the UK. If this is the case, the PCO may stipulate a different but equivalent range for this indicator, but it should be noted that the National Diabetes Support Team has advised that all laboratories should now report DCCT aligned results. This issue is discussed in the English NSF under ‘Standards: Supplementary information: Clinical care of adults with diabetes: Monitoring blood glucose control.’
www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Diabetes/fs/en
The practice should report the percentage of patients on the diabetic register in which the last HbA1c measurement was 7.5 or less. The test must have been carried out in the last 15 months.
In verifying that this information has been correctly recorded, a number of approaches could be taken by a PCO:
i. inspection of the output from a computer search that has been used to provide information on this indicator
ii. inspection of a sample of record of patients with diabetes to look at the proportion with last recorded HbA1c 7.5 or less
iii. inspection of a sample of records of patients for whom a record of HbA1c 7.5 or less is claimed, to see if there is evidence of this in the medical records.
Prepared By Jean Keenan