Carmarthenshire
Hospitals Diabetes Service
Annual Report
January 2010
Contents
Recent developments in the local diabetes services
- Key points
-New clinical developments
-Multidisciplinary high risk foot clinic
- Vector Diabetes Electronic
Patient Record
- Shared Diabetes
Electronic Record (SDER)
-Prosiect
Sir Gâr
-Patient participation
-Structured patient
education
-Education of
healthcare professionals
-Diabetes Network
-Carmarthenshire
Chronic Conditions Collaboration
-Research and Clinical Trial work
-Clinical Audit and
Quality Assurance
Recorded
clinical contacts in 2009
Patients followed up in
hospital diabetic clinics
-Demographics:
type 1 vs type 2
-Quality
of electronic patient record
-Macrovascular complications
-Microvascular complications
-Glycaemic control
-Blood pressure
-Smoking
-Serum
cholesterol
-Cardiovascular
prophylaxis: lipid lowering drugs
-Cardiovascular prophylaxis:
antiplatelet agents
-Cardiovascular
prophylaxis: ACEI’s and ARB’s
Comparison
with GP Contract Standards
Recent developments in the local
diabetes services
Key points
- Prosiect Sir Gâr:
Workplace cardiovascular health checks for those over the age of 40
began in September 2009, with over 300 checks performed in the first 3
months on employees of Corus Steelworks and Hywel Dda Heath Board.
- The
Swansea Masters level module in Diabetes takes the form of 5 teaching days at monthly
intervals, with an MCQ test, an audit project and a 2,000 word long case
at the end. Five courses involving 70 participants have been held so far,
including one held in the St David’s Education Centre in
- The Community Diabetes Nurse Specialists, along with the dietitian, continue to deliver the XPERT structured
education course for people with type 2 diabetes. From 2006-2009, 18
courses have been completed by 237 participants.
- The multidisciplinary foot clinic at WWGH will help to identify
potentially limb threatening foot problems at an early stage, enabling
preventive measures to be adopted.
- The Carmarthenshire Chronic Conditions Collaboration is a demonstrator site for
chronic disease management in
- The
number of clinical contacts made by members of the PPH and WWGH diabetes
team in various settings during 2009 was 17,996. Audit of electronic
records for the 1,418 patients followed up in the Trust’s outpatient
clinics show a further improvement in the
completeness of the clinical record. Mean duration of diabetes was 22
years for Type 1 patients and 15 years for Type 2 patients. Cardiovascular
risk factor mean values in these patients with advanced diabetes were:
HbA1c 8.4%, blood pressure 136/72 and cholesterol 4.2, respectively.
New clinical
developments
A pilot Diabetic
nephropathy
clinic has commenced in WWGH
A pilot Specialist Weight Management Clinic,
based on the Blaenau Gwent model has commenced in Carmarthenshire,
incorporating medical, psychological and dietetic treatment.
Continuous blood glucose
monitoring equipment is
now available to investigate those patients with erratic glycaemia,
particularly those with difficult hypoglycaemia problems.
We have now been using GLP-1
agonists for over 12 months. They are particularly useful for those people
with type 2 diabetes who require insulin in whom there is a major concern about
potential weight gain. Our data on the first 10 patients showed an average
reduction in HbA1c by 0.8% whilst achieving average weight reduction of 7.6kg
after 6 months’ treatment.
Multidisciplinary
high risk foot clinic
Amputation in diabetic foot
disease, which is related to almost 75% five year mortality, has been reduced
significantly in those centres running a high risk multidisciplinary foot
clinic. This fortnightly clinic
held at WWGH is now into its third year. The aim of this clinic is firstly, to manage the foot problem
using a multidisciplinary approach and secondly, to identify and manage any
other complications or inadequately controlled risk factors. We have established a referral system from primary and secondary care
podiatry. A range of Diabetic foot complications are seen in the clinic, ranging
from Charcot neuroarthropathy, osteomyelitis,
peripheral vascular disease and related ulceration etc. So far we have achieved
significant success in ulcer healing and reduction of the amputation rate. After
the completion of treatment patients are referred back to community podiatry
for long term follow up. We are planning a further audit of diabetic foot
amputations during 2010.
