Summary

Clinical prioritisation and a value-based healthcare approach to patient care requires access to accurate, contemporaneous, accessible data. The development of the All Wales Diabetes Audit Plus module enables every practice in Wales to access up-to-date, practice-level data across many aspects of diabetes care, enabling a variety of Quality Improvement work. Cluster and Health Board-level data utilising this platform is driving improvements in care nationwide and the identification and targeting of inequalities in care.

Innovation

Prioritisation of care to those most in need and providing care that brings the highest value to the greatest number of people forms a vital part of taking a value-based healthcare lens to health services, which is a focus in NHS Wales. The National Diabetes Audit is a valuable data collection, but differing agreements in data sharing mean that Wales does not have access to timely quarterly reports or practice-level data, as practices in England do. The only access is to annual reports, which are often published a year after collection. This means no access to contemporaneous data to reflect the current situation and practices cannot access their own data for prioritisation of care and quality improvement work. To address this problem, the All Wales Diabetes Audit Plus module was developed. Audit Plus is accessible to all practices across Wales and links directly to electronic patient record systems. It allows standardisation of searches to be available to all practices and data is refreshed daily. It also allows access to anonymised data at a Wales, health board and cluster level, assisting the sharing of good practice, identification of inequity of care and the ability to plan service delivery where it is most needed. Digital Health Care Wales was involved in the design of the module in 2021/22. It is already widely used in Wales for Quality Assurance and Improvement Framework (QUAIF) targets, such as flu vaccinations, so it is familiar to most practices and has all appropriate information governance procedures in place. Data at practice level remains accessible only to individual practices and there is no patient-level data outside of individual practices. The searches within the module reflect the need for care prioritisation. It also has searches related to prescribing and to frailty, with a focus on identifying patients suitable for deprescribing.

Equality, Diversity and Variation

The Audit Plus platform is accessible to every practice in Wales, meaning that there is equality of access to the data across the country. The amalgamation of the data down to cluster level allows identification of variations in care. For example, in Cardiff and Vale UHB there is a 19% difference between the best and worst performing cluster in attainment of all care processes. The poorest performing cluster is also the cluster in Cardiff with the highest level of deprivation, highest levels of people of ethnic minority background and highest prevalence of type 2 diabetes. Identifying such inequity has allowed system planning. The Wales Diabetes Strategic Network is using Audit Plus data to produce quarterly reports on performance in completion of the care processes and attainment of treatment targets. These reports are sent to executive leads in each Health Board at a cluster level to initiate discussion and focus on performance in these areas. Having these quarterly reports in a timely fashion is a significant advance on the 12-18 month delay in National Diabetes Audit data annual reports.

Results

Looking at the care process from June 2022 to the present, covering all people with diabetes in Wales, all eight care processes increased from 33% to 42%. Completion of UACR (worst performing care process in Wales): increase from 51% to 58%. The Cardiff and Vale project (June 2022 to present) showed SGLT2i usage in people with type 2 diabetes and heart failure increased from 36% to 60% and SGLT2i usage in people with type 2 diabetes and ACR >30mg/mol increased from 37% to 55%. In terms of impact for people with diabetes, access to extensive, current data allowed the ongoing improvement in care noted here. Completion of care processes has been shown to be associated with reduced complications of diabetes, including amputation and kidney disease. The data is allowing focus on areas of greatest need, such as the cluster in Cardiff with poorest completion of care processes, improving access to care for those harder-to-reach groups. NICE guidelines support the clear clinical and cost effectiveness of early use of SGLT2is in those at high cardiovascular risk with with type 2 diabetes to reduce cardiovascular events, reduce hospital admissions and reduce progression of CKD to dialysis. The project allows a focus on implementation of these guidelines by identifying those eligible individuals. The development of the project was funded through Digital Health Care Wales provision with no additional cost to the NHS.

User Feedback

Dr Julia Platts, national clinical lead for diabetes, Wales, stated, “The Audit plus module has been central to improving diabetes services in Wales: it has enabled the monitoring of current essential parameters and targets to share with Health Boards, clusters and practices to request focus and solutions where needed. This has had a direct impact, with improvements seen in most parameters in most areas. It has supported the development of new interventions and solutions in areas such as diabetic kidney disease and will allow direct monitoring of quality improvement projects. It has become a shining example of how data can feed service improvement.” Julie Lewis, nurse consultant/ diabetes clinical lead, BCUHB, said, “I use this all the time for HB oversight/PC education sessions and in clinical practice day to day for QI. One of the key benefits we have experienced at practice level is using the data to manage risk via relatively small QI work. For example, Addressing HbA1c >48 mmol/mol with no diagnosis of diabetes, or improving safety of prescribing in frailty and diabetes, or active recall for individuals with a HbA1c >100mmol/mol, or active recall for individuals with type 1 diabetes to complete all care processes – straightforward task and finish improvement work.”