The CDRC Diabetes Prevention Module is designed to make it easy and efficient for practices to identify patients at high risk of Diabetes and instigate appropriate intervention. In particular it is designed to integrate into other primary prevention and long term condition management.
Accessing CDRC resources on SystmOne
To access the below resources you will need to be a member of the DCS group on SystmOne. To do this, please follow the instructions on the CDRC SystmOne Access webpage.
Set-Up
You will need to perform certain actions before using the CDRC Diabetes Prevention/Identification scheme:
- Ensure that the practice is a member of the DCS organisation group on SystmOne. If the practice is not a member, you can find out how to join the group by clicking here.
- Ensure that the following patient status alerts are enabled:
- CDRC NAFLD
- CDRC At high risk of diabetes
- High risk of diabetes – Recommend DMUK Score
- High risk of diabetes – Recommend HbA1c
- Contact CDRC to ask for the diabetes prevention alerts to be activated at your unit by emailing contact-cdrc@ahsn-nenc.org.uk
- This step is not essential but is quite helpful for reviewing patients
- Set up a pathology preset to help with the review of patient records
- Retrieve any patient
- Click on the Pathology button on the top ribbon
- Select any of the preset options
- Click Edit Presets
- Click New Organisation Preset
- Use the name * Glucose
- Select the following numerics
Reports – Review of Records for Missing NDH Diagnosis
This part of the system is to ensure that disease registers for patients with diabetes and NDH are accurate and up to date.
To identify the patients whose records need to be reviewed, run the following reports.
These reports are found in the folder CDRC Quality > Diabetes IGR
| Report Name | Returns |
| ? DM 1.11 NDH Casefinding – Latest HbA1C in the NDH range but no code for DM/NDH | Patients whose last HbA1c is in the NDH range 42-47 who aren’t diagnosed with NDH (or equivalent) |
| ? DM 1.12 NDH Casefinding – NDH recorded as resolved | Patients who have been coded as IGR resolved. Such patients will not be flagged with an NDH icon on their record and will not be recalled in the CDRC recall system. QoF does not count ‘IGR Resolved’ codes so they will still be counted for QoF purposes. You may wish to consider removing the resolved code. Long term checking of HbA1c is recommended for patient with NDH even if HbA1c is currently back in the normal range. |
| ? DM 1.13 GDM Casefinding – Possible missed gestational diabetes | Women who have had prescriptions for BM testing equipment during reproductive years. This might be due to gestational diabetes. Consider reviewing the record and coding gestational diabetes if appropriate. |
Reports – Identifying Patients for NDPP
Patients can be invited to the National Diabetes Prevention Programme during annual review or opportunistic assessment (via the High Risk of Diabetes template).
Alternatively, a series of searches is available to help identify and invite patients for the National Diabetes Prevention Programme.
These reports are found in the folder CDRC Quality > Diabetes IGR
! NDPP – *Appears to be eligible (all) and no record of referral (not declined in the last 12 months) # is probably the most useful report that will identify eligible patients who have not been referred but who haven’t already declined in the last 12 months.
More detailed eligibility searches are also available, subdivided into those patients who are/are not coded with NDH. This allows practices to take a different approach for patients who may need to be informed of their NDH diagnosis before invitation – they may be ‘missed NDH’ patients.
Inviting Patients to NDPP
- In Person Invitation
A patient information/invitation sheet can be printed from the High Risk of Diabetes template
- Postal Invitation
Invitation letters are available in the Word document library
WW NDPP Invitation GP Referral – ask patients to contact the surgery to arrange GP referral
WW NDPP Invitation Self Referral – invites patients to refer themselves
- Electronic Invitation
The SystmOne Communication Annexe can be used to invite patients using SMS and/or email.
Right click on the search list and, from Actions, choose the Use Communications Annexe option.
Suggested messages are shown below (these can be set as presets for future use).
