National Diabetes Audit. Report 1: Care Processes and Treatment Targets

Transcription

1 Ntionl Dibetes Audit Report 1: Cre Processes nd Tretment Trgets

2 The Ntionl Dibetes Audit is commissioned by The Helthcre Qulity Improvement Prtnership (HQIP) promotes qulity in helthcre. HQIP holds commissioning nd funding responsibility for the Ntionl Dibetes Audit nd other ntionl clinicl udits. The Ntionl Dibetes Audit is delivered by The Helth nd Socil Cre Informtion Centre (HSCIC) is Englnd s centrl, uthorittive source of essentil dt nd sttisticl informtion for frontline decision mkers in helth nd socil cre. The HSCIC mnged the publiction of the reports. Dibetes UK is the lrgest orgnistion in the UK working for people with dibetes, funding reserch, cmpigning nd helping people live with the condition. The Ntionl Dibetes Audit is supported by The Ntionl Dibetes Informtion Service (NDIS) provides support to the NHS by providing stremlined ccess to comprehensive suite of dibetes informtion products, dtsets nd tools. NDIS provides helth commissioners, providers nd people with dibetes with the necessry informtion to id decision mking nd improve services on locl nd ntionl level.

3 Ntionl Dibetes Audit Report 1: Cre Processes nd Tretment Trgets Findings bout the qulity of cre for people with dibetes in Englnd nd Wles Report for the udit period Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 3

4 Contents Foreword 5 Executive Summry 6 Recommendtions 8 Introduction 9 Prticiption 10 Registrtions 10 Demogrphics 11 Cre Processes 13 Tretment Trgets 16 Structured Eduction 19 Dt Completeness 20 NDA Methodology 21 Further Informtion 22 References 22 Appendix 1: Chrcteristics of People with Dibetes 23 Appendix 2: Regressions Anlysis 25 Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 4

5 Foreword The Ntionl Dibetes Audit (NDA) continues to be success, with 87.9 per cent of GP prctices now included, cpturing informtion on 2,473,239 people with dibetes. Since eye screening is not reported this yer, we must refer to completion of eight bsic cre processes rther thn the more fmilir nine. However, completion of ll eight is still low t 43.2 per cent nd 62.6 per cent for those with Type 1 nd Type 2 dibetes respectively. Independently, the NHS Dibetic Eye Screening Progrmme reports low uptke of eye screening ntionlly t only 73.9 per cent i in Englnd, mjor concern s dibetic retinopthy remins the commonest cuse of blindness in Englnd. There is lso still mrked geogrphicl vrition in the chievement of cre process delivery. Consistent with the lower completion rtes of the eight cre processes in those with Type 1 dibetes, chievement of NICE recommended glucose tretment trgets is mrkedly worse for those with Type 1 dibetes compred to those with Type 2 dibetes (27.0 per cent vs per cent), perhps reflecting the need to do more to tilor specific services for those with Type 1 dibetes in the primry cre setting with esy ccess to integrted specilist cre. This my provide n importnt messge to clinicl commissioning groups s they prepre to commission dibetes services in Englnd. There is long lg time between improvements in dibetes cre delivery nd ssocited reductions in complictions. This cn spn severl decdes. While the pprent low rtes of delivery of bsic cre processes nd low rtes of ttinment of tretment gols ws criticised by the Ntionl Audit Office Report 1 lst yer nd thought to relte to dibetes relted excess of 24,000 deths nnully, we did not know how our performnce compred to other countries. This yer, the Globl Burden of Disese Study 2 suggests tht premture mortlity ttributble to dibetes is lower in the UK thn in the other 18 welthy countries included in the nlysis. It my be therefore tht despite the pprent low completion rtes of cre processes nd the low ttinment of tretment gols, the fct tht we plce emphsis on processes of dibetes cre delivery vi the Qulity nd Outcomes Frmework t ll nd continully udit these processes my be contributing positively to the longer term clinicl outcomes tht relly mtter. However, this should not cuse us to be complcent nd there is still gret del tht cn be chieved to further reduce morbidity nd mortlity ssocited with dibetes through improved cre delivery. The cler ssocitions between glycemic control nd blood pressure nd the microvsculr complictions of dibetes, nd between blood pressure nd cholesterol nd the mcrovsculr complictions of dibetes, hve been pprecited for mny yers nd should cuse us to do ll we cn to improve the chievement of tretment gols round these three prmeters. Successful prtnership between those with dibetes nd those tht deliver cre is crucil if we re to continue to improve clinicl outcomes nd improve the experience of cre for those with dibetes. Structured eduction is crucil to provide people with the tools to mnge their own dibetes nd we welcomed the introduction in April of this yer of the new Qulity nd Outcomes Frmework metric incentivising the offer of structured eduction to ll t dignosis. Previously too few hve been offered structured eduction, nd up to three-qurters of those offered hve not mnged to ttend. Delivery must be t times convenient to people living busy lives. The recommendtions of this report, including improved delivery of structured eduction nd the principle of shring best prctice in cre delivery, we hope cn be delivered successfully within the new structures of the NHS in Englnd. Professor Jonthn Vlbhji MD FRCP Ntionl Clinicl Director for Obesity nd Dibetes, NHS Englnd. Consultnt Physicin, Dibetologist nd Endocrinologist, Imperil College Helthcre NHS Trust Adjunct Professor of Dibetes nd Endocrinology, Imperil College London i This percentge vlue ws clculted from vlues tken from the NHS Dibetic Eye Screening Progrmme, which re vilble on the NHS Englnd website: Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 5

