NHS GREATER GLASGOW &CLYDE
CHRONIC DISEASE IN NHS
GREATER GLASGOW &
CLYDE
Insights from Local Enhanced Services 2008-2009
April 2010
KEEP WELL/ENHANCED SERVICES DATA GROUP
Contents
Section
I
INTRODUCTION
II
POPULATION NEED
III
Page
3
4
2.1: Disease prevalence
2.2: Premature disease
2.3: Comorbidity
2.4: Levels of service utilisation relative to need
4
5
5
6
CLINICAL SERVICE DELIVERY & KEY OUTCOMES
8
3.1: Coronary Heart Disease
3.2: Stroke
3.3: Type 2 Diabetes
3.4: Discussion points
8
12
17
22
Foreword
This paper provides some initial insights into the challenges and achievements of NHS
GG&C’s care for patients with three major chronic diseases, Coronary Heart Disease (CHD),
Stroke and Type 2 Diabetes through its programme of Local Enhanced Services. LES are
contractual arrangements with primary care services, designed to augment the basic GMS
Quality & Outcomes Framework (QOF) specification. Enhanced services for these three
chronic diseases have now been established for over five years in Greater Glasgow and are
being incrementally introduced into Clyde. The LES contracting process generates a rich
quantity of clinical and process data, which is essential for programme delivery. However,
these data are also enormously valuable in building a picture of the needs and
characteristics of patients with chronic disease and in helping us to understand how our
local healthcare system is responding to their needs. In this short introductory paper, we
provide a brief overview of these themes, drawing on data from the LES to provide
important insights into the following aspects of CHD, Stroke and Type 2 Diabetes:





Estimates of population need
Levels of service utilisation relative to need
Variations in care processes
Variations in clinical status
Variations in clinical management
These themes will be further developed in a series of detailed thematic reports during 2010.
Anne Scoular,
Keep Well/Enhanced Services Data Group Chair
April 2010
2
I
Introduction
In common with many developed healthcare systems, NHS GG&C delivers an
evidence-based programme of chronic disease management (CDM); randomised
trials show that effective CDM programmes, incorporating proactive case-finding,
assessment, care and ongoing monitoring of people with chronic disease, are highly
cost effective. Not only do they achieve significantly reductions in hospitalisation
rates and bed days, but they also improve health status, increase participation in
health-promoting behaviours, improve communication with physicians and reduce
fatigue, disability and the social/role limitations associated with chronic disease.
Although CDM operates at a basic level through the GMS Quality & Outcomes
Framework (QoF) contract across the entire GG&C area, Local Enhanced Services
(LES) contracts extend the clinically based QoF into the all-important health related
behaviour areas, using the practice nurse annual interview to screen for problems
and support onward referral to appropriate services who can provide ongoing support
for individuals. This includes compliance; up to half of all people with long term
conditions do not take, or do not regularly take, their prescribed medication, with a
serious impact on their quality of life, clinical outcomes and cost effectiveness.
Coverage of the GG&C population is, however, not yet complete, as summarised
below:



Diabetes: Established across entire GG&C area
CHD: Established across most of the GG&C area, except Renfrewshire.
Stroke: Old Greater Glasgow area only (not operational in Clyde).
The completeness of chronic disease registers allows some estimation of the
prevalence of these diseases at community level in the CHCPs where the LESs are
established. Caution should be used in interpreting population prevalence data in
areas where there is only partial coverage by the LES. This applies in North
Lanarkshire, South Lanarkshire and West Dunbartonshire. Data from North and
South Lanarkshire have therefore been excluded from this paper and will be
presented separately, as the NHS GG&C CDM programme only operates in a small
proportion of the entire Local Authority area. Data from West Dunbartonshire are also
complex to interpret, as the new CHCP incorporates some practices who were
previously part of the old Argyll & Clyde Health Board area and others who were
within Greater Glasgow. As the CHD and diabetes LESs are now established in West
Dunbartonshire, valid prevalence estimates can be generated at CHCP level.