For SMS text, two messages will usually be needed as the reply web address will usually not allow the message to fit into a single SMS
Message 1 (not set to allow reply)
<forename> <surname> Your record shows you are eligible for the free Healthier You Programme to help prevent diabetes.
https://www.weightwatchers.com/uk/healthieryou
[Organisation Name here]
Message 2 (set to allow reply)
You can refer yourself online or just reply to this text and we will refer you.
For email:
<forename> <surname> Your record shows you are eligible for the free Healthier You Programme to help prevent diabetes.
https://www.weightwatchers.com/uk/healthieryou
You can refer yourself online or just reply to this text and we will refer you.
Regards
[Organisation Name here]
Screening of Patients at High Risk of Diabetes
The clinical system will identify patients who are at high risk of diabetes who have not yet been coded with any form of impaired glucose regulation or gestational diabetes or NAFLD. They will be identified by the sugar cube icon to the right of the GMS icon. The patients are identified based on information such as BMI, waist circumference, age, hypertension, sex, ethnicity and family history.
These patients could be offered an assessment of their diabetes risk using the Diabetes UK Risk Score. This can be done as part of an annual review, opportunistically or by specific recall.
Clicking on the icon will take you to the Diabetes UK Score template. The right panel shows the information that is needed for calculating the score. If you have just completed a LTC annual review this information will probably be up to date. Clicking on the Launch Diabetes UK Score button will calculate the DM UK Score. If any data is missing or out of date you will be prompted to enter up-to-date data during this process. If the DM UK Score is 16 or over (which it will be for the majority (~90%) of these patients) you should offer them an assessment of their HbA1c level.
Data from pilot practices suggested that around 4% of those with a score >=16 with have diabetes and 40% IGR.
Patients with an HbA1c between 42 and 47 should be coded with impaired glucose regulation.
Patients over 25 from high risk ethnicity groups with a BMI >23 should be offered an assessment of HbA1c without a DMUK risk assessment as their risk of diabetes is so high. These patients are identified by a patient status alert, as are those patients with an actual DMUK score >=16 who have not taken up the offer of an HbA1c test.
Annual Review for Patients known to be at High Risk
Guidelines recommend that patients with IGR/NDH, gestational diabetes, NAFLD or PCOS have an annual health assessment. This assessment should include measurement of BMI, BP, lifestyle intervention and an assessment of HbA1c level. The CDRC call/recall system can be designed to include recall for these non-QoF conditions.
The High Risk of Diabetes template displays key measurements and information. Body measurements and lifestyle advice should be recorded and delivered via the Core Data Entry template as usual.
There is a link to a patient information leaflet about impaired glucose.
NHS Diabetes Prevention Programme
Consider a referral to a Diabetes Prevention Programme. The right hand panel shows if the patient is eligible for referral and the latest information about referrals.
Clicking on the DPP Referral button will allow you to create a DPP referral using a prepopulated proforma, first checking if this is available in your area and then whether the patient is eligible.
More detailed information about the NDPP for the patient can be found on the second tab of the template.
Other Lifestyle Programme Referrals
For patients who want lower level intervention than that offered by NDPP, there is a link to the lifestyle programme template at the bottom of the page.
Please get in touch if you want to set up the lifestyle programme referral for your area.
Patient Status Alerts
There are three PSAs:
Patients known to be at high risk
All patients who have a Read code suggesting a high risk of diabetes will be identified with a sugar cube icon to the left of the GMS icon, on the patient home screen and on the LTC Master template.
Qualifying codes include: IFGT, IGT, IGR, non-diabetic hyperglycaemia, pre-diabetes, PCOS, gestational diabetes
Patients estimated to be at high risk
All patients who are estimated to be at high risk of diabetes, based on information such as BMI, age, sex etc will be identified by a sugar cube to the right of the GMS icon. Patients who have an HbA1c measurement or diabetes UK score calculated in the past three years will not have the icon
Patients who should be offered an HbA1c without further assessment
Again, identified by a sugar cube to the right of the GMS icon. These are patients:
- Over 25 with South Asian, Chinese, black African or Afro-Caribbean ethnicity with a BMI >23
- Patients with an actual DMUK score >=16 but no subsequent record of HbA1c assessment