6 Executive Summry The Ntionl Dibetes Audit Report 1: Cre Processes nd Tretment Trgets presents findings on cre processes nd tretment trget chievement rtes from The dt in this report is bsed on: Dt recorded on people with dignosed dibetes in Englnd nd Wles from the 1st Jnury 2011 to the 31st Mrch This dt ws collected between October nd December Dt recorded on people with ll types of dibetes mellitus, excluding gesttionl dibetes, impired glucose tolernce (IGT) nd impired fsting glucose (IFG) 3. The Red codes used for the extrction re described in the Primry Cre Extrction Specifiction (PCES) vilble on the NDA website: Prevlence nd registrtion sections of the report re bsed on dt collections from both primry nd secondry cre. The reminder of the report (including the ppendices) focuses on ptients registered in primry cre only. This ensures tht the popultion bsed denomintors re comprble. Results for groups of ptients treted by individul specilist cre units will be published seprtely. The NDA reports on the provision of core dibetes cre for everyone with dibetes. This provides commissioners with ge, ethnicity nd socil deprivtion relted perspectives cross the whole popultion for which they re responsible. The NDA lso reports to prticipting individul Generl Prctices nd dult specilist services llowing them to benchmrk their cre ginst their peers. The NPDA (Ntionl Peditric Dibetes Audit) reports seprtely to individul prticipting peditric dibetes centres regrding their provision of dibetes cre for the children nd young people ttending their services. Those reviewing the NDA nd NPDA reports side by side need to be wre of these differences but, eqully, those wnting to get the most complete picture of locl needs nd service provision should consider the two reports together. ii Prticiption 2,473,239 people with dibetes (2,235,810 in ; 1,997,646 in ) per cent of prctices (80.9 per cent in ; 75.8 per cent in ). People with Dibetes At ll ges dibetes prevlence is higher for men thn women. Between ges 20 to 74 yers pproximtely one in 195 men (0.5 per cent) nd one in 273 women (0.4 per cent) hs Type 1 dibetes. Between ges 60 to 89 yers more thn one in ten men (13.9 per cent) nd one in ten women (10.1 per cent) hs Type 2 dibetes. Cre processes For ech of the cre processes, nnul completion rtes hve reched plteu. Cre process completion rtes re gin lower for people with Type 1 thn Type 2 dibetes. The number of people with dibetes recorded in electronic ptient records s hving eye screening is not reported this yer. To improve lignment with NICE guidelines, revised Red code set of terms describing digitl eye screening ws used. This identified tht vrition in the use of terminology nd its impct on the consistency of dt extrction from electronic clinicl records rendered it unrelible s mesure of this cre process. The NHS Dibetic Eye Screening Progrmme (NHS DESP) records every digitl eye screening nd we believe tht its records should now be used s the preferred mesure for this nnul cre process. Presently this is reported only ntionlly. ii Becuse the cre of dults nd children with dibetes is mixed between GP services (this includes ALL ptients) nd hospitl, peditric nd community specilist services (these ech include SOME ptients), the different views tht the two ntionl udits NDA nd NPDA give to the providers of the services will inevitbly include overlpping ptients. Thus someone with dibetes ttending specilist service should lso pper in the relevnt GP report. The NDA integrtes dt from prticipting specilist nd GP services for dults with dibetes so tht if cre process or tretment trget is recorded by one but not the other both get the complete dt reported bck to them i.e. whole person view. This mkes sense becuse it reflects the fct tht there is no clinicl vlue in duplicting something crried out elsewhere. The popultion level NDA reports include ll people with dibetes in geogrphicl re irrespective of their mix of provider services nd use integrted dt where they re vilble. But NPDA runs independently of the NDA nd of GP services so its dt re not integrted mking it possible tht GP reports do not include ll cre processes or tretment trgets mesured in specilist peditric units nd vice vers. Specilist peditric dibetes units re primrily responsible for the cre of most children nd young people with dibetes nd for the collection of their cre process nd outcome dt. Although GPs do not provide the mjority of cre for children nd young people living with dibetes they do prescribe ll their medictions. Therefore it is in this ge group, nd lso dults with Type 1 or complex dibetes tht ttend specilist services not prticipting in NDA, where lck of dt integrtion is most likely to result in slightly deficient whole systems view. Furthermore, for under-17s, the ge cut-off for the QOF GP incentive scheme mens tht there is no finncil vlue to the prctice in replicting results from externl services. Nonetheless, becuse less thn 10% of ll people with Type 1 dibetes, nd less thn 1% of people with dibetes in generl re under 17yr, the overll impct on popultion level NDA results is miniml. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 6

7 The wy in which the screening test for erly kidney disese (Urine Albumin Cretinine Rtio, UACR) is recorded is lso cuse for concern. The wy in which some lbortories report very low (norml) results nd the wy in which such results re stored in one type of GP clinicl system cn influence whether the cre process (crrying out the mesurement) is extrcted relibly. We would therefore wish to pste helth wrning on the number of tests performed but not on the number of bnorml results recorded. There ws considerble vrition in the completion of the eight recorded cre processes. CCGs/LHBs in the bottom qurter of performers hd completion rtes t lest 10.9 percentge points lower thn those in the top qurter (56.1 per cent vs 66.9 per cent). When other fctors, such s ge, gender nd type nd durtion of dibetes, were tken into ccount the eight relible cre processes were 7.1 per cent less likely to be recorded mong ptients with Asin ethnicity nd 4.2 per cent less likely to be recorded for those with Blck ethnicity thn those with White ethnicity. Tretment Trgets Concurrent chievement of ll three NICE recommended glucose, blood pressure nd serum cholesterol levels continues to improve very slowly (19.3 per cent in ; 19.7 per cent in ; 20.8 per cent in ). NICE recommended glucose control (HbA1c 58mmol/mol) ws recorded in 27.0 per cent of people with Type 1 dibetes nd 65.8 per cent of people with Type 2 dibetes. NICE recommended blood pressure (<140/80 in ll; <130/80 if complictions) ws recorded in 51.9 per cent of people with Type 1 dibetes nd 37.7 per cent of people with Type 2 dibetes. NICE recommended cholesterol <4mmol/l ws recorded in 29.7 per cent of people with Type 1 dibetes nd 41.3 per cent of people with Type 2 dibetes; cholesterol <5mmol/l (QOF incentivised) ws recorded in 71.1 per cent of people with Type 1 dibetes nd 77.5 per cent of people with Type 2 dibetes. Concurrent chievement of ll three NICE tretment trgets (HbA1c <58 mmol/mol + cholesterol <5 mmol/ mol + trget BP) ws recorded for more ptients in some CCGs/LHBs thn others. Those CCGs/LHBs in the bottom qurter of performers hving t lest 3.1 percentge points lower thn those in the top qurter (19.2 per cent vs per cent). Structured Eduction Very few people with dibetes re recorded s hving been offered structured eduction. 2.2 per cent Type 1, 12.0 per cent Type 2 for those who re newly dignosed. 1.6 per cent Type 1, 4.5 per cent Type 2 for ll people with dibetes. Even fewer people with dibetes re recorded s ttending structured eduction. 0.6 per cent Type 1, 3.1 per cent Type 2 for those who re newly dignosed. 1.0 per cent Type 1, 1.4 per cent Type 2 for ll people with dibetes. Comment The NDA shows tht the huge progress mde in core dibetes cre between 2004 nd 2009 hs been sustined but it seems to hve reched n overll plteu with substntil underlying vrition. Improvement depends on chnging systems of cre. If helth economies with low results (bottom 25 per cent) dopted the systems used by those with higher cre process nd tretment trget chievement rtes (top 25 per cent) there would be nother step chnge. However, better performers hve results tht still leve much room for improvement, especilly for Type 1 dibetes, young people nd people from ethnic minorities; they need to discover more effective dibetes cre delivery systems for the future, they need to innovte. Cre processes re mens to n end, not n end in themselves. They represent the core gend for n nnul cre plnning discussion. Their results prompt negotition between the clinicin nd person with dibetes bout how they will jointly ddress risk fctors nd personl priorities. Dibetes is mjor risk fctor for crdiovsculr disese. Reducing premture mortlity by improving crdiovsculr disese outcome is n NHS priority. A lrge number of middle ged nd elderly people (one in ten) hve Type 2 dibetes. These results suggest tht there is considerble scope for chieving better blood pressure nd cholesterol risk fctor mngement in these groups of people with high crdiovsculr risk. Effective risk fctor mngement is dependent on people with dibetes understnding wht the risk fctors re, wht they cn do to minimise their risks nd wht support they receive. Therefore, the presently limited mount of structured eduction for people with recently dignosed dibetes would seem to be mjor missed opportunity. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 7

