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

Transcription

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

2 The Ntionl Dietes Audit is commissioned y The Helthcre Qulity Improvement Prtnership (HQIP) The Ntionl Dietes Audit is commissioned y the Helthcre Qulity Improvement Prtnership (HQIP) s prt of the Ntionl Clinicl Audit Progrmme (NCA). HQIP is led y consortium of the Acdemy of Medicl Royl Colleges, the Royl College of Nursing nd Ntionl Voices. Its im is to promote qulity improvement, nd in prticulr to increse the impct tht clinicl udit hs on helthcre qulity in Englnd nd Wles. HQIP holds the contrct to mnge nd develop the NCA Progrmme, comprising more thn 30 clinicl udits tht cover cre provided to people with wide rnge of medicl, surgicl nd mentl helth conditions. The progrmme is funded y NHS Englnd, the Welsh Government nd, with some individul udits, lso funded y the Helth Deprtment of the Scottish Government, DHSSPS Northern Irelnd nd the Chnnel Islnds. The Ntionl Dietes Audit is delivered y The Helth nd Socil Cre Informtion Centre (HSCIC) is the trusted source of uthorittive dt nd informtion relting to helth nd cre. The HSCIC mnged the puliction of the report. Dietes UK is the lrgest orgnistion in the UK working for people with dietes, funding reserch, cmpigning nd helping people live with the condition. The Ntionl Dietes Audit is supported y The ntionl crdiovsculr intelligence network (NCVIN) is prtnership of leding ntionl crdiovsculr orgnistions which nlyses informtion nd dt nd turns it into meningful timely helth intelligence for commissioners, policy mkers, clinicins nd helth professionls to improve services nd outcomes.

3 Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets Findings out the qulity of cre for people with dietes in Englnd nd Wles Report for the udit period 1st Jnury 2012 to 31st Mrch 2013 Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 3

4 Contents Acknowledgements 05 Foreword 06 Executive Summry 08 Introduction 12 Prticiption 13 Registrtions 14 Demogrphics 16 Cre Processes 17 Tretment Trgets 21 Structured Eduction 24 Dt Completeness 25 NDA Methodology 26 Further Informtion 27 References 28 Appendix 1: Chrcteristics of people with dietes 29 Appendix 2: Regression Anlysis 31 Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 4

5 Acknowledgments The Ntionl Dietes Audit (NDA) progrmme, is commissioned y The Helthcre Qulity Improvement Prtnership (HQIP) s prt of the Ntionl Clinicl Audit progrmme (NCA). The NDA is mnged y the Helth nd Socil Cre Informtion Centre (HSCIC) in prtnership with Dietes UK nd is supported y Pulic Helth Englnd (PHE). Throughout the udit there hs een invlule support from ptients nd their representtives, clinicl stff nd other helth professionls. Development nd delivery of the NDA is guided y multi-professionl ntionl group of Dietologists, GPs, consultnts, pulic helth physicins, nd service user representtives. The NDA is chired y Dr Bo Young Consultnt Dietologist & CMIO, Clinicl Led NDA (Ntionl Dietes Audit) & NCVIN (Ntionl Crdiovsculr Intelligence Network). Our thnks go to Ctherine Sylvester, Andy Hyton nd Trin Evns-Cheung t the HSCIC for producing the NDA nlysis within this report. The NDA Advisory Group memers include: Lur Frgher NDA Enggement Mnger Bo Young Specilist Clinicil Led Nomi Holmn Hed of Intelligence Pulic Helth Englnd Roger Gdsy GP Clinicl Led Louise Dunn Clinicl Audit Mnger Grnt Price Ptient Representtive Mo Roshn Dietes GP led Hether Lindsy Pulic Helth Mnger Sm Bentley Ptient Representtive Lind Dewsury Dietes Specilist Nurse Chris Mieszkowski Ptient Representtive Prth Kr Consultnt Endocrinologist Gordon Dixon Ptient Representtive Peter Dvies Consultnt in Dietes nd Endocrinology Rustm Re Consultnt Endocrinologist Shid Tnweer Audit Co-ordintor Rquel Delgdo Dietes GP Led Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 5

6 Foreword The Ntionl Dietes Audit (NDA) continues to provide comprehensive view of Dietes Cre in Englnd nd Wles despite the technicl nd orgnistionl limittions encountered this yer tht hve led to drop in prticiption per cent of GP prctices nd 79 specilist services hve een included cpturing informtion on 2,058,321 people with dietes. Although there is opportunity for improvement everywhere nd vrition etween loclities nd providers remins significnt, the outstnding messge from this report is the need to ddress the sustntilly worse routine cre nd tretment in younger people with Type 1 nd Type 2 dietes nd in people with Type 1 dietes t ll ges. The NDA results hve een consistent in highlighting this issue for severl yers which suggests tht the current systems of cre tht work resonly well for older people do not deliver the sme enefits to younger people with dietes especilly for those ged less thn 40 (pproximtely 130,000). Given the potentil dverse consequences for these younger people of disility nd premture mortlity in middle life, designing etter systems of cre for them would yield considerle helth enefits. This my e n importnt messge for Clinicl Commissioning Groups s they prepre to commission dietes services in Englnd, nd for Locl Helth Bords in Wles. Whtever the systems of cre, successful prtnership etween those with dietes nd those tht deliver cre will remin centrl to improvements. Structured eduction provides people with the tools to mnge their own dietes. Unfortuntely few seem to e offered structured eduction, nd up to three-qurters of those offered do not mnge to ttend. We hve to improve the delivery of structured eduction so tht it is more ville nd ccessile. The recommendtions of this report include improved delivery of structured eduction nd improved cre for younger people with dietes, something tht we hope cn e developed successfully y providers nd commissioners of dietes services in Englnd nd Wles. Professor Jonthn Vlhji MD FRCP Ntionl Clinicl Director for Oesity nd Dietes, NHS Englnd Consultnt Physicin, Dietologist nd Endocrinologist, Imperil College Helthcre NHS Trust Adjunct Professor of Dietes nd Endocrinology, Imperil College London Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 6

