The NHS Atlas of Variationin Healthcare for Peoplewith DiabetesMay 2012                         Copyright 2011 Right Care
2
The burden of diabetes in England    There are thought to be more    than 3 million adult diabetics    in England. Only 2....
National Diabetes Audit (NDA)    (audit period 1 January 2009 and 31 March 2010)    • More than 60% of people of all ages ...
Diabetes is costly to treat…    • In 2010/11, prescribing for anti-diabetic items, including      blood-testing items, cos...
The concept of unwarranted variation in diabetes care    The aim of the Diabetes Atlas is to identify and quantify the ext...
“.. the indicators in this Diabetes Atlas clearly demonstrate there is     considerable variation in both the processes an...
Selection of indicators    The indicators included in the Diabetes Atlas were    chosen:    ›› to reflect the range of dia...
The Atlas has been produced in collaboration with…    Diabetes Health Intelligence is a strategic programme within the Yor...
In presenting variation in this Atlas, PCTs are allocated   Shifting the curve…to five groups, determined by their differe...
Magnitude of variationWith respect to the percentage ofpeople in the NDA with Type 1diabetes receiving all nine key carepr...
Magnitude of variationWith respect to the percentage ofpeople in the NDA with Type 1diabetes receiving all nine keycare pr...
Options for actionAs almost half of the people with Type 2 diabetes and two out of threepeople with Type 1 diabetes have n...
Magnitude of variationFor PCTs in England, insulin totalnet ingredient cost per patient onGP diabetes registers rangedfrom...
There is no correlation between spending on insulin items and thepercentage of people with Type 1 diabetes or with Type 2 ...
Magnitude of variationPeople with diabetes are more likelythan those without diabetes to beadmitted to hospital. When inho...
Magnitude of variationWith respect to excess emergencyre-admissions among people withdiabetes when compared withpeople wit...
Options for actionCommissioners and providers need to investigate variation in length ofstay at a local level, and conside...
Magnitude of variationPeople with diabetes are predisposedto developing foot ulcers primarilybecause of an increased risk ...
Options for actionintroduction of multidisciplinary teams to assess and treat diabetic footdisease has reduced major and m...
www.rightcare.nhs.uk/atlas     In print     You can order free printed copies     using the online form on out website    ...
Follow Right Care online:     - Subscribe to get a weekly digest of our blog in your inbox     - Receive Occasional eBulle...
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Diabetes atlas key headlines 2012

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Diabetes atlas key headlines 2012

  1. 1. The NHS Atlas of Variationin Healthcare for Peoplewith DiabetesMay 2012 Copyright 2011 Right Care
  2. 2. 2
  3. 3. The burden of diabetes in England There are thought to be more than 3 million adult diabetics in England. Only 2.3 million of these have been diagnosed. By 2020, 3.8 million are expected to have diabetes – more than 1 in 12 of the total population. Variation in current processes and outcomes in people have significant implications for the NHS today and in the future3
  4. 4. National Diabetes Audit (NDA) (audit period 1 January 2009 and 31 March 2010) • More than 60% of people of all ages with Type 1 diabetes and almost half of people of all ages with Type 2 diabetes did not receive all nine care processes essential for management and detection of early complications • Two in 10 children aged 0–15 years have a most recent HbA1c of over 10%, making the long-term complications of diabetes more likely • People of all ages with diabetes are more than twice as likely to be admitted to hospital than people of a similar age who do not have the condition • People of all ages with diabetes stay in hospital almost 20% longer than people of a similar age who do not have the condition4
  5. 5. Diabetes is costly to treat… • In 2010/11, prescribing for anti-diabetic items, including blood-testing items, cost £725.1 million and accounted for 8.4% of the total spend on prescriptions in primary care • an increase of 41.2% since 2005/06 • The cost of prescribing for the treatment of diabetes is increasing faster than that for any other category of drugs Prescribing for Diabetes in England 2005/06 to 2010/11 http://www.ic.nhs.uk/webfiles/publications/prescribing%20diabetes%20200506%20to%20201011/P rescribing_for_Diabetes_in_England_20056_to_201011.pdf5