8 Recommendtions We recommend tht ll commissioners nd ll providers of dibetes cre review their locl results nd consider one or more of the following ctions: If you re in the bottom 25 per cent for cre process chievement or the bottom 25 per cent for tretment trget chievement find out nd lern from how the top 25 per cent get their results. Also mke sure everything tht is done is recorded. If your cre process chievement or tretment trget chievement results re verge or bove verge they will still be short of delivering mximum helth benefit. Consider developing nd testing the effectiveness of novel pproches to cre delivery, prticulrly for young people, people from ethnic minorities nd people with Type 1 dibetes. Review nd improve the current systems for providing structured eduction nd improve delivery of nd ccess to eduction meeting NICE stndrds. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 8

9 Introduction The Ntionl Dibetes Audit (NDA) is commissioned by the Helthcre Qulity Improvement Prtnership (HQIP) s prt of the Ntionl Clinicl Audit nd Ptient Outcomes Progrmme (NCAPOP) following dvice to the Deprtment of Helth from the Ntionl Advisory Group on Clinicl Audit nd Enquiries (NAGCAE). The NDA is mnged by the Helth nd Socil Cre Informtion Centre (HSCIC) in prtnership with Dibetes UK. This ntionl report from the ninth yer of the udit, presents key findings on key cre processes nd tretment trget chievement rtes from in ll ge groups in Englnd nd Wles. The report sets out to nswer the following udit questions: Registrtions: Is everyone with dibetes dignosed nd recorded on prctice dibetes register? Cre Processes: Wht percentge of people registered with dibetes received the eight NICE key processes of dibetes cre? Tretment Trgets: Wht percentge of people registered with dibetes chieved NICE defined tretment trgets for glucose control, blood pressure nd blood cholesterol? The NDA hs been developed to support orgnistions implementing the Ntionl Service Frmework (NSF) for Dibetes 4 nd chieving the cre process nd tretment trget stndrds specified in Ntionl Institute for Helth nd Cre Excellence (NICE) Clinicl Guidelines (CG15 5, CG66 6 nd CG87 7 ) nd the NICE Dibetes in Adults Qulity Stndrds 8. It provides overll, sequentil nd comprtive informtion t GP, hospitl, Clinicl Commissioning Group (CCG; Englnd) or Locl Helth Bord (LHB; Wles) nd ntionl levels. The NDA report on the complictions of dibetes including mortlity will be published towrds the end of the yer. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 9

10 Prticiption Prctice prticiption rtes in Englnd nd Wles by udit yer re shown in Tble 1. Tble 1 Prctice prticiption rtes in Englnd nd Wles by udit yer Audit yer Totl number of prctices Number of prticipting prctices Ntionl prticiption rte ,549 7, % ,659 7, % ,842 6, % Registrtions The udit collects informtion from both primry cre (1 ) nd secondry (2 ) cre; the vst mjority of cses re registered in primry cre with only reltively smll percentge (2.0 per cent) of records ppering only in secondry cre submissions. Tbles 2, 3 nd 4 show the volume of records collected in the udit over the lst 3 yers. Tble 2 Dibetes registrtions nd prevlence for ll dibetes in Englnd nd Wles by source nd udit yer Audit yer Totl number of registrtions Percentge of the popultion b Registrtions from 1 cre Registrtions from 2 cre not collected from 1 cre Percentge of ptients unrecorded in 1 cre ,473, % 2,422,938 50, % ,235, % 2,171,528 64, % ,997, % 1,949,973 47, % All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. b Dibetes prevlence is clculted using ptient registrtions from primry cre nd ptient registrtions from secondry cre, where the ptients GP prctice prticipted in the udit. Tble 3 Dibetes registrtions nd prevlence for Type 1 dibetes in Englnd nd Wles by source nd udit yer Audit yer Totl number of registrtions Percentge of the popultion Registrtions from 1 cre Registrtions from 2 cre not collected from 1 cre Percentge of ptients unrecorded in 1 cre , % 207,566 6, % , % 193,238 8, % , % 178,829 7, % Dibetes prevlence is clculted using ptient registrtions from primry cre nd ptient registrtions from secondry cre, where the ptients GP prctice prticipted in the udit. Tble 4 Dibetes registrtions nd prevlence for Type 2 dibetes in Englnd nd Wles by source nd udit yer Audit yer Totl number of registrtions Percentge of the popultion Registrtions from 1 cre Registrtions from 2 cre not collected from 1 cre Percentge of ptients unrecorded in 1 cre ,216, % 2,190,665 25, % ,986, % 1,954,768 31, % ,762, % 1,737,388 24, % Dibetes prevlence is clculted using ptient registrtions from primry cre nd ptient registrtions from secondry cre, where the ptients GP prctice prticipted in the udit. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 10

