Short form National Diabetes Audit, 2017-18 (published 8/11/18)

[DCUKMod]

I haven't spent any proper time reading this yet, but I will over the coming days. There are usually some sobering numbers in there.

https://files.digital.nhs.uk/E6/369...ort, Care Processes and Treatment Targets.pdf

The full report is due in March.

 

[bulkbiker]

I haven't spent any proper time reading this yet, but I will over the coming days. There are usually some sobering numbers in there.

https://files.digital.nhs.uk/E6/369B83/National Diabetes Audit 2017-18 Short Report, Care Processes and Treatment Targets.pdf

The full report is due in March.

Very sobering indeed
"Primary prevention of cardiovascular disease (CVD): The percentage of people with diabetes aged 40 to 80 years with no history of heart disease that received statins during the audit period."
That is number 1 on the New targets to hit.. your surgery will be judged on whether they can get perfectly healthy people onto statins...

 

[Diakat]

I wish my surgery was judged on ability to deliver prescriptions to the pharmacy correctly!

I'm struggling to understand why more T2s hit check targets than T1s. Is it because we tend to go to hospital clinics which are less frequent (over a year sine I saw anyone) or is because T2s end up at the surgery more often? Any clues?

 

[bulkbiker]

I wish my surgery was judged on ability to deliver prescriptions to the pharmacy correctly!

I'm struggling to understand why more T2s hit check targets than T1s. Is it because we tend to go to hospital clinics which are less frequent (over a year sine I saw anyone) or is because T2s end up at the surgery more often? Any clues?

That surprises me too.. I would have thought that Type 1's were more careful about their health so would visit the doctors more regularly or is it because thy have given up on their GP's and self monitor relying on themselves?

 

[Alison54321]

Not particularly impressive. I'm intrigued by the idea of NICE changing the HbA1c target for Type 1s to 48mmol/mol when the 58mmol/mol target has shown minimal improvement, and most years hangs around below 30%.

Especially when the tool most likely to achieve that target, is Libre, and the resistance to prescribing it is massive.

Is this a serious target or not, it really doesn't seem like it.

 

[Alison54321]

I wish my surgery was judged on ability to deliver prescriptions to the pharmacy correctly!

I'm struggling to understand why more T2s hit check targets than T1s. Is it because we tend to go to hospital clinics which are less frequent (over a year sine I saw anyone) or is because T2s end up at the surgery more often? Any clues?

Management of Type 1 improves as people get older, working old adults are less likely to achieve targets than retired ones. So because the Type 2 population is, on average, older that might be a factor.

Also, the numbers needing insulin are smaller, and so I suspect the amount by which their blood sugars deviate from the normal range is not as high, as for type 1s. That's all average, obviously individual experiences vary. I don't I've phrased that very well, I'm sort of trying to say blood sugars aren't quite so random, if your beta cells are producing at least a bit of insulin.

 

[Diakat]

That surprises me too.. I would have thought that Type 1's were more careful about their health so would visit the doctors more regularly or is it because thy have given up on their GP's and self monitor relying on themselves?

Thoughts - and willing to be shot down on any:
1. Many T2s are older so retired so able to make GP appointments that are often at silly times and may be going because of other health issues
2. Some GP surgeries (mine) won't do a T1 hba1c as "you get it at the hospital"
3. Hospital clinics are so busy the times between appointments get longer and longer
4. Many GPS are not up to scratch on any type of diabetes
5. Many diabetics just don't want to know/think about it

 

[bulkbiker]

Many GPS are not up to scratch on any type of diabetes

I think that one is probably very true and more so in the case of Type 1's where they simply won't have much of a clue apart from "they need insulin".

 

[SamJB]

I was on the steering committee for a number of years, so may be able to answer some questions:

1. Why are more T2 hitting their targets?
I can only speculate on this, but I suspect it's because many T1s are under the care of a hospital, whereas T2s tend to be under the care of GPs. GPs get financial incentives if they hit their QoF targets, whereas I don't think departments in hospitals do.

2. HbA1c targets being 58mmol/mol instead of 48mmol/mol.
The NDA used to have 48mmol/l as it's own target level, but it was brought in-line to be the same as NICE. I agree NICE is too high, many on the NDA did too, but it has to be standardised to what NICE wants otherwise it's not an affective measuring tool if the NDA decided on its own targets for everything.

3. Why to T2s get better results that T1s?
One thing I got onto the complications report was breaking it into T2 and T1 (both used to be lumped in together). The surprising thing was that T1s have much worse complication rates that T2s. We discussed this a lot and concluded that T2 is more of a spectrum disorder than T1 - T1 control is, generally, much more difficult than T2 control.

 

[tim2000s]

That surprises me too.. I would have thought that Type 1's were more careful about their health so would visit the doctors more regularly or is it because thy have given up on their GP's and self monitor relying on themselves?

It's usually down to the age groups that the T1 and T2 fall into. There's a much higher proportion of T1s under 35, and they are least likely to attend GP clinics. I'll have to try and find that data.

Not particularly impressive. I'm intrigued by the idea of NICE changing the HbA1c target for Type 1s to 48mmol/mol when the 58mmol/mol target has shown minimal improvement, and most years hangs around below 30%.

Especially when the tool most likely to achieve that target, is Libre, and the resistance to prescribing it is massive.

Is this a serious target or not, it really doesn't seem like it.

This was changed in the 2015 guidelines. It was argued for by the people with T1D on the guidelines working group, and not by the HCPs involved.

