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Type 1 diabetes in adults

About

What is covered

This pathway covers the diagnosis and management of type 1 diabetes in adults.
Type 1 diabetes affects over 370,000 adults in the UK. It results from destruction of the cells that normally make insulin. Loss of insulin secretion results in high blood glucose and other metabolic and haematological abnormalities, which have both short-term and long-term adverse effects on health. Over years, type 1 diabetes causes tissue damage which, if not detected and managed early, can result in disability: blindness, kidney failure and foot ulceration leading to amputation, as well as premature heart disease, stroke and death. The risk of all of these complications is greatly reduced by treatment that keeps circulating glucose levels to as near normal as possible, reducing tissue damage. Disability from complications that are not avoided can often be prevented by early detection and active management.
Type 1 diabetes is treated by insulin replacement, supported by active management of other cardiovascular risk factors, such as hypertension and high circulating lipids. Modern insulin replacement therapy aims to recreate normal fluctuations in circulating insulin concentrations. This supports a flexible lifestyle with minimal restrictions and, properly done, can improve blood glucose levels, reducing the risk of both structural complications and episodes of hypoglycaemia. Flexible insulin therapy usually involves self-injecting multiple daily doses of insulin, with doses adjusted based on taken or planned exercise, intended food intake and other factors, including current blood glucose, which the insulin user needs to test on a regular basis. This self-management needs the insulin user to have the skills and confidence to manage the regimen. One of the most important roles of healthcare professionals providing diabetes care to adults with type 1 diabetes is to ensure that systems are in place to provide informed, expert support, education and training for insulin users, as well as a range of other more conventional biomedical services and interventions.
Although type 1 diabetes in adults is not rare, it is not common enough that all healthcare professionals who deal with it are able to acquire and maintain all the necessary skills for its management. The aim of this pathway is to provide evidence-based, practical advice on supporting adults with type 1 diabetes to live full, largely unrestricted, lives and to avoid the short-term and long-term complications of both the disease and of its treatment.

Blood glucose and plasma glucose

This pathway refers frequently to circulating glucose concentrations as 'blood glucose'. A lot of the evidence linking specific circulating glucose concentrations with particular outcomes uses 'plasma' rather than 'blood' glucose. In addition, patient-held glucose meters and monitoring systems are all calibrated to plasma glucose equivalents. However, the term 'blood glucose monitoring' is in very common use, so in this pathway we use the term 'blood glucose', except when referring to specific concentration values.

Updates

Updates to this pathway

20 September 2016 Link to NICE pathway on multimorbidity added.
17 August 2016 Diabetes in adults (NICE quality standard 6) updated.
15 July 2016 Recommendation reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen at eye disease.
11 February 2016 Integrated sensor-augmented pump therapy systems for managing blood glucose levels in type 1 diabetes (the MiniMed Paradigm Veo system and the Vibe and G4 PLATINUM CGM system) (NICE diagnostics guidance 21) added to blood glucose measurement and targets.
18 January 2016 Diabetes in pregnancy (NICE quality standard 109) added to this pathway.
25 August 2015 Major update on publication of the type 1 diabetes guideline update NG17.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on diagnosing and managing type 1 diabetes in adults in an interactive flowchart

What is covered

This pathway covers the diagnosis and management of type 1 diabetes in adults.
Type 1 diabetes affects over 370,000 adults in the UK. It results from destruction of the cells that normally make insulin. Loss of insulin secretion results in high blood glucose and other metabolic and haematological abnormalities, which have both short-term and long-term adverse effects on health. Over years, type 1 diabetes causes tissue damage which, if not detected and managed early, can result in disability: blindness, kidney failure and foot ulceration leading to amputation, as well as premature heart disease, stroke and death. The risk of all of these complications is greatly reduced by treatment that keeps circulating glucose levels to as near normal as possible, reducing tissue damage. Disability from complications that are not avoided can often be prevented by early detection and active management.
Type 1 diabetes is treated by insulin replacement, supported by active management of other cardiovascular risk factors, such as hypertension and high circulating lipids. Modern insulin replacement therapy aims to recreate normal fluctuations in circulating insulin concentrations. This supports a flexible lifestyle with minimal restrictions and, properly done, can improve blood glucose levels, reducing the risk of both structural complications and episodes of hypoglycaemia. Flexible insulin therapy usually involves self-injecting multiple daily doses of insulin, with doses adjusted based on taken or planned exercise, intended food intake and other factors, including current blood glucose, which the insulin user needs to test on a regular basis. This self-management needs the insulin user to have the skills and confidence to manage the regimen. One of the most important roles of healthcare professionals providing diabetes care to adults with type 1 diabetes is to ensure that systems are in place to provide informed, expert support, education and training for insulin users, as well as a range of other more conventional biomedical services and interventions.
Although type 1 diabetes in adults is not rare, it is not common enough that all healthcare professionals who deal with it are able to acquire and maintain all the necessary skills for its management. The aim of this pathway is to provide evidence-based, practical advice on supporting adults with type 1 diabetes to live full, largely unrestricted, lives and to avoid the short-term and long-term complications of both the disease and of its treatment.

Blood glucose and plasma glucose

This pathway refers frequently to circulating glucose concentrations as 'blood glucose'. A lot of the evidence linking specific circulating glucose concentrations with particular outcomes uses 'plasma' rather than 'blood' glucose. In addition, patient-held glucose meters and monitoring systems are all calibrated to plasma glucose equivalents. However, the term 'blood glucose monitoring' is in very common use, so in this pathway we use the term 'blood glucose', except when referring to specific concentration values.

