Over 70,000 people in Bedfordshire, Luton and Milton Keynes (BLMK) are living with diabetes. To help improve quality of life for patients and reduce adverse outcomes, clinicians needed a tool to help them improve care delivery and identify unmet need. BLMK ICB and NHS Arden & GEM’s advanced analytics unit have co-developed a diabetes early warning system (EWS) which is enabling proactive, personalised interventions within primary and community care.
The challenge
Nearly 6.5% of the BLMK population has been diagnosed with diabetes, with a significant proportion from ethnic minority backgrounds and residing in high-deprivation areas. Studies show that proactive completion of eight care process checks including HbA1c blood tests, blood pressure and kidney function, reduces mortality, improves quality of life and reduces adverse outcomes. However, completion of these processes varied among practices and in 2022/23, only 57% of patients across BLMK had received all eight checks.
Existing sources of patient data (the national diabetes audit and clinical systems) provided limited functionality to support effective monitoring. In creating the diabetes EWS, BLMK ICB wanted to take a holistic approach, using population health management data to create a comprehensive system that would enable targeted interventions based on need, and provide benchmarking data to support commissioners. This meant bringing together multiple data sets that would support more efficient working for clinicians and better outcomes for patients.
A collaborative approach
In scoping the development of an EWS, the ICB outlined a number of aims which included:
- Being able to identify people with diabetes using key clinical indicators e.g. HbA1c, blood pressure, outstanding care processes, A&E attendances
- Identifying cohorts with unmet clinical need and taking action accordingly
- Selecting patients for further investigation and review, based on NICE guidelines
- Investigating health inequalities in care delivery and outcomes
- Enabling the ICB and PCNs to undertake benchmarking and strategic planning.
From the outset, this was a collaborative project, with widespread engagement across primary and specialist care, to build ownership and investment in the project across the system. A dedicated project group met fortnightly and included participants from primary and specialist care, ICS partner organisations and the ICB.
Tapping into the ICS’s existing ‘super user group’ enabled the project team to seek broader input, which consequently led to a more comprehensive and effective solution. This group included directors, partners and specialists from primary care, specialist clinicians and those working with PCNs and practices, as well as ICB staff working in commissioning, clinical and quality assurance, and population health management.
Data-driven activity
The diabetes EWS brings together over 16 million records, spanning three years, covering events for BLMK diabetes patients. Sources include:
- Acute, emergency, community and mental and primary care health data
- Johns Hopkins risk stratification tool outputs
- Population segmentation from Arden & GEM’s SMITH model
- An enhanced version of QOF indicators
- Clinical markers for unacceptable risk levels (as define by clinicians)
- QRISK scores.
The EWS enables practices to proactively monitor care process completion and diagnostic data updates, correlating this with other elements such as prescribing and hospital attendance.
A case-finding tool helps clinicians easily identify and better understand who could benefit from immediate attention. Users can interrogate the data to produce a prioritised list of patients for proactive intervention based on bespoke parameters e.g. by age group. Individual patient records can be selected to view longitudinal clinical and event information, including risk scoring and historic admission information.
Role-based data access
To deliver the benefits intended for individual patients, clinical users with appropriate access can reidentify patients from aggregate data. Access to personal confidential data (PCD) has been authorised by individual GP practice Caldicott Guardians/IG leads for records of patients within a named practice. Additional approvals, including primary care network (PCN) clinical directors and ICB SIROs, are in place where staff, such as those working in the Bedfordshire integrated community diabetes service, need access to PCD across multiple practices.
Non-clinical stakeholders have access to aggregate benchmarking and summary views for the entire ICB. The summary view at a PCN and practice level shows prevalence levels and recent diagnosis figures. This insight supports referrals to structured education programmes as well as identifying gaps in care.
Outcomes
The EWS is enabling clinicians to shift from reactive to proactive care, by making it easier to identify and prioritise patients requiring additional care, leading to earlier, more effective interventions and improved outcomes. The risk stratification tool is helping to identify patients at risk of hospitalisation, leading to targeted interventions which will in turn lead to a subsequent decrease in hospital admissions.
Clinicians are using the case finding feature to implement more timely and effective interventions including lifestyle programmes, pharmacological interventions or structured education, depending on individual needs.
‘What we’re able to do with the diabetes EWS is truly proactive working. We can quickly and easily identify issues or opportunities, and then introduce proactive streams of work to improve adherence and overall care quality for patients. I am very excited about the potential of this tool,’ said Julia Pledger, consultant diabetes nurse in the integrated community diabetes service for Bedfordshire.
Access to timely, relevant, and well-presented information is also supporting staff to streamline processes and improve access which reduces the strain on an incredibly stretched workforce. Furthermore, the collaborative approach and input from multiple stakeholders has led to a more holistic approach to patient care.
We are now using the learning from this project to develop an EWS for COPD, with scoping underway for further projects to support other long term conditions.
Prasanth Peddaayyavarla is head of data science at NHS Arden & GEM, and Buz Dodd is associate director of strategy & planning at Bedfordshire, Luton and Milton Keynes ICB
