Electronic Diabetes Audit Guide - Great Lakes Intertribal Council
Contents
1. MAIN MENU IHS DIABETES Patient Management Reports Register Maintenance Delete Patient from the Register ADD EDIT DMS Letters Switch to another DIABETES Register Browse Health Summary Diabetes QA Audit Menu Update Diabetes Patient Data Generate Health Summary Generate Multiple Health Summaries Q Man PCC Query Utility A P R RI D L S BH D D H MH Q Select Diabetes Management System Option DA Diabetes QA Audit Menu Electronic Diabetes Audit Guide 12 DM02 DMO1 DM99 DM96 TS FS PLDX NDOO DAL APCL DMV DPCS HSRG KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK a PCC Management Reports Ae xx Diabetes Audit Report Menu KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Version 3 0 2002 Diabetes Program Audit 2001 Diabetes Program Audit 1999 Diabetes Program Audit 1996 Diabetes Program Audit Taxonomy Setup Flow Sheet Setup Patients w no Diagnosis of DM on Problem List DM Register Pts w no recorded DM Date of Onset Display Audit Logic List Patients on a Register w an Appointment DM Register Patients and Select Values in 4 Months Display a Patient s DIABETES CARE SUMMARY Print Health Summary for DM Patients W Appt Select Diabetes QA Audit Menu Option DM02 2002 Diabetes Program Audit DM02 Te21 DAL KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK AR PCC Management Reports ER 2002 Diabetes Audit Report Menu KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Version 3 0 2002 Diabetes Program Audit2. Whatever changes result from an audit it is vital that the change process is not left to chance In other words a detailed audit action plan should be made stating exactly who when what and how changes are to be implemented Further all members of the team should be informed of the proposed changes and someone should take a lead role in overseeing that the changes take place 6 Re Audit The final phase of the audit cycle is to undertake a re audit i e recollect audit data and analyse this The main purpose of the re audit phase is to find out if the changes that were implemented have led to an improvement Electronic Diabetes Audit Guide 8 Section 1 SOFTWARE REQUIREMENTS In order to run electronic diabetes audit first you need to have installed and use the following Diabetes Management System software Case Management System V 2 0 patch 2 PCC Management Reports V 3 0 through patch 7 Health Summary V 2 0 through patch 5 Q Man V 21 0 through patch 16 PCC Data Entry V 2 0 through patch 3 Menu Options and Security Keys required DMS Menu BBMMENU DMS Keys BDBMZMENU BDMZ REGISTER MAINTENANCE Q Man Menu AMQQMENU Q Man Keys AMQQZMENU AMQQZCLIN AMQQZRPT AMQQZEMAN Reports Menu APCLMENU Reports Keys APCLZMENU Case Management System Menu ACMZMENU Case Management System Keys ACMZMENU ACMZ DELETE PATIENT ACMZ TRANSFER PATIENT Note If any of the above options and the security keys are not installed or missi
3. End of report Press ENTER Electronic Diabetes Audit Guide Section 5 SOME NOTES ON MEDICAL TERMINOLOGY Note the following is provided for the benefit of non medically qualified personnel working on data quality improvement schemes While every effort has been made to be accurate some simplifications have inevitably been made They are no substitute for more precise clinical definitions If in doubt consult a clinically qualified person Angina pectoris Chest pain on exercise caused by an inadequate supply of oxygen to the heart muscle Often attributable to obstructive disease of the coronary arteries Blood pressure BP Blood pressure is measured by reference to the sounds the Korotkoff sounds heard through a stethoscope placed over the brachial artery as the pressure from a cuff around a patient s arm is reduced It is expressed in two numbers which describe the systolic pressure and the diastolic pressure respectively The systolic pressure derives from the contraction of the heart driving the blood outwards the diastolic measures the pressure during the relaxed state of the heart The systolic is therefore the larger of the two numbers The units of measurement are millimetres of mercury generally written mm Hg Body mass index BMI The ratio of a person s weight in kilogrammes to the square of his her height in metres As a rough guide a person whose BMI is less than 20
4. Check Taxonomies for 2002 Diabetes Audit Display Audit Logic Select Diabetes QA Audit Menu Option DM02 2002 Diabetes Program Audit Run 2002 Diabetes Program Audit Electronic Diabetes Audit Guide 13 Checking for Taxonomies to support the 2002 Audit All Taxonomies are present Note Before running electronic diabetes program audit report needs to establish Medication and Lab test Taxonomies in the existing IHS Diabetes Registry ASSESSMENT OF DIABETES CARE 2002 PCC DIABETES AUDIT Enter the Official Diabetes Register IHS DIABETES lt Enter gt Enter the date of the audit This date will be considered the ending date of the audit period For most data items all data for the period one year prior to this date will be reviewed Enter the Audit Date 12 31 2002 DEC 31 2002 Note The audit goes back one year from the date entered Select one of the following P Individual Patients S Search Template of Patients C Members of a CMS Register Electronic Diabetes Audit Guide 14 Run the audit for P Search Template of Patients Enter Search Template Name IHS DIABETES REGISTER 2 Sep 27 1999 User 605 File 2 There are 162 patients in the IHS DIABETES REGISTER 2 template cohort You have selected a register or template cohort of patients You can run the audit just for the subset of patients in the cohort or register who live in a particular community or have a particular primary care provider
5. Diabetic neuropathy nerve disease is the most common diabetic complication of a microvascular nature Hyperglycaemia is a significant risk factor which can cause diabetic neuropathy Diabetic neuropathy is a major cause of impotence in men with diabetes Oral hypoglycaemic agents Drugs taken to lower the level of blood glucose The drugs work for some people with Type 2 diabetes They can help the body in several ways such as causing the cells in the pancreas to release more insulin All oral hypoglycaemic agents belong to a class of drugs known as sulfonylureas Organic An organic disease is one associated with detectable or observable changes in body organs or metabolism Prevalence The number of people in a given group or population who are reported to have a disease at any point in time Peripheral circulatory disease See peripheral ischaemia under Ischaemia Retinopathy Retinopathy eye disease is the leading cause of blindness and visual impairment in adults in developed societies Sequela plural sequelae A morbidity occurring as a result of another earlier disease Serum fructosamine A measure of the level of blood sugar Used as an indicator of control in diabetes See also HbAIc Stroke Also referred to as a cerebrovascular accident CVA Interruption of the blood supply to the brain caused by arterial obstruction or haemorrhage leading to some loss of functionality e g movement speech etc which may be