Updates

Updates to this pathway

20 September 2016 Link to NICE pathway on multimorbidity added.
17 August 2016 Diabetes in adults (NICE quality standard 6) updated.
15 July 2016 Recommendation reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen at eye disease.
11 February 2016 Integrated sensor-augmented pump therapy systems for managing blood glucose levels in type 1 diabetes (the MiniMed Paradigm Veo system and the Vibe and G4 PLATINUM CGM system) (NICE diagnostics guidance 21) added to blood glucose measurement and targets.
18 January 2016 Diabetes in pregnancy (NICE quality standard 109) added to this pathway.
25 August 2015 Major update on publication of the type 1 diabetes guideline update NG17.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Type 1 diabetes in adults: diagnosis and management (2015 updated 2016) NICE guideline NG17
Aflibercept for treating diabetic macular oedema (2015) NICE technology appraisal guidance 346
Ranibizumab for treating diabetic macular oedema (2013) NICE technology appraisal guidance 274
Allogeneic pancreatic islet cell transplantation for type 1 diabetes mellitus (2008) NICE interventional procedures guidance 257
Diabetes in pregnancy (2016) NICE quality standard 109
Diabetes in adults (2011 updated 2016) NICE quality standard 6
Type 1 diabetes: insulin degludec (2013) NICE evidence summary ESNM24

Quality standards

Quality statements

Preventing type 2 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme.

Rationale

Many cases of type 2 diabetes are preventable through changes to a person’s diet and physical activity levels. Evidence-based intensive lifestyle-change programmes can significantly reduce the risk of developing the condition for those at high risk.

Quality measures

Structure
Evidence of local arrangements to ensure that adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme.
Data source: Local data collection.
Process
a) Proportion of adults at high risk of type 2 diabetes who are referred to an intensive lifestyle-change programme.
Numerator – the number in the denominator who are referred to an intensive lifestyle-change programme.
Denominator – the number of adults at high risk of type 2 diabetes.
Data source: Local data collection.
b) Proportion of adults at high risk of type 2 diabetes who attend an intensive lifestyle-change programme after a referral.
Numerator – the number in the denominator who attend an intensive lifestyle-change programme.
Denominator – the number of adults at high risk of type 2 diabetes who are referred to an intensive lifestyle-change programme.
Data source: Local data collection.
Outcome
a) Weight loss of participants in intensive lifestyle-change programmes.
Data source: Local data collection.
b) Incidence of type 2 diabetes in adults.
Data source: Local data collection.

What the quality statement means for service providers, health and public health practitioners, and commissioners

Service providers (such as local authorities who provide the NHS Health Check programme) ensure that systems are in place for adults at high risk of type 2 diabetes to be offered a referral to an intensive lifestyle-change programme.
Health and public health practitioners (such as those carrying out diabetes risk assessments and other health checks, GPs and pharmacists) ensure that they offer adults at high risk of type 2 diabetes a referral to an intensive lifestyle-change programme.
Commissioners (such as local authorities and NHS England) ensure that they commission services in which adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme.

What the quality statement means for patients, service users and carers

Adults who have been told they are at high risk of getting type 2 diabetes are offered a referral to a programme that will help them to change their lifestyle (for example, by become more physically active and improving their diet) and so reduce their risk.

Source guidance

Definitions of terms used in this quality statement

High risk of type 2 diabetes
A fasting plasma glucose level of 5.5–6.9 mmol/litre or an HbA1c level of 42–47 mmol/mol (6.0–6.4%) indicates that a person is at high risk of type 2 diabetes.
Fasting plasma glucose or HbA1c tests should be offered to adults with high risk scores from a validated computer-based risk-assessment tool or a validated self-assessment questionnaire. A blood test should also be considered for those aged 25 and over of South Asian or Chinese descent whose BMI is greater than 23 kg/m2.
[Adapted from NICE's guideline on Type 2 diabetes: prevention in people at high risk, recommendations 4 and 5]
Intensive lifestyle-change programme
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes. It should be local, evidence-based and quality-assured. The aim is to help people to become more physically active and improve their diet. If the person is overweight or obese, the programme should result in weight loss. Programmes may be delivered to individuals or groups (or involve a mix of both) depending on the resources available. They can be provided by primary care teams and public, private or community organisations with expertise in dietary advice, weight management and physical activity.
[Adapted from NICE's guideline on Type 2 diabetes: prevention in people at high risk, recommendation 5 and glossary]

Equality and diversity considerations

Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated if needed.
Programmes should be offered at times, and in locations, that meet the needs of groups such as older people, people from minority ethnic backgrounds and vulnerable or socially disadvantaged people. Provision should also be made for people who may have difficulty accessing services in conventional healthcare venues.

Structured education programmes for adults with type 2 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 2 diabetes are offered a structured education programme at diagnosis.

