Ntionl Dibetes Audit 2011 2012 Report 1: Cre Processes nd Tretment Trgets
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 2011-2012 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.
Ntionl Dibetes Audit 2011 2012 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 2011-2012 Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 3
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
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. 65.8 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: http://www.englnd.nhs.uk/sttistics/sttisticl-work-res/integrted-performncemesures-monitoring/dibetes-dt/ Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 5
Executive Summry The Ntionl Dibetes Audit 2011-2012 Report 1: Cre Processes nd Tretment Trgets presents findings on cre processes nd tretment trget chievement rtes from 2011-2012. 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 2012. This dt ws collected between October nd December 2012. 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 2011-2012 Primry Cre Extrction Specifiction (PCES) vilble on the NDA website: www.hscic.gov.uk/nd 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 2010-2011; 1,997,646 in 2009-2010). 87.9 per cent of prctices (80.9 per cent in 2010-2011; 75.8 per cent in 2009-2010). 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
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 2009-2010; 19.7 per cent in 2010-2011; 20.8 per cent in 2011-2012). 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. 22.3 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
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
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 2011-2012 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 2011-2012 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
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 2011-2012 8,549 7,515 87.9% 2010-2011 8,659 7,008 80.9% 2009-2010 8,842 6,700 75.8% 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 2011-2012 2,473,239 4.73% 2,422,938 50,301 2.0% 2010-2011 2,235,810 4.59% 2,171,528 64,282 2.9% 2009-2010 1,997,646 4.38% 1,949,973 47,673 2.4% 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 2011-2012 213,960 0.40% 207,566 6,394 3.0% 2010-2011 202,134 0.41% 193,238 8,896 4.4% 2009-2010 185,962 0.40% 178,829 7,133 3.8% 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 2011-2012 2,216,129 4.25% 2,190,665 25,464 1.1% 2010-2011 1,986,611 4.10% 1,954,768 31,843 1.6% 2009-2010 1,762,184 3.88% 1,737,388 24,796 1.4% 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
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 2011-2012 2,269,580 2,566,436 88.4% 2010-2011 2,086,593 2,455,937 85.0% 2009-2010 1,875,642 2,338,813 80.2% Wles 2011-2012 137,768 167,537 82.2% 2010-2011 83,802 160,533 52.2% 2009-2010 55,403 153,131 36.2% 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) 90+ 85 89 80 84 75 79 70 74 65 69 60 64 55 59 50 54 45 49 40 44 35 39 30 34 25 29 20 24 15 19 10 14 Femle Mle 5 9 0 4 1.0% 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
Figure 2 Age nd gender of ptients with Type 2 dibetes in Englnd nd Wles Age group (yers) 90+ 85 89 80 84 75 79 70 74 65 69 60 64 55 59 50 54 45 49 40 44 35 39 30 34 25 29 20 24 15 19 10 14 5 9 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
