QOF

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Age must be 17 or over with a diagnostic code for diabetes mellitus

The latest IFCC HbA1c having a value of 59 or less in the last 12 months.

Or Maximum tolerated diabetes treatment (Added in the last 12 months)

8BL2. Patient on maximal tolerated therapy for diabetes

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IFCC HbA1c code

42W5. Haemoglobin A1c level - International Federation of Clinical Chemistry and Laboratory Medicine standardised

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Codes for blood test declined (In last 12 months)

41M.. Blood test declined (v28)

Diabetes exception reporting codes (Added in the last 12 months)

9h4.. Exception reporting: diabetes quality indicators
9h41. Excepted from diabetes quality indicators: Patient unsuitable
9h42. Excepted from diabetes quality indicators: Informed dissent

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DM 007.1 Rationale

The three target levels for HbA1c (59, 64 and 75 mmol/mol) in the QOF are designed to provide an incentive to improve glycaemic control across the distribution of HbA1c values. The lower level may not be achievable or appropriate for all patients. Also practitioners should note that in the 2009 guideline for Type 2 diabetes, NICE advises against pursuing highly intensive management to levels below 48mmol/mol in certain patient subgroups.

There is a near linear relationship between glycaemic control and death rate in people with type 2 diabetes. In the EPIC Norfolk population cohort, a one per cent higher HbA1c was independently associated with 28 per cent higher risk of death, an association that extended below the diagnostic cut off for diabetes. These results suggest that, as with blood pressure and cholesterol, over the longer term at least, the lower the HbA1c the better.

However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial has highlighted the risks of adopting an aggressive treatment strategy for patients at risk of cardiovascular disease. In the trial's intervention group, HbA1c fell from 8.1 per cent to 6.4 per cent, but this was associated with increased mortality. However, a recent meta-analysis did not confirm such an increase in risk and reassuringly, the ADVANCE study and the Veteran Affairs Diabetes Trial found no increase in all-cause mortality in their intensive treatment groups. Also, long term follow-up of the UK Prospective Diabetes Study demonstrated a 'legacy effect', with fewer deaths after ten years in those initially managed intensively.

A retrospective analysis of cohort data from the UK General Practice Research Database (GPRD) has reopened the debate about how low to aim. The study found that, among people whose treatment had been intensified by the addition of insulin or a sulphonylurea, there was no benefit in reducing HbA1c below 7.5 per cent, although these differences were not statistically significant. The mortality rate was higher among those with the tightest control (this lowest decile of cohort had HbA1c below 6.7%; median = 6.4%). The reasons for these findings are unclear, but they raise further questions about the possibility of some groups of patients for whom a tight glycaemic target is inappropriate.

The NICE clinical guideline on the management of Type 2 diabetes identifies the following key priorities for implementation to help people with Type 2 diabetes achieve better glycaemic control:

The NICE and SIGN clinical guidelines are consistent.

Given that there is strong evidence to support tight glycaemic control in type 1 diabetes, which is reflected in current NICE and SIGN guidelines, this indicator aims to balance risks and benefits for patients with type 2 diabetes. Younger patients with little co-morbidity are more likely to reap the benefits of tighter control, whereas less stringent goals may be more appropriate for patients with established CVD, those with a history of hypoglycaemia, or those requiring multiple medications or insulin to achieve a NICE suggested target HbA1c of 48 mmol/mol.

From 1 June 2011, HbA1c results were reported as IFCC-HbA1c mmol/mol (see table one below).

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Table 1: IFCC values expressed as mmol/mol

DCCT values for HbA1c(%)
IFCC values for HbA1c (mmol/mol)
4.0
20
5.0
31
6.0
42
6.5
48
7.0
53
7.5
59
8.0
64
9.0
75
10.0
86
11.0
97
12.0
108

 

DM 007.2 Reporting and verification

See indicator wording for requirement criteria.

 

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Prepared By Jean Keenan