However, the stroke LES is only operational in practices within the old ‘Greater
Glasgow Health Board’ locality, thus the numbers of patients on the stroke register
has not been used to estimate CHCP level stroke prevalence.
The information presented in this paper largely draws on data from the 2008/09
contracting year, with appropriate comparisons with previous years when relevant.
3
II
Population need
2.1
Disease prevalence
Crude CHD and stroke show twofold variations in prevalence within GG&C (Figure
1), with the highest prevalence in East Glasgow and the lowest in East Renfrewshire.
Crude rates of disease reflect the actual prevalence of disease.
Figure 1: Crude CHD, Stroke & Type 2 Diabetes prevalence, by CHCP
70.0
Crude prevalence per 1,000
60.0
50.0
40.0
30.0
20.0
10.0
0.0
East Glasgow
South East
Glasgow
Inverclyde
West Glasgow
South West
Glasgow
East
Renfrewshire (pt)
CHD
59.8
52.5
48.5
West
East
North Glasgow
Dunbartonshire Dunbartonshire
45.6
41.9
39.6
39.4
36.8
26.0
Stroke
29.5
27.2
22.1
20.3
19.8
17.5
13.5
T2 Diabetes
44.2
44.2
37.6
37.4
36.1
34.4
34.1
30.0
29.3
19.5
CHD, stroke and, to a lesser extent, Type 2 diabetes are all commoner among older
people. South Asian populations have an approximately fourfold increased risk of
Type 2 Diabetes. Thus, some of this variation could simply be due to their differing
population structures. However, even after standardisation for age and sex, the steep
internal gradient in disease prevalence within GG&C remains (Figure 2).
Figure 2: Age & sex standardised disease prevalence, by CHCP
45.0
Age & sex standardised prevalence per 1,000
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
East
Glasgow
SE Glasgow
Inverclyde
W Glasgow
W Dun
N Glasgow
SW Glasgow
East Dun
East Ren
CHD
41.9
41.4
32.5
30.4
30.0
27.1
25.2
22.9
13.6
Stroke
19.0
19.6
12.6
11.1
10.8
5.9
Diabetes
31.6
35.1
21.0
25.7
18.4
11.6
14.4
23.7
29.7
26.4
4
Renfrewshire
25.1
As there are no current reliable estimates of the ethnic composition in each CHCP, it
was not possible to standardise for ethnicity.
2.2
Premature disease
The GG&C population experiences more premature cardiovascular disease
compared with other regions and developed nations. There are also large spatial
variations in disease prevalence within GG&C, with a five-fold variation between East
Renfrewshire and East Glasgow in CHD prevalence in those aged less than 65 years
(Figure 3). Socioeconomic deprivation explains some of this effect, acting through a
variety of different mechanisms.
Figure 3: CHD, Stroke & Type 2 Diabetes prevalence (per 1,000), males <65yrs
CHD
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
2.3
Type 2 Diabetes
Stroke
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Comorbidity
87,554 individual patients appeared on one or more of the three disease registers
during the financial year 2008/09; 16,818 (19%) had two diagnoses and 1,193 (1%)
had all three (Figure 4).
Figure 4: Comorbidity
Total
CHD
44,654
CHD
29,746
(34%)
Total
Type 2
diabetes
42,152
CHD & T2
diabetes
8,235
(9%)
Type 2
diabetes
29,622
(34%)
All 3
1,193
(1%)
Diabetes
& Stroke
3,102
(4%)
CHD &
Stroke
5,481
(6%)
Stroke
10,176
(12%)
Total
Stroke
19,952
In eight CHCPs, the LES programme is fully implemented across all three disease
areas; in these areas, we can use the LES data to estimate the population
prevalence of individuals with at least one chronic disease (ie diabetes, CHD and/or
Stroke). Again, the highest prevalence (110.4 per 1,000) is observed in East
Glasgow and the lowest (50.5 per 1,000) in East Renfrewshire (Figure 5,overleaf).