6. Limit the audit to a particular primary care provider N lt Enter gt Limit the patients who live in a particular community N lt Enter gt There are 162 patients selected so far to be used in the audit Note You may change your responses to the above questions depending on your preferences at the time the audit is run Select one of the following A ALL Patients selected so far R RANDOM Sample of the patients selected so far Do you want to select A lt Enter gt Select one of the following 1 Print Individual Reports 2 Create EPI INFO file 3 Cumulative Audit Only 4 Both Individual and Cumulative Audits Enter Print option 1 4 lt Enter gt Note Be sure to request the cumulative report so that it will be easy to spot deficiencies in data recording data entry or procedures For example if the audit reports 0 compliance on the DM Foot exam and you know that almost all patients get an annual DM foot exam it may be a recording issue in which providers are not documenting the exam properly or perhaps data entry personnel does not recognize what is recorded as an exam Electronic Diabetes Audit Guide 15 If you select option 2 2 lt Enter gt Enter the name of the FILE to be Created 3 8 characters DMCY02 I am going to create a file called dmcy902 rec which will reside in the C EXPORT directory Actually the file will be placed in the same directory that the data export glo
7. Public Health located at http ih jhsph edu cnah index htm 9 Sandy Lake Health amp Diabetes Project located at http www sandylakediabetes com 10 Association if American Indian Physicians located at http www aaip com home index2 html 11 National Indian Health Board located at http www nihb org 12 Cherokee Rural Health Network located at http www cherokee org Services Health asp 13 Southeast Alaska Regional Health Consortium located at http www searhc org 14 Healthy Nations Initiative Univ of Colorado Health Sciences Center located at http www uchsc edu ai hni 15 Center for American Indian Research and Education Univ of California Berkeley located at http www caire org 16 National Native American AIDS Prevention Center located at http www nnaapc org 17 Native Elder Health Care Resource Center located at http www uchsc edu ai nehcre 18 National Indian Child Welfare Association located at http www nicwa org 19 Native American Cancer Research located at http members aol com natamcan 20 NAIIP Health and Medical Path Information amp Resources North American Indian amp Indigenous People located at http www yvwiiusdinvnohii net medinfo html 21 Tribal Health Connections located at www tribehealth org 22 Tribal Homepages and Health Websites Tribal Connections in the Pacific Northwest located at http www tribalconnections org resourc
8. be analysed Often staff assume that analysis of audit data is a highly scientific and mathematical process but this is not the case Electronic Diabetes Audit Guide 7 In most instances analysis of audit data simply involves calculating basic percentages For instance using our earlier example the team would firstly focus on the actual percentage of CHD patients who had no record of an annual review in their notes This calculation would inform the practice if they were meeting the expected standard or not Audit data should also be analysed to identify particular trends and problems For example using our CHD example once again analysis of the audit data might reveal that a particular group of patients is not being reviewed annually e g housebound patients or that recently diagnosed CHD patients are not being invited back for a review after a year 5 Implementing Changes The penultimate stage of the audit cycle is one of the most crucial and often also one of the most difficult Once all audit data has been analysed and the audit results calculated the audit team need to decide what changes need to be implemented Obviously changes should be designed to rectify any major problems that the audit has identified Implementing changes that will be effective and lead to improvements is complex In some cases subtle changes will lead to considerable improvements However in other instances major changes will need to be set in place
9. but below the level of a person with diabetes Ischaemia Localised diminution of the blood supply due to partial or complete obstruction of the arteries which may be due to a variety of causes Hence the terms ischaemic heart disease and Electronic Diabetes Audit Guide 24 peripheral ischaemia the latter being a reduction of the blood supply to the lower limbs and a complication of diabetes Incidence It indicates how often a disease occurs More precisely it corresponds to the number of new cases of a disease among a certain group of people for a certain period of time Insulin A hormone that enables cells to absorb glucose from the blood and use it for energy Insulin is produced by the beta cells of the islets of Langerhans in the pancreas Islets of Langerhans Named after Paul Langerhans the German scientist who discovered these clusters of cells located in the pancreas in 1869 They produce and secrete hormones that help the body break down and use food There are five types of cells in an islet alpha cells which produce glucagon beta cells which produce insulin delta cells which produce somatostaton and PP cells and D1 cells about which little is known Ketones Chemicals that the body produces when there is not enough insulin in the blood and breaks down fat for its energy Ketones can poison and even kill body cells Without insulin ketones build up in the blood and then pass into urine so that the body can dispose o