Rationale

Type 2 diabetes is a progressive long-term medical condition that the person predominantly self-manages. Managing type 2 diabetes involves lifestyle changes, and treatment can be complex. Structured education programmes can help adults with type 2 diabetes to improve their knowledge and skills and also help to motivate them to take control of their condition and self-manage it effectively.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 2 diabetes are referred for a structured education programme at diagnosis.
Data source: Local data collection.
Process
a) Proportion of adults with type 2 diabetes who are referred for a structured education programme at diagnosis.
Numerator – the number in the denominator who are referred for a structured education programme at diagnosis.
Denominator – the number of adults newly diagnosed with type 2 diabetes.
Data source: Local data collection. National data are collected in the Quality and Outcomes Framework indicator DM014 and the National Diabetes Audit.
b) Proportion of adults with type 2 diabetes who attend a structured education programme after a referral.
Numerator – the number in the denominator who attend a structured education programme.
Denominator – the number of adults with type 2 diabetes who are referred for a structured education programme at diagnosis.
Data source: Local data collection. National data are collected in the National Diabetes Audit.
c) Proportion of adults with type 2 diabetes who complete a structured education programme.
Numerator – the number in the denominator who complete a structured education programme.
Denominator – the number of adults with type 2 diabetes who attend a structured education programme.
Data source: Local data collection.
Outcome
Patient satisfaction with ability to self-manage their type 2 diabetes after attending a structured education programme.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community healthcare providers) ensure that systems are in place for adults with type 2 diabetes to be offered a structured education programme at diagnosis.
Healthcare professionals (such as GPs, practice nurses and community healthcare providers) ensure that they offer a structured education programme to adults with type 2 diabetes at diagnosis.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission structured education programmes for adults with type 2 diabetes.

What the quality statement means for patients, service users and carers

Adults with type 2 diabetes are offered a course to help them improve their understanding of type 2 diabetes and how to manage it in their everyday life. This course should be offered at the time of diagnosis.

Source guidance

Definitions of terms used in this quality statement

Structured education programme
Should include the following components:
  • It is evidence-based, and suits the needs of the person.
  • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes.
  • It has a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials, and is written down.
  • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.
  • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
  • The outcomes are audited regularly.
Further information on these components can be found in the Department of Health's Structured patient education in diabetes: report from the Patient Education Working Group.
Information given to adults with type 2 diabetes should cover aspects of lifestyle modification that may be necessary, such as dietary advice, and weight loss for adults who are overweight.
[Adapted from NICE's guideline on Type 2 diabetes in adults: management, recommendations 1.2.2, 1.3.2 and 1.3.4, and expert opinion]

Equality and diversity considerations

Structured education programmes should meet the cultural, linguistic, cognitive and literacy needs in the local area. Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated if needed.
Alternative programmes of equal standard should be made available for people unable to participate in group education.

Structured education programmes for adults with type 1 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 1 diabetes are offered a structured education programme 6–12 months after diagnosis.

Rationale

Adults with type 1 diabetes need to acquire a large range of new skills and knowledge, such as how to manage their insulin therapy. Patient education enables self-management, which is important in diabetes management. It allows adults with type 1 diabetes to adapt their diabetes management to changes in their daily lives and to maintain a good quality of life. The first few months after diagnosis involve considerable adjustment, so although information should be given from diagnosis, a more intensive structured education programme will be more beneficial 6–12 months after diagnosis.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 1 diabetes are referred for a structured education programme 6–12 months after diagnosis.
Data source: Local data collection.
Process
a) Proportion of adults with type 1 diabetes who are referred for a structured education programme 6–12 months after diagnosis.
Numerator – the number in the denominator who are referred for a structured education programme 6–12 months after diagnosis.
Denominator – the number of adults diagnosed with type 1 diabetes in the last 12 months.
Data source: Local data collection. National data are collected in the Quality and Outcomes Framework indicator DM014 and the National Diabetes Audit.
b) Proportion of adults with type 1 diabetes who attend a structured education programme after a referral.
Numerator – the number in the denominator who attend a structured education programme.
Denominator – the number of adults with type 1 diabetes who are referred for a structured education programme.
Data source: Local data collection. National data are collected in the National Diabetes Audit.
c) Proportion of adults with type 1 diabetes who complete a structured education programme.
Numerator – the number in the denominator who complete a structured education programme.
Denominator – the number of adults with type 1 diabetes who attend a structured education programme.
Data source: Local data collection.
Outcome
Patient satisfaction with ability to self-manage their type 1 diabetes after attending a structured education programme.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and secondary care providers) ensure that systems are in place for adults with type 1 diabetes to be offered a structured education programme 6–12 months after diagnosis.
Healthcare professionals (such as GPs, diabetologists and diabetes specialist nurses) ensure that they offer a structured education programme to adults with type 1 diabetes 6–12 months after diagnosis.
Commissioners (clinical commissioning groups) ensure that they commission structured education programmes for adults with type 1 diabetes.

What the quality statement means for patients, service users and carers

Adults with type 1 diabetes are offered a course to help them improve their understanding of type 1 diabetes and how to manage it in their everyday life. This should cover checking their blood glucose levels, using insulin and advice about having a healthy lifestyle. The course should be offered between 6 months and a year after they are diagnosed.

Source guidance

Definitions of terms used in this quality statement

Structured education programme
Should include the following components:
  • It is evidence-based, and suits the needs of the person.
  • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes.
  • It has a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials, and is written down.
  • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.
  • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
  • The outcomes are audited regularly.
Further information on these components can be found in the Department of Health's Structured patient education in diabetes: report from the Patient Education Working Group.
An example is the DAFNE (dose-adjustment for normal eating) programme.
[Adapted from NICE's guideline on Type 1 diabetes in adults: diagnosis and management, recommendations 1.3.1 and 1.3.4]

Equality and diversity considerations

Structured education programmes should meet the cultural, linguistic, cognitive and literacy needs in the local area. Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated if needed.
Alternative programmes of equal standard should be made available for people unable to participate in group education.