Vector Diabetes
Electronic Patient Record
We now have detailed clinical information on 8,275 people with diabetes. The annual
number of patient contact entries by diabetes nurses and doctors in 2009 was
17,996. This enables excellent communication between members of the diabetes
team and also with patients, their carers and primary care staff. As the
electronic record is used by the whole multidisciplinary diabetes team, we
often look at each other’s entries and this provides a powerful safeguard
against errors that could cause harm. Since
the EPR system enables us to aggregate large amounts of data, we can get an
accurate assessment of many clinical and laboratory data which reflect upon the
quality of the service (see below).
The
link to the Telepath system allows automatic transfer of patients’
pre-clinic test results to the EPR, making the clinical process more efficient.
Shared Diabetes
Electronic Record (SDER)
This pilot project was the result of a partnership with
Informing Healthcare (the IT programme for NHS Wales) resulting in the integration of individual patient
electronic diabetes records from primary and secondary care into one database
by 2007 which could be accessed from both hospitals and 85% of local GP
surgeries. The project could not be sustained on a locality basis, but has
demonstrated that shared electronic records facilitate clinical management by reducing
gaps in the clinical records and also help to avoid duplication of care. There
are now plans to adopt an all
Prosiect Sir Gâr (The Carmarthenshire
Project)
. The project’s main aims are to achieve reductions in a) mortality
and b) morbidity from cardiovascular disease significantly in excess of that
which would be expected as a natural trend over a timescale of 10 years in
residents of Carmarthenshire aged 35-74 years.
The partners involved in this project are:
•
Hywel Dda Health Board
•
•
The National Public Health Service
•
Carmarthenshire County Council
•
Diabetes Reference Group
•
Corus Steelworks, Trostre
•
Astra-Zeneca, Sanofi-Aventis,
Schering-Plough, Pfizer and Lilly Pharmaceuticals
In the pilot phase of the
project which began in Sept 2009 we have conducted cardiovascular health checks
on 300 employees of Corus and of the Hywel Dda Health Board aged over 40.
Results are summarised in the following table:
|
QRISK2 >20% (high CV
risk) |
3.7% |
|
QRISK2 10-20%
(intermediate CV risk) |
15% |
|
HbA1c>6.5% (probable
diabetes) |
1.3% |
|
HbA1c 6-6.5% (Impaired
glucose regulation) |
5.7% |
|
Total Cholesterol:HDL
ratio >6 |
13% |
|
BP>140/90 (either or
both) |
33% |
|
BMI >30 |
31% |
|
Waist circumference
>94cm (male) or >80cm (female) |
70% |
As a result, 18% were
referred to the dietitian, 24% to primary care for
possible pharmacological management and 15% to the intensive lifestyle
management course.
Patient
participation
Patients continue to be represented at all stages in the
design and delivery of diabetes services. The Carmarthenshire Diabetes Patient
Reference Group meets regularly before each Diabetes Network meeting to discuss
a range of issues relevant to the local diabetes services. Five members of this
group also attend the Network meetings where these issues are further
discussed.
Structured patient education
The Community Diabetes Nurse
Specialists, along with the dietitian, continue to
deliver the XPERT structured education course for people with type 2 diabetes
funded from charitable sources until NHS funding is forthcoming. From
2006-2009, 18 courses have been completed by 237 participants. The Table below summarises the results:
|
|
Basal |
12
months |
|
Patient
empowerment score (1-5) |
3.8 |
4.1 |
|
Mean
HbA1c |
7.8 |
7.0 |
|
Mean
Weight (kg) |
93.3 |
89.3 |
|
BP
mmHg |
138/79 |
135/76 |
|
Total
cholesterol mmol/l |
4.4 |
4.2 |
Education of healthcare
professionals
The following are examples of educational courses designed and/or
delivered by our multidisciplinary diabetes team:
- Link Nurse
Training: a link nurse from each clinical area within the Trust attends
for diabetes training sessions with the diabetes nurses every 3 months
- Diabetes Update
for Nurses: a two day course for nurses within the Trust
- Annual Diabetes
Update Day for certificate trained diabetes staff: the last one was held
in June 2009 and was attended by over 120 diabetes care professionals from
Carmarthenshire and the rest of
- Podiatry
Training Day for Practice Nurses to enable them to examine diabetic feet
competently.
- Diabetes
Training Days were also organised by the Community Diabetes Nurse
Specialists for Care Home and Social Services staff.
- The hospital
based diabetes team also delivered Merit I and Merit II courses to local
GP’s and Practice Nurses to enable them to care for patients who
require insulin.
