The CDRC Diabetes Module is designed to make it easy and efficient for practices to identify patients at high risk of Diabetes, instigate appropriate intervention, and appropriately manage your Diabetic patients.
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.
Reports
Quality Improvement Reports
CDRC has a number of reports that you may find useful to identify uncoded diabetic patients and to manage your existing cohorts.
These reports are located in the CDRC Quality > Diabetes IGR folder and have been broken down into sub-groups.
Concordance Alerts
Identifies patients with diabetic medication on repeat but may have poor concordance.
Diabetes Annual Review
Reports that identify patients who have had their diabetic annual review but have not had a ACR, or a Foot Check in the 3 months prior to their annual review.
Diabetes Mellitus Prevention
Reports to ensure that disease registered for patients with Diabetes and Non-diabetic hyperglycaemia (NDH) are accurate and up to date and to help identify patients eligible for the National Diabetes Prevention Programme (NDPP).
Diabetes Mellitus Management
There are a significant number of reports available to support you with the management of your Diabetic patients.
These reports improve coding accuracies, identifies where certain elements of Key Care has not been completed, those with overdue monitoring requirements,
GLP1
These reports identify patients on GLP1 that you may want to review due to specific results or prior conditions.
Diabetes Performance
The following reports can give you an overview of the HbA1c management at your unit.
These reports can be found in the folder CDRC Quality > Diabetes IGR
The reports are subdivided into different treatment regimens and HbA1c achievement.
The following algorithm is used to highlight patients for review.
Patients who are not on the frailty or palliative care registers
| No treatment | Oral Monotherapy Metformin | Oral Monotherapy Other | Oral Dual Therapy with Metformin | Oral Dual Therapy w/o Metformin | Oral >=3 Therapy with Metformin | Oral >=3 Therapy with Metformin | GLP1 no insulin | Insulin | |
| >=75 | NPR | NPR | NPR | NPR | NPR | NPR(S) | NPR(S) | NPR(S) | NPR(S) |
| 58-74 | NR | NR | NR | NR | NR | NR | NR | NR | NR(S) |
| 53-57 | NR | NA | NA | NA | NA | NA | NA | NA | NA |
| 48-52 | NUR | NA | NA | NA | NA | NA | NA | NA | CDPR |
| <48 | NA | NA | NA* | CDPR* | CDPR* | CDPR* | CDPR* | CDPR* | SA |
NA – No action
SA – safety alert
CDPR – Consider deprescribing/dose reduction review
NUR – Non-urgent review
NR – Needs review
NPR – Needs prompt review
(S) – indicates that specialist input may be needed depending on local expertise
* – upgraded to safety alert if the patient is taking a sulfonylurea
The algorithm looks for the last HbA1C result when that result in at least 15 weeks old.
Diabetes Drug Reports
These reports have been created using the County Durham and Darlington integrated diabetes model.
These reports can be found in the folder CDRC Quality > Diabetes IGR
Reports to identify possible overtreatment:
Reports to identify patients who might be eligible for drug switches:
Patient Status Alerts
Set-Up and Alerts
CDRC has a number of Patient Status Alerts (PSAs) than can improve the opportunistic care of your patients.
To activate these alerts, you will need to follow 2 steps:
First, ensure that the following patient status alerts are enabled by going to Setup > Data Output > Patient Status Alerts and searching for the following:
- CDRC At high risk of diabetes
- High Risk of Diabetes – Recommend DMUK Score
- High Risk of Diabetes – Recommend HbA1c
Second, contact CDRC to ask for the diabetes prevention alerts to be activated at your unit by emailing contact-cdrc@healthinnovationnenc.org.uk
This will then activate the following PSAs that will be located underneath the Patient’s demographic box once their record is retrieved.
CDRC At High Risk of Diabetes
This 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. The patients are identified based on information such as BMI, waist circumference, age, hypertension, sex, ethnicity and family history.
They will be identified by the sugar cube icon.
High Risk of Diabetes – Recommend DMUK Score
All patients who are estimated to be at high risk of diabetes, based on information such as BMI, age, sex etc. Patients who have an HbA1c measurement or diabetes UK score calculated in the past three years will not have the icon
They will be identified by the sugar cube icon.
High Risk of Diabetes – Recommend HbA1c
Again, identified by a sugar cube 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
Clicking on each of the icons will take you to a Data Entry Template where you can review, manage and update the patient’s record accordingly.
Templates
Diabetes – CDRC
The Diabetes – CDRC Data Entry Template can be accessed by using the search bar in the bottom left-hand corner of SystmOne.
The Home page displays a summary of key information and measurements for the patient. From here, you can navigate to other Data Entry Templates such as Lipids, Renal Function / Coding and to perform Foot/Retinal Assessments.
You can also navigate to the different pages of this template (Sex, Care Model/Planning, Patient Information etc.) by clicking on the page headings at the top of the template. These pages will provide you with further information and the ability to input information onto the patient’s record.
For example, the Coding / Casefinding page provides a summary of the patient’s diabetes coding history, their previous HbA1c results and allows you to quickly select a Diabetes code via a checkbox, drop down or by selecting any DM code from the codes hierarchy.
High Risk of Diabetes – CDRC
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 – CDRC 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.
Visualisations
GLP1 Dashboard – CDRC
The GLP1 Dashboard – CDRC Visualisation can be accessed by typing in ‘Launch Visualisation’ in the search bar in the bottom left-hand corner of SystmOne’s main screen and select the returned feature. This will open the ‘Select Visualisation’ page where you can select the GLP1 Dashboard – CDRC visualisation.
This visualisation provides a summary of your unit’s GLP1 prescribing.
There are separate sections in this visualisation for Safety Issues and Patients for Review.
Expanding the nodes, as shown on the left-hand side of the visualisation, provides you with more information. Clicking on the red jigsaw piece will bring up the patient list containing the patients identified in each row.
