diabetes health needs assessment greg fell [email protected]
TRANSCRIPT
Structure and contentsright click on the hyperlink
1. Risk Factors and prevalence2. Prevalence of diabetes3. Health outcomes associated with diabetes
a) Emergency admissions – i. direct complicaitons and microvascular ii. Emergency admissions – cardiovascular
b) Mortality associated with diabetes
4. Services available for treating diabetesa) Primary Careb) GPwSI – Satellite Clinicsc) Diabetic Retinopathy Screeningd) Dieteticse) Secondary care – Outpatient
5. Overview of Programme Budget.6. Key messages, recommendations and issues for service design
a) Do we under implement lifestyle interventions and prevention. There is scope for system and scale development.b) Obesity as a future risk should not be ignored.c) Prevalence varies across the alliances. Diagnosed and actuald) Outcomes associated with diabetes are expressed principally as cardiovascular end points. It is possible to estimate the scal
e of the link.e) Primary Care services achieve improving outcomes, but there is variation across practices and alliances. Variations in except
ion reporting has been suggested as a quick winPrimary care improvement – what are the options
f) The quality and reach of self care for diagnosed diabetic patients is untested in this HNA.g) GPSI satellite clinics – locations and capacity – correlations with % prevalence.h) Secondary Care servicesi) Data issues – what data do (and should) we record: socio-demographics and outcomes.
7. Next steps
1) Risk Factor prevalence
Obesity
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Obesity, deprivation (IMD 2004) and location of satellite clinics.
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Airedale DM % Prevalence Diagnosed (06 07): 3.8Estimated actual: 4.8
YCPA DM % Prevalence Diagnosed (06 07): 3.7Estimated actual: 5.1
S&W - DM % Prevalence Diagnosed (06 07): 3.6Estimated actual: 5.0
City DM % Prevalence Diagnosed (06 07): 4.8Estimated actual: 6.4
2) Prevalence of diabetes
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Prevalence in Bradford District.
Approximate Prevalence at Alliance Level (0607 QOF Registers)
Alliance
Average of % practice population aged 75 plus
Average of Practice Deprivation score
Registered diagnosed diabetic patients (QOF 0607)
Registered population (FHS Dec 07)
Estimated diagnosed prevalence
YHPHO Estimated Actual Prevalence (2006) - old PCTs
implied diagnosis rate
Airedale 8.5 23.1 3524 92341 3.8 4.84 78.85%
CityCare 3.4 49.8 6972 146211 4.8 6.42 74.27%
Independent 10.7 7.3 214 11293 1.9
S&W 6.6 35.6 6000 166023 3.6 5.01 72.13%
YCPA 8.2 23.8 4313 117967 3.7 5.05 72.40%
Bradford and Airedale District 21023 533835 3.9 5.34 73.75%
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There are differences between diagnosed and (estimated) actual prevalence at practice level. There is variance in the
scale of this difference across all the practices in the district
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
% p
reva
lenc
e
Practice
Diabetes PrevalenceGP Practice prevalence compared to locally expected prevalence by ward
QOF Prevalence Expected Diabetes Prevalence
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3) Health outcomes associated with diabetesa) Emergency Admission –
i. Direct complications and micro vascular, ii. cardiovascular
b) Mortality risk
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i) Emergency Admissions – direct complications and microvascular.
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Reason for admission. Direct complications and microvascular.
reasons for admission - average admissions per year, % of total
110, 30%
44, 12%
81, 23%
56, 16% 66.5, 19%
Diabetic Hypoglycaemia
Diabetic Ketoacidosis
Diabetic Lower Limb Amp
Diabetic Nephropathy
Diabetic Retinopathy
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Ethnicity of patients admitted for direct complications and microvascular.
