New algorithm aims to reduce complications and costs associated with the disease.
Each week, 500 people with diabetes die prematurely in England and Wales. Across the UK, diabetes is a contributing factor to 680 strokes, 530 heart attacks and 2,000 cases of heart failure every seven days.1 In short, diabetes is a major problem in this country.
In many respects, the way diabetes is currently handled is contrary to the spirit of the Quadruple Aim for health and care – interventions are usually reactive and may not be delivered soon enough to prevent complications that negatively impact on the experience of both the patient and the clinician. Then, there are the financial costs.
A report from the London School of Economics indicates that diabetes treatment costs the UK £13.75bn a year, with £11.72bn being spent on Type 2 alone. The cost of diabetes-related absenteeism, early retirement and social benefits brings the total annual total to £29.2bn.2
The direct costs are associated with 80,000 bed days per year for people faced with complications relating to diabetes.1 The condition doubles the risk of cardiovascular disease, can cause mental health issues, and may affect the kidneys, eyes and feet – up to 100 people per week have a amputation because of diabetes, and it’s often avoidable. Many people with diabetes have at least one other long-term condition, with this number set to grow by 250 percent by 2050.3
Diabetes UK estimates that there are around 630,000 people in the UK unaware that they have diabetes, and without a formal diagnosis. By the time they are diagnosed – which could be a decade after the actual onset – half of people with Type 2 diabetes already show some signs of complications. It’s possible that these complications actually began five or six years earlier, but patients and clinicians had been unaware of their link to diabetes.4
Being able to diagnose diabetes earlier will lead to the prompt provision of appropriate education and care, for both the condition itself, and any of the emerging related complications. For people with Type 1 diabetes, this could save lives, while for those with Type 2, it can allow people to manage complications that could become life-threatening if left unattended.3
In 2004, Paul developed diabetes, but it wasn’t until 2007 that his GP first recorded a raised fasting blood sugar level. Over the following seven years, separate visits to A&E found glucose in Paul’s urine, three venues of care found his renal function worsening, and a community provider was required to dress an ulcer. It was only in July 2014 when Paul was diagnosed as having Type 2 diabetes, and the following year he developed renal failure.
For healthcare providers, earlier diagnosis and effective management means a reduction in the costs that would otherwise come about had a patient required life-long care for more developed complications. Prevention isn’t just better than cure, it’s cheaper too.
For commissioners and service planners, data quality and availability can also be an barrier to tackling diabetes, as Martin Wilkinson – the managing director of Lewisham CCG – points out: “as a commissioning organisation I get data from providers, but on a good day, it’s about three months out of date. So, it's very retrospective. It's not really easy to join up that data.”
Out of every ten people diagnosed with Type 2 diabetes, six will have shown no symptoms previously, as they can take years to develop into something tangible.5 This clearly adds a layer of difficulty for both individuals and health and care professionals – why would you think about getting treated for something if you are unaware that you have a condition?
There are still risk factors that can suggest an increased risk of developing diabetes, which may encourage people to get tested. These include obesity, age, socio economic status, inactivity, high blood pressure, and a family history of diabetes, while people of black and Asian ethnicities are also more susceptible. Diabetes UK provides a risk calculator that can help inform individuals of their potential risk level and similar tools exist in some primary care electronic patient record systems.
Should citizens or healthcare professionals they interact with decide to test for Type 2 diabetes, they are likely to use HbA1c, the average blood glucose level for the past two to three months as an indicator. If it is found that the glucose (A1c) level is elevated to 48 mmol/mol or above on two consecutive occasions within a three-month period, a diabetes diagnosis is the likely outcome.
Needing multiple tests over a fixed period of time is an area where people can fall through the gaps. For instance, a patient in an acute setting may register an elevated HbA1c level, but could be discharged before the second test, and be unaware that it is required. The three-month window could pass, rendering the initial test obsolete and potentially causing a delay in diabetes diagnosis and the commencement of education and treatment.
Diabetes tests
- Average blood glucose (HbA1c)
- Urine glucose
- Fasting plasma glucose
- Oral glucose tolerance
- Random blood glucose
Dr Charles Gostling, GP and Lewisham CCG diabetes lead, highlights the importance of digital and connected information to help tackle the issue: “We need to have effective IT systems that collect data and can share data from a variety of sources so that somebody who might have a blood test done in one hospital or in a previous GP, has that result flagged up when they're seen elsewhere so we are aware of people who might be at risk.
“Similarly, people who might have had blood tests done that are actually in the diabetic range elsewhere, will be unseen to me unless I have a means of being able to connect to update it from a variety of sources to centrally see what their blood results have been. So, it increases the opportunity for me to be able to see people who are actually at risk by comparing data sources across a place, rather than just from my own practice data.”
Around 300,000 people live in Lewisham in South East London, with about 15,000 recorded cases of diabetes and approximately 8,000 people estimated to be living with undiagnosed Type 2 diabetes.6
To try to identify some of these people, Cerner has been working with 13 GP practices that are responsible for 130,000 Lewisham citizens. These practices have been selected as they are the first in the area to share data through the Population Health and Care programme, which utilises the power of HealtheIntent®. The vendor-agnostic population health platform allows health and care professionals to aggregate, transform and reconcile individuals’ data across the continuum of care.
