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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