The National Diabetes Audit Improving Care Delivery Bob Young Clinical Lead NDA & NCVIN The National Diabetes Audit (NDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) following advice to the Department of Health from the National Advisory Group on Clinical Audit and Enquiries (NAGCAE). NDA Consortium

Why Measure (Audit)? All improvement requires change BUT change does not necessarily lead to improvement. Change is hard work; not everything can be changed at once. Measurement enables: – Choice of priorities for Change (focus effort/capacity) – Evaluation of impact of Change (keep or start again) Without measurement it is impossible to know whether improvement efforts (changes) are – well directed – or working

THE PURPOSE OF MEASUREMENT IS TO ENABLE CHANGE FOR IMPROVEMENT

National Measurement (Audit) Economy of effort – Re-use of routinely recorded data Electronic care records (structured/coded components) Hospital activity statistics (HES, PEDW) Mortality Records – Standard, secure, recording and submission – Shared Information Governance Reliability – Data Quality Checks – Consistent, curated statistical analysis Minimal erosion of change capacity by measurement effort Peer comparison Downside is slower reporting

NDA Linked Data GP and Specialist Electronic Records Diabetes Diagnosis, Year -> NDA core dataset NHS No, Sex, Post Code (IMD), Year of birth BMI, Smoking, BP, HbA1c, TC, eGFR, UACR Eye & Foot surveillance Hospital Episode Statistics NHS number Admission for DKA, Amputation, Dialysis/Kidney Transplant, Angina, MI, HF, Stroke ONS (MRIS) NHS number Date of death Patient level linked extensions: Pregnancy, NPID (started 2013); Foot disease NDFA (starts July 2014) Also unlinked: Inpatients, NaDIA (started 2011); Patient Experience, PEDS (Piloted )

Core NDA (from ) Data Completeness >99%Gender, Age, Diabetes Type 90-99%Diagnosis year, BMI, BP, HbA1c, Creatinine, Cholesterol 80-89%Smoking, Foot Surveillance 75-79%Ethnicity, UACR, (Retinopathy Screening) Annual GP/Specialist EPR extracts (outpatient care) Linked to HES/PEDW (hospital admissions) and ONS (death) 2,473,239 people with diabetes in % of people with diagnosed diabetes

Core NDA Reports Diagnosis and Registration NICE specified annual Care Process completion rates NICE Specified Treatment Target & Structured Education achievement rates Complication Rates – Acute (DKA, HHS) – Microvascular (Retinopathy treatment, CKD stage and RRT, Amputation) – Cardiovascular (Angina, MI, HF, Stroke) – Death

Treatment target achievement all CCGs – TREATMENT VARIATION

% achieving all treatment targets vs Age and Ethnicity Age in years Ethnic Group

% achieving all treatment targets vs Deprivation Quintile and BMI Deprivation Quintile BMI

Treatment target achievement rates for all patients in NHS Salford CCG and England and Wales by treatment target, diabetes type and audit year

% patients meeting all treatment targets for all GP practices within NHS Salford CCG 26.1% = Q4 Practice Variation

Age-specific mortality rate ratios by type of diabetes and sex NDA Report YOUNG TYPE 1

NDA Standardised Mortality Ratio for Type 1 and Type 2 Diabetes Encouraging but still ~24,000 excess deaths

Odds Ratio for death in the next year - driven by Complications NDA Report

Funnel chart of CCG/LHB standardised ratios for HF among people with diabetes OUTCOME VARIATION NDA Report BP Measured in 95% BP<140/80 T1 57.9% T2 47.3% Am I one of these?

Core Care: where to focus change effort? Younger people & Type 1 Obesity management Blood Pressure Management Improve 25% poorest performing practices (services) to level of middle 50% (emulate) Encourage 25% best performing practices to improve through tests of innovation

NaDIA Snapshot Audit; all inpatients, one September day, 233 hospitals

Inappropriate duration IV infusion

Prescription Errors

Insulin Errors

But Continuing Evidence of Harm from Medication Errors

Inpatient Care: where to focus change effort? Safer IV insulin Safer inpatient prescribing Prevention of severe adverse incidents Does it sound like flying in the 1960’s? Lots of ‘near misses’ and occasional disasters

P LAN DODO S TUDY (meeting Standards?) A CT PDSA - THE QUALITY SPIRAL Improvement Is Driven By Self-Assessment directed Change CLINICAL QUALITY IMPROVEMENT MEASUREMENT PDSA

‘Whole Systems’ Clinical Quality Improvement SERVICE SELF-ASSESSMENT ANNUAL ACTION PLAN Multidisciplinary, multi-sector, professional, patient, management, commissioner Steering Group

USING INFORMATION To Improve Patient Outcomes Get all stakeholders round the table Select measurements appropriate to service Review and use comparisons with peers to choose manageable number of priorities Assign leaders to improvement projects Develop and implement action plans with agreed goals Use measurements to determine whether goals have been achieved Start again!

AN ‘EPISODE’ OF DIABETES ‘THE REST OF LIFE’ Diagnosis Initial Management Continuing Care PREVENTIONPREVENTION EVENTS Non diabetes Related Hospital Admissions New Protenuria New CHD New CVA New Erectile dysfunction Pregnancy Institutional Care Foot Disease New Eye Complications DKA HONK Severe Hypoglycaemia Major Life Events Major Treatment Change e.g. Starting Insulin Other new complicat ions SUB-PATHWAYS FOR EACH EVENT ALWAYS RETURNING TO CONTINUING CARE HUB Laying the Foundations Support & Early Detection Reacting when Things go Wrong Experience of Care Reacting when Things may/do go Wrong += NDAA Scope of NDA

The National Diabetes Audit Improving Care Delivery Bob Young Clinical Lead NDA & NCVIN The National Diabetes Audit (NDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) following advice to the Department of Health from the National Advisory Group on Clinical Audit and Enquiries (NAGCAE). NDA Consortium