1. NPDA 2017/18 results presentation template
This slide deck has been designed to be amended by paediatric diabetes teams to:
communicate the main national and unit level findings from the audit
facilitate interpretation of results
use the data to stimulate quality improvement activity
develop awareness of the functionality of NPDA Results Online (our interactive online reporting tool), and the NPDA data capture system
All unit level graphs displayed are placeholders, and there are instructions for the generation of bespoke graphs for your unit on the slides displaying these place holders
The results displayed are for children and young people with Type 1 diabetes, as numbers with other types of diabetes are currently too low at unit level to enable meaningful reporting within the vast majority of participating services
In order to compare your validated 2017/18 results against data submitted for the 2018/19 audit, please view the service level summaries within the data completeness report generated upon submission of your data

2. NPDA 2017/18 results presentation template:
Resources to support your presentation
NPDA Results Online and user guide (inc. how to load and download graphs, and download the data behind each)
Data completeness report user guide
National Paediatric Diabetes Audit core report 2017/18
PDF generator for unit level summary reports
How to use the snipping tool to cut and paste graphs
Excel files of current and historical summary NPDA data

3. [Name of Paediatric Diabetes Unit]
National Paediatric Diabetes Audit results 2017/8

4. Context
The National Paediatric Diabetes Audit is funded by NHS England and the Welsh Government, commissioned by the Healthcare Quality Improvement Partnership (HQIP), and managed by the Royal College of Paediatrics and Child Health.
The audit was established in 2003 to support improvements in paediatric diabetes care and outcomes required to bring these in line with those achieved in comparable western European countries, and to measure progress towards achievement of NICE guidance.
The audit’s aims are to:
Monitor the incidence and prevalence of diabetes amongst children and young people receiving care from a PDU in England and Wales
Establish whether recommended health checks are being received by children and young people with diabetes
Enable benchmarking of performance against standards of care specified by the National Institute for Health and Care Excellence (NICE) guidance at PDU, regional, CCG (England), Health Board (Wales) and national level
Determine the prevalence and incidence of diabetes-related complications amongst children and young people with diabetes
Audit scope
The 2017/18 NPDA included all 173 PDUs in England and Wales, and captured information on 29,748 children and young people with all forms of diabetes up to the age of 24 years under the care of a consultant paediatrician.

5. 2017/18 NPDA Key Findings – Type 1 diabetes
The NPDA national report contains a comprehensive list of key findings and recommendations in addition to in-depth analysis of audit measures. Presented here are a selection:
64.0
mmol/mol
was the national median HbA1c
for children and young people with T1D, unchanged from 2016/17
28.2%
of CYP with T1D were assessed as requiring additional psychological or CAMHS support outside of MDT clinics
49.8%
of young people with T1D aged 12+ received all key health checks in the audit year, up from 43.5% in 2016/17
Increased use of insulin pump therapy was associated with female gender, younger age, living in the least deprived areas and White ethnicity
67.6%
of CYP with T1D received Level 3 carbohydrate counting at diagnosis

6. 2017/18 NPDA Key Findings – Type 2 diabetes
The NPDA national report contains a comprehensive list of key findings and recommendations in addition to in-depth analysis of audit measures. Presented here are a selection:
There were proportionally more girls, those of non-White ethnicity, and those living in the most deprived areas amongst the cohort with T2D
44.9%
of young people with T2D had high blood pressure
25.7%
of young people with T2D age 12+ received all key health checks in the audit year, compared to 49.8% of those with T1D
745
children and young people with T2D were receiving care from a paediatric diabetes unit, an increase of 30 since 2016/17
22.1%
of young people with T2D had albuminuria compared to
10.2%
of those with T1D

7. How did we do on key audit measures
How did we do on key audit measures? Key health checks for Type 1 diabetes
Health check completion rate improvement resources
Presentation from Alder Hey Hospital: Improving health check completion rates through service redesign
Directory of retinopathy services to contact if results are not being sent directly to you:
Please download the graph below for your unit from NPDA results online (select: Unit data > Key care process completion breakdown (all) > Column chart > Date range 2017/18 – 2017/18)