7 Recommendtions We recommend tht ll commissioners, ll dietes leds nd ll GP nd Specilist providers of dietes cre review their results nd consider one or more of the following ctions: Review nd enourcge improvements to systems for providing structured eduction Review nd improve systems for delivering effective cre to younger people with Type 1 nd Type 2 dietes; lern from the est performers Encourge nd support qulity improvement pproches within the ottom 25 per cent of CCGs nd prctices to chieve ll process nd outcome ge results, similr to the middle 50 per cent. These recommendtions re congruent with the NHS Englnd Action for Dietes 1 report pulished erlier this yer. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 7

8 Executive Summry The Ntionl Dietes Audit (NDA) Report 1: Cre Processes nd Tretment Trgets, presents findings on cre processes nd tretment trget chievement rtes from The dt in this report is sed on: Dt recorded on people with dignosed dietes in Englnd nd Wles from the 1st Jnury 2012 to the 31st Mrch The dt ws collected etween Octoer 2013 nd Jnury 2014 Dt recorded on people with ll types of dietes mellitus, excluding gesttionl dietes, impired glucose tolernce (IGT) nd impired fsting glucose (IFG)4. The Red codes used for the extrction re descried in the Primry Cre Extrction Specifiction (PCES) ville on the NDA wesite: The prevlence nd registrtion sections of the report re sed on dt collections from oth primry nd secondry cre. The reminder of the report (including the ppendices) includes only ptients registered in primry cre to ensure tht the popultion sed denomintors re comprle. Results for individul CCGs nd individul specilist cre units will e pulished seprtely The NDA report 1 covers the provision of core dietes cre for everyone with dietes. This provides clinicl leds nd commissioners with ge, ethnicity nd socil deprivtion relted perspectives cross the whole popultion for which they re responsile. The NDA lso reports to prticipting individul Generl Prctices nd dult specilist services llowing them to enchmrk their cre ginst their peers. The NPDA (Ntionl Peditric Dietes Audit) reports seprtely to individul prticipting peditric dietes centres regrding their provision of dietes cre for the children nd young people ttending their services. Those reviewing the NDA nd NPDA reports side y side need to e wre of these differences ut, eqully, those wnting to get the most complete picture of locl needs nd service provision should consider the two reports together. i Prticiption 2,058,321 people with dietes in Englnd nd Wles; pprecily less thn (2,473,239) or (2,235,810) ) due to fctors noted elow ii 70.6 per cent of prctices in Englnd nd Wles (87.9 per cent in ; 80.9 per cent in ). People with Dietes Dietes prevlence is higher for men thn women. i Becuse the cre of dults nd children with dietes is mixed etween 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 inevitly include overlpping ptients. Thus someone with dietes ttending specilist service should lso pper in the relevnt GP report. The NDA integrtes dt from prticipting specilist nd GP services for dults with dietes so tht if cre process or tretment trget is recorded y one ut not the other oth get the complete dt reported ck to them i.e. whole person view. This mkes sense ecuse 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 dietes in geogrphicl re irrespective of their mix of provider services nd use integrted dt where they re ville. But NPDA runs independently of the NDA nd of GP services so its dt re not integrted mking it possile tht GP reports do not include ll cre processes or tretment trgets mesured in specilist peditric units nd vice vers. Specilist peditric dietes units re primrily responsile for the cre of most children nd young people with dietes 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 dietes they do prescrie ll their medictions. Therefore it is in this ge group, nd lso dults with Type 1 or complex dietes 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, ecuse less thn 10.0 per cent of ll people with Type 1 dietes, nd less thn 1.0 per cent of people with dietes in generl re under 17yr, the overll impct on popultion level NDA results is miniml. ii The drop in prticiption in the NDA this yer ws expected due to the restructuring of the NHS strting in April This hs left oth chllenges nd opportunities for clinicl udit ut undoutedly the orgnistionl trnsition hd disrupted mny well estlished people nd systems. The NDA lso cknowledges the chnges in the governnce lndscpe long with the dded pressures of significnt numers of GP prctices moving clinicl systems ll which dd to the complexities of primry cre dt extrction for ntionl clinicl udit. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 8

