Quality standard
Quality statement 4: 9 key care processes
Quality statement 4: 9 key care processes
Quality statement
Adults with type 1 diabetes have 9 key care processes completed every 12 months. [new 2023]
Rationale
Regular testing and completion of the 9 key care processes to monitor and manage type 1 diabetes can help to reduce the risk of complications and identify any complications earlier.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly. Services may want to use these measures to focus on dimensions of health inequality, for example by reporting data grouped by age, ethnicity or indices of deprivation.
Process
a) Proportion of adults with type 1 diabetes who had a urine albumin to creatinine ratio (ACR) test in the previous 12 months.
Numerator – the number in the denominator who had a urine ACR test in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had a urine albumin test in the audit year.
b) Proportion of adults with type 1 diabetes who had an HbA1c test in the previous 12 months.
Numerator – the number in the denominator who had an HbA1c test in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had an HbA1c test in the audit year.
c) Proportion of adults with type 1 diabetes who had their blood pressure measured in the previous 12 months.
Numerator – the number in the denominator who had their blood pressure measured in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had their blood pressure measured in the audit year.
d) Proportion of adults with type 1 diabetes who had foot surveillance and risk classification recorded in the previous 12 months.
Numerator – the number in the denominator who had foot surveillance and risk classification recorded in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had foot surveillance in the audit year. NHS Digital's Quality and Outcomes Framework indicator DM012 reports data on the percentage of patients with diabetes who have a record of a foot examination and risk classification in the preceding 12 months.
e) Proportion of adults with type 1 diabetes who had a serum creatinine test in the previous 12 months.
Numerator – the number in the denominator who had a serum creatinine test in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had a serum creatinine test in the audit year.
f) Proportion of adults with type 1 diabetes who had a serum cholesterol test in the previous 12 months.
Numerator – the number in the denominator who had a serum cholesterol test in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had a serum cholesterol test in the audit year.
g) Proportion of adults with type 1 diabetes who had a record of their body mass index (BMI) in the previous 12 months.
Numerator – the number in the denominator who had a record of their BMI in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had a record of their BMI in the audit year.
h) Proportion of adults with type 1 diabetes who had their smoking status recorded in the previous 12 months.
Numerator – the number in the denominator who had their smoking status recorded in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had a record of their smoking status in the audit year.
i) Proportion of adults with type 1 diabetes who had retinal screening in the previous 12 months.
Numerator – the number in the denominator who had retinal screening in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who had a record of retinal screening in the audit year.
j) Proportion of adults with type 1 diabetes who had 9 key care processes performed in the previous 12 months.
Numerator – the number in the denominator who had 9 key care processes in the previous 12 months.
Denominator – the number of adults with type 1 diabetes.
Data source: The National Diabetes Audit collects and reports data on the number of adults with type 1 diabetes who received 8 care processes in the audit year. It does not include retinal screening. This data can be collected locally.
Outcome
Prevalence of cardiovascular complications, renal replacement therapy (end-stage kidney disease) or minor or major amputations in adults with type 1 diabetes.
Data source: The National Diabetes Audit report on complications and mortality includes data on the number of people with type 1 diabetes admitted to hospital with cardiovascular complications, renal replacement therapy (end-stage kidney disease) and minor or major amputations.
What the quality statement means for different audiences
Service providers (such as primary care services, secondary care services, community health services, and foot protection services) ensure that systems are in place for adults with type 1 diabetes to have 9 key care processes to identify and monitor complications of type 1 diabetes completed every 12 months.
Healthcare professionals (such as GPs, practice nurses, consultant diabetologists, diabetes specialist nurses and members of the foot protection service) are aware of local protocols for 9 key care processes associated with type 1 diabetes and ensure that adults with type 1 diabetes have key care processes completed every 12 months. This should include measurement of urine ACR, HbA1c, blood pressure, serum creatinine, serum cholesterol and BMI, foot surveillance and smoking status. They refer adults to the local eye screening service when they are diagnosed with type 1 diabetes. They refer adults who are at moderate or high risk of developing a foot problem to the foot protection service and adults with an active diabetic foot problem to the multidisciplinary foot care service or foot protection service. They refer adults with a limb- or life-threatening active diabetic foot problem to acute services for assessment by the multidisciplinary foot care service.
Integrated care systems ensure that services are available in which adults with type 1 diabetes have 9 key care processes completed every 12 months to identify and monitor complications of type 1 diabetes. This includes laboratory provision for testing blood and urine tests, and access to a foot protection service, multidisciplinary foot care service and eye screening service.
Adults with type 1 diabetes have regular tests to check if they are at risk of developing, or have, complications of type 1 diabetes. They are referred to an appropriate service if any complications are identified.
Source guidance
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Type 1 diabetes in adults: diagnosis and management. NICE guideline NG17 (2015, updated 2022), recommendations 1.6.1 and 1.13.2
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Diabetic foot problems: prevention and management. NICE guideline NG19 (2015, updated 2019), recommendation 1.3.3
The 12-month timeframe for recording of serum creatinine, BMI and retinal screening is not derived from NICE guidance. It can be used as a practical timeframe to enable stakeholders to measure performance. The timeframe is used in the National Diabetes Audit.
Definitions of terms used in this quality statement
Equality and diversity considerations
Appointments for completion of 9 key care processes should be offered at times, and in locations, that meet the needs of adults with type 1 diabetes. Appointments should be accessible to adults who do not speak or read English, and should be culturally appropriate and age appropriate. Adults should have access to an interpreter or advocate if needed.
For adults with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.