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National Diabetes Audit 2021-22, Report 1: Care Processes and Treatment Targets, Overview

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National Diabetes Audit 2021-22, Report 1: Care Processes and Treatment Targets, Overview


Change to mapping used for integrated care board (ICB) analysis

An issue was found with the mapping used to define ICB in this report resulting in larger than expected cohorts for each ICB. This has been corrected in this report and has resulted in slight changes to the results of analyses broken down by ICB.

21 December 2023 00:00 AM

Summary

The National Diabetes Audit (NDA) provides a comprehensive view of diabetes care in England and Wales. It measures the effectiveness of diabetes healthcare against National Institute for Health and Care Excellence (NICE) Clinical Guidelines and NICE Quality Standards. This NICE guidance is based on evidence that regular systematic review of people with diabetes and achievement of glucose, blood pressure and cardiovascular risk standards maintains health and reduces long term complications.


This State of the Nation overview details the findings and recommendations relating to diabetes care for people with diabetes for the 2021-22 audit, which covers the period 01 January 2021 to 31 March 2022.

The detailed analyses behind this summary report can be found here

These reports provide in-depth and extended analysis of the data in the National Diabetes Audit Core Report 1: Care Processes and Treatment Targets 2021-22, Underlying data.

This NDA report focuses on NICE guidelines and Quality Standards for the routine care of people with type 1 and type 2 diabetes (1). Everyone with diabetes should be reviewed at least once a year. The review should include the following 8 care processes (2):

  • blood tests for HbA1c (glucose control)
  • creatinine (kidney function)
  • cholesterol (heart risk)
  • urine test for albumin (kidney risk)
  • blood pressure measurement
  • weight measurement (body mass index; BMI)
  • examination of the feet (foot ulcer risk)
  • review of smoking habit

The ninth care process is retinal screening, which is run by dedicated screening programmes (2).

At review, treatment should be adjusted where necessary to achieve the 3 NICE recommended treatment targets (2):

  • HbA1c level ≤ 58 mmol/mol
  • blood pressure level ≤ 140/80
  • those with high heart risk should be prescribed a statin

Data on routine diabetes care (care processes, treatment targets and structured education) is publicly available at national, regional, integrated care board (ICB), primary care network (PCN), general practice (GP) and specialist service level in the quarterly (3) and annual dashboards.

Notes:

1. The National Diabetes Audit, Type 1 Diabetes and Young People with Type 2 Diabetes reports use additional diagnosis validation steps to determine diabetes diagnosis. Therefore, the cohort used for these reports differs from that used in this report. 

2. See Definitions in Additional information for details of the 8 care processes, ninth care process and treatment targets.

3. The quarterly dashboard presents primary care data for England only. Therefore, data is not available at specialist service level nor for Wales. 


What does the National Diabetes Audit provide?

The NDA supports delivery of high-quality diabetes care by enabling NHS services and organisations to:

  • assess local practice against NICE guidelines
  • compare their care processes, and care outcomes, with similar services and organisations
  • identify gaps or shortfalls that are priorities for improvement
  • track responses to change programmes
  • identify and share best practice
  • provide a comprehensive national picture of diabetes care and outcomes in England and in Wales

Introduction

The number of people with diabetes continues to increase. In England between 2017-18 and 2021-22 type 1 diabetes prevalence went up from 248,240 to 270,935 and type 2 and other diabetes prevalence increased from 2,952,695 to 3,336,980. In Wales between 2017-18 and 2021-22 type 1 diabetes prevalence went up from 15,210 to 16,090 and type 2 and other diabetes prevalence increased from 182,325 to 191,205 (see the Incidence and prevalence section of the detailed report for further information).

This year’s report highlights three 5-year trends:

  1. Impact of the pandemic on care delivery from 2017-18 to 2021-22: Changes that occurred during the pandemic are described and progress towards restoration of the pre-pandemic trends are reported.
  2. Health inequalities in routine diabetes care from 2017-18 to 2021-22: Includes variation in whether people received all relevant care processes and the personal characteristics (age, sex, duration of diabetes, deprivation and ethnicity) associated with this variation.
  3. Treatment target achievement in people with type 1 diabetes and type 2 and other diabetes from 2017-18 to 2021-22.

Geographical variation in whether people received all relevant care processes in 2021-22 is presented in Key finding 2: Inequalities in routine diabetes care delivery below. Analyses on people with frailty, learning disabilities and severe mental illness are available in the Health inequalities in diabetes section of the detailed report.

Logistic regression modelling was used to quantify the relative impacts of the different personal characteristics in Key finding 2: Inequalities in routine diabetes care delivery below. An explanation of the methodology is provided in Additional information of the detailed report, and the results presented as forest plots are in the Appendix of the detailed report.

National Diabetes Audit core annual dashboard

Through this dashboard, you can explore local analysis on care process and treatment target achievement, structured education referral and attendance, national and within-locale practice ranking and more.

 

Data from this report relates to the 2021-22 audit period. Latest data from the National Diabetes Core Audit is available online at National Diabetes Audit Dashboards.


