Latest National Diabetes Audit Released

[xyzzy]

The latest UK audit on diabetes

http://www.ic.nhs.uk/webfiles/Servi...ort1_Care_Processes_And_Treatment_Targets.pdf

Pretty grim as per usual In HbA1c terms

Percentage of registered Type 1 patients in England

HbA1c greater than 6.5% (48 mmol/mol) = 92.6%
HbA1c greater than 7.5% (58 mmol/mol) = 71.3%
HbA1c greater than 10.0% (86 mmol/mol) = 18.1%

Percentage of registered Type 2 patients in England

HbA1c greater than 6.5% (48 mmol/mol) = 72.5%
HbA1c greater than 7.5% (58 mmol/mol) = 32.6%
HbA1c greater than 10.0% (86 mmol/mol) = 6.8%

Roughly one third of Type 1's get below the NHS 7.5% target
Roughly two thirds of Type 2's get below the NHS 7.5% target

 

[hanadr]

Does anyone have data from anyother countries? I'd love to know how we compare
Hana

 

[Grazer]

xyzzy, since when did the target go to 7.5%? I know about the poor report on mortality rates at 7 cf 7.5, but the target for T2s was still 7%, with 7.5% being for T1's last time I knew. Did I miss something?

 

[xyzzy]

xyzzy, since when did the target go to 7.5%? I know about the poor report on mortality rates at 7 cf 7.5, but the target for T2s was still 7%, with 7.5% being for T1's last time I knew. Did I miss something?

Not sure I always thought the NHS wanted you between 6.5 and 7.5 regardless of what type you were but could well be wrong

 

[Paul1976]

I remember "Nurse death" on Diagnosis telling me that a HbA1c of 7% represented "Very good control" but when you work out that an A1c of 7% represents an average BG of around 9-10mmol,twice the level of a healthy non Diabetic,then I have to say it's an appalling target to push! :thumbdown:

 

[Paul_c]

I strongly suspect it's the target at which they consider the costs to the NHS of control to be better than the costs to the NHS from complications and deaths. A lower target would require higher costs of control and the beancounters have decided that it's not worth the extra cost on the NHS. Unfortunately, as usual, the costs to the patient and the rest of society don't come into consideration... just the NHS costs

 

[Anonymous]

Hmmn, my last official HBA1C was 6.4%, so just under the lowest percentage documented and I consider myself as pretty actively controlling my condition. The fact that I'm therefore in the bottom 25% of type 2's isn't that surprising.

A few comments having skim read the report.

The percentage figures for type 1's are quite shocking, given that they 'have' to take insulin and are at risk of immediate problems if they don't. I expected their care and control to be generally better (this is not a dig at type 1's by the way - more of an indictment of their care).

That men are worse at their control than women - though I suspect this is due to the fact that men are more reluctant to visit their GP.

These are figures from 'diagnosed' diabetics - I wonder what the un-diagnosed population is at present.. 1 in 4, 1 in 6 perhaps? That would alter these figures markedly.

 

[Paul1976]

I admit I would be happy if my next A1c was as low as 7.5% but only as a stepping stone down from the shocking 14.1% result I got back in April! :thumbdown: I would hope to then lower it further.
What puzzles me is (correct me if I'm wrong) that >6.5% would be considered diagnostic of DM and the patient would be told to try diet and exercise YET they consider 7% as good control,SURELY they should be advocating that patients aimed below 6.5% or have I missed the point somewhere?(Which knowing me,is very possible :crazy: )

 

[smidge]

Hey Guys!

The percentage figures for type 1's are quite shocking, given that they 'have' to take insulin and are at risk of immediate problems if they don't. I expected their care and control to be generally better (this is not a dig at type 1's by the way - more of an indictment of their care).

Yep, this is what I keep trying to tell people when they state that Type 1s get better care. We really don't! We get different care than Type 2s, but it isn't necessarily better and is certainly not more effective. However, as with all diabetes care, you tend to get the care commensurate with your education, intellect and ability to stand your ground and argue your case. For me, that is not an acceptable situation. Several times, I have been told to get my HbA1c higher (I try to keep it in the 5s and it has recently slipped to 6.1) - their reasoning is that I will die of hypos. Now, I know enough to object to this and argue my case - many people don't, and therefore accept the recommendation that they should run their HbA1c in the 7s. Add the poor care and advice to the lack of interest among many Type 1s and the results above are not surprising.

