Publication, Part of National Diabetes Audit, Type 1 Diabetes

National Diabetes Audit, 2020-21, Type 1 Diabetes

Publication Date:: 16 Jun 2022
Geographic Coverage:: England, Wales
Geographical Granularity:: Regions, Clinical Commissioning Groups, Integrated Care Boards
Date Range:: 01 Jan 2020 to 31 Mar 2021

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16 June 2022 09:30 AM

Additional information

Definitions

Diabetes

Diabetes is a condition where the amount of glucose in the blood is too high because the pancreas doesn’t produce enough insulin. Insulin is a hormone produced by the pancreas that allows glucose to be used as a body fuel and other nutrients to be used as building blocks. There are 2 main types of diabetes: Type 1 diabetes (no insulin); Type 2 diabetes (insufficient insulin).

Glucose control

A flash glucose monitor is a small sensor that is worn just under the skin and known as flash for short. It records glucose (sugar) levels continuously throughout the day and night. The information collected can be obtained by scanning the device.

A continuous glucose monitor (CGM) also records glucose (sugar) levels continuously throughout the day and night, but the information collected is fed through to a display device. The user can also set alerts for high/medium/low levels.

Annual Review

This is a GP appointment where the annual National Institute for Health and Care Excellence (NICE) recommended Care Processes are undertaken.

Care Processes (NICE recommends all of these at least once a year)

Blood Pressure is a measurement of the force driving the blood through the arteries. Blood pressure readings contain 2 figures, e.g.130/80. The first is known as the systolic pressure which is produced when the heart contracts. The second is the diastolic pressure which is when the heart relaxes to refill with blood.

BMI measurement – Body Mass Index is calculated from weight and height and used to classify body weight as low, normal, overweight and obese.

Serum creatinine – this is a blood test used to measure kidney function.

Urinary albumin – this urine test detects the earliest stages of kidney disease.

Cholesterol - this blood test measures a type of fat that can damage blood vessels.

Foot check - this examination checks the blood supply and sensation (feeling) in the feet. Loss of either is a risk for foot disease.

Smoking Status - this records whether the person is a smoker. Smoking increases the risk of heart attacks and stroke on people with diabetes.

HbA1c – this is a blood test for average blood glucose levels during the previous 2 to 3 months.

Treatment Targets (NICE defines target levels to reduce risks of complications for people with diabetes)

HbA1c - the closer this is to normal (less than 42mmol/mol) the lower is the risk of all long term complications of diabetes.

Blood Pressure – high levels are a risk for heart attacks and strokes; they also drive progression of eye and kidney disease.

Primary prevention of CVD – the prescription of statins for people with diabetes aged 40 to 80 years with no history of cardiovascular disease (CVD) to reduce the risk of CVD.

Secondary prevention of CVD – the prescription of statins for people with diabetes (any age) with a history of cardiovascular disease (CVD) to reduce the risk of CVD.

Combined prevention of CVD – the prescription of statins for people with diabetes that fall into either of the primary or secondary prevention groups.

Meeting all 3 treatment targets – having HbA1c ≤58mmol/mol, blood pressure ≤140/80 and for people falling in the combined prevention CVD group: receiving statins.

Specialist Service

This is a service (often hospital based but sometimes delivered in a community setting) which includes diabetes specialists working in multidisciplinary teams. These teams usually comprise physicians (diabetologists), diabetes specialist nurses and dieticians; it may also include clinical psychologists.

Insulin Administration

Basal-bolus insulin treatment comprises background, slow acting (basal) insulin, self-injected once or twice daily, plus rapid acting (bolus) insulin at mealtimes

Fixed mix insulin combines rapid and longer acting insulin at a fixed ratio. It is usually self-injected twice daily.

Insulin pump or Continuous Insulin Infusion therapy uses rapid acting insulin delivered subcutaneously under the control of a ‘Pump’. Background rates are programmed and mealtime boluses are added manually.

Statistical terms

Where a result is flagged as significant at 0.05 level, there is only a 5% probability that the result is due to chance.

Logistic regression is used to examine the relationship between an outcome (e.g. HbA1c ≤ 58 mmol/mol) and related variables (e.g. insulin treatment regimen). Backwards elimination is used to remove variables found not to be significant at 0.05 level, producing a final model that includes variables with significant associations only.

2 outputs are particularly useful when interpreting the results of a logistic regression model:

The c-statistic can be used to assess the goodness of fit, with values ranging from 0.5 to 1.0. A value of 0.5 indicates that the model is no better than chance at making a prediction of membership in a group and a value of 1.0 indicates that the model perfectly identifies those within a group and those not. Models are typically considered reasonable when the c-statistic is higher than 0.7 and strong when the c-statistic exceeds 0.8 (Hosmer and Lemeshow, 2000*).
Odds ratios (OR) illustrate how strongly a particular value of a variable is associated with the outcome. The further from 1 the ratio is (either above or below), the stronger the association between it and the outcome. For example, an odds ratio of 0.764 would suggest a stronger association than an odds ratio of 0.830. An odds ratio of 1 would show that the variable value has no bearing on how likely the outcome is.

The degree of uncertainty inherent in the odds ratio is described by the confidence interval. The wider the confidence interval, the less certainty there is in the odds ratio. If the confidence intervals are either side of 1 (the line of no effect) this indicates that the value taken by the variable (e.g. female) has no bearing on how likely the outcome is (e.g. HbA1c ≤ 58 mmol/mol). Where the confidence interval approaches this indicates that the association with the outcome may be weak. Odds ratios can be displayed on a forest plot (see example forest plot right).

Forest plot showing odds ratios indicating how strongly variables are associated with the outcome

Modelling – interpreting a funnel plot

Adjusting for each service’s unique patient casemix allows fairer comparisons between services.

Statistical models for outcomes were built. The models were used to estimate the number of events expected to occur at each CCG/LHB. The expected figures were then compared with the observed number of events, to produce a standardised ratio (SR).

If more patients had the event than expected the SR is greater than 100 and if there were fewer than expected the SR is less than 100. Deviation from 100 does not necessarily mean that an organisation is performing better or worse than expected. Instead, control limits (2 and 3 standard deviations (SD)) are used to assess whether the SR for an organisation is within an expected range or not. Results are displayed on a funnel plot.

Figure 22: Example funnel plot

Example funnel plot

Notes and Additional Information

Suppression:

Disclosure control has been applied to mitigate the risk of patient identification. Zeros are reported, and all numbers are rounded to the nearest 5, unless the number is 1 to 7, in which case it is rounded to ‘5’. This allows for more granular data to be made available.
Rounded numbers are used to calculate percentages such as care process completion and treatment target achievement. At CCG/LHB level and above this makes virtually no difference to the resultant percentages. At Specialist Service Provider level, where the numbers can be small, this rounding can have a relatively large impact. However, where numbers are small, percentages are volatile and should already be treated with caution.

Prepared in collaboration with:

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). HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations and crown dependencies.

NHS Digital is the trading name for the Health and Social Care Information Centre (HSCIC). NHS Digital managed the publication of the annual report.

Diabetes UK is the charity leading the fight against the most devastating and fastest growing health crisis of our time, creating a world where diabetes can do no harm.

National Diabetes Audit, 2020-21 Type 1 Diabetes

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Last edited: 3 October 2024 8:13 am