First intensification of blood glucose lowering therapy in type 2 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy.

Rationale

Good blood glucose control in people with type 2 diabetes is important for mitigating the risk of microvascular and macrovascular complications associated with hyperglycaemia, such as damage to the eyes, kidneys and nerves. If HbA1c levels are not well controlled with single-drug treatment, it is important to offer intensification of drug treatment, as well as reinforcing advice about diet, lifestyle and adherence to drug treatment and supporting the person to aim for an HbA1c level of 53 mmol/mol (7.0%). A timescale of 6 months allows time to improve diet, lifestyle and adherence to drug treatment, while also ensuring that first intensification is not unnecessarily delayed. Timely first intensification can delay the need for second intensification, which may involve insulin therapy.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 2 diabetes are offered dual therapy if their HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment.
Data source: Local data collection.
Process
Proportion of adults with type 2 diabetes who are started on dual therapy when their HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment.
Numerator – the number in the denominator who are started on dual therapy.
Denominator – the number of adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment.
Data source: Local data collection.
Outcome
a) Adults with type 2 diabetes feel supported to aim for an HbA1c level of 53 mmol/mol (7.0%) or less.
Data source: Local data collection.
b) Incidence of diabetes-related complications.
Data source: Local data collection. National data are collected in the National Diabetes Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community healthcare providers) ensure that processes are in place so that adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy.
Healthcare professionals (such as GPs, practice nurses and community healthcare providers) ensure that they offer dual therapy to adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment. They also reinforce advice about diet, lifestyle and adherence to treatment.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy.

What the quality statement means for patients, service users and carers

Adults with type 2 diabetes who need medication to control their blood glucose levels usually start off by taking a single medicine. If after 6 months this first medicine doesn’t help or their diabetes gets worse over time, despite advice about diet, lifestyle and taking the medicine properly, they are offered another type of medicine as well as the one they already take.

Source guidance

Definitions of terms used in this quality statement

Dual therapy
Consider dual therapy with:
  • metformin and a DPP-4 inhibitor or
  • metformin and pioglitazoneWhen prescribing pioglitazone, exercise particular caution if the person is at high risk of the adverse effects of the drug. Pioglitazone is associated with an increased risk of heart failure, bladder cancer and bone fracture. Known risk factors for these conditions, including increased age, should be carefully evaluated before treatment: see the manufacturers’ summaries of product characteristics for details. Medicines and Healthcare products Regulatory Agency (MHRA) guidance (2011) advises that ‘prescribers should review the safety and efficacy of pioglitazone in individuals after 3–6 months of treatment to ensure that only patients who are deriving benefit continue to be treated’. or
  • metformin and a sulfonylurea.
If metformin is contraindicated or not tolerated, consider dual therapyBe aware that the drugs in dual therapy should be introduced in a stepwise manner, checking for tolerability and effectiveness of each drug. with
  • a DPP-4 inhibitor and pioglitazone or
  • a DPP-4 inhibitor and a sulfonylurea or
  • pioglitazone and a sulfonylurea.
Treatment with combinations of medicines including sodium–glucose cotransporter 2 (SGLT 2) inhibitors may be appropriate for some people with type 2 diabetes; see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes, dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating type 2 diabetes.
[Adapted from NICE's guideline on Type 2 diabetes in adults: management, recommendations 1.6.25 and 1.6.26]

Equality and diversity considerations

An individualised approach to diabetes care should be taken that is tailored to the needs and circumstances of each adult with type 2 diabetes. The target HbA1c level may need to be relaxed on a case-by-case basis. Examples include adults who have a reduced life expectancy, adults for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia and adults with significant comorbidities for whom intensive management would not be appropriate. Particular consideration should be given for people who are older or frail.

Referral for adults at moderate or high risk of diabetic foot problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.

Rationale

Referring people at moderate or high risk of developing a diabetic foot problem to the foot protection service allows their feet to be assessed at an early stage and then reassessed at regular intervals. This can reduce the likelihood of them getting foot ulcers or other foot problems.

Quality measures

Structure
Evidence of local arrangements to ensure that adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.
Data source: Local data collection. Contained in the National Diabetes Foot Care Audit.
Process
Proportion of adults at moderate or high risk of developing a diabetic foot problem who are referred to the foot protection service.
Numerator – the number in the denominator who are referred to the foot protection service.
Denominator – the number of adults at moderate or high risk of developing a diabetic foot problem.
Data source: Local data collection.
Outcome
Incidence of foot and lower limb amputations in people with diabetes.
Data source: The National Diabetes Audit collects information on minor and major amputations in people with diabetes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community services) ensure that adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.
Healthcare professionals (such as podiatrists, GPs, practice nurses and district nurses) ensure that they refer adults at moderate or high risk of developing a diabetic foot problem to the foot protection service.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.

What the quality statement means for patients, service users and carers

Adults with diabetes have regular foot checks, and if a check shows that they have a moderate or high risk of having a foot problem related to their diabetes, they are referred to see another healthcare professional in the foot protection service.

