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National Paediatric Diabetes Audit (NPDA) Context Page

The National Paediatric Diabetes Audit (NPDA) was established to compare the care and outcomes of all children and young people with diabetes receiving care from Paediatric Diabetes Units (PDUs) in England and Wales. The audit is commissioned by the Health Quality Improvement Partnership (HQIP), funded by NHS England and the Welsh Government, and is managed by the Royal College of Paediatrics and Child Health.

The 2016/17 NPDA included all 173 PDUs in England and Wales and captured information on 29,153 children and young people up to the age of 24 years under the care of a consultant paediatrician. Case ascertainment is not reported for this audit. The audit aims to capture data on all eligible patients within the sampling period.

To view the full audit dataset visit the RCPCH website

Metrics:

1. Completion of health checks (care processes) of patients (with type 1 diabetes) aged 12 and above

  • Rationale: There are seven key care processes recommended by NICE2 3 for children and young people aged 12 and above with Type 1 diabetes that should be performed at least once annually. This metric measures the percentage of patients who have received all of the seven care processes (HbA1c (blood test for diabetes control), Body mass index (BMI; measure of cardiovascular risk), Blood pressure (measure of cardiovascular risk), Urinary albumin (urine test for kidney function), Eye screening (photographic test for eye risk), Foot examination (for ulcer risk), Thyroid screen (blood test for hyper/hypothyroidism). Care processes are also related to outcomes as they are screening for potential complications of diabetes. Recognition of early complications allows early intervention and reduces the burden on the patient, family and the NHS. There is considerable variation across hospitals for the completion of all seven key care processes, although the completion rate has improved compared to previous years.
  • Guideline/mapping: NICE CG 18 Diabetes (type 1 and type 2) in children and young people: diagnosis and management and  NICE CG 19 Diabetic foot problems: prevention and management
  • Graph/relative performance: Individual hospitals’ rates are compared against other hospitals’ and the national average (see key). Higher values indicate better performance. This metric is not adjusted. Unadjusted scores mean that the comparison across units does not account for case-mix. A funnel-plot cross-section shows the position of the Trust relative to 95% (alert) and 99.8% (alarm) control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means that the performance is different to the national average.
  • Quality improvement prompt question: Investigation of negative outliers should be a priority. The audit expects that local quality improvement initiatives are undertaken. The audit makes recommendations for all multidisciplinary teams, notably that barriers to the annual provision of key care processes should be identified, and quality improvement initiatives should be undertaken to mitigate these. How does the trust assure itself that children and young people with diabetes are receiving the key essential healthcare checks specific to their diabetes type? How does the trust identify barriers to this annual provision and develop quality improvement initiatives to mitigate these? How does the trust assure itself that screening for psychological co-morbidities in children and young people with diabetes occurs [such as eating disorders, anxiety, and depression]?

2. Case-mix adjusted mean HbA1c

  • Rationale: HbA1c levels are an indicator of how well an individual’s blood glucose levels are controlled over the preceding six to eight weeks. This metric measures the mean HbA1c levels for all children and young people with Type 1 diabetes only. Good blood glucose control is the key to preventing development of complications of diabetes and is likely to be influenced both by the quality of healthcare services (such as access to clinical review and provision of patient education) and by patient factors (such as patient age and socio-economic status).
  • Guideline/mapping: NICE CG 18 Diabetes (type 1 and type 2) in children and young people: diagnosis and management (https://www.nice.org.uk/guidance/ng18)  Section 1.2.6.7recommends a HbA1c of <48mmol/mol. But very few patients achieve this.
  • Graph/relative performance: Individual hospitals’ rates are compared against other hospitals’ and the national average (see key). Higher values indicate worse glucose control, with individuals who have >80mmol/mol identified as poorly controlled. This metric is adjusted. Adjusted scores means that the comparison across providers takes into account the differences in the case-mix of patients treated. This means that differences in outcomes are not due to the types of patient seen. Due to changes made to the year-on-year case-mix adjustment calculation, this measure must not be used to assess change over time within a unit. It is provided only for benchmarking against other units during an audit year. The median HbA1c measure (see below) is supplied below to show change in performance over time. A risk-adjusted funnel-plot cross-section shows the position of the Trust relative to 95% (alert) and 99.8% (alarm) control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means that the performance is different to the national average.
  • Quality improvement prompt question: Investigation of negative outliers should be a priority. The audit recommends all MDTs should aim to achieve the HbA1c target set by NICE (individualized for the child) from diagnosis. Each child should have an individualized care plan.. The audit expects that local quality improvement initiatives are undertaken. How does the trust assure itself that MDTs are aiming to achieve the HbA1c target set by NICE (individualized for the child) from diagnosis? Each child should have an individualized care plan. How do trusts pay particular attention to the vulnerable subgroup with persistently high HbA1c levels?

3. Median HbA1c

  • Rationale: As above
  • Guideline/mapping: As above
  • Graph/relative performance: This metric is provided to compare individual units’ performance between two time periods. A change of more than 1 mmol/mol is deemed by the audit body to be indicative of a clinically significant change.
  • Quality improvement prompt question: As above.

 

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