Targets and variations: How does it all fit together?

I have recently looked at some reports which have made me think about how target-driven we are, how some of these targets don’t always match up, and how confusing this whole ‘diabetes and target’ issue must be for the lay person with diabetes. The National Service Framework for Diabetes (NSF; Department of Health, 2001) talks of empowerment for people with diabetes; sometimes I think that we healthcare professionals also need guidance to best help our patients.

The Quality and Outcomes Framework
The new General Medical Services (nGMS) contract (British Medical Association, 2003) has completed its first year and all primary care practices will know how well they fared in treating patients with a variety of long-term conditions, including diabetes. Assessment of services is made using the Quality and Outcomes Framework (QOF); points are accrued for recording clinical and other markers against given criteria. Other conditions are addressed by the QOF but, for most of us, diabetes will be of prime interest. 

The results (e.g. Health and Social Care Information Service [HSCIC], 2005a for results in England), when viewed nationally, show a mixed picture. Some practices achieved the maximum amount of points it is possible to score in diabetes care, thereby securing 18% of the available funding for their practice. Other practices were not so successful. QOF data did, however, supply prevalence figures with a national figure of 3.3% in England; at last a fairly accurate baseline.

In the QOF data, regional variations were also shown in the rates for complications such as coronary heart disease and stroke. If these variations are a result of poor recording or coding, inaccurate data will make it difficult for problems to be identified and good programmes of care to be implemented and shared across communities.

The National Diabetes Audit
Another recent report, the National Diabetes Audit (HSCIC, 2005b), also showed some interesting data: only 56% of patients in England achieved an HbA_1c level of 7.5% or less, and only 21% achieved a blood pressure of 135/75 mmHg or less. Here lies one of the confounding factors – the nGMS, in contrast, aims for an HbA_1c of 7.4% or less (although there are points if a certain number of patients achieve an HbA_1c of less than 10%) and a blood pressure of 145/85 mmHg. If the targets had been matched between the National Diabetes Audit and the nGMS, would there have been a better result? 

Pre-pregnancy care
Another report that caught my attention was Pregnancy In Women With Type 1 And Type 2 Diabetes 2002–2003 from the Confidential Enquiry into Maternal and Child Health (2005). One disturbing, but not unexpected, issue for me was the poor uptake of pre-pregnancy care by women with both type 1 and type 2 diabetes. According to the report, only 35% of women attended pre-conception counselling. The study also showed that the perinatal mortality rate of babies of mothers with type 2 diabetes was as high as that of the babies of mothers with type 1 diabetes. Again, this report showed variations regionally and states that:

‘The regions in which the prevalence of type 2 diabetes in pregnancy is high do not necessarily coincide with the regions in which diabetes is most prevalent overall.’

Many women with type 2 diabetes are managed in primary care, and we must ensure that all healthcare professionals, but especially those working in primary care, are aware of the needs of women with type 2 diabetes, especially if they are planning a pregnancy. 

Conclusion
These reports have raised my awareness of the regional variations that exist in diabetes services and the differences that exist in the targets we are all striving to achieve with our patients. They also highlight the continued hard work of everyone working within diabetes care to try to achieve the NSF Standards.