Another factor is the younger age that Type 1 tends to be diagnosed at. The average age of Type 2s is significantly higher. With age comes experience and knowledge - a different set of priorities. It is hard to get diabetic children through their teenage years and young adulthood with the committment and priority to keep control of their diabetes - this is an area that I really think needs to be targetted if those figures are to be improved.

Smidge

 

[Grazer]

SURELY they should be advocating that patients aimed below 6.5% or have I missed the point somewhere?(Which knowing me,is very possible )

Of course they should. Cynical I know but:-
1) The lower the target, the bigger the %age that don't achieve it and the worse it looks
2) The lower the target, the greater the chance of some insulin dependant diabetics having hypos - so let's be safe rather than do what's right.

The American association of endocrinologists say "below 6.5%" and the American Diabetes association say "below 6.0% "if safe"" - or it could be the other way around!

 

[phoenix]

What puzzles me is (correct me if I'm wrong) that >6.5% would be considered diagnostic of DM and the patient would be told to try diet and exercise YET they consider 7% as good control,SURELY they should be advocating that patients aimed below 6.5% or have I missed the point somewhere?(Which knowing me,is very possible :crazy: )

The figures aren't good but neither is the idea that a low (normal) HbA1c is always a sensible target.
For T1s If they are able to get their HbA1c down in the 5s and 6s without severe hypos then fine. At the moment I can and so it makes sense to keep my levels where they are (around 5.8%). I have to say my doctors still feel I keep my levels too low and at one time they were right as I lost hypo awareness when my HbA1c was lower. There are many T1s with far more volatile glucose levels than I, for example people who find it difficult to keep their overnight levels stable. These people may be safer with higher HbA1cs. Also children and adolescents often have very rapid fluctuations. The amount of insulin they need varies as they grow, as teenage hormones kick in etc
In the DCCT trial the risk of complications shot up from an HbA1c of about 7.5% but the risk of severe hypoglycaemia (ie requiring help) increases as HbA1cs fall below 7%.



Also the 50 year Joslin medallist studies in the US and smaller similar ones in the UK have found that their long term survivors have an average HBA1c of around 7.7% In the Joslin study they have HbA1cs going back to 1993. "A high proportion of Medalists remain free from proliferative diabetic retinopathy (PDR) (42.6%), nephropathy (86.9%), neuropathy (39.4%), or cardiovascular disease (51.5%).
Current and longitudinal (the past 15 years) glycemic control were unrelated to complications You have to remember when these people were diagnosed they probably had 1 or 2 injections of insulin a day and no blood glucose meters. So it appears that it is not just glycemic control in T1 that determines outcomes.
http://care.diabetesjournals.org/conten ... 8.full.pdf

 

[lucylocket61]

I may have misunderstood this figure but:

I am reading that only 15.9% of treated type 2's are achieving HbA1c's of 6.5 or less

Wouldnt that be considered a failure by any other organisation? Only 15.9% success in most industries would cause the engineers to see what was going wrong and halt production, not to carry on and ignore the problem :crazy:

 

[Grazer]

I may have misunderstood this figure but:

I am reading that only 15.9% of treated type 2's are achieving HbA1c's of 6.5 or less

Wouldnt that be considered a failure by any other organisation? Only 15.9% success in most industries would cause the engineers to see what was going wrong and halt production, not to carry on and ignore the problem :crazy:

Think you read it right! And it's just my point - if the target was 6.5, 80%+ would be failing and it would look really bad. Set a target at 7.5% and suddenly almost 70% of T2's are hitting target - well done the NHS!
Phoenix points out that for T1s it can be dangerous to have HbA1cs too low; but why then not have differtent targets for differtent types on different medication regimes? I know NICE talk about "individual targets", but I'm not sure people get them, and it's always the headline ones that are used anyway. I've never had a doctor or nurse say "you're only on metformin minimal dose, you obviously understand about carbs and control, so your target is 5.9%" (for example)

 

[smidge]

They just work to the lowest common denominator. They take no account of modern insulin regimes and their relative safety. All diabetes targets need to be agreed with the individual according to his/her medication and circumstances - with all risks being explained properly. We are a very long way from that.