The reason for doing so was that the DCCT and EDIC studies show that once you hit 6.5%, the risk of complications is much closer to that on people without Diabetes. For the last two years, the proportion that are at this level has remained around 30% as you say.

 

[SamJB]

It's usually down to the age groups that the T1 and T2 fall into. There's a much higher proportion of T1s under 35, and they are least likely to attend GP clinics. I'll have to try and find that data.


This was changed in the 2015 guidelines. It was argued for by the people with T1D on the guidelines working group, and not by the HCPs involved.

The reason for doing so was that the DCCT and EDIC studies show that once you hit 6.5%, the risk of complications is much closer to that on people without Diabetes. For the last two years, the proportion that are at this level has remained around 30% as you say.

Before the HbA1c targetr was raise, only 5% of T1s acheived the 6.5% target. I personally feel this is the correct target, although NICE disagrees because of the (ill) percieved risk that is raises hypo frequency and severity

 

[tim2000s]

Before the HbA1c targetr was raise, only 5% of T1s acheived the 6.5% target. I personally feel this is the correct target, although NICE disagrees because of the (ill) percieved risk that is raises hypo frequency and severity

Sorry - got my stats wrong. I'm not disagreeing - I think that 48mmol/mol is the correct target, and I think you'll see the NDA target change as more Libre take up occurs.

 

[Alison54321]

Before the HbA1c targetr was raise, only 5% of T1s acheived the 6.5% target. I personally feel this is the correct target, although NICE disagrees because of the (ill) percieved risk that is raises hypo frequency and severity

I thought NICE lowered the target, which previously was 7.5%, to 6.5%, a couple of years ago.

Which is fine, but if NICE are going to lower the target then it seems reasonable to put some resources into helping people achieve it.

Whereas if only 30% are hitting the higher target, then the numbers for the lower target must be even worse, so then who takes responsibility for moving towards increasing the numbers reaching the lower target?

 

[SamJB]

Sorry - got my stats wrong. I'm not disagreeing - I think that 48mmol/mol is the correct target, and I think you'll see the NDA target change as more Libre take up occurs.

Sorry, I was agreeing with you; disagreeing with NICE!

 

[SamJB]

I thought NICE lowered the target, which previously was 7.5%, to 6.5%, a couple of years ago.

Which is fine, but if NICE are going to lower the target then it seems reasonable to put some resources into helping people achieve it.

Whereas if only 30% are hitting the higher target, then the numbers for the lower target must be even worse, so then who takes responsibility for moving towards increasing the numbers reaching the lower target?

Yes they lowered it to 6.5% as a result of the DCCT trail many years ago, then around 5 years ago raised it to 7.5%. Anecdotally (I don't have time to look for the exact reasons), was because of the risk of hypos some people have when lowering their HbA1c.

The percentage of T1s hitting 6.5% when that was the target was only 5%. Pitiful numbers.

 

[tim2000s]

Just to be clear (and mods feel free to remove the confusing posts in this thread) - NICE target is still 48 mmol/mol: https://www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#blood-glucose-management-2

Targets
1.6.6 Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long‑term vascular complications. [new 2015]

NDA is still at 7.5% because it doesn't make the results look so bad.... IMHO!

 

[Alison54321]

Just to be clear (and mods feel free to remove the confusing posts in this thread) - NICE target is still 48 mmol/mol: https://www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#blood-glucose-management-2

Targets
1.6.6 Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long‑term vascular complications. [new 2015]

NDA is still at 7.5% because it doesn't make the results look so bad.... IMHO!

I thought it was 6.5%. Are we accepting @tim2000s as the ultimate authority on this, I think we should.

I actually think a NICE target of 6.5% is useful, because in reality you can't achieve it without Libre, and the ,more people who reach the target when using it, the harder it becomes to resist it.

I'm trying to make sure mine stays in that range for my next hospital appointment, with as few hypos as I can manage, but it isn't until end January, so I've got to keep it nice and low until them. The pressure!!!

 

[SueJB]

That surprises me too.. I would have thought that Type 1's were more careful about their health so would visit the doctors more regularly or is it because thy have given up on their GP's and self monitor relying on themselves?

@bulkbiker I only go to the vet when I'm sick, in fact I'm going in a coupe of days. My diabetic disease is dealt with at the hospital. I'm not sure how informed my vet is on T1 but he certainly knew enough to send me straight to hospital last year. I agree though that the numbers are surprising indeed.

 

[Alison54321]

@bulkbiker I only go to the vet when I'm sick, in fact I'm going in a coupe of days. My diabetic disease is dealt with at the hospital. I'm not sure how informed my vet is on T1 but he certainly knew enough to send me straight to hospital last year. I agree though that the numbers are surprising indeed.

Were you diagnosed by a vet?

My poor mother took me to the doctors for months and months, before I got a proper diagnosis, he had decided I had an eating disorder, while she, who had had a years training as a nurse, before she walked out in a huff, was convinced it was Type 1 diabetes, but he ignored her.

So the vet might be quite a good option.

 

[SueJB]

Were you diagnosed by a vet?

My poor mother took me to the doctors for months and months, before I got a proper diagnosis, he had decided I had an eating disorder, while she, who had had a years training as a nurse, before she walked out in a huff, was convinced it was Type 1 diabetes, but he ignored her.

So the vet might be quite a good option.

Sorry if I've confused you @Alison54321 we've always referred to the doctor as a vet. I have nothing but admiration for the profession and my vet in particular but can't shake the habit of using the name. Good on your mum