8. How are we doing compared to others
How are we doing compared to others? Health check outlier measure - overall completion rate
How to interpret this funnel plot
The horizontal red dotted line shows the mean health check completion rate for England and Wales, and the curved lines indicate units whose results are within two standard deviations (dotted curve) or three standard deviations (dashed curve) of the mean.
HQIP guidance (HQIP, 2017) defines services with a result outside of three standard deviations of the mean value on key quality measures as ‘alarm’ outliers. In this graph, PDUs below the bottom dashed line (>3SD) are considered ‘alarm’ outliers as their overall completion rates are significantly lower than others in England and Wales. PDUs above the top dashed line are considered to be ‘positive outliers’ as their completion rates are significantly higher.
Alarm level outliers for 2017/18 have been contacted by the NPDA and requested to submit action plans to the CQC/Welsh government.
Outlier status is defined statistically, so even if you are not a negative outlier in one audit year, if national rates improve but yours doesn’t, you may be a negative outlier in the next year.
Please download the graph below for your unit from NPDA results online (select: Outlier data > Overall health check completion rate for young people aged 12 years and older > Date range 2017/18 > Show ‘All other units on the same network’ and ‘All other units’)
The outlier plot above shows the percentage of the expected checks received by patients at each unit. An additional measure of health check provision is the percentage of patients receiving all 7 key health checks. X% of children and young people aged 12+ received all 7 key health checks at our service, compared to 49.8% nationally

9. Additional health checks for children and young people with Type 1 diabetes
For discussion
(please refer to NPDA results online for comparative data necessary to answer)
How do our health check completion rates compare to previous audit years?
Which health checks are being provided at lower rates?
Why is it difficult to provide/record these health checks?
How might clinics/communication with parents/patients be reconfigured/improved to improve these results? Or, how can we ensure our high completion rates are maintained?
Which units in the region are achieving higher rates of provision? (choose caterpillar plot on NPDA results online to show)
How are they achieving these higher rates? Who can be contacted to find out? Who will do this?
If we have achieved high rates of health check completion, how can we support other units to do the same to help ensure all children and young people in England and Wales receive the best standards of care?
How can we engage with ward-based colleagues to facilitate carb counting from diagnosis?
Please download the graphs below for your unit from NPDA results online (Select: Unit data > ‘Additional health checks’ graph > Column chart > Date range 2017/18 – 2017/18)
Additional health checks Care at diagnosis

10. Monitoring health check completion rates throughout the audit year
A summary of results is generated upon every entry of data into the NPDA data collection platform, both at service and individual patient level within the data completeness report (DCR) (see below). If you don’t have an in-house system to monitor health checks received, we recommend uploading and checking your data 3 months before the end of audit period (i.e in December) to follow up on patients who have missed checks, and to make sure all patients have checks scheduled before the end of the audit year.
Summary data displayed within the DCR:
Individual patient data displayed within the DCR:

11. What progress are we making towards lower average HbA1c?
On NPDA results online, select: Unit data > Median HbA1c > Column Chart > Name of your clinic > date range to
The NPDA recommends tracking year-on-year unit level HbA1c results using the median, as this is less affected by extreme high or low values Please note that only HbA1c measurements recorded >90 days following diagnosis are included in HbA1c outcome analysis, and if a patient has had more than one measurement recorded in the audit year, the median value per patient is used

12. How does our HbA1c trajectory compare with other units in our region?
On NPDA results online, select: Longitudinal data > Median HbA1c > Name of your clinic > Date range to > ‘Show units in region’
Which units in the region have improved on this measure most? What efforts have underpinned this improvement?

13. Case mix-adjusted HbA1c results
Given the variations in HbA1c associated with different demographic and social characteristics, the NPDA produces case-mix adjusted HbA1c figures to allow for equitable benchmarking of individual PDU performance.
The case-mix adjustment applied to the 2017/18 data adjusted for the effects of age, sex, ethnicity, duration of diabetes, and deprivation on mean HbA1c according to the results of a regression model that identified the strength of association between these factors and higher HbA1c.
Units with higher proportions of younger children, White children, and children living in the least deprived areas were therefore more likely to have their unit mean adjusted upwards, and units with higher proportions of older children, non-White children, and children living in the most deprived areas were more likely to have their mean HbA1c adjusted down.
Case mix adjustment is not an exact science, but the adjustment applied takes into account all patient characteristics available to the NPDA. The model explains 12.6% of the variation in mean HbA1c, and it is impossible to say what part of the residual variation is attributable to case-mix and or clinical practice. However, clinical practice is a more significant factor in the  clinical performance reported once the effects of the patient demographic data we have access to is adjusted for. 
Please also note that it is not a given that patients with characteristics shown to be associated with higher HbA1c will have higher HbA1c themselves, and indeed there are some units within the NPDA achieving good adjusted and unadjusted results even with higher proportions of patients with characteristics associated with suboptimal diabetes management.

