Preventing diabetes by improving NHS Health Checks in Bromley
Audit to ensure patients identified as being at increased risk of diabetes by the NHS Health Check in Bromley receive appropriate assessment and management.
Summary
A comprehensive baseline audit was conducted by the Public Health Vascular Team in Bromley to identify areas of good practice with regards to assessing and managing patients at high risk of developing diabetes, as well as areas requiring improvement.
Background
With the continuing increase in diabetes prevalence, it is essential we maximise prevention opportunities, ensuring the effectiveness of the NHS Health Check (NHSHC) programme in identifying people at high risk of developing diabetes and people with undiagnosed diabetes.
In Bromley, an estimated 29,872 people (11.5%) of the population are at high risk of diabetes, and an estimated 5,000 adults have undiagnosed diabetes.
The NHSHC programme has a diabetes filter, to aid identification of those at high risk:
- body mass index greater than or equal to 30 or greater than or equal to 27.5 in South Asian and Chinese population
- blood pressure greater than or equal to 140mmHg Systolic and/or greater than or equal to 90mmHg Diastolic
People captured by this filter then require further assessment through blood testing of glycated haemoglobin (HbA1c) or fasting plasma glucose (FPG).
People identified as meeting the diabetes filter should be managed according to the South London Diabetes Filter Pathway, which was launched in 2010 (and updated in 2015) to support the implementation of the diabetes assessment component of the NHSHC in general practice locally.
There is strong evidence that providing intensive lifestyle interventions for patients at increased risk of developing diabetes can prevent or slow its progress. Once identified, support can be put in place, either through means of referral to Bromley’s diabetes prevention programme, advice around diet and physical activity or referral to a structured education programme.
This report assesses the follow up and outcomes of those people at risk of premature vascular morbidity, who had a NHSHC over the period 1 April 2014 to 31 March 2015. This time delay between the NHSHC and the audit, allows for the time taken to perform investigation, follow up, diagnosis and review. It follows on from an initial audit carried out in 2011 to 2013.
What was involved?
Computer searches
Computer searches were developed in order to examine relevant data for patients who received a NHSHC from 1 April 2014 to 31 March 2015. Each of the GP practices performed the computer search in their clinical system and exported the search results to Excel worksheets and securely emailed to Public Health.
Audit standards for the project were developed to measure recommendations in national and local guidelines with consideration to the local lifestyle services available at that time. Computer searches were designed to report on features from clinical records that would help inform measurement of the following audit standards:
- blood test
- repeat blood test
- coding
- intensive lifestyle intervention
- risk factor profiles
For this re-audit, data collection only used computer searches, and did not include a comprehensive notes review as in the original audit. A notes review was considered unnecessary for the small additional benefits that would be obtained as the majority of data is linked to READ codes which can be searched on. The additional workload to general practice and cost involved in writing to patients to obtain their consent was not warranted in this re-audit.
Initial findings from computer searches
44 out of 45 GP practices participated in the audit. Results of computer searches from the participating practices produced the following initial findings:
- 8,726 patients underwent a NHSHC in 2014 to 2015
- 2,770 (32%) of this population met the diabetes filter as described above
- 2,232 (81%) of these patients underwent blood sampling for HbA1c and or FPG
- 1,725 (77%) of these patients who had a blood test were found not to be at high risk of diabetes mellitus according to their blood test result and not included in further analysis
- 507 (23%) patients who had received a blood test had a result indicating high risk of diabetes
- however not all the 507 patients were included in further analysis because:
- 62 (12%) of these patients who had a blood test, were tested more than one year after the NHSHC, so were not included in further analysis as that blood test was assumed not to have been as a result of the NHSHC
- 8 (2%) patients had been coded with a diagnosis of type 2 diabetes prior to having a NHSHC so were not eligible
- 38 (7% patients were coded with a diagnosis of type 2 diabetes following their NHSHC; this is a good outcome that patients with undiagnosed diabetes are being identified as part of the NHSHC but it is assumed they will receive appropriate follow up which is not the subject of this audit project
- therefore 399 (79%) of patients who had a blood test less than one year after the NHSHC and were found to be at high risk of diabetes mellitus were included in further analysis
What works well?
When comparing this re-audit with the original audit in 2011 to 2013 there have been demonstrable improvements in the identification process and outcomes of people at high risk of diabetes. In particular, a far greater proportion of patients who met the diabetes filter then went on to have an HbA1c and (or) FPG test in 2014 to 2015 (81%) compared to 2011 to 2013 (39%).
The recommendations made in the previous audit have undoubtedly contributed to this, from the increased support and education, the improvement of the template and identification of blood test requesting and the commissioning strategies of non-payment for people who are not documented to have been offered a blood test.
Next steps
Further improvements are still required for the recommended 1 year follow up reassessment of risk factors. Significant gaps exist in this area. Following discussion with colleagues it was felt the best way to make improvements in the follow up, is for it to be incorporated in the service specification GP practices have with the diabetes service.
It is proposed we introduce key performance indicators into the GP contract to ensure patients with NDH are correctly coded and reassessed annually. It is possible there is some reluctance to ‘label’ people with a READ code on their medical records, with consideration to health insurance. However although there have been some improvements in percentage coded, it is still low at 17%. Improved levels of READ coding is likely to improve the numbers of patients who are appropriately followed up.
The re-audit flags up the need for further investigation into patients that are at high risk of diabetes but are not responding to health advice of lifestyle interventions. For example, are the patients with improvements in blood results also the patients who are recording weight loss or other lifestyle improvement markers? If the patients who are showing a worse blood level at the repeat test, what sort of lifestyle interventions were they offered and are they receiving the appropriate level of support? This group might require a higher level of support, for example a more intensive intervention programme or a greater level of motivational support.
Questions around use of resource and targeting patients in most need of intervention advice. For example, the re-audit showed that 56 patients with a good physical activity score were given exercise advice (65% of the total patients for this category) compared to 77% in the inactive range. It might be a worthwhile trade off to aim for 100% activity advice in the inactive range at the expense of less advice to the already active.
Further collaborative working is continuing between Public Health, CCG, Diabetes service, GP practices and the Diabetes Prevention Interventions ( Walking away from Diabetes and the NHS Diabetes Prevention Programme), with the aim of building on the improvements made, addressing gaps and continuing to link the NHS Health Check with the identification and appropriate management of people with NDH in Bromley.
Further information:
Gillian Fiumicelli, Head of Vascular Disease Prevention Programme, Public Health, London Borough of Bromley.
Acknowledgements: Cathy Aiken, former Public Health Vascular Disease Nurse Specialist, Public Health, London Borough of Bromley.