Source guidance

Definitions of terms used in this quality statement

Moderate or high risk of developing a diabetic foot problem
Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:
  • Moderate risk:
    • deformity or
    • neuropathy or
    • non-critical limb ischaemia.
  • High risk:
    • previous ulceration or
    • previous amputation or
    • on renal replacement therapy or
    • neuropathy and non-critical limb ischaemia together or
    • neuropathy in combination with callus and/or deformity or
    • non-critical limb ischaemia in combination with callus and/or deformity.
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendation 1.3.6]
Foot protection service
A service for preventing diabetic foot problems, and for treating and managing them in the community. It should be led by a podiatrist with specialist training in diabetic foot problems and have access to healthcare professionals with skills in:
  • diabetology
  • biomechanics and orthoses
  • wound care.
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendations 1.2.1 and 1.2.2]

Referral for urgent diabetic foot problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment.

Rationale

Rapid referral to specialist services for adults with a limb-threatening or life-threatening diabetic foot problem, so that they can be assessed and an individualised treatment plan put in place, can reduce the risk of amputation and death.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment.
Data source: Local data collection.
Process
a) Proportion of presentations of limb-threatening or life-threatening diabetic foot problems that are referred immediately for specialist assessment and treatment.
Numerator – the number in the denominator that are referred immediately for specialist assessment and treatment.
Denominator – the number of presentations of limb-threatening or life-threatening diabetic foot problems.
Data source: Local data collection.
b) Proportion of presentations of limb-threatening or life-threatening diabetic foot problems in which the multidisciplinary foot care service is informed.
Numerator – the number in the denominator in which the multidisciplinary foot care service is informed.
Denominator – the number of presentations of limb-threatening or life-threatening diabetic foot problems.
Data source: Local data collection.
Outcome
Incidence of foot and lower limb amputations in people with diabetes.
Data source: The National Diabetes Audit collects information on minor and major amputations in people with diabetes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as foot protection services, GPs and community services) ensure that systems are in place so that adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service is informed.
Health and social care practitioners (such as podiatrists, GPs, practice nurses and district nurses) ensure that they refer adults with a limb-threatening or life-threatening diabetic foot problem immediately for specialist assessment and treatment, and inform the multidisciplinary foot care service.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service is informed.

What the quality statement means for patients, service users and carers

Adults with diabetes who have a serious foot problem are sent to hospital immediately, so that they can be assessed and treated straight away. Serious foot problems are those that might result in amputation or even death, and include a diabetic foot ulcer with a fever or any other symptoms of blood poisoning (the medical name for this is sepsis), a problem with the blood supply to the foot, gangrene, or a severe foot or bone infection.

Source guidance

Definitions of terms used in this quality statement

Limb-threatening or life-threatening diabetic foot problem
Limb-threatening and life-threatening diabetic foot problems include:
  • ulceration with fever or any signs of sepsis
  • ulceration with limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease)
  • clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration)
  • gangrene (with or without ulceration).
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendation 1.4.1]
Specialist assessment and treatment
The specialist service should be the multidisciplinary foot care service wherever possible. However, if the multidisciplinary foot care service is not available (for example, if the person presents out of hours) then, in order to avoid any delay in treatment, the person should be referred immediately to acute services and the multidisciplinary foot care service informed.
The multidisciplinary foot care service should be led by a named healthcare professional, and consist of specialists with skills in the following areas:
  • diabetology
  • podiatry
  • diabetes specialist nursing
  • vascular surgery
  • microbiology
  • orthopaedic surgery
  • biomechanics and orthoses
  • interventional radiology
  • casting
  • wound care.
The multidisciplinary foot care service should have access to rehabilitation services, plastic surgery, psychological services and nutritional services.
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendations 1.2.3 and 1.2.4, and expert opinion]

Inpatient care for adults with type 1 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.

Rationale

Adults with type 1 diabetes may be admitted to hospital for diabetes-related or unrelated conditions. This can disturb normal routines, affecting carbohydrate intake and insulin therapy, and special regimens may be needed in response to procedures that affect the usual management of diabetes. The person’s expertise in managing their own diabetes should be respected, and the specialist multidisciplinary team has the knowledge to help the person understand how to best to adapt management when in hospital. The person should be supported to continue to self-manage their diabetes and administer their own insulin if they are willing and able and it is safe for them to do so. Input from a multidisciplinary specialist team can reduce the length of hospital stay for adults with type 1 diabetes and improve their experience of hospital.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.
Data source: Local data collection.
Process
Proportion of hospital admissions for adults with type 1 diabetes in which they receive advice from a multidisciplinary team with expertise in diabetes.
Numerator – the number in the denominator in which the person receives advice from a multidisciplinary team with expertise in diabetes.
Denominator – the number of hospital admissions for adults with type 1 diabetes.
Data source: Local data collection. Contained in the National Diabetes Inpatient Audit.
Outcome
a) Length of hospital stay.
Data source: Local data collection.
b) Patient satisfaction that staff met their diabetes needs while in hospital.
Data source: Local data collection. Contained in the National Diabetes Inpatient Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (hospitals) ensure that adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.
Healthcare professionals (members of the multidisciplinary team) ensure that they provide advice to adults with type 1 diabetes who are in hospital, and enable them to continue to administer their own insulin if they are willing and able and it is safe for them to do so.
Commissioners (clinical commissioning groups) ensure that they commission services in which adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.

What the quality statement means for patients, service users and carers

Adults with type 1 diabetes who go into hospital if they are ill or need an operation get advice from a team of specialists in diabetes, who will respect their expertise in managing their own diabetes. They are supported to carry on injecting their own insulin if they want to and can do so safely, although sometimes intravenous insulin will be needed instead (for example, if they can’t eat or are having an operation that affects blood glucose levels).