5
Figure 5: Crude chronic disease prevalence,* by CHCP, 2008-09
*Diagnosed with: Diabetes, CHD and/or Stroke as proportion of total CHCP population
120.0
100.0
80.0
60.0
40.0
20.0
0.0
East Glasgow
South East
Glasgow
West Glasgow
East
Dunbartonshire
South West
Glasgow
North Glasgow
East
Renfrewshire
110.4
104.0
80.1
78.9
74.1
73.8
50.5
Prevalence/1,000
2.4: Levels of service utilisation relative to need
The total volume of individual diagnosed on the diabetes, CHD and Stroke registers
in each CHCP is shown in Figure 6. This includes those who are exception coded
and also does not reflect the number of individuals involved, as many have more
than one disease (see previous section).
Figure 6: Number of chronic disease registrations in 2008-09, by CHCP
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
East
South West
Dunbartonshi
Glasgow
re
North
Glasgow
West
East
Dunbartonshi Inverclyde Renfrewshire Renfrewshire
re
(pt)
East Glasgow
West
Glasgow
South East
Glasgow
Type 2 diabetes
5463
4994
4475
3979
3183
2934
3417
Stroke
3651
2806
2748
2029
2337
1977
1124
CHD
7389
5453
5315
4255
4444
3959
4165
2798
6385
1716
1184
3984
2280
Of the total cohort of patients on each disease register, the overall proportion who
received disease monitoring in 2008/09 was 70.9% for stroke patients, 77.2% for
CHD and 83.5% for diabetes, with significant variations between CHCPs (Table 1).
6
The between-CHCP variation was greatest for stroke (ranging from 56.9 to 75.0%)
and least for diabetes (72.7 to 86.5%). As with all healthcare performance
monitoring, there are many possible reasons for these variations and adjustment for
age, sex, comorbidity and other determinants of casemix within each CHCP would be
required before drawing any substantive conclusions.
Table 1: Proportion of patients who received monitoring in 2008/09, by CHCP
Proportion of patients on each disease register who received disease monitoring in 2008/09
Type 2 Diabetes
CHCP
% (95% ci)
Inverclyde
86.5 (85.1 to 87.7)
West Dun
83.0 (81.7 to 84.2)
Renfrewshire
80.3 (79.3 to 81.2)
SW Glasgow
78.8 (77.5 to 80.1)
E Glasgow
77.8 (76.7 to 78.9)
East Ren
77.6 (75.5 to79.5)
W Glasgow
77.0 (75.8 to78.1)
East Dun
76.8 (75.3 to 78.2)
SE Glasgow
73.7 (72.4 to75.0)
N Glasgow
72.7 (71.1 to 74.3)
Overall
83.5 (83.2 to 83.9)
CHCP
West Dun
Inverclyde
SW Glasgow
W Glasgow
East Dun
E Glasgow
East Ren
N Glasgow
SE Glasgow
Overall
CHD
% (95% ci)
80.3 (79.0 to 81.4)
77.4 (76.1 to 78.7)
75.6 (74.2 to 76.8)
73.4 (72.2 to 74.5)
72.1 (70.7 to 73.4)
71.9 (70.9 to 72.9)
66.8 (64.8 to 68.7)
65.3 (63.8 to 66.8)
62.9 (61.6 to 64.2)
77.2 (72.2 to 74.5)
7
CHCP
West Dun
SW Glasgow
W Glasgow
East Dun
E Glasgow
N Glasgow
East Ren
SE Glasgow
Overall
Stroke
% (95% ci)
75.0 (72.4 to 77.4)
71.4 (69.4 to 73.3)
70.2 (68.5 to 71.8)
65.0 (63.1 to 66.9)
65.0 (63.5 to 66.6)
60.6 (58.5 to 62.8)
56.9 (54.1 to 59.7)
56.9 (55.0 to 58.7)
70.9 (70.2 to 71.6)
III: Clinical service delivery & key outcomes
3.1: Coronary Heart Disease
Of the 44,635 patients on the disease register, 7,867 (17.6%) were exception coded.