Key findings and recommendations

Key finding 1: Impact of pandemic

Key finding 1: Impact of pandemic

  • In the last 4 years the incidence (1) of type 1 diabetes in under 19 year olds in England has increased year-on-year, from 3,250 people in 2018-19 to 4,145 in 2021-22.

  • A similar pattern can be seen in under 19 year olds in Wales with the incidence (1) of type 1 diabetes rising year-on-year from 170 in 2018-19 to 245 in 2021-22.

  • There has been improvement in the completion of all 8 key care processes (2) in 2021-22 across all diabetes type following the reduction seen between 2019-20 and 2020-21 (the first pandemic year). However, in both people with type 1 diabetes and people with type 2 and other diabetes, care process completion remains below pre-pandemic levels. For example:
    • In people with type 1 diabetes in England the HbA1c care process completion dropped from 83.6% in 2019-20 to 75.8% in 2020-21 and is at 78.9% in 2021-22, still below pre-pandemic levels (see figure 1).
    • Similarly for people with type 1 diabetes in Wales, HbA1c care process completion rates were 71.4% in 2019-20, 61.3% in 2020-21 and 64.8% in 2021-22 (see figure 2).
  • The care processes with the greatest drop from 2019-20 to 2020-21 in people with type 1 and type 2 and other diabetes in England were digital retinal screening and foot risk surveillance (3,4) and for those with type 1 and type 2 and other diabetes in Wales were blood pressure, BMI and foot risk surveillance (3) (see figures 1- 4).
  • For all people across almost all of the 5 years, urine albumin/creatinine ratio (3) was the lowest performer. For example, in 2021-22:
    • In England, 49.8% of people with type 1 diabetes received this care process (see figure 1) and 60.7% of those with type 2 and other diabetes (see figure 3).
    • In Wales, 29.0% of people with type 1 diabetes (see figure 2) received this care process and 47.8% of those with type 2 and other diabetes (see figure 4).

Figure 1: Percentage of people with type 1 diabetes receiving NICE recommended care processes by audit year, England (4), 2017-18 to 2021-22

Figure 2: Percentage of people with type 1 diabetes receiving NICE recommended care processes by audit year, Wales (4), 2017-18 to 2021-22

Figure 3: Percentage of people with type 2 and other diabetes receiving NICE recommended care processes by audit year, England (4), 2017-18 to 2021-22

Figure 4: Percentage of people with type 2 and other diabetes receiving NICE recommended care processes by audit year, Wales (4), 2017-18 to 2021-22

See the sections Incidence and prevalence and Care processes and treatment targets of the detailed report for further information.

Notes:

1. Incidence in this report refers to the number of new cases of disease in a population over a specified period of time.

2. For details of the 8 care processes, see Definitions in Additional information.

3. For definitions of retinal screening, foot risk surveillance, blood pressure, BMI and urine albumin/creatinine ratio, see Definitions in Additional information.

4. 9 care processes includes retinal screening, the data for which is only available from 2019-20 for England. Retinal screening data is currently not received for Wales meaning that Wales can only achieve completion of the 8 NICE recommended care processes in the NDA data.

Recommendation 1

Commissioners of care should continue to work with providers in restoring and then further improving pre-pandemic care process completion levels.

Key finding 2: Inequalities in routine diabetes care delivery

Key finding 2: Inequalities in routine diabetes care delivery

  • Among people with type 1 diabetes and type 2 diabetes, people living in the most deprived quintile were the least likely to receive all 8 key care processes when compared to those living in less deprived areas in 2021-22. For example, in 2021-22 people with type 2 diabetes who lived in the most deprived quintile were less likely (0.90 times as likely) to receive all 8 care processes than those who lived in the second most deprived quintile reference group (1,2). A similar finding can be interpreted from the NDA core dashboard, in that for people with type 2 and other diabetes in England in 2021-22, only 44.7% of those living in the most deprived quintile received all 8 care processes compared to 47.4% of those living in the 2nd most deprived quintile and 51.1% of those living in the least deprived quintile (2).
  • Younger people with type 1 diabetes and type 2 diabetes were the least likely to receive all 8 key care processes when compared to their older counterparts. For example, in 2021-22, when compared to people with type 1 diabetes in the reference age group 40-49 years, those in the age group 17-24 years were less likely (0.55 times as likely) and those in the age group 70-79 years were more likely (2.14 times as likely) to receive all 8 care processes (1,2). A similar finding can be interpreted from the NDA core dashboard, in that for people with type 1 diabetes in England in 2021-22, only 26.2% of those aged 20-29 years received all 8 care processes compared to 35.2% of those aged 40-49 years and 53.5% of those aged 70-79 years (2).
  • When looking at the area where diabetes care was received, there was great variation across England in the percentage of people with diabetes receiving all relevant care processes. For example, in 2021-22 when looking across ICBs (3,4) the percentage of people receiving all 8 care processes ranged from 16.3% to 56.3% of people with type 1 diabetes and 26.1% to 63.0% of people with type 2 and other diabetes (see figure 5 and figure 6 respectively).