Ethnicity of admitted patients (02 - 07)
0%
20%
40%
60%
80%
100%
31/0
3/20
02
31/0
3/20
03
31/0
3/20
04
31/0
3/20
05
31/0
3/20
06
31/0
3/20
07
31/0
3/20
08
All yea
rs
not given, not stated or other
Black (African, Caribbean,Asian, Other)
White (British, Irish, Other)
Pakistani
Indian
Bangladeshi
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Age and sex profile of admitted patients – numbers (aggregate numbers over 7yrs)
Admissions by Age and Gender (7 years)
0
20
40
60
80
100
120
140
160
180
0 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 - 94 95 +
Age Band
Num
ber (
over
who
le 7
year
per
iod)
F
M
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Spend on diabetes admissions – glycaemia control and microvascular
Assumed average per year (£)
Registered population (Dec 2007 FHS)
Diagnosed Diabetic Patients (06 07 QOF)
Assumed average spend on admitted patients (£) per head of registered population
Assumed average spend on admitted patients (£) per diagnosed diabetic
unknown and not available 32,313
Airedale Alliance 151,563 92341 3524 1.64 43.01
CityCare Alliance 254,146 147323 6972 1.73 36.45
Independent 9,516 11293 214 0.84 44.47
South And West Alliance 299,973 164911 6000 1.82 50.00
Yorkshire Primary Care Alliance 163,232 117967 4313 1.38 37.85
District 910,743 533835 21023 1.71 43.32
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ii) Emergency Admissions – cardiovascular (estimations based on
population attributable risk)
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Population Attributable Risk – an estimation of the % of first time MI associated with diabetes
Population Attributable risk % of first time MI associated with Diabetes
Total Airedale Alliance 5.0
Total City care Alliance 6.1
Total S&W Alliance 4.7
Total YPCA Alliance 4.8
Total Independent Alliance 2.5
Bradford and Airedale 5.1
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Micro and Macro Vascular risks compared
DM17 (Macrovascular - Cholesterol) plotted against DM20 (Microvascular - HBA1C) 0607
B83624
B83620
B83602
B83061
B83033
B83027
B83023
B83021
B83008
B83006
B83019
B83002Y01118
B83700
B83661
B83660
B83659
B83653
B83642
B83641
B83638
B83631
B83629
B83628
B83627
B83626
B83622
B83621
B83619
B83618
B83617
B83614
B83613
B83611B83604
B83070
B83069B83058
B83052
B83051
B83043
B83034
B83032
B83026
B83025
B83016
B83011
B83005 B83658
B83657
B83647
B83630
B83071
B83055
B83050B83049
B83045
B83044
B83042
B83041
B83037
B83035
B83030
B83029
B83028
B83020
B83017B83015
B83012
B83010
B83009
B83007B83067
B83066
B83064
B83063
B83062
B83056
B83054
B83040
B83039
B83038
B83031
B83022
B83018
B83014
B83013
50
55
60
65
70
75
80
85
90
95
100
30 40 50 60 70 80 90 100DM20 - Micro Vascular Control HBA1C < 7.5
DM
17 C
on
tro
lled
Ch
ole
ste
rol -
Test
<5m
mo
l
Airedale
CityCare
Independent
S&W
YCPA
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Low outcome
High outcome
b) Mortality associated with diabetes
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All cause and cardiovascular mortality
All Cause CV Death associated with Diabetes Prevalence
all cause mortality associated with Diabetes
Total Airedale Alliance 8.71 3.07
Total City care Alliance 10.58 3.78
Total S&W Alliance 8.34 2.93
Total YPCA Alliance 8.37 2.95
Total Independent Alliance 4.52 1.55
Bradford and Airedale 8.96 3.17
Risk Ratio (FPH Toolkit) - Relative risk DM and CV death - all cause
Risk Factor adjusted Risk Ratio (both sexes) - DM and first time MI (Bertoni et al, Am J Epid, 2004)
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Programme expenditure compared with CVD Mortality at ‘old PCT’ level
S&W
North
Airedale
City
4) Services available for treating diabetes
a) Primary Careb) Dieteticsc) Diabetic Retinopathy Screeningd) GPwSI – Satellite Clinicse) Secondary care – Outpatient
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a) Primary Care
Data from QOF, Px
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DM12 at practice level, with exception reporting.
