# National Diabetes Insulin Pump Audit, 2016-2017 England And Wales

Prepared in collaboration with:
The Healthcare Quality Improvement Partnership (HQIP). The National Diabetes Audit 
(NDA) is part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) 
which is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England. HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the NCAPOP Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.

NHS Digital is the trading name for the Health and Social Care Information Centre 
(HSCIC). NHS Digital managed the publication of the 2016-17 annual report.

Diabetes UK is the charity leading the fight against the most devastating and fastest growing health crisis of our time, creating a world where diabetes can do no harm.

Supported by:
The National Cardiovascular Intelligence Network (NCVIN) is a partnership of leading national cardiovascular organisations which analyses information and data and turns it into meaningful timely health intelligence for commissioners, policy makers, clinicians and health professionals to improve services and outcomes.

## Introduction

The Insulin Pump Audit collects information on the number and characteristics of people with diabetes using an insulin pump, the reasons for going on an insulin pump and the outcomes achieved since starting the pump. The guidance states that Continuous Subcutaneous Insulin Infusion (CSII) or 
'insulin pump' therapy is recommended as a treatment option for adults, and children 12 years and over, with Type 1 diabetes mellitus if:

- attempts to reach target haemoglobin A1c (HbA1c) levels with multiple 
daily injections result in the person having 'disabling hypoglycaemia', 
or
- HbA1c levels have remained high (69mmol, 8.5%, or above) with 
multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to 
manage their diabetes.
CSII therapy is not recommended as treatment for people with Type 2 diabetes mellitus.

## Key Findings

•
Improved participation and data quality means that the report this year is more comprehensive and clinically useful. 
•
The rate at which people with Type 1 diabetes are starting pump 
treatment has stabilised.
•
The proportion of people with Type 1 diabetes attending specialist 
services that are treated with pumps varies from >40% to <5%.
•
Between two thirds and three quarters of pump users are recorded 
as achieving their pump treatment goals.
•
Nine out of ten people reached their target goal for hypoglycaemia.
•
Seven out of ten people reached their target goal for glucose control.
•
Despite being a younger cohort, Type 1 diabetes pump users more often achieve all their treatment targets, and on average have a lower HbA1c, than their non-pump using peers.

## Recommendations

•
The variation in provision and apparent benefit suggests that 
more people with Type 1 diabetes should be considered for pump treatment in line with NICE guidance.
- **Who**: all services delivering Type 1 diabetes care.
- **What**: offer pump therapy to all people with Type 1 diabetes who meet 
NICE criteria.
- **Where/when**: during annual, or more frequent, review with named 
doctor or nurse.
•
The ten fold variation between specialist centres in pump use by people with Type 1 diabetes suggests a lack of access for patients attending some services and should be investigated.
- **Who**: all specialist services and commissioners.
- **What**: consider whether there is adequate understanding, capacity and 
capability to explain and provide pump treatment.
- **Where/when**: during National Diabetes Audit review and action 
planning.

## 1. Participation And Data Quality Participation

More centres have participated in the insulin pump component of the NDA for 2016-17.

Number of units participating
2013-2014
2014-2015
2015-2016
2016-17
England
England
England
Wales1
England
Wales1
Insulin pump and NDA
29
64
69
N/A
55
N/A
Insulin pump only
2
2
0
14
18
15
NDA only
46
30
29
N/A
26
N/A

1. Wales specialist services were permitted to submit only pump patients due to  near 100% GP practice participation in Wales. The records were matched to the primary care submissions from Wales; the rest of this report will report by Local Health Board (LHB)  for Wales instead of by specialist organisation.

