CLINICAL AUDIT TOOL:
Type 2 Diabetes Management of
Blood Pressure and
Microalbuminuria
1
Introduction
This clinical audit tool addresses management of blood pressure and microalbuminuria for
people with type 2 diabetes.
It draws on best practice guidance reproduced in the New Zealand Primary Care Handbook
2102 from the source document Guidance on the Management of Type 2 Diabetes (2011).
See http://www.health.govt.nz/publication/new-zealand-primary-care-handbook-2012 for
further content from the Handbook.
TOPIC
Type 2 Diabetes - Management of Blood Pressure
and Microalbuminuria
Why is this topic of interest?
 Raised blood pressure is an important risk factor for
microvascular and macrovascular complications in patients
with type 2 diabetes.
 Microalbuminuria is the earliest sign of diabetic renal disease
and requires prompt treatment.
Key points from the guidance:

Māori, Pacific Island and South Asian peoples are at a higher risk of renal
complications and require more frequent monitoring of renal status.

Younger people with type 2 diabetes have a higher lifetime risk of renal
and other diabetes-related complications. Consider tighter BP control in
this patient group.

Microalbuminuria is confirmed if, in the absence of infection or overt
proteinuria, two out of three specimens have an elevated
albumin:creatinine ratio (ACR).

Dietary salt restriction is important in the management of hypertension.
Reducing daily salt intake by 5g/day (a teaspoon) on average reduces BP
by 5/3 mm Hg.
For details of recommended drug therapy for management of raised blood
pressure and microalbuminuria see Figure 4 page 55 of the Handbook.
PLAN
Indicators
(elements of practice performance to be measured)
The practice effectively manages patients with type 2 diabetes with respect to
raised blood pressure and microalbuminuria:
1.
Lifestyle modification (using the FAB approach), including dietary salt
restriction, is provided as part of initial and ongoing treatment.
The FAB approach is a combination of changes to food/diet, increased physical
activity, and behavioural strategies (problem-solving and goal setting).
2.
An appropriate BP target guides clinical management.
2
3.
Patients with type 2 diabetes and confirmed microalbuminuria are treated with
appropriate BP medications, irrespective of whether or not hypertension is
present.
4.
Drug therapy for raised blood pressure is instigated as appropriate.
5.
Current drug therapy for blood pressure management is consistent with
recommended stepped drug therapy.
6.
Follow-up and stepwise protocol adjustments are timely in relation to BP
target.
Criteria
1.
(how the indicator will be measured)
Patient records indicate patient has had brief counselling and an
appropriate action plan for lifestyle modification has been initiated,
monitored and altered as appropriate.
2.
Patient records indicate treatment goals, including target BP, have been
discussed.
Target BP should be appropriate for the individual patient. Recommended
BP target <130/80 mm Hg. This may not be appropriate for specific
patients and should not be pursued in patients with a short life expectancy
or those at significant risk of hypotension. (Note: a BP <120 mmHg may be
harmful.)
3.
Patients with confirmed microalbuminuria are treated with an ACE inhibitor
or an angiotensin 2 receptor blocker (ARB), whether or not hypertension is
present. Antihypertensive treatment takes into account renal impairment:
if significant renal impairment (eGFR < 45 ml/min/1.73m 2) is present loop
diuretics may be used instead of or in combination with thiazide diuretics.
4.
Drug therapy for raised blood pressure is commenced after inadequate
response (BP does not closely approach target) within 3 months lifestyle
modification.
5.
Drug therapy prescribed is consistent with recommended intensification of
BP treatment – starting with ACE inhibitor with dose titration (ARB if
intolerant); adding one of calcium channel blocker (CCB) or thiazide-type
diuretic if above target on review; adding another of thiazide type diuretic
or CCB if above target on review; adding one of alpha-blocker or betablocker or further diuretic therapy (potassium sparing) if above target on
review; adding another of alpha-blocker or beta-blocker or further diuretic
therapy (potassium sparing) if above target on review.
See Fig. 4 of Handbook for further details.
Changes in drug therapy reflect measured BP and individual patient
response to drug therapy.
6.
Intensive monthly follow-up and stepwise protocol adjustments are
advised until BP consistently below target. BP is reviewed at least 6
monthly once at target.
Standards
(the standards to be achieved)
Note that the focus is on improving standards of clinical practice, with 80%
achievement identified by the RNZCGP as an appropriate target and 100% as an
ideal. Individual GPs and practices may choose to set a differing target for a first or
subsequent audit/s, with a view to increasing standards over time.
1.
Patients have received lifestyle modification brief counselling (standard:
80%). Patient records indicate planned lifestyle modification (80% of
records).
2.
80% of patient notes indicate current treatment goal and/or target BP if
differs from recommended target BP <130/80 mm Hg.
3.
80% of patient notes indicate initiation of appropriate drug therapy for
patients with type 2 diabetes and confirmed microalbuminuria.
4.
80% of patient notes indicate initiation of drug therapy for BP meets
criteria (post trial of lifestyle modification).
5.
80% of patient records indicate patient receiving a recommended
treatment regimen for BP management with appropriate intensification.
6.
80% of patient records indicate appropriate follow-up interval and
stepwise protocol adjustments made when indicated in relation to
treatment goal or BP target (most recent follow-up noted for standard).
DO
Discover what you are doing now
(collect data)