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 2 2009-2010 2010-2011 2011-2012 2009-2010 2010-2011 2011-2012 2009-2010 2010-2011 2011-2012 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% 2009-2010 2010-2011 2011-2012 80% 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
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% 2009-2010 20% 2010-2011 10% 2011-2012 0% 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, 2011-2012 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
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
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 2 2009-2010 2010-2011 2011-2012 2009-2010 2010-2011 2011-2012 2009-2010 2010-2011 2011-2012 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
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
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, 2011-2012 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
Structured Eduction The NDA hs collected dt on structured eduction in Englnd nd Wles since 2005. 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 2011-2012 for ptients dignosed in the sme period. Tble 9 shows structured eduction records in 2011-2012 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, 2011-2012 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 8,952 197 57 245 % 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 6,653 301 44 333 % 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, 2011-2012 Number dignosed Offered Attended Offered or ttended All dibetes b n 2,422,938 102,958 32,921 124,924 % 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 30,764 119,143 % n/ 4.5% 1.4% 5.4% Other c n 24,707 549 140 662 % 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
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 2009-2010 2010-2011 2011-2012 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
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
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 http://www.no.org.uk/report/the-mngementof-dult-dibetes-services-in-the-nhs/ 2. Globl Burden of Disese Study Lncet 2013 Mr 23;381(9871):997-1020 3. World Helth Orgnistion (WHO) guidelines for the dignosis nd clssifiction of dibetes. http://www.who.int/dibetes/publictions/dignosis_ dibetes2006/en/index.html 4. Ntionl Service Frmework (NSF) for Dibetes https://www.gov.uk/government/publictions/ 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 http://www.nice.org.uk/cg15 6. NICE Clinicl Guidelines CG66: Type 2 Dibetes (prtilly updted by CG87) http://www.nice.org.uk/cg66 7. NICE Clinicl Guidelines CG87: Type 2 Dibetes newer gents (prtil updte of CG66) http://www.nice.org.uk/cg87 8. NICE Dibetes in Adults Qulity Stndrd http://guidnce.nice.org.uk/qs6 9. Qulity Outcomes Frmework (QOF) http://www.hscic.gov.uk/qof 10. NICE recommended cre processes http://www.nice.org.uk/guidnce/index. jsp?ction=byid&o=12165 11. Ntionl Peditric Dibetes Audit, Royl College of Peditrics nd Child Helth http://www.rcpch.c.uk/npd Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 22
