Spotlight on Diabetes

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					Spotlight on
Diabetes: update




May 2002
8 May 2002
Dr Christine Hine, Consultant in Public Health Medicine



If you need further copies of this document please telephone Penny
Rye on 0117 900 22648

If you need this document in a different format please telephone Penny
Rye on 0117 900 2648
                                                    Contents


1        Section 1: Diabetes and the National Service Framework in Avon ------------- 1
         1.1      What is diabetes? -------------------------------------------------------------------------------- 1
         1.2      Why is diabetes a priority? --------------------------------------------------------------------- 1
         1.3      Can diabetes be prevented? ------------------------------------------------------------------- 1
         1.4      What is the national policy for diabetes?---------------------------------------------------- 2
         1.5      How will the National Service Framework be implemented in Avon? ---------------- 2
         1.6      Who is the lead for my area? ------------------------------------------------------------------ 3
         1.7      How are diabetes services provided in Avon? --------------------------------------------- 3

2        Section 2: How Common is Diabetes? ---------------------------------------------------- 4
         2.1      Number of people with diabetes -------------------------------------------------------------- 4
         2.2      Trends in numbers of People with Diabetes ----------------------------------------------- 5
         2.3      Distribution of Diabetes across Avon -------------------------------------------------------- 6
         2.4      Risk factors for type 1 diabetes --------------------------------------------------------------- 6
         2.5      Risks factors for type 2 diabetes -------------------------------------------------------------- 8
         2.6      Diabetes and minority ethnic groups--------------------------------------------------------- 8

3        Section 3: Diabetes Complications--------------------------------------------------------10
         3.1      Diabetes complications ------------------------------------------------------------------------- 10
         3.2      Diabetes and lower limb complications------------------------------------------------------ 10
         3.3      Prevention of Lower Limb Complications --------------------------------------------------- 12
         3.4      Diabetes and Eyesight -------------------------------------------------------------------------- 12
         3.5      Prevention of Eyesight Complications ------------------------------------------------------- 13
         3.6      Hospital Admission for diabetes coma ------------------------------------------------------ 14

4        Section 4: Deaths due to diabetes----------------------------------------------------------16

5        Section 5: Primary Care Prescribing Costs for Diabetes---------------------------18




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1        Section 1: Diabetes and the National Service Framework in Avon


         What is diabetes?
                  Diabetes is a condition in which the body is unable to control the amount of sugar
                  in the blood. There are 2 types of diabetes; type 1 and type 2.

                  Type 1 diabetes (previously known as Insulin Dependent Diabetes Mellitus
                  [IDDM]) affects children and younger adults. They lack insulin.

                  Type 2 diabetes (previously known as Non-Insulin Dependent Diabetes Mellitus
                  [NIDDM]) tends to affect people over 40. They may lack insulin, or their insulin
                  may not work properly.

                  During pregnancy, some women develop temporary ‘gestational diabetes’.

         Why is diabetes a priority?
                  Diabetes has a high cost for individuals and the NHS. For individuals, there are
                  both health and financial costs. For the UK, the Audit Commission note an
                  estimate of 9% of hospital costs (£1.9 billion) attributed to diabetes, with additional
                  costs in primary care. Provisional results of the T2ARDIS survey estimate £2.0
                  billion NHS costs for caring for type 2 diabetes alone (4.7% NHS spend in 1998).

                  Although 2-3% of the population have diabetes, people with diabetes account for
                  10% of hospital admissions

                  People with diabetes are at higher risk of damage to nerves and the body's large
                  and small blood vessels. This can lead to heart disease, stroke, loss of eyesight,
                  foot ulceration (in some cases leading to amputation) and kidney disease.

         Can diabetes be prevented?
                  Reducing excess weight and taking regular physical exercise are important in
                  preventing type 2 diabetes, and to tackle the risk of heart disease in people who
                  have already developed diabetes.

                  More children and adolescents are becoming overweight. Levels of physical
                  activity are falling. Consequently, we expect the incidence of type 2 diabetes in
                  younger people as well as the older adult population, to rise. This is a serious
                  problem. The longer one has diabetes, the more likely one is to develop
                  complications.

                  Access to good advice and effective health care is a priority for people who want
                  to reduce these risks. Medical care aims to help reduce blood sugar levels and
                  blood pressure, and to detect and treat complications at an early stage.




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                  Better blood pressure control can reduce the risk of:

                              Death from long term complications of diabetes;

                              Strokes;

                              Serious deterioration of vision.

                 Better blood glucose control can reduce the risk of:

                              Diabetic eye disease;

                              Early kidney damage.

