Appendix 1 : Data Collection Sheets , Definititons, Form Completion Instructions and Upper Limit of Normal Form

Page last updated: 09 October 2012

NADC - ANDIAB
Australian National Diabetes
Information Audit & Benchmarking



Final Report
ANDIAB 2011
[November 2011]



ANDIAB 2011 Adult Data Form


Start of the ANDIAB 2011 Adult Data Form

ANDIAB 2011 Australian National Diabetes Information Audit & Benchmarking Project

Identification


Centre ID :
Patient ID (optional) :
Sex : Male Female
Staff ID :
Date of Birth :
Date of Patient Visit :
Initial Visit :
Indigenous:


Diabetes Type and Management and Smoking
Month and Year of Diagnosis :
Type of Diabetes : Type1 Type2 GDM Don't Know Other
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Management Method


Diet only No Yes
Glitazone No Yes
Acarbose No Yes
Metformin No Yes
GLP1 Agonist No Yes
Insulin No Yes
Sulphonylurea No Yes
DPP4 Inhibitor No Yes
Nil No Yes

In on Insulin: Since (year) :

Smoking Status: Current Smoker Past Smoker Never Smoked


Weight/Height(latest)


Weight - Kg
Height- m


Current Pregnant

No Yes


Blood Pressure (most recent, measured after 5 mins sitting)


BP : mm Hg

On anti-hypertensive treatment?
No Yes


Other Therapy

ACE inhibitor : No Yes
ACE + Thiazide : No Yes
A2 Antagt : No Yes
A2 + Thiazide : No Yes
Beta Blocker : No Yes
Calcium Antag : No Yes
Thiazides : No Yes
Other : No Yes

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Diabetic Eye Disease last 12 mths


Saw Optometrist : No Yes
Ophthalmologist : Referred to : No Yes Attended : No Yes
Visual Acuity : Right Eye : 6/
Visual Acuity : Left Eye : 6/

Fundus examination(in the last 12 months) : No Yes

Retinal Camera : No Yes

If yes
Right Retina :
Normal
Diabetes Abnormality
Non Diabetes Abnormality
Not Visualised

Left Retina :
Normal
Diabetes Abnormality
Non Diabetes Abnormality
Not Visualised

Cataract Right : No Yes

Cataract Left : No Yes


Diabetic Foot Problems / Seen by Health Professionals last 12 months



Peripheral Neuropathy : No Yes
Past History of Ulceration : No Yes
Foot Deformity : No Yes
Attended Podiatrist : No Yes
Peripheral Vascular Disease : No Yes
Current Foot Ulcer : No Yes
Active Foot Lesion : No Yes

Attended Podiatrist : No Yes
Attended Educator : No Yes
Attended Dietitian : No Yes

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Lipids (most recent result last 12 mths)


Fasting : No Yes
Cholesterol :
LDL :
HDL :
Triglycerides :

On Anti-Lipid Rx : No Yes
Fibrate Rx : No Yes
Statin Rx : No Yes
Vytorn Rx : No Yes
Statin Side Effects / Contraindicated : No Yes
Ezetrol Rx : No Yes
Fish Oil : No Yes


Blood Glucose Control (most recent last 12 mths)


Glycated Hb : Result : %



Asipirin Therapy : No Yes Contraindicated

Clopidogrel Therapy : No Yes Contraindicated


eGFR > 60 No Yes

eFGR Result:


Diabetic Nephropathy (most recent last 12 mths)


Microalbumin/Proteinuria :
Units : mg/L ug/min mg/24hr ratio Yes

Microalbumin/Proteinuria is Not Applicable

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Serum Creatinine:(Micromol/L) umol/L

Complications/Events

Complications/EventsLast 12 mthsPrevious
Cerebral Stroke No YesNo Yes
Lower Limb AmputationNo YesNo Yes
CABG / AngioplastyNo YesNo Yes
Severe HypoglycaemiaNo YesNo Yes
Myocardial InfarctionNo YesNo Yes
End Stage Renal Disease No YesNo Yes
BlindnessNo YesNo Yes
Erectile DysfunctionNo YesNo Yes


Copyright 2011 NADC-ANDIAB2011V1.0-Adult


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End of the ANDIAB 2011 Adult Data Form