- We
are now into our third year for delivering the Swansea Masters level
module in Diabetes. Five courses involving 70 participants have been held
so far, including one held in the St David’s Education Centre in
Diabetes Network
The Hywel Dda Health Board was
formed in October 2009 following amalgamation of the former separate
Carmarthenshire, Ceredigion and Pembrokeshire acute Trusts and LHB’s into
a single organisation. To aid the process of integration of local diabetes
services the Hywel Dda Diabetes Network was established in 2008. The Network is
an inclusive group with representation from all the important local
stakeholders in diabetes. These include the hospital based diabetes teams,
Community Diabetes Nurses, GP’s, health managers, patients and the
voluntary sector. It provides the focus for strategic planning of local diabetes
services. In addition individual group members, in their capacity as leaders of
the various components of the local diabetes services, are also able to
implement agreed developments in service delivery.
Carmarthenshire
Chronic Conditions Collaboration (C4)
The Carmarthenshire Chronic Conditions Collaboration has by
now acquired flagship status from the Welsh Assembly Government. The aim is to
coordinate the development of services (including social services)for the management of diabetes, ischaemic
heart disease and chronic pulmonary disease, in appropriate settings that
minimise the burden on the acute sector. The appointment in 2006 of three
Community Specialist Nurses in each of these specialties is already helping to
achieve this aim. We have evidence of reduction in acute hospital admissions
among these patient groups. This model has also proved a powerful catalyst to
breaking down the barriers between primary and secondary care services.
Research and
Clinical Trial work
Our Clinical
Research Fellow completed a study titled “Microvascular and Macrovascular
complications in screening versus symptom diagnosed type 2 diabetes: an
observational study”,
which was presented at the annual Diabetes UK Conference in Glasgow in March
2009.
We also participated in studies on prandial
insulin commencement (LanScape) ad basal insulin
follow –up (ATLANTUS).
Clinical Audit and Quality Assurance
The Diabeta 3 EPR has been in use at PPH since 2000 and in WWGH
since 2002. The diabetes details of
inpatients as well as outpatients with are entered onto the system and the
number reached 8,275 by the end of 2009. This represents approximately 80% of
those recorded on GP diabetes registers in Carmarthenshire and
Recorded
clinical contacts in 2009
The table below records the number of clinical contacts made by members of the PPH and WWGH diabetes team in various settings during 2009:
|
|
PPH/AVH |
WWGH |
Total |
|
No of In-patient contacts (no of patients) |
2,601 (683) |
3,934 (854) |
6,535 |
|
No Telephone contacts (no of patients) |
2,013 (480) |
3,461 (605) |
5,474 |
|
DSN Clinic contacts (no of patients) |
1,322 (509) |
1,831 (486) |
3,153 |
|
New Patients – OPD |
112 (109) |
128 (125) |
240 |
|
F/U
Patients – OPD |
883 (658) |
1,390 (759) |
2,273 |
|
Podiatry |
131 (88) |
105 (76) |
236 |
|
Dietetics |
36 (35) |
49 (39) |
85 |
|
Total No. of Contacts: |
|
|
17,996 |
Patients
followed up in hospital diabetic clinics
The remainder of the data
presented in this report is process and outcome data for patients attending for
follow up in the diabetic clinics at Prince Philip Hospital (PPH) and
|
Year |
PPH |
WWGH |
|
2000 |
730 |
N/A |
|
2001 |
788 |
200 |
|
2002 |
810 |
571 |
|
2003 |
813 |
931 |
|
2004 |
876 |
1,061 |
|
2005 |
815 |
1094 |
|
2006 |
759 |
945 |
|
2007 |
739 |
818 |
|
2008 |
693 |
768 |
|
2009 |
658 |
760 |
Demographics: type 1 vs type 2
The
table below contrasts the main findings from type 1 and type 2 patients
followed up in the combined hospital diabetic clinics in 2008:
|
|
Type 1 |
Type 2 |
|
Number |
472 |
907 |
|
Mean age
(y) |
39.8 |
64.7 |
|
Diabetes
duration (y) |
21.6 |
14.5 |
|
% on
insulin |
100 |
65 |
|
% with
BMI>30 |
19 |
63 |
|
% current