  6. 6. The concept of unwarranted variation in diabetes care The aim of the Diabetes Atlas is to identify and quantify the extent of ‘unwarranted’ variation that may be due to unjustified geographical differences in medical practice and/or patients not gaining access to the appropriate level of intervention for their need. The resulting suboptimal (either over-use or under-use) uptake of medical intervention is defined as ‘unwarranted’.6
  7. 7. “.. the indicators in this Diabetes Atlas clearly demonstrate there is considerable variation in both the processes and outcomes of care. Sadly, there are a substantial number of patients who are not receiving all of the nine basic care processes designed to identify treatable risks and early complications of diabetes. In the absence of these care processes, patients do not know if their level of health matches the recommended outcomes or if further care is needed, and neither do the healthcare professionals ” Dr Rowan Hillson MBE National Clinical Director for Diabetes7
  8. 8. Selection of indicators The indicators included in the Diabetes Atlas were chosen: ›› to reflect the range of diabetes care ›› because they could be calculated using robust nationally collated data at PCT level ›› Indicators were revised following consultation with the National Diabetes Information Service (NDIS) Expert Reference Group.8
  9. 9. The Atlas has been produced in collaboration with… Diabetes Health Intelligence is a strategic programme within the Yorkshire and Humber Public Health Observatory (YHPHO). The YHPHO has a commitment to support the diabetes community by providing timely, quality-assured national diabetes health intelligence. YHPHO is part of a network of nine public health observatories in England. http://www.yhpho.org.uk/ The National Diabetes Information Service (NDIS) is a national strategic partnership which provides health commissioners, providers and people with diabetes with the necessary information to aid decision-making and improve services on a local and national level. The five partner organisations are NHS Diabetes, Diabetes UK, Diabetes Health Intelligence, Innove and the NHS Information Centre for health and social care. The service is funded by NHS Diabetes. http://www.diabetes-ndis.org/9
  10. 10. In presenting variation in this Atlas, PCTs are allocated Shifting the curve…to five groups, determined by their difference from theEngland average. This type of comparison is usefulwhen rapidly analysing the potential for variationamong populations or datasets.It is also important to pay attention to the Englandaverage value – in some examples the Englandaverage itself is relatively poor. For example, thepercentage of people with diabetes in the NDA whohave received all nine NICE recommended basic careprocesses : ›› For people with Type 1 diabetes, the England value is 31.9% and the range is 5.4–47.9% ›› For people with Type 2 diabetes, the England value is 52.9% and the range is 7.0–71.4%For indicators where the England value is relativelypoor, the focus should be on shifting the distribution 10
  11. 11. Magnitude of variationWith respect to the percentage ofpeople in the NDA with Type 1diabetes receiving all nine key careprocesses:›› For PCTs in England, the range isfrom 5.4% to 47.9%, a 9-foldvariation;›› The England value is 31.9%: atthe high end of the range 24.5% ofPCTs (n=37) and at the low end ofthe range 24.5% of PCTs (n=37)are very significantly different fromthe England value (at the 99.8%level). 11
  12. 12. Magnitude of variationWith respect to the percentage ofpeople in the NDA with Type 1diabetes receiving all nine keycare processes:›› For PCTs in England, therange is from 7.0% to 71.4% , a10-fold variation;›› The England value is 52.9%: atthe high end of the range 48.3%of PCTs (n=73) and at the lowend of the range 37.7% of PCTs(n=57) are very significantlydifferent from the England value(at the 99.8% level).12
  13. 13. Options for actionAs almost half of the people with Type 2 diabetes and two out of threepeople with Type 1 diabetes have not received the basic standard of care,it is important that all commissioners and service providers ensure robustarrangements are put in place for everyone with diabetes to receive anannual review covering all nine care processes. Arrangements couldinclude:›› Administrative systems that reliably invite all people with Type 1diabetes for their annual checks;›› Processes to follow-up and remind non-attenders;›› Alternative access arrangements;›› Ensuring that scheduled checks are undertaken on attendance, andresults recorded accurately.13
  14. 14. Magnitude of variationFor PCTs in England, insulin totalnet ingredient cost per patient onGP diabetes registers rangedfrom £79 to £176 (2.2-foldvariation).When the five PCTs with thehighest costs and the five PCTswith the lowest costs areexcluded, the range is £95–£158per patient, and the variation is1.7-fold.14
