Diabetes: annual foot exam and risk classification

Indicator

The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) or 4) ulcerated foot within the preceding 15 months.

Introduction

This report provides a high level budget impact discussion for one indicator relating to diabetes mellitus piloted for the 2011/12 NICE menu of indicators for QOF. The intention is for this indicator to replace the 2009/10 QOF indicator DM9 which incentivises testing for foot complications and monitoring of foot problems in patients with diabetes through the recording of the presence or absence of peripheral pulses. Foot complications such as peripheral vascular disease (the damage caused to large blood vessels supplying lower limbs) and neuropathy (damage/degeneration of the nerves) are common in patients with diabetes. The NICE commissioning guide ‘Foot care services for people with diabetes’ (NICE 2006) estimates that approximately 40% of people with diabetes are likely to be at some degree of elevated risk of foot ulceration, of whom:

• 25–28% are likely to be at increased risk
• 10% are likely to be at high risk
• 2–5% are likely to require emergency foot care

Checks for vasculopathy and neuropathy should be carried out at an annual
review and these are undertaken as part of standard care under QOF
indicators DM9 and DM10.

Cost implication
Assessment of pilot feedback for this indicator suggested that foot risk assessment is performed routinely in the majority of practices, although it is not necessarily made using a formal classification system. It is difficult to estimate the cost impact of more intensive recording of risk classification and risk scores since there are a number of variables to consider in terms of testing outcomes. The identification of high risk patients will require delivery of more rigorous care and may lead to an increase in the number of individuals who are referred to secondary care. At the same time, the identification of low risk patients may prevent disease progression which has the potential to decrease the potential number of future high risk patients that may not have otherwise been identified and thus result in future savings for the NHS.

It is reasonable to assume that more intensive foot risk assessment would result in increased availability of information, leading to improved outcomes in the early detection of foot complications in people with diabetes in general practice and that this would result in future savings for the NHS (reducing the risk of foot ulcers, infections and amputations, which can release capacity in secondary care, and improve quality of care).

Indicative costs of potential future savings can be gauged using the Payment by Results national tariff costs 2010/11 for HRG QZ12Z (Foot Procedures for Diabetes or Arterial Disease, and Procedures to Amputation Stumps) which quantifies an elective spell for this procedure as £2,613 and £5,664 for a nonelective spell.

Conclusion

Checks for vasculopathy and neuropathy are already undertaken as part of standard care under QOF indicators DM9 and DM10 and foot risk assessment is already performed routinely in the majority of practices despite not necessarily recorded using a formal classification system. There may be some additional costs in identifying high risk patients but this would reduce over time as the at-risk population is more rigorously monitored. Implementation of this indicator is therefore not expected to result in significant costs.

Related QOF indicators
National level results for 2008/09 for the current QOF indicator (NHS Information Centre 2009)

Current QOF indicator	Numerator	Denominator	Underlying achievement
DM9. The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months	1,905,192	2,089,195	91.2%
DM10. The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months	1,897,915	2,087,789	90.9%

References
National Institute for Clinical Excellence (NICE) (2006) Foot care service for people with diabetes. NICE commissioning guide. London: NICE.

NHS Information Centre (2009) QOF 2008/09 results: England level QOF
tables 2008/09 – clinical tables 2008/09.