Results presented from this point onwards relate to the remaining 36,768 patients.
20,839 (57%) were male and 15,929 (43%) female. Women were, on average,
slightly older (mean age 73.6 years) than men (mean age 69.5 years). Ethnicity
information was available in 29,822 (81%) of patients. Overall, 28,844 (96.7%) were
white (Table 2)
Table 2: Non-exception coded CHD patients, by ethnic subgroup
Ethnic subgroup
White
South Asian
Black
Chinese
Other ethnic subgroups
TOTAL (known ethnicity)
Number (%)
28,844 (96.7%)
746 (2.5%)
21 (0.07%)
12 (0.04%)
150 (0.5%)
29,822 (100%)
There were significant variations across GG&C in the ethnic composition of the CHD
register; non-white patients represented a very small minority (0.7%) of CHD patients
in West Dunbartonshire, but 10.3% in SE Glasgow (Figure 7). In SE Glasgow, nonwhite subgroups were virtually all South Asian, whereas North Glasgow, Inverclyde
and West Dunbartonshire were more diverse.
Figure 7: Spatial variations in ethnic distribution of diagnosed CHD patients
Ethnic distribution within non-white subgroup
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Other
Chinese
Black
South Asian
The patient’s postcode of residence was known in 34244 (93%), allowing estimation
of small area deprivation. The vast majority of GG&C’s CHD patients live in highly
deprived areas, with an inverse relationship between age and deprivation (Figure 8).
Figure 8: Mean age by SIMD deprivation quintile of diagnosed CHD patients
73.0
16,000
72.0
14,000
71.0
12,000
10,000
70.0
8,000
69.0
6,000
68.0
4,000
67.0
2,000
0
Number
Mean age
1 (Most
deprived)
2
3
4
5 (Least
deprived)
15,701
6,971
4,100
3,967
3,505
68.5
70.7
71.1
71.6
72.0
8
66.0
Mean age (years)
Pts on disease register
18,000
Cholesterol monitoring: 27,766 (76%) patients had total cholesterol recorded in the
past year, of whom 20,187 values were considered to be valid (2-15 mmol/l). Of
these, 15,706 (78%) met the target cholesterol value (<5 mmol/l). There was
considerable variation by CHCP in the proportion of patients monitored, ranging from
63% in SE Glasgow to 88% in SW Glasgow, however the proportion of patients who
met the target cholesterol value was similar across the system (Figure 9).
Figure 9: Cholesterol monitoring activity & outcomes in CHD patients, by CHCP
7000
100.0
90.0
80.0
5000
70.0
4000
60.0
50.0
3000
40.0
2000
30.0
20.0
1000
0
% pts
Number of pts
6000
10.0
SW
Glasgow
W
Glasgow
N
Glasgow
West Dun
E
Glasgow
East Dun
East Ren
Inverclyde
SE
Glasgow
Patients
3380
4318
3000
3568
6183
3634
1757
3704
4563
Recorded
2964
3544
2414
2708
4683
2751
1251
2520
2851
Useable
2091
2632
2216
1934
3542
1444
1088
1137
2323
Healthy range
1609
2067
1697
1474
2731
1139
887
896
1799
% healthy range
76.9
78.5
76.6
76.2
77.1
78.9
81.5
78.8
77.4
% recorded
87.7
82.1
80.5
75.9
75.7
75.7
71.2
68.0
62.5
0.0
Support with stopping smoking: 30,988 (84%) patients had smoking status
recorded in the past year. Overall, 7,476 (24%) of CHD patients were current
smokers; however this ranged from 7.4% in the least deprived areas to 28.5% in the
most deprived (Figure 10).