Retrieve records for 15-20 random patients with type 2 diabetes.

Review patient records using copies of the Individual Patient Record Review
Sheet.
STUDY
Next steps: what do the results tell you

(interpret the data)
Collate the data according to the standards set and compile a brief summary
for each indicator.

What are you doing well?

What needs improving?

What gaps between standards and performance do you want to close?

Identify possible solutions.
ACT
Make changes – what changes can be made to
improve patient care?
Write an action plan

Choose one or two achievable goals.

Identify any barriers and enablers to change e.g. resources, skills, IT.

Decide what needs to be done and by when.

Plan a review date to follow up on changes.
Implement changes
Monitor change and progress

Review your action plan to see if you are keeping to timeline for implementing
change.

Monitor to see if actions are taking place.

Solve problems as they arise.

Obtain qualitative feedback from staff and patient about the improvement/s.

Consider if you need to develop new strategies to achieve the goals you have
set?
Clinical Audit Tool: Type 2 Diabetes - Management of
Raised Blood Pressure and Microalbuminuria
Patient Record Review Sheet
Date:
Patient 1 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 2 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
6
Patient 3 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 4 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 5 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 6 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 7 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 8 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 9 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 10 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 11 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 12 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 13 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 14 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 15 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 16 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 17 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals
modification
goals
regimen for BP
appropriate for
are appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium
sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 18 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals
modification
goals
regimen for BP
appropriate for
are appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium
sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 19 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
Patient 20 (add initials/NHI):
Lifestyle
Treatment
Drug therapy
Drug therapy
Follow-up intervals are
modification
goals
regimen for BP
appropriate for
appropriate
Offered
noted/BP
appropriate
microalbuminuria or
target
(standards 4 &
more significant renal
recorded
5)
impairment
Yes/No/NA
Yes/No
Yes/No
Yes/No/Don’t know
Yes/No
Current drug therapy for BP/microalbuminuria (circle):
ACE inhibitor/ARB/CCB/thiazide type diuretic/alpha-blocker/beta-blocker/diuretic (potassium sparing)
Rationale/comments re. drug therapy:
Other comments (e.g. lifestyle management, follow-up interval):
RNZCGP Summary Sheet
Continuous Quality Improvement (CQI) Activity
Type 2 diabetes - management of blood
pressure and microalbuminuria
Topic:
Doctor's name: ________________________________________________________________
First cycle
Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.
Action: Describe how these improvements will be implemented
Monitor: Describe how well the process is working. When will you undertake a second cycle?
16
Second cycle
Data: Date of data
collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.
Action: Describe how these improvements will be implemented.
Monitor: Describe how well the process is working.
Comments: