Improving Diabetes Care The role of the integrated diabetes network. Ian Gallen Royal Berkshire Hospital

Transcription

1 Improving Diabetes Care The role of the integrated diabetes network Ian Gallen Royal Berkshire Hospital

2 Need for Change? National Diabetes now accounts for >12% NHS spend and is rising Increasing incidence, prevalence and complexity Need to reduce hospital admissions and develop other pathways of care But T2 DM is largely avoidable, and in both T1 and T2 complications reduced Management of DM remains largely sub-optimal, linear, reactive with delayed interventions. Local Previous poor performance in care processes and cost/outcomes 50 th of 52 nationally Glycaemic control was poor (46.8% vs. 56.8% nationally achieving HbA1c<60mmol/mol) 2x progression to renal replacement, and high DKA admission Majority of care provided at GP practices by GPs and Practice nurses, unsupported. Insufficient capacity in diabetes centre

3 What are the risks for patients with HbA1c>85 mmol/mol? The relative risk of premature death or cardiovascular event more than doubles for people with HbA1c >85 compared with those <58 mmol/mol. The risk of stroke increases still further with those patients with the poorest control (HbA1c >85mmol/mol) for diabetes have 5 times the risk of stroke than people without diabetes Recent meta-analysis of 26 prospective studies provides evidence that chronic exposure to increased glycaemic level was associated with increased risks of all-cause mortality and cardiovascular outcomes in type 2 diabetes. Risk of premature death for person <55 with HbA1c >85 over 5 years is >50% Every 1% increase in HbA1c is associated with a 15% increase in hazard of all-cause mortality, 25% in CVD mortality, 17% in CVD.

4 How dangerous is poor diabetic control? N Engl J Med 2015; 373:

5 Poor diabetic control an issue In BW? 1500 people with Type 2 diabetes and 300 with Type 1 diabetes who have extremely poor control (HbA1c >85 mmol/mol). This group requires specific urgent attention, because they have the highest risk of cardiovascular events and premature deaths from diabetes, but also have low risk of harm from intervention. Review of outcomes show that there is marked variation in the numbers of patients with poor control between practices, with some having none or few patients with very poor control but others having >20% of patients with HbA1c >85mmol. Mapping of practices demonstrate that these variations in performance are not explained by either socio-economic or demographic factors, and are more likely to reflect differences in clinical practice.

6 Redesign of services Local champion appointed (Richard Croft) Stakeholder network - Diabetes Sans Frontières Collaboration across organisational boundaries: acute trust, CCGs, community provider, public health, patients House of Care became the overarching model Funded change at scale and pace Novel Local solutions Do things differently No procrastination

7 Service developments Structured patient education X-PERT for Type 2, CHOICE and Carbaware for Type 1 Care planning HCP education: Deployment of DSNs to the community (1 for each of the 4 CCGs) and now 2 DSN for in practice group insulin intensification Care pathway and treatment guidelines development. Introduction of Eclipse, a cloud-based IT system to facilitate audit, risk stratification and provide a patient portal Website for patients, carers and HCPs Appointment of a specialist diabetes consultant in the community Virtual clinics in GP surgeries providing case review and HCP education. Seamless contact for GPs and practice nurses for advice 3 new RBH consultants

8 Poor glycaemic control How are we managing this issue locally? Identifying the at risk group of patients in practice is the first step by Eclipse. Followed by a Virtual Clinic review Much of the work centres on glycaemic control and reviews of therapy with the addition or substitution oral agents, the introduction or change in GLP1 agonist agents or initiation of insulin therapy being the outcome. These outcomes are recorded in the practice records, for implementation in the care planning process. For practices which are engaged in the virtual diabetic clinic process and who have had more than 3 visits, a clear majority have the proportion of patients HbA1c >85mmol/mol below 10%, whereas practices which are not engaged the virtual diabetic clinic process have higher values.