Source guidance

Definitions of terms used in this quality statement

Multidisciplinary team with expertise in diabetes
The basic structure of a specialist inpatient diabetes team should comprise:
  • for every 300 beds, at least 1 diabetes inpatient specialist nurse whose focus is predominantly on inpatient care
  • a consultant specialist in diabetes management.
There should also be access to a diabetes specialist:
  • podiatrist
  • dietitian.

High-dose folic acid

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Women with diabetes planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.

Rationale

High-dose folic acid supplements (5 mg/day) should be prescribed for women with diabetes who are planning a pregnancy from at least 3 months before conception until 12 weeks of gestation. This is because these women are at greater risk of having a baby with a neural tube defect. The benefits of high-dose folic acid supplementation should be discussed with the woman during preconception counselling as part of her preparation for pregnancy.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that women with diabetes planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Process
a) Proportion of pregnant women with type 1 diabetes prescribed 5 mg/day folic acid from at least 3 months before conception.
Numerator – the number in the denominator prescribed 5 mg/day folic acid from at least 3 months before conception.
Denominator – the number of pregnant women with type 1 diabetes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
b) Proportion of pregnant women with type 2 diabetes prescribed 5 mg/day folic acid from at least 3 months before conception.
Numerator – the number in the denominator prescribed 5 mg/day folic acid from at least 3 months before conception.
Denominator – the number of pregnant women with type 2 diabetes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Outcome
Neural tube defects.
Data source: National Pregnancy in Diabetes Audit and local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in primary and secondary care) ensure that they have systems and processes in place so that women with diabetes who are planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.
Healthcare professionals (GPs, community midwives and healthcare professionals in joint diabetes and antenatal care teams) ensure that they prescribe 5 mg/day folic acid for women with diabetes who are planning a pregnancy, from at least 3 months before conception. Healthcare professionals also ensure that they advise women with diabetes who are planning a pregnancy about the benefits of taking high-dose folic acid as part of preconception counselling.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission pre-pregnancy services in which 5 mg/day folic acid is prescribed for women with diabetes who are planning a pregnancy, from at least 3 months before conception.

What the quality statement means for patients

Women with diabetes who are planning a pregnancy are given a prescription for high-dose folic acid (one 5 mg tablet a day) for at least 3 months before they get pregnant and for the first 12 weeks of pregnancy. This helps to lower the chances of the baby having a condition called a neural tube defect (for example, spina bifida).

Source guidance

First contact with joint diabetes and antenatal care team

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.

Rationale

Women with diabetes who become pregnant need extra care in addition to routine antenatal care. Members of the joint diabetes and antenatal care team are able to ensure that specialist care is delivered to minimise adverse pregnancy outcomes. Immediate access to the joint diabetes and antenatal care team within 1 week of her pregnancy being confirmed will help to ensure that a woman’s diabetes is controlled during early pregnancy, when there in an increased risk of fetal loss and anomalies. It will also help to ensure that the woman’s care is planned appropriately throughout her pregnancy.

Quality measures

Structure
a) Evidence of local arrangements to provide a joint diabetes and antenatal care team.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Data source: Local data collection.
Process
Proportion of women with pre-existing diabetes who are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Numerator – the number in the denominator who are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Denominator – the number of pregnant women with pre-existing diabetes.
Outcome
a) Maternal satisfaction.
Data source: Local data collection.
b) Perinatal morbidity.
Data source: Local data collection.
c) Perinatal mortality.
Data source: Local data collection.
d) Maternal adverse outcomes.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in secondary care) ensure that referral pathways are in place so that pregnant women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of the pregnancy being confirmed.
Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they see pregnant women with pre-existing diabetes within 1 week of the pregnancy being confirmed.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission joint diabetes and antenatal care teams that see pregnant women with pre-existing diabetes within 1 week of the pregnancy being confirmed.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant have an appointment with a joint diabetes and antenatal care team within 1 week of telling a doctor, nurse or midwife that they are pregnant.

Source guidance

Definitions of terms used in this quality statement

Joint diabetes and antenatal care team
A clinic with a multidisciplinary team consisting of an obstetrician, a diabetes physician, a diabetes specialist nurse, a midwife and a dietitian.
Pregnancy confirmed
The notification of a positive pregnancy test to a healthcare professional. This may be a GP, practice nurse, midwife or member of the secondary care diabetes team.
[Expert opinion]

Measuring HbA1c levels at booking appointment

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.

Rationale

Measuring a woman’s HbA1c levels can be used to determine the level of risk for her pregnancy. Women who had diabetes before they became pregnant should have their HbA1c levels measured during early pregnancy to identify the risk of potential adverse pregnancy outcomes and to ensure that any identified risks are managed.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Process
Proportion of pregnant women with pre-existing diabetes who have their HbA1c levels measured at their booking appointment.
Numerator – the number in the denominator who have their HbA1c levels measured at their booking appointment.
Denominator – the number of pregnant women with pre-existing diabetes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Outcome
a) Mode of birth.
Data source: National Pregnancy in Diabetes Audit and local data collection.
b) Adverse fetal outcomes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
c) Maternal diabetic complications.
Data source: National Pregnancy in Diabetes Audit and local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in secondary care) ensure that systems are in place so that pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.
Healthcare professionals (in antenatal care and in joint diabetes and antenatal care teams) ensure that they measure the HbA1c levels of pregnant women with pre-existing diabetes at the booking appointment.
Commissioners (clinical commissioning groups) ensure that they commission services in which pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant have their HbA1c levels measured at their booking appointment (their first official antenatal appointment).

