Report 1: Care Processes and Treatment Targets 2020-21, Full Report

The electronic Frailty Index (eFI) has been autogenerated by GP electronic records for several years. It is included in the 2020-21 NDA dataset for the first time. It has three grades: mild, moderate and severe.

Frailty describes a dynamic state of increased vulnerability to adverse health outcomes resulting from loss of physiological reserve. The prevalence of frailty increases with increasing age. However, frailty is not universal among older people (aged 65+ years), and can also be identified in younger people (aged <65 years), particularly in the context of long-term conditions, including diabetes.

Severe hypoglycaemia (blood glucose level <2.2mmol/l) is always hazardous but the hazard, including death, is amplified by cardiovascular co-morbidities and poor resilience.

Severe hypoglycaemia is only possible if a drug is being used that can push glucose levels into the subnormal range (<3.5mmol/l) and is more likely if average glucose levels are low (HbA1c<=53). The drugs used in type 2 diabetes management that can cause hypoglycaemia are sulphonylureas and insulin

People with frailty have reduced life-expectancy so are unlikely to live long enough to benefit from near normal blood glucose levels and are at increased risk from hypoglycaemia. NICE therefore recommends relaxing target HbA1c levels in people who are frail (https://www.nice.org.uk/guidance/ng28/chapter/Recommendations#blood-glucose-management)

Table 1: People with severe frailty or low HbA1c or both by diabetes type

Table 2: People with type 2 or other diabetes that are recorded as severely frail or have low HbA1c or both, by prescription of insulin or sulphonylureas or both

For people with type 1 diabetes, those with a learning disability are less likely to have received all 8 care processes in Wales, but more likely to receive all 8 care processes in England.

For people with type 2 or other diabetes, those with a learning disability are less likely to have received all 8 care processes.

For people with type 1 diabetes in both England and Wales, those with a learning disability are less likely to have achieved all three treatment targets.

The opposite is observed for people with type 2 and other diabetes.

For people with type 1 diabetes in England, those that have been diagnosed with severe mental illness are more likely to have received all 8 care processes. In Wales, those diagnosed with severe mental illness are less likely to have received all 8 care processes.

For people with type 2 or other diabetes in both England and Wales, those that have been diagnosed with severe mental illness are less likely to have received 8 care processes.

For people with type 1 diabetes in both England and Wales, those that have been diagnosed with severe mental illness are less likely to have achieved all three treatment targets.

For people with type 2 or other diabetes, no appreciable difference between the groups was observed in either England or Wales.