DM 12 - % patients whose BP <= 145/85
0%
20%
40%
60%
80%
100%
Practice Code
Target Met Target Missed Exception coded
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DM 12 – range of BP Control achieved across all practices
DM 12 (06 07) - % of diabetic patients with BP 145 / 80 or less. Range and alliance.
0
10
20
30
40
50
60
70
80
90
100Airedale
CityCareIndependentS and W
YCPA
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DM17 – Cholesterol control with exception coding
DM 17 - % patients whose last measured cholesterol <= 5 mmol/l (measured in last 15
months)
0%
20%
40%
60%
80%
100%
Practice code
Target Met Target Missed Exception coded
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Range of % of diabetic patients with controlled cholesterol at practice level.
DM 17. % of Diabetic patients with cholesterol of 5mmol or less. Range and alliance
50
55
60
65
70
75
80
85
90
95
100
Airedale
CityCare
Independent
S and W
YCPA
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There is a relationship between % of DM patients achieving cholesterol control and deprivation
DM17 0607 - % of patients with DM with cholesterol reading (last 15m) <5mmol, plotted against practice deprivation score. Practices Grouped by alliance.
HAWORTH MEDICAL PRACTICE
FARFIELD GROUP PRACTICE
NORTH STREET SURGERYKILMENY SURGERY
HOLYCROFT SURGERYILKLEY MOOR MEDICAL PRACTICE
ADDINGHAM SURGERY SILSDEN GROUP PRACTICE
OAKWORTH HEALTH CENTRE
LINGHOUSE MEDICAL CENTRE
SMITH LANE MEDICAL PRACTICE
POLLARD PARK HEALTH CENTRE
BERTRAM ROAD
SAI MEDICAL CENTRE FOUNTAINS HALL MEDICAL PRACTICE
BRADFORD MOOR PRACTICE MANNINGHAM MEDICAL PRACTICEPEEL PARK SURGERY
ALICE STREET SURGERYPARK GRANGE MEDICAL CENTREOTLEY ROAD MEDICAL CENTRE
WOODHEAD ROAD SURGERY WHITES TERRACE - MAHMOODWOODROYD CENTRE - LONGFIELD
DR CP SAHAYOAK LANE SURGERYFARROW MEDICAL CENTRE BARKEREND HC - EL ELIWI
ASHWELL MEDICAL CENTRE
DR BASUTHE AVICENNA MEDICAL PRACTICEDR GILKARDR FENWICK
BARKEREND HEALTH CENTRE - EL AZABBARKEREND HC - HAQUEKENSINGTON ST HC - MALHOTRABILTON MEDICAL CENTREUNIVERSITY STUDENT HC
DR A AZAMKENSINGTON ST HC - WILSONLITTLE HORTON LANE MEDICAL CENTRE-MALL
PICTON MEDICAL CENTRE
THORNBURY MEDICAL PRACTICEFRIZINGHALL MEDICAL CENTRE MUGHAL MEDICAL CENTRE
DR SHM HAMDANI
THORNTON MEDICAL CENTRE
SUNNYBANK MEDICAL CENTRE
THE HEATON MEDICAL PRACTICEWILSDEN HEALTH CENTRE
WIBSEY & QUEENSBURY MED P
ROYDS HEALTHY LIVING CTREPHOENIX MEDICAL PRACTICE
MAYFIELD MEDICAL CENTRE
THE RIDGE MEDICAL PRACT.THE WILLOWS MEDICAL CTR.