9 Cre processes For ech of the cre processes, nnul completion rtes continue to plteu. In , completion of eight cre processes ws 59.9 per cent, compred to 60.5 per cent in nd 60.6 per cent in Recorded rtes of completion for ll eight cre processes re: lower for people with Type 1 (41.3 per cent) thn Type 2 dietes (61.9 per cent) nd remin lower even when other fctors, such s ge, gender, BMI, ethnicity nd durtion of dietes re tken into ccount less likely to e chieved y those ged under 40 compred to older people for oth Type 1 nd Type 2 dietes, with those with Type 1 dietes showing igger difference Vrile etween loclities; CCGs/LHBs in the ottom qurter of performers hd completion rtes 11.8 percentge points lower thn those in the top qurter (55.4 per cent vs per cent) unrelted to socil deprivtion It is notle tht only 16 per cent of people with dietes re current smokers compred to the Ntionl Figure of 20 per cent iii 2. Tretment Trgets Concurrent chievement of ll three NICE recommended glucose, lood pressure nd serum cholesterol levels remins t 35.9 per cent (35.9 per cent in ; 33.7 per cent in ) NICE recommended serum cholesterol <4mmol/l ws recorded in 28.7 per cent of people with Type 1 dietes nd 40.5 per cent of people with Type 2 dietes; serum cholesterol <5mmol/l (QOF incentivised) ws recorded in 70.2 per cent of people with Type 1 dietes nd 76.8 per cent of people with Type 2 dietes Concurrent chievement of ll three NICE tretment trgets (HA 1c <58 mmol/mol + serum cholesterol <5 mmol/mol + BP <140/80) ws recorded for more ptients in some CCGs/LHBs thn others. Those CCGs/LHBs in the ottom qurter of performers were 3.8 percentge points lower thn those in the top qurter (34.1 per cent vs per cent) Achievement of ll three NICE recommended tretment trgets show mrked difference mong the different ge groups; s people get older or if they hve Type 2 dietes they re more likely to hve chieved the tretment trgets. Structured Eduction Very few people with dietes re recorded s hving een offered structured eduction. 3.9 per cent Type 1, 16.7 per cent Type 2 for those who re newly dignosed nd 2.4 per cent Type 1, 6.0 per cent Type 2 for ll people with dietes Even fewer people with dietes re recorded s ttending structured eduction. 0.9 per cent Type 1, 3.6 per cent Type 2 for those who re newly dignosed nd 1.1 per cent Type 1; 1.6 per cent Type 2 for ll people with dietes. NICE recommended glucose control (HA 1c <58mmol/mol) ws recorded in 27.3 per cent of people with Type 1 dietes nd 64.8 per cent of people with Type 2 dietes NICE recommended lood pressure (<140/80) ws recorded in 73.4 per cent of people with Type 1 dietes nd 68.7 per cent of people with Type 2 dietes (NB trget BP in this NDA yer includes Blood pressure less thn or equl to 140/80 rther thn just less thn 140/80 s in previous reports iv ) iii The NDA percentge Includes under 16s, Englnd nd Wles only nd is not directly comprle to the Ntionl figure which covers over 16s only nd Gret Britin. iv A pper detiling the chnges to the methodology cn e found This explins the impct of this chnge to the Blood Pressure Trget nd the All 3 Tretment Trget figures. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 9

10 Comment It is disppointing ut understndle tht the turulence of the NHS reorgnistion hs undermined the comprehensiveness of this NDA report. This mens tht locl reports will e less comprehensive ut we elieve tht consistency with previous yers in the high level results mens tht the ntionl conclusions hve not een dversely impcted. However we hope tht GP system suppliers will hve completed their upgrdes nd tht locl systems to ensure comprehensive dt sumission will hve recovered in time for the next round in 2015 when the NDA will e endevouring to pulish reports just 6 months fter the end of the udit yer in Novemer Nonetheless the udit pints picture tht hs ecome fmilir in the pst two or three yers nd which we elieve should set the gend for dietes cre improvement y every dietes cre provider, y every clinicl led for dietes services nd y every dietes cre commissioner. It is the continued finding tht younger people with Type 1 or Type 2 dietes nd people with Type 1 dietes t ll ges less often receive ll the nnul cre processes or chieve the sic tretment trgets. Notle lso is the continued low rte of offering nd receiving structured dietes eduction; this is key foundtion of effective self-cre ut presently seems to e ssigned low priority. This yer the Blood Pressure trget hs een minimlly modified from <140/80 to <140/80 to lign with the QOF trget. We were surprised t the resulting size of the difference suggesting tht Blood Pressure mesurement my still e plgued y the long recognised issue of rounding (digit preference). We hve previously highlighted in the NDA report 2 ( ) how lrge the contriution of Hert Filure to premture mortlity so Blood Pressure control is one of the most vlule components of routine dietes cre nd it is therefore essentil for it to e mesured relily. This link etween the effectiveness of routine cre nd complictions is the sis of our concern out the ge inequlity in dietes cre. Though it my e common experience tht it is much more difficult to support younger people nd people with Type 1 dietes ecuse they often hve dietes tht is inherently more difficult to mnge nd lives tht re full of competing priorities the prize of success would e huge. Yet the mount of vrition suggests tht there re lredy some pproches from which we could ll lern. Younger people with dietes who re not chieving tretment trgets contriute disproportionte shre of the urden of dietes disility nd premture mortlity greter focus on designing services to mke them more ppropritely suited to the needs of those who re working, students, nd living full lives needs to e considered. These deductions re, we elieve, reinforced y setting the udit results in the context of the key studies which shped the guidelines on which the mesurements re sed. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 10

