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The NHS Atlas of Variation
in Healthcare for People
with Diabetes

May 2012


                         Copyright 2011 Right Care
2
The burden of diabetes in England

    There are thought to be more
    than 3 million adult diabetics
    in England. Only 2.3 million
    of these have been
    diagnosed. By 2020, 3.8
    million are expected to have
    diabetes – more than 1 in 12
    of the total population.

    Variation in current
    processes and outcomes in
    people have significant
    implications for the NHS
    today and in the future


3
National Diabetes Audit (NDA)
    (audit period 1 January 2009 and 31 March 2010)

    • More than 60% of people of all ages with Type 1 diabetes and
      almost half of people of all ages with Type 2 diabetes did not
      receive all nine care processes essential for management and
      detection of early complications

    • Two in 10 children aged 0–15 years have a most recent HbA1c of
      over 10%, making the long-term complications of diabetes more
      likely

    • People of all ages with diabetes are more than twice as likely to
      be admitted to hospital than people of a similar age who do not
      have the condition

    • People of all ages with diabetes stay in hospital almost 20%
      longer than people of a similar age who do not have the condition
4
Diabetes is costly to treat…


    • In 2010/11, prescribing for anti-diabetic items, including
      blood-testing items, cost £725.1 million and accounted for
      8.4% of the total spend on prescriptions in primary care

    • an increase of 41.2% since 2005/06

    • The cost of prescribing for the treatment of diabetes is
      increasing faster than that for any other category of drugs




    Prescribing for Diabetes in England 2005/06 to 2010/11
    http://www.ic.nhs.uk/webfiles/publications/prescribing%20diabetes%20200506%20to%20201011/P
    rescribing_for_Diabetes_in_England_20056_to_201011.pdf


5
The concept of unwarranted variation in diabetes care


    The aim of the Diabetes Atlas is to identify and quantify the extent of
    ‘unwarranted’ variation that may be due to unjustified geographical
    differences in medical practice and/or patients not gaining access to
    the appropriate level of intervention for their need.

    The resulting suboptimal (either over-use or under-use) uptake of
    medical intervention is defined as ‘unwarranted’.




6
“.. the indicators in this Diabetes Atlas clearly demonstrate there is
     considerable variation in both the processes and outcomes of care.
         Sadly, there are a substantial number of patients who are not
      receiving all of the nine basic care processes designed to identify
    treatable risks and early complications of diabetes. In the absence of
      these care processes, patients do not know if their level of health
            matches the recommended outcomes or if further care is

             needed, and neither do the healthcare professionals   ”
    Dr Rowan Hillson MBE
    National Clinical Director for Diabetes



7
Selection of indicators

    The indicators included in the Diabetes Atlas were
    chosen:
    ›› to reflect the range of diabetes care

    ›› because they could be calculated using robust
    nationally collated data at PCT level

    ›› Indicators were revised following consultation with the
    National Diabetes Information Service (NDIS) Expert
    Reference Group.


8
The Atlas has been produced in collaboration with…

    Diabetes Health Intelligence is a strategic programme within the Yorkshire and
    Humber Public Health Observatory (YHPHO). The YHPHO has a commitment to
    support the diabetes community by providing timely, quality-assured national diabetes
    health intelligence. YHPHO is part of a network of nine public health observatories in
    England.

    http://www.yhpho.org.uk/

    The National Diabetes Information Service (NDIS) is a national strategic
    partnership which provides health commissioners, providers and people with diabetes
    with the necessary information to aid decision-making and improve services on a local
    and national level. The five partner organisations are NHS Diabetes, Diabetes UK,
    Diabetes Health Intelligence, Innove and the NHS Information Centre for health and
    social care. The service is funded by NHS Diabetes.

    http://www.diabetes-ndis.org/




9
In presenting variation in this Atlas, PCTs are allocated   Shifting the curve…
to five groups, determined by their difference from the
England average. This type of comparison is useful
when rapidly analysing the potential for variation
among populations or datasets.