Figure 10: Smoking in CHD patients, by deprivation quintile
5000
30.0
4500
Pts who smoke
3500
20.0
3000
2500
15.0
2000
10.0
1500
1000
% who smoke
25.0
4000
5.0
500
0
1 (Most
deprived)
2
Smokers
4479
1438
% CHD pts who smoke
28.5
20.6
4
5 (Least
deprived)
611
421
261
14.9
10.6
7.4
3
0.0
The proportion of CHD patients in whom smoking status was recorded ranged from
69% in SE Glasgow to 96% in SW Glasgow (Figure 11, overleaf). Around one third of
smokers were recorded as wanting to stop, although again this varied from 17% in
Inverclyde to 42% in North Glasgow. The proportion of all smokers referred to
smoking cessation services ranged from 13% in Inverclyde to 61% in East
9
Renfrewshire; in four CHCPs, the number of smokers referred to smoking cessation
services exceeded those wanting to stop.
1800
100.0
1600
90.0
1400
80.0
70.0
1200
%
Number
Figure 11: Documented support to CHD patients who smoke, by CHCP
60.0
1000
50.0
800
40.0
600
30.0
400
20.0
200
10.0
0
E
Glasgow
W
Glasgow
SW
Glasgow
N
Glasgow
Current smokers
1655
1065
921
815
781
Want to stop
605
380
323
343
225
Referred smoking cessation
717
530
366
214
% status recorded
84.2
92.7
95.7
% smokers referred
43.3
49.8
% who want stop
36.6
35.7
0.0
SE
Glasgow
East Dun
East Ren
616
576
422
140
107
165
105
57
162
80
94
65
85
84.9
91.0
73.5
68.5
88.2
86.2
39.7
26.3
20.7
13.0
16.3
15.4
60.7
35.1
42.1
28.8
17.4
28.6
24.8
40.7
West Dun Inverclyde
Recording of Body Mass Index (BMI): 23,940 (65%) patients had a BMI recorded
in the past year. Of these, 2,236 (9.3%) were excluded from the analyses as their
BMI fell outside a plausible range of 10-150. Of the remainder, the mean BMI was
28.5 and only 5,575 (26%) CHD patients were of healthy weight (BMI 18.5 – 25); this
proportion decreased from 20 to 14% with increasing deprivation (Table 3).
Table 3: Proportion (%) CHD patients with healthy weight
SIMD Quintile
1 Most deprived
2
3
4
5 Least deprived
TOTAL (known postcode)
Number (%)
2228 (14.2%)
1114 (16.0%)
576 (14.0%)
684 (17.2%)
686 (19.6%)
5,288 (100%
Figure 12: BMI in CHD patients, by CHCP
90.0
80.0
% CHD patients
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
East Ren
East Dun
SE
Glasgow
W
Glasgow
SW
Glasgow
E
Glasgow
% healthy BMI
30.4
30.1
28.1
27.1
25.3
24.2
23.7
23.0
22.4
% recorded
72.3
72.8
53.5
73.1
78.7
70.3
63.3
40.3
61.4
10
West Dun Inverclyde
N
Glasgow
Assessment of mental health: Assessment of patients’ mental wellbeing, using
HADS scoring for anxiety and depression, is an important component of the annual
review. Valid reasons for excluding patients from this component of the review
include ongoing psychological care, receipt of psychoactive medication or
unsuitability for HADS scoring. During 2008/2009, 9,501 (25.8%) CHD patients were
excluded for one of these reasons. Of those eligible, 12,873 patients (47%) had a
recorded HADS score for anxiety and 12,825 (47%) for depression.
Figure 14: % Eligible patients assessed for anxiety & depression, by CHCP
100.0
% patients with recorded HADS
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
East Ren
East Dun
W
Glasgow
SW
Glasgow
West Dun
E
Glasgow
N
Glasgow
SE
Glasgow
Inverclyde
% recorded (anxiety)
46.3
40.6
37.3
35.4
33.6
27.3
22.9
19.8
8.4
% recorded (depression)
46.6
40.9
38.1
36.2
34.1
27.6
23.0
20.6
8.2
Of the eligible patients with valid values, 514 (4%) had HADS scores suggesting
significant anxiety (>12) and 263 (2%) had equivalent scores for depression.
