Transcript Document

The National Diabetes Audit (NDA) is commissioned by the Healthcare Quality Improvement
Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme
(NCAPOP) following advice to the Department of Health from the National Advisory Group on
Clinical Audit and Enquiries (NAGCAE).
The National Diabetes Audit
Improving Care Delivery
Bob Young
Clinical Lead NDA & NCVIN
NDA
Consortium
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Why Measure (Audit)?
• All improvement requires change BUT change
does not necessarily lead to improvement.
• Change is hard work; not everything can be
changed at once.
• Measurement enables:
– Choice of priorities for Change (focus effort/capacity)
– Evaluation of impact of Change (keep or start again)
• Without measurement it is impossible to know
whether improvement efforts (changes) are
– well directed
– or working
THE PURPOSE OF
MEASUREMENT IS TO
ENABLE CHANGE FOR
IMPROVEMENT
National Measurement (Audit)
• Economy of effort
– Re-use of routinely recorded data
• Electronic care records (structured/coded components)
• Hospital activity statistics (HES, PEDW)
• Mortality Records
– Standard, secure, recording and submission
– Shared Information Governance
• Reliability
– Data Quality Checks
– Consistent, curated statistical analysis
• Minimal erosion of change capacity by measurement effort
• Peer comparison
• Downside is slower reporting
NDA Linked Data
GP and Specialist Electronic Records
Hospital Episode Statistics
Diabetes Diagnosis, Year
ONS (MRIS)
-> NDA core dataset
NHS number
NHS No, Sex, Post Code
(IMD), Year of birth
Admission for DKA,
Amputation,
BMI, Smoking, BP, HbA1c, Dialysis/Kidney
Transplant, Angina, MI,
TC, eGFR, UACR
HF, Stroke
Eye & Foot surveillance
NHS number
Date of death
Patient level linked extensions:
Pregnancy, NPID (started 2013);
Foot disease NDFA (starts July 2014)
Also unlinked:
Inpatients, NaDIA (started 2011); Patient Experience, PEDS (Piloted 2013-14)
Core NDA (from 2003-4)
•
•
•
•
Annual GP/Specialist EPR extracts (outpatient care)
Linked to HES/PEDW (hospital admissions) and ONS (death)
2,473,239 people with diabetes in 2011-12
88.4% of people with diagnosed diabetes
Data Completeness
>99%
Gender, Age, Diabetes
Type
90-99%
Diagnosis year, BMI, BP,
HbA1c, Creatinine,
Cholesterol
80-89%
Smoking, Foot
Surveillance
75-79%
Ethnicity, UACR,
(Retinopathy Screening)
Core NDA Reports
• Diagnosis and Registration
• NICE specified annual Care Process completion
rates
• NICE Specified Treatment Target & Structured
Education achievement rates
• Complication Rates
– Acute (DKA, HHS)
– Microvascular (Retinopathy treatment, CKD stage and
RRT, Amputation)
– Cardiovascular (Angina, MI, HF, Stroke)
– Death
Treatment target achievement
all CCGs – TREATMENT VARIATION
% achieving all treatment targets vs
Age and Ethnicity
30
25
25
20
15
10
5
T1 % all
treatment
targets
T2 % all
treatment
targets
15
T1 % all
treatment
targets
10
T2 % all
treatment
targets
5
0
0
Age in years
White
Mixed
Asian
Black
Other
Not Known
20
Ethnic
Group
% achieving all treatment targets vs
Deprivation Quintile and BMI
% all treatment targets
21.4
21.3
21.2
21.1
21
20.9
20.8
20.7
20.6
20.5
20.4
% all treatment targets
30
25
20
% all
treatment
targets
15
% all
treatment
targets
10
5
Q1 Q2 Q3 Q4 Q5
Deprivation Quintile
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
40+
0
BMI
Treatment target achievement rates for all patients in
NHS Salford CCG and England and Wales by treatment
target, diabetes type and audit year
% patients meeting all treatment targets for all
GP practices within NHS Salford CCG
Practice Variation
26.1% = Q4
Age-specific mortality rate ratios by
type of diabetes and sex
TYPE 1
YOUNG
NDA Report 2 2013
300
NDA
Standardised Mortality Ratio
for Type 1 and Type 2 Diabetes
250
200
2008-9
150
2009-10
2010-11
100
50
0
T1
T2
Encouraging but still ~24,000 excess deaths
Odds Ratio for death in the next year
- driven by Complications
NDA Report 2 2013
Funnel chart of CCG/LHB standardised
ratios for HF among people with diabetes
OUTCOME VARIATION
Am I one of these?
BP Measured in 95%
BP<140/80
T1 57.9%
T2 47.3%
NDA Report 2 2013
Core Care:
where to focus change effort?
•
•
•
•
Younger people & Type 1
Obesity management
Blood Pressure Management
Improve 25% poorest performing practices
(services) to level of middle 50% (emulate)
• Encourage 25% best performing practices to
improve through tests of innovation
NaDIA
Snapshot Audit; all inpatients, one
September day, 233 hospitals
Inappropriate duration IV infusion
Prescription Errors
Insulin Errors
But Continuing Evidence of Harm
from
Medication Errors
Inpatient Care:
where to focus change effort?
• Safer IV insulin
• Safer inpatient prescribing
• Prevention of severe adverse incidents
• Does it sound like flying in the 1960’s? Lots of
‘near misses’ and occasional disasters
CLINICAL QUALITY
IMPROVEMENT
PLAN
ACT
PDSA
MEASUREMENT
STUDY
(meeting
Standards?)
PDSA - THE
QUALITY
SPIRAL
DO
Improvement
Is Driven
By
Self-Assessment
directed Change
SERVICE SELF-ASSESSMENT
Multidisciplinary, multi-sector,
professional, patient, management,
commissioner Steering Group
‘Whole Systems’
Clinical Quality
Improvement
ANNUAL ACTION PLAN
USING INFORMATION
To Improve Patient Outcomes
• Get all stakeholders round the table
• Select measurements appropriate to service
• Review and use comparisons with peers to
choose manageable number of priorities
• Assign leaders to improvement projects
• Develop and implement action plans with agreed
goals
• Use measurements to determine whether goals
have been achieved
• Start again!
Scope of NDA
AN ‘EPISODE’ OF DIABETES
‘THE REST OF LIFE’
+
P
R
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V
E
N
T
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N
= NDAA
Non diabetes
Related
Hospital
Admissions
Other
new
complicat
ions
New
CHD
Major Life
Events
New CVA
Diagnosis
Initial
Management
Continuing
Care
Major
Treatment
Change e.g.
Starting
Insulin
New
Erectile
dysfunction
EVENTS
Pregnancy
Severe
Hypoglycaemia
Institutional
Care
DKA
HONK
Foot
HUB
Disease
New
Protenuria
New Eye
Complications
SUB-PATHWAYS FOR EACH EVENT
ALWAYS RETURNING TO CONTINUING CARE
Laying the
Foundations
Support & Early
Detection
Reacting
Reacting
when
when
Things
may/do
Things go Wrong
The National Diabetes Audit (NDA) is commissioned by the Healthcare Quality Improvement
Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme
(NCAPOP) following advice to the Department of Health from the National Advisory Group on
Clinical Audit and Enquiries (NAGCAE).
The National Diabetes Audit
Improving Care Delivery
Bob Young
Clinical Lead NDA & NCVIN
NDA
Consortium