It is also important to pay attention to the England
average value – in some examples the England
average itself is relatively poor. For example, the
percentage of people with diabetes in the NDA who
have received all nine NICE recommended basic care
processes :

      ›› For people with Type 1 diabetes, the England
          value is 31.9% and the range is 5.4–47.9%
      ›› For people with Type 2 diabetes, the England
          value is 52.9% and the range is 7.0–71.4%

For indicators where the England value is relatively
poor, the focus should be on shifting the distribution


 10
Magnitude of variation

With respect to the percentage of
people in the NDA with Type 1
diabetes receiving all nine key care
processes:

›› For PCTs in England, the range is
from 5.4% to 47.9%, a 9-fold
variation;

›› The England value is 31.9%: at
the high end of the range 24.5% of
PCTs (n=37) and at the low end of
the range 24.5% of PCTs (n=37)
are very significantly different from
the England value (at the 99.8%
level).



 11
Magnitude of variation

With respect to the percentage of
people in the NDA with Type 1
diabetes receiving all nine key
care processes:

›› For PCTs in England, the
range is from 7.0% to 71.4% , a
10-fold variation;

›› The England value is 52.9%: at
the high end of the range 48.3%
of PCTs (n=73) and at the low
end of the range 37.7% of PCTs
(n=57) are very significantly
different from the England value
(at the 99.8% level).



12
Options for action

As almost half of the people with Type 2 diabetes and two out of three
people with Type 1 diabetes have not received the basic standard of care,
it is important that all commissioners and service providers ensure robust
arrangements are put in place for everyone with diabetes to receive an
annual review covering all nine care processes. Arrangements could
include:

›› Administrative systems that reliably invite all people with Type 1
diabetes for their annual checks;

›› Processes to follow-up and remind non-attenders;

›› Alternative access arrangements;

›› Ensuring that scheduled checks are undertaken on attendance, and
results recorded accurately.



13
Magnitude of variation

For PCTs in England, insulin total
net ingredient cost per patient on
GP diabetes registers ranged
from £79 to £176 (2.2-fold
variation).

When the five PCTs with the
highest costs and the five PCTs
with the lowest costs are
excluded, the range is £95–£158
per patient, and the variation is
1.7-fold.




14
There is no correlation between spending on insulin items and the
percentage of people with Type 1 diabetes or with Type 2 diabetes whose
most recent HbA1c measurement was 7.5% (58 mmol/mol) or less at PCT
level (see Figure 10.1).

This would indicate that the PCTs spending the most on insulin do not
necessarily have the greatest percentage of people with diabetes who
have optimal blood-glucose control.

There is a strong correlation between spending on insulin items in 2008/09
and that in 2009/10 (correlation coefficient, r=0.977; p<0.00005; see
Figure 10.2), suggesting that prescribing patterns at a PCT level are
persistent over time.

These results suggest that the degree of variation observed in spending
on insulin items is related to how local services are organised.




15
Magnitude of variation

People with diabetes are more likely
than those without diabetes to be
admitted to hospital. When in
hospital, people with diabetes stay
for longer when compared with
people of a similar age admitted for
similar conditions but who do not
have diabetes.

›› For PCTs in England, the range is
from –0.4% to 46.7%;

›› The England value is 19.4%: at
the high end of the range 36.4% of
PCTs (n=55) and at the low end of
the range 42.4% of PCTs (n=64)
are very significantly different from
the England value (at the 99.8%
level).
16
Magnitude of variation

With respect to excess emergency
re-admissions among people with
diabetes when compared with
people without
diabetes:

›› For PCTs in England, the range is
from 15.8% to 100.2% , a 6-fold
variation;

›› The England value is 59.1%: at
the high end of the range 12.6% of
PCTs (n=19) and at the low end of
the range 9.9% of PCTs (n=15) are
very significantly different from the
England value (at the 99.8% level).

This indicator is taken from the Variation in Inpatient
Activity: Diabetes (VIA: Diabetes)

17
Options for action

Commissioners and providers need to investigate variation in length of
stay at a local level, and consider auditing the reasons for re-
admission of people with diabetes to identify whether there are specific
factors that could be addressed.