Source guidance

Definitions of terms used in this quality statement

Booking appointment
A woman with diabetes will usually have a booking appointment with the joint diabetes and antenatal care team by 10 weeks of pregnancy. In some cases this appointment may take place earlier in the pregnancy.
[Diabetes in pregnancy (NICE guideline NG3) and expert opinion]

Equality and diversity considerations

Pregnant women with diabetes and complex social needs may be less likely to access or maintain contact with antenatal care services, and may present to a service later than 10 weeks. Services should give special consideration to these groups of women and ensure that they have their HbA1c levels measured at the earliest opportunity.  

Referral for retinal assessment

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Pregnant women with pre-existing diabetes are referred at their booking appointment for retinal assessment.

Rationale

Pregnant women with pre-existing diabetes can have an increased risk of progression of diabetic retinopathy. Women should therefore be screened for diabetic retinopathy regularly during pregnancy. Early assessment ensures that treatment can start as soon as possible, and can act as a baseline to observe any further deterioration. A referral for retinal assessment should be offered at the booking appointment unless the woman has had an assessment in the last 3 months.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that pregnant women with pre-existing diabetes are referred at their booking appointment for retinal assessment.
Data source: Local data collection.
Process
a) Proportion of pregnant women with pre-existing diabetes who are referred at their booking appointment for retinal assessment.
Numerator – the number in the denominator who are referred at their booking appointment for retinal assessment.
Denominator – the number of pregnant women with pre-existing diabetes attending a booking appointment who have not had retinal assessment in the last 3 months.
Data source: Local data collection.
b) Proportion of pregnant women with pre-existing diabetes who have a retinal assessment in the first 3 months of pregnancy.
Numerator – the number in the denominator who have a retinal assessment in the first 3 months of pregnancy.
Denominator – the number of pregnant women with pre-existing diabetes referred at their booking appointment for a retinal assessment.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Outcome
a) Rates of diabetic retinopathy during pregnancy.
Data source: Local data collection.
b) Diabetic retinopathy progression during pregnancy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in primary and secondary care) ensure that pregnant women with pre-existing diabetes are referred at their booking appointment for a retinal assessment if they have not had a retinal assessment in the last 3 months.
Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they refer pregnant women with pre-existing diabetes at their booking appointment for a retinal assessment, unless the woman has had a retinal assessment in the last 3 months.
Commissioners (clinical commissioning groups) ensure that they commission services in which pregnant women with pre-existing diabetes are referred at their booking appointment for a retinal assessment if they have not had a retinal assessment in the last 3 months. Commissioners also ensure that services communicate the results of retinal assessments to the joint diabetes and antenatal care team.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant are referred at their booking appointment for a screening check for eye damage (retinopathy) if they have not had this type of check in the last 3 months.

Source guidance

Definitions of terms used in this quality statement

Retinal assessment
A retinal assessment should be done by digital imaging with mydriasis (dilation of the pupils) using tropicamide, in accordance with the National Screening Committee’s diabetic retinopathy screening programme.
[Diabetes in pregnancy (NICE guideline NG3) recommendation 1.3.24]
Booking appointment
A woman with diabetes will usually have a booking appointment with the joint diabetes and antenatal care team by 10 weeks of pregnancy. In some cases this appointment may take place earlier in the pregnancy.
[Diabetes in pregnancy (NICE guideline NG3) and expert opinion]

Equality and diversity considerations

Pregnant women with diabetes and complex social needs may be less likely to access or maintain contact with antenatal care services, and may present to a service later than 10 weeks. Services should give special consideration to these groups of women and ensure that they are referred for a retinal assessment at the earliest opportunity.  

Review after a diagnosis of gestational diabetes

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.

Rationale

Women diagnosed with gestational diabetes should have specialist advice and treatment in a timely manner, and should be reviewed by members of the joint diabetes and antenatal care team within 1 week of being diagnosed. The joint team should provide the woman with advice, including why gestational diabetes occurs, potential risks and complications, and treatments aimed at reducing those risks.

Quality measures

Structure
a) Evidence of local arrangements to provide a joint diabetes and antenatal care team.
Data source: Local data collection.
b) Evidence of local arrangements and written clinical protocols to ensure that women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Data source: Local data collection.
Process
Proportion of women diagnosed with gestational diabetes who are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Numerator – the number in the denominator who are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Denominator – the number of women diagnosed with gestational diabetes.
Data source: Local data collection.
Outcome
a) Maternal satisfaction.
Data source: Local data collection.
b) Perinatal morbidity.
Data source: Local data collection.
c) Perinatal mortality.
Data source: Local data collection.
d) Maternal adverse outcomes.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in secondary and community care) ensure that referral pathways are in place so that women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they see women diagnosed with gestational diabetes within 1 week of diagnosis.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission services in which women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.

What the quality statement means for patients

Pregnant women who are diagnosed with gestational diabetes (that is, diabetes that develops during pregnancy) have an appointment with a joint diabetes and antenatal care team within 1 week of their diagnosis.