  15. 15. There is no correlation between spending on insulin items and thepercentage of people with Type 1 diabetes or with Type 2 diabetes whosemost recent HbA1c measurement was 7.5% (58 mmol/mol) or less at PCTlevel (see Figure 10.1).This would indicate that the PCTs spending the most on insulin do notnecessarily have the greatest percentage of people with diabetes whohave optimal blood-glucose control.There is a strong correlation between spending on insulin items in 2008/09and that in 2009/10 (correlation coefficient, r=0.977; p<0.00005; seeFigure 10.2), suggesting that prescribing patterns at a PCT level arepersistent over time.These results suggest that the degree of variation observed in spendingon insulin items is related to how local services are organised.15
  16. 16. Magnitude of variationPeople with diabetes are more likelythan those without diabetes to beadmitted to hospital. When inhospital, people with diabetes stayfor longer when compared withpeople of a similar age admitted forsimilar conditions but who do nothave diabetes.›› For PCTs in England, the range isfrom –0.4% to 46.7%;›› The England value is 19.4%: atthe high end of the range 36.4% ofPCTs (n=55) and at the low end ofthe range 42.4% of PCTs (n=64)are very significantly different fromthe England value (at the 99.8%level).16
  17. 17. Magnitude of variationWith respect to excess emergencyre-admissions among people withdiabetes when compared withpeople withoutdiabetes:›› For PCTs in England, the range isfrom 15.8% to 100.2% , a 6-foldvariation;›› The England value is 59.1%: atthe high end of the range 12.6% ofPCTs (n=19) and at the low end ofthe range 9.9% of PCTs (n=15) arevery significantly different from theEngland value (at the 99.8% level).This indicator is taken from the Variation in InpatientActivity: Diabetes (VIA: Diabetes)17
  18. 18. Options for actionCommissioners and providers need to investigate variation in length ofstay at a local level, and consider auditing the reasons for re-admission of people with diabetes to identify whether there are specificfactors that could be addressed.Length of stay for people with diabetes can be reduced by introducingdedicated inpatient diabetes teams, as achieved in local studies inPlymouth and Norwich. Dedicated inpatient diabetes teams, includingdiabetes specialist nurses, can reduce the length of stay for peoplewith diabetes by providing:›› diabetes training and awareness raising for non-diabetes clinicalstaff;›› protocols for the management of patients with diabetes;›› specific input into the management of patients experiencingproblems with the control of their diabetes.18
  19. 19. Magnitude of variationPeople with diabetes are predisposedto developing foot ulcers primarilybecause of an increased risk of bothperipheral arterial disease (PAD) andperipheral neuropathy. Chroniculceration is the commonestprecursor to major lower limbamputation (defined as above theankle).›› For PCTs in England, the range isfrom 0.1% to 0.5%, a 6-fold variation ;›› The England value is 0.24%: at thehigh end of the range 3.3% of PCTs(n=5) and at the low end ofthe range 7.9% of PCTs (n=12) arevery significantly different from theEngland value (at the 99.8% level). 19
  20. 20. Options for actionintroduction of multidisciplinary teams to assess and treat diabetic footdisease has reduced major and minor amputation rates, and hasgenerated savings.¹In current guidelines it is recommended that all people with diabetes:›› have an annual examination to assess individual risk, and those atincreased risk are referred to a member of a foot protection team(typically includes podiatrists, orthotists and footcare specialists withexpertise in protecting the foot) for long-term surveillance;›› have their foot risk assessed on admission to hospital for anyreason;›› who have newly occurring foot disease are referred for urgentassessment by a member of a specialist multidisciplinary team.1. Rogers LC, Frykberg RG, Armstrong DG et al (2011) The Charcot foot in diabetes.Diabetes Care 34: 2123-2129.20
  21. 21. www.rightcare.nhs.uk/atlas In print You can order free printed copies using the online form on out website Online High and Low resolution PDFs are available for download Interactive A fully interactive InstantAtlastm is available online21
  22. 22. Follow Right Care online: - Subscribe to get a weekly digest of our blog in your inbox - Receive Occasional eBulletins - Follow us on Twitter @qipprightcare www.rightcare.nhs.uk22

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