11 Cse Ascertinment The Qulity Outcomes Frmework (QOF) 9 collects the number of ptients with dibetes ged 17 yers nd bove with Type 1 nd Type 2 dibetes. Tble 5 compres the number of dibetes registrtions in the NDA with the number of dibetes registrtions in QOF nd shows the following cse scertinment. Tble 5 Dibetes registrtions for Type 1 nd Type 2 dibetes for ptients ged 17 yers nd over in Englnd nd Wles by udit yer Country Audit yer NDA registrtions QOF registrtions Percentge of ptients recorded in NDA compred with QOF Englnd ,269,580 2,566, % ,086,593 2,455, % ,875,642 2,338, % Wles , , % , , % , , % NDA dt is collected over 15 month period, between 1st Jnury nd 31st Mrch, wheres QOF dt is collected over 12 month period, between 1st April nd the 31st Mrch. Therefore, the figures re not directly comprble. Demogrphics Figures 1 nd 2 show the prevlence of Type 1 nd Type 2 dibetes for ech ge group nd gender. Figure 1 Age nd gender of ptients with Type 1 dibetes in Englnd nd Wles Age group (yers) Femle Mle % 0.8% 0.6% 0.4% 0.2% 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% Prevlence Due to limittions with ptient registrtions from GP prctices dt, the ge nd gender of ptients with Type 1 dibetes prevlence ws clculted using the Office for Ntionl Sttistics (ONS) mid-yer popultion estimtes for 2011 by ge group nd gender. As result, Figure 1 my show n underestimtion of Type 1 dibetes prevlence. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 11

12 Figure 2 Age nd gender of ptients with Type 2 dibetes in Englnd nd Wles Age group (yers) Femle 0 4 Mle 20% 15% 10% 5% 0% 5% 10% 15% 20% Prevlence Due to limittions with ptient registrtions from GP prctices dt, the ge nd gender of ptients with Type 2 dibetes prevlence ws clculted using the ONS mid-yer popultion estimtes for 2011 by ge group nd gender. As result, Figure 2 my show n underestimtion of Type 2 dibetes prevlence. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 12

13 Cre Processes All ptients ged 12 yers nd over should receive ll of the nine, NICE recommended cre processes 10. These re the nnul checks for the effectiveness of dibetes tretment (HbA1c), crdiovsculr risk fctors (blood pressure (BP), serum cholesterol, body mss index (BMI), smoking) nd emergence of erly complictions (eye screening, foot surveillnce nd urine lbumin/serum cretinine (kidney surveillnce)). A red, mber, green scle hs been used in the following tble to indicte the level of completion. RAG (Red-Amber-Green) Score Key <70% 70% 90% >90% Tble 6 shows the completion rtes for eight of the nine, NICE recommended cre processes s eye screening is not included in this yer s nlysis. Tble 6 Percentge of ptients in Englnd nd Wles receiving NICE recommended cre processes (excluding eye screening) by cre process, dibetes type nd udit yer All dibetes Type 1 Type HbA1c b 92.1% 92.5% 90.3% 85.7% 86.0% 83.0% 93.2% 93.5% 91.3% Blood pressure 95.2% 95.0% 95.0% 88.9% 88.7% 88.4% 96.1% 95.9% 95.8% Cholesterol 91.7% 91.6% 90.9% 79.1% 78.8% 77.8% 93.2% 93.1% 92.4% Serum cretinine 92.5% 92.5% 92.5% 81.0% 81.2% 81.1% 93.9% 93.8% 93.8% Urine lbumin c 72.3% 75.1% 76.0% 56.2% 58.4% 59.2% 74.3% 77.1% 77.9% Foot surveillnce 84.1% 84.3% 85.3% 71.7% 71.5% 72.8% 85.9% 86.1% 87.0% BMI 90.1% 89.9% 90.3% 83.6% 83.4% 83.7% 91.1% 90.8% 91.3% Smoking 86.9% 84.8% 85.1% 80.8% 78.6% 79.0% 87.7% 85.7% 85.9% Eight cre processes d 59.4% 60.6% 60.5% 42.4% 43.3% 43.2% 61.6% 62.8% 62.6% All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. b For ptients under 12 yers of ge, 'll cre processes' is defined s HbA1c only s other cre processes re not recommended in the NICE guidelines for this ge group. c There is helth wrning regrding the screening test for erly kidney disese (Urine Albumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. d The eye screening cre process hs been removed from this tble; therefore eight cre processes comprises the eight cre processes tht re listed bove. Figure 3 shows the percentge of ll ptients in Englnd nd Wles receiving NICE cre processes by udit yer. Figure 3 Percentge of ll ptients in Englnd nd Wles receiving NICE cre processes (excluding eye screening) by cre process nd udit yer Percentge of ptients 100% 90% % 70% 60% 50% 40% 30% 20% 10% 0% HbA1c Blood pressure Chlolesterol Serum cretinine Urine lbumin b Cre process Foot surveillnce BMI Smoking For ptients under 12 yers of ge, 'll cre processes' is defined s HbA1c only s other cre processes re not recommended in the NICE guidelines for this ge group. b There is helth wrning regrding the screening test for erly kidney disese (Urine Albumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 13