10. combined with microvascular disease disease of the small blood vessels can result in foot ulceration and amputation Regular inspection and good care of the foot by healthcare professionals and people with diabetes themselves can prevent foot ulceration and amputation Gestational diabetes mellitus GDM A carbohydrate intolerance of varying degrees of severity with onset or first recognition during pregnancy Gestational diabetes develops during some cases of pregnancy but usually disappears when pregnancy is over However women who have had gestational diabetes are at greater risk of developing Type 2 diabetes at a later stage in their lives Electronic Diabetes Audit Guide 23 Glucose Also called dextrose The main sugar the body produces from proteins fats and carbohydrates Glucose is the major source of energy for living cells and is carried to each cell through the bloodstream However the cells cannot use glucose without the help of insulin Haemoglobin Alc HbA1c Shorthand for glycosylated haemoglobin a measure of the level of blood glucose which provides an indication of the average level over several weeks Used as an indicator of control in diabetes See also serum fructosamine The substance of red blood cells that carries oxygen to the cells and sometimes joins with glucose sugar As the glucose stays attached for the life of the cell about four months a test to measure HbA Ic shows what the person s average blood g
11. education program University of Texas school of Public Health information located at http www sph uth tmc edu catch PHYSICAL_ED HTML 8 Circle of Life a Native American school based K 8 HIV AIDS prevention education curriculum Bureau of Indian Affairs Office of Indian Education Programs briefly described at http www oiep bia edu programs_prek12 html 9 Lifestyle Balance curriculum produced by the University of Pittsburgh for the national DPP Diabetes Prevention Program but available for community use in its entirety at http www bsc gwu edu dpp Ismop htmlvdoc 10 Strong in Body and Spirit community based program Native American Diabetes Project available at http www laplaza org health dwc prof nadp index htm 11 Awakening the Spirit Pathways to Diabetes Prevention and Control American Diabetes Association information available at http www diabetes org main community outreach native_americans default2 jsp 12 EPEC Exemplary Physical Education Curriculum Project Michigan Council on Physical Fitness Health and Sports information available at http www michiganfitness org EPEC default htm 13 Planet Health Harvard Univ Prevention Research Center on Nutrition and Physical Activity an interdisciplinary curriculum for 6th 8th graders with information located at http www hsph harvard edu prc planet html 14 Kitchen Creations Cooking school program jointly supported by the New Mexico Diabetes
12. insulin receptors Classified into Type I also known as insulin dependent diabetes mellitus IDDM and occasionally referred to as juvenile onset diabetes and Type II also known as noninsulin dependent diabetes NIDDM and occasionally referred to as late or maturity onset diabetes Diabetes can lead to a number of complications including peripheral ischaemia neuropathy disease of the nervous system kidney disease nephropathy and eye problems Peripheral ischaemia may lead to the necessity for an amputation of part of the lower limbs The eye problems may lead to blindness Early detection and good control of diabetes are believed to be significant in minimising the incidence and severity of these complications NIDDM may sometimes be controlled by diet alone If medication is required the class of drugs used is known as hypoglycaemics Diastolic pressure See blood pressure Dyslipidaemia It indicates abnormalities of the lipid metabolism and is often associated with insulin resistance in Type 2 diabetes Epidemiology The branch of medicine which deals with the incidence distribution and possible control of diseases and other factors relating to health Foot ulceration Foot ulceration and amputation are among the most costly diabetic complications Diabetes is the most common cause of amputation that is not the result of an accident Diabetic neuropathy nerve disease can reduce sensation in the feet and especially when
13. is an online comprehensive K 12 school based health education curriculum located at http www healthteacher com default asp 2 Dole 5 A Day Dole Food Company offers free school health materials to elementary schools at http www doleSaday com Is part of the national 5 A Day for Better Health Program described on the national Cancer Institute website at http www Saday gov 3 CDC Centers for Disease Control Guidelines to Promote Health Lifelong Eating at http www cdc gov nccdphp dash healthtopics nutrition guidelines and Guidelines to Promote Lifelong Physical Activity at http www cdc gov nccdphp dash healthtopics physical_activity guidelines index htm and the School Health Index located at http www cdc gov nccdphp dash SHI index htm and School Health Program Guidelines located at http www cdc gov nccdphp dash healthtopics guidelines htm 4 Pathways Univ of New Mexico Center for Health Promotion amp Disease Prevention a comprehensive school based health promotion program available online at http hsc unm edu pathways Note the entire issue of the American Journal of Clinical Nutrition for April 1999 was devoted to the Pathways program 5 SPARK San Diego State Univ produced school based physical activity program information available at http www foundation sdsu edu projects spark 6 RISTRA program a school based health program good site not available 7 CATCH school based physical
14. the Diabetes Management System the Case Management System is no longer required for entry of the Diabetes related data items in the list above However if you elect to maintain data elements that are not contained in the list above you must enter those data elements using the data entry option in the Case Management System Electronic Diabetes Audit Guide 11 Section 3 Each year since 1986 the IHS Diabetes Program has conducted a medical records review of a sample of diabetic patients from the local diabetic registry The audit measures 87 different items some reflecting the process of diabetes care and others reflecting diabetic outcomes The DA Diabetes Audit option in the Diabetes Management System allows you to either partially or fully automate the process of compiling the official IHS Diabetes Quality Assurance Audit Report This section contains instructions for running the electronic diabetes audit report from the RPMS Diabetes registry Please note that the examples given in this manual reflect the standards of care and audit tools developed from the National Diabetes program THIS SYSTEM CONTAINS CONFIDENTIAL PATIENT INFORMATION COVERED BY THE PRIVACY ACT UNAUTHORIZED USE OF THIS DATA IS ILLEGAL KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK DIABETES MANAGEMENT SYSTEM TERK KK KK RR RK RK KK RK KK KK KK KK KK KK KK KK KK KK VERSION 1 0 RHINELANDER TRAINING CENTER CURRENT USER AREA ADAM