                              Loss of feeling in the feet

                 For detailed evidence on blood glucose reduction, look up diabetes
                 in the endocrine section of Clinical Evidence 4 at
                 http://www.nelh.nhs.uk/ There is a Diabetes UK position statement
                 on evidence from the UKPD Study and type 2 diabetes in the
                 information section under ‘P’ at http://www.diabetes.org.uk/


                  Delays in diagnosing a person with diabetes, which can be as long as 12 years
                  after the onset of diabetes, mean that between one-third and one-half of those
                  with diabetes already have evidence of organ or tissue damage when diagnosed.

                  General practitioner reports suggest that over 1 in 50 people in Avon are known to
                  have diabetes. Research suggests that as many again may have diabetes, but
                  they are not aware of it.


         What is the national policy for diabetes?
                  In 2001 the Government published standards for the National Service Framework
                  for Diabetes. An Implementation Plan is due to be published during the summer
                  of 2002. The Department of Health has a NSF webpage at

                  http://www.doh.gov.uk/nsf/diabetes/

                  The National Institute for Clinical Excellence (NICE) has published guidelines on
                  diabetes care (see http://www.nice.org.uk/ ).

                  Other sources of information

                  Diabetes UK (formerly known as the British Diabetic Association) is an important
                  source of advice on good practice in diabetes care. For further information see
                  http://www.diabetes.org.uk/home.htm.


         How will the National Service Framework be implemented locally?

                  Diabetes lead managers in Primary Care Trusts (PCTs) will convene local
                  implementation groups, involving people with diabetes, clinicians and health
                  services managers, to advise on how the NSF targets will be met.


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                  There are eight topic headings within the NSF:

                          type 1 diabetes;
                          prevention and early detection of type 2 diabetes;
                          management of type 2 diabetes;
                          diabetic retinopathy;
                          diabetic nephropathy;
                          lower limb complications;
                          cardiovascular disease and other complications;
                          management of diabetic pregnancy
         Who is the lead for my area?
                  Each primary care trust (PCT) has identified a lead manager for diabetes (listed in
                  the table below).




                             Diabetes Lead
        PCT                  Manager       e-mail address
                             (May 2002)

        Bath and North
        East Somerset To be appointed To be appointed
        PCT
        Bristol North Barbara
                                                  barbara.coleman@bristolnorth-pct.nhs.uk
        PCG           Coleman
        Bristol South
        and West PCG Gill Velleman                Gill.Velleman@bristolswpct.nhs.uk


        North Somerset
        PCG
                       Mike James                 Mike.James@nsomerset-partnership.nhs.uk

        South
        Gloucestershire Maggie Rogers Maggie.Rogers@userm.avonhealth.swest.nhs.uk
        PCT


         How are diabetes services provided?
                  Services are provided by general practices, specialist community services eg
                  podiatry, optometrists and dieticians, and specialist nurses and doctors employed
                  by hospital trusts.

                  Some general practices run diabetes clinics, whilst others offer appointments
                  during routine surgeries. Until 2000/01, 99% of Avon practices participated in the
                  national Chronic Disease Management Programme for diabetes, which required
                  that they run chronic disease management registers, conduct audit and report
                  data annually on the standard of care provided. However this situation has
                  changed subsequent to NHS reorganisation. Avon Health Authority has now



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                  ceased, most of its responsibilities being devolved to 5 PCTs . The PCTs will
                  commission specialist services, and develop services from their practices and
                  community services. Also, increasing numbers of practices have changed their
                  contracts with the PCTs, to ‘PMS’ (personal medical services). This means that
                  they will not be required to be in the CDM programme, which means the data
                  recording previously used to monitor diabetes prevalence and care will cover
                  fewer practices. This means we are in a poorer position to compare services
                  across Avon. Hopefully this will change when the NSF is implemented, with
                  standard requirements to assess and monitor standards of care.

                  Consultant and specialist nurse diabetes services are available at Frenchay
                  Hospital, Southmead Hospital, Weston General Hospital, Bristol Royal Infirmary
                  and the Royal United Hospital, Bath. These services involve podiatrists, dieticians
                  and optometrists in advising and assessing people for complications. Eye, renal,
                  maternity vascular orthopaedic, impotence and psychology services are involved
                  in treating complications of diabetes. There are specialist services for children,
                  based at the Bristol Children’s Hospital and the Royal United Hospital, Bath.

                  Weston General Hospital provides information on its diabetes services at
                  http://www.westondiabetes.org.uk/



                  Section 2: How Common is Diabetes?

         Number of people with diabetes

                  Until 2001/2002, Avon GPs reported on the number of people with diabetes in
                  their practices for the Chronic Disease Management Scheme. This data is shown
                  in table 1 below.

                  This data is available to practices in ‘Avon Practice Comparisons’. Practices can
                  download this from
                  http://nww.avon.nhs.uk/imtconsortium/Info_management/practice_comps/default.h
                  tm



Avon PCGs and PCTs ,               Number of People with          Total        % Population with
1999/2000                          diabetes                       Population   diabetes
Bath & NE Somerset PCT                          3883                 183854            2.1
Bath PCG                                        2044                 102213            2.0
Greater Wansdyke PCG                             1839                 81641             2.3
Bristol North PCG                               5492                 226618            2.4
Bristol East PCG                                1682                  70400            2.4
Bristol Inner City PCG                          1584                 53169             3.0
Bristol North West PCG                          2619                 119783            2.2
Bristol South & West PCG                        4088                 202737            2.0
Bristol South East PCG                          1503                 66864             2.2
Bristol South PCG                               2032                 79023             2.6
Bristol West PCG                                553                  56850             1.0
North Somerset PCG                              3901                 187922            2.1



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Weston Super Mare PCG                            1660               81714               2.0
Woodspring PCG                                   2241              106208               2.1
South Gloucestershire
                                                4828               237265               2.0
PCT
Severnvale PCG                                  1217                68215               1.8
South East Gloucestershire
                                                3218               152316               2.1
PCG
Avon                                           22192               1038396              2.1

                  Table 1 - Number of registered patients with diabetes reported by Avon in
                            the former and current PCG/Ts (Year ending March 2000)
                  A person can have diabetes for a number of years without realising. The numbers
                  reported by GPs do not include these people.

                  Research studies designed to find out how many people have diabetes are
                  generally considered more accurate than GP registers. The 1993 National Health
                  Survey for England provided an estimate of self reported diabetes, and
                  investigated undiagnosed diabetes. Overall 2.4% of adults said they had
                  diabetes. This was adjusted to 3.4% to take account of undiagnosed cases.
                  Against these estimates for adults only, the Avon figure for all ages is higher. This
                  could be because it is more up to date (diabetes is getting commoner), Avon GP
                  registers may overestimate diabetes prevalence, diabetes could be commoner in
                  Avon e.g. because of differences in the age, sex, and ethnicity of our population.

                  Changes in the criteria for deciding whether or not a person has diabetes will have
                  an effect on estimates of the population with diabetes. This will occur gradually as
                  clinicians change to the new diagnostic criteria produced by the World Health
                  Organisation in 2000.

                  The estimated number new (incident) cases of diabetes in 2001 for each PCT are
                  shown in the table 2 below. Please note, these are estimates based on national
                  studies and may not reflect the actual number of new cases that occurred in 2001.



                  PCT                            New cases        95% confidence
                                                 2001             intervals

                  B&NES                          267              235-299

                  Bristol North                  324              288-359

                  Bristol South & West           251              220-282

                  North Somerset                 324              289-360

                  South Gloucestershire          372              334-410

                  Table 2: Estimated new cases of diabetes in 2001



         Trends in numbers of People with Diabetes




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                  In 1999/2000, Avon GPs reported that over 22,000 of their patients had diabetes.
                  Of these, nearly 75% had type 2 diabetes. In 1995, Avon GPs reported that 1.6%
                  of their patients had diabetes. This percentage has grown steadily to 2.1%
                  reported in 1999/2000.
                  The growth in the registered diabetic population in Avon over recent years
                  is greater than the increase in the Avon population, and this trend is
                  mirrored throughout the UK and globally. Graph 1 below illustrates the
                  changes in the number of people with diabetes in Avon.
                  This could reflect a real increase, migration, the fact that people with
                  diabetes are living longer, better diagnosis, improved recording, better
                  statistical returns to Avon Health Authority - or a combination of these.
                  Most professionals feel that there is a real increase in the new (incident)
                  cases of diabetes throughout the country.

