Evidence into Practice: Diabetes Public Health England May 2014 Dr Junaid Bajwa

About me GP, CCG Board Member NHS Greenwich Primary Care Transformation Board Member, NHSEL Associate in Public Health, NHS Greenwich Council Member of the Clinical Senate, London GP Appraiser NHSE Programme Director, Greenwich VTS Prepare to Lead alumni, NHS London Value Based Healthcare Alumni, Harvard Business School

What motivated us?

Life Expectancy at birth Greenwich and England and NHS Greenwich was one of 13 PCTs identified by the National Health Inequalities Support Team that account for 40% of the National Gap in life expectancy

The impact of improved CVD prevention on life expectancy CVD Health Checks includes the impact of schemes to improve Long Term Conditions management and the NHS Health Checks Programme

Diabetes in Greenwich Diabetes is a major cause health inequalities Priority disease area for Greenwich in the JSNA ,033 patients with diabetes recorded. YHPHO prevalence model estimates it should be 12,900 Suggesting more than 22% of patients with diabetes in Greenwich are undiagnosed¹ YHPHO prevalence model estimates by 2020 there will be an estimated Increase of 37%.¹ 1 – YHPHO prevalence model for England

NHS Greenwich GOAL 2 – A systematic approach A systematic approach to primary and secondary prevention in primary and community care This includes ensuring that service provision and quality is consistent across Greenwich To ensure robust easy referral relationships between primary care teams and primary prevention services e.g. GHLiS To help improve the skills and confidence of primary care practitioners – through appropriate investment Cultural shift towards a proactive approach to prevention through routine and opportunistic screening approaches in practices and other settings Data provided by Greenwich PCT’s from Greenwich commissioning strategy for the 5 years 2008/09 – 2012/13 – Pg34

EVIDENCE into PRACTICE™ Delivered as a free of charge pilot across 14 practices in Greenwich. Practices selected using health inequalities markers.

How did we start? Who was involved? What happened?

EiP Process and Tools EIP.12.GB SL Date of Preparation March 2012

What did we achieve? What change was there for patients?

Data on File MSD, September 2011 Date of Preparation September 2011 *Risk Factor Targets Based on NICE Type 2 Diabetes Guidelines, CG87, May 2009 Greenwich PCT Amalgamated Data: Number of Patients Achieving NICE Endorsed* Risk Factor Targets at Baseline and Follow-Up

Data on File NHS Greenwich, September 2011

Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatient attendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilot sites (32). Figures standardised per 1000 patients with diabetes. Data on File NHS Greenwich, September 2011

Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatient attendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilot sites (32). Figures standardised per 1000 patients with diabetes. Data on File NHS Greenwich, September 2011

Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatient attendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilot sites (32). Figures standardised per 1000 patients with diabetes. Data on File NHS Greenwich, September 2011

Who did what in the practice? How did we change? What roles did different people in the practice take to make the change happen? What were the key changes?

Failing Practice, poor performance Deprived local area, within spearhead PCT Large BME population High incidence of Diabetes and CVD- not on risk registers or being optimally managed Practice Transformation Background

Key focus areas (DCiP/Patient list file) Data Quality Risk Registers Ensuring patients on current registers are being optimally treated/managed/ have the right support Personal/Practice Development issues: clinical exercises Confidence mapping of existing skill mix within practice Critical event review exercise Case for change

Clear diabetes management strategy roles/responsibilities Addressed training in issues (Evidence Review) Ensuring consistent treatment approach (HbA1c, BP, Cholesterol targets) Stratifying cardio-metabolic risk in the population focus on optimising treatment in existing patients What we did

All diabetics Data on File MSD, September 2011 Date of Preparation September 2011 Risk Factor targets Based on NICE CG87, May Baseline Vs 3rd Repeat Follow-Up data for Conway Medical Centre Time between data extractions = 18 Months 6 Days

Data on File MSD, September 2011

What impact did the EiP approach to diabetes have on the whole practice population health otucomes?

The UKPDS Outcomes Model Computerised simulation designed to estimate Life Expectancy, Quality Adjusted Life Expectancy and costs of complications in people with type 2 diabetes. Uses algorithms published in the UK Prospective Diabetes Study (UKPDS). The model was developed using data from patients with newly-diagnosed type 2 diabetes who participated in the UKPDS 2 and were followed up for between six and twenty years. It predicts likely outcomes using risk factors that include; age, sex, ethnicity, duration of diabetes, height, weight, smoking status, total cholesterol, HDL cholesterol, systolic blood pressure and HbA1c. The UKPDS Outcomes Model is able to simulate event histories that closely match observed outcomes in the UKPDS and that can be extrapolated over patients’ lifetimes. The model allows simulation of a range of long-term outcomes, which should assist in informing future economic evaluations of interventions in Type 2 diabetes A model to estimate the lifetime health outcomes of patients with Type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS no. 68). PM Clarke, AM Gray, A Briggs,AJ Farmer, P Fenn, RJ Stevens, DR Matthews, IM Stratton, RR Holman. Diabetologia 2004; 47:1747–1759.

Data on File MSD October 2011 Time between Baseline and Follow-Up Audit: 18 Months 6 Days

Modelled outcomes across the current diabetes list of 355 patients over a 10 year period show: Data on File MSD October % increase in life expectancy equating to an average of 1.0 additional years of life per patient 22.7% increase in Quality Adjusted Life Expectancy equating to 1.0 additional quality adjusted life years/pt 34.1% reduction in the incidence of Ischemic Heart Disease over 10 years= 11 Patients 41.3% reduction in the incidence of Heart Failure over 10 years = 18 Patients 35.4% reduction in the incidence of Stroke over 10 years = 12 Patients 19.3% reduction in the incidence of Myocardial Infarction over 10 years = 13 Patients 42.5% reduction in the incidence of Blindness over 10 years = 12 Patient 64.8% reduction in the incidence of Amputation over 10 years= 12 Patients 12.5% reduction in the incidence of Renal Failure over 10 years= 1 Patient 28.2% reduction in all deaths over 10 years = 50 Patients

The UKPDS model also calculates the health care costs associated with each modelled fatal or non-fatal diabetes-related complication. The costs that accrue in all subsequent years are also taken into consideration. The default costs are derived from the UKPDS paper and have been updated using the Hospital and Health Services Price Index to reflect health care resource use in the United Kingdom. Based on the avoided complications modelled, an average saving of £ per patient with diabetes over 10 years can be calculated. This equates to £719, across 1000 patients with diabetes over 10 years Data on File MSD October 2011

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