15. Guide to Run RPMS Electronic Diabetes Audit Produced by Great Lakes EpiCenter Great Lakes Inter Tribal Council Inc For additional copies please contact Dr Chandra Reddy MD MPH Medical Epidemiologist Great Lakes EpiCenter Great Lakes Inter Tribal Council Inc P O Box 9 Lac du Flambeau WI 54538 800 472 7207 creddy glitc org Electronic Diabetes Audit Guide Table of Contents Diabetes Management Systems DMS Section 1 Software Requirements Section 2 The IHS Diabetes Register Section 3 Diabetes Program Audit Section 4 Diabetes Audit Sample Section 5 Some Notes on Medical Terminology Appendix A Diabetes Standards of Care Appendix B Resources Electronic Diabetes Audit Guide Pages 4 7 9 10 11 16 17 20 21 26 27 28 29 32 About this Guide This guide is provided by the Great Lakes EpiCenter and funding is provided through Bemidji Area Diabetes Surveillance grant from the Indian Health Service IHS The purpose of the project is to assist and empower Tribes in Michigan Wisconsin and Minnesota in the collection analysis and interpretation of diabetes care data across Bemidji Area This guide has been developed for physicians mid level practitioners nurses case managers and diabetic coordinators responsible for the care of Native Americans with diabetes It provides step by step instructions for the diabetes team to generate electronic diabetes audit from the established RPMS Diabetes
16. Mao Epidemiologist Kimmine Pierce Epidemiologist Gregory Rachu Epidemiologist Dina George Data Management System Educator P O Box 9 Lac du Flambeau WI 54538 715 588 3324 Bemidji Area Office Indian Health Service Federal Building 522 Minnesota Ave Bemidji MN 56601 218 759 3440 Epidemiology Branch Indian Health Service 5300 Homestead Dr NE Albuquerque NM 87110 505 248 4226 Health amp Diabetes Websites A Government agencies 1 National Institute of Diabetes amp Digestive amp Kidney Diseases locate at http www niddk nih gov 2 NIDDK National Diabetes Education Program located at http ndep nih gov 3 NIDDK National Diabetes Information Clearinghouse located at http www niddk nih gov health diabetes ndic htm 4 National Kidney and Urologic Diseases Information Clearinghouse located at http www niddk nih gov health kidney nkudic htm 5 Weight control Information Network located at http www niddk nih gov health nutrit win htm 6 Diabetes Research and Training Centers located at http www niddk nih gov health diabetes pubs drtc 7 National Eye Institute located at http www nei nih gov Electronic Diabetes Audit Guide 30 8 National Heart Lung and Blood Institute Health Information located at http www nhlbi nih gov health index htm 9 Centers for Disease Control and Prevention Diabetes Public Health Resource located at http www cdc gov diabe
17. Prevention and Control Program and New Mexico State Univ Cooperative Extension Service information located at http www nmdiabetes com programs kitchen html Electronic Diabetes Audit Guide 33
18. SE Use in pts with overt proteinuria 0 Use in pts with known hypertension 0 0 LIPID LOWERING AGENT USE Use in pts with total chol gt 240 0 Use in pts with LDL chol gt 160 0 Enter RETURN to continue or to exit Electronic Diabetes Audit Guide 19 xxx HEALTH STATUS OF DIABETIC PATIENTS RHINELANDER TRAINING CENTER Reporting Period Jan 10 2002 to Jan 10 2003 50 patients were reviewed n percent refused EXAMS Yearly Foot Exam Neuro amp Vasc 0 0 0 Eye Exam Dilated 0 O 0 Dental Exam 0 0 0 Pap Smear Females Only 0 0 0 DIABETES RELATED EDUCATION Yearly Diet Instruction 0 0 0 Exercise Instruction 0 0 0 Other Diabetes Education 0 0 0 Any of the above topics 0 0 IMMUNIZATIONS Flu Vaccine yearly 0 O 0 Pneumovax once 7 14 0 Tetanus Diptheria q 10 yrs 12 24 0 LABORATORY EXAMS Urinalysis in the past 12 months 0 0 Proteinuria present 0 0 Proteinuria absent 0 0 Proteinuria result unknown 0 0 Proteinuria test not done 50 100 Of the 0 without proteinuria Microalbuminuria present 0 Microalbuminuria absent 0 Microalbuminuria not tested 0 Creatinine obtained in the past 12 months 0 0 Creatinine gt 2 0 mg dl 0 0 Creatinine lt 2 0 mg dl 0 0 Unable to determine result 0 0 Creatinine not tested unknown 50 100 Total Cholestero
19. bals are placed S your site manager for assistance in finding the file after it is created PLEASE jot down and remember the following file name kkkKKKKKKK dmcy02 rec k kkk kkk It may be several hours or overnight before your report and flat file are finished The records that are generated and placed in file dmcy02 rec are in a format readable by EPI INFO For a definition of the format please see your user manual Is everything ok Do you want to continue Y lt Enter gt THE DIABETES QUALITY ASSURANCE AUDIT REPORT To run this report select the DA Diabetes Audit option menu The system defaults to the IHS Diabetes Register that was installed when the Diabetes Management System was installed at your facility You can change the name of the Register to that used at your facility When prompted enter the date of the audit For most data items all data for the period one year prior to this date will be reviewed You can audit individual patients a search template of patients or members of a Case Management System register For a large register you may select to generate the audit for a random sample of the patients in the register You can enter individual patients by name or chart number or the name of a template of patients created with Q Man or one of the Register Reports options Instructions for generating an audit template follow the sample reports at the end of this section In addition you may