Data Definitions for NADC–ANDIAB

\Andiab Def 2011 Adult.doc 10-01-2011
Australian National Diabetes Information Audit & Benchmarking Project [V1-Adult Copyright 2011 NADC-ANDIAB]

Identification


Patient ID (Optional field).
Enter some identifier such as record number or first the 2 letters of the first name and surname and month and year of birth (e.g. FFSSMMYY) to enable you to check your records if there is a question regarding the data.
Date of Birth
Record as DD/MM/YYYY. [If unknown other than year : Record as 01/01/YYYY].
Sex
Mark Male or Female indicating phenotypic (physical) sex at birth.
Date of Patient Visit
Record the date the patient attended as DD/MM/2009.
Initial Visit
Mark No or Yes indicating if this is an initial visit assessment.
Indigenous
Mark No or Yes indicating Aboriginal / Torres Strait Islander background.
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Diabetes Type & Management & Smoking


Mth & Year of Diagnosis
Record as MM/YYYY of first diagnostic blood glucose estimation. [If date unknown other than year, record as 01/YYYY].
Type of Diabetes
Mark Type1 [IDDM] or Type2 [NIDDM] or GDM or Don't Know, or Other to indicate the clinical classification of
diabetes.
Management Method
Mark No or Yes to indicate if the patient’s management method is Diet Only, Metformin, Sulphonylurea, Glitazone,
GLP1 Agonist, DDP4 Inhibitor, Acarbose, and/or Insulin or NIL. Answer all.
If on Insulin: Since (yr)
If the patient is on Insulin, record the YEAR insulin was started. Record as YYYY.
Smoking Status
Mark Current Smoker or Past Smoker or Never Smoked to indicate smoking of any tobacco material.
Current Smoker = regular smoking over the past 3mths, Past Smoker = no regular smoking for 1month or more,
Never smoked = never smoked any tobacco material.


Height, Weight & Currently Pregnant


Weight
Record in kilograms the weight measurement without shoes or jacket.
Height
Record in metres the height measurement without shoes.
Currently Pregnant
Mark No or Yes to indicate if the patient is currently pregnant.

Blood Pressure & Anti-hypertensive Treatment & Other Therapy


Blood Pressure
Record Systolic / Diastolic (mm Hg) measured after 5 minutes sitting, [1st and 5th phases].

On anti-hypertensive Treatment & Other Therapy
Mark No or Yes to indicate if the patient is on treatment for hypertension and each specific medication they are taking - for
ACE Inhibitors, ACE + Thiazide, A2 Antagonists; A2 + Thiazide, Beta Blockers, Calcium Antagonists, Thiazides and Other.
Answer all.

Diabetic Eye Disease


Optometrist
Mark No or Yes to indicate if the patient Attended an Optometrist in the last 12mths.
Ophthalmologist
Mark No or Yes to indicate if the patient was Referred to and Attended an Ophthalmologist in the last 12mths. Answer All.
Visual Acuity
Record actual result for both right and left eyes as 6/5, 6/6, 6/7.5, 6/9, 6/12, 6/18, 6/24, 6/36, 6/60, CF (Count fingers),
HM (Hand movement), PL (Perceive Light), BL (Blind). Tested wearing glasses (or using pinhole if acuity is not normal).
Fundus examination
Mark No or Yes to indicate if the patient has had an Ophthalmological Assessment (Direct or Indirect) in the last 12mths.
Retinal Camera
Mark No or Yes to indicate if the Ophthalmological Assessment was using a Retinal Camera.
If Fundus examination
Indicate the fundus examination results by marking Normal or Diabetes Abnormality or Non Diabetes Abnormality or
was Not Visualised. Record for both Right Retina and Left Retina. Answer one only.
Cataract
Mark No or Yes to indicate if the patient currently has a cataract present or has had one removed previously. Record for
Right and Left eye.
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Diabetic Foot Problems & Seen By Health Professionals


Peripheral Neuropathy
Mark No or Yes to indicate clinical judgement following assessment using pin prick and vibration (using perhaps a Biosthesiometer) or Monofilament.
Peripheral Vascular Disease
Mark No or Yes to indicate Peripheral Vascular Disease. Record YES as absence of both dorsalis pedis and posterior tibial pulses in either foot.
Foot Ulcers, Deformity, Lesion Mark No or Yes to indicate Past History of Foot Ulceration, Current Foot Ulceration, the presence of Foot Deformity and/or Active Foot Lesion (other than a foot ulcer). Answer all.
Seen by Health Professionals
Mark No or Yes to indicate if the patient attended a Podiatrist, a Diabetes Educator, and/or a Dietitian/Nutritionist, in the last 12mths. Answer all.