                                                                  Graph 1: Number of Avon residents with diabetes. GP reporting 1995-
                                                                                                2000.
                                                          25000
                         Number of people with diabetes




                                                          20000


                                                          15000


                                                          10000


                                                          5000


                                                             0
                                                                  1995       1996        1997          1998     1999       2000
                                                                                                Year



                  Source – Avon Practice Comparisons


         Distribution of Diabetes across Avon


                  Diabetes is commoner in some parts of Avon than others. There is considerable
                  variation in the size of the local population with diabetes, reported by GPs within
                  the twelve former PCGs in Avon (table 1). For example in Bristol Inner City, the
                  percentage of the population reported to have diabetes is more than double that
                  for Bristol West.
         Risk factors for type 1 diabetes
                  New cases of type 1 diabetes arise most commonly in childhood. Graph 2 below
                  shows the incidence of diabetes in childhood, i.e. the number of new childhood
                  people with diabetes each year. The cause of type 1 diabetes is not known, and
                  we do not know how to prevent it. Incident cases of type 1 diabetes are getting
                  commoner. The reason for this in unknown.




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                                                                                  Graph 2: Incidence of diabetes in childhood


                                                                         25
                                                                         20




                        incidence rate per
                           100,000/year
                                                                         15
                                                                         10
                                                                          5
                                                                          0
                                                                                     0–4             5–9                10–14       Total 0–14
                                                                                                            age group




                  Source - appendix 3 of Health care needs assessment. Diabetes. Williams R, Farrar H.
                  Oxford 2000. See http://hcna.radcliffe-online.com/diabetes.htm


                  At the end of 2000, specialist paediatricians at the Bristol Children’s Hospital and
                  Royal United Hospital estimated that they had caseloads of just over 300 and 43
                  children and young people under 20 who live throughout Avon, respectively. It is
                  likely that these figures include almost all children with diabetes, but in late
                  adolescence, people with diabetes start to transfer to adult services. Hence this
                  caseload is not a reliable indicator of the number of children and teenagers with
                  diabetes.

                  Graph 3 below provides annual incidence rates of type 1 diabetes per 100,000
                  population in children and adults, as estimated by the University of Southampton
                  Diabetic Retinopathy Screening Project using studies by Green and Gale (1993),
                  Green et al. (1992) and Cudworth (1978). The data is published at
                  http://www.soton.ac.uk/~scb/data.htm



                                                                                         Graph 3: Incidence of Type 1 Diabetes
                                                                                                per 100,000 population

                                                                          30
                                      incidence per 100,000 population




                                                                          25

                                                                          20

                                                                          15

                                                                          10

                                                                              5

                                                                              0
                                                                                   0-4        5-9     10-14      15-19      20-24    25-29       30-34

                                                                                                               Ages
                                                                                                     Male             Female




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         Risks factors for type 2 diabetes
                  Graph 4 shows that new cases of type 2 diabetes arise more frequently in older
                  age groups. New cases are commoner in non-white populations, for all age
                  groups. New cases are slightly commoner amongst men than women. New cases
                  of type 2 diabetes are now arising amongst young people, associated with being
                  overweight and less physically active.


                                                                  Graph 4: Incidence of Type 2 Diabetes per 100,000 population

                                                            800
                        incidence per 100,000 population




                                                            700
                                                            600
                                                            500
                                                            400
                                                            300
                                                            200
                                                            100
                                                              0
                                                                  20-29    30-39   40-49   50-59      60-69   70-79   80-89   90-99
                                                                                                Ages


                                                           White male       White female       Non-white male         Non-white female




                  Source – University of Southampton Diabetic Retinopathy Screening Project at
                  http://www.soton.ac.uk/~scb/data.htm,using a USA study (Lipton et al, 1994).
                  Estimates in ‘Health care needs assessment: Diabetes. Williams R, Farrar H.
                  Oxford 2000 at http://hcna.radcliffe-online.com/diabetes.htm are higher, and the
                  authors question their value given that diagnosis tends to be late in type 2
                  diabetes.

                  The people most at risk of developing Type 2 diabetes are:

                                                          People with a family history of diabetes
                                                          People aged between 40 and 75
                                                          People of South-Asian or Black Caribbean origin
                                                          People who are overweight
                                                          Women who have had a baby weighing more than 4kg (8lb 8oz).
         Diabetes and minority ethnic groups

                  The 1999 national survey of Health of Minority Ethnic Groups found that South
                  Asian men and women had the highest rates of diabetes, with Pakistanis and
                  Bangladeshis of both sexes being 5 times more likely to develop diabetes
                  compared with the general population. Indian men and women were 3 times more



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                  likely, and Black Caribbean men and women were 2.5 times and 4 times more
                  likely to have diabetes, respectively.

                  Rates amongst Chinese and Irish people were not significantly raised above the
                  general population level.

                  With the exception of Black Caribbean people, all groups were achieving physical
                  activity levels below the general population.