9 Virtual Diabetic Clinic MDT in practice to review diabetes cases Patients who require review identified by Eclipse. Highest priority is patients with very poor diabetic control (HbA1c>85mmom/mol) Outcome of the virtual clinic recorded for implementation in the care planning process Reviews of therapy Adult education Review by the DSNs in practice Review by specialist or Bariatric team

10 Care Planning GPs/PNs from all 54 practices trained by local trainers in 2 years 2-stage review with collection of metrics by HCA, then sharing by post before collaborative care planning consultation with HCP Now standard method of annual review in nearly 90% of practices

11 Patient Education: X-PERT Implementation started May facilitators including DSNs, dieticians and bank nurses. Year 1: 38 courses completed. Year 2: 60 courses completed. Reduction in HbA1c from 67.5mmol/mol to 55.5mmol/mol at 6 months post course.

12 CarbAware course for Type 1 DM Problem 1200 people with T1DM needed adult education to improve control in Berkshire West DAFNE started but is limited by cost and staff Difficult to attend a 5 day course Solution Designed and delivered a structured 3 hour group teaching program So far 120 courses, 750 participants

13 CarbAware To introduce/refresh the principles of carbohydrate counting To practice how to estimate the carbohydrate content in a range of food and drinks To improve understanding of the interaction between diet and insulin To use carbohydrate counting to improve diabetes self-management To correctly treat a hypoglycaemic episode To use the Accu-Chek Aviva Expert bolus advisor meter

14 Results: Baseline Characteristics 336 CarbAware attendees 175 (52%) male Median age 44.7 yrs (range yrs) HbA1c at baseline in 329 patients (98%) Mean ± SD HbA1c = 75.4 ± 18.7 mmol/mol Baseline HbA1c (mmol/mol) 5% 12% 48 41% >75 42%

15 Results: Improved HbA1c Baseline 3-12 months >12 months All attendees 75.4 ± 18.7 (n = 329) Initial HbA1c 58 Initial HbA1c >58 and 75 Initial HbA1c > ± 5.0 (n=54) 67.6 ± 4.8 (n=140) 92.8 ± 15.4 (n=135) 72.4 ± 17.6* (n = 287) 55.6 ± 11.0* (n=51) 68.6 ± 9.7 (n=119) 83.6 ± 18.8* (n=117) 70.8 ± 16.6* (n = 266) 56.9 ± 9.5* (n=43) 67.3 ± 8.8 (n=117) 80.5 ± 19.6* (n=106) Data shown as mean ± SD HbA1c (mmol/mol) n= number of patients * P<0.05 vs. baseline (paired T-test) Thanabalasingham G, ABCD 2016

16 HCP Education Foundation course - developed by local team - 66 attendees both GPs and PNs PITstop national injectable therapies initiation course delivered locally with local DSN mentor, 54 attendees Best4Diabetes facilitated by MDT to meet the needs found in local surveys: oral therapies, insulin optimisation, renal diabetes

17 Our services to help achieve better control There are a wide range of services available for patients with very poor control. Patients can be referred for adult education; XPERT for T2DM CHOICE or CarbAware (an intensive 3 hours course) for T1DM. In-practice insulin intensification group work (mean reduction of HbA1c 16mmol/mol) Patients with T1 diabetes should be referred to the specialist team at the diabetes centre or community located clinic for investigation and management of complications of diabetes, managing hypoglycaemia or consideration of insulin infusion pump therapy. Patients with BMI >35 kg/m2 can be referral to our Bariatric service/endobarrier service 2017.

18 How dangerous is poor diabetic control with renal disease? N Engl J Med 2015; 373:

19 Increased risk of renal replacement therapy for people with diabetes in Berkshire West (E+W average is 164%) CCG Excess over not diabetic Excess number of people Newbury 106% +7 Wokingham 247% +16 South Reading 198% +35 North and West Reading 181% +15

20 Virtual Renal Diabetic clinic Problem High rate of progression to renal failure Action Eclipse search for high risk patients Review in practice or remotely Outcome Ensure a diagnosis is made Review of therapy Management plan recorded in care planning Optimize glycaemic and CVS risk factors

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25 Some big wins! 1 st wave NDPP Exemplar Status for ACO External Recognition (NICE/DUK/BMJ/QiC awards) Working with the AHSN on remote monitoring Massive investment fro DoH Diabetes transformation fund ( 0.6m) 7 day DSN working New community T1DM clinic Expanded T1 education

26 Summary Reconfiguration of our diabetes services has Improved measures of process Improved surrogate markers of outcomes Reduced unit costs on background of rising demand Beginning to show real improvements in patient outcomes Being copied as a pathway of care