HANSON PLACE SURGERYTHE GRANGE PRACTICE DR MILLS & PRTNRS
COWGILL SURGERYDR MICALLEF & PRTNRS
CARLTON MEDICAL PRACTICEHORTON BANK PRACTICE
ROOLEY LANE MED. CENTRELOW MOOR SURGERY
BOWLING HALL MED PRACTICE
PARKLANDS MEDICAL PRACTICE
BEACON RD SURGERY
BEVAN HOUSE
HORTON PARK SURGERY - GAGUINE
THE SPRINGFIELD SURGERY (BINGLEY)SALTAIRE MEDICAL PRACTICE DR MC EISNER'S PRACTICE
DR GS OVEREND'S PRACTICEDR JG CRAIG'S PRACTICE
DR NB WINN'S PRACTICEDR JA BIBBY'S PRACTICEPRIESTTHORPE MEDICAL CENTRE
DR PM GOMERSALL'S PRACTICE LEYLANDS MEDICAL CENTREDRS JENNINGS AND ROBSON
DRS RAI AND DUKE DR RT VAN DER WERT'S PRACTICE
DR WSG PASSANT'S PRACTICEDR AM ROBERTS' PRACTICE
45
55
65
75
85
95
0 10 20 30 40 50 60 70
Practice deprivation score (higher is more deprived)
% o
f D
M p
ati
en
ts w
ith
ch
ol
rea
din
g o
f 5
mm
ol
or
les
s
Airedale
CityCare
Independent
S and W
YCPA
Linear (CityCare)
y = -0.2303x + 88.877R2 = 0.2135
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Range of % of diabetic patients with controlled HBA1C at
practice level.
DM20 0607 - Range of Glycaemic control. Range and alliance
25
35
45
55
65
75
85
95
%
Airedale
CityCare
Independent
S and W
YCPA
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DM 20. With Exception Codes. There is a high proportion of exceptions and approx 50% of patients (taking into account
exceptions) are not achieving glycaemic control.
DM 20 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
0%
20%
40%
60%
80%
100%
Practice code
Target Met Target Missed Exception coded
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b) Dietetics
Distribution of primary care dietetic hours for diabetic patients.
Alliance
% of registered population aged 75 plus
Number of DM patients (QOF 06 07)
% of registered patients diagnosed with Diabetes
Number of Dietetic clinics per year for DM patients
total DM dietetic hours per year (based on number of 3 hour sessions per practice)
Number of DM dietetic hours per diabetic patient (annual)
Number of DM dietetic hours per 1,000 DM patients
Airedale Alliance 8.13 3524 3.82 76* 228* 0.065* 64.69*
City care Alliance 3.30 6972 4.73 466 1398 0.201 200.52
S&W Alliance 6.57 6000 3.64 164 492 0.082 82.00
YPCA Alliance 8.04 4313 3.66 106 318 0.074 73.73
Independent Alliance10.27 214 1.89 0 0 0.000 0.00
Bradford and Airedale District. 6.34 21023 3.94 812 2436 0.116 115.87
* The model for dietetic provision in Airedale is different. Historic arrangement of centralisation of dietetic services for DM patients. Model is currently provision at Keighley, Bingley HC, AGH and Ilkley Coronation. GPs and Consultants can refer into this. In addition 18sessions per year at Wilsden and 12 Sessions per year for diabetic patients at Howarth practices. Due to geographical isolation
c) Diabetic Retinopathy Screening
DR Screening
% of At risk patients DR Screened Jan 01 - Dec 31 07
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Dr Abb
as S
F
Wes
twoo
d Par
k DTC
Founta
in Hall M
edica
l Pra
ctice
Grange
Park
Surger
y
Ilkley
& W
harfe
dale M
edica
l Pra
ctice
Bilton M
edica
l Cen
tre
Man
ningha
m Medic
al Pra
ctice
Dr Mahm
ood
M
Picton M
edical
Centre