                  Central obesity (excess weight particularly around the waist) is associated with
                  higher risk of diabetes. South Asian men were more likely to have central obesity
                  than the general population. Central obesity in women was commoner than in the
                  general population for all minority ethnic groups at higher risk of diabetes.

                  The full national survey report is available via http://www.official-
                  documents.co.uk/document/doh/survey99/hse99.htm

                  A Bristol Black and ethnic minority health survey 10 years earlier found that 8% of
                  respondents aged 18-64yrs said they had diabetes. Two out of 3 of this group did
                  not experience difficulty attending the surgery for care. A subsequent audit by 4
                  local general practices found that patients from different backgrounds received the
                  same level of routine diabetes examinations. However further survey analysis
                  highlighted the particular barriers faced by South Asian women with respect to
                  achieving higher levels of physical activity.


                                Graph 5: Prevalence of diabetes in Black and Minority Ethnic
                                                       Groups 1999

                        12
                        10
                         8
                         6
                         4
                         2
                         0
                                                           Pakistani




                                                                                                      Irish
                                Caribbean




                                                                       Bangladeshi
                                                 Indian




                                                                                            Chinese




                                                                                                              population
                                                                                                               General
                                  Black




                                            Men Observed prev %                      Women observed prev%



                  Source: National survey of Health of Minority Ethnic Groups, 1999. Published at
                  http://www.official-documents.co.uk/document/doh/survey99/hse99.htm




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2        Section 3: Diabetes Complications
         Diabetes complications

                  Diabetes can lead to a number of complications, including problems with eye
                  sight, blood supply to lower limbs, and increased risk of kidney failure and
                  cardiovascular disease.
                  Clinical Evidence 4 (2001) noted that:

                          Mortality rates from coronary heart disease are up to 3 times higher in
                           people with diabetes compared to their peers.
                          About 45% of middle aged and older men with diabetes have evidence of
                           coronary heart disease compared with 25% of people of the same age
                           group and population.


                  The Clinical Evidence website at
                  http://www.clinicalevidence.nhs.uk/
                  provides a regularly updated review of effective interventions that can reduce
                  cardiovascular risks in people with diabetes.


                  As diabetes affects large blood vessels, the risk of stroke is also increased.

                  1999 data from the UK Renal Registry reports diabetes as the commonest single
                  cause of end stage renal (kidney) failure amongst adults starting on renal
                  replacement therapy (accounting for 16% of the total).


         Diabetes and lower limb complications

                  Poor blood supply (‘peripheral vascular disease’ or PVD) and damage to the nerve
                  supply (neuropathy) of the lower limbs are relatively common complications of
                  diabetes. An estimated 20% men and 25% women with type 2 diabetes have
                  PVD, estimates for people with type 1 diabetes are lower. Peripheral neuropathy
                  becomes commoner with age, rising from 5% of 20-29 year old, to 60% of 80-89
                  year old people with diabetes.

                  These changes to blood and nerve supply mean that diabetic feet are more
                  susceptible to damage and infection. Ulcers can be serious and difficult to heal. A
                  minority of cases lead to substantial damage to the foot, and in some cases,
                  amputation to prevent further damage.

                  From GP reports we estimate that at least 22,000 Avon residents have diabetes.
                  Between 1999/00 and 2001/02, there were approximately:

                          290 hospital admissions each year because of lower limb ulcers in people
                           with diabetes;
                          89 hospital operations for amputations involving people with diabetes,
                           each year. (graph 6)



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                                                 on average, each year over 2063 bed days were used for these
                                                  admissions


                  Graph 6 shows the number of hospital operations for amputation affecting lower
                  limbs in people with diabetes.


                                                    Graph 6: Number of operations for amputations in people with
                                                                       diabetes (99/00-01/02)

                                             50
                                             45
                      number of operations




                                             40
                                             35
                                             30
                                             25
                                             20
                                             15
                                             10
                                              5
                                              0
                                                      B&NES       Bristol North    Bristol South &    North Somerset   South Glos
                                                                                        West

                                                                                  Foot   Leg    Toe




                  Source: Admitted Patient Care Data, Avon IM&T Consortium
                  Note: Main operation codes Lower Limb Amputations (ICD10 X09, X10, X11) with
                  any diagnosis diabetes code (ICD10 E10-14)

                  National data allows us to compare the rate of amputation in people with diabetes
                  in Avon with similar health districts, and the rest of England (graph7).

                  In each of the three years between 1997/98 and 1999/00, the Avon rates were not
                  significantly different from the average for the South West or England. Note that
                  this data counts the number of operations only in those people where diabetes is
                  noted as a primary diagnosis. This gives a lower total than in graph 6, where all
                  admissions mentioning diabetes have been included.




