Publication, Part of National Diabetes Audit

National Diabetes Audit 2021-22, Report 1: Care Processes and Treatment Targets, Detailed Analysis Report

Audit, Survey, Other reports and statistics

Publication Date:: 12 Oct 2023
Geographic Coverage:: England, Wales
Geographical Granularity:: NHS Trusts, GP practices, Integrated Care Boards, Regions
Date Range:: 01 Jan 2021 to 31 Mar 2022

Change to mapping used for integrated care board (ICB) analysis

An issue was found with the mapping used to define integrated card boards (ICB) in this report resulting in larger than expected cohorts for each ICB. This has been corrected in this report and has resulted in slight changes to the results of analyses broken down by ICB.

21 December 2023 00:00 AM

Additional information

Statistical terms

Where a result is flagged as significant at 0.05 level, there is up to a 5% probability of the observed result being due to chance.

Logistic regression is used to examine the relationship between an outcome (e.g. completing all 8 care processes) and related variables (e.g. diabetes duration).

For this report, each variable is split into groups (e.g. ethnicity is split into white, Asian, black, mixed, other and not stated). One of these groups is chosen to be the reference group which all other groups within the variable are compared to. The reference group in this report is defined as the group with the largest cohort in the 2017-18 type 1 diabetes model.

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 (1)).
Odds ratios (OR) illustrate how strongly a particular group within a variable is associated with the outcome compared to the reference group. 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 group has no bearing on how likely the outcome is. Where a variable group is the reference group the odds ratio for that group is 1.

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 (eg. unknown diabetes duration) has no bearing on how likely the outcome is (e.g. completing all 8 care processes). Where the confidence interval approaches 1 this indicates that the association with the outcome may be weak. Odds ratios can be displayed on a forest plot (see example forest plot below).

Figure 45: Forest plot showing odds ratios indicating how strongly variables are associated with the outcome:

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

Notes:

1. Hosmer DW, Lemeshow S (2000) Applied Logistic Regression (2nd Edition) New York, NY: John Wiley & Sons.

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 two main types of diabetes: type 1 diabetes (no insulin); type 2 diabetes (insufficient insulin).

‘Type 1’ includes where a person is recorded as having type 1 diabetes in the National Diabetes Audit (NDA).
‘Type 2 and other’ includes where a person is recorded as having type 2 diabetes, Maturity-onset Diabetes of the Young (MODY), other or non-specified diabetes in the NDA.

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.

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 the 8 care processes annually: blood pressure, body mass index (BMI), foot risk surveillance, HbA1c, serum cholesterol, serum creatinine, smoking status, urine albumin/creatinine ratio (UACR); and the ninth care process, eye screening (see Retinal screening (eye exam)/retinopathy below for details on frequency).

Blood pressure

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.

Body mass index (BMI) measurement

BMI is calculated from weight and height and used to classify body weight as underweight, healthy, overweight and obese.

Category	BMI value
Underweight	< 18.5
Healthy weight	18.5 to 24.9
Overweight	25 to 29.9
Obese	≥ 30

Foot risk surveillance

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

HbA1c

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

Retinal screening (eye exam)/retinopathy

Diabetic retinopathy is a microvascular disease specific to the people with diabetes. Everyone with diabetes from the age of 12 is eligible for diabetic eye screening to detect the development of diabetic retinopathy.

In England, there is to be a move to alternate year retinal screening for those known not to have retinopathy for the past 2 screening occasions. This was implemented to some extent early during the pandemic in order to deal with the reduced screening capacity.

Serum cholesterol

This blood test measures a type of fat that can damage blood vessels.

Serum creatinine

This is a blood test used to measure kidney function.

Smoking status

This records whether the person is a smoker. Smoking increases the diabetic risk for heart attacks and stroke.

Urine Albumin/Creatinine Ratio (UACR)

UACR is a ratio between two measured substances urine albumin and urine creatinine. Unlike a urine dipstick test for albumin, UACR is unaffected by variation in urine concentration. This urine test detects the earliest stages of kidney disease.

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

HbA1c

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

The treatment target within the NDA for people with diabetes is defined as HbA1c ≤ 58 mmol/mol.

Blood pressure

High levels are a risk for heart attacks and strokes; high blood pressure also drives progression of eye and kidney disease.

The treatment target within the NDA for people with diabetes is defined as ≤ 140/80.