Avicenn
a Med
ical P
ract
ice
Dr Bas
u S
Thorn
bury
Medical
Centre
Litt le
Hor
ton L
ane M
edical
Centre
- Dr M
all
Woo
dhead
Roa
d Sur
gery
The B
radfo
rd M
oor P
racti
ce
Ilkley
Moor
Med
ical P
racti
ce
Ashwell
Medic
al Centr
e
Park Gra
nge M
edical
Centre
Dr C M
icalle
f & P
artn
ers
Ashcro
ft Sur
gery
Peel Par
k Surg
ery
Dr Aza
m A
The R
idge M
edica
l Pra
ctice
Dr I G
ilkar
Pollard
Park
Surg
ery
Dr Adil
Sule
man
- The
Surg
ery
Carlto
n Med
ical P
racti
ce
Dr M L
ongf ie
ld
The S
pringfi
eld Surg
ery
Haigh H
all M
edica
l Cen
tre
Sunnyb
ank M
edica
l Pra
ctice
Cowgil
l Surg
ery
Priestt
horp
e Medic
al Cen
tre
Dr Cla
rke R
& P
artn
ers
Hanso
n Plac
e Surg
ery
The H
ealth
Centr
e (D
r Jen
nings)
May
field M
edica
l Cen
tre
Rockw
ell M
edica
l Cen
tre
Silsde
n Healt
h Cent
re
Low M
oor M
edical
Centre
The W
illows M
edica
l Cen
tre
Oakworth
Healt
h Cen
tre
Windh
ill Gre
en M
edical
Centre
Wes
tcliffe
Med
ical C
entre
Saltaire
Med
ical C
entre
Farfie
ld G
roup P
racti
ce
Karet B
J - Le
yland
s Med
ical C
entre
Newto
n Way
Sur
gery
Clif fe A
venue
Surg
ery
Otley R
oad M
edica
l Cen
tre
c) GPwSI Satellite clinics
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Level 2 Clinics – location, capacity and diabetes prevalenceMAGS – had we best come up with some explanation of
this……..I have lifted it from something you sent me.
Number of
persons registere
d with Diabetes
(QOF 0607)
Registered List Size (FHS
Dec 07)
Registered
Diabetes %
prevalence
Diagnosed
Estimated 2006 diabetes
true prevalen
ce %
Predicted Total patients in Level 2 service
Annual new patients - estimated
New patient assessment appointments
New patient - not insulin appointments insulin starts
Number of FU appts
Total number of sessions
Airedale
352492341 3.81
4.85
500 159 318 320 960 1500 309
YPCA
4313
117967
3.65 5.05
717 223 446 360 1080 2151 403
City
6972147323
4.73 6.43
982 350 700 400 1200 2946 749**
South and West
6000164911
3.64 5.01
955 236 472 360 1020 2865 471
B&A District 21023 533835 3.94 5.34 3154 968 1936 1440 4260 9462 1183
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d) OPD utilisation
??? Treat with suspicionDM Nurse OPD appointments are
under what they should be???where is the medic appts??
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Opth and Chiropady are the areas mostly involved in DM care
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What specialties are involved in OPD care - proprotionate split
5771, 19%
822, 3%
20190, 67%
2070, 7%
15, 0%
242, 1%30, 0%
944, 3%
Ophthalmology Diabetic
Diabetic Nurse
Diabetic Chiropody
Diabetic Dietitian
Paediatric Diabetic
Paediatric Diabetic Transfer
Postnatal Diabetic OPD
Antenatal Diabetic OPD
Utilisation by speciality and age
utliisation of OPD specialties with age - cumulative numbers - 04/05 - 07/08
0
1000
2000
3000
4000
5000
6000
7000
8000
0 - 14 15 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 85 +
age group
nu
mb
er
of
ap
po
intm
en
ts (
ov
er
4 y
ea
r p
eri
od
)
PaediatricDiabeticDiabeticDietitianDiabeticChiropodyDiabetic Nurse
OphthalmologyDiabetic
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5) Overview of Programme Budget.
