Diabetes care

Background

Diabetes is a condition where the amount of glucose in your blood is too high. There are two main types of diabetes: Type 1 diabetes (when the body is unable to produce any insulin) and Type 2 diabetes (when the body is unable to produce enough insulin or the body's cells don't respond to insulin). While around 90% of diabetes cases among children and young people are Type 1, Type 2 is increasing in prevalence. For adults, it is estimated that around 90% of cases are Type 2. In 2019, diabetes ranked as the seventh highest cause of death and disability in the UK.

The National Institute for Health and Clinical Excellence (NICE) provides recommendations on annual care processes that adults and children with diabetes should receive, as well as three treatment targets that adults should achieve in order to reduce the risk of diabetic complications. Here we use data from the National Diabetes Audit and National Paediatric Diabetes Audit to look at how the quality of care for diabetics has changed over time.

The National Institute for Health and Care Excellence (NICE) recommends that all people with diabetes aged 12 years and over should receive nine annual care processes. These include:

1. HbA1c – blood test for glucose control

2. Blood pressure – measurement for cardiovascular risk

3. Serum cholesterol – blood test for cardiovascular risk

4. Serum creatinine – blood test for kidney function

5. Urine albumin/creatinine ratio – urine test for risk of kidney disease

6. Foot risk surveillance – examination for foot ulcer risk

7. Body mass index – measurement for cardiovascular risk

8. Smoking history – question for cardiovascular risk

9. Digital retinal screening – photographic eye test for early detection of eye disease.

Fewer people with Type 1 than with Type 2 diabetes receive their annual checks in England. In 2019-20, 37% of people with Type 1 diabetes received nine care processes compared to 52% of people with Type 2 diabetes.  Urine albumin and foot surveillance are most often missed out, while blood pressure and smoking history are most often checked. The National Diabetes Audit suggests that a change to the smoking care process calculation and the way that BMI data were collected may account for the increase in percentages for these checks.

Data for the ninth care process – digital retinal screening – was included for the first time in 2019-20. Prior to this, the National Diabetes Audit reported on the percentage of people with diabetes receiving eight care processes, which has fluctuated over time for both Type 1 and Type 2 diabetes.

NICE recommends treatment targets for HbA1c (glucose control), blood pressure and serum cholesterol. Meeting these targets has the following benefits:

• The HbA1c target (≤58 mmol/mol) reduces the risk of all diabetic complications.
• The blood pressure target (≤140/80) reduces the risk of cardiovascular complications and reduces the progression of eye and kidney disease.
• The cholesterol target (<5mmol/L) reduces the risk of cardiovascular complications.

Between 2012-13 and 2019-20, the proportion of patients achieving all three treatment targets in England has improved slightly for both Type 1 and Type 2 diabetes, by 3.5 and 2.8 percentage points respectively. However, all three treatment targets are achieved in Type 1 diabetes less than half as often as in Type 2 diabetes.

Achievement of the blood pressure and cholesterol targets is roughly the same for Type 1 and Type 2 diabetes, but glucose control is worse in patients with Type 1 diabetes. In 2019-20, 66% of patients with Type 2 diabetes achieved the glucose control target, compared to only 32% of patients with Type 1 diabetes.

Younger adults with either Type 1 or Type 2 diabetes are less likely to achieve all three treatment targets than older adults. The National Diabetes Audit states that this is mostly due to poorer glucose and cholesterol control in those aged under 65 years, and that there has been no change over the past five years.

Measuring changes to this indicator over time is important given that one of the Quality and Outcomes Framework (QOF) indicators aims to address the potential over-treatment of frail patients and under-treatment of patients without frailty.

The National Paediatric Diabetes Audit considers seven annual care processes to be essential for children and young people with diabetes:

1. HbA1c – blood test for glucose control
2. Body Mass Index (BMI) – measure of cardiovascular risk
3. Blood pressure – measure of cardiovascular risk
4. Urine albumin – urine test for kidney function
5. Thyroid screen – blood test for hyper/hypothyroidism
6. Eye screening – photographic test for eye risk
7. Foot surveillance – foot examination for ulcer risk

Guidelines specify a starting age of 12 years for all checks for those with Type 1 diabetes, except for HbA1c and measurement of height and weight which should be recorded in all patients. Thyroid screening should also be performed at diagnosis and annually thereafter.

Between 2004/05 and 2018/19, the percentage of children and young people receiving all the recommended care processes increased steadily, reaching 55% in 2018/19. In 2019/20, it fell very slightly to 54%. This compares to only 27% of those with Type 2 diabetes (data not shown). HbA1c and BMI are most often checked, while urine albumin and eye screening are most often missed out.

From 2015/16, data were reported separately for children with Type 1 and Type 2 diabetes so are not directly comparable to previous years. However, the audit states that, as the majority of children and young people have Type 1 diabetes, the improvements in completion rates can be taken to reflect real improvements. Additionally, in 2015/16, cholesterol testing was replaced by thyroid screening as one of the seven essential care processes.