14 Figure 4 shows the percentge of ll ptients in Englnd nd Wles receiving the eight (excluding eye screening) NICE recommended cre processes by udit yer nd dibetes type. Figure 4 Percentge of ll ptients in Englnd nd Wles receiving eight NICE recommended cre processes by udit yer nd dibetes type Percentge of ptients 70% 60% 50% 40% 30% % % % All dibetes b Type 1 Type 2 Dibetes type The eight NICE recommended cre processes re those tht re listed in Tble 6 (i.e. eye screening is not included in this nlysis). b All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. When looking t cre process completion rtes by CCG/ LHB considerble vrition is evident. Figure 5 shows the rnge nd distribution of cre process chievement by CCGs/LHBs. Key Minimum Medin Mximum Inter-qurtile rnge Figure 5 The rnge of CCG/LHB cre process completion in Englnd nd Wles, Cre process Blood pressure Serum cretinine BMI Cholesterol Foot surveillnce Smoking Urine lbumin HbA1c b Eight cre processes c 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentge of ptients There is helth wrning regrding the screening test for erly kidney disese (Urine Albumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. b For ptients under 12 yers of ge, 'll cre processes' is defined s HbA1c only s other cre processes re not recommended in the NICE guidelines for this ge group. c The eye screening cre process hs been removed from this tble; therefore eight cre processes comprises the eight cre processes tht re listed bove. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 14

15 Logistic regression nlysis of cre process completion The NDA core udit mesures recorded clinicl prctice ginst NICE clinicl guidelines nd qulity stndrds nd mkes recommendtions for improvement where necessry. All people with dibetes should hve equitble ccess to cre so the udit does not stndrdise the udit results to djust for socil nd demogrphic fctors. To investigte whether there re demogrphic nd clinicl fctors tht influence the equity of cre, logistic regression model nlysis hs been used. Logisticl regression nlysis is sttisticl method for investigting the potentil impct of multiple, sometimes intercting, fctors on n observtion. In this cse, the possible influence of demogrphic fctors on cre process completion hs been studied. The model ssessed the potentil reltionships of gender, dibetes type, ge, ethnicity, deprivtion, body mss index nd durtion of dibetes with cre process completion. Using these fctors resonble to strong model fit ws found for seven cre processes (HbA1c, BP, serum cretinine, cholesterol, urine lbumin, smoking, foot surveillnce) with poorer fit for BMI. Significnt ssocitions included: Age cre process completion ws usully higher in those 60 yers nd bove. Ethnicity cre process completion ws lower in nonwhite ethnic groups except for urine lbumin testing. Whilst individul deprivtion groups did hve significnt differences, the model does not demonstrte cler deprivtion reltionship with regrds to equity of cre. Full results of the multivrite nlysis cn be found in Appendix 2. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 15

16 Tretment Trgets Helthcre professionls nd ptients should work in prtnership to ensure ptients chieve their NICE recommended tretment trgets for glucose control, blood pressure nd serum cholesterol. A red, mber, green scle hs been used in the following tble to indicte the level of completion. RAG (Red-Amber-Green) Score Key <70% 70% 90% >90% Tble 7 Tretment trget chievement rte for ll ptients in Englnd nd Wles by tretment trget, dibetes type nd udit yer All dibetes Type 1 Type HbA1c <48mmol/mol (6.5%) b 25.0% 24.8% 24.7% 7.1% 6.8% 6.5% 26.7% 26.4% 26.2% HbA1c 58mmol/mol (7.5%) b 63.3% 63.3% 62.7% 28.7% 28.1% 27.0% 66.6% 66.5% 65.8% HbA1c 86mmol/mol (10.0%) b 92.5% 92.1% 91.9% 83.2% 82.4% 81.9% 93.4% 93.0% 92.8% Trget BP c 35.2% 36.2% 38.8% 49.1% 49.9% 51.9% 34.0% 35.0% 37.7% BP <140/80 d 43.9% 44.6% 48.1% 54.7% 55.3% 57.9% 42.9% 43.7% 47.3% Cholesterol <4mmol/L 40.0% 40.7% 40.4% 30.5% 30.4% 29.7% 40.8% 41.6% 41.3% Cholesterol <5mmol/L 77.7% 77.6% 77.0% 72.6% 72.0% 71.1% 78.3% 78.1% 77.5% Meet ll tretment trgets e 19.3% 19.7% 20.8% 11.9% 11.8% 11.8% 19.9% 20.3% 21.5% All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. b For ptients under 12 yers of ge, 'll tretment trgets' is defined s HbA1c only s other tretment trgets re not recommended in the NICE guidelines for this ge group. c Blood pressure trget of <140/80 pplied to those ptients without recorded eye, kidney or vsculr disese (EKV-) nd blood pressure trget of <130/80 pplied to those ptients with recorded eye, kidney or vsculr disese (EKV+). d BP <140/80 does not tke into ccount whether or not ptients hve eye, kidney or vsculr disese. e Where ptients hve chieved HbA1c 58mmol/mol, cholesterol <5mmol/L nd their relevnt blood pressure trget. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 16

17 When considering tretment trget chievement, it is instructive to look t the overlps in trget chievement mong the 2,044,511 ptients who hd ll 3 tretment trgets mesured. Figure 6 shows tht 20.8 per cent of ptients met ll three tretment trgets, whilst the mjority of ptients (65.4 per cent) met t lest two of the tretment trgets nd 6.4 per cent of ptients did not meet ny of the tretment trgets. Figure 6 Proportionl Venn digrm showing the percentge of ptients chieving HbA1c 58mmol/mol, cholesterol <5mmol/L, their relevnt blood pressure trget b nd the interction between these three tretment trgets c,d Trget BP 3.2% Trget BP nd HbA1c 58mmol/mol 4.6% Cholesterol <5mmol/L nd Trget BP 10.2% Meeting ll tretment trgets 20.8% Cholesterol <5mmol/L 16.7% HbA1c 58mmol/mol 8.4% HbA1c 58mmol/mol nd Cholesterol <5mmol/L 29.8% 6.4% did not meet ny of the tretment trgets For ptients under 12 yers of ge, 'll tretment trgets' is defined s HbA1c only s other tretment trgets re not recommended in the NICE guidelines for this ge group. b Blood pressure trget of <140/80 pplied to those ptients without recorded eye, kidney or vsculr disese (EKV-) nd blood pressure trget of <130/80 pplied to those ptients with recorded eye, kidney or vsculr disese (EKV+). c Where ptients hve chieved HbA1c 58mmol/mol, cholesterol <5mmol/L nd their relevnt blood pressure trget. d A single denomintor ws used for the Venn digrm (i.e. ptients hving been mesured for ll three tretment trgets nd registered in primry cre). This is different to the denomintors used in Tble 8; therefore, vlues pper different to those recorded in Tble 8. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 17

