This section provides advice on the resource implications associated with implementing the key clinical recommendations, and advice on audit as a tool to aid implementation.
Implementation of national clinical guidelines is the responsibility of each NHS board and is an essential part of clinical governance. Mechanisms should be in place to review care provided against the guideline recommendations. The reasons for any differences should be assessed and addressed where appropriate. Local arrangements should then be made to implement the national guideline in individual hospitals, units and practices.
13.1 ResoURCe iMPLiCations of KeY ReCoMMendations
A cost and resource impact report and an associated spreadsheet have been developed to provide each NHS board with resource and cost information to support the implementation
of the recommendations judged to have a material impact on resources (see Table 7). These
documents are available from the SIGN website: www.sign.ac.uk
Table 7: Recommendations costed in the cost and resource impact report
Recommendation section
a obese adults with type 2 diabetes should be offered individualised
interventions to encourage weight loss (including lifestyle, pharmacological
or surgical interventions) in order to improve metabolic control.
3.6.2
a Children and adults with type 1 and type 2 diabetes should be offered psychological interventions (including motivational interviewing, goal
setting skills and CBT) to improve glycaemic control in the short and medium term.
4.3.3
a Csii therapy is associated with modest improvements in glycaemic control and should be considered for patients unable to achieve their glycaemic targets.
5.3.2
b Csii therapy should be considered in patients who experience recurring
episodes of severe hypoglycaemia. 5.3.2
; An insulin pump is recommended for those with very low basal insulin
requirements (such as infants and very young children), for whom even small doses of basal insulin analogue may result in hypoglycaemia.
5.3.2
; Pump therapy should be available from a local multidisciplinary pump clinic
for patients who have undertaken structured education. 5.3.2
a soluble human insulin or rapid-acting insulin analogues can be used when
intensifying insulin regimens to improve or maintain glycaemic control. 6.10.5
a a suitable programme to detect and treat gestational diabetes should be offered to all women in pregnancy. 7.8
a intensive lipid-lowering therapy with atorvastatin 80 mg should be considered for patients with diabetes and acute coronary syndromes, objective evidence of coronary heart disease on angiography or following coronary revascularisation procedures.
8.4.7
a in patients with diabetes, des are recommended as opposed to bMs in stable coronary heart disease or non-st elevation myocardial infarction to reduce in-stent re-stenosis and target lesion revascularisation.
13.2 aUditing CURRent PRaCtiCe
A first step in implementing a clinical practice guideline is to gain an understanding of current clinical practice. Audit tools designed around guideline recommendations can assist in this process. Audit tools should be comprehensive but not time consuming to use. Successful implementation and audit of guideline recommendations requires good communication between staff and multidisciplinary team working.
The guideline development group has identified the following as key points to audit to assist with the implementation of this guideline:
13.2.1 LIFESTyLE MANAGEMENT
The availability of specific structured education programmes for people with type 1 or
type 2 diabetes at Health board level and capacity of available programmes.
The proportion of patients with type 1 and type 2 diabetes being offered structured
education, including measurement of the proportion who are invited, and who fail to attend.
Evaluation of glycaemic and QoL outcomes in patients attending structured education
programmes.
Availability of services in each Health Board for patients with diabetes who are obese/
overweight including, dietetic, psychological support and bariatric surgery.
Measurement of outcomes (weight, diabetes resolution, glycaemia) in patients
receiving these interventions. 13.2.2 PSyCHOSOCIAL FACTORS
Extent to which services regularly assess psychological problems in children and
adults.
Frequency with which the service refers children and adults for psychological
interventions to improve glycaemic control. 13.2.3 MANAGEMENT OF TyPE 1 DIAbETES
Monitoring of provision of a private area for SMbG and insulin injection at school,
and the availability of assistance for these activities.
Examples of good working collaboration between education and health services
should be recorded.
13.2.4 PHARMACOLOGICAL MANAGEMENT OF GLyCAEMIC CONTROL IN PEOPLE WITH TyPE 2 DIAbETES
Rates of use of NPH insulin versus long-acting analogue insulin as initial basal insulin.
Rates of continuation of metformin and sulphonylureas in people with type 2 diabetes
when basal insulin is commenced.
Rates of discontinuation of sulphonylureas in people with type 2 diabetes when
prandial insulin is added to basal insulin.
Rates of pancreatitis and other GI symptoms in people prescribed GLP-1 agonists.
Rates of infections in people prescribed DPP-4 inhibitors.
13.2.5 MANAGEMENT OF DIAbETES IN PREGNANCy
Outcomes of managing women with type 1 and type 2 diabetes during pregnancy
including birth weight, rate of macrosomia, intrauterine growth retardation and shoulder dystocia, caesarean section rate, perinatal mortality rate and neonatal hypoglycaemia.
Number of women diagnosed with GDM under the international consensus criteria.
Outcomes of managing women with GDM using the international consensus
criteria including birth weight, rate of macrosomia, intrauterine growth retardation and shoulder dystocia, caesarean section rate, perinatal mortality rate and neonatal hypoglycaemia.
13.2.6 MANAGEMENT OF DIAbETIC CARDIOVASCuLAR DISEASE
Numbers of diabetic patients aged over 40 years on statins.
Numbers of patients receiving intensive glycaemic control following acute coronary
syndromes.
Numbers of patients with previous acute coronary syndromes on beta blockers.
Numbers of patients with chronic heart failure on beta blockers.
13.2.7 MANAGEMENT OF KIDNEy DISEASE IN DIAbETES
Proportion of people with diabetes who have eGFR and urine protein excretion
assessed annually.
Proportion of people with diabetes who have stage 3, 4 and 5 CKD and who have
microalbuminuria and diabetic nephropathy.
Proportion of people with diabetic kidney disease who are receiving an ACE inhibitor
or an ARb.
Proportion of people with diabetic kidney disease who have BP >120/70 and
135/75 mm Hg respectively.
Proportion of people with diabetes and CKD stage 3-5 who have haemoglobin
checked annually.
13.2.8 PREVENTION OF VISuAL IMPAIRMENT
The proportion of patients receiving retinal screening within the appropriate timescale
for them (ie 6, 12 or 24 months).
The proportion of patients with referable retinopathy.
The mean, and maximum time from the episode of retinal screening to being seen in
an ophthalmology clinic.
The mean, and maximum time from retinal screening to receiving laser
photocoagulation, where required.
Retinal grading should undergo internal and external quality assurance.
The proportion of patients registered with partial vision or blindness who receive
disability benefits.
The proportion of patients registered with partial vision or blindness who receive low
vision aids.
The proportion of eligible patients receiving the national Diabetes Retinal Screening
leaflet.
13.2.9 MANAGEMENT OF DIAbETIC FOOT DISEASE
To determine if the traffic light system improves care.
13.3 additionaL adviCe to nHssCotLand fRoM nHs QUaLitY iMPRoveMent sCotLand and tHe sCottisH MediCines ConsoRtiUM
The Scottish Medicines Consortium has published guidance on a range of drugs used in the management of people with diabetes. A summary of these findings is available from the SIGN
web site (www.sign.ac.uk).
NHS Quality Improvement Scotland advises that the recommendations in the following NICE technology apprisals are as valid for Scotland as for England and Wales:
NICE Technology Appraisal Guidance No 53 - The use of long-acting insulin analogues for
the treatment of diabetes - insulin glargine (Dec 2002)
NICE Technology Appraisal Guidance 60 - guidance on the use of patient-education models
for diabetes (May 2003)
NICE (Multiple) Technology Appraisal Guidance No 151 - insulin pump therapy (jul 2008).