Appendix 1: Chrcteristics of People with Dibetes Tble 11 Chrcteristics of people with dibetes, 2011-2012 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 2,422,938 60.5% 20.8% 207,566 43.2% 11.8% 2,190,665 62.6% 21.5% Sex Mle 1,349,440 61.8% 21.4% 117,688 43.9% 12.2% 1,218,651 64.0% 22.2% Femle 1,073,497 58.8% 20.0% 89,878 42.3% 11.2% 972,013 60.8% 20.6% Age (yers) 0 to 9 5,451 50.7% 24.4% 5,174 52.2% 24.0% 83 21.7% 29.4% 10 to 19 24,125 17.1% 13.8% 22,270 17.2% 13.0% 1,212 19.4% 22.9% 20 to 29 41,038 34.0% 13.5% 29,498 32.9% 11.8% 10,409 40.2% 17.8% 30 to 39 92,671 43.8% 15.7% 32,177 37.9% 13.0% 58,601 48.1% 17.1% 40 to 49 259,087 52.3% 15.1% 41,748 44.3% 10.2% 213,997 54.4% 16.1% 50 to 59 459,372 59.0% 17.7% 33,350 51.5% 10.0% 421,503 60.0% 18.3% 60 to 69 631,264 65.1% 22.2% 23,625 58.3% 12.2% 602,374 65.7% 22.6% 70 to 79 584,566 67.3% 24.0% 14,129 62.3% 12.9% 565,845 67.7% 24.2% 80 to 89 289,219 61.3% 22.7% 5,180 56.0% 13.4% 281,392 61.8% 22.9% 90+ 36,143 44.3% 20.9% 414 41.5% 13.6% 35,248 44.8% 21.0% Ethnic White 1,443,134 62.6% 21.0% 133,614 45.2% 11.9% 1,296,744 64.8% 21.8% group Mixed 19,370 56.7% 19.3% 1,707 39.8% 12.9% 17,385 59.2% 19.8% Asin 226,043 59.5% 21.8% 7,598 46.8% 11.9% 216,009 60.4% 22.1% Blck 78,143 59.0% 18.4% 4,466 46.2% 11.6% 72,642 60.4% 18.8% Other 60,734 56.4% 22.0% 4,547 38.8% 13.8% 55,382 58.4% 22.5% Not stted/ 595,514 56.4% 20.0% 55,634 38.3% 11.4% 532,503 58.8% 20.7% Not known Deprivtion Most deprived fifth 535,881 60.6% 21.1% 38,580 42.9% 10.0% 491,294 62.4% 21.8% 2nd most 484,715 59.6% 20.7% 39,387 42.7% 11.1% 439,931 61.6% 21.4% deprived fifth 3rd most 462,424 60.2% 20.7% 40,160 43.6% 12.0% 417,708 62.2% 21.4% deprived fifth 2nd lest 423,317 60.5% 20.9% 39,202 43.5% 12.6% 380,128 62.6% 21.6% deprived fifth Lest deprived fifth 376,362 60.2% 21.3% 38,668 43.6% 13.6% 334,228 62.6% 22.0% BMI <18.5 (Underweight) 15,613 53.0% 27.1% 5,426 48.3% 18.6% 9,924 56.4% 30.7% 18.5 to 24.9 339,213 64.0% 26.2% 58,554 47.5% 13.9% 277,846 67.8% 28.4% (Norml weight) 25.0 to 29.9 730,819 68.2% 23.1% 60,201 53.3% 11.5% 665,747 69.9% 24.1% (Pre-obesity) 30.0 to 34.9 602,971 68.3% 19.3% 29,411 55.9% 9.1% 569,680 69.2% 19.8% (Obesity clss I) 35.0 to 39.9 294,491 67.2% 16.9% 10,161 55.3% 8.8% 282,303 67.9% 17.1% (Obesity clss II) 40.0+ 185,824 64.0% 14.8% 4,810 53.9% 8.8% 179,743 64.5% 15.0% (Obesity clss III) Smoking Never smoked 947,471 71.6% 20.7% 77,842 54.2% 13.1% 862,369 73.5% 21.3% sttus Ex smoker 747,035 73.9% 22.0% 37,372 60.6% 11.2% 704,561 74.9% 22.6% Current smoker 326,182 63.6% 19.2% 35,532 47.3% 7.8% 287,651 66.0% 20.4% Durtion <1 239,251 51.3% 18.6% 8,952 30.6% 19.7% 223,646 53.1% 18.7% of dibetes (yers) 1 to 4 703,035 62.7% 23.5% 27,068 38.5% 16.7% 668,250 64.2% 23.7% 5 to 9 709,407 62.2% 22.5% 34,748 38.4% 12.0% 670,022 63.8% 22.9% 10 to 14 377,237 61.4% 19.1% 32,853 41.4% 9.9% 342,035 63.6% 19.8% 15 to 19 171,258 59.7% 16.4% 26,306 44.7% 9.9% 143,792 62.8% 17.4% 20 to 29 117,292 56.9% 14.5% 34,222 46.4% 10.9% 82,360 61.6% 15.8% 30 to 39 35,374 52.9% 12.6% 21,264 48.7% 11.2% 13,911 59.8% 14.5% 40 to 49 13,716 53.8% 12.5% 10,165 52.9% 11.6% 3,451 57.8% 14.8% 50+ 7,029 58.3% 14.7% 4,199 57.3% 12.1% 2,781 60.6% 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