18 When looking t tretment trget chievement rtes by CCG/LHB considerble vrition is evident. Figure 7 shows the rnge nd distribution of tretment trget chievement by CCG/LHB. Key Minimum Medin Mximum Inter-qurtile rnge Figure 7 The rnge of CCG/LHB tretment trget chievement in Englnd nd Wles, Tretment trget HbA1c <48mmol/mol (6.5%) HbA1c 58mmol/mol (7.5%) HbA1c 86mmol/mol (10.0%) Trget BP b BP <140/80 c Cholesterol <4mmol/L Cholesterol <5mmol/L Meet ll tretment trgets d 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentge of ptients For ptients under 12 yers of ge, 'll tretment trgets' is defined s HbA1c only s other tretment trgets re not recommended in the NICE guidelines for this ge group. b Blood pressure trget of <140/80 pplied to those ptients without recorded eye, kidney or vsculr disese (EKV-) nd blood pressure trget of <130/80 pplied to those ptients with recorded eye, kidney or vsculr disese (EKV+). c BP <140/80 does not tke into ccount whether or not ptients hve eye, kidney or vsculr disese. d Where ptients hve chieved HbA1c 58mmol/mol, cholesterol <5mmol/L nd their relevnt blood pressure trget. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 18

19 Structured Eduction The NDA hs collected dt on structured eduction in Englnd nd Wles since NICE guidnce recommend tht people with dibetes (Type 1 or Type 2) be offered ptient eduction progrmmes, officilly known s structured eduction. The NDA reports whether there is record tht person with dibetes hs been offered or hs ttended structured eduction. When looking t dt for ll people dignosed with dibetes, structured eduction ws recorded s being offered to 1.6 per cent of those with Type 1 dibetes nd 4.5 per cent of those with Type 2 dibetes, whilst 1.0 per cent of those with Type 1 dibetes nd 1.4 per cent of those with Type 2 dibetes were recorded s ttending structured eduction. The nlysis in Tble 8 considers structured eduction records in for ptients dignosed in the sme period. Tble 9 shows structured eduction records in for ll ptients. In 2013 the CCG outcome indictor set will report indictor C2.5 People with dibetes dignosed less thn one yer, referred to structured eduction. This indictor will use similr construction to the informtion presented below but will use dignosis dte (rther thn yer), which is currently unvilble for nlysis, to define ptients dignosed less thn yer. Tble 8 Structured eduction for newly dignosed people with dibetes, Number dignosed Offered Attended Offered or ttended All dibetes b n 239,251 27,429 7,024 32,392 % n/ 11.5% 2.9% 13.5% Type 1 n 8, % n/ 2.2% 0.6% 2.7% Type 2 n 223,646 26,931 6,923 31,814 % n/ 12.0% 3.1% 14.2% Other c n 6, % n/ 4.5% 0.7% 5.0% Due to issues with dt qulity, ptient my be recorded s ttending structured eduction without it recorded s being offered to them; the offered or ttended column, which is included in this tble, gives n indiction of the scle of this issue. b All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. c Other dibetes comprises mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. Tble 9 Structured eduction for ll people with dibetes, Number dignosed Offered Attended Offered or ttended All dibetes b n 2,422, ,958 32, ,924 % n/ 4.2% 1.4% 5.2% Type 1 n 207,566 3,389 2,017 5,119 % n/ 1.6% 1.0% 2.5% Type 2 n 2,190,665 99,020 30, ,143 % n/ 4.5% 1.4% 5.4% Other c n 24, % n/ 2.2% 0.6% 2.7% Due to issues with dt qulity, ptient my be recorded s ttending structured eduction without it recorded s being offered to them; the offered or ttended column, which is included in this tble, gives n indiction of the scle of this issue. b All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. c Other dibetes comprises mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 19

20 Dt Completeness Tble 10 shows the completeness, following clening of key fields, used in the nlysis of this report. Tble 10 Comprison of NDA dt completeness by udit yer Audit yer Denomintor 1,949,973 2,171,528 2,422,938 Gender (%) >99.9% >99.9% >99.9% Dibetes type (specified) (%) 99.5% 99.5% 99.5% Age (%) >99.9% >99.9% >99.9% Ethnicity (known nd stted) (%) 70.8% 74.6% 75.4% Yer of dignosis (%) 97.8% 98.0% 98.0% Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 20