smokers |
17 |
14 |
|
Mean HbA1c
% |
8.7 |
8.3 |
|
Mean BP |
130/70 |
140/73 |
|
Mean total
cholesterol mmol/l |
4.4 |
4.1 |
|
% on lipid
lowering agents |
50 |
89 |
|
% on antiplatelet agents |
39 |
76 |
|
% on ACEI
or ARB |
41 |
76 |
Quality of electronic patient record
The percentage of electronic
records (type 1 and type 2 combined) from 2009 containing entries for the
following clinical and laboratory data during the previous 15 months is
recorded in the table below and compared with 2007 and 2008:
|
Data field |
PPH% |
WWGH% |
||||
|
Year |
2007 |
2008 |
2009 |
2007 |
2008 |
2009 |
|
Type of diabetes |
100 |
100 |
100 |
100 |
100 |
100 |
|
Duration of diabetes |
96 |
98 |
99 |
98 |
98 |
98 |
|
BMI |
91 |
96 |
97 |
94 |
94 |
95 |
|
Eye examination* |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
|
Foot examination* |
92 |
94 |
95 |
79 |
85 |
92 |
|
BP |
97 |
97 |
98 |
97 |
96 |
98 |
|
Smoking |
94 |
96 |
97 |
96 |
96 |
94 |
|
HbA1 |
97 |
97 |
97 |
97 |
100 |
99 |
|
Cholesterol |
95 |
94 |
97 |
92 |
97 |
94 |
|
Serum Creatinine |
98 |
97 |
97 |
93 |
95 |
95 |
|
Urine Microalbumin |
63 |
63 |
71 |
56 |
61 |
57 |
*It should be noted that
retinopathy screening is now carried out by the Diabetic Retinopathy Screening
Service for
Macrovascular
complications
The percentage of patients
(type 1 and type 2 combined) recorded as having macrovascular
complications was as follows:
|
Complication |
PPH % |
WWGH % |
|
Ischaemic heart disease |
23 |
18 |
|
Cerebrovascular disease |
4 |
4 |
|
Peripheral vascular disease |
6 |
6 |
These figures emphasise the
high prevalence of ischaemic heart disease among the
diabetic population.
Microvascular
complications
The prevalence and degree of microvascular complications in this hospital clinic
population is illustrated in the following table:
|
Complication |
PPH % |
WWGH % |
|
Retinopathy |
28 |
17 |
|
Microalbuminuria
30-300mg/l |
26 |
26 |
|
Macroalbuminuria
>300mg/l |
8 |
8 |
|
Serum creatinine >150umol/l |
9 |
8 |
|
Neuropathy |
16 |
8 |
|
At risk
foot* |
15 |
16 |
*This
group includes those with ischaemia, neuropathy or
foot deformity or a combination of these.
Glycaemic
control
The figure below shows the percentage of patients with
poor glycaemic control as illustrated by a HbA1 value of >10%. Annual data for PPH is shown over
the period 2000-2009 and for WWGH over the period 2001-2009.
The overall percentage of
patients (type 1 and type 2 combined) with HbA1 >10% was 15%.
The following figure shows
the percentage of patients with good glycaemic
control as shown by a HbA1 level of <7.5%
In 2009 the overall
percentage of patients (type 1 and type 2 combined) with HbA1 <7.5% was 32%.
Note that as the diabetes duration increases year on year in this hospital follow
up group (now being 21.6 and 14.5 years for patients with type 1 and type 2 diabetes, respectively) glycaemic
control is known to worsen. Mean HbA1c for all follow up patients in 2009 (PPH
and WWGH combined) was 8.4%. Mean HbA1 for type 1 patients
was 8.7%. Mean HbA1c for type 2 patients was 8.3%.
Blood pressure
The percentage of patients whose systolic blood
pressure exceeded 140 mmHg are shown below. In 2009
the overall percentage of patients with a systolic pressure above 140 was 34%.
The percentage of patients
whose diastolic pressure exceeded 80 mmHg are shown
below. The overall percentage of patients with a diastolic pressure >80 was
16%.
The mean blood pressure for
all follow up diabetic patients at PPH and WWGH in 2009 was 140/73. Mean blood
pressure for people with type 1 diabetes was 130/70.
Mean blood pressure for
people with type 2 diabetes was 140/73
Smoking
The percentage of patients
(PPH+WWGH) who admit to being current smokers was 15%:
The percentage of current
smokers who have type 1 diabetes was 17%.
The percentage of current
smokers who have type 2 diabetes was 14%.
Serum cholesterol
The percentage of patients with a serum total
cholesterol level above the level of 5mmol/l is shown below:
Mean serum total cholesterol
in 2009 (PPH and WWGH combined) was 4.2 mmol/l.