Tble 12 Chrcteristics of people with dibetes, 2011-2012 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 239,251 51.3% 18.6% 8,952 30.6% 19.7% 223,646 53.1% 18.7% Sex Mle 136,558 51.7% 19.3% 5,268 30.1% 19.6% 127,563 53.5% 19.3% Femle 102,693 50.7% 17.8% 3,684 31.2% 19.9% 96,083 52.5% 17.8% Age (yers) 0 to 9 1,608 35.7% 29.9% 1,499 37.1% 29.2% 25 8.0% 50.0% 10 to 19 2,898 14.6% 28.3% 2,397 15.1% 28.9% 320 14.7% 25.4% 20 to 29 4,858 33.9% 18.3% 1,733 29.4% 20.8% 2,808 39.7% 16.8% 30 to 39 15,032 43.5% 15.2% 1,288 32.9% 19.7% 13,175 45.9% 14.8% 40 to 49 38,628 49.0% 13.6% 901 42.8% 12.2% 36,657 50.0% 13.7% 50 to 59 55,382 51.9% 15.5% 580 45.7% 10.6% 53,377 52.8% 15.6% 60 to 69 61,030 55.2% 20.5% 336 44.6% 11.7% 59,273 56.0% 20.6% 70 to 79 41,390 56.0% 23.8% 163 40.5% 18.5% 40,224 56.9% 23.9% 80 to 89 16,601 50.6% 22.3% 52 34.6% 3.6% 16,035 51.8% 22.5% 90+ 1,824 33.8% 20.2% 3 33.3% 0.0% 1,752 34.8% 20.5% Ethnic White 137,498 53.2% 18.9% 5,194 33.2% 19.9% 128,839 54.9% 19.0% group Mixed 2,024 50.5% 17.7% 129 30.2% 20.7% 1,829 53.1% 17.8% Asin 23,139 51.8% 19.4% 424 33.5% 18.1% 22,018 53.2% 19.5% Blck 8,311 52.4% 15.3% 320 36.3% 13.1% 7,684 54.6% 15.5% Other 6,516 49.0% 19.4% 232 28.0% 18.0% 6,057 51.1% 19.6% Not stted/ 61,763 47.0% 18.1% 2,653 24.6% 20.8% 57,219 49.0% 18.1% Not known Deprivtion Most deprived fifth 56,097 52.2% 18.7% 1,999 32.1% 17.8% 52,447 54.0% 18.8% 2nd most 48,480 50.6% 18.1% 1,840 29.9% 18.0% 45,194 52.6% 18.2% deprived fifth 3rd most 45,089 50.5% 18.8% 1,682 30.1% 19.7% 42,266 52.2% 18.9% deprived fifth 2nd lest 40,824 50.5% 19.2% 1,543 31.0% 20.5% 38,212 52.1% 19.2% deprived fifth Lest deprived fifth 35,271 49.9% 19.1% 1,467 28.5% 24.8% 32,882 51.8% 19.1% BMI <18.5 (Underweight) 1,685 45.9% 26.9% 780 42.9% 29.2% 833 51.1% 25.3% 18.5 to 24.9 26,375 57.0% 25.0% 2,582 37.1% 21.6% 22,988 60.4% 25.5% (Norml weight) 25.0 to 29.9 67,169 59.2% 21.5% 1,460 41.7% 15.7% 64,187 60.4% 21.7% (Pre-obesity) 30.0 to 34.9 62,537 57.2% 17.8% 647 45.7% 12.2% 60,650 57.9% 17.9% (Obesity clss I) 35.0 to 39.9 32,706 55.0% 15.3% 198 41.4% 11.2% 31,789 55.7% 15.4% (Obesity clss II) 40.0+ 23,487 51.8% 12.2% 136 41.2% 13.8% 22,883 52.4% 12.2% (Obesity clss III) Smoking Never smoked 99,077 57.5% 18.5% 2,924 35.3% 21.4% 93,724 59.0% 18.5% sttus Ex smoker 72,961 59.2% 20.3% 877 42.8% 15.5% 70,507 60.1% 20.4% Current smoker 39,509 52.0% 16.4% 1,479 35.3% 12.8% 37,012 53.5% 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
Appendix 2: Regressions Anlysis Logistic regression modelling hs been used s the multivrite sttisticl technique throughout this report. The results of the logistic regression nlyses re presented in Tble 13. A logistic regression model ws used to explore which person nd environmentl vribles were ssocited with hving cre process recorded s complete. The model llows ech vrible to be considered independently by controlling for the effects of other, sometimes relted fctors. The model llows n evlution of the strength of the reltionship between ech of the vribles nd the probbility of cre process completion. When modelling dt in this wy the im is to produce model which both stisfies certin sttisticl criteri nd mintins connection with the rel-world understnding of the behviours we re trying to explin. The bility of the model to explin the vrition seen in our dt hs been presented