d.  Assessment of Diabetes Care & Outcomes, 2008 ITEM DESCRIPTION

For the purposes of this audit, a VISIT is defined as any primary care visit, including ER and walk-in clinics. Do not include dental, eye care, patient education, surgery clinics, etc.

AUDIT DATE, CHART NUMBER, DATE OF BIRTH, SEX: Self-explanatory.

FACILITY NAME: Enter your facility's name or abbreviation.

AREA, SERVICE UNIT and FACILITY codes: use the 2-digit official IHS codes ("ASUFAC" codes). Contact your Area diabetes consultant if you are unsure about your correct ASUFAC numbers.

DOES LOCAL COMMUNITY RECEIVE SPDI GRANT FUNDS?  (1) Yes  (2) No or (3) Don't know.
If "Yes", record the official SDPI grant number (for example, H1D01234-09) in the designated space.

TRIBAL ENROLLMENT: Enter the 3 digit Tribal code. 

# OF PTS IN DIABETES REGISTRY: Enter the number of active patients in your diabetes register. If your service unit has multiple facilities participating in the audit, make sure you use the correct sample size (number of active DM patients) for each component. Please take care to assure accuracy on this critical item.

DATE of Diabetes Diagnosis: Enter the date the patient was first diagnosed with diabetes.  If only the year of diagnosis is stated, enter "07/01" of that year.  If only the month and year are stated, enter the 15th of that month. Leave blank if date is unknown.

TYPE of Diabetes: Specify if the patient has (1) Type 1 (a.k.a. IDDM, juvenile onset diabetes), or (2) Type 2 (a.k.a. NIDDM, adult-onset diabetes). Keep in mind that not all insulin-using patients have type 1 diabetes - in fact, most of them have type 2 diabetes. If uncertain, mark as (2) Type 2.

TOBACCO USE: Current status of tobacco use (cigarettes, chewing tobacco, snuff, etc) taken from the health summary, problem list or flow sheet. Mark (1) Currently uses tobacco, (2) Does not currently use tobacco, or (3) Tobacco use is  undocumented.

Referred for cessation counseling? [to be completed only if currently uses tobacco]. (1) Yes, if provider documents cessation counseling or referral for cessation counseling during the past 12 mo. (2) No, if no cessation counseling in past year, or (3) Refused, if documented that patient declines/refuses cessation counseling efforts.

HEIGHT: Enter height in inches, or in feet and inches.

LAST RECORDED WT: Record in pounds. If pregnant, use last non-pregnant weight. A note to re-confirm the value appears during data entry if an adult weight is <60 lbs or >600 lbs.

HTN documented (DX or RX): (1) Yes, hypertension diagnosis is on the problem list or visit assessment, or medication for hypertension is prescribed. (2) No documented hypertension diagnosis or meds.

Last 3 BLOOD PRESSURES: Record the last 3 blood pressures obtained within the last year. If a value falls outside of the expected range (e.g., >240 systolic or >140 diastolic) it will not be accepted; a cautionary note to confirm the level appears if systolic BP is >210 or diastolic BP is >130.

FOOT EXAM: Exam must include evaluation of sensation and vascular status.

EYE EXAM: Exam must include a dilated eye exam or stereo fundus photographs.

DENTAL EXAM: Must include examination of the gingiva and mucosal surfaces. Dental records may be kept separate from medical records at your facility.

EDUCATION in past year
From flow sheets, progress notes, PHN referral or consults.

DIET INSTRUCTION: Note any mention of diet instruction in the past year and code by provider type: (1) Registered dietitian, (2) Non-R.D., (3) Both, or (4) None. If it is documented that pt. refused diet counseling, select (5) Refused.

EXERCISE INSTRUCTION: Note any mention of exercise instruction in the past year.

Any GENERAL DM EDUCATION: Note any recorded patient education in the past year on any topic(s) related to diabetes, other than diet or exercise.

TREATMENT (at time of chart review)

DM THERAPY: Enter a 1 (Yes) or 2 (No) for each of the following therapy groups:
(1) Diet & Exercise Alone
(2) Insulin (all forms, including insulin aspart (NovoLog), lispro (Humalog) and glargine (Lantus))
(3) Sulfonylureas, including the following:

(4) Metformin (Glucophage) Note: Select choices 3 and 4 for Glucovance (glyburide + metformin)
(5) Acarbose (Precose) or miglitol (Glyset)
(6) Glitazones, including pioglitazone (Actos) or rosiglitazone (Avandia)

(7) Incretin mimetics (Byetta)

(8) DPP4 inhibitors (Januvia, Galvus)
(9) Refuses therapy, or unknown.