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There is an approximate 7 fold difference in diabetic medication spend per patient at HBA1C target
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DIABETES (6.1) SPEND PER PATIENT PER YEAR AT TARGET
£0.00
£200.00
£400.00
£600.00
£800.00
£1,000.00
£1,200.00
£1,400.00
£1,600.00
Sp
en
d o
n a
ll D
M D
rug
s (
BN
F 6
.1)
airedale
Citycare
YPCA / S&W
Estimation of total spend on diabetes care at Alliance level
AllianceTotal Sec Care Spend estimate QOF costs
Drug Cost (BNF 6.1) - Prim Care
Sec Care (OPD and Admit)
Total Spend Estimate - prim care drugs, sec care, QOF
Number of diabetic patients diagnosed
Estimation of cost per patient diagnosed
Airedale172,072 (NB underestimate
– No OPD)118,534 975,176 172,072 1,265,782
3524 359.19
City Care 481,578 446,577 1,937,760 481,578 2,865,9146972 411.06
S&W 581,561 283,272 1,647,009 581,561 2,511,8426000 418.64
YPCA 327,940 174,417 1,050,570 327,940 1,552,9274313 360.06
Independent 10,955 15,896 68,214 10,955 95,065214 444.23
Bradford and Airedale District (Registered Bradford practice)
1,574,106 1,038,695 5,678,728 1,574,106 8,291,52921023 394.40
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Micro vascular outcomes and total estimated spend on DM care at practice levelPBMA microvascular control - DM20 - HBA1C <7.5 in last 15 months. Spend (drugs, OPD,
admits)
B83624 Ilkley Moor Medical Practice
B83620 103 Main Street
B83602 North Street Surgery
B83061 Oakworth Health Centre
B83033 Kilmeny Surgery
B83027 Station Road SurgeriesB83023 Holycroft Surgery
B83021 Farfield Group PracticeB83008 Ling House Medical Centre
B83006 Silsden Health Centre
B83700 Fountains Hall Medical Practice
B83661 The Bluebell Building
B83660 Bilton Medical Centre
B83659 Park Grange Medical Centre
B83653 Little Horton Lane Medical Centre
B83642 21 Bertram Road
B83641 Ashwell Medical Centre
B83638 Pollard Park Health Centre
B83631 Woodhead Road Surgery
B83629 Peel Park Surgery
B83628 The Surgery, Alice Street
B83627 Frizinghall Medical Centre
B83626 Otley Road Medical Centre
B83622 Kensington St Health Centre
B83621 9 Pemberton Drive
B83619 Sai Medical Centre
B83618 1, Smith Lane
B83617 27 Whites Terrace
B83614 Picton Medical Centre
B83613 Manningham Medical Practice
B83611 The Bluebell Building
B83604 Westbourne Green CHC Centre
B83070 Mughal Medical Centre
B83069 3 Whites Terrace
B83058 The Avicenna Medical Practice
B83052 Kensington St Health Centre
B83051 University of Bradford Health Centre
B83043 Woodroyd Centre
B83034 Grange Medical Centre
B83032 The Daff odil BuildingB83026 The Daff odil BuildingB83025 Little Horton Lane Medical Centre
B83016 Farrow Medical Centre
B83011 Woodroyd Centre
B83005 Laisterdyke Clinic
B83658 Royds Healthy Living Centre
B83657 Bevan House
B83647 71 Beacon Road
B83630 5 Hanson Place
B83071 Phoenix Medical Practice
B83055 The Ridge Medical Practice
B83050 The Grange Practice
B83049 Grange Lea
B83045 Mayfield Medical Centre
B83044 Highfield Health Centre
B83042 Rooley Lane Medical Centre
B83041 Bowling Hall Medical Practice
B83037 Wilsden Medical Centre
B83035 Horton Park Surgery
B83030 Thornton Medical Centre
B83029 Low Moor House
B83028 Wibsey & Queensbury Medical Practice
B83020 The Willows Medical Centre
B83017 Horton Bank Practice
B83015 Highfield Health Centre
B83012 Carlton Medical Practice
B83010 Parklands Medical Practice
B83009 Sunny Bank Medical Centre
B83007 Heaton Medical PracticeB83067 The Springfield Surgery, Park Rd
B83066 Bingley Health Centre
B83064 Wrose Health CentreB83063 Shipley Health Centre
B83062 Ashcroft Surgery
B83056 1 Thornbridge MewsB83054 Haigh Hall Medical Centre
B83040 Saltaire Medical Centre
B83039 Windhill Green Medical Centre
B83038 Leylands Medical Centre
B83031 Bingley Health Centre
B83022 Newton Way Surgery
B83018 Idle Medical Centre
B83014 Priestthorpe Medical Centre
B83013 Westcliff e Medical Centre
0
10
20
30
40
50
60
70
80
90
100
0 50,000 100,000 150,000 200,000 250,000 300,000
annual spend at practice level - drugs, OPD and admissions - per practice
% p
ati
en
ts a
ch
eiv
ing
HB
A1
C <
7.5
(D
M2
0)
Airedale
CityCare
Independent
S&W
YCPA
low spend / high outcomehigh spend / high outcome
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Blue line is mean for district.
