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10 points. Diabetes Practice Profile 2011

10 points. Diabetes Practice Profile 2011 . Greg.fell@bradford.nhs.uk Jonathan.stansbie@bradford.nhs.uk Helen.Mcauslane@bradford.nhs.uk Simon.grant@bradford.nhs.uk. What we did was simple. Routinely available data QOF - 07/08 to 09/10 Admits – NHS comparators 07/08 to 09/10

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10 points. Diabetes Practice Profile 2011

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  1. 10 points. Diabetes Practice Profile 2011 Greg.fell@bradford.nhs.uk Jonathan.stansbie@bradford.nhs.uk Helen.Mcauslane@bradford.nhs.uk Simon.grant@bradford.nhs.uk

  2. What we did was simple. • Routinely available data • QOF - 07/08 to 09/10 • Admits – NHS comparators 07/08 to 09/10 • Px – Epact. 2011 only • Only the simplest level of analysis is incorporated here.

  3. Point 1 Growth in prevalence. Variation in prevalence

  4. There is substantial variation in prevalence of diagnosed diabetes at practice level.09 10 there the prevalence of DM was 5% (95%CI 4.9 – 5.1), 26,000 cases.There has been growth in prevalence diagnosed – 13% growth in list size over 3 yearsestimated true prevalence is approx

  5. Prevalence varies across practices

  6. Not all diabetes is diagnosed.77% of diabetes is diagnosed, a slightly higher proportion in Bradford than elsewhere. ?case finding?

  7. Point 2 there has been improvement in achievement in key indicators of CV riskDM 12 - BPDM 17 – Cholesterolthere is variation

  8. Achievement DM12 and DM17 Exceptions - DM12 and DM17

  9. Point 3There is variation in achievement of HBA1C targets, and exception coding ratesDM 23, 24, 25 – HBA1C target of 7,8 and 9

  10. Point 4City Care is consistently exception coding more patients from glycaemic indicatorsthe picture is less clear for macro-vascular indicators

  11. Micro vascular Macro vascular

  12. Point 5Of the top 10 highest achieving practices for DM23 (HBA1C 7), half are in the lowest 50% spending practices for DM meds.There seems a poor relationship between med spend and controlOnly 1 of the top 10 spending practices is in the top 10 achieving practices

  13. Spend / DM patient (medicines) and glycaemia control

  14. Point 6Quadrant chartscan give indicators to spend and outcomes

  15. Practice level spend (meds) and glycaemia control

  16. Point 7 The prescribing bill for diabetes is approx £3m.There is significant spend per head variation

  17. We spend £54 per diabetic patient per year on testing strips £1.4m per year. The correlation between spend per head on test strips and spend per head on insulin is moderate – R2 = 0.68 - but cant un itself totally explain the variation.

  18. Point 8It is relatively expensive to manage people to tight HBA1C targetsit costs twice as much per patient to meet the HBA1C target of 7 as it does 9.are the outcomes twice as good?

  19. Is the additional spend to get p to target of 7 worth it in terms of the additional health it buys The evidence might suggest it is NOT – ACCORD tailored prescribing rather than blanket approach Squaring this with QOF points for meeting stringent targets will be interesting.

  20. The nature of the evidence, and interpretation of the evidence re blanket approach to tight control appears to be shifting. • The evidence to support tight glycaemic control in either macro or micro vascular complications is weak, especially when expressed epidemiologically and in absolute terms. • There is growing evidence highlighting limited significant differences between different classes of third line agents. • Large expense might not be justified.

  21. Point 9 There is a large variation in spend to get people to the HBA1C target.Concordance and compliance might be an issue.

  22. Variation in spend to get DM patients to each of the 3 targets – 7,8 and 9 Practice level. All DM Medicines.

  23. Point 10 There is moderate correlation between ethnicity in the practice and glycaemic control same for deprivation profilepoorer populations have worse outcomesAsian populations have worse outcomes.

  24. NB treat with caution. This is not adjusted for % exception coded. correlation between deprivation score and HBA1C 9 - DM25Acheivement = -.051 Practices with poorer populations have lower achievement oftheDM25 indicator correlation between % S Asian score and HBA1C 9 - DM25Acheivement = -0.47 Practices with high % S Asian have lower achievement of the DM25 indicator correlation between spend / pt at 9 target and % S Asian = 0.60. Practices with higher % S Asian spend more / pt to get them to the HBA1C target of 9

  25. And so what?

  26. QIPP – scope for improving quality and reducing cost • Targeting services and support where outcomes are least good • More nuanced interpretation • Formulary. • Nuanced vs blanket approach to prescribing 3rd line agents – taking into account pt preferences, circumstances AND cost. • Systematic approach – DH HI NST • Quality Improvement methodology • Targeted and focused approach to reducing spend

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