ACE INHIBITOR/ARB* use:
(1) Currently uses (is prescribed) an ACE inhibitor/ARB,
(2) does not currently use an ACE inhibitor/ARB, or
(3) Refused ACE inhibitor/ARB therapy, or adverse reaction.
*Both ACE inhibitors and angiotensin II receptor blockers (ARBs) are included here.

Examples of ACE inhibitor drugs include:

Examples of angiotensin II receptor blockers (ARBs) include:

If unsure, check with your pharmacist regarding the ACE inhibitors and angiotensin II receptor blockers used at your facility.

ANTIPLATELET Therapy: (1) Currently uses (is prescribed) chronic aspirin or other antiplatelet/anticoagulant medication, including:

(2)  Is not on chronic aspirin or other antiplatelet/anticoagulant therapy, or (3) Refused antiplatelet therapy or had adverse reaction.

LIPID LOWERING AGENT* use:
(1) Currently uses (is prescribed) a "statin" lipid lowering agent, including any of the following:

(2) Currently uses (is prescribed) another class of lipid lowering agent, including any of the following:

(3) Currently uses both a "statin" and any other type of lipid lowering agent, (4) Is not currently on a lipid lowering agent, or (5) Refused lipid lowering therapy or had an adverse reaction.

FLU VACCINE past year: (1) Yes, if administered during the audit period,  (2) No, or  (3) Refused, if flu vaccine offered but documented refusal noted on medical record.

PNEUMOVAX ever: Self-explanatory.

Td in past 10 years: Self-explanatory.

TB Status (PPD): (1) Last PPD skin test result was positive, or patient has known history of TB, (2) Last PPD was negative, (3) Refused PPD skin testing, or (4) Unknown.

If PPD Pos, is INH Tx Complete: (1) Yes, if the patient has documentation of at least 6 months of prophylactic INH or at least 12 months of multiple drug therapy documented for active TB, (2) No, if patient has not completed therapy. Include individuals for whom INH therapy was contraindicated. (3) Refused, if the patient declined therapy. (4) Unknown treatment status.

If PPD Neg, Date of last negative PPD: Self-explanatory.

DATE OF LAST ECG: Self-explanatory. Leave blank if no EKG has ever been recorded.

Hemoglobin A1c: Record the most recent HbA1c value and the date it was drawn.  If the HbA1c value exceeds the upper limit of the  test range, enter the upper limit of the range (e.g., if value is ">15" then enter "15"). 

CREATININE: Enter most recent value during audit period.  For patients on renal DIALYSIS of any type, enter a notation to that effect in the "Comments" field.

CHOLESTEROL (TOTAL, HDL, LDL), TRIGLYCERIDES: For each test, enter most recent value during the audit period. If the last value is more than 12 months old, do not record it.

Most Recent URINE PROTEIN TESTING during audit period: Mark the appropriate choice:

      (1) Urinary Albumin:Creatinine Ratio (UACR)

      (2) Urinary Protein:Creatinine Ratio (UPCR)

      (3) Other quantitative urine protein test (for example, a 24 hr urine albumin)

      (4) None

       For choices (1) and (2) above, provide the actual value in milligrams of albumin (or protein) per gram of creatinine.  If more than one of the above tests was performed during the audit period, provide the most recent UACR.  [Note: If the UACR or UPCR value you are trying to enter is a range, such as <30, 30-300, or >300, then the test is only semi-quantitative and should not be included -- select choice (4) in this case.]

DEPRESSION as an active problem:  (1) Yes, if depression is listed on active problem list or listed as a Purpose of Visit during the audit period, otherwise (2) No.

DEPRESSION SCREENING during the audit period:  (1) Yes, if provider used PHQ-2, Zung, Beck or similar depression screening scale, or  otherwise documented that pt was assessed for possible depression;  (2) No, if no documentation of depression screening found; or (3) Refused the depression screen.    

[OPTIONAL]

A LOCAL OPTION QUESTION, if present, will be found at the end of the audit. Read the question carefully and then select the appropriate response. (For more information on the Local Option Question, see the next section).