6) Key messages, recommendations and issues for
service design
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a) Do we under implement lifestyle interventions and prevention. There is scope for system and scale development.
b) Obesity as a future risk should not be ignored.
c) Prevalence varies across the alliances. Diagnosed and actual
d) Outcomes associated with diabetes are expressed principally as cardiovascular end points. It is possible to estimate the scale of the link.
e) Primary Care services achieve improving outcomes, but there is variation across practices and alliances. Variations in exception reporting has been suggested as a quick win
f) The quality and reach of self care for diagnosed diabetic patients is untested and un-researched in this HNA.
g) GPSI satellite clinics – locations and capacity – correlations with % prevalence.
h) Secondary Care services
i) Data issues – what data do (and should) we record: socio-demographics and outcomes.
a) Do we under implement lifestyle interventions and prevention. There is scope for system and scale
development.• Lifestyle interventions. American and Finnish studies have reported excellent
results.– 58% preventable / Significant delay in onset / Delay in development of complications.
• Do we under implement these interventions?• What is the role we need to develop for a range of support services• What of ‘industrialisation’? Systematise and scale. Equality component to this!• Development of Cardiovascular Risk Screening, as per recent DH announcement will
assist greatly with this process – especially system and scale.– Issues re equality and the capacity in services to ‘treat’ those identified as high risk
remain unresolved issues.• The notion of a ‘health gain schedule’, as part of a contract with all providers. Setting out
a minimum suite of lifestyle interventions to be systematically applied. • Careful commissioning needed. This crosses over into many other disease areas. Some
considerations:– Appropriate, intense and repeated social marketing. Continually reinforce healthy
living messages – appropriate to a range of target audiences– Weight management, smoking cessation, Exercise, Health trainers– Community development – in some parts of the district…….use the expertise, on the
ground knowledge and contacts to access groups that might not otherwise come to health care services.
– Smoking cessation – macro vascular risk - how much / how intense efforts to goes in to help diabetic smokers to stop
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b) Obesity as a future risk should not be ignored.
• Under-ascertainment of obesity in primary care. – Understandable given the weight given in
QOf?– If not picked up, possibly not well managed. – Even minor weight loss can confer significant
health benefits.– Capacity in weight management pathway.
Pharmacological and non pharmacological interventions – particularly the latter.
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c) Prevalence varies across the alliances. Diagnosed and actual
• Incidence – certain population groups more likely to develop diabetes. – Ethnicity risk, over an above deprivation. – People living in socio economically deprived areas (most likely lifestyle
risk). – Older people.
• 21,000 diagnosed diabetics, 3.9% (3.7 – 4.8%)• True population prevalence is greater – estimated in 2006 to be 5.4%
– Bradford estimates commonly seen as significantly under estimates – ethnicity as a genetic risk / ethnic profile of the district is not the same as England
– Strong correlation with deprivation– 60% female, 40% male (approaching 50:50 in city)– Much higher prevalence as age increases
• Some evidence that some pop groups less likely to access services once diagnosed – or poorer control if they do access.– Not all about deprivation – some practices in the most deprived areas
achieve highly.
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d) Outcomes associated with diabetes are expressed principally as cardiovascular end points. It
is possible to estimate the scale of the link.
• Relatively few deaths directly attributable to diabetes.