Figure 5: Percentage of people with type 1 diabetes receiving all 8 NICE recommended care processes, by ICB, England, 2021-22

Figure 6: Percentage of people with type 2 and other diabetes receiving all 8 NICE recommended care processes, by ICB, England, 2021-22

  • The proportion of people with no care processes recorded rose sharply during the pandemic year 2020-21 and has not returned to pre-pandemic 2019-20 levels. Of particular concern, is the widening inequality by age. For example, in 2021-22:
    • In England, only 0.8% of people with type 1 diabetes aged 70-79 received no (zero) care processes, whereas the percentage was greater in those aged 17-24 at 9.8%. The same was found in people with type 2 and other diabetes in England (1.4% of those aged 70-79 and 10.1% of those aged 17-24).
    • In Wales, 3.6% of people with type 1 diabetes aged 70-79 received no care processes, whereas the percentage was greater in those aged 17-24 at 25.4%. For people with type 2 and other diabetes, 3.5% of those aged 70-79 and 14.5% of those aged 17-24 received no care processes.

See Health inequalities in diabetes and Care processes and treatment targets sections of the detailed report for further information.

Notes:

1. These figures are based on the logistic regression models. The forest plots based on these figures can be viewed in the Appendix of the detailed report. To see details on odds ratio, reference groups and the interpretation of forest plots, see Additional information in the detailed report.

2. Predictive ability of the regression models are weak (c statistic around 0.6). Therefore, the findings from these models should be considered in conjunction with the findings from the People/demographics section of the NDA core dashboard

3. ICBs replaced clinical commissioning groups (CCGs) in the NHS in England from 01 July 2022. For ICB lookup codes, see Additional information in the detailed report.

4. This breakdown is for England only, as there is no comparable regional unit in Wales in terms of population size.

Recommendation 2

Commissioners of care should work with providers to focus particularly on improving care process completion in young people and those living in the most deprived communities. The target should be levels already attained in people older than 70 years and in people living in the least disadvantaged areas.

Key finding 3: Treatment target achievement trends

Key finding 3: Treatment target achievement trends

  • Among people with type 1 diabetes the percentage of people achieving the HbA1c ≤ 58 mmol/mol treatment target (1) has improved. For example:
    • In England, between 2017-18 and 2019-20 the percentage of people achieving the HbA1c treatment target improved slightly from 29.9% to 31.6%, whereas between 2019-20 (the first year of the pandemic) and 2021-22 the improvement was greater from 31.6% to 36.3% (see figure 7).
  • By contrast, in people with type 2 and other diabetes in England, although the changes in HbA1c ≤ 58 mmol/mol treatment target achievement were smaller, there were reductions (from 65.8% in 2017-18 to 65.6% in 2019-20 to 63.1% in 2021-22; see figure 8).
  • For all people with diabetes, percentages of those with blood pressure ≤ 140/80 showed no change from 2017-18 to 2019-20 but this reduced sharply during 2019-20 (the year of the pandemic) and failed to recover in 2021-22: 
    • For people in England with type 1 diabetes the percentage fell from 74.8% in 2017-18 to 69.8% in 2021-22 (see figure 7) and in people with type 2 and other diabetes the percentage fell from 73.8% in 2017-18 to 66.8% in 2021-22 (see figure 8).
    • For people in Wales with type 1 diabetes the percentage fell from 71.6% in 2017-18 to 63.5% in 2021-22 (see figure 9) and in people with type 2 and other diabetes the percentage fell from 68.4% in 2017-18 to 59.6% in 2021-22 (see figure 10).
  • There were no appreciable changes over 5 years in achievement of the statin prescription treatment target:
    • Rates for people with type 1 diabetes in England were 68.9% in 2017-18 and 71.2% in 2021-22 (see figure 7), while the corresponding figures for people with type 2 and other diabetes were 76.1% and 76.5% (see figure 8).
    • In Wales, rates for people with type 1 diabetes were 67.3% in 2017-18 and 65.2% in 2021-22 (see figure 9), while the corresponding figures for people with type 2 and other diabetes the rates were 73.5% and 71.7% (see figure 10).

Figure 7: Percentage of people with type 1 diabetes achieving NICE recommended treatment targets by audit year, England, 2017-18 to 2021-22

Figure 8: Percentage of people with type 2 and other diabetes achieving NICE recommended treatment targets by audit year, England, 2017-18 to 2021-22

Figure 9: Percentage of people with type 1 diabetes achieving NICE recommended treatment targets by audit year, Wales, 2017-18 to 2021-22

Figure 10: Percentage of people with type 2 and other diabetes achieving NICE recommended treatment targets by audit year, Wales, 2017-18 to 2021-22

See section Care processes and treatment targets of the detailed report for further information.

Notes:

1. For details of treatment targets, see Definitions in Additional information.

Recommendation 3

Commissioners of care should work with providers of diabetes care to sustain progress in type 1 glucose control and restore pre-pandemic glucose control in people who have type 2 and other diabetes; and to first restore and then surpass pre-pandemic levels of blood pressure treatment target attainment in all people with diabetes.


Last edited: 12 April 2024 3:39 pm


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