Smidge

 

[phoenix]

if the target was 6.5, 80%+ would be failing and it would look really bad. Set a target at 7.5% and suddenly almost 70% of T2's are hitting target - well done the NHS!

Not certain what the NICE guidelines now say
DUK says

For most people with diabetes, the HbA1c target is below 48 mmol/mol,(6.5%) since evidence shows that this can reduce the risk of developing diabetic complications, such as nerve damage, eye disease, kidney disease and heart disease.

Individuals at risk of severe hypoglycaemia should aim for an HbA1c of less than 58 mmol/moll(7.5%). However, any reduction in HbA1c levels (and therefore, any improvement in control), is still considered to have beneficial effects on the onset and progression of complications

I agree that people should have individual targets. Shouldn't that form part of the care plan? The one that forms part of the 'quality standards'

Quality statement 3: Care planning
o People with diabetes participate in annual care planning which leads to documented
agreed goals and an action plan.

They do on this one but I haven't heard of anyone on here describe that they have a care plan. Has anyone?
http://www.diabetes-stourbridgeanddudle ... _record_(5).pdf

 

[Grazer]

That's my point Phoenix; I know NICE talks about individual plans, but I don't have one....?
As far as the 6.5 %, i know that's on the DUK website, but the National Audit in this thread only seems to refer to one "target" of 7.5%, and the audit is supposedly delivered in conjunction with the NHS and others. which is what i was querying with xyzzy about target change.

 

[xyzzy]

Actually if you take say this doc http://medweb.bham.ac.uk/easdec/prevention/hba1c_and_retinopathy.htm which Catherine posted on another thread it is making distinctions between insulin and non insulin using diabetics and also how long people have been diagnosed for.

Ideal Targets for HbA1c

if well, and diet or tablet controlled HbA1c less than 6.5%

if very ill higher levels may be accepted

if using insulin and keen to control diabetes and able to test glucose 4-6 times day (basal bolus insulin/pump)
HbA1c 6.5-7.5% (without many hypos)

if using insulin and keen to control diabetes and able to test glucose <4 times day (basal bolus insulin/pump) HbA1c 7.0-7.5%
(or as low as possible without many hypos)

That diet only < 6.5% target is new? If so that is quite encouraging.

It explains at the end why that target overrides that dodgy 2010 study that says 7.5% is safest as it seems to recognise that should only apply in a limited number of cases.

 

[Grazer]

It's nice that a ".org" is suggesting that, but it's still not an official NICE or NHS target as far as I can tell.

 

[noblehead]

Another factor is the younger age that Type 1 tends to be diagnosed at. The average age of Type 2s is significantly higher. With age comes experience and knowledge - a different set of priorities. It is hard to get diabetic children through their teenage years and young adulthood with the committment and priority to keep control of their diabetes - this is an area that I really think needs to be targetted if those figures are to be improved.

Good point and speaking from experience achieving a low Hba1c was far from my list of priorities when diagnosed with type 1 at the age of 18, it isn't until years later when you start a family and realise that you may not see them grow-up or live to see your grandchildren that you start to sit-up and pay attention.

I know a lady with type 1 who has brittle diabetes and her bg's can drop like stone, she's had diabetes 47 years and has no hypo-awareness so aims to keep her bg around 9/10mmol at all times, this is in agreement with her HCP's after having been hospitalised on several occasions.

 

[Paul1976]

I know a lady with type 1 who has brittle diabetes and her bg's can drop like stone, she's had diabetes 47 years and has no hypo-awareness so aims to keep her bg around 9/10mmol at all times, this is in agreement with her HCP's after having been hospitalised on several occasions.

Yes,I would totally agree in those circumstances that Hypoglycaemia is more of a threat to her life and wellbeing than keeping levels as tight as possible.Poor lady,it must be a nightmare for her!