10 points. diabetes practice profile 2011 [email protected]...
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10 points. Diabetes Practice Profile 2011
[email protected]@[email protected]@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