s the c-sttistic. This sttistic is the probbility tht predicting the outcome is better thn chnce. The vlues for this mesure rnge from 0.5 to 1.0. A vlue of 0.5 indictes tht the model is no better thn chnce t mking bout whether person will get their cre process nd vlue of 1.0 indictes tht the model perfectly identifies those who will hve the process nd those not. Models re typiclly considered resonble when the c-sttistic is higher thn 0.7 nd strong when the c-sttistic exceeds 0.8 iii. The choice of explntory vribles cme from consulttion with our clinicl led. All vribles were found to mke significnt improvements to the bility of the model to explin observed vrition. The vribles included in the models to explin cre process completion were: gender, dibetes type, ge group, ethnicity, deprivtion group, body mss index (BMI), nd durtion of dibetes. Following initil nlysis of the dt ll our explntory vribles were grouped into ctegoricl vribles, which group cses into number of discrete ctegories (for exmple deprivtion is grouped into five ctegories or quintiles). Missing vlues for explntory vribles were included in the models. Excluding missing vlues for explntory vribles cn cuse significnt smple ttrition, since cses re lost if they hve missing vlue for ny one of the relevnt vribles. Hd these vlues been excluded we would hve reduced the precision of estimtes nd my hve introduced bis. The model identifies ssocitions, not cuses; in other words, fctors which identify individuls with n incresed or decresed probbility of hving cre process in the udit period. These vritions in risk re expressed s odds rtios nd expressed reltive to reference ctegory, which is given vlue of 1. Odds rtios greter thn 1 indicte incresed probbility of the cre process being completed in the group nd odds rtios less thn 1 indicte decresed probbility of the cre process being completed. Also provided re the 95% confidence intervls for the odds rtio. Where the intervl does not include 1, the ctegory is significntly different (P<0.05) from the reference ctegory. iii Hosmer & Lemeshow, 1989, 2000 Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 25
Tble 13 Results from multivrite nlysis of 2011-2012 dt for cre process completion HbA1c Blood pressure Cholesterol Serum cretinine Cre process completion Urine lbumin Foot surveillnce Body Mss Index Smoking Eight cre processes excluding eye screening Number of observtions 2,422,938 2,414,375 2,414,375 2,414,375 2,414,375 2,414,375 2,414,375 2,414,375 2,422,938 used in model Ridging option Absolute Reltive Reltive Reltive Reltive Reltive Reltive Reltive Reltive Filters None Age>=12 Age>=12 Age>=12 Age>=12 Age>=12 Age>=12 Age>=12 None Intercept 2.9046 (2.8828 to 2.9265) c sttistic (model fit) 0.792 (resonble) Gender: Femle vs. Mle 1.041 (1.031 to 1.051) Dibetes Type 1 vs. Type 2 0.803 (0.789 to 0.817) Age: 0-49 vs. 60-69 0.602 (0.593 to 0.611) Age: 50-59 vs. 60-69 0.829 (0.817 to 0.842) Age: 70-79 vs. 60-69 1.150 (1.133 to 1.167) Age: 80+ vs. 60-69 1.104 (1.085 to 1.123) Ethnicity: Asin vs. White 0.915 (0.900 to 0.931) Ethnicity: Blck vs. White 0.907 (0.883 to 0.931) Ethnicity: Other vs. White 0.742 (0.724 to 0.760) Deprivtion: 2nd most deprived fifth vs. most deprived fifth Deprivtion: 