Diabetic care is high on the agenda of all primary care organisations. There are currently over 3 million people with Type 2 diabetes. Type 2 diabetes can usually be prevented and the NHS are piloting the National Diabetes Prevention programme (NDPP) which aims to identify those at high risk and refers them onto a behavior change programme.


The NHS DPP is a joint commitment from NHS England, Public Health England and Diabetes UK (NDPP).


During the pandemic it has been recognised that Diabetic patients and those at risk of diabetes may be more vulnerable from COVID 19 than some other members of the population.


In June 2020 a new report for managing diabetic patient during the pandemic was released – “Delivering Diabetes Care during the COVID-19 Pandemic – the ‘new normal’ Guidance for General Practice” (Diabetes during COVID-19 Pandemic).

 

Ardens have produced searches to help practices monitor their diabetic and pre diabetic patients more closely particularly during the pandemic.


Diabetes Care Searches

To navigate to the searches, click on the EMIS bubble > Reporting > Population Reporting > Ardens folder > Ardens Main Searches > Diabetes Care. The folder contains two sub folders.


Ardens Diabetes Care Prioritisation Searches



The NHS recommendations are to divide diabetic patients in three status, particularly during the pandemic when practices may only be able to offer limited appointments. The searches reflect these to enable the practice diabetic team to manage them accordingly:

  • Red status - this search includes patients who have a HBA1C of >86 mmol/mol*, a latest BP of  ≥ 160/100 and not on statin despite hx of CVD (excl. haem stroke)
  • Amber status - this search includes patient who have a HBA1C of 59 – 86 mmol/mol, a latest BP of 141/81 – 159/99** and not on statin despite age ≥ 40 yrs and QRISK ≥ 10%.
  • Green status - this search includes patients who have a HBA1C of  ≤ 58 mmol/mol, a latest BP of ≤ 140/80** and are on statin (or statin not indicated / declined).


National Diabetes Prevention Programme (NDPP)

This folder contains three sub folders.


Audit

The first folder includes searches that measure the latest NDPP status in the last 12 months, including patients who have DNA and declined.



The final three searches show separately the NDPP status completed ever and those completed and invited in the last 12 months.



Housekeeping

The housekeeping searches folder includes three searches that are looking at the practice population reporting on: 

  • Adults with no HBA1C or fasting glucose in the last 2 years who are not on the QOF diabetes register.
  • Adults whose latest HBA1C is high at 42-47 or a abnormal or impaired glucose result but they are not on either the Diabetes or non-diabetic hypoglycemia QOF registers. (Patients who are currently pregnant are automatically excluded from this search).
  • And finally patients who have an abnormal or impaired glucose result but who are not on the Diabetes or non-diabetic hypoglycemia QOF registers



These housekeeping searches should help practice ensure that their diabetic and pre-diabetic patients are picked up by QOF and therefore monitored appropriately.


Invitations

 The invitation folders includes searches that provide a way to invite patients for a diabetic/pre-diabetic check who may otherwise have been missed.

  • The parent search includes patients over 18 whose latest HBA1C is  raised and between 42-47 or have a latest glucose result of 5.5-6.9 in the last 24 months and are not on the Diabetes register or pregnant. 
  • The first “child” search below includes patients in the parent search who have not DNA a NDPP appointment or have completed a NDPP recorded in their medical record.
  • The second child search includes patients in the parent search who have had a invitation to the NDPP in the last 7 days to 12 months before the search date and haven’t DNA a NDPP appointment or have completed a NDPP recorded in their medical record.
  • The third child search includes patients in the parent search who have had 2 invitations in the last 12 months and have not declined, DNA or completed a NDPP.

 

Each of the three searches have a hierarchy of searches below them grouping patients into the best way to contact them:

  • By SMS (patients who have a mobile number and not opted out of being contacted by text)
  • By email (patients whose preference is to contacted by email)
  • By letter (patients who are not included in either of the above)
  • And a search including all patients in the relevant search.

 

These can be used to send text, emails or mail merge. If the practice prefers to do a mail merge for all patients it is recommended that the practice use the search including all patients.

 

If you require any further assistance on the process above, please contact Ardens support on: support-emis@ardens.org.uk