For people with type 1
diabetes mean total cholesterol was 4.4 mmol/l.
For people with type 2
diabetes mean total cholesterol was 4.1 mmol/l.
Cardiovascular prophylaxis: lipid lowering
drugs
The percentage of patients
taking stains or other lipid lowering agent has increased progressively as
shown below:
The total percentage of
patients taking lipid lowering agents (PPH and WWGH combined) in 2009 was 74%.
The percentage of type 1
patients taking lipid lowering agents was 50% (including 84% of those
aged>40). The percentage of type 2 patients taking lipid lowering agents was
89%.
Cardiovascular prophylaxis: antiplatelet agents
Aspirin or other
anti-platelet prophylaxis likewise increased progressively as illustrated
below.
The
overall mean percentage of people with diabetes taking anti-platelet agents in
2009 was 63%.
The percentage of type 1
patients taking aspirin was 33% (including 70% of those aged>40).
The percentage of type 2
patients taking aspirin was 76%.
Cardiovascular
prophylaxis: ACE inhibitors and angiotensin blockers
The percentage of patients taking either ACE
inhibitors or Angiotensin II receptor blockers (ARB’s)
was as follows:
The
total percentage of people with diabetes taking ACEI’s or ARB’s in
2008 was 63%.
The percentage of type 1
patients taking ACEI’s or ARB’s was 41% (including 67% of those
aged >40).
The percentage of type 2
patients taking ACEI’s or ARB’s was 76%.
Comparison with GP
Contract Standards
The Table below presents a
comparison of some of the above data (both hospitals combined) with the Quality
and Outcomes Framework Standards for the GP Contract. Note that this hospital
outpatient population is biased towards those with the most advanced diabetes.
|
Indicator |
Points |
Max
Threshold |
2009 value |
|
|
DM1 |
The practice can produce a
register of all patients with diabetes mellitus |
6 |
N/A |
N/A |
|
DM2 |
The percentage of patients
whose notes record BMI in the previous15 months |
3 |
90% |
96% |
|
DM3 |
The percentage of patients
with diabetes in whom there is a record of smoking status in the previous 15
months except those who have never smoked where smoking status should be
recorded once |
3 |
90% |
96% |
|
DM4 |
The percentage of patients
with diabetes who smoke and whose notes contain a record that smoking
cessation advice has been given in the previous 15 months |
5 |
90% |
N/A |
|
DM5 |
The percentage of patients
with diabetes who have a record of HbA1c or equivalent in the past 15 months |
3 |
90% |
98% |
|
DM6 |
The percentage of patients
with diabetes in whom the last HbA1c is 7.4% or less in the past 15 months |
16 |
50% |
32% |
|
DM7 |
The percentage of patients
with diabetes in whom the last HbA1c is 10% or less in the past 15 months |
11 |
85% |
85% |
|
DM8 |
The percentage of patients
with diabetes who have a record of retinal screening in the past 15 months |
5 |
90% |
N/A |
|
DM9 |
The percentage of patients
with diabetes with a record of the presence or absence of peripheral pulses
in the past 15 months |
3 |
90% |
93% |
|
DM10 |
The percentage of patients
with diabetes with a record of neuropathy testing in the past 15 months |
3 |
90% |
93% |
|
DM11 |
The percentage of patients
with diabetes who have a record of the blood pressure in the past 15 months |
3 |
90% |
98% |
|
DM12 |
The percentage of patients
with diabetes in whom the last blood pressure is 145/85 or less |
17 |
55% |
65% |
|
DM13 |
The percentage of patients
with diabetes who have a record of microalbuminuria
testing in the past 15 months |
3 |
90% |
64% |
|
DM14 |
The percentage of patients
with diabetes who have a record of serum creatinine
testing in the past 15 months |
3 |
90% |
96% |
|
DM15 |
The percentage of patients
with diabetes with proteinuria or microalbuminuria who are treated with ACE inhibitors or angiotensin receptor blockers |
3 |
70% |
82% |
|
DM16 |
The percentage of patients
with diabetes who have a record of total cholesterol in the past 15 months |
3 |
90% |
95% |
|
DM17 |
The percentage of patients
with diabetes whose last measured total cholesterol within the past 15 months
is 5 mmol/l or less |
6 |
60% |
79% |
|
DM18 |
The percentage of patients
with diabetes who have had influenza immunisation in the preceding 1st
September to 3Ist March |
3 |
85% |
N/A |