11 How does current dietes cre compre to lndmrk clinicl studies? Current guidelines for the mngement of Dietes hve een shped y numer of lndmrk studies tht identified the influence of lood glucose levels, lood pressure nd sttin mediction in reducing the risk of mcro nd micro vsculr complictions. Differences etween crefully selected tril popultions nd ll people with dietes nd etween pproches to dt is presenttion mke direct ssessments of current cre with reserch studies difficult. However, rod comprisons etween people in the NDA with similr chrcteristics to those recruited for the trils my help inform ssessment of the chievements priorities for improvement in contemporry cre progrmmes. Between 1983 nd 1989 people ged 13 to 39 yers old with Type 1 dietes of etween one nd 15 yers durtion were enrolled in the Dietes Control nd Complictions Tril (DCCT). The findings of this tril nd its follow on oservtionl study, the Epidemiology of Dietes Interventions nd Complictions (EDIC) study, highlighted the reltionship etween lood glucose levels nd risk of micro-vsculr disese (chronic kidney disese nd retinopthy 3 ). After n verge follow up of six nd hlf yers tril people llocted to conventionl tretment (mnging lood glucose levels to prevent symptoms) hd men HA 1c of 76 mmol/mol (9.1 per cent) whilst those in the intensive tretment (iming for HA 1c in the norml rnge) group hd men HA 1c of 56 mmol/mol (7.3 per cent 4 ). A rodly comprle cohort of people with Type 1 dietes from the NDA cohort hd men HA 1c of 72 mmol/mol (8.7 per cent). The UK Prospective Dietes Study (UKPDS) recruited people ged 25 to 65 yers old with newly dignosed Type 2 dietes etween 1977 nd This study identified tht more intensive mngement of lood glucose in people with Type 2 dietes reduced the future risk of micro- nd mcro-vsculr complictions. It lso highlighted the importnt role of mnging high lood pressure nd cholesterol in this group of people. After 10 yers of follow up the verge HA 1c ws 53mmol/mol (7.0 per cent) in the intensive mngement group compred to 63mmol/mol (7.9 per cent) in the conventionl tretment group 5. A comprle cohort of people in the NDA cohort hd men HA 1c of 57mmol/mol (7.4 per cent). In this group of people the men systolic lood pressure ws 131.3mmHg, the men distolic lood pressure ws 77.7mmHg nd men totl cholesterol ws 4.5mmol/l. These comprisons highlight the much greter progress tht hs een mde in the mngement of Type 2 dietes thn Type 1 dietes over the pst 15 yers. The tretment outcomes chieved y people with Type 2 dietes cross Englnd nd Wles for HA 1c, lood pressure nd cholesterol re only slightly higher thn those chieved y people in the intensive mngement group of UKPDS. By contrst the smll improvement in men HA 1c mong people with Type 1 dietes leves the men level t 72mmol/mol still firmly in the high risk rnge. We elieve tht improvements will require new pproches to cre especilly for Type 1 dietes. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 11

12 Introduction The Ntionl Dietes Audit is commissioned y the Helthcre Qulity Improvement Prtnership (HQIP) s prt of the Ntionl Clinicl Audit Progrmme (NCA). HQIP is led y consortium of the Acdemy of Medicl Royl Colleges, the Royl College of Nursing nd Ntionl Voices. Its im is to promote qulity improvement, nd in prticulr to increse the impct tht clinicl udit hs on helthcre qulity in Englnd nd Wles. HQIP holds the contrct to mnge nd develop the NCA Progrmme, comprising more thn 30 clinicl udits tht cover cre provided to people with wide rnge of medicl, surgicl nd mentl helth conditions. The progrmme is funded y NHS Englnd, the Welsh Government nd, with some individul udits, lso funded y the Helth Deprtment of the Scottish Government, DHSSPS Northern Irelnd nd the Chnnel Islnds. The NDA is mnged y the Helth nd Socil Cre Informtion Centre (HSCIC) in prtnership with Dietes UK, supported y Pulic Helth Englnd. This ntionl report from the tenth 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 dietes dignosed nd recorded on prctice dietes register? Cre Processes: Wht percentge of people registered with dietes received the nine NICE key processes of dietes cre? Tretment Trgets: Wht percentge of people registered with dietes chieved NICE defined tretment trgets for glucose control, lood pressure nd lood cholesterol? The NDA hs een developed to support orgnistions implementing the Ntionl Service Frmework (NSF) for Dietes 6 nd chieving the cre process nd tretment trget stndrds specified in Ntionl Institute for Helth nd Clinicl Excellence (NICE) Clinicl Guidelines (CG15 7, CG66 8 nd CG87 9 ) nd the NICE Dietes in Adults Qulity Stndrds 10. 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 dietes including mortlity will e pulished in erly Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 12

13 Prticiption Tle 1 Prctice prticiption rtes in Englnd nd Wles y udit yer Audit yer Totl numer of prctices Numer of prticipting prctices Ntionl prticiption rte ,476 5, % ,549 7, % ,659 7, % The drop in prticiption in the NDA this yer ws expected due to the restructuring of the NHS since April This hs left oth chllenges nd opportunities for clinicl udit ut undoutedly the orgnistionl trnsition hd disrupted mny well estlished people nd systems. The NDA lso cknowledges tht uncertinties induced y the dete out chnges in the governnce lndscpe longside pressures relted to high rtes of chnges nd upgrdes to GP clinicl systems dded to the complexities of primry cre dt extrction during this ntionl clinicl udit yer. So the drop hs een technicl nd orgnistionl. It does not reflect unwillingness to prticipte; only very smll numer (1.3 per cent) of prctices declined inclusion. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 13

14 Registrtions The udit collects informtion from oth primry cre (1 ) nd secondry (2 ) cre; the vst mjority of ptients re registered in primry cre with only reltively smll percentge (3.8 per cent) of records ppering only in secondry cre sumissions. Tles 2, 3 nd 4 show the volume of records collected in the udit over the lst 3 yers. Tle 2 Dietes registrtions nd prevlence for ll dietes in Englnd nd Wles y source nd udit yer Audit yer Totl numer of registrtions Percentge of the popultion Registrtions from 1 cre Registrtions from 2 cre not collected from 1 cre ,058, % 1,979,929 78, ,473, % 2,422,938 50, ,235, % 2,171,528 64,282 All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. Dietes prevlence is clculted using ptient registrtions from primry cre nd ptient registrtions from secondry cre, where the ptients GP prctice prticipted in the udit. Tle 3 Dietes registrtions nd prevlence for Type 1 dietes in Englnd nd Wles y source nd udit yer Audit yer Totl numer of registrtions Percentge of the popultion Registrtions from 1 cre Registrtions from 2 cre not collected from 1 cre , % 163,562 13, , % 207,566 6, , % 193,238 8,896 Dietes prevlence is clculted using ptient registrtions from primry cre nd ptient registrtions from secondry cre, where the ptients GP prctice prticipted in the udit. Tle 4 Dietes registrtions nd prevlence for Type 2 dietes in Englnd nd Wles y source nd udit yer Audit yer Totl numer of registrtions Percentge of the popultion Registrtions from 1 cre Registrtions from 2 cre not collected from 1 cre ,835, % 1,792,968 42, ,216, % 2,190,665 25, ,986, % 1,954,768 31,843 Dietes 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 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 14