• Approx 9% of CV deaths, 3% all cause mortality and 5% of first time MI admits attributable to diabetes.
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e) Primary Care services achieve improving outcomes, but there is variation across practices and alliances.
Variations in exception reporting has been suggested as a quick win
Macro vascular• BP recording good and improving
– 22% of non exempted DM patients do not meet BP control target. 60% in the worst performing practice, 5% in the best.
• Chol recording good and improving.– 20% of non exempted DM patients do not meet Chol targets. 45% in worst, 3% in
best.– For chol – deprivation profile of registered patients is a significant factor, as is
age profile. (Less of an issue for BP control.)
Microvascular• 35% of non exempted patients don’t meet HBA1C targets. 70% in worst performing
practice, 3% in best.
• EXPLORING DIFFERENCES IN EXCEPTION REPORTING is a key area for consideration. The figures above don’t take into account the variability in exemptions.
• The QOF data gives suggestions as to which practices to target service improvement and support activities
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Primary Care Improvement – what are the options
Some options:• The QOF data suggest where improvements are needed.• Not all about deprivation – some practices in deprived areas
achieve.• ‘buddying’ and partnering – high and low performing practices.
Clinical and organisational.• Robust performance management, and use of powers in contract to
introduce competition where appropriate to do so.• Role of GPSI in supporting clinical and organisational aspects of
care• Role of CD workers – explore fully. In the broader context of CVD• GPSI buddying supporting poorly performing practices• Access strategies / user interface – informed by social marketing
and strong community development – getting a REAL understanding of the target market and preferred communication styles.
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f) The quality and reach of self care for diagnosed diabetic patients is untested in this HNA.
• No data here on self care.• Most people see their Dr only 1 or 2 per year – thus for 363 days,
self care• NICE (and NSF) – recommend structured group education –
provided locally– HCC review DM services nationally (2006) – 11% of DM patients had
received self care support / advice of any type (regardless of whether meets NICE standard)……socio economic / ethnic divide presumably sharp…….(though not tested)
– Funding for self care made available from DH – but in the baseline – thus local prioritisation
• How good are our self care programmes?– Under implemented (esp in areas / pop with most need?)– Culturally and ethnically sensitive– Language / reading age / AV material etc etc……..health trainers etc….
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g) GPSI satellite clinics – locations and capacity – correlations with % prevalence.
• Prevalence should tell us something about location.
• Capacity in CityCare equals need, especially given the complexity of the population.
• Equality across the whole district, and geographic accessibility to pockets of high prevalence outside CityCare needs to be tested and assessed.
• Language support may need to be addressed, written and translation
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h) Secondary Care services
Admits• 2400 over a 7 year period –
admits directly related to DM and micro vascular complications.
• Length of stay is shortening over time.
• Men seem more likely to be admitted (despite lower prevalence)
• Static trend in admissions• Average spend on admitted
patients per diagnosed diabetic patient varies from £36 (Citycare) to £50 (S&W).
OPD• 30,000 OPD appointments
over 4 year. • Bradford FT ONLY. No
Airedale OPD data
• Chiefly chiropody (67%), opth (19%), dietician (7%).
• First Attendance to Follow up – 1:10, relatively static. – S&W, YCPA higher rate than
City Care
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i) Data issues – what data do (and should) we record: socio-demographics and outcomes.
• This review considered routinely available data.• Is there a need for more detailed review, plus
addition of additional audits of specific areas of care? This might include:– Within primary care, satellite clinics, secondary
care…….• Agree a clear and common set of clinical quality,
organisational performance and public health data for ongoing analysis. A core data set.
• Analyst capacity within Performance and Information Directorate to undertake needs consideration if this is taken forward.
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7) Next Steps
Next Steps
• This Health Needs Assessment might inform development of future services
• It is only one of the considerations• Patient experience, user involvement not sought
during this HNA. It should be.• Some options for change already on the table.
– Prioritisation of these and other developments– A range of perspectives to be considered in this
(clinical, patient, corporate). And a mechanism for doing so. PBMA approach is recommended.
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