Publication, Part of National Diabetes Audit, Type 1 Diabetes
National Diabetes Audit 2021-22, Type 1 Diabetes - Overview
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3 June 2024 00:00 AM
Summary
This is an overview of the treatment and demographics of 227,435 adults with type 1 diabetes. From 2019 to 2022 glucose control in people with type 1 diabetes in England and Wales improved while blood pressure control deteriorated. Use of diabetes technology (wearable glucose monitoring devices in England and insulin pumps in England and Wales) was associated with lower glucose levels. Diabetes technology was used less by those in the most deprived groups and in ethnic minorities. 30% of people with type 1 diabetes did not attend specialist care in 2021-22 and were less likely to receive annual checks or achieve treatment targets as recommended by the National Institute for Health and Care Excellence (NICE). There are 3 recommendations for commissioners of care.
Highlights
Introduction
This is the third National Diabetes Audit (NDA) report on adults with type 1 diabetes. This State of the Nation overview details the findings and recommendations relating to routine diabetes care for people with type 1 diabetes. It covers the period 01 January 2021 to 31 March 2022.
The NDA provides a comprehensive view of diabetes care in England and Wales. It includes results from more than 98% of people with diagnosed diabetes. It measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines and NICE Quality Standards. NICE guidance recommends that everyone with diabetes is reviewed at least once a year. NICE also recommends treatment targets for glucose control, blood pressure and cardiovascular disease (CVD) risk reduction. The guidelines are based on evidence that regular healthcare checks and achieving the treatment targets maintains health and reduces long term complications.
The cohort of adults with type 1 diabetes used for this report
To ensure that this report only included adults with type 1 diabetes a validation process was used to exclude people who may have been wrongly coded as having type 1 diabetes. The cohort consists of people in the audit period aged 19 years and over, with a recorded diagnosis of type 1 diabetes and who were prescribed insulin treatment via insulin pump, basal bolus or fixed mix. This validation process aims to exclude adults with type 2 or other diabetes inadvertently coded as type 1, but may also exclude a few frail type 1 individuals being treated with very simple insulin regimens.
Over 98% of all general practices in England and Wales participated in the 2021-22 audit and data was extracted from their electronic records. Specialist diabetes services generally take the lead in care for people with type 1 diabetes. Where specialist services have electronic records, extracts from these records can be submitted. This audit also links to outpatient attendance records in Hospital Episode Statistics (HES) which identifies all specialist service attendances irrespective of whether they have an electronic clinical record.
Aims of the Report
This NDA report focusses on NICE guidance and Quality Standards for the routine care of people with type 1 diabetes. Everyone with diabetes should be reviewed at least once a year. Having diabetes can lead to health complications such as blindness, kidney failure, heart disease, stroke and premature death. The review should include blood tests for HbA1c (glucose control), creatinine (kidney function), cholesterol (heart risk), a urine test for albumin (kidney risk), measurements of blood pressure and weight, examination of the feet (foot ulcer risk) and review of smoking habit. These are called the 8 care processes. Retinal screening run by dedicated screening programmes, is the ninth care process. At review, treatment should be adjusted where necessary to achieve NICE recommended HbA1c and blood pressure levels; also, those with high heart risk should be prescribed a statin. These are known as the 3 treatment targets. NICE also has guidance for the use of Continuous Subcutaneous Insulin Infusion (Insulin Pumps) and Continuous Glucose Monitoring Systems (CGMS) .
Measurements of routine diabetes care for people with type 1 diabetes are reported in the publicly available quarterly dashboard (England GP record extracts only, for all ages: NDA England primary care quarterly dashboard), the annual care processes and treatment targets dashboard (GP record extracts plus data submitted by specialist services: NDA Core annual dashboard - England and Wales) and the NDA Type 1 dashboard - England and Wales (using the cohort validated with prescription data and including data on CGMS and pumps). Data are published at national, regional, integrated care board (ICB), sub ICB, local health board (LHB) and specialist service levels (all dashboards), and at primary care network (PCN) and practice levels (quarterly and core dashboards only).
For this summary report the detailed extra analyses can be found here: NDA Type 1, 2021-22, detailed analysis
The online detailed analysis document has 4 sections:
- Information on the creation of the type 1 cohort, and details on use of the HES outpatient attendance data
- Treatment target achievement across sub ICBs (formerly clinical commissioning groups (CCGs) and LHBs for years 2019-20 to 2021-22
- HbA1c levels, the use of glucose technologies and equality of access to these technologies
- Specialist services care
Key findings and recommendations
Key finding 1: Glucose control (HbA1c) has improved but blood pressure has deteriorated
The improvement in achievement of the HbA1c treatment target which took place between 2019-20 and 2020-21 continued in 2021-22. Median achievement of the HbA1c treatment target was 27.6% in 2019-20, rising to 30.8% in 2020-21 and to 32.6% in 2021-22. In 2021-22, a third of adults with type 1 diabetes had an HbA1c level of 58 mmol/mol (7.5%) or lower and a fifth had an HbA1c level of 53mmol/mol (7.0%) or lower. Wearable glucose monitoring systems started roll-out in England in Summer 2020. Key finding 2 highlights their role in HbA1c improvement.
Although HbA1c improved during the pandemic, blood pressure deteriorated. Blood pressure target achievement (BP<=140/80) fell from 73.4% in 2019-20 to 69.9% in 2021-22. Appropriate use of statins, the third treatment target, did not change (median 70%).