21 NDA Methodology Prticiption in the NDA is voluntry; however it does cover 88.4 per cent of the people dignosed with dibetes in Englnd nd 82.2 per cent in Wles (when compred with QOF). The NDA collects informtion on ll ptients who hve been dignosed with dibetes before the udit end dte (31st Mrch 2012). Clinicl Commissioning Groups (CCGs), Locl Helth Bords (LHBs), GP prctices nd dult outptient secondry cre units submit dt bout the cre tht is being delivered for people with dibetes in their orgnistion. This will include children tht hve been treted in n dult cre setting. For the full picture on the peditric cre for children with dibetes plese refer to the Ntionl Peditric Dibetes Audit which is conducted by the Royl College of Peditrics nd Child Helth (RCPCH) 11. In ddition to the dt submitted by prticipting orgnistions, supplementry informtion relting to specific complictions nd procedures is sourced from the Hospitl Episodes Sttistics (HES) dtbse nd the Ptient Episode Dtbse for Wles (PEDW). The NDA dt is linked to HES or PEDW dt to the correct ptient record to provide fuller nlysis. The Qulity nd Outcomes Frmework (QOF) is n ggregted return which provides informtion from GP Prctices. This informtion is used within the report when discussing coverge. However, the NDA provides more detiled picture of the clinicl processes nd cre pthwy for those dignosed with dibetes. Plese note tht for time series nlysis, results re compred with previous yers dt nlysed using NDA methodology. Time series dt should not be compred to other reports where different methodology my hve been used. Dt qulity sttement Recording of Urine Albumin Cretinine Rtio (Albumin) in EMIS LV systems using MiQuest extrction. The udit tem re wre of n issue effecting the extrction of urine lbumin dt from 100 prctices tht use EMIS LV prctice systems in combintion with MiQuest extrction. Where user hs entered vlue tht is vlid though not fully numericl (e.g. <2 ) this vlue is not being extrcted for the udit nd the cre process not being mesured s complete. This will led to lower levels of chievement in this mesure nd the ll 8 cre process mesure thn is ctully the cse. Affected CCGs re: CCG Nme CCG Code Number of prctices ffected NHS Brnet CCG 07M 6 NHS Brnsley CCG 02P 2 NHS Birminghm South And Centrl CCG 04X 3 NHS Blckburn With Drwen CCG 00Q 7 NHS Brcknell And Ascot CCG 10G 1 NHS Chorley And South Ribble CCG 00X 3 NHS Coventry And Rugby CCG 05A 1 NHS Cumbri CCG 01H 2 NHS Dudley CCG 05C 2 NHS Est And North Hertfordshire CCG 06K 1 NHS Enfield CCG 07X 1 NHS Gloucestershire CCG 11M 1 NHS Greter Huddersfield CCG 03A 1 NHS Greter Preston CCG 01E 1 NHS Hringey CCG 08D 1 NHS Herts Vlleys CCG 06N 1 NHS Kingston CCG 08J 2 NHS Medwy CCG 09W 1 NHS Mid Essex CCG 06Q 1 NHS Nene CCG 04G 1 NHS Newbury And District CCG 10M 1 NHS North Durhm CCG 00J 4 NHS North Est Hmpshire And Frnhm CCG 99M 1 NHS North Stffordshire CCG 05G 1 NHS North Tyneside CCG 99C 3 NHS Nottinghm City CCG 04K 1 NHS Nottinghm North And Est CCG 04L 1 NHS Nottinghm West CCG 04M 2 NHS Oxfordshire CCG 10Q 3 NHS Redbridge CCG 08N 2 NHS Rushcliffe CCG 04N 1 NHS Slough CCG 10T 1 NHS Somerset CCG 11X 1 NHS South Norfolk CCG 06Y 1 NHS South Sefton CCG 01T 1 NHS South Tyneside CCG 00N 4 NHS Southwrk CCG 08Q 1 NHS Stoke On Trent CCG 05W 4 NHS Sunderlnd CCG 00P 2 NHS Telford And Wrekin CCG 05X 6 NHS Wlthm Forest CCG 08W 1 NHS West Cheshire CCG 02F 7 NHS West Lncshire CCG 02G 2 NHS Wign Borough CCG 02H 4 NHS Wirrl CCG 12F 4 NHS Wokinghm CCG 11D 1 NHS Wolverhmpton CCG 06A 1 The impct of this issue does not mterilly ffect the ntionl findings. Cution should be used when interpreting informtion for these prctices nd the CCGs to which they belong. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 21

22 Further Informtion All helth economies (CCGs nd LHBs) re receiving loclity report. Prticipting Specilist Services re lso receiving reports bout the ptients who ttended their clinics. References 1. Ntionl Audit Office: The mngement of dult dibetes services in the NHS 2. Globl Burden of Disese Study Lncet 2013 Mr 23;381(9871): World Helth Orgnistion (WHO) guidelines for the dignosis nd clssifiction of dibetes. dibetes2006/en/index.html 4. Ntionl Service Frmework (NSF) for Dibetes ntionl-service-frmework-dibetes 5. NICE Clinicl Guidelines CG15: Type 1 dibetes: Dignosis nd mngement of Type 1 dibetes in children, young people nd dults 6. NICE Clinicl Guidelines CG66: Type 2 Dibetes (prtilly updted by CG87) 7. NICE Clinicl Guidelines CG87: Type 2 Dibetes newer gents (prtil updte of CG66) 8. NICE Dibetes in Adults Qulity Stndrd 9. Qulity Outcomes Frmework (QOF) NICE recommended cre processes jsp?ction=byid&o= Ntionl Peditric Dibetes Audit, Royl College of Peditrics nd Child Helth Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 22