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                                                                   Graph 7: Lower limb amputations in diabetic patients (1997/98, 1998/99
                                                                                               & 1999/00)


                                                                 14.00

                                                                 12.00



                        directly standardised rate per 100,000
                                                                 10.00

                                                                  8.00

                                                                  6.00

                                                                  4.00

                                                                  2.00

                                                                  0.00
                                                                         England   South West   Avon      B&NES UA Bristol UA    North     South Glos
                                                                                                                                Somerset      UA
                                                                                                                                  UA

                                                                                                1997/98   1998/99   1999/00

                   Source: Compendium of Clinical Indicators


         Prevention of Lower Limb Complications

                  The risk of diabetes complications can be reduced by good control of blood
                  pressure and blood sugar, and regular examination for early signs of
                  complications can ensure that early preventive treatment and advice are given.
                  For prevention of lower limb complications in particular, people are advised to
                  inspect their feet regularly and wear well-fitting shoes to reduce the risk of
                  developing a foot ulcer, and it is essential to take care and seek early treatment
                  for foot problems. Evidence on prevention of lower limb complications has been
                  published in ‘Clinical Evidence’ – see the endocrine section at
                  http://www.clinicalevidence.nhs.uk/


         Diabetes and Eyesight
                  Diabetic complications in the blood vessels of the retina (diabetic retinopathy) can
                  lead to visual impairment and blindness.

                  We do not have a formal diabetes eye screening programme covering all of Avon.
                  There are retinal photography screening services in Weston and Bath. In Bristol,
                  doctors and optometrists commonly use ophthalmoscopes to examine the eyes
                  (‘fundoscopy’).

                  GPs reported that 57% of people with diabetes underwent fundoscopy in
                  1999/2000 (Table 3). The percentages of the PCT diabetic populations receiving
                  eye tests vary, and it appears that for a substantial proportion of these
                  populations, there is no record of an annual eye screening test. This is so even if
                  we assume there is no overlap between those receiving fundoscopy and retinal
                  photography – the minimum estimate is 25% people with diabetes have no record
                  of either a retinal photograph or fundoscopy in 1999/2000. Visual acuity checks



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                  are currently recommended as an annual check for all people with diabetes, but
                  only half of patients had a record of this check for 1999/2000
                  In 1999/2000, 864 laser procedures aimed at preventing visual impairment were
                  performed on Avon residents with diabetes, for an estimated 607 people.
                  A survey of 40 practices in Avon and Somerset has shown that the risk of
                  developing diabetes eye disease is related to socio-economic factors. Lower
                  levels of education and income are associated with higher risks of eye and heart
                  disease. Less advantaged individuals have more ill health but appear to use
                  specialist care less.
                                                                              % Retinal
                             % Fundoscopy                   % Visual Acuity
                                                                              Photography
BANES PCT                                  72                        68                 48
Greater Wansdyke                           64                        62                 39
Bath                                       80                        73                 57
N SOMERSET PCG                             39                        44                 17
Woodspring                                 60                        51                 3
Weston Super Mare                          17                        36                 32
BRISTOL NORTH
                                           57                        36                11
PCG
Bristol East                               36                        24                12
Bristol Inner City                         65                        19                3
Bristol North West                         65                        53                16
BRISTOL S & W PCG                          60                        52                2
Bristol South                              68                        58                3
Bristol South East                         39                        34                2
Bristol West                               82                        82                0
SOUTH
GLOUCESTERSHIRE                            62                        51                16
PCT
South East
                                           62                        48                16
Gloucestershire
Severnvale                                 60                        57                14
AVON HEALTH
                                           57                        49                18
AUTHORITY
Source: Avon Practice Comparisons

                  Table 3: Percentage of people with diabetes with eye checks recorded as
                           part of a diabetes annual review. Avon General Practices,
                           1999/2000.




         Prevention of Eyesight Complications
                  The risk of complications for diabetes can be reduced by good control of blood
                  pressure and blood sugar. Regular screening tests for early signs of
                  complications can help ensure that early preventive treatment and advice are
                  given.




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                  There is no information system recording how many people in Avon have lost their
                  sight due to diabetes. We have used research data to estimate the scale of this
                  complication of diabetes. By implementing a programme using the preferred
                  screening test (retinal photography), we estimate:

                           At least 18,000 people with diabetes would attend for screening each year
                          The benefits of preventive treatment would emerge over time: within a year
                           of treatment, between 16 and 48 people would have had blindness
                           prevented.
                          Within 10 years, up to 300 people would have had blindness prevented.
                          Despite screening and treatment, a small number of people would still lose
                           their sight, as this cannot be prevented in 100% of cases.