15 Cse Ascertinment The Qulity Outcomes Frmework (QOF) 11 collects the numer of ptients with dietes ged 17 yers nd ove with Type 1 nd Type 2 dietes. Tle 5 compres the numer of dietes registrtions in the NDA with the numer of dietes registrtions in QOF nd shows the following cse scertinment. Tle 5 Dietes registrtions for Type 1 nd Type 2 dietes for ptients ged 17 yers nd over in Englnd nd Wles y udit yer Country Audit yer NDA registrtions QOF registrtions Percentge of ptients recorded in NDA compred with QOF Englnd ,921,771 2,703, % ,269,580 2,566, % ,086,593 2,455, % Wles , , % , , % , , % NDA dt is collected over 15 month period, etween 1st Jnury nd 31st Mrch, wheres QOF dt is collected over 12 month period, etween 1st April nd the 31st Mrch. Therefore, the figures re not directly comprle. In QOF methodology ws updted to include ll dietes (prt from gesttionl dietes), not just type 1 nd type 2.NDA methodology for this tle hs een updted in ccordnce. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 15

16 Demogrphics Figures 1 nd 2 show the prevlence of Type 1 nd Type 2 dietes for ech ge group nd gender. Figure 1 Age nd gender of ptients with Type 1 dietes 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 dietes prevlence ws clculted using the Office for Ntionl Sttistics (ONS) mid-yer popultion estimtes for 2012 y ge group nd gender. As result, Figure 1 my show n underestimtion of Type 1 dietes prevlence. Figure 2 Age nd gender of ptients with Type 2 dietes in Englnd nd Wles Age group (yers) Femle Mle % 15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0% 20.0% Prevlence Due to limittions with ptient registrtions from GP prctices dt, the ge nd gender of ptients with Type 2 dietes prevlence ws clculted using the ONS mid-yer popultion estimtes for 2012 y ge group nd gender. As result, Figure 2 my show n underestimtion of Type 2 dietes prevlence. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 16

17 Cre Processes All ptients ged 12 yers nd over should receive ll of the nine, NICE recommended cre processes 12. These re the nnul checks for the effectiveness of dietes tretment (HA 1c ), crdiovsculr risk fctors [lood pressure (BP), serum cholesterol, ody mss index (BMI), smoking] nd emergence of erly complictions [eye screening, foot surveillnce nd urine lumin/serum cretinine (kidney surveillnce)]. Tle 6 shows the completion rtes for eight of the nine, NICE recommended cre processes. Eye screening is not included ecuse it is orgnised y NHS Dietes Eye Screening. Tle 6 Percentge of ptients in Englnd nd Wles receiving NICE recommended cre processes (excluding eye screening) y cre process, dietes type nd udit yer All dietes Type 1 Type HA 1c 92.5% 90.3% 92.4% 86.0% 83.0% 80.5% 93.5% 91.3% 93.8% Blood pressure 95.0% 95.0% 95.3% 88.7% 88.4% 88.8% 95.9% 95.8% 96.1% Cholesterol 91.6% 90.9% 91.1% 78.8% 77.8% 78.0% 93.1% 92.4% 92.5% Serum cretinine 92.5% 92.5% 92.5% 81.2% 81.1% 81.0% 93.8% 93.8% 93.7% Urine lumin c 75.1% 76.0% 73.6% 58.4% 59.2% 57.1% 77.1% 77.9% 75.4% Foot surveillnce 84.3% 85.3% 85.1% 71.5% 72.8% 72.3% 86.1% 87.0% 86.7% BMI 89.9% 90.3% 90.7% 83.4% 83.7% 84.1% 90.8% 91.3% 91.5% Smoking 84.8% 85.1% 86.1% 78.6% 79.0% 79.8% 85.7% 85.9% 86.8% Eight cre processes d 60.6% 60.5% 59.9% 43.3% 43.2% 41.3% 62.8% 62.6% 61.9% All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. For ptients under 12 yers of ge, 'll cre processes' is defined s HA 1c 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 Alumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. d The eye screening cre process hs een removed from this tle; therefore eight cre processes comprises the eight cre processes tht re listed ove. Tle 7 Percentge of ptients in Englnd nd Wles receiving NICE recommended cre processes (excluding eye screening) y cre process, dietes type nd ge group Type 1 Type 2 Under to to nd over Under to to nd over HA 1c 68.9% 88.0% 93.5% 92.4% 85.7% 92.7% 95.6% 93.6% Blood pressure 81.3% 93.0% 96.9% 95.8% 89.3% 95.0% 97.5% 96.8% Cholesterol 64.0% 86.1% 92.6% 89.5% 82.5% 91.6% 94.6% 91.7% Serum cretinine 68.5% 88.1% 94.0% 93.2% 84.8% 92.3% 95.6% 94.6% Urine lumin c 43.7% 63.0% 76.4% 75.0% 59.2% 72.0% 79.6% 77.0% Foot surveillnce 59.3% 79.4% 87.6% 83.8% 73.8% 84.8% 90.1% 85.5% BMI 77.6% 87.9% 91.9% 85.5% 86.4% 91.4% 93.6% 87.4% Smoking 75.8% 82.1% 84.8% 79.4% 84.1% 86.8% 88.3% 83.3% Eight cre processes d 29.1% 47.7% 59.9% 54.4% 46.3% 59.2% 66.7% 59.8% All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. For ptients under 12 yers of ge, 'll cre processes' is defined s HA 1c 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 Alumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. d The eye screening cre process hs een removed from this tle; therefore eight cre processes comprises the eight cre processes tht re listed ove. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 17