Statin prescription

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

Primary prevention of cardiovascular disease (CVD): Those aged between 40 and 80 years old, with no history of admission to hospital for cardiovascular disease.
Secondary prevention of CVD: Those of any age, with a confirmed history of admission to hospital for cardiovascular disease.
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 ≤ 58 mmol/mol, blood pressure ≤ 140/80 and for people falling in the combined prevention CVD group: receiving statins.

For those aged 12 and under, meeting all 3 treatment targets is defined as having HbA1c ≤ 58 mmol/mol only, as other treatment targets are not recommended in the NICE guidelines for this age group.

ICB look up

Table 7: ICB codes and names

ICB code	ICB name
QE1	NHS LANCASHIRE AND SOUTH CUMBRIA INTEGRATED CARE BOARD
QF7	NHS SOUTH YORKSHIRE INTEGRATED CARE BOARD
QGH	NHS HEREFORDSHIRE AND WORCESTERSHIRE INTEGRATED CARE BOARD
QH8	NHS MID AND SOUTH ESSEX INTEGRATED CARE BOARD
QHG	NHS BEDFORDSHIRE, LUTON AND MILTON KEYNES INTEGRATED CARE BOARD
QHL	NHS BIRMINGHAM AND SOLIHULL INTEGRATED CARE BOARD
QHM	NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
QJ2	NHS DERBY AND DERBYSHIRE INTEGRATED CARE BOARD
QJG	NHS SUFFOLK AND NORTH EAST ESSEX INTEGRATED CARE BOARD
QJK	NHS DEVON INTEGRATED CARE BOARD
QJM	NHS LINCOLNSHIRE INTEGRATED CARE BOARD
QK1	NHS LEICESTER, LEICESTERSHIRE AND RUTLAND INTEGRATED CARE BOARD
QKK	NHS SOUTH EAST LONDON INTEGRATED CARE BOARD
QKS	NHS KENT AND MEDWAY INTEGRATED CARE BOARD
QM7	NHS HERTFORDSHIRE AND WEST ESSEX INTEGRATED CARE BOARD
QMF	NHS NORTH EAST LONDON INTEGRATED CARE BOARD
QMJ	NHS NORTH CENTRAL LONDON INTEGRATED CARE BOARD
QMM	NHS NORFOLK AND WAVENEY INTEGRATED CARE BOARD
QNC	NHS STAFFORDSHIRE AND STOKE-ON-TRENT INTEGRATED CARE BOARD
QNQ	NHS FRIMLEY INTEGRATED CARE BOARD
QNX	NHS SUSSEX INTEGRATED CARE BOARD
QOC	NHS SHROPSHIRE, TELFORD AND WREKIN INTEGRATED CARE BOARD
QOP	NHS GREATER MANCHESTER INTEGRATED CARE BOARD
QOQ	NHS HUMBER AND NORTH YORKSHIRE INTEGRATED CARE BOARD
QOX	NHS BATH AND NORTH EAST SOMERSET, SWINDON AND WILTSHIRE INTEGRATED CARE BOARD
QPM	NHS NORTHAMPTONSHIRE INTEGRATED CARE BOARD
QR1	NHS GLOUCESTERSHIRE INTEGRATED CARE BOARD
QRL	NHS HAMPSHIRE AND ISLE OF WIGHT INTEGRATED CARE BOARD
QRV	NHS NORTH WEST LONDON INTEGRATED CARE BOARD
QSL	NHS SOMERSET INTEGRATED CARE BOARD
QT1	NHS NOTTINGHAM AND NOTTINGHAMSHIRE INTEGRATED CARE BOARD
QT6	NHS CORNWALL AND THE ISLES OF SCILLY INTEGRATED CARE BOARD
QU9	NHS BUCKINGHAMSHIRE, OXFORDSHIRE AND BERKSHIRE WEST INTEGRATED CARE BOARD
QUA	NHS BLACK COUNTRY INTEGRATED CARE BOARD
QUE	NHS CAMBRIDGESHIRE AND PETERBOROUGH INTEGRATED CARE BOARD
QUY	NHS BRISTOL, NORTH SOMERSET AND SOUTH GLOUCESTERSHIRE INTEGRATED CARE BOARD