Length of stay for people with diabetes can be reduced by introducing
dedicated inpatient diabetes teams, as achieved in local studies in
Plymouth and Norwich. Dedicated inpatient diabetes teams, including
diabetes specialist nurses, can reduce the length of stay for people
with diabetes by providing:

›› diabetes training and awareness raising for non-diabetes clinical
staff;

›› protocols for the management of patients with diabetes;

›› specific input into the management of patients experiencing
problems with the control of their diabetes.

18
Magnitude of variation

People with diabetes are predisposed
to developing foot ulcers primarily
because of an increased risk of both
peripheral arterial disease (PAD) and
peripheral neuropathy. Chronic
ulceration is the commonest
precursor to major lower limb
amputation (defined as above the
ankle).

›› For PCTs in England, the range is
from 0.1% to 0.5%, a 6-fold variation ;

›› The England value is 0.24%: at the
high end of the range 3.3% of PCTs
(n=5) and at the low end of
the range 7.9% of PCTs (n=12) are
very significantly different from the
England value (at the 99.8% level).
 19
Options for action

introduction of multidisciplinary teams to assess and treat diabetic foot
disease has reduced major and minor amputation rates, and has
generated savings.¹

In current guidelines it is recommended that all people with diabetes:

›› have an annual examination to assess individual risk, and those at
increased risk are referred to a member of a foot protection team
(typically includes podiatrists, orthotists and footcare specialists with
expertise in protecting the foot) for long-term surveillance;

›› have their foot risk assessed on admission to hospital for any
reason;

›› who have newly occurring foot disease are referred for urgent
assessment by a member of a specialist multidisciplinary team.

1. Rogers LC, Frykberg RG, Armstrong DG et al (2011) The Charcot foot in diabetes.
Diabetes Care 34: 2123-2129.

20
www.rightcare.nhs.uk/atlas

     In print
     You can order free printed copies
     using the online form on out website

     Online
     High and Low resolution PDFs are
     available for download

     Interactive
     A fully interactive InstantAtlastm
     is available online



21
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     www.rightcare.nhs.uk




22

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Diabetes atlas key headlines 2012

