+

Diabetic Care at Broadmoor Hospital Dr Alan Cohen FRCGP Dr Ignazio Puzzo

+What I am going to cover

n  Clinical framework for achieving high quality care

n  Organisational framework for achieving high quality care

n  Achieved Health Outcomes

n  Impact for National CQUIN for mental health trusts

+The most important bit…

After 5 years the % of people who have died

+In context…

n  Broadmoor Hospital n  High secure

n  200 patients – all male

n  30 patients have diabetes

n  Ealing Hospital n  Medium and Low secure

n  300 patients of which 70 are women

n  58 patients have diabetes

+What is high quality care?

n  National Diabetic Audit

n  Acute hospitals, and general practice contribute n  Analysed nationally

n  Look at both processes of care, and outcomes (achieving targets)

+Clinical models of care

Ealing Broadmoor

Virtual W/R OP clinic

Consultant X X

Specialist diabetic nurse X

GP X

Trust employed diabetic practice nurse

X X

Dietitian X

Pharmacy X

Exercise X

+Organisational Framework

n  Clear and shared clinical aim n  “to deliver the same clinical outcomes that would be achievable

in the community if the patient did not have a severe mental illness”

n  An IT system that worked n  EMIS Web

n  SystmOne

n  Applying reasonable, evidence based interventions n  NICE guidelines

n  Leadership

+Diabetic processes and outcomes

+Diabetic Targets

n  HbA1c n  <48 (<6.5%) Good control

n  <58 (<7.5%) Moderate control

n  <86 (<10%) Poor control

n  Cholesterol n  <4.0

n  Blood pressure n  <140/80

n  BMI

+Diabetic processes and outcomes

+Comparison between Ealing and Broadmoor (males)

Ealing (mean)

Broadmoor (mean)

Stat sig

BMI 33.82 35.89 n.s.

Diastolic blood pressure 81.21 83.24 n.s.

Systolic blood pressure 121.37 123.21 n.s.

HbA1c 52.44 63.93 <0.05

Creatinine 85.83 83.62 n.s.

Cholesterol 3.88 4.17 n.s.

+Comparison between Males and Females (Ealing)

Females (mean)

Males (mean)

Stat sig

BMI 38.64 33.81 <0.05

Diastolic blood pressure 75.83 81.21 <0.05

Systolic blood pressure 115.72 121.37 n.s.

HbA1c 50.44 52.44 n.s.

Creatinine 74.56 85.83 <0.05

Cholesterol 3.89 3.88 n.s.

+Comparison to National Data

Ealing (%)

Broadmoor (%)

National (%)

BP <150/90 94 75 91

BP <140/80 41.4 36.7 78

Cholesterol <5 86.2 70 81

Recorded ACR 94.9 90.3 86

HbA1c <59 52 26.7 70

HbA1c <64 79 46.7 77

HbA1c <75 96 76.7 86

Retinal screening 64 66 90

Foot examination 83 86 89

Dietary review 100 76 89

Educational Programme 100 76 95

+Unfinished work

n  The results seem to indicate that HbA1c control is not as good at Broadmoor as it is at Ealing

n  Could this be due to medication?

n  Data for comparing diabetogenic complications of anti-psychotic medication is difficult (impossible) to elicit

+National CQUIN

n  Extracting this data took less than two minutes

n  Benefits of an effective IT system are overwhelming

n  Costs of an effective IT system ( in comparison to the value of one years CQUIN) is less than 10%

n  The National CQUIN needs to move away from processes of care, towards outcome based care – as exemplified by the NDA

Thank you

doctoralancohen@me.com