Source guidance

Definitions of terms used in this quality statement

Joint diabetes and antenatal care team
A clinic with a multidisciplinary team consisting of an obstetrician, a diabetes physician, a diabetes specialist nurse, a midwife and a dietitian.
Diagnosis of gestational diabetes
Diagnose gestational diabetes (using a 75 g 2-hour oral glucose tolerance test) if the woman has either:
  • a fasting plasma glucose level of 5.6 mmol/litre or above or
  • a 2-hour plasma glucose level of 7.8 mmol/litre or above.
[Adapted from Diabetes in pregnancy (NICE guideline NG3) recommendations 1.2.6 and 1.2.8]

Self-monitoring of blood glucose levels during pregnancy

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Pregnant women with diabetes are supported to self-monitor their blood glucose levels.

Rationale

Women with diabetes need to be able to self-monitor their blood glucose during pregnancy. Some women with type 2 diabetes and all women with gestational diabetes will not have been monitoring their blood glucose levels at all before pregnancy and will start doing so. For women with type 1 diabetes, and some women with type 2 diabetes, frequency of monitoring will increase from 4 times a day to up to 10 times per day. More frequent monitoring will help women to maintain good blood glucose control throughout pregnancy. This in turn will reduce the risk of adverse outcomes, such as a baby that is large for gestational age, trauma during birth, neonatal hypoglycaemia and perinatal death. The likelihood of induction of labour and caesarean section should also be lower. Support should be provided to ensure that women have access to appropriate blood glucose meters and are prescribed enough testing strips, and know how to use them.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that pregnant women with diabetes are supported to self-monitor their blood glucose levels.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women with diabetes have access to appropriate blood glucose meters and are prescribed enough testing strips.
Data source: Local data collection.
Process
a) Proportion of pregnant women with diabetes who feel supported to self-monitor their blood glucose levels.
Numerator – the number in the denominator who feel supported to self-monitor their blood glucose levels.
Denominator – the number of pregnant women with diabetes.
Data source: Local data collection.
b) Proportion of pregnant women with diabetes who have an appropriate blood glucose meter.
Numerator – the number in the denominator who have an appropriate blood glucose meter.
Denominator – the number of pregnant women with diabetes.
Data source: Local data collection.
c) Proportion of pregnant women with diabetes who are prescribed enough blood glucose testing strips.
Numerator – the number in the denominator who are prescribed enough blood glucose testing strips.
Denominator – the number of pregnant women with diabetes.
Data source: Local data collection.
Outcome
a) Adverse fetal outcomes.
Data source: Local data collection.
b) Maternal diabetic complications.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in primary and secondary care) ensure that pregnant women with diabetes have an appropriate blood glucose meter and are prescribed enough testing strips, and so are supported to self-monitor their blood glucose levels during pregnancy.
Healthcare professionals (GPs, community midwives and healthcare professionals in joint diabetes and antenatal care teams) support pregnant women with diabetes to self-monitor their blood glucose levels during pregnancy, including ensuring that the woman has an appropriate blood glucose meter and is prescribed enough testing strips.
Commissioners (NHS England area teams and clinical commissioning groups) commission services that ensure that pregnant women with diabetes have an appropriate blood glucose meter and are prescribed enough testing strips, and so are supported to self-monitor their blood glucose levels.

What the quality statement means for patients

Pregnant women with diabetes are supported to monitor their own blood glucose levels during pregnancy. They are given a blood glucose meter that suits them, and are prescribed enough testing strips for their needs.

Source guidance

Definitions

Appropriate blood glucose meter
Ensure that blood glucose meters meet current ISO standards and take the needs of the woman with diabetes into account.
[Adapted from Type 1 diabetes (NICE guideline NG17) recommendation 1.6.17]

Equality and diversity considerations

When advising women to start or increase the frequency of blood glucose monitoring, take into account that some women may be anxious and feel pressure to adjust and overly regulate their blood glucose levels.

Annual HbA1c testing after gestational diabetes

This quality statement is taken from the diabetes in pregnancy quality standard. The quality standard defines clinical best practice in diabetes in pregnancy and should be read in full.

Quality statement

Women who have had gestational diabetes have an annual HbA1c test.

Rationale

Women who have had gestational diabetes are at increased risk of getting it again in future pregnancies. They are also at higher risk of type 2 diabetes: if they are not diagnosed with type 2 diabetes in the immediate postnatal period, they are still at high risk of developing it in the future. Early detection of type 2 diabetes by annual HbA1c testing in primary care can delay disease progression and reduce the risk of complications. Annual testing can also reduce the risk of uncontrolled or undetected diabetes in future pregnancies.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that women who have had gestational diabetes have an annual HbA1c test.
Data source: Local data collection.
Process
Proportion of women who have had gestational diabetes who have an annual HbA1c test.
Numerator – the number in the denominator who have had an HbA1c test in the last 12 months.
Denominator – the number of women who have had gestational diabetes and whose baby was born at least 12 months ago.
Data source: GP Patient Survey and local data collection.
Outcome
Earlier detection of type 2 diabetes.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in primary care) ensure that systems are in place so that women who have had gestational diabetes have an annual HbA1c test.
Healthcare professionals (in primary care) ensure that they test HbA1c levels annually for women who have had gestational diabetes.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission services that provide annual HbA1c testing for women who have had gestational diabetes.

What the quality statement means for patients

Women who have had gestational diabetes have the HbA1c levels in their blood measured once a year. This is to check whether they have type 2 diabetes, or are at risk of getting it.

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Paths in this pathway

Pathway created: May 2011 Last updated: December 2016

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