3rd lest deprived fifth vs. most deprived fifth Deprivtion:2nd lest deprived fifth vs. most deprived fifth Deprivtion: Lest deprived fifth vs. most deprived fifth 0.958 (0.945 to 0.972) 0.992 (0.978 to 1.007) 1.006 (0.991 to 1.022) 1.098 (1.081 to 1.117) BMI: <18.5 vs. 18.5-24.9 0.519 (0.494 to 0.545) BMI: 25-29.9 vs. 18.5-24.9 1.239 (1.218 to 1.261) BMI: 30-34.9 vs. 18.5-24.9 1.282 (1.259 to 1.306) BMI: 35-39.9 vs. 18.5-24.9 1.280 (1.252 to 1.308) BMI: 40+ vs. 18.5-24.9 1.184 (1.155 to 1.213) Dibetes Durtion: 0 vs. 1-4 Dibetes Durtion: 5-9 vs. 1-4 Dibetes Durtion: 10-14 vs. 1-4 Dibetes Durtion: 15+ vs. 1-4 0.471 (0.464 to 0.478) 0.963 (0.951 to 0.976) 1.030 (1.014 to 1.047) 1.072 (1.055 to 1.091) 4.4618 (4.4228 to 4.5008) 0.927 (strong) 1.144 (1.127 to 1.161) 0.755 (0.737 to 0.774) 0.407 (0.397 to 0.416) 0.705 (0.689 to 0.721) 1.438 (1.403 to 1.473) 1.836 (1.789 to 1.885) 0.836 (0.815 to 0.858) 0.771 (0.742 to 0.801) 0.792 (0.763 to 0.823) 0.979 (0.958 to 1.001) 0.977 (0.955 to 0.999) 0.986 (0.962 to 1.010) 1.012 (0.987 to 1.037) 0.266 (0.245 to 0.289) 1.785 (1.715 to 1.857) 1.923 (1.842 to 2.006) 1.884 (1.789 to 1.984) 1.350 (1.280 to 1.423) 1.574 (1.530 to 1.618) 0.970 (0.951 to 0.988) 1.037 (1.014 to 1.062) 1.236 (1.205 to 1.267) 3.0117 (2.9891 to 3.0342) 0.804 (strong) 0.947 (0.938 to 0.957) 0.505 (0.496 to 0.514) 0.436 (0.429 to 0.443) 0.769 (0.757 to 0.782) 1.184 (1.164 to 1.203) 1.015 (0.997 to 1.033) 1.007 (0.989 to 1.025) 0.881 (0.857 to 0.905) 0.929 (0.904 to 0.954) 0.989 (0.974 to 1.004) 1.026 (1.010 to 1.043) 1.060 (1.042 to 1.077) 1.061 (1.043 to 1.079) 0.381 (0.363 to 0.399) 1.468 (1.443 to 1.495) 1.548 (1.519 to 1.578) 1.509 (1.474 to 1.544) 1.366 (1.332 to 1.402) 1.149 (1.127 to 1.171) 0.933 (0.921 to 0.946) 0.928 (0.914 to 0.943) 1.053 (1.035 to 1.071) 3.2360 (3.2111 to 3.2610) 0.821 (strong) 1.039 (1.028 to 1.051) 0.534 (0.524 to 0.544) 0.428 (0.421 to 0.436) 0.742 (0.730 to 0.755) 1.349 (1.324 to 1.373) 1.484 (1.453 to 1.514) 0.949 (0.931 to 0.968) 0.802 (0.779 to 0.826) 0.801 (0.779 to 0.824) 0.961 (0.945 to 0.977) 0.980 (0.964 to 0.997) 0.967 (0.949 to 0.984) 0.929 (0.912 to 0.946) 0.404 (0.382 to 0.427) 1.397 (1.369 to 1.426) 1.522 (1.489 to 1.556) 1.519 (1.480 to 1.560) 1.440 (1.397 to 1.483) 1.397 (1.368 to 1.427) 0.955 (0.942 to 0.969) 0.987 (0.970 to 1.005) 1.192 (1.170 to 1.215) 1.7112 (1.6969 to 1.7254) 0.713 (resonble) 0.885 (0.880 to 0.891) 0.657 (0.649 to 0.666) 0.509 (0.504 to 0.514) 0.751 (0.743 to 0.758) 1.259 (1.247 to 1.272) 1.227 (1.213 to 1.241) 1.052 (1.040 to 1.065) 1.029 (1.010 to 1.048) 0.959 (0.942 to 0.976) 0.963 (0.953 to 0.972) 0.968 (0.958 to 0.978) 0.936 (0.926 to 0.946) 0.933 (0.923 to 0.943) 0.527 (0.507 to 0.547) 1.167 (1.155 to 1.180) 1.175 (1.162 to 1.188) 1.142 (1.127 to 1.157) 1.058 (1.042 to 1.073) 0.618 (0.611 to 0.625) 0.951 (0.943 to 0.959) 0.930 (0.921 to 0.940) 0.937 (0.927 to 0.948) 2.6152 (2.5959 to 2.6344) 0.812 (strong) 0.984 (0.975 to 0.993) 0.580 (0.571 to 0.590) 0.495 (0.488 to 0.502) 0.763 (0.753 to 0.773) 1.173 (1.157 to 1.189) 0.972 (0.957 to 0.987) 1.015 (0.999 to 1.031) 0.999 (0.976 to 1.024) 0.940 (0.919 to 0.963) 0.999 (0.986 to 1.012) 1.032 (1.018 to 1.046) 1.058 (1.043 to 1.073) 1.089 (1.073 to 1.105) 0.397 (0.381 