A substantial number of patients were reported to have declined HADS; 1,488 (12%)
for anxiety and 1,475 (12%) for depression. Conversely, 41% of the patients
excepted from HADS actually did have scoring performed (3,923 for anxiety and
3,937 for depression). There was some variation in these proportions across CHCPs,
particularly in the proportions reported to have declined HADS (Figure 15).
Figure 15: HADS scores for depression in CHD patients, by CHCP
11
Finally, there was a strong association between residential deprivation and poor
mental health, as evidenced by HADS scores over 12 (Figure 16).
Figure 16: % patients with significant anxiety & depression, by SIMD quintile
3.2: Stroke
Of the 19,952 patients on the disease register, 4,653 (30.4%) were exception coded.
Results presented below relate to the remaining 15,299 patients. 7,557 (49%) were
male and 7,742 (51%) female. Women were, on average, slightly older (mean age
73.4 years) than men (mean age 70.8 years). Ethnicity information was available in
12,543 (82%) of patients. Overall, 12,219 (97.2%) were white (Table 4)
Table 4: Non-exception coded stroke patients, by ethnic subgroup
Ethnic subgroup
White
South Asian
Black
Chinese
Other ethnic subgroups
TOTAL (known ethnicity)
Number (%)
12,219 (97.2%)
227 (1.8%)
10 (0.08%)
39 (0.3%)
48 (0.4%)
12,543 (100%)
As with CHD, there were significant variations across GG&C in the ethnic
composition of the stroke register (Figure 17)
Figure 17: Spatial variations in ethnic distribution of diagnosed stroke patients
100%
% White
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
90%
GG&C average=97.2%
80%
70%
60%
50%
40%
30%
Chinese
20%
Black
10%
South Asian
0%
12
Other
The patient’s postcode of residence was known in 14,675 (96%) patients, allowing
estimation of small area deprivation. The vast majority of GG&C’s stroke patients live
in highly deprived areas, with an inverse relationship between age and deprivation
(Figure 18).
Figure 18: Mean age by SIMD deprivation quintile of diagnosed stroke patients
Cholesterol monitoring: 11,093 (73%) patients had total cholesterol recorded in the
past year, of whom 8,530 values were considered to be valid (2-15 mmol/l). Of these,
6,323 (74%) met the target cholesterol value (<5 mmol/l). There was considerable
variation by CHCP in the proportion of patients monitored, ranging from 58% in SE
Glasgow to 85% in SW Glasgow, however the proportion of patients who met the
target cholesterol value was similar across the system (Figure 19).
Figure 19: Cholesterol monitoring & outcomes in stroke patients, by CHCP
Support with stopping smoking: 12,314 (80%) patients had smoking status
recorded in the past year. Overall, 3,361 (27%) of CHD patients were current
smokers; however this ranged from 9% in the least deprived areas to 30% in the
most deprived (Figure 20, overleaf).
13
Figure 20: Smoking in stroke patients, by deprivation quintile
The percentage of patients in whom smoking status was recorded ranged from 62%
in SE Glasgow to 94% in SW Glasgow (Figure 21). The proportion of smokers
recorded as wanting to stop varied from 21% in East Dunbartonshire to 41% in East
Renfrewshire. The proportion referred to smoking cessation services ranged from
13% in SE Glasgow to 61% in East Renfrewshire; in four CHCPs, the number of
smokers referred to smoking cessation services exceeded those wanting to stop.
Figure 21: Documented support to stroke patients who smoke, by CHCP
Recording of Body Mass Index (BMI): 9,463 (62%) patients had a BMI recorded in
the past year. Of these, 842 (8.9%) were excluded from the analyses as their BMI fell
outside a plausible range of 10-150. Of the remainder, the mean BMI was 27.7 and
only 2,734 (31.6%) of stroke patients were of healthy weight (BMI 18.5 – 25),
decreasing from 24 to 16% with increasing deprivation (Table 5).
