10 points. Diabetes Practice Profile 2011

Greg.fell@bradford.nhs.ukJonathan.stansbie@bradford.nhs.ukHelen.Mcauslane@bradford.nhs.ukSimon.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• Px – Epact. 2011 only• Only the simplest level of analysis is

incorporated here.

Point 1 Growth in prevalence. Variation in prevalence

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

Prevalence varies across practices

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

estimated number of people with

diabetes

Prevalence (True -

diagnosed + undiagnosed)

Lower uncertainty limit

Upper uncertainty limit

QOF 2008/09 prevalence (aged

17+ years)

Proportion of estimated

cases on QOF registers

England 3,034,972 7.3% 5.3% 10.7% 2,213,138 72.9%Yorkshire and Humber SHAQ32 310,569 7.4% 5.2% 10.7% 225,280 72.5%Bradford and Airedale 5NY 32,440 8.3% 5.5% 13.2% 25,074 77.3%

2009

Point 2 there has been improvement in achievement in key indicators of CV riskDM 12 - BPDM 17 – Cholesterol

there is variation

Achievement DM12 and DM17

Exceptions - DM12 and DM17

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

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

AllianceDM23

numeratorDM23

denominatorDM23

exceptions

DM23 exception

rate

Airedale 1,894 3,730 604 13.9%BANCA 2,429 4,705 603 11.4%City Care 2,819 6,911 1,415 17.0%Independent 206 394 53 11.9%S&W 3,772 7,175 916 11.3%

AllianceDM24

numeratorDM24

denominatorDM24

exceptionsDM24

exception rate

Airedale 3,028 3,918 416 9.6%BANCA 3,806 4,923 385 7.3%City Care 5,142 7,356 970 11.7%Independent 324 404 43 9.6%S&W 5,753 7,407 684 8.5%

Practice code

DM25 numerator

DM25 denominator

DM25 exceptions

DM25 exception

rate

Airedale 3,614 4,030 304 7.0%BANCA 4,501 5,026 282 5.3%City Care 6,441 7,643 683 8.2%Independent 375 413 34 7.6%S&W 6,713 7,564 527 6.5%

AllianceDM12

numeratorDM12

denominatorDM12

exceptions

DM12 exception

rate

Airedale 3,199 3947 387 8.9%BANCA 3,923 4982 326 6.1%City Care 6,181 7621 705 8.5%Independent 335 411 36 8.1%S&W 5,962 7555 536 6.6%

AllianceDM17

numeratorDM17

denominatorDM17

exceptions

DM17 exception

rate

Airedale 3,109 3,802 532 12.3%BANCA 3,881 4,798 510 9.6%City Care 5,923 7,496 830 10.0%Independent 299 394 53 11.9%S&W 5,808 7,236 855 10.6%

Micro vascular

Macro vascular

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

Spend / DM patient (medicines) and glycaemia control

Practice code Practice name

Spend per patient on diabetes register

(QOF 2009/10)

Rank of spend /

DM patient.

1=lowest

DM23 7 or less 09-10

achievement

Rank of DM23

Acheivement 1=best

DN24 8 or less 09-10

achievement

DM25 9 or less09-10

achievement

B83658 ROYDS HEALTHY LIVING CTRE £188 5 68.7% 1 86.7% 92.6%

B83624 ILKLEY MOOR MEDICAL PRACTICE£246 18 65.5% 2 86.0% 92.7%

B83067 THE SPRINGFIELD SURGERY (BINGLEY)£319 64 64.8% 3 86.8% 93.5%

B83620 ADDINGHAM SURGERY £278 35 64.5% 4 90.4% 98.3%

B83621 DR A AZAM £340 72 61.9% 5 81.0% 94.7%

B83026 DR HAQUE & PARTNER £359 75 61.3% 6 84.1% 92.4%

B83028 WIBSEY & QUEENSBURY MED P £267 29 61.0% 7 83.5% 90.2%

B83006 SILSDEN GROUP PRACTICE £282 40 60.5% 8 83.1% 91.6%

B83040 SALTAIRE MEDICAL PRACTICE £244 16 59.6% 9 81.9% 92.8%B83045 MAYFIELD MEDICAL CENTRE £297 52 59.0% 10 83.3% 93.9%

Point 6Quadrant chartscan give indicators to spend and outcomes

Practice level spend (meds) and glycaemia control

DM medication spend per patient with HBA1C (8) achievement

Ilkley

Thornbury

Linghouse

FenwickCarlton

Craig

MicallefFarrow

HortonWillows

Farfield

Holycroft

Mall

Haque

Falls

Kilmeny

Imtiaz

Gaguine

BowlingLongfield MillsWilson

Passant

Wert

Avicenna

Oakworth

Overend

Eisner

Winn

Springfield

Basu

Mughal

Phoenix

Alim

Sahay

EliwiManningham

Picton

Mahmood

Azam A

Iqbal

Valley View

Frizinghall

Bindu

Pollard

Ashwell

Masood

Sinha

Gilkar

Azam M

Bilton

El Azab

Hamdani

Silsden

Heaton

Sunnybank

Parklands

Priestthorpe

Roberts

Burley

Gomersall Haworth

Wibsey

Collins Thornton

Rai

WilsdenLeylands

Bibby

Saltaire

Rooley

Mayfield

Cowgill

Allerton

Ridge

Addingham

Poulier

Peel

Royds

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

£150 £200 £250 £300 £350 £400 £450

DM medication spend per patient

DM

24 -

HB

A1C

(8)

ach

ieve

men

t

Point 7The prescribing bill for diabetes is approx £3m.

There is significant spend per head variation

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.

Point 8It is relatively expensive to manage people to tight HBA1C targets

it costs twice as much per patient to meet the HBA1C target of 7 as it does 9.are the outcomes twice as good?

Is the additional spend to get p to target of 7 worth it in terms of the additional health it buysThe evidence might suggest it is NOT – ACCORDtailored prescribing rather than blanket approachSquaring this with QOF points for meeting stringent targets will be interesting.

• 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.

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

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

Point 10There is moderate correlation between ethnicity in the practice and glycaemic control same for deprivation profile

poorer populations have worse outcomesAsian populations have worse outcomes.

NB treat with caution. This is not adjusted for % exception coded.

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

correlation between deprivation score and HBA1C 9 - DM25Acheivement = -.051Practices with poorer populations have lower achievement oftheDM25 indicator

correlation between % S Asian score and HBA1C 9 - DM25Acheivement = -0.47Practices with high % S Asian have lower achievement of the DM25 indicator

And so what?

1. QIPP – scope for improving quality and reducing cost2. Targeting services and support where outcomes are

least good3. More nuanced interpretation4. Formulary.5. Nuanced vs blanket approach to prescribing 3rd line

agents – taking into account pt preferences, circumstances AND cost.

6. Systematic approach – DH HI NST7. Quality Improvement methodology8. Targeted and focused approach to reducing spend