18 Figure 3 Percentge of ll ptients in Englnd nd Wles receiving NICE cre processes (excluding eye screening) y cre process nd udit yer Percentge of ptients (%) HA 1c Blood pressure Cholestrol Serum cretinine Urine lumin Foot surveillnce BMI Smoking Cre process For ptients under 12 yers of ge, 'll cre processes' is defined s HA 1c only s other cre processes re not recommended in the NICE guidelines for this ge group. There is helth wrning regrding the screening test for erly kidney disese (Urine Alumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. Figure 4 shows the percentge of ll ptients in Englnd nd Wles receiving eight of the nine (excluding eye screening) NICE recommended cre processes y udit yer nd dietes type. Figure 4 Percentge of ll ptients in Englnd nd Wles receiving eight of the nine (excluding eye screening) NICE recommended cre processes y udit yer nd dietes type Percentge of ptients (%) All dietes Type 1 Type 2 Dietes type The eight NICE recommended cre processes re those tht re listed in Tle 6 (i.e. eye screening is not included in this nlysis). All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 18

19 Figure 5 Percentge of ll ptients in Englnd nd Wles receiving eight of the nine (excluding eye screening) NICE recommended cre processes y dietes type nd ge group Percentge of ptients (%) Under to to nd over Under to to nd over Type 1 Type 2 Age group nd dietes type The eight NICE recommended cre processes re those tht re listed in Tle 6 (i.e. eye screening is not included in this nlysis). Tles 6 nd 7 nd Figures 3,4,nd 5 highlight: Declining cre process chievement rtes for Type 1 dietes Lower cre process chievement rtes in younger people with Type 1 nd Type 2 dietes No rel chnge in the overll cre process performnce over the pst three yers. When looking t cre process completion rtes y CCG/ LHB, considerle vrition is evident. Figure 6 shows the rnge nd distriution of cre process chievement y CCGs/LHBs. Key: Minimum Medin Inter-qurtile rnge Mximum Figure 6 The rnge of CCG/LHB cre process completion in Englnd nd Wles, Cre process Blood pressure Serum cretinine d BMI Cholestrol Foot surveillnce Smoking Urine lumin d HBA 1c Eight cre processes c 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ptients There is helth wrning regrding the screening test for erly kidney disese (Urine Alumin Cretinine Rtio, UACR); plese see the NDA Methodology section of this report. For ptients under 12 yers of ge, 'll cre processes' is defined s HA 1c only s other cre processes re not recommended in the NICE guidelines for this ge group. c The eye screening cre process hs een removed from this tle; therefore eight cre processes comprises the eight cre processes tht re listed ove. d Plese note the Cretinine vlue for Southmpton nd Mid Essex CCG, nd Urine Alumin vlue for Mid Essex nd Hrrogte nd Rurl District CCG hve een removed from this chrt due to dt qulity resons. The impct of this issue does not mterilly ffect the ntionl findings Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 19

20 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 dietes should hve equitle 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 een used. Logisticl regression nlysis is sttisticl method for investigting the potentil impct of multiple sometimes intercting fctors on n oservtion. In this cse, the possile influence of demogrphic fctors on completion of ech cre process, plus ll 8 cre processes hs een studied. The models ssessed the potentil reltionships of gender, dietes type, ge, ethnicity, deprivtion, ody mss index nd durtion of dietes with cre process completion. The c-sttistic is one method of ssessing model fit. C-sttistic vlues over 0.7 indicte resonle model fit. Six of the nine models (see Appendix 2) hd c-sttistic vlues tht were over 0.7. Using these fctors resonle to strong* model fit ws found for seven cre processes (HA 1c, BP, serum cretinine, cholesterol, smoking, foot surveillnce). Significnt ssocitions included: Dietes type cre process completion ws lower for ptients with Type 1 dietes compred with those with Type 2 dietes Age group cre process completion ws lowest for the youngest ge group (0-49 yers), when compred to the ge group. This my e due to higher proportion of younger ptients for those with Type 1 dietes BMI cre process completion ws lowest for the <18.5 group. Agin, this my e due to more Type 1 ptients within this BMI group. Cre process completion for those with BMI of 25 nd over ws higher for ll cre processes, compred with those with BMI of 18.5 to 24.9 Ethnicity cre process completion is lower in nonwhite ethnic groups, most notly for smoking. The lowest BMI group (<18.5) lso hd low completion for recording of smoking sttus. Full results of the multivrite nlysis cn e found in Appendix 2. * Models re typiclly considered to demonstrte resonle ssocitions when the c-sttistic is higher thn 0.7 nd strong when the c-sttistic exceeds 0.8 (Hosmer & Lemeshow, 1989, 2000). Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 20