20. betes may require oral hypoglycaemic drugs and may also need insulin injections As with the treatment of Type 1 diabetes diabetes education a controlled diet and physical exercise are all important components of the management of Type 2 diabetes Urine protein A diagnostic test performed on urine samples The presence of protein in urine may be an indicator of kidney disease Electronic Diabetes Audit Guide 27 Standards of Care for People with Diabetes Based on ADA Clinical Practice Recommendations Recommendations for Glycemic Control Glycemic Control Normal Goal Action Suggested Whole Blood Calibrated Meter Fasting preprandial glucose lt 100 mg dl 80 120 lt 80 or gt 140 Bedtime glucose lt 110 mg dl 100 140 lt 100 or gt 160 Plasma Calibrated Meter Fasting preprandial glucose lt 110 mg dl 90 130 lt 90 or gt 150 Bedtime glucose lt 120 mg dl 110 150 lt 110 or gt 180 Hemoglobin Alc lt 6 lt 7 gt 8 These values are for nonpregnant adults Action suggested depends on individual patient circumstances Such actions may include enhanced diabetes self management education comanagement with a diabetes team referral to an endocrinologist change in pharmacological therapy initiation or increased SMBG or more contact with the patient HbAIc is referenced to a nondiabetic range of 4 0 6 0 mean 5 0 SD 0 5 Lipid and Blood Pressure Goals for nonpregnant adults Blood Pressure mmHg Lipids mg dl S
21. es tribalsites html 23 National Resource Center on Native American Aging located at http www und edu dept nrcnaa 24 Inter Tribal Council of Arizona Inc located at http www itcaonline com Programs html D Community diabetes and health education programs 1 CDC National Diabetes Education Program located at http www cdc gov diabetes projects ndeps htm or http ndep nih gov 2 American Association of Diabetes Educators Continuing Education located at http www aadenet org ce eduoffer htm 3 Joslin Diabetes Center Continuing Medical Educational Programs located at http professionaled joslin org CourseListing LiveCourseListing asp and a description of classes located at http www joslin harvard edu jboston classes shtml 4 Diabetes Planner com Diabetes Education Classes CDE located at http diabetesplanner com diabetes_education default asp 5 American Diabetes Association Education Recognition Program located at http www diabetes org education eduprogram asp 6 American Medical Association Online Continuing Medical Education Programs located at http www ama assn org ama pub category 7537 html 7 National Certification Board for Diabetes Educators located at http www ncbde org Electronic Diabetes Audit Guide 32 F School based diabetes and health education programs 1 HealthTeacher com Owned by Health Strategies company It
22. f them See also diabetic ketoacidosis Ketosis A condition of having ketones build up in body tissues and fluids The signs of ketosis are nausea vomiting and stomach pain Ketosis can lead to ketoacidosis Myocardial infarction MI Popularly known as a heart attack More precisely necrosis localised tissue death of a part of the cardiac heart muscle caused by obstruction in a coronary artery The term old MI refers to the evidence that a patient has suffered an MI at some time in the past Macrovascular disease Disease of the large blood vessels that may occur in people who have had diabetes for a long time Fat and blood clots build up in the large blood vessels and stick to the vessel walls Three kinds of macrovascular disease are coronary disease cerebrovascular disease and peripheral vascular disease Microvascular disease Disease of the smallest blood vessels that may occur in people who have had diabetes for a long time The walls of the vessels become abnormally thick but weak They therefore bleed leak protein and slow the flow of blood through the body Electronic Diabetes Audit Guide 25 Nephropathy Diabetes is also the leading cause of nephropathy kidney disease The progress of nephropathy can be slowed down by control of hyperglycaemia control of hypertension and restriction of protein in the diet Nephropathy can be detected by testing for traces of protein in the urine Neuropathy
23. is considered underweight a BMI between 20 and 25 is normal over 25 and less than 30 is overweight a BMI of 30 or over defines obesity Example A woman whose weight is 59 kilos approximately 9 st 3 Ibs and whose height is 1 63 metres approximately 5 feet 4 inches has a BMI of 59 1 632 22 to the nearest whole number Work out your own BMI For those still steeped in Imperial measure 1 inch 2 54 cm and 11b 0 45 kilos Cardiovascular disease In many countries cardiovascular disease disease of the circulatory system is the leading cause of death among people with diabetes Smoking hypertension high cholesterol and obesity are significant risk factors that can cause cardiovascular disease Recognition and effective management of these risk factors can prevent cardiovascular disease in people with diabetes Cerebrovascular Relating to the supply of blood to the brain Cerebrovascular accident CVA See stroke Cerebrovascular disease Electronic Diabetes Audit Guide 22 A morbidity in which either the supply of blood to the brain is inadequate because of arterial narrowing atherosclerosis or other obstruction of the blood supply to the brain Dementia A progressive organic mental disorder characterised by memory loss chronic personality disintegration confusion etc Diabetes mellitus A disorder of glucose metabolism Primarily a result of relative or complete lack of insulin secretion or defects of
24. ister You may wish to create additional registers Using the Create Register option in the Case Management System you can create new registers or change the name of the existing register perhaps to maintain multiple registers for communities or facilities within a single service unit However in order for the new Diabetes Management software to work with a register the word DIABETES must be in the name of the register If you change the name of an existing register You must answer YES when you are asked if you wish to re index files The following data items are included in the IHS Diabetes Register Patient Status Complications Active CVA Stroke Inactive End Stage Renal Disease Transient High Risk Foot Unreviewed Hypertension Deceased Laser Tx for Retinopathy Non IHS Care Major Amputation s Diagnosis Microalbuminuria Gestational DM Minor Amputation s Type 1 Myocardial Infarction Impaired Glucose Tolerance Retinopathy Type 2 Entry Date Last Edited Date Date entered in Register Last Review Date Electronic Diabetes Audit Guide Date data last updated Next Review Date 10 The main advantage of using the IHS Diabetes Register is its link to all of the data in the PCC This link eliminates redundant entry of visit related data for example lab values measurements patient education topics and health factors Also the IHS Register provides for standardization of data elements Upon installation of