14
Table 5: Proportion (%) stroke patients with healthy weight
SIMD Quintile
1 Most deprived
2
3
4
5 Least deprived
TOTAL (known postcode)
Number (%)
1,090 (16.4%)
523 (17.6%)
302 (17.7%)
356 (20.0%)
367 (23.6%)
2,734 (100%
Figure 22: BMI in stroke patients, by CHCP
Assessment of mental health: During 2008/2009, 4,262 (27.9%) stroke patients
were excluded from HADS assessment. Of those eligible, 4,908 patients (44.5%)
had a recorded HADS score for anxiety and 4,895 (44.4%) for depression.
Figure 23: % Eligible stroke pts assessed for anxiety & depression, by CHCP
Of the eligible patients with valid values, 203 (4%) had HADS scores suggesting
significant anxiety (>12) and 117 (2%) had equivalent scores for depression.
15
A substantial number of patients were reported to have declined HADS; 678 (13.8%)
for anxiety and 670 (13.7%) for depression. Conversely, 40% of the patients
excepted from HADS actually did have scoring performed (1,707 for anxiety and
1,693 for depression). There was some variation in these proportions across CHCPs,
particularly in the proportions reported to have declined HADS (Figure 24).
Figure 24: HADS scores for depression in stroke patients, by CHCP
Finally, there was a strong association between residential deprivation and poor
mental health. Figure 25 shows the proportion of stroke patients with HADS scores of
greater than 12.
Figure 25: % patients with significant anxiety & depression, by SIMD quintile
16
3.3: Type 2 Diabetes
Of the 42,152 patients on the disease register, 7,647 (18.1%) were exception coded.
Results presented below relate to the remaining 34,505 patients. 18,780 (54%) were
male and 15,725 (46%) female. Women were, on average, slightly older (mean age
66.1 years) than men (mean age 63.2 years). Ethnicity information was available in
29,966 (87%) of patients. A higher proportion of diabetic patients (8.7%) were of nonwhite ethnic subgroups compared with 2.7 and 3.3 for stroke and CHD respectively
(Table 6).
Table 6: Non-exception coded Type 2 diabetic patients, by ethnic subgroup
Ethnic subgroup
White
South Asian
Black
Chinese
Other ethnic subgroups
TOTAL (known ethnicity)
Number (%)
27,365 (91.3%)
1,939 (6.5%)
127 (0.4%)
197 (0.7%)
535 (1.2%)
29,966 (100%)
In contrast to patients on the CHD and stroke registers, non-white ethnic subgroups
accounted for a substantial proportion of diabetic patients in some CHCPs,
accounting for up to 28% (Figure 26). In some areas, patients of South Asian
ethnicity were clearly predominant, whereas others were more diverse.
Figure 26: Spatial variations in ethnic distribution of diabetic patients
The patient’s postcode of residence was known in 32,996 (96%). In contrast to CHD
and stroke, diabetic patients were less concentrated to GG&C’s most deprived
areas, with only 2.5 years’ difference in mean age between patients resident in the
most deprived areas compared with the most affluent (Figure 27).
Figure 27: Mean age by SIMD deprivation quintile of diabetic patients
17
Cholesterol monitoring: 28,858 (84%) patients had total cholesterol recorded in the
past year, of whom 20,963 (73%) values were considered to be valid (2-15 mmol/l).
Of these, 15,472 (74%) met the target cholesterol value (<5 mmol/l). The proportion
of patients monitored was more consistent across CHCPS compared with the stroke
and CHD patient groups (Figure 28).
Figure 28: Cholesterol monitoring & outcomes in diabetic patients, by CHCP
Support with stopping smoking: 31,452 (91%) patients had smoking status
recorded in the past year. Overall, 6,150 (20%) of diabetic patients were current
smokers; however this ranged from 9.2% in the least deprived areas to 23.8% in the
most deprived (Figure 29).
Figure 29: Smoking in diabetic patients, by deprivation quintile
Recording of smoking status in diabetic patients was more consistent across CHCPs
compared with the other two disease areas (Figure 30, overleaf). The proportion of
smokers recorded as wanting to stop ranged from 38% in East Glasgow to 51% in
East Renfrewshire. The proportion of all smokers referred to smoking cessation
services ranged from 9% in Inverclyde to 64% in East Renfrewshire; in five CHCPs,
18
the number of smokers referred to smoking cessation services exceeded those
wanting to stop.
