General practice management of type 2 diabetes

What should be evaluated yearly?
☰ Table of contents

The annual review is a time for more detailed assessment, updating the problem priority list, re-establishing goals and checking agreed arrangements for management.

As there is an increasing trend towards involving specialist allied health professionals, the yearly visit is a good opportunity to coordinate follow-up.

Annual review

A full system review checking for vascular, renal, eye, nerve and podiatric problems is required. An annual review or cycle of care may address the following:


  • Review issues specific to diabetes:
    • including symptoms of hyperglycaemia, hypoglycaemia and diabetes complications.
  • Preventive health issues:
    • smoking
    • nutrition (last contact with APD or CDE)
    • alcohol intake
    • physical activity.
  • Adequacy of, or problems with, team care arrangements.
  • Patients with diabetes can be assessed for perspectives on adequacy of treatment, quality of life, medication burden, and concerns regarding diabetes such as mental health issues, social isolation/networks and family or work stress. Daily diabetes self care and management can place a considerable burden upon people with diabetes. It is common for people with diabetes, at times, to feel overwhelmed, frustrated, guilty, or to worry about their current and/or future diabetes management and health outcomes.
  • Immunisations.

Clinical examination

  • Visual acuity. Retinal screening – every two years with no retinopathy, more frequently if abnormal.
  • Cardiovascular system, including postural BP, and central and peripheral vascular systems. Calculate or re-evaluate absolute CVD risk assessment.
  • Weight, waist, height (children and adolescents).
  • Feet examination without shoes – pulses, monofilament check, any foot discomfort.
  • Consider assessment of diabetes distress through the use of the PAID94 questionnaire and depression with the PHQ-295 (refer to Appendix C. Problem areas in diabetes questionnaire and Appendix D. Patient health questionnaire-2 tool).

Routine investigations

  • Re-evaluate lipid parameters. If the patient has low CVD risk, these tests can be performed every three years. More frequent testing can be justified if the clinical situation varies or if therapeutic changes have been instituted. Some guidelines suggest yearly testing of lipids when the patient is deemed to be at clinically high risk.
  • Re-evaluate urine microalbumin annually, unless existing pathology necessitates more frequent testing.
  • Based upon a clinical risk assessment, individually assess the need for further investigations such as liver enzyme abnormalities for hepatic steatosis.

Evaluation and management

  • Shared decision making − Identify specific clinical areas for focus within the consultation and re-establish patient-specific goals for support and re-evaluation.
  • Renew team care planning with identified specific interventions.
  • Identify therapeutic management changes and additional education goals with patient involvement.
  • Organise appropriate referral where clinically necessary. Some patients may require ongoing specialist or other allied health review. Others will have changed priorities; hence, it is sometimes wise not to commit to referrals too early.

Table 3. Suggested actions and health professionals providing treatment or service

Suggested actions

Team resource – Who?



General practitioner (GP)

Goal setting supporting self management


Cardiovascular issues (eg blood pressure [BP] measurement)

GP/practice nurse

Glycaemic control

GP/practice nurse/Credentialled Diabetes Educator (CDE)/diabetes educator (DE)

Assess (inclusive within an annual cycle of care)

Risk factors for modification

GP/practice nurse/CDE/DE

Weight, height

GP/practice nurse

Cardiovascular disease risk assessment

GP/practice nurse

Foot examination

GP/Podiatrist/practice nurse

Presence of other complications, especially hypoglycaemia risk with insulin or sulphonylureas

GP/practice nurse/CDE/DE/ endocrinologist

Psychological status

GP/ psychologist

Eye examination


Dental review


Consider other assessments where appropriate  (eg cognitive impairment, obstructive sleep apnoea)

GP/endocrinologist/specialist (where indicated)


Review smoking, nutrition, alcohol, physical activity (SNAP) profiles, including specific issues

GP/registered nurse/CDE/DE


GP/Accredited Practising Dietitian (APD)

Physical activity levels

GP/Accredited Exercise Physiologist (AEP)/physiotherapy


GP/practice nurse/CDE


GP/practice nurse

Sick day management

GP/practice nurse/CDE

Medication issues


Self-monitoring blood glucose

GP/CDE/DE/practice nurse

Insulin/injectable management

GP/CDE/registered nurse/accredited nurse practitioner/endocrinologist

Psychological issues

GP/practice nurse/CDE/DE/psychologist


Register for National Diabetes Services Scheme (NDSS)

GP/CDE/nurse practitioner

General practice management plan (GPMP) and  Chronic disease management plan

GP/practice nurse

Cultural, psychosocial issues

GP/Aboriginal health worker/social worker/CDE/DE/psychologist


Addition to the practice’s diabetes register and recall

GP/practice nurse/practice staff

Organise reviews including pathology and annual  cycle of care

GP/practice nurse

Driver’s licence assessment

GP/practice nurse/endocrinologist  (when indicated)

Refining the management plan

Review the goals and individual targets with the patient to identify specific areas for ongoing or interval therapeutic review.

Patient support – refer to structured self-management education (eg CDE). Does other allied health intervention need to be considered (eg psychologist, APD)?
Medication/therapy choices – adjustment of agent, dose, combinations, enquire about symptoms of hypoglycaemia. Review use of medication using the principles of the ‘Stop rule’ every three or six months.

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  1. Polonsky WH, Anderson BJ, Lohrer PA, et al. Assessment of diabetes-related distress. Diabetes Care 1995;18(6):754–60.
  2. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41(11):1284–92.