Jump to: navigation, search

Delay of Progression of Diabetic Nephropathy

Stage of development

Tested

Potential or current usage

Data extracts have been carried out in 4 practices in relation to this measure, using a query designed by Compass.

Brief overview of the measure

General description

This measure is one of two diabetes indicators that are intended to improve management of diabetic nephropathy in primary care. This measure identifies the proportion of patients with diabetes with proteinuria, or with two out of three abnormal albumin/ creatinine ratio test results within 4 months, that are prescribed an Angiotensin Converting Enzyme inhibitor or Angiotensin II antagonist.

Rationale for selection

Diabetes is a leading cause of morbidity and mortality in New Zealand. Maori and Pacific peoples have a higher incidence of diabetes and are more likely to die from diagnosed diabetes. Diabetic nephropathy occurs in 20–40% of people with diabetes.[7][7][7][7] Best practice recommends treatment with ACE inhibitors or angiotensin-II receptor antagonists unless contraindicated.

Type of measure

Process

Domain(s) of quality

Effectiveness

Application and interpretation of the measure

Stated intent of the measure

Quality improvement tool to assist the practices improve care of people with diabetes by ensuring all patients with diabetes with persistent microalbuminuria and proteinuria are treated with ACE inhibitors or angiotensin-II receptor antagonists, unless contraindicated.

Caveats - Considerations

Caveats: The indicator is dependant on the accurate maintenance of an up-to-date register of people with diabetes within the practice population. The indicator is dependant on appropriate diagnosis of people with diabetes within the practice population. Sequential frequency of events: For this measure to work in practice it would need to rely on accurate flagging of proteinuria within PMS systems either through a READ code or screening term. Feasibility testing across 4 practices did not identify screening terms or proteinuria READ codes used. Considerations A potential adverse effect is that manipulation of diabetic register is a theoretical possibility which may lead to inaccurate data recording. Practice activity/systems for follow up of test results and follow up of patients.

Links to other measures

Identification of microalbuminuria in people with diabetes

Level of health care delivery/setting

Individual practices, although may be applicable to larger groupings of practices

Target population

Funded patients with diabetes within a general practice

Stratification by vulnerable populations

If proxy available (i.e. query by quintile), then stratification by ethnicity or socio economic status may be of interest.

Associated incentives

Use of this measure is linked to: • MOPS • Cornerstone

Possible sources of bias or confounding

Integration with national ‘Get-checked’ programme Patient consent and compliance with advice/laboratory testing/medicines Availability of laboratory services - See more at: https://www.hqmnz.org.nz/measures/long-term-conditions/delay-of-progression-of-diabetic-nephropathy#sthash.Y4hlp74M.dpuf

Calculation of the measure

Output of calculation

Percentage of patients with diabetes with proteinuria, or with two out of three abnormal albumin/ creatinine ratio test results within 4 months that are prescribed an Angiotensin Converting Enzyme inhibitor or Angiotensin II antagonist.

Numerator description

Patients with diabetes prescribed an Angiotensin Converting Enzyme inhibitor or Angiotensin II antagonist

Numerator exclusions

Patients under 12 years of age; non-funded patients; patients with contraindications to angiotensin converting enzyme inhibitors or angiotensin II antagonists; pregnant women

Denominator description

Patients with diabetes with proteinuria, or with two out of three abnormal albumin/ creatinine ratio test results within 4 months

Denominator exclusions

Patients under 12 years of age, non-funded patients; patients with contraindications to angiotensin converting enzyme inhibitors or angiotensin II antagonists; pregnant women

Time period

One year

Criteria/standard for optimal performance

Known diabetics with persistent microalbumniuria or proteinuria (according to definition) should be commenced on an angiotensin converting enzyme inhibitor or angiotensin-II receptor antagonists unless contraindicated. The creators of the measure believed there are currently too many unknown variables to be able to accurately assess appropriate quantitative standards of care within a general practice setting.

Data source

Primary care electronic practice management systems.

Method of extraction

Diabetes: All codes in the diabetes mellitus hierarchy are included, with the exception of codes beginning with C10A (malnutrition-related diabetes mellitus) and C10B (diabetes mellitus induced by steroids). Where a specified code is suffixed with the wild card symbol (*), all codes directly below that code in the hierarchy should also be included. C100* C101* C102* C103* C104* C105* C106* C107* C108* C109* C10y* C10z* Note for practices: Please also include any Read codes omitted from the above list that are used within your own practice setting and known to be relevant. Microalbuminuria: 46W0. Note for practices: Please also include any Read codes omitted from the above list that are used within your own practice setting and known to be relevant. Suggested Read code(s) for future use C108. insulin dependant diabetes C109. non-insulin dependant diabetes 46TC. urine albumin:creatinine ratio 4678. proteinuria Prescription data Angiotensin Converting Enzyme inhibitors: Captopril Cilazapril Enalaparil Lisinopril Perindopril Quinapril Trandolapril Angiotensin II antagonists: Candesartan (available under Special Authority) Irbesartan# Losartan (available under Special Authority) # not funded by Pharmac (June 2010)

Key issues and challenges for data management

Sequential frequency of events This measure requires identifying sequential frequency of events, i.e. patients with diabetes with proteinuria or, two out of three abnormal albumin/ creatinine ratio test results within 4 months. Using such frequency measures makes sense in clinical terms; they are however difficult to determine using existing database structure query language (SQL). For this measure to work in practice it would need to rely on accurate flagging of proteinuria within PMS systems either through a READ code or screening term. Feasibility testing across 4 practices did not identify screening terms or proteinuria READ codes used. Because of the complexity in the SQL required to observe this type of measure, it would be sensible to predefine the SQL to be used for such measures. Practices use a wide variety of screening terms, which makes authoring a generic SQL statement difficult. A custom built integrated tool within patient management systems may be able to be configured for each practice. Exclusions Even though best practice suggests contraindications for use of drugs including pregnancy must be allowed for, it is currently not possible to identify through data extracts which patients with diabetes have contraindications and which ones are pregnant (even if there was a READ code for, pregnancy is a temporary state). Exclusions are important both to ensure that safety parameters are adhered to in specifying the indicator, and to ensure that indicator results are not confounded by factors other than performance.

Appraisal of the measure

Availability of evidence to support application of the measure

Measure is formulated on and underpinned by evidence from a published systematic review, meta-analysis, or other peer-reviewed synthesis of clinical evidence relating to the area of focus., The measure has been reviewed using the Sieve Tool and a report is available.

Evidence of feasibility and reliability of implementation

Validity - The measure has been demonstrated to be valid (i.e. it measures what it purports to).

Development approach

Measure defined and feasibility of implementation has been tested. This measure is part of a suite of 11 measures the WSoM developed[1]. The process followed to develop this set of measures is summarized below: 1. Priority areas for measure development were identified in consultation with the College, MoH, PPP and the wider primary health care sector. 2. A measure development template was devised, based on a measure appraisal tool (the sieve). 3. The template was populated and specifications for each measure were refined through discussions. 4. Generic implementation plans were developed. Compass field tested indicator on a sample of four practices[2].

Other items

Links to educational activities

WSM, BMJ, BPAC, RNZCGP

Owner details

Reference number

1830

Date of entry to library

2012-07-30 11:34:34

Owner (Organisation name)

Royal New Zealand College of General Practitioners

Owner (Email contact)

jane.o’hallahan@rnzcgp.org.nz

Creator (Organisation name)

Primary Health Care Quality Research Unit, Wellington School of Medicine and Health Sciences, University of Otago

Creator (Email contact)

roshan.perera@otago.ac.nz