evidence into practice: diabetes public health england may 2014 dr junaid bajwa
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Evidence into Practice: Diabetes
Public Health EnglandMay 2014
Dr Junaid Bajwa
About meGP, CCG Board Member NHS GreenwichPrimary Care Transformation Board Member, NHSELAssociate in Public Health, NHS GreenwichCouncil Member of the Clinical Senate, London
GP Appraiser NHSEProgramme Director, Greenwich VTS
Prepare to Lead alumni, NHS LondonValue Based Healthcare Alumni, Harvard Business School
WHY?What motivated us?
Life Expectancy at birth Greenwich and England 1996-1998 and 2007-2009
NHS Greenwich was one of 13 PCTs identified by the National Health Inequalities Support
Team that account for 40% of the National Gap in life expectancy
The impact of improved CVD prevention on life expectancy
CVD Health Checks includes the impact of schemes to improve Long Term Conditions management and the NHS Health Checks Programme
Diabetes in Greenwich
Diabetes is a major cause health inequalitiesPriority disease area for Greenwich in the
JSNA 201010,033 patients with diabetes recorded. YHPHO prevalence model estimates it should be
12,900Suggesting more than 22% of patients with
diabetes in Greenwich are undiagnosed¹YHPHO prevalence model estimates by 2020
there will be an estimated Increase of 37%.¹
1 – YHPHO prevalence model for England
NHS GreenwichGOAL 2 – A systematic approach
A systematic approach to primary and secondary prevention in primary and community care
This includes ensuring that service provision and quality is consistent across Greenwich
To ensure robust easy referral relationships between primary care teams and primary prevention services e.g. GHLiS
To help improve the skills and confidence of primary care practitioners – through appropriate investment
Cultural shift towards a proactive approach to prevention through routine and opportunistic screening approaches in practices and other settings
Data provided by Greenwich PCT’s from Greenwich commissioning strategy for the 5 years 2008/09 – 2012/13 – Pg34
EVIDENCE into PRACTICE™
Delivered as a free of charge pilot across 14 practices in Greenwich.
Practices selected using health inequalities markers.
HOW?How did we start? Who was involved? What
happened?
EiP Process and Tools
EIP.12.GB.100102.SL
Date of Preparation March 2012
WHAT?What did we achieve? What change was there
for patients?
Data on File MSD, September 2011
Date of Preparation September 2011
*Risk Factor Targets Based on NICE Type 2 Diabetes Guidelines, CG87, May 2009
Greenwich PCT Amalgamated Data: Number of Patients Achieving NICE Endorsed* Risk Factor Targets at Baseline and Follow-Up
Data on File NHS Greenwich, September 2011
Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatient attendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilot sites (32). Figures standardised per 1000 patients with diabetes.
Data on File NHS Greenwich, September 2011
Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatient attendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilot sites (32). Figures standardised per 1000 patients with diabetes.
Data on File NHS Greenwich, September 2011
£23,385
£177,734
*£201,119*
Impact of the EVIDENCE into PRACTICE™ programme on Diabetic 25 Medicine Outpatient attendances and CVD admissions in NHS Greenwich pilot sites (14) compared to non pilot sites (32). Figures standardised per 1000 patients with diabetes.
Data on File NHS Greenwich, September 2011
*£731,688*
*£14,366/pr*
WHO?Who did what in the practice? How did we change? What roles did different people in
the practice take to make the change happen? What were the key changes?
Failing Practice, poor performanceDeprived local area, within spearhead PCTLarge BME populationHigh incidence of Diabetes and CVD- not on risk
registers or being optimally managedPractice Transformation
Background
Key focus areas (DCiP/Patient list file)Data QualityRisk RegistersEnsuring patients on current registers are being optimally treated/managed/ have the right supportPersonal/Practice Development issues: clinical exercises Confidence mapping of existing skill mix within practiceCritical event review exercise
Case for change
Clear diabetes management strategyroles/responsibilities
Addressed training in issues (Evidence Review)Ensuring consistent treatment approach
(HbA1c, BP, Cholesterol targets)Stratifying cardio-metabolic risk in the population
focus on optimising treatment in existing patients
What we did
All diabetics
Data on File MSD, September 2011
Date of Preparation September 2011
Risk Factor targets Based on NICE CG87, May 2009.
Baseline Vs 3rd Repeat Follow-Up data for Conway Medical CentreTime between data extractions = 18 Months 6 Days
Data on File MSD, September 2011
POPULATION HEALTH IMPACT?
What impact did the EiP approach to diabetes have on the whole practice population health
otucomes?
The UKPDS Outcomes Model• Computerised simulation designed to estimate Life Expectancy, Quality Adjusted Life
Expectancy and costs of complications in people with type 2 diabetes.
• Uses algorithms published in the UK Prospective Diabetes Study (UKPDS).
• The model was developed using data from patients with newly-diagnosed type 2 diabetes who participated in the UKPDS 2 and were followed up for between six and twenty years.
• It predicts likely outcomes using risk factors that include; age, sex, ethnicity, duration of diabetes, height, weight, smoking status, total cholesterol, HDL cholesterol, systolic blood pressure and HbA1c.
• The UKPDS Outcomes Model is able to simulate event histories that closely match observed outcomes in the UKPDS and that can be extrapolated over patients’ lifetimes. The model allows simulation of a range of long-term outcomes, which should assist in informing future economic evaluations of interventions in Type 2 diabetes
A model to estimate the lifetime health outcomes of patients with Type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS no. 68). PM Clarke, AM Gray, A Briggs,AJ Farmer, P
Fenn, RJ Stevens, DR Matthews, IM Stratton, RR Holman. Diabetologia 2004; 47:1747–1759.
Data on File MSD October 2011
Time between Baseline and Follow-Up Audit:
18 Months 6 Days
Modelled outcomes across the current diabetes list of 355 patients over a 10 year period show:
Data on File MSD October 2011
• 16.7% increase in life expectancy equating to an average of 1.0 additional years of life per patient
• 22.7% increase in Quality Adjusted Life Expectancy equating to 1.0 additional quality adjusted life years/pt
• 34.1% reduction in the incidence of Ischemic Heart Disease over 10 years = 11 Patients
• 41.3% reduction in the incidence of Heart Failure over 10 years = 18 Patients
• 35.4% reduction in the incidence of Stroke over 10 years = 12 Patients
• 19.3% reduction in the incidence of Myocardial Infarction over 10 years = 13 Patients
• 42.5%% reduction in the incidence of Blindness over 10 years = 12 Patient
• 64.8% reduction in the incidence of Amputation over 10 years = 12 Patients
• 12.5% reduction in the incidence of Renal Failure over 10 years = 1 Patient
• 28.2% reduction in all deaths over 10 years = 50 Patients
The UKPDS model also calculates the health care costs associated with each modelled fatal or non-fatal diabetes-related complication. The costs that accrue in all subsequent years are also taken into consideration. The default costs are derived from the UKPDS paper and have been updated using the Hospital and Health Services Price Index to reflect health care resource use in the United Kingdom.
Based on the avoided complications modelled, an average saving of £719.50 per patient with diabetes over 10 years can be calculated.
This equates to £719,050.00 across 1000 patients with diabetes over 10 years
Data on File MSD October 2011
HOW DO WE SCALE-UP THIS APPROACH?