21 Tretment Trgets Helthcre professionls nd ptients should work in prtnership to ensure ptients chieve their NICE recommended tretment trgets for glucose control, lood pressure nd serum cholesterol. Plese note there hs een methodology updte to the Blood Pressure tretment trget. This yer the Blood Pressure trget hs een minimlly modified from <140/80 to <140/80 to lign with the QOF trget. This will lso ffect the All tretments trgets result. We were surprised t the resulting size difference suggesting tht Blood Pressure mesurement my still e plgued y the long recognised issue of digit preference. We hve previously highlighted in the NDA report 2 ( ) how lrge the contriution of Hert Filure to premture mortlity so Blood Pressure control is one of the most vlule components of routine dietes cre nd it is therefore essentil for it to e mesured relily. For further informtion plese see the pulished methodology updte report: Tle 8 Tretment trget chievement rte for ll ptients in Englnd nd Wles y tretment trget, dietes type nd udit yer All dietes Type 1 Type HA 1c <48mmol/mol (6.5%) 24.8% 24.7% 25.1% 6.8% 6.5% 7.5% 26.4% 26.2% 26.4% HA 1c <58mmol/mol (7.5%) 63.3% 62.7% 62.2% 28.1% 27.0% 27.3% 66.5% 65.8% 64.8% HA 1c <86mmol/mol (10.0%) 92.1% 91.9% 92.4% 82.4% 81.9% 83.0% 93.0% 92.8% 93.1% BP <140/80 c 62.0% 67.1% 69.0% 68.8% 72.2% 73.4% 61.4% 66.7% 68.7% Cholesterol <4mmol/L 40.7% 40.4% 39.6% 30.4% 29.7% 28.7% 41.6% 41.3% 40.5% Cholesterol <5mmol/L 77.6% 77.0% 76.2% 72.0% 71.1% 70.2% 78.1% 77.5% 76.8% Meet ll tretment trgets d 33.7% 35.9% 35.9% 16.5% 16.5% 16.2% 35.2% 37.5% 37.4% All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. For ptients under 12 yers of ge, 'll cre processes' is defined s HA 1c only s other cre processes re not recommended in the NICE guidelines for this ge group. c BP <140/80 does not tke into ccount whether or not ptients hve eye, kidney or vsculr disese. d Where ptients hve chieved HA 1c <58mmol/mol, cholesterol <5mmol/L nd the lood pressure trget. Tle 9 Tretment trget chievement rte for ll ptients in Englnd nd Wles y tretment trget, dietes type nd ge group Type 1 Type 2 Under to to nd over Under to to nd over HA 1c <48mmol/mol (6.5%) 7.7% 6.7% 8.6% 12.6% 24.4% 22.9% 27.6% 33.5% HA 1c <58mmol/mol (7.5%) 24.8% 26.0% 35.5% 40.5% 51.9% 57.7% 69.6% 74.8% HA 1c <86mmol/mol (10.0%) 77.5% 84.4% 91.4% 90.5% 84.0% 89.9% 95.8% 96.8% BP <140/ % 70.3% 71.7% 70.7% 65.0% 64.9% 71.7% 72.2% Cholesterol <4mmol/L 22.3% 28.4% 41.6% 43.7% 23.7% 35.7% 44.9% 45.2% Cholesterol <5mmol/L 64.1% 70.4% 81.5% 81.5% 60.2% 72.5% 81.2% 79.9% Meet ll tretment trgets c 14.7% 14.7% 22.4% 25.5% 24.3% 30.3% 42.6% 45.1% For ptients under 12 yers of ge, 'll cre processes' is defined s HA 1c only s other cre processes re not recommended in the NICE guidelines for this ge group. BP <140/80 does not tke into ccount whether or not ptients hve eye, kidney or vsculr disese. c Where ptients hve chieved HA 1c <58mmol/mol, cholesterol <5mmol/L nd their relevnt lood pressure trget. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 21

22 Figure 7 Percentge of ll ptients in Englnd nd Wles chieving tretment trgets y udit yer nd dietes type Percentge of ptients (%) All dietes Type 1 Type 2 Dietes type Where ptients hve chieved HA 1c <58mmol/mol, cholesterol <5mmol/L nd the lood pressure trget. All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. Figure 8 Percentge of ll ptients in Englnd nd Wles chieving tretment trgets y dietes type nd ge group Percentge of ptients (%) Under to to nd over Under to to nd over Type 1 Type 2 Age group nd dietes type Where ptients hve chieved HA 1c <58mmol/mol, cholesterol <5mmol/L nd the lood pressure trget. Tles 8 nd 9 nd Figures 7 nd 8 highlight; Lower levels of tretment trget chievement, prticulrly for HA 1c in people with Type 1 s compred to Type 2 dietes (Tle 8 nd Tle 9). Age relted tretment trget chievement in oth Type 1 nd Type 2 dietes (worst in youngest est in oldest; Tle 9 nd Figure 8). Sustntil numers with exceptionlly high risk glucose levels (17.0 per cent of Type 1 nd 6.9 per cent of Type 2 ptients hve HA 1c equl to or ove 86mmol/mol (10 per cent) (Tle 8). Smll improvements in Type 2 ut not in Type 1 dietes over the lst three yers (Figure 7). Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 22

23 When looking t tretment trget chievement rtes y CCG/LHB considerle vrition is evident. Figures 9 nd 10 shows the rnge nd distriution of tretment trget chievement y CCG/LHB y Type 1 nd Type 2. Key: Minimum Medin Mximum Inter-qurtile rnge Figure 9 The rnge of CCG/LHB tretment trget chievement for ptients with Type 1 dietes in Englnd nd Wles Tretment trget HA 1c <48mmol/mol (6.5%) HA 1c <58mmol/mol (7.5%) HA 1c <86mmol/mol (10.0%) BP <140/80 Cholesterol <4mmol/L Cholesterol <5mmol/L Meet ll tretment trgets 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ptients For ptients under 12 yers of ge, 'll tretment trgets' is defined s HA 1c only s other tretment trgets re not recommended in the NICE guidelines for this ge group. For ptients over 12, ptients hve chieved HA 1c <58mmol/mol, cholesterol <5mmol/L nd the lood pressure trget. BP <140/80 does not tke into ccount whether or not ptients hve eye, kidney or vsculr disese. Figure 10 The rnge of CCG/LHB tretment trget chievement for ptients with Type 2 dietes in Englnd nd Wles Tretment trget HA 1c <48mmol/mol (6.5%) HA 1c <58mmol/mol (7.5%) HA 1c <86mmol/mol (10.0%) BP <140/80 Cholesterol <4mmol/L Cholesterol <5mmol/L Meet ll tretment trgets 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ptients For ptients under 12 yers of ge, 'll tretment trgets' is defined s HA 1c only s other tretment trgets re not recommended in the NICE guidelines for this ge group. For ptients over 12, ptients hve chieved HA 1c <58mmol/mol, cholesterol <5mmol/L nd the lood pressure trget. BP <140/80 does not tke into ccount whether or not ptients hve eye, kidney or vsculr disese. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 23