25. l obtained in the past 12 months 0 0 Desirable lt 200 mg dl 0 0 Borderline 200 239 mg dl 0 0 High 240 mg dl or more 0 0 Unable to determine result 0 0 Not tested 50 100 Electronic Diabetes Audit Guide 20 xxx HEALTH STATUS OF DIABETIC PATIENTS RHINELANDER TRAINING CENTER Reporting Period Jan 10 2002 to Jan 10 2003 50 patients were reviewed n Percent LDL Cholesterol obtained in the past 12 months 0 0 LDL lt 100 mg dl 0 0 LDL 100 129 mg dl 0 0 LDL 130 160 mg dl 0 0 LDL gt 160 0 0 Unable to determine result 0 0 ot tested 50 100 HDL Cholesterol obtained in the past 12 months 0 0 HDL lt 35 mg dl 0 0 HDL 35 45 mg dl 0 0 HDL 46 55 mg dl 0 0 HDL gt 55 0 0 Unable to determine result 0 0 Not tested 50 100 Triglycerides obtained in the past 12 months 0 0 TG lt 150 mg dl 0 0 TG 150 199 mg dl 0 0 TG 200 400 mg dl 0 0 TG gt 400 mg dl 0 0 Unable to determine result 0 0 Not tested 50 100 EKG Performed in past 3 years 1 2 Performed in past 5 years 1 2 Ever performed 1 2 Tuberculosis Status PPD INH treatment complete 1 2 PPD untreated incomplete or tx unknown 3 6 PPD placed since DM dx 0 0 PPD placed before DM dx or date unknown 14 28 PPD status unknown 32 64 Self monitoring of blood glucose documented Yes 0 0 No 50 100 Refused 0 0 Participating in SDM Yes 0 No 50 100 Undetermined 0
26. lucose level was for that period of time Heart attack See Myocardial infarction Hyperglycaemia Too high a level of glucose sugar in the blood a sign that diabetes is out of control Many things can cause hyperglycaemia It occurs when the body does not have enough insulin or cannot use the insulin it does have to turn glucose into energy Signs of hyperglycaemia are a great thirst a dry mouth and a need to urinate often For people with Type 1 or insulin dependent diabetes hyperglycaemia may lead to diabetic ketoacidosis Hypoglycaemia A complication of diabetes characterised by a deficiency of glucose in the blood leading to muscular weakness mental confusion and sweating In severe cases it can lead to hypoglycaemic coma and death Hypoglycaemia may result from inadequate intake of carbohydrate or over treatment with hypoglycaemic drugs see below Hypoglycaemics Drugs used to control non insulin dependent diabetes Hypertension Persistent high blood pressure where high is determined by reference to a patient s age and sex persistent usually refers to high BP readings on three distinct occasions Can sometimes be associated with an organic cause but if not is referred to as essential hypertension Uncontrolled hypertension can lead to heart and cerebrovascular disease and to other complications including kidney disease Impaired Glucose Tolerance IGT Blood glucose levels that are higher than normal
27. more 1 2 Diagnosis date not recorded 44 88 Weight Control BMI does not add up to 100 Overweight or Obese BMI gt 85 ile 0 0 Obese BMI gt 95 ile 0 0 BMI could not be calculated 50 100 Blood Sugar Control uses last HGB A1C value HbAlc lt 7 0 HbAlc HbAlc HbAlc HbAlc 10 0 10 9 HbAlc 11 0 or higher Undocumented 5 wo N 20 s0 20 wo oOo N WO WO WO OVO O OOO Electronic Diabetes Audit Guide 18 xxx HEALTH STATUS OF DIABETIC PATIENTS KEK RHINELANDER TRAINING CENTER Reporting Period Jan 10 2002 to Jan 10 2003 50 patients were reviewed n Percent Blood Pressure Control based on mean of last 3 bp s Ideal BP Control lt 120 lt 80 0 0 Target 120 80 lt 130 lt 85 0 0 Adequate 130 85 lt 140 lt 90 0 0 Inadequate 140 90 lt 160 lt 95 0 0 Markedly Poor 160 95 or higher 0 0 BP Control Undetermined 50 100 Tobacco use Current Tobacco User 23 46 Counseled Yes 0 0 Counseled No 23 100 Not a current tobacco user 4 Tobacco use not documented 23 46 DIABETES TREATMENT Diet and Exercise Alone 50 100 Insulin 0 Oral Med monotherapy Sulfonylurea 0 0 Metformin 0 0 Acarbose 0 0 Troglitazone 0 0 Combination of Oral Meds 0 0 Combination of Oral Medst Insulin 0 0 Refused or Undetermined 0 0 CHRONIC ASPIRIN THERAPY Yes 0 No 50 100 Undetermined 0 ACE INHIBITOR OR ARB U
28. ng please contact Chuck Tudor Computer Systems Specialist at the Rhinelander Field Office and his contact telephone is 715 365 5106 or you may also contact Dennis Yost Systems Analyst MIS at the Bemidji Indian Health Office and the contact telephone is 218 444 0539 Electronic Diabetes Audit Guide Section 2 THE IHS DIABETES REGISTER The standard IHS Diabetes Register is a tool for maintaining a list of your diabetes patients their disease type complications family members and case review dates The Diabetes Register facilitates the addition inactivation and removal of patients from the list entry of data to be monitored for patients on the list printing of case summaries generation of reports and retrieval of virtually all clinical data entered into the PCC for patients on the register The Standard IHS Diabetes Register is installed automatically with installation of the Diabetes Management System BDM Version 1 0 It provides a core set of data items with predefined lists and standard definitions It also permits you to establish your own lists and definitions in support of these data items The IHS Diabetes Register helps to simplify the process of creating a Case Management based register but you are in no way limited to this core set of data items and the lists that accompany them Remember that you always have access to all existing PCC demographic and clinical data without keeping these items in the Diabetes Reg
29. nical event occurred Both the individual and cumulative printed reports provide space for the DM auditor to manually enter that data directly from the patient record Additional data may be added to the Epi file using the Epi Info software as described below When making additions or modifications to the data file you may find it helpful to print out individual audit reports on the same cohort of patients that you named to create the Epi file The individual audit reports are printed in the same order that they appear in the data file You may use the individual printed reports for recording additional data from chart reviews Once you have obtained the necessary additional data these data items can be added to the Epi file in the appropriate places using the Enter Data option of the Epi Info software For further instructions regarding the Epi Info DM audit program consult Chandra Reddy Medical epidemiologist at the Great Lakes Inter Tribal Council Electronic Diabetes Audit Guide 17 Section 4 Cumulative Audit report Jan 10 2003 x x HEALTH STATUS OF DIABETIC PATIENTS KKK RHINELANDER TRAINING CENTER Reporting Period Jan 10 2002 to Jan 10 2003 50 patients were reviewed n Percent Gender Female 25 50 Male 25 50 Age lt 15 yrs 2 15 44 yrs 22 44 45 64 yrs 19 38 65 yrs and older 7 14 Diabetes Type Type 1 1 2 Type 2 49 98 Unknown 0 0 Duration of Diabetes Less than 10 years 2 10 10 years or