Lipids


Fasting Lipids Mark No or Yes to indicate if total, LDL & HDL cholesterol and triglycerides were measured in a fasting specimen.
Lipid Levels Record absolute result of most recent result of total, LDL & HDL cholesterol and triglycerides in the last 12mths.
Lipid Rx Mark No or Yes to indicate whether the patient is specifically on drug treatment for Dyslipidaemia and whether they are on Statin, Fibrate, Vytorin, Ezetrol and/or Fish Oil and whether they have Statin Side Effects / Contraindicated. Answer all.


Blood Glucose Control


Glycated Hb
Record absolute result [%] of the most recent HbA1c result in the last 12mths.


Aspirin & Clopidogrel


Aspirin & Clopidogrel
Mark No or Yes or Contraindicated to indicate if patient is currently on Aspirin and/or Clopidogrel. Answer all.

Diabetic Neuropathy


Microalbumin / Proteinuria
Record absolute result of total microalbumin measurement in a spot test, 24 hour or timed collection, expressed as
absolute amount of albumin [mg/L] or as albumin excretion rate [AER: μg/min or mg/24hr] or Ratio. Mark the
applicable units.
Mark Yes if microalbumin / proteinuria collection is not applicable.

Creatinine


Creatinine
Record absolute result measurement of serum creatinine in MICROMOLS/L [μmol/L].
eGFR
Mark No or Yes to indicate if eGFR is >60. Record absolute result in the box provided if known [eg: 45 or 87 or 101].
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Complications Events


Mark No or Yes to indicate a history of complication or an event in the last 12mths AND/OR previously. Answer all:
Cerebral Stroke Due to vascular disease.
Myocardial Infarction Evidenced by ECG changes or plasma enzyme changes.
Lower Limb Amputation Amputation of toe, forefoot or leg [above or below knee], not due to trauma or causes other than vascular disease.
End Stage Renal Dis. Requiring dialysis or having undergone a kidney transplantation (due to diabetic nephropathy).
CABG/Angioplasty CABG, Angioplasty or Stent.
Blindness Patient became legally blind (>6/60) in either eye.
Severe Hypoglycaemia Severe hypoglycaemia [DCCT definition] requiring assistance.
Erectile Dysfunction History or treatment of failure to achieve or maintain erection sufficient for penetration.


How To Fill In ANDIAB Forms


You will need to Photocopy Forms for use. Retain the Master Copies in a safe place to use when additional copies are needed.
Please always make copies from the Original Master Copy.
For scanning purposes, photocopies must be of perfect quality and the copy must be straight on the page and appropriately centred. If any of the four black cornerstones [black triangles] on the Form are damaged in any way or not completely visible, please do NOT complete that Form as the computer system will not accept it.
Also, please do NOT reduce the size of Forms when photocopying them.
Adult Forms should be filled in for individuals over 18 years old. [Adolescent / Paediatric Forms should be filled in for individuals aged under 19].
  • Forms should be completed for each Patient WITH A FINE FELT TIP PEN.
  • Please write UPRIGHT, clearly and within the boxes. Try NOT to write on box borders.
  • You should fill in all fields, but do NOT use dashes etc if data is missing - leave the field blank [as anything in a box will be interpreted as data].
  • No/Yes boxes etc can be filled in with a ‘X’. This must go through the centre of the circle/oval box, not the corner :

Image showing how to correctly cross mark in the circle

Image showing Incorrect way of putting cross mark in the circle when selecting a option

If a mistake is made Do Not Use Whiteout - put a line through it and clearly mark the correct choice