Figure 1: Median achievement of HbA1c and blood pressure treatment targets across sub ICBs and local health boards for adults with type 1 diabetes, England and Wales, 2019-20 to 2021-22
To read more, see the detailed report: Section 1 - Care processes and treatment targets
Recommendation 1
Commissioners of care should ensure that type 1 diabetes services have the capacity and capability to support all those who can benefit from appropriate glucose technologies and return blood pressure management to pre-pandemic levels.
Key finding 2: There is inequality of access to glucose technology
England
By March 2022 50.4% of people with type 1 diabetes in England were using wearable glucose monitoring devices. Lower HbA1c levels were associated with use of insulin pumps and wearable glucose monitors. Insulin pumps were being used by 16.6% of those with HbA1c<=53 and 6.6% of those with HbA1c>69. Similarly, 58.5% of those with HbA1c <=53mmol/mol (7.0%) were using a wearable glucose monitoring device compared to 46.1% of those with HbA1c >69mmol/mol (8.5%).
Figure 2: Percentage of adults in each HbA1c range who were prescribed/ not prescribed wearable glucose monitors, England 2021-22 (1)
(1) NICE guidance is that people with type 1 diabetes should be supported to aim for a target HbA1c level of 48mmol/mol or lower, and that diabetes services should document the proportion of adults with type 1 diabetes who reach an HbA1c level of 53mmol/mol or lower.
Younger people had the highest rates of diabetes technology use, with 14.2% of the 19 to 29 age group using insulin pumps and 58.9% being prescribed wearable glucose monitors, compared to 11.5% and 50.4% respectively of the overall population of adults with type 1 diabetes in England. People with white ethnicity and less deprived groups were more likely to be using diabetes technology. 8.5% of people living in the most deprived group were pump users and 44.7% had been prescribed wearable glucose monitors compared to 13.9% and 55.8% respectively of the least deprived group. Similarly, only 4.3% of people with black ethnicity were insulin pump users and 33.4% had been prescribed wearable glucose monitors, compared to 12.1% and 52.0% respectively of people with white ethnicity. There were variations in diabetes technology use at ICB level that were not fully related to the age, ethnicity and deprivation patterns. Insulin pump use between ICBs spanned 6.4% to 18.4% and wearable glucose monitoring 33.7% to 64.0%.
Wales
Please note that data on flash glucose monitoring is not available for Wales, so there is no analysis of wearable glucose monitors for Wales.
Lower HbA1c levels were associated with use of insulin pumps. In Wales, insulin pumps were being used by 20.3% of people with HbA1c<=53 mmol/mol and by 10.5% of people with HbA1c>69 mmol/mol.
Younger people had the highest rates of insulin pump use, with 21.5% of people aged 19 to 29 using insulin pumps, compared to 16.7% of the overall population of adults with type 1 diabetes in Wales. People with white ethnicity and less deprived groups were more likely to be using insulin pumps. 15.6% of people living in the most deprived areas were insulin pump users, compared to 18.8% of people in the least deprived areas. Similarly, only 10.0% of people with black ethnicity were insulin pump users, compared to 17.2% of people with white ethnicity. There were variations in insulin pump use across LHBs, spanning 7.9% to 29.9%.
To read more, see the detailed report: Section 2 - Inequalities
Recommendation 2
In England, commissioners of care should ensure that their providers of type 1 diabetes care embed principles of Core20PLUS5 in delivery of access to diabetes technology. In Wales, local health boards should support their providers of type 1 diabetes care to reduce apparent inequalities in use of insulin pumps.
Key finding 3: Almost 7 in 10 adults with type 1 diabetes in England were seen in specialist services. Those who had been seen in specialist services had higher rates of care process completion and treatment target achievement than those who had not.
Figure 3: Proportion of adults with type 1 diabetes who were seen/ not seen in specialist services, England, 2021-22
The management of type 1 diabetes including the provision and supported use of diabetes technologies should be led by specialist services. 113 out of 130 (87%) of specialist type 1 diabetes services who responded to the 2022 Specialist Services Survey reported that they have the capability to provide and support diabetes technology.
69.1% of adults with type 1 diabetes were recorded as having attended a specialist service during 2021-22. Not attending a specialist service was associated with older age, ethnic minorities (excluding white minorities), and social deprivation.
For each individual care process completion rates were higher for those seen in specialist services. For the overall measure, 38.7% of the people who had been seen in specialist services had received all 8 care processes, compared to 35.3% of those who had not been seen in specialist services. Achievement of treatment targets was also generally better in the group who had been seen in specialist services than in the group who had not. The exception was the blood pressure treatment target, where 68.7% of people who had been seen in specialist services had blood pressure 140/80 or less, compared to 70.7% of those who had not been seen in specialist services. Overall, 20.9% of those seen in specialist services had achieved all 3 treatment targets, compared to 19.2% of those who had not been seen in specialist services.
Please note that the specialist services analysis is dependent on HES data, which covers England only, so there is no analysis of specialist services attendance for Wales.
To read more, see the detailed report: Section 3 - Specialist services care
Recommendation 3
Commissioners of care should ensure that everyone with type 1 diabetes has access to a specialist service.
Resources
Last edited: 3 October 2024 8:22 am