30. nnual review recorded in their records Criteria and standards should be based on the latest available research and evidence If evidence is not available it is acceptable to base criteria and standards on a consensus agreement by members of the team 3 Collecting Data Once you have set the criteria and standards for your audit i e decided what you are going to measure against you will need to collect audit data There are a number of factors to consider at this point First audit data must be representative and therefore you will need to ensure that enough patients are included in the audit to make sure that the data collected is valid and representative Second it is important to make sure that any data collection forms used are understandable consistent and robust If two people using the same audit data collection form interpret the questions and data differently the audit will be prone to failure Therefore in order to make sure data collection forms are valid it is advisable that teams pilot their data collection tools thoroughly In recent times NHS staff have started to move from manual collection of audit data to the electronic capture of data This is clearly more preferable as electronic capture of data is likely to be much quicker and more accurate However it is important that electronic audit tools are thoroughly checked as problems can still emerge 4 Analysing Data Once audit data has been collected it needs to
31. ocated at http www diabetes com 15 National Kidney Foundation located at http www kidney org 16 Roche located at http www roche diagnostics com 17 World Health Organizations located at http www who int en 18 Taking on Diabetes located at http www takingondiabetes org 19 Diabetesatwork org located at http www diabetesatwork org AAYDMNFWNeE C Native American organizations and diabetes and health programs 1 University of Oklahoma Health Promotion Programs located at http hpp ou edu 2 Indian Health Service Medical and Professional Programs located at http www ihs gov MedicalPrograms Medical_index asp 3 Northwestern Portland Area Indian Health Board The Western Tribal Diabetes Data Project located at http www npaihb org epi diabetes html 4 The Native American Prevention Research Center located at http w3 ouhsc edu coph CophSub PRC htm 5 Univ of Arizona Native American Research and Training enter located at http www ahsc arizona edu nartc 6 Center for American Indian Health Research University of Okalahoma Health Sciences Center located at http w3 uokhsc edu coph CophSub CAITHRtxt htm Electronic Diabetes Audit Guide 31 7 Native American Diabetes Project Strong in Body and Spirit located at http www laplaza org health dwc nadp 8 The Center for American Indian Health The Johns Hopkins School of
32. permanent The primary cause is in the heart or the blood vessels the effect on the brain by which the disease is manifest is a consequential effect Systolic pressure See blood pressure Electronic Diabetes Audit Guide 26 Transient ischaemic attack TIA The result of a temporary disruption of the blood supply to the brain Symptoms similar to stroke but last less than 24 hours Type 1 or insulin dependent diabetes mellitus IDDM Type 1 or insulin dependent diabetes mellitus develops most frequently in children and adolescents but is now also increasingly found in adults About 10 of people with diabetes have Type 1 The symptoms vary in intensity and include excessive thirst excessive passing of urine weight loss and lack of energy Insulin is a life sustaining medication for people with Type 1 diabetes They require daily insulin injections for survival Diabetes education a controlled diet and physical exercise are all important components of the management of Type 1 diabetes Type 2 or non insulin dependent diabetes NIDDM Type 2 or non insulin dependent diabetes is much more common than Type 1 and occurs mainly in adults The symptoms of Type 1 in a less marked form may also affect people with Type 2 diabetes Some people with Type 2 however have no early symptoms These people are only diagnosed several years after the onset of the condition when various diabetic complications are already present People with Type 2 dia
33. registry This guide will facilitate the Indian Health Service Diabetes Management System User Manual We welcome your interest in learning the Diabetes Management System and also hope you will find it very useful for generating electronic Diabetes Audit reports to make diabetes surveillance more meaningful and practical for your diabetes program We appreciate your feedback on how we can better serve your tribal health care facility to improve the quality of Diabetes Care please do not hesitate to call us at 1 800 472 7207 Electronic Diabetes Audit Guide 4 DIABETES MANAGEMENT SYSTEM DMS INTRODUCTION This instruction manual describes the RESOURCE AND PATIENT MANAGEMENT SYSTEM RPMS of Diabetes Management System DMS Diabetes Audit report generator and provides a step by step approach This document has been designed primarily as an instructional guide for Diabetes Coordinators Diabetes team working in the Diabetes Management System We hope you will find it a very useful guide for generating electronic Diabetes Audit reports What do Diabetes Audits measure Diabetes Audits monitor the use of particular interventions or the care received by diabetic patients against agreed standards Any departures from best practices can then be examined in order to understand and act upon the causes We will recommend simple methods that health professionals diabetes teams can use to monitor how they follow the guidance offered by