For Example

Image showing If a mistake is made in selecting a option using selection circle box then not use whiteout  but put a line through it and clearly mark the correct choice
  • Do Not use 'less than' < signs, and for Visual Acuity do NOT report 6/6-2 [minus 2]:[Report 6/6].
  • Do Not use leading zeros in number fields leave the first cell blank if it is a zero and having numerics in the remaining cells. Not leading with a zero
  • I draw your attention to the data field definitions. These indicate the interpretation of each field and the valid entries for each. Whilst the Patient ID field is optional, the use of the medical record number or a combination of name/DOB [first two letters surname, first three letters firstname, month and year of birth [SSFFFMMYY] eg FLJEF1251 would enable you to check the records if data needs to be verified or corrected and would enable progress reports for individuals to be generated if the individual was seen previously.
  • When mailing Forms to be Scanned: Please do NOT staple Forms together and mail forms flat, do NOT fold them. If you wish, photocopy and retain a copy in the patient’s file, but please forward the ORIGINAL copies. They will be returned to you after data entry and analysis if you wish.
  • Completed Forms will be Scanned into a computer system for analysis and reporting. When completed, Forms should be forwarded to :
Ms Gina Chen
National Association of Diabetes Centres
PO Box 163
WODEN ACT 2606
Tel : (02) 6287 4822
Email : nadc

If you have any enquiries, please don’t hesitate to contact your Site Coordinator or Gina.

The types of reports requested by your site will indicate which forms are completed by whom before returning:

Pooled Data - If your Centre has elected to receive pooled data reports only, you will only be allocated a single site code. Individuals will need to complete copies of the form provided to your Centre. Please note the instructions relating to copying of the master form contained in this letter.

Individual Report for Doctors Contributing Data - If your Centre has nominated to collect information from individual doctors to contribute to the Centre’s aggregate data, you will receive a site code for the Centre as well as an identifying code for each individual doctor. The allocated Form (as per Staff ID) should be issued to that individual, and he/she should only use Forms with that number on them. If individuals other than those with an allocated Form see patients, they should use the Form with the Staff ID ending in ‘00’.

Individual Doctor Reports Independent of a Pooled Centre - If your Centre/site has nominated to collect information separate from a Centre, a separate site code will be allocated.

Data Collection Forms
We have managed to keep the Forms to one page and in order to reduce the costs of running the study, we are using scannable Forms. These place some restrictions on the amount of data and the format of data entry, and it is requested that you follow the guidelines in the attached information ‘HOW TO FILL IN ANDIAB FORMS’.

When we forward your Master Copies we will enclose extra copies of the information sheet to enable all staff members to be familiar with the procedures for completing the Forms.

When you receive your Master Data Collection Forms, you should photocopy these Forms for use, and retain the “Master Copies” in a safe place. For scanning purposes, photocopies must be of perfect quality and the copy must be straight on the page and appropriately centred. If any of the four black cornerstones on the Form are damaged in any way or not completely visible, please do not complete the Form as the computer system will not accept it. Also, please do not reduce the size of Forms when photocopying them.
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When completed, all Forms should be forwarded to the National Office of the National Association of Diabetes Centres at the above address.

When mailing Forms to be Scanned: Please do not staple Forms together and mail forms flat, do not fold them. If you wish, photocopy and retain a copy in the patient’s file but please forward the original copies. They can be returned to you after data entry and analysis, if you request us to do so.

What’s New In 2011
Essentially the collection form is identical to that collected in 2011 and concentrates on demographic, clinical, biochemical and outcomes data.
In 2011, the only difference compared to 2099 is that we have added 2 fields on eGFR, one to record if the eGFR is >60 (No or Yes) and the other, to record the actual eGFR result (if known) eg 45 or 87 or 101.
See Definitions Form for full detail on all items.
The changes are suited to Adult Centre patients [over 18 years].
An adapted Paediatric / Adolescent Form is under consideration.

The Data Collection Form remains a one-page scannable format


Again, if you have any further inquiries, please contact Ms Gina Chen on 02 62874822 or Email to nadc

ANDIAB 2011

SITE NUMBER : DC__________________________

The Upper limit of Normal values in our Laboratory for the following are:

HbA1c ___________ %

Microalbumin
Mg/L ____________

Ug/Min ____________

ACR ______________Male ______________Female

Albumin/Creatinine Ratio

Protein
Mg / 24 hrs ____________

Please Complete and forward to
Ms Gina Chen
National Association of Diabetes Centres
PO Box 163
Woden ACT 2606
Tel : (02) 6287 4822
Email : nadc

If you have any enquiries please don’t hesitate to contact your Site Coordinator or Gina.
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