Diabetes Health Needs Assessment

1. Diabetes Health Needs Assessment Greg Fell Greg.fell@bradford.nhs.uk

2. Structure and contentsright click on the hyperlink • Risk Factors and prevalence • Prevalence of diabetes • Health outcomes associated with diabetes • Emergency admissions – • direct complicaitons and microvascular • Emergency admissions – cardiovascular • Mortality associated with diabetes • Services available for treating diabetes • Primary Care • GPwSI – Satellite Clinics • Diabetic Retinopathy Screening • Dietetics • Secondary care – Outpatient • Overview of Programme Budget. • Key messages, recommendations and issues for service design • Do we under implement lifestyle interventions and prevention. There is scope for system and scale development. • Obesity as a future risk should not be ignored. • Prevalence varies across the alliances. Diagnosed and actual • Outcomes associated with diabetes are expressed principally as cardiovascular end points. It is possible to estimate the scale of the link. • 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 Primary care improvement – what are the options • The quality and reach of self care for diagnosed diabetic patients is untested in this HNA. • GPSI satellite clinics – locations and capacity – correlations with % prevalence. • Secondary Care services • Data issues – what data do (and should) we record: socio-demographics and outcomes. • Next steps

3. 1) Risk Factor prevalence Obesity Back to top

4. Obesity, deprivation (IMD 2004) and location of satellite clinics. Airedale DM % Prevalence Diagnosed (06 07): 3.8 Estimated actual: 4.8 YCPA DM % Prevalence Diagnosed (06 07): 3.7 Estimated actual: 5.1 S&W - DM % Prevalence Diagnosed (06 07): 3.6 Estimated actual: 5.0 City DM % Prevalence Diagnosed (06 07): 4.8 Estimated actual: 6.4 Back to top

5. 2) Prevalence of diabetes Back to top

6. Prevalence in Bradford District. Back to top

7. 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 Back to top

8. 3) Health outcomes associated with diabetes Emergency Admission – Direct complications and micro vascular, cardiovascular Mortality risk Back to top

9. i) Emergency Admissions – direct complications and microvascular. Back to top

10. Reason for admission. Direct complications and microvascular. Back to top

11. Ethnicity of patients admitted for direct complications and microvascular. Back to top

12. Age and sex profile of admitted patients – numbers (aggregate numbers over 7yrs) Back to top

13. Spend on diabetes admissions – glycaemia control and microvascular Back to top

14. ii) Emergency Admissions – cardiovascular (estimations based on population attributable risk) Back to top

15. Population Attributable Risk – an estimation of the % of first time MI associated with diabetes Back to top

16. Micro and Macro Vascular risks compared High outcome Low outcome Back to top

17. b) Mortality associated with diabetes Back to top

18. All cause and cardiovascular mortality Back to top

19. Programme expenditure compared with CVD Mortality at ‘old PCT’ level Airedale North S&W City

20. 4) Services available for treating diabetes Primary Care Dietetics Diabetic Retinopathy Screening GPwSI – Satellite Clinics Secondary care – Outpatient Back to top

21. a) Primary Care Data from QOF, Px Back to top

22. DM12 at practice level, with exception reporting. Back to top

23. DM 12 – range of BP Control achieved across all practices Back to top

24. DM17 – Cholesterol control with exception coding Back to top

25. Range of % of diabetic patients with controlled cholesterol at practice level. Back to top

26. There is a relationship between % of DM patients achieving cholesterol control and deprivation Back to top

27. Range of % of diabetic patients with controlled HBA1C at practice level. Back to top

28. 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. Back to top

29. b) Dietetics

30. Distribution of primary care dietetic hours for diabetic patients. * 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

31. c) Diabetic Retinopathy Screening

32. DR Screening

33. c) GPwSI Satellite clinics Back to top

34. 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. Back to top

35. d) OPD utilisation ??? Treat with suspicion DM Nurse OPD appointments are under what they should be ???where is the medic appts?? Back to top

36. Opth and Chiropady are the areas mostly involved in DM care Back to top

37. Utilisation by speciality and age Back to top

38. 5) Overview of Programme Budget. Back to top

39. There is an approximate 7 fold difference in diabetic medication spend per patient at HBA1C target Back to top

40. Estimation of total spend on diabetes care at Alliance level Back to top

41. Micro vascular outcomes and total estimated spend on DM care at practice level Blue line is mean for district. Back to top

42. 6) Key messages, recommendations and issues for service design • Do we under implement lifestyle interventions and prevention. There is scope for system and scale development. • Obesity as a future risk should not be ignored. • Prevalence varies across the alliances. Diagnosed and actual • Outcomes associated with diabetes are expressed principally as cardiovascular end points. It is possible to estimate the scale of the link. • 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 • The quality and reach of self care for diagnosed diabetic patients is untested and un-researched in this HNA. • GPSI satellite clinics – locations and capacity – correlations with % prevalence. • Secondary Care services • Data issues – what data do (and should) we record: socio-demographics and outcomes. Back to top

43. 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 Back to top

44. 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. Back to top

45. 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. Back to top

46. 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. Back to top

47. 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 Back to top

48. 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. Back to top

49. 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…. Back to top

50. 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 Back to top