to 0.415) 1.301 (1.282 to 1.321) 1.277 (1.257 to 1.297) 1.197 (1.176 to 1.219) 1.042 (1.021 to 1.063) 0.394 (0.389 to 0.400) 0.994 (0.982 to 1.006) 0.991 (0.977 to 1.006) 1.030 (1.015 to 1.046) 2.7996 (2.7839 to 2.8153) 0.920 (0.912 to 0.928) 0.615 (0.606 to 0.625) 0.516 (0.508 to 0.523) 0.772 (0.761 to 0.783) 0.984 (0.970 to 0.998) 0.469 (0.462 to 0.475) 0.958 (0.943 to 0.974) 0.807 (0.788 to 0.827) 0.785 (0.767 to 0.804) 0.962 (0.949 to 0.975) 1.002 (0.989 to 1.016) 1.053 (1.038 to 1.068) 1.059 (1.043 to 1.075) 1.050 (1.033 to 1.067) 0.959 (0.948 to 0.970) 0.956 (0.943 to 0.969) 0.960 (0.946 to 0.975) Text shown in blck indictes where there is significnt difference when compred to the reference group (>95% significnt). Text shown in grey indictes where there is not significnt difference when compred to the reference group (>95% significnt). Results re presented s odds rtios with 95% confidence intervls in brckets. 2.6916 (2.6736 to 2.7096) 0.626 0.730 (resonble) 0.886 (0.878 to 0.893) 0.822 (0.809 to 0.835) 0.881 (0.870 to 0.893) 0.927 (0.915 to 0.938) 0.974 (0.963 to 0.985) 0.853 (0.842 to 0.864) 0.625 (0.616 to 0.634) 0.599 (0.587 to 0.612) 0.659 (0.645 to 0.672) 0.860 (0.849 to 0.870) 0.805 (0.795 to 0.815) 0.805 (0.795 to 0.816) 0.778 (0.767 to 0.788) n/ 0.648 (0.618 to 0.679) n/ 1.033 (1.019 to 1.047) n/ 1.036 (1.021 to 1.051) n/ 1.022 (1.005 to 1.039) n/ 0.942 (0.924 to 0.961) 1.746 (1.717 to 1.775) 0.906 (0.897 to 0.915) 0.887 (0.877 to 0.898) 0.868 (0.857 to 0.880) 1.0384 (1.0261 to 1.0507) 0.697 0.882 (0.877 to 0.887) 0.678 (0.670 to 0.686) 0.599 (0.593 to 0.605) 0.806 (0.799 to 0.812) 1.121 (1.111 to 1.130) 0.952 (0.942 to 0.961) 0.929 (0.920 to 0.939) 0.958 (0.942 to 0.974) 0.833 (0.820 to 0.846) 0.949 (0.940 to 0.957) 0.944 (0.935 to 0.952) 0.935 (0.926 to 0.943) 0.932 (0.923 to 0.941) 0.750 (0.725 to 0.775) 1.121 (1.111 to 1.131) 1.121 (1.110 to 1.131) 1.097 (1.085 to 1.109) 1.004 (0.991 to 1.016) 0.616 (0.610 to 0.623) 0.932 (0.925 to 0.939) 0.897 (0.889 to 0.905) 0.862 (0.854 to 0.871) c sttistic: The probbility tht predicting the outcome is better thn chnce. Used to compre the goodness of fit of logistic regression models, vlues for this mesure rnge from 0.5 to 1.0. A vlue of 0.5 indictes tht the model is no better thn chnce t mking prediction of membership in group nd vlue of 1.0 indictes tht the model perfectly identifies those within group nd those not. Models re typiclly considered resonble when the c-sttistic is higher thn 0.7 nd strong when the c-sttistic exceeds 0.8 (Hosmer & Lemeshow, 1989, 2000). Copyright 2013, Helth nd Socil Cre Informtion Centre. All rights reserved. 26
Published by the Helth nd Socil Cre Informtion Centre Prt of the Government Sttisticl Service This publiction my be requested in lrge print or other formts. For further informtion: www.hscic.gov.uk 0845 300 6016 enquiries@hscic.gov.uk Copyright 2013 Helth nd Socil Cre Informtion Centre. All rights reserved. This work remins the sole nd exclusive property of the Helth nd Socil Cre Informtion Centre nd my only be reproduced where there is explicit reference to the ownership of the Helth nd Socil Cre Informtion Centre. This work my be re-used by NHS nd government orgnistions without permission.