24 Structured Eduction The NDA hs collected dt on structured eduction in Englnd nd Wles since NICE guidnce recommend tht people with dietes (Type 1 or Type 2) e offered ptient eduction progrmmes, officilly known s 'structured eduction'. The NDA reports whether there is record tht person with dietes hs een offered or hs ttended structured eduction. When looking t dt for ll people dignosed with dietes, structured eduction ws recorded s eing offered to 2.4 per cent of those with Type 1 dietes nd 6.0 per cent of those with Type 2 dietes, whilst 1.1 per cent of those with Type 1 dietes nd 1.6 per cent of those with Type 2 dietes were recorded s ttending structured eduction. The nlysis in Tle 10 considers structured eduction records in for ptients dignosed in the sme period. In 2013 the CCG outcome indictor set reported indictor C2.5 People with dietes dignosed less thn one yer, referred to structured eduction. This indictor uses similr construction to the informtion presented elow ut uses dignosis dte (rther thn yer), which is currently unville for nlysis, to define ptients dignosed less thn yer. Tle 10 Structured eduction for newly dignosed people with dietes Numer dignosed Offered Attended Offered or ttended All dietes n 196,675 31,336 6,740 36,270 % N/A 15.9% 3.4% 18.4% Type 1 n 6, % N/A 3.9% 0.9% 4.7% Type 2 n 182,045 30,409 6,569 35,201 % N/A 16.7% 3.6% 19.3% Other c n 7, % N/A 8.5% 1.4% 9.6% Due to issues with dt qulity, ptient my e recorded s ttending structured eduction without it recorded s eing offered to them; the offered or ttended column, which is included in this tle, gives n indiction of the scle of this issue. All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. c Other dietes comprises mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. Tle 11 Structured eduction for ll people with dietes Numer dignosed Offered Attended Offered or ttended All dietes n 1,979, ,166 31, ,473 % N/A 5.7% 1.6% 6.8% Type 1 n 163,562 3,953 1,879 5,579 % N/A 2.4% 1.1% 3.4% Type 2 n 1,792, ,173 29, ,681 % N/A 6.0% 1.6% 7.1% Other c n 22,954 1, ,197 % N/A 4.5% 1.0% 5.2% Due to issues with dt qulity, ptient my e recorded s ttending structured eduction without it recorded s eing offered to them; the offered or ttended column, which is included in this tle, gives n indiction of the scle of this issue. All dietes includes mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. c Other dietes comprises mturity onset dietes of the young (MODY), other specified dietes nd not specified dietes. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 24

25 Dt Completeness Tle 12 shows the completeness, following clening of key fields, used in the nlysis of this report. Tle 12 Comprison of NDA dt completeness y udit yer Audit yer Denomintor 2,171,528 2,422,938 1,979,929 Gender % >99.9% >99.9% >99.9% Dietes type (specified) % 99.5% 99.5% 99.2% Age % >99.9% >99.9% >99.9% Ethnicity (known nd stted) % 74.6% 75.4% 76.9% Yer of dignosis % 98.0% 98.0% 97.9% Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 25

26 NDA Methodology Prticiption in the NDA is voluntry; however it does cover 71.1 per cent of the people dignosed with dietes in Englnd nd 69.3 per cent in Wles (when compred with QOF). The NDA collects informtion on ll ptients who hve een dignosed with dietes efore the udit end dte (31st Mrch 2013). Clinicl Commissioning Groups (CCGs), Locl Helth Bords (LHBs), GP prctices nd dult outptient secondry cre units sumit dt out the cre tht is eing delivered for people with dietes in their orgnistion. This will include children tht hve een treted in n dult cre setting. For the full picture on the peditric cre for children with dietes plese refer to the Ntionl Peditric Dietes Audit which is conducted y the Royl College of Peditrics nd Child Helth (RCPCH) 13. In ddition to the dt sumitted y prticipting orgnistions, supplementry informtion relting to specific complictions nd procedures is sourced from the Hospitl Episodes Sttistics (HES) dtse nd the Ptient Episode Dtse for Wles (PEDW). The NDA dt is linked to HES or PEDW dt to the correct ptient record to provide fuller nlysis. Plese note tht for time series nlysis, results re compred with previous yers dt nlysed using NDA methodology. Time series dt should not e compred to other reports where different methodology my hve een used. There hve een chnges to Blood pressure trgets to e less thn or equl to insted of just less thn. These chnges re documented in pulished pper which cn e locted Dt Qulity There is helth wrning regrding the screening test for erly kidney disese (Urine Alumin Cretinine Rtio, UACR). An issue with dt supplied to the HSCIC for the Audit ws rought to our ttention prior to puliction, which is elieved to e restricted to Urine Alumin dt extrction cross numer of prctices. Cution should e orne in mind when looking t the vrition cross CCG s for this cre process. The udit tem re investigting this further nd once more informtion is known note will e pulished with conclusions nd ny ctions which my need to e mde. 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 dietes. Copyright 2014, Helth nd Socil Cre Informtion Centre, Ntionl Dietes Audit Report 1: Cre Processes nd Tretment Trgets. All rights reserved. 26