                  For national recommendations on screening for diabetic retinopathy, look at the
                  National Screening Committee’s advice at http://www.diabetic-
                  retinopathy.screening.nhs.uk/ . NICE (http://www.nice.org.uk/) has issued a
                  guideline on early management of diabetic retinopathy. Further advice on
                  screening is expected in the Diabetes NSF Implementation Plan (due summer
                  2002).

                  The proposal for a diabetic retinopathy screening programme in the Bristol and
                  South Gloucestershire areas can be accessed at
                  http://nww.avon.nhs.uk/phnet/Publications/retinopathy_screening.doc


         Hospital Admission for diabetes coma
                  Lack or loss of control of diabetes can lead to sudden and severe rises in blood
                  sugar, and changes in body chemistry. This can lead to coma and death.
                  Ketoacidosis is a term describing the production of ketones, which can be a
                  serious feature of acute loss of control of diabetes. Coma can also be described
                  as ‘hyperosmolar’ where ketones are not produced, but there are other potentially
                  life threatening changes in body chemistry.

                  Treatment of diabetes can be complicated by a different type of coma, if blood
                  sugar falls to a dangerously low level (hypoglycaemic coma).

                  Hospital episodes for both types of coma are monitored nationally, and results for
                  the Avon area are presented in graph 8. This shows that in the three years
                  between 1997/98 and 1999/00, the overall rate for Avon was higher than the
                  average for the South West region and England. In one of these years (1998/99),
                  the hospital episode rate was significantly higher in Avon compared to England
                  and the South West region. Within Avon, the rates for Bath and North East
                  Somerset and North Somerset unitary authority populations were particularly high.




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                                                                   Graph 8: Hopsital Episodes for ketoacidosis and coma (1997/98-99/00)


                                                                 60.00


                                                                 50.00



                        directly standardised rate per 100,000
                                                                 40.00


                                                                 30.00


                                                                 20.00


                                                                 10.00


                                                                  0.00
                                                                         England   South West   Avon      B&NES UA    Bristol UA    North     South Glos
                                                                                                                                   Somerset      UA
                                                                                                1997/98   1998/99    1999/00         UA




                  Source: Compendium of Clinical Indicators.

                  These high rates could be due to differences in the way that episodes of care are
                  counted. An episode refers to a period of time when a patient is recorded as
                  being under the care of a particular consultant. If the patient was transferred to a
                  different consultant during a single hospital admission, then this would count as
                  two episodes.

                  Local data has been analysed in more detail ie for the 12 former PCG areas within
                  Avon, and over a three year period (April 1997-March 2000) to provide a larger
                  and more reliable dataset. Hospital admissions have been estimated to overcome
                  the problem of counting episodes described above (table 4). This suggests that
                  the highest ratios (compared to the Avon standard of 100) were for the Bath and
                  Weston-Super-Mare populations. The ratios were significantly lower than Avon in
                  Bristol East, Bristol West, Severnvale and South East Gloucestershire.




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                                 Hospital                  Indirectly       95% Confidence
                                Admissions,              Standardised          Limits for
                                April 1997 –           Hospital Admission    standardised
                                March 2000                   Ratios         admission ratios

Bath                                   98                         127            110-164

Bristol East                           24                         50              30-70

Bristol Inner City                     43                         125            80-162

Bristol North West                     83                         100            78-121

Bristol South                          57                         109            81-137

Bristol South East                     37                         82             56-108

Bristol West                           24                         63              38-88

Greater Wansdyke                       62                         118            89-147

Severnvale                             24                         57              34-80

S E Gloucestershire                    74                         75              58-92

Weston Super Mare                      93                         159            127-192

Woodspring                             67                         92             70-114

Avon HA                               697                         100            93-107

Source: Avon Practice Comparisons package, AHA Information Department.

         Table 4: Hospital admissions for ketoacidosis and hypoglycaemic coma, former
                PCGs in Avon, April 1997 – March 2000

                  Standardised admission ratio is the ratio of observed to expected admissions in an
                  area multiplied by 100. Age specific admission rates for Avon HA are used as the
                  standard for deriving expected admissions.

                  As this indicator combines hospital admissions for different types of coma, further
                  analysis is needed to find out what the underlying pattern is. However in all
                  cases, the major issues to address are quality of control and timely diagnosis of
                  diabetes. Clinical audit is needed to monitor quality of control.