23 Appendix 1: Chrcteristics of People with Dibetes Tble 11 Chrcteristics of people with dibetes, registrtions from primry cre All dibetes Type 1 Type 2 Totl Receiving ll eight cre processes bc Meeting ll tretment trgets d Totl Receiving ll eight cre processes bc Meeting ll tretment trgets d Totl Receiving ll eight cre processes bc Meeting ll tretment trgets d All 2,422, % 20.8% 207, % 11.8% 2,190, % 21.5% Sex Mle 1,349, % 21.4% 117, % 12.2% 1,218, % 22.2% Femle 1,073, % 20.0% 89, % 11.2% 972, % 20.6% Age (yers) 0 to 9 5, % 24.4% 5, % 24.0% % 29.4% 10 to 19 24, % 13.8% 22, % 13.0% 1, % 22.9% 20 to 29 41, % 13.5% 29, % 11.8% 10, % 17.8% 30 to 39 92, % 15.7% 32, % 13.0% 58, % 17.1% 40 to , % 15.1% 41, % 10.2% 213, % 16.1% 50 to , % 17.7% 33, % 10.0% 421, % 18.3% 60 to , % 22.2% 23, % 12.2% 602, % 22.6% 70 to , % 24.0% 14, % 12.9% 565, % 24.2% 80 to , % 22.7% 5, % 13.4% 281, % 22.9% , % 20.9% % 13.6% 35, % 21.0% Ethnic White 1,443, % 21.0% 133, % 11.9% 1,296, % 21.8% group Mixed 19, % 19.3% 1, % 12.9% 17, % 19.8% Asin 226, % 21.8% 7, % 11.9% 216, % 22.1% Blck 78, % 18.4% 4, % 11.6% 72, % 18.8% Other 60, % 22.0% 4, % 13.8% 55, % 22.5% Not stted/ 595, % 20.0% 55, % 11.4% 532, % 20.7% Not known Deprivtion Most deprived fifth 535, % 21.1% 38, % 10.0% 491, % 21.8% 2nd most 484, % 20.7% 39, % 11.1% 439, % 21.4% deprived fifth 3rd most 462, % 20.7% 40, % 12.0% 417, % 21.4% deprived fifth 2nd lest 423, % 20.9% 39, % 12.6% 380, % 21.6% deprived fifth Lest deprived fifth 376, % 21.3% 38, % 13.6% 334, % 22.0% BMI <18.5 (Underweight) 15, % 27.1% 5, % 18.6% 9, % 30.7% 18.5 to , % 26.2% 58, % 13.9% 277, % 28.4% (Norml weight) 25.0 to , % 23.1% 60, % 11.5% 665, % 24.1% (Pre-obesity) 30.0 to , % 19.3% 29, % 9.1% 569, % 19.8% (Obesity clss I) 35.0 to , % 16.9% 10, % 8.8% 282, % 17.1% (Obesity clss II) , % 14.8% 4, % 8.8% 179, % 15.0% (Obesity clss III) Smoking Never smoked 947, % 20.7% 77, % 13.1% 862, % 21.3% sttus Ex smoker 747, % 22.0% 37, % 11.2% 704, % 22.6% Current smoker 326, % 19.2% 35, % 7.8% 287, % 20.4% Durtion <1 239, % 18.6% 8, % 19.7% 223, % 18.7% of dibetes (yers) 1 to 4 703, % 23.5% 27, % 16.7% 668, % 23.7% 5 to 9 709, % 22.5% 34, % 12.0% 670, % 22.9% 10 to , % 19.1% 32, % 9.9% 342, % 19.8% 15 to , % 16.4% 26, % 9.9% 143, % 17.4% 20 to , % 14.5% 34, % 10.9% 82, % 15.8% 30 to 39 35, % 12.6% 21, % 11.2% 13, % 14.5% 40 to 49 13, % 12.5% 10, % 11.6% 3, % 14.8% 50+ 7, % 14.7% 4, % 12.1% 2, % 18.7% All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. b The eight cre processes re those tht re listed in Tble 6 (i.e. eye screening is not included in this nlysis). c For ptients under 12 yers of ge, 'll cre processes' is defined s HbA1c only s other cre processes re not recommended in the NICE guidelines for this ge group. d Where ptients hve chieved HbA1c 58mmol/mol, cholesterol <5mmol/L nd their relevnt blood pressure trget. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 23

24 Tble 12 Chrcteristics of people with dibetes, registrtions from primry cre newly dignosed All dibetes Type 1 Type 2 Totl Receiving ll eight cre processes bc Meeting ll tretment trgets d Totl Receiving ll eight cre processes bc Meeting ll tretment trgets d Totl Receiving ll eight cre processes bc Meeting ll tretment trgets d All 239, % 18.6% 8, % 19.7% 223, % 18.7% Sex Mle 136, % 19.3% 5, % 19.6% 127, % 19.3% Femle 102, % 17.8% 3, % 19.9% 96, % 17.8% Age (yers) 0 to 9 1, % 29.9% 1, % 29.2% % 50.0% 10 to 19 2, % 28.3% 2, % 28.9% % 25.4% 20 to 29 4, % 18.3% 1, % 20.8% 2, % 16.8% 30 to 39 15, % 15.2% 1, % 19.7% 13, % 14.8% 40 to 49 38, % 13.6% % 12.2% 36, % 13.7% 50 to 59 55, % 15.5% % 10.6% 53, % 15.6% 60 to 69 61, % 20.5% % 11.7% 59, % 20.6% 70 to 79 41, % 23.8% % 18.5% 40, % 23.9% 80 to 89 16, % 22.3% % 3.6% 16, % 22.5% 90+ 1, % 20.2% % 0.0% 1, % 20.5% Ethnic White 137, % 18.9% 5, % 19.9% 128, % 19.0% group Mixed 2, % 17.7% % 20.7% 1, % 17.8% Asin 23, % 19.4% % 18.1% 22, % 19.5% Blck 8, % 15.3% % 13.1% 7, % 15.5% Other 6, % 19.4% % 18.0% 6, % 19.6% Not stted/ 61, % 18.1% 2, % 20.8% 57, % 18.1% Not known Deprivtion Most deprived fifth 56, % 18.7% 1, % 17.8% 52, % 18.8% 2nd most 48, % 18.1% 1, % 18.0% 45, % 18.2% deprived fifth 3rd most 45, % 18.8% 1, % 19.7% 42, % 18.9% deprived fifth 2nd lest 40, % 19.2% 1, % 20.5% 38, % 19.2% deprived fifth Lest deprived fifth 35, % 19.1% 1, % 24.8% 32, % 19.1% BMI <18.5 (Underweight) 1, % 26.9% % 29.2% % 25.3% 18.5 to , % 25.0% 2, % 21.6% 22, % 25.5% (Norml weight) 25.0 to , % 21.5% 1, % 15.7% 64, % 21.7% (Pre-obesity) 30.0 to , % 17.8% % 12.2% 60, % 17.9% (Obesity clss I) 35.0 to , % 15.3% % 11.2% 31, % 15.4% (Obesity clss II) , % 12.2% % 13.8% 22, % 12.2% (Obesity clss III) Smoking Never smoked 99, % 18.5% 2, % 21.4% 93, % 18.5% sttus Ex smoker 72, % 20.3% % 15.5% 70, % 20.4% Current smoker 39, % 16.4% 1, % 12.8% 37, % 16.5% All dibetes includes mturity onset dibetes of the young (MODY), other specified dibetes nd not specified dibetes. b The eight cre processes re those tht re listed in Tble 6 (i.e. eye screening is not included in this nlysis). c For ptients under 12 yers of ge, 'll cre processes' is defined s HbA1c only s other cre processes re not recommended in the NICE guidelines for this ge group. d Where ptients hve chieved HbA1c 58mmol/mol, cholesterol <5mmol/L nd their relevnt blood pressure trget. Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 24