QVV	NHS DORSET INTEGRATED CARE BOARD
QWE	NHS SOUTH WEST LONDON INTEGRATED CARE BOARD
QWO	NHS WEST YORKSHIRE INTEGRATED CARE BOARD
QWU	NHS COVENTRY AND WARWICKSHIRE INTEGRATED CARE BOARD
QXU	NHS SURREY HEARTLANDS INTEGRATED CARE BOARD
QYG	NHS CHESHIRE AND MERSEYSIDE INTEGRATED CARE BOARD
QE1	NHS LANCASHIRE AND SOUTH CUMBRIA INTEGRATED CARE BOARD
QF7	NHS SOUTH YORKSHIRE INTEGRATED CARE BOARD
QGH	NHS HEREFORDSHIRE AND WORCESTERSHIRE INTEGRATED CARE BOARD
QH8	NHS MID AND SOUTH ESSEX INTEGRATED CARE BOARD
QHG	NHS BEDFORDSHIRE, LUTON AND MILTON KEYNES INTEGRATED CARE BOARD
QHL	NHS BIRMINGHAM AND SOLIHULL INTEGRATED CARE BOARD
QHM	NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
QJ2	NHS DERBY AND DERBYSHIRE INTEGRATED CARE BOARD
QJG	NHS SUFFOLK AND NORTH EAST ESSEX INTEGRATED CARE BOARD
QJK	NHS DEVON INTEGRATED CARE BOARD
QJM	NHS LINCOLNSHIRE INTEGRATED CARE BOARD
QK1	NHS LEICESTER, LEICESTERSHIRE AND RUTLAND INTEGRATED CARE BOARD
QKK	NHS SOUTH EAST LONDON INTEGRATED CARE BOARD
QKS	NHS KENT AND MEDWAY INTEGRATED CARE BOARD
QM7	NHS HERTFORDSHIRE AND WEST ESSEX INTEGRATED CARE BOARD
QMF	NHS NORTH EAST LONDON INTEGRATED CARE BOARD
QMJ	NHS NORTH CENTRAL LONDON INTEGRATED CARE BOARD
QMM	NHS NORFOLK AND WAVENEY INTEGRATED CARE BOARD
QNC	NHS STAFFORDSHIRE AND STOKE-ON-TRENT INTEGRATED CARE BOARD
QNQ	NHS FRIMLEY INTEGRATED CARE BOARD
QNX	NHS SUSSEX INTEGRATED CARE BOARD
QOC	NHS SHROPSHIRE, TELFORD AND WREKIN INTEGRATED CARE BOARD
QOP	NHS GREATER MANCHESTER INTEGRATED CARE BOARD
QOQ	NHS HUMBER AND NORTH YORKSHIRE INTEGRATED CARE BOARD
QOX	NHS BATH AND NORTH EAST SOMERSET, SWINDON AND WILTSHIRE INTEGRATED CARE BOARD
QPM	NHS NORTHAMPTONSHIRE INTEGRATED CARE BOARD
QR1	NHS GLOUCESTERSHIRE INTEGRATED CARE BOARD
QRL	NHS HAMPSHIRE AND ISLE OF WIGHT INTEGRATED CARE BOARD
QRV	NHS NORTH WEST LONDON INTEGRATED CARE BOARD
QSL	NHS SOMERSET INTEGRATED CARE BOARD
QT1	NHS NOTTINGHAM AND NOTTINGHAMSHIRE INTEGRATED CARE BOARD
QT6	NHS CORNWALL AND THE ISLES OF SCILLY INTEGRATED CARE BOARD
QU9	NHS BUCKINGHAMSHIRE, OXFORDSHIRE AND BERKSHIRE WEST INTEGRATED CARE BOARD
QUA	NHS BLACK COUNTRY INTEGRATED CARE BOARD
QUE	NHS CAMBRIDGESHIRE AND PETERBOROUGH INTEGRATED CARE BOARD
QUY	NHS BRISTOL, NORTH SOMERSET AND SOUTH GLOUCESTERSHIRE INTEGRATED CARE BOARD
QVV	NHS DORSET INTEGRATED CARE BOARD
QWE	NHS SOUTH WEST LONDON INTEGRATED CARE BOARD
QWO	NHS WEST YORKSHIRE INTEGRATED CARE BOARD
QWU	NHS COVENTRY AND WARWICKSHIRE INTEGRATED CARE BOARD
QXU	NHS SURREY HEARTLANDS INTEGRATED CARE BOARD
QYG	NHS CHESHIRE AND MERSEYSIDE INTEGRATED CARE BOARD

Acknowledgements

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.

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.

Last edited: 12 April 2024 3:37 pm