34. select a subset of patients to audit based on the particular community where they live or a primary care provider Electronic Diabetes Audit Guide 16 You can obtain three types of audit reports 1 a printed report for each individual patient 2 a printed cumulative report that summarizes the results for all patients or 3 a data file readable by the Epi Info software program You must specify which type of report you want to generate from the list provided on the screen To generate printed reports you can choose the individual report cumulative report or both Each patient s individual report takes at least 10 seconds to run When running the Audit Report for a large number of patients it is recommended that you queue the report to a printer to generate after regular hours A sample computer dialogue of setting up an audit report for the 2002 calendar year is displayed below The dialog demonstrates the Creating an Epi Info File option and uses the entire IHS Diabetes Register The directory where the file is created varies depending on the kind of computer system used at a facility When generating Audit reports keep in mind that certain patient clinical data for example lab results and EKG data may not currently be available from the PCC at your site This report is generated from the PCC database if the clinical information needed for generating this report was not entered into the PCC the report cannot recognize that the cli
35. sue 4 Compare Giparce performance ay seth erita practice data and standards collection In order to carry out a successful audit the diabetes audit team should work round the various stages of the audit cycle 1 Selecting an appropriate audit topic The first stage of any audit is obviously to select an appropriate topic to be audited However selecting an appropriate audit topic isn t as straight forward as it may appear Itis important that your audit topic focuses on a real problem and that it is also measurable and relevant to your field of work practice Electronic Diabetes Audit Guide 6 2 Choosing appropriate criteria and standards Criteria and standards are two audit terms which often confuse people This is unfortunate as criteria and standards are not difficult to understand In essence if we refer back to our definition of audit criteria and standards relate to what we should be doing A criterion is essentially an item of care or an aspect of practice that we can use to assess quality Each criterion should be recorded as a succinct statement Therefore an example of a criterion would be The records show that patients with CHD are reviewed annually A standard is a statement of the proportion of occasions or patients which must fulfil each criterion Standards are expressed as percentages For example we may set a standard stating that 100 of CHD patients should have an a
36. tes 10 Indian Health Service Medical and Professional Programs located at http www ihs gov MedicalPrograms Medical_index asp 11 Office of Minority Health U S Dept of Health amp Human Services located at http www omhrc gov omhhome htm 12 USDA Food and Nutrition Information Center located at http www nal usda gov fnic 13 Code Talk located at http www codetalk fed us B Professional corporate amp private associations American Association of Diabetes Educators located at http www aadenet org American Diabetes Association located at http www diabetes org main application commercewf American Dietetic Association located at http www eatright org International Diabetes Federation located at http www idf org home Juvenile Diabetes Foundation located at http www jdrf org National Certification Board for Diabetes Educators located at http www ncbde org Joslin Diabetes Center located at http www joslin org American Heart Association located at http www americanheart org 9 American Podiatric Medical Association located at http www apma org 10 American Council on Exercise located at http www acefitness org 11 American Optometric Association located at http www aoanet org 12 Becton Dickinson located at http www bd com diabetes 13 Bristol Meyers Squibb Company located at http www bms com 14 Diabetes com l
37. the Indian Health Service Why is Diabetes Audit important Effective diabetes audit is important for health professionals health directors diabetes team managers patients and the public e It supports health professionals in making sure their patients receive the best possible care e It can inform diabetes teams about the need for organisational change or new investment to support health professionals in their practice e It helps to ensure that patients are given the best possible care and provides the public with confidence in the quality of the service as a whole Diabetes audit allows an opportunity to update the diabetes register Audit should include review of the diagnosis and whether the patient is still registered with the practice Audit data will also provide a practice with prevalence data which may indicate if numbers of patients on the register are accurate for a given population Diabetes audit data will also provide data on process and outcome measures being achieved for people with diabetes The Diabetes Audit Cycle The diabetes audit cycle also referred to as the audit spiral audit loop etc sets out the various steps that must be undertaken to ensure that an audit project is systematic and successful Electronic Diabetes Audit Guide 5 The following diagram graphically illustrates the Diabetes Audit Cycle 2 Set criteria and standards 5 Implementing change 1 Identify problem or is
38. ystolic lt 130 Cholesterol lt 200 Diastolic lt 85 LDL lt 100 HDL gt 45 Triglycerides lt 200 Electronic Diabetes Audit Guide 28 For patients with an isolated systolic hypertension of gt 180 the goal is a blood pressure lt 160 For those with systolic blood pressures of 160 179 the goal is a reduction of 20 mmHg If these goals are achieved and well tolerated further lowering to 140 may be appropriate Without CHD PVD and CVD drug therapy is suggested for LDL levels gt 130 For diabetic patients with multiple CHD risk factors some authorities recommend initiation of drug therapy when LDL levels are between 100 and 130 mg dl MNT should be attempted before starting drug therapy Key Tests Exams Test Exam Frequency HbA 1c Quarterly if treatment changes or not meeting goals 2 times year if stable Dilated eye exam yearly Foot exam Inspection every regular diabetes visit Complete exam yearly Lipid profile yearly if stable Microalbumin creat ratio Yearly Blood pressure Each regular diabetes visit Weight Each regular diabetes visit EKG Every 1 5 years as needed Dental exam Every 6 12 months Serum creatinine yearly Vaccination update yearly Nutritional counseling yearly more often as needed Electronic Diabetes Audit Guide 29 Resources Great Lakes Inter Tribal Council Inc Great Lakes EpiCenter Nancy Miller Korth Project Coordinator Chandra Reddy Medical Epidemiologist Jingnan
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