  • 1. The NHS Atlas of Variation in Healthcare for People with Diabetes May 2012 Copyright 2011 Right Care
  • 2. 2
  • 3. The burden of diabetes in England There are thought to be more than 3 million adult diabetics in England. Only 2.3 million of these have been diagnosed. By 2020, 3.8 million are expected to have diabetes – more than 1 in 12 of the total population. Variation in current processes and outcomes in people have significant implications for the NHS today and in the future 3
  • 4. National Diabetes Audit (NDA) (audit period 1 January 2009 and 31 March 2010) • More than 60% of people of all ages with Type 1 diabetes and almost half of people of all ages with Type 2 diabetes did not receive all nine care processes essential for management and detection of early complications • Two in 10 children aged 0–15 years have a most recent HbA1c of over 10%, making the long-term complications of diabetes more likely • People of all ages with diabetes are more than twice as likely to be admitted to hospital than people of a similar age who do not have the condition • People of all ages with diabetes stay in hospital almost 20% longer than people of a similar age who do not have the condition 4
  • 5. Diabetes is costly to treat… • In 2010/11, prescribing for anti-diabetic items, including blood-testing items, cost £725.1 million and accounted for 8.4% of the total spend on prescriptions in primary care • an increase of 41.2% since 2005/06 • The cost of prescribing for the treatment of diabetes is increasing faster than that for any other category of drugs Prescribing for Diabetes in England 2005/06 to 2010/11 http://www.ic.nhs.uk/webfiles/publications/prescribing%20diabetes%20200506%20to%20201011/P rescribing_for_Diabetes_in_England_20056_to_201011.pdf 5
  • 6. The concept of unwarranted variation in diabetes care The aim of the Diabetes Atlas is to identify and quantify the extent of ‘unwarranted’ variation that may be due to unjustified geographical differences in medical practice and/or patients not gaining access to the appropriate level of intervention for their need. The resulting suboptimal (either over-use or under-use) uptake of medical intervention is defined as ‘unwarranted’. 6
  • 7. “.. the indicators in this Diabetes Atlas clearly demonstrate there is considerable variation in both the processes and outcomes of care. Sadly, there are a substantial number of patients who are not receiving all of the nine basic care processes designed to identify treatable risks and early complications of diabetes. In the absence of these care processes, patients do not know if their level of health matches the recommended outcomes or if further care is needed, and neither do the healthcare professionals ” Dr Rowan Hillson MBE National Clinical Director for Diabetes 7
  • 8. Selection of indicators The indicators included in the Diabetes Atlas were chosen: ›› to reflect the range of diabetes care ›› because they could be calculated using robust nationally collated data at PCT level ›› Indicators were revised following consultation with the National Diabetes Information Service (NDIS) Expert Reference Group. 8
  • 9. The Atlas has been produced in collaboration with… Diabetes Health Intelligence is a strategic programme within the Yorkshire and Humber Public Health Observatory (YHPHO). The YHPHO has a commitment to support the diabetes community by providing timely, quality-assured national diabetes health intelligence. YHPHO is part of a network of nine public health observatories in England. http://www.yhpho.org.uk/ The National Diabetes Information Service (NDIS) is a national strategic partnership which provides health commissioners, providers and people with diabetes with the necessary information to aid decision-making and improve services on a local and national level. The five partner organisations are NHS Diabetes, Diabetes UK, Diabetes Health Intelligence, Innove and the NHS Information Centre for health and social care. The service is funded by NHS Diabetes. http://www.diabetes-ndis.org/ 9
  • 10. In presenting variation in this Atlas, PCTs are allocated Shifting the curve… to five groups, determined by their difference from the England average. This type of comparison is useful when rapidly analysing the potential for variation among populations or datasets. It is also important to pay attention to the England average value – in some examples the England average itself is relatively poor. For example, the percentage of people with diabetes in the NDA who have received all nine NICE recommended basic care processes : ›› For people with Type 1 diabetes, the England value is 31.9% and the range is 5.4–47.9% ›› For people with Type 2 diabetes, the England value is 52.9% and the range is 7.0–71.4% For indicators where the England value is relatively poor, the focus should be on shifting the distribution 10
  • 11. Magnitude of variation With respect to the percentage of people in the NDA with Type 1 diabetes receiving all nine key care processes: ›› For PCTs in England, the range is from 5.4% to 47.9%, a 9-fold variation; ›› The England value is 31.9%: at the high end of the range 24.5% of PCTs (n=37) and at the low end of the range 24.5% of PCTs (n=37) are very significantly different from the England value (at the 99.8% level). 11
  • 12. Magnitude of variation With respect to the percentage of people in the NDA with Type 1 diabetes receiving all nine key care processes: ›› For PCTs in England, the range is from 7.0% to 71.4% , a 10-fold variation; ›› The England value is 52.9%: at the high end of the range 48.3% of PCTs (n=73) and at the low end of the range 37.7% of PCTs (n=57) are very significantly different from the England value (at the 99.8% level). 12
