‘Dare to compare: reducing unwarranted variation in healthcare’ 1 December 2017

Diabetes complications A/Prof Anthony Russell

Director of Diabetes and Endocrinology, PAH (Julia Connors, Chris Galvin and Robert Seaton, PSQIS)

Second Australian Atlas of Healthcare Variation

What does the data on potentially preventable hospitalisations for Diabetes Complications tell us?

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Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.

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Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.

DC - Top 10 Principal Diagnoses in Qld (as % of episodes)

5 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection (extracted 28/9/2017).

PD ICD name 2012-13 2013-14 2014-15 2015-16

E1173 Type 2 with foot ulcer due to multiple causes 18.8% 17.5% 19.5% 16.6%

E1011 Type 1 with ketoacidosis, without coma 14.6% 15.9% 15.1% 15.8%

E1165 Type 2 with poor control 11.0% 11.2% 10.5% 11.3%

E1164 Type 2 with hypoglycaemia 7.9% 8.3% 7.3% 6.6%

E1065 Type 1 with poor control 4.9% 5.4% 5.2% 4.9%

E109 Type 1 without complication 6.5% 4.5% 4.4% 3.8%

E1064 Type 1 with hypoglycaemia 4.3% 4.7% 4.1% 4.3%

E1151 Type 2 with peripheral angiopathy, without gangrene 2.5% 2.6% 2.7% 3.5%

E1152 Type 2 with peripheral angiopathy, with gangrene 2.5% 2.8% 3.0% 2.9%

E119 Type 2 without complication 2.2% 2.1% 2.2% 1.9%

Total 75.2% 74.9% 74.1% 71.6%

DC - Top 5 PDs over 5 years to 2016-17

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Rat

e R

ank

Area name Episodes

Type 2 w/ foot ulcer due to multiple causes

Type 1 w/ ketoacidosis, w/out coma

Type 2 w/ poor control

Type 2 w/ hypoglycaemia

Type 1 w/ poor control

. Qld statewide 48,602 18.3% 15.6% 10.8% 7.4% 5.1%

1 Far North 752 50.1% 4.5% 10.5% 6.4% 3.5%

2 Outback - North 631 34.7% 4.9% 13.5% 7.4% 1.4%

3 Outback - South 465 16.3% 22.2% 22.6% 3.7% 4.3%

4 Maryborough 863 24.7% 18.9% 10.5% 7.1% 2.7%

5 Tablelands (East) - Kuranda 712 24.0% 17.4% 13.6% 7.6% 5.9%

76 Sunnybank 273 16.5% 13.9% 14.3% 9.5% 4.0%

77 Gold Coast Hinterland 94 14.9% 11.7% 7.4% 11.7% 5.3%

78 Brisbane Inner - West 239 9.2% 14.2% 4.2% 2.5% 3.8%

79 Kenmore - Brookfield - Moggill 208 11.1% 15.4% 10.1% 2.9% 4.8%

80 Sherwood - Indooroopilly 176 14.8% 16.5% 9.1% 6.3% 4.0%

Source: CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).

Source: Australian Commission on Safety and Quality in Health Care (2017), Second Australian Atlas of Healthcare Variation.

Older males are at higher risk of Diabetes PPH

8 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection (extracted 28/9/2017).

0.65 0.55 0.45 0.35 0.25 0.15 0.05 0.05 0.15 0.25 0.35

00-0405-0910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Hospitalisations ('000s)

Female

Male

Age

Diabetes Complications

DC - Indigenous/Distance

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700 Atlas: Diabetes complications 2014/2015 Indigenous rate (LHS) Non-Indigenous rate (LHS) Smoker (current) rate (LHS) Rate w/diabetic complication diagnosis (LHS) Qld statewide rate (LHS) Home-to-treatment distance (RHS)*

Rate/100k persons KMs

*Trimmed mean (removes lowest and highest 5% to reduce skew)

Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld

Source: CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).

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Smoking and BMI

10 Source: *QH Preventive Risk Survey estimates for 2015 & 2016 (confidence intervals omitted), and CED analysis using QHAPDC & ABS population estimates (extracted 28/9/2017).

Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld

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100 Atlas: Diabetes complications 2014/2015

BMI Healthy (LHS)* BMI Overweight (LHS)* BMI Obese (LHS)* Not daily smoker (RHS)*

Percentage Percentage

DC - Mortality/Length of stay/Additional diagnoses

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*Trimmed mean (removes lowest and highest 5% to reduce skew)

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Atlas: Diabetes complications 2014/2015 In-hospital mortality rate (LHS) 30-day all-cause mortality rate (from discharge) (LHS) # of additional diagnoses (RHS)* Length-of-stay (days) (RHS)*

Rate/100k persons Number

11 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection, Death register & ABS population estimates (extracted 28/9/2017).

Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld

DC - Transfers/readmissions/recurrent admissions

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Atlas: Diabetes complications 2014/2015

Rate excluding trfrs/readmits in 30-days (LHS) Rate with trnfr/epis chgs (LHS) 30-day readmission rate (LHS) Qld statewide rate (LHS) % of patients with 2+ admits/year (RHS)

Rate/100k persons Per cent

12 Source: CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).

Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld

DC - MBS GP & Specialist spend/SES

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Atlas: Diabetes complications 2014/2015 MBS GP spend/person (LHS)* MBS Specialist spend/person (LHS)* Socioeconomic status (SEIFA IRSD) (RHS)

Avg $ per person Percentile

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Source: *AIHW Medicare Benefits statistics 2014-15 and CED analysis using Queensland Hospital Admitted Patient Data Collection & ABS population estimates (extracted 28/9/2017).

Note: Rates are per 100,000 people. Rates / rankings differ slightly from 2017 Atlas estimates as QH data reflect updated ABS population estimates and include only Queenslanders treated in Qld

Summary: Factors associated with high PPH • Geographic location – rural and remote with

greater distance from residence to health centre • Increased age and male • Lower socioeconomic status • Increased obesity and smoking rates • Higher readmission rates • Reduced access to specialist care

• Consequences

– Higher in-hospital and post-discharge mortality rates and

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Predictors of preventable hospitalisation

15 Muenchberger H and Kendall E. J Pub Health Policy 2010; 31: 150-163

Potential drivers of variation - Diabetes complications • Prevalence of diabetes & risk factors for Type 2 diabetes, eg smoking,

dialysis, poor glycaemic control • Access (and continuity) to primary health care • Adherence to evidence-based guidelines • Long distance to travel (and isolation) from home to treatment (hospital

admission may be best form of treatment) • Availability of foot clinics, eye clinics & diabetes educators • Integration of hospital and primary care • Frequency of preventive checks in primary care • SES status, health literacy, access to healthy food • Cost and access to medications • Ability & motivation to self-manage diabetes • Clusters of groups with high prevalence of type 2 diabetes, e.g. Indigenous,

Pacific islanders • Access to quality, culturally appropriate care

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Case Study Diabetes complications

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Case Study 1 – Diabetes complications

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• 61 year old male:

– Type 1 diabetes. – No next of kin. – Lives housing commission in Wynnum

• Background: likely mental health issues and a smoker.

• Presents 3/11/17

– found by neighbour – lying naked on front step, confused, covered in text marker with Egyptian hieroglyphics

• Brought to ED – Hypothermic – Tachycardic – Glucose “Hi” – Infected gangrenous foot – Cachectic

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Case Study 1 – Diabetes complications

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• 61 year old male, Type 1 diabetes. No next of kin. Lives housing commission • History: likely schizophrenia. • 3/11/17 - found by neighbour – lying naked on front step, confused, covered in text marker with

Egyptian hieroglyphics • Brought to ED – hypothermic, tachycardic, glucose Hi. Infected gangrenous foot. Cachectic • Issues:

– DKA and acute kidney injury – Sepsis with gangrenous ulcer – Acute myocardial infarction – Delirium

• Progress: – Treatment of DKA – Developed heart failure – Right forefoot amputation under regional block with adult guardian consent – Coronary angiogram and angioplasty to 75% stenosis LAD – Awaiting lower limb angiogram and right BKA as foot not healing

• Issues: Mental health issues, poor self-care, sick-day management and prevention of

DKA, management of the high risk foot to avoid amputation

Case Study 2

• 47yo indigenous Australian male from Boulia

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Case Study 2 • 47yo indigenous Australian male from Boulia (Community health

centre – with RFDS visit fortnightly. Check-up funded annual Endocrinologist visit) – Lives with his sister’s family – Works for the council on roads

• Type 2 diabetes

– On metformin and once daily insulin with poor BGL control (HbA1c-9.8%)

– Sister’s kids take his glucometer – infrequent BGLs – Complicated by peripheral neuropathy (also excess alcohol)

• Chronic neuropathic ulcer on sole of foot which became infected and

required transfer to Mt Isa Hospital for ray amputation. Spent two months in Mt Isa staying with an Aunt until healed

• Issues: Remote, self–care, resources to assist better management

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