3        Section 4: Deaths due to diabetes

         Between 1998 and 2000, 253 deaths due to diabetes were recorded amongst Avon
         residents. Almost 90% of these deaths were in people aged over 65yrs. Diabetes
         contributes to further deaths, but may not be registered as the main cause. Graph 9
         below includes those deaths where diabetes is stated as the main cause so they
         represent a minimum estimate of the impact of diabetes in terms of deaths.

         About half of all deaths in people with diabetes are due to heart disease, for which
         diabetes is a risk factor. Diabetes shortens life expectancy, but improving heart disease
         risk factors (being physically active, stopping smoking and reducing blood pressure and
         lipids) can improve survival. Evidence on treating heart disease in diabetes has been
         reviewed – see the endocrine section at http://www.clinicalevidence.nhs.uk/ . The


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         remainder of deaths are due to other complications of diabetes, including kidney failure
         and infection.

                                                                                                       Graph 9: Mortality from diabetes in all ages (1998-2000)


                                                                     120


                                                                     100
             indirectly standardised ratio (SMR)




                                                                                      80


                                                                                      60


                                                                                      40


                                                                                      20


                                                                                      0
                                                                                                 England &   South West   Avon    B&NES UA    Bristol UA   N. Somerset South Glos
                                                                                                  Wales                                                        UA         UA



         Source: Compendium of Clinical Indicators 2001

                                                                                      Mortality rates from diabetes are higher in areas of deprivation. By dividing Avon
                                                                                      into five equal parts (quintiles) according to deprivation scores, it can be seen that
                                                                                      mortality rates in the two most deprived quintiles were significantly higher than
                                                                                      rates of the two affluent deprived quintiles between 1995 and 1999 (graph 10).



                                                                                             Graph 10: Mortality rates from diabetes by deprivation quintile in Avon
                                                                                                                            (1995-99)

                                                                                           1.2
                                              directly standardised rate per 10,000




                                                                                           1.0


                                                                                           0.8


                                                                                           0.6


                                                                                           0.4


                                                                                           0.2


                                                                                           0.0
                                                                                                    most affluent -       2             3                  4        most deprived -
                                                                                                     Quintile 1                                                       Quintile 5



         Source: ONS mortality files; 1991 census for calculation of Townsend scores




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4        Section 5: Primary Care Prescribing Costs for Diabetes

         Table 5 gives the primary care prescribing costs for diabetic medication and monitoring
         agents for 1999/2000. The figures (in £) represent payments per 1000 STAR PUs
         (Specific Therapeutic Age-Sex Related Prescribing Units) for the PCG. STAR PUs have
         been developed to allow for the differences in the age and sex of patients for whom drugs
         in a specific therapeutic groups are usually prescribed. The STAR PUs used here are for
         endocrine drugs for which there is a particularly large difference between prescribing
         costs for men and women between 35 to 64.

         The costs of endocrine drugs prescribed for women aged 45 to 54 is 13 times that for
         males. These figures therefore account for differences in the age and sex distribution of
         the PCGs, but not for the ethnic, social or economic variations between the PCGs and
         PCTs - or the local prevalence of diabetes.




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                                                                                           Total
Former PCGs in
Avon
                             Prescribing costs (in £) per 1000 STAR PUs                    Prescribing
                                                                                           costs (£)
                                                            Screening and
                                        Oral anti                         Total cost per
                      Insulin                               Monitoring
                                        Diabetics                         STAR PU *
                                                            Agents
Bath                        293                 107                 211        617            392,888

Bristol East                250                133                 178         565            250,052
Bristol Inner
City
                            356                254                 221         835            250,794
Bristol North
                            290                 141                 170        605            460,217
West
Bristol South
                            294                 142                 152        592            254,165
East
Bristol South               364                 181                 171        721            345,618

Bristol West                222                 67                  136        430            120,762
Greater
Wansdyke
                            286                 134                 199        628            351,193

Severnvale                  318                 106                 199        633            262,076
SE
                            258                 119                 166        547            542,006
Gloucestershire
Weston Super
Mare
                            391                175                  211        782            434,494

Woodspring                  273                 109                 183        572            431,309
Avon                        296                135                  183        620           4,095,576
                                                                                             120,762-
       Range             222-391             67-254               136-221    430-835
                                                                                              542,006
                 Table 5: Prescribing costs for former PCGs in Avon Health Authority,
                           1999/2000 : diabetes medications and monitoring agents.
                           Source Prescribing And Cost Database (PACT).
                           Note: *Includes treatment of hypoglycaemia.




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