  • 13. Options for action As almost half of the people with Type 2 diabetes and two out of three people with Type 1 diabetes have not received the basic standard of care, it is important that all commissioners and service providers ensure robust arrangements are put in place for everyone with diabetes to receive an annual review covering all nine care processes. Arrangements could include: ›› Administrative systems that reliably invite all people with Type 1 diabetes for their annual checks; ›› Processes to follow-up and remind non-attenders; ›› Alternative access arrangements; ›› Ensuring that scheduled checks are undertaken on attendance, and results recorded accurately. 13
  • 14. Magnitude of variation For PCTs in England, insulin total net ingredient cost per patient on GP diabetes registers ranged from £79 to £176 (2.2-fold variation). When the five PCTs with the highest costs and the five PCTs with the lowest costs are excluded, the range is £95–£158 per patient, and the variation is 1.7-fold. 14
  • 15. There is no correlation between spending on insulin items and the percentage of people with Type 1 diabetes or with Type 2 diabetes whose most recent HbA1c measurement was 7.5% (58 mmol/mol) or less at PCT level (see Figure 10.1). This would indicate that the PCTs spending the most on insulin do not necessarily have the greatest percentage of people with diabetes who have optimal blood-glucose control. There is a strong correlation between spending on insulin items in 2008/09 and that in 2009/10 (correlation coefficient, r=0.977; p<0.00005; see Figure 10.2), suggesting that prescribing patterns at a PCT level are persistent over time. These results suggest that the degree of variation observed in spending on insulin items is related to how local services are organised. 15
  • 16. Magnitude of variation People with diabetes are more likely than those without diabetes to be admitted to hospital. When in hospital, people with diabetes stay for longer when compared with people of a similar age admitted for similar conditions but who do not have diabetes. ›› For PCTs in England, the range is from –0.4% to 46.7%; ›› The England value is 19.4%: at the high end of the range 36.4% of PCTs (n=55) and at the low end of the range 42.4% of PCTs (n=64) are very significantly different from the England value (at the 99.8% level). 16
  • 17. Magnitude of variation With respect to excess emergency re-admissions among people with diabetes when compared with people without diabetes: ›› For PCTs in England, the range is from 15.8% to 100.2% , a 6-fold variation; ›› The England value is 59.1%: at the high end of the range 12.6% of PCTs (n=19) and at the low end of the range 9.9% of PCTs (n=15) are very significantly different from the England value (at the 99.8% level). This indicator is taken from the Variation in Inpatient Activity: Diabetes (VIA: Diabetes) 17
  • 18. Options for action Commissioners and providers need to investigate variation in length of stay at a local level, and consider auditing the reasons for re- admission of people with diabetes to identify whether there are specific factors that could be addressed. Length of stay for people with diabetes can be reduced by introducing dedicated inpatient diabetes teams, as achieved in local studies in Plymouth and Norwich. Dedicated inpatient diabetes teams, including diabetes specialist nurses, can reduce the length of stay for people with diabetes by providing: ›› diabetes training and awareness raising for non-diabetes clinical staff; ›› protocols for the management of patients with diabetes; ›› specific input into the management of patients experiencing problems with the control of their diabetes. 18
  • 19. Magnitude of variation People with diabetes are predisposed to developing foot ulcers primarily because of an increased risk of both peripheral arterial disease (PAD) and peripheral neuropathy. Chronic ulceration is the commonest precursor to major lower limb amputation (defined as above the ankle). ›› For PCTs in England, the range is from 0.1% to 0.5%, a 6-fold variation ; ›› The England value is 0.24%: at the high end of the range 3.3% of PCTs (n=5) and at the low end of the range 7.9% of PCTs (n=12) are very significantly different from the England value (at the 99.8% level). 19
  • 20. Options for action introduction of multidisciplinary teams to assess and treat diabetic foot disease has reduced major and minor amputation rates, and has generated savings.¹ In current guidelines it is recommended that all people with diabetes: ›› have an annual examination to assess individual risk, and those at increased risk are referred to a member of a foot protection team (typically includes podiatrists, orthotists and footcare specialists with expertise in protecting the foot) for long-term surveillance; ›› have their foot risk assessed on admission to hospital for any reason; ›› who have newly occurring foot disease are referred for urgent assessment by a member of a specialist multidisciplinary team. 1. Rogers LC, Frykberg RG, Armstrong DG et al (2011) The Charcot foot in diabetes. Diabetes Care 34: 2123-2129. 20
  • 21. www.rightcare.nhs.uk/atlas In print You can order free printed copies using the online form on out website Online High and Low resolution PDFs are available for download Interactive A fully interactive InstantAtlastm is available online 21
  • 22. Follow Right Care online: - Subscribe to get a weekly digest of our blog in your inbox - Receive Occasional eBulletins - Follow us on Twitter @qipprightcare www.rightcare.nhs.uk 22