Dr Gostling, whose practice was also involved in the trial, notes that “HealtheIntent brings data together and allows us to collect a huge richness of data that wouldn't otherwise be available to individual organisations... That allows us to see a whole person, not just a set of biometric parameters.”
In Lewisham, the intelligent platform has been able to discover people who have had two elevated HbA1c readings within a three-month period from across the system. This is vital to help those who are asymptomatic to start receiving education and treatment as quickly as possible.
“My experience to date of HealtheIntent, looking at the analytics part, is that it gives us a much greater opportunity to be able to identify people who may have currently undiagnosed diabetes, or might be at risk of developing diabetes in the future.”
Dr Charles Gostling, GP, Morden Hill Surgery
The algorithm searches for people over the age of 12 that have two HbA1c results of 48 mmol/mol or more within the given time span, and do not have a coded diagnosis of either Type 1 or Type 2 diabetes. Once the system finds people who meet these criteria, the information is fed back to individual practices via One Health Lewisham, the local GP federation.
Several uncoded patients were swiftly identified by HealtheAnalytics℠, the analytical component of Cerner’s HealtheIntent platform that helps find people unknowingly living with diabetes. To ensure that the accuracy of the data and query with the new tool, five of these patients were specifically validated by their GPs. Once these five examples were presented to the steering group for Lewisham’s population health and care benefits, they decided there was no need for further validations, as the query was working as intended.
One of the identified patients actually registered their second elevated HbA1c result a month before being confirmed, but once they had been flagged by the algorithm, their GP indicated that the practice would proactively reach out to get them to come in for diagnosis and commence the process of education and condition management. Without the prompt, this period could have been much more pronounced and damaging in the long term.
Proactively knowing the identity of your patients, being able to engage with them and supporting them as they manage their condition are the key principles of population health management. By being able to get on the front foot to counter diabetes, health and care professionals will potentially be able to reduce the risk of their patients developing the complications associated with it.
Martin agrees, highlighting that “what's great about population health is the work that we’re doing on clinical transformation, our work on integrated care systems across South East London, with particularly focus for me in Lewisham around community-based care. We will have the opportunity to use the intelligence to commission and deliver services differently to our population, moving away from traditionally siloed hospital and community work… It’s about getting a collective agreement about what needs to change. Then using data to drive that change, and to track that we are making change work for our local people.”
“We took a team of our analysts away… [to spend] a couple of days with Cerner colleagues looking at analytical tools, and just looking at the power of them, what they can do. I know that they’ve come back really enthused.”
Martin Wilkinson, managing director, Lewisham CCG
As well as being able to introduce suitable medication earlier in the process, lifestyle changes – such as diet and exercise – can be made to reduce controllable risk factors, such as weight and inactivity. Taking these actions sooner rather than later will not only improve the chances of a better quality of life, with fewer complications, but can also have a marked impact on costs to the system.
The London School of Economics estimates the annual cost of treating a diabetes outpatient at between £304-367, covering the cost of medications and monitoring supplies. For an inpatient, the cost includes the treatment of short- and long-term complications too, coming in at £1,807-£2,552 per patient.2
Through education, following best practice, and supporting people to self-manage to reduce the amount of people experiencing diabetes-related complications like strokes, renal failure and amputations, the savings for the NHS could be considerable.
Being able to detect Type 2 diabetes earlier is the first of its type for Cerner and Lewisham, and as with all leading-edge technology, it will only be improved in the future, and expand its reach, thus becoming even more powerful as more health and care providers are included in the search for multiple HbA1c flags. Martin adds, “we are seeing some early signs that HealtheIntent can really give us the power to… work those issues through with people to make changes”.
And let’s not forget – for the people who have already been diagnosed earlier than they otherwise might have been, the benefits are already on show. As Dr Gostling remarks, “we've had the opportunity to be able to inform those people and make sure that they have begun to make the relevant lifestyle changes to prevent future complications, and where necessary to start medication, give them the opportunity to attend structured education programmes for diabetes.”
“One example is the digital retinal screening data available across southeast London from St Thomas' Hospital. We discovered that the data that they have on digital retinal screening differs quite significantly from that which is found on GP databases, and is likely to be more accurate and more comprehensive. Onboarding that data gives us a much greater opportunity to see not only who has specific diabetic eye disease, but who hasn't been able to engage with diabetes retinal screening.”
Meanwhile for Dr Gostling and other health and care professionals using HealtheIntent-based tools, they will be able to spend less time duplicating tests and inputting discharge summaries and find it easier to track patient management and create actionable reports.
Ultimately the new system will enable elements of population health management to be introduced and tackle a range of conditions, to improve the experience for patients and care professionals, and potentially save a lot of money. In short, it will support partner organisations like those in Lewisham to integrate care, design the right services and deliver the Quadruple Aim for health and care.
1 https://www.diabetes.org.uk/about_us/news/premature-deaths-diabetes
3 https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2016/08/act-for-diabetes-31-01.pdf
4 https://www.diabetes.org.uk/resources-s3/2017-11/diabetes-key-stats-guidelines-april2014.pdf
5 https://www.diabetes.org.uk/diabetes-the-basics/diabetes-symptoms
6 Lewisham Clinical Commissioning Group Public Sector Equality Duty Report 2017–2018
7 NHS Rightcare. Paul’s story. https://www.england.nhs.uk/rightcare/products/ltc/