## Data Quality

Data for 2016-17 was more comprehensive, and overall the data quality has improved.

| England             | Wales     | England   | Wales     |
|---------------------|-----------|-----------|-----------|
| 2015-2016           | 2015-2016 | 2016-2017 | 2016-2017 |
| No. of              | %         | No. of    | No. of    |
| Data Field          |           |           |           |
| No. of              |           |           |           |
| Responses           | People    | Complete  | Responses |
| Reason for starting |           |           |           |
| pump                |           |           |           |
| Hypoglycaemia       |           |           |           |
| Reduction           |           |           |           |
| 5,615               | 9,183     | 61.1      | 904       |
| 7,020               | 9,770     | 71.9      | 1,055     |
| Glucose Control     |           |           |           |
| 5,668               | 9,183     | 61.7      | 903       |
| 7,000               | 9,770     | 71.6      | 1,055     |
| Other               |           |           |           |
| 5,211               | 9,183     | 56.7      | 904       |
| 6,155               | 9,770     | 63.0      | 1,055     |
| Treatment Goals     |           |           |           |
| 1                   |           |           |           |
| Hypoglycaemia       |           |           |           |
| Reduction           |           |           |           |
| 4,636               | 9,183     | 50.5      | 55        |
| 4,435               | 9,770     | 45.4      | 460       |
| Glucose Control     |           |           |           |
| 4,636               | 9,183     | 50.5      | 55        |
| 4,510               | 9,770     | 46.2      | 540       |
| Year started using  |           |           |           |
| pump                |           |           |           |
| 8,575               | 9,183     | 93.4      | 872       |
| 9,030               | 9,770     | 92.4      | 1,035     |

## 2. Demographics Of People On Pump Diabetes Type Of People On Pump

A small number of people using insulin pumps are still recorded as having Type 2 diabetes.

## Age Of Adults On Pump

Pump treatment is more often seen among younger people with Type 1 diabetes.

This report is for people attending adult clinics. The National Paediatric Diabetes Audit  is the source for information on people attending paediatric clinics. 

## Sex Of People On Pump

Nearly twice as many women with Type 1 diabetes use an insulin pump compared to men, though overall there are more males with Type 1 diabetes in the population.

## Sex And Age Of People On Pump

Female pump users outnumber males in all age groups, except 70 to 
79 years where the split is equal. The difference is most marked in the 
30 to 39 years age group.

## Deprivation And People On Pumps

The number of people using pumps decreases with increasing levels of deprivation.

3. Prevalence of insulin 
pump use in people with 
Type 1 diabetes

## Proportion Of People On Pump

The proportions of patients attending specialist Type 1 diabetes services that use pumps varies tenfold. The apparent difference between England and Wales is likely due to differences in submission. For England, the denominator is the number of people with Type 1 diabetes attending the participating centres. For Wales, it is the total number of people with Type 1 diabetes in the LHB.

1 The two trusts reporting 100% of patients using insulin pumps have been excluded from this graph. 

## Proportion Of People On Pump

The apparent difference between England and Wales is likely to be due to submission arrangements. For England, the percentage is of those people with Type 1 diabetes being treated in a specialist service that participated in the pump audit. For Wales, the percentage is of all people with Type 1 diabetes in the local population, as pump information is submitted by Local Health Boards.

## Year Started On Pump

The rate of pump uptake increased steadily until 2012 and has stabilised since. 

## 4. Reason For Starting On Insulin Pump Therapy Reason For Starting Pump Therapy

It is important to note the poorer data completeness for England than for Wales. A similar proportion of people in both England and Wales are recorded with hypoglycaemia as a reason for moving to pump treatment. In Wales a greater proportion are recorded with glucose lowering as a reason.

## 5. Achievement Of Treatment Goals Treatment Goal - Hypoglycaemia

Treatment goal achievement is not a mandatory field in the collection. It is important to consider data completeness for this, even though it has considerably improved for Wales this year. Within the limitations of the data, around nine out of ten people on insulin pump reach their target goal for hypoglycaemia.  

## Treatment Goal - Glucose Control

Treatment goal achievement is not a mandatory field in the collection. It is important to consider data completeness for this, even though it has considerably improved for Wales this year. Within the limitations of the data, around seven out of ten people on insulin pump reach their target goal for glucose control.  

## 6. Care Process Completion Care Processes

All people with diabetes aged 12 years and over should receive all of the nine, NICE recommended care processes1,2 and attend a structured education programme when diagnosed.

## Nine Annual Care Processes For All People With Diabetes Aged 12 And Over

Responsibility of diabetes care providers (included in the NDA 8 Care Processes)
1 - HbA1c
(blood test for glucose control)
2 - Blood Pressure 
(