The New National Diabetes Foot-care Audit NDFA The National Diabetes Audit (NDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) following advice to the Department of Health from the National Advisory Group on Clinical Audit and Enquiries (NAGCAE). NDA Consortium

NDA Linked Data GP and Specialist Electronic Records Diabetes Diagnosis, Year -> NDA core dataset NHS No, Sex, Post Code (IMD), Year of birth BMI, Smoking, BP, HbA1c, TC, eGFR, UACR Eye & Foot surveillance Hospital Episode Statistics NHS number Admission for DKA, Amputation, Dialysis/Kidney Transplant, Angina, MI, HF, Stroke ONS (MRIS) NHS number Date of death Patient level linked extensions: Pregnancy, NPID (started 2013); Foot disease NDFA (started July 2014) Also unlinked: Inpatients, NaDIA (started 2011); Patient Experience, PEDS (Piloted )

NDFA Advisory Group Multidisciplinary & Technical Plus People with Diabetes William Jeffcoate (Chair), Alexandra Harrington, Louise Dunn, Catherine Gooday, Fiona King, Gerry Rayman, Hana Rous, Ian Loftus, Linda Milburn, Naomi Holman, Rhys Thomas, Roger Gadsby, Roy Johnson, Sue Brown, Claire Hanrahan, Laura Fargher, Bob Young

Incidence (per 10 3 of diabetes population) of major amputation in adults with diabetes by PCT: variation x10 England N. Holman, R. J. Young and W. J. Jeffcoate. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 2012 :

Pilot Audit NHS Diabetes Structures – DiabetesE: 20 item questionnaire (70u) New DFU – 23 units, 3mo; 652 patients – 61% reached MDT in <2 days (poor DQ) – 53% had a SINBAD score >3 – 4.0% developed ulcers in hospital FU Healing - Multivariate regression – Associated: hind-foot, depth, PAD – Not associated: age, sex, DM type, deprivation

Funnel plot of Standardised* Healing Ratios (* location, depth, PAD) N Holman 2013 Would be reliable with minimum 100 ulcers/centre

Learning from Pilot Prospective DFU audit is practicable Standardised comparative measurement is possible SINBAD severity score is valid and easy QoL (EUROQOL) not practicable or useful BUT Simplify Minimise local participation burden

Questions for NDFA The aim is to improve outcomes overall and reduce the massive variation in the incidence of major amputation Are nationally recommended foot-care service structures are in place? Does referral and treatment comply with national recommended guidance? Are the outcomes of treatment are as good as they can be?

How does NDFA work?

Structures of Care Annual/Bi-annual online questionnaire Is there a training programme to ensure that all health care professionals who undertake routine screening to define foot risk in people with diabetes have the necessary competence? – YES/NO Is there an established pathway to ensure that people with increased foot risk are referred to a designated Foot Protection Service for further assessment and for long-term surveillance and risk management when appropriate? – YES/NO Is there a pathway to ensure that a person with new, deteriorating or recurrent diabetic foot disease can be assessed by a member of an expert Multidisciplinary Footcare Team (MDFT) within 24 hours when appropriate? – YES/NO

For each new DFU (1) LINKED From Core NDA (via NHS Number) Age, Sex, Ethnicity, Social Deprivation BMI, HbA1c, Cholesterol, BP, EGFR LOCAL RECORDING 1.Consent 2.Patient details

Obtaining Consent

For each new DFU (2) Case-mix – lesion type

OUTCOMES LINKED from Core NDA, HES, MRIS – Admission, Amputation, Other Complication, Death LOCALLY COLLECTED

When Outcome Sections Complete (12/24wk after presentation) Submit via secure web form (clinical audit dept?) DQ checks Aggregation up to 1yr – first data ‘cut’ probably July 2014 Linkage to Core NDA, HES/PEDW, MRIS Data management Data analysis by – Service – Trust – CCG – SCN – National

Analyses and Reports Structures – Simple statistics, presented geographically Processes – Risk assessment completion rates – Referral delays Outcomes (Service, Trust, CCG, National) – Reported before and after adjustment for confounding factors (e.g. age, sex, ethnicity, deprivation, severity at presentation, type of diabetes, weight, glucose control) Standardised healing rates Hospital Admissions Amputations and Mortality in NDFA patients Amputations and Mortality in patients admitted without MDFT intervention Associations with Structures and Processes

How to get involved Contact a steering group member Go to the home page – Contact the help desk – Register your DFU treatment service (NB Caldicott Guardian step) Just get started!