14. Adjusted mean HbA1c How are we doing compared to others?
How to interpret this funnel plot
The horizontal red dotted line shows the mean (unadjusted) HbA1c for England and Wales, and the curved lines indicate units whose results are within two standard deviations (dotted curve) or three standard deviations (dashed curve) of the mean.
HQIP guidance (HQIP, 2017) defines services with a result outside of three standard deviations of the mean value on key quality measures as ‘alarm’ outliers. In this graph, PDUs above the top dashed line (>3SD) are considered ‘alarm’ outliers as their adjusted mean HbA1c is significantly higher than others in England and Wales. PDUs below the bottom dashed line are considered to be ‘positive outliers’ as their adjusted mean HbA1c is significantly lower.
Alarm level outliers for 2017/18 have been contacted by the NPDA and requested to submit action plans to the CQC/Welsh government.
Outlier status is defined statistically, so even if you are not a negative outlier in one audit year, if national mean HbA1c improves but yours doesn’t, you may be a negative outlier in the next year.
Please download the graph below for your unit from NPDA results online (Select: Outlier data > Adjusted HbA1c > Date range 2017/18 > ‘All other units on the same network’ and ‘All other units’). You can zoom in on the graph if necessary.
To compare your unit against others with similar patient demographics you can identify these within the Excel data files of unit results published on the NPDA website.

15. Percentage of children and young people with an HbA1c < 48 mmol/mol
NICE (NG18) guidance recommends aiming for an HbA1c of 48mmol/mol to reduce the risk of micro- and macro- vascular complications
To show the percentage of your patients at lower risk of diabetes complications on NPDA Results Online, please select unit data, HbA1c (unadjusted) < 48 mmol/mol, caterpillar plot

16. HbA1c outcomes: For discussion
Do NPDA results shown demonstrate the impact of team quality improvement initiatives trialed to make improvements in care over the audit period?
Which quality improvement initiatives introduced within the audit year do team members consider as the most successful, and why?
What initiatives could be trialed to improve engagement and outcomes amongst the groups of patients shown by the NPDA to have typically higher HbA1c (adolescents, girls, those living in the most deprived areas, those of non-white ethnicity)?
Even clinics with lower-than-average HbA1cs have a small proportion of patients achieving an HbA1c <48 mmol/mol. What support can be provided to patients already achieving an HbA1c <63mmol/mol to help them reach 48?

17. Projects undertaken
through the RCPCH diabetes
quality programme- Wave 1
Basildon- Clear targets for self-management,
Diasend introduction from diagnosis
Bolton- Carb counting at diagnosis, improved
team working, shared purpose, pre- and post
clinic MDTs
East Sussex- Developing structured education package, maintain reduced HbA1c at 6 and 12 months post diagnosis, increased family engagement and improved team working
West Sussex- Improved MDT working by video linked meetings, High HbA1c policy, introduction ‘Diasend Master classes’
Derby- Improved use of Diasend, a nurse-led pump process, remote Diasend clinic, new MDT structure
Gloucester and Sheffield – Officer of fun, carb counting from diagnosis, reinventing the clinic experience
Bedford –Self-management, increased appointment length, topics choice for consultation, 5 min reminder in clinic, Novo Goals for all contacts
Hillingdon – Reduce pump patients’ HbA1c by 100mmol/mols using pump refreshers/contracts/policy. Use of HbA1c map.
South Tees- Working on patient education booklet and newly diagnosed quiz to assess knowledge prior to discharge, encouraging patients to download their own meters in clinic
HbA1c QI Examples
Reducing HbA1c via Carb Counting from diagnosis and staff education - Sunderland Royal Hospital (7 mins 26)
Empowering children and young people and their families – a response to outlier status - Torbay Hospital (29 mins 53)
Achieving national HbA1c reduction in Sweden via a QI collaborative - Dr Lena Hanburger, University of Linkoping (34 mins 52)
Improving clinical outcomes: The Wye Valley Experience - Hereford Hospital (17 mins 46)
“Improving HbA1c or children and young people living with diabetes (CYPD) who are treated with continuous subcutaneous insulin infusion (CSII) – Hillingdon Hospital
How can parents, carers and patients be best involved in informing improvements to your service?