Figure 30: Support to diabetic patients who smoke, by CHCP
Recording of Body Mass Index (BMI): 27,364 (79%) patients had a BMI recorded
in the past year. Of these, 2,873 (11%) were excluded as their BMI fell outside a
plausible range of 10-150. Of the remainder, the mean BMI was 31.4. Only 3,282
(13%) were of healthy weight, a smaller proportion than the other disease areas, with
little deprivation gradient (Table 7).
Table 7: Proportion (%) diabetic patients with healthy weight
SIMD Quintile
1 Most deprived
2
3
4
5 Least deprived
TOTAL (known postcode)
Number (%)
1,231 (12.4%)
666 (13.5%)
401 (13.3%)
419 (15.0%)
404 (15.3%)
3,282 (100%
Figure 31: BMI in diabetic patients, by CHCP
19
Assessment of mental health: During 2008/2009, 9,169 (27%) diabetic patients
were excluded from HADS assessment. Of those eligible, the proportion with
recorded scores varied enormously across CHCPs (Figure 23). The average for
GG&C as a whole was 38%, for both anxiety and depression assessment.
Figure 23: % Eligible diabetic pts assessed for anxiety & depression, by CHCP
Of the eligible patients with valid values, 432 (3%) had HADS scores suggesting
significant anxiety (>12) and 240 (2%) had equivalent scores for depression. Around
11% of patients were reported to have declined HADS; 1,477 for anxiety and 1,450
for depression. Conversely, 40% of the patients excepted from HADS actually did
have scoring performed (3,684 for anxiety and 3,671 for depression, with variations
between CHCPs (Figure 24).
Figure 24: HADS scores for depression in diabetic patients, by CHCP
20
Finally, in contrast to other disease areas, although there was some association
between residential deprivation and poor mental health, this appeared to be strongly
concentrated in the most deprived areas rather than an overall gradient, suggesting
confounding with other cofactors (Figure 25).
Figure 25: % patients with significant anxiety & depression, by SIMD quintile
Assessment of glycaemic control: During 2008/2009, 22,650 (66%) diabetic
patients had HbA1c measurements, of which 97% had valid values. Of these, 12,074
(55%) were in the target range of <7.5%. Recording was uniform across deprivation
quintiles (Figure 26)
Figure 26: % Recording of HbA1c, by residential deprivation quintile
However, there was some evidence that glycaemic control was poorer among
patients living in more deprived areas (Figure 27, overleaf).
21
Figure 27: % Achievement of HbA1c levels within ‘healthy’ range (<7.5%)
3.4
Discussion points
This paper represents a first step in demonstrating the potential for understanding
variations in the needs and characteristics of patients with chronic disease and in
helping us to understand how our local healthcare system is responding to their
needs. As powerfully demonstrated in each of the sections on clinical service
delivery, there remain enormous health inequalities within our Board area, yet in
several areas there is evidence of considerable progress in achieving more even
distribution of intermediate clinical outcomes (such as cholesterol values) as a result
of the LES programmes. In some areas, there is a clear need to do better, both in
terms of data recording and, possibly to achieve more appropriate referral patterns to
services, such as smoking cessation services.
3.5
Next steps
We would be very grateful for commenst and feedback on the contents of this
document. It is planned to release a series of further thematic issues that will
address:








Local report for North & South Lanarkshire
Multiple morbidity in GG&C
The challenge of overweight & obesity in patients with chronic disease
The challenge of alcohol misuse in patients with chronic disease
Blood pressure management – tackling the ‘rule of halves’ in GG&C
Reducing the prevention gap in chronic disease management
Impact of LES on CVD burden in GG&C
Referral to health improvement services
Finally, although every effort has been made to ensure accuracy of all data, there
may be areas of omission or definitional issues that will be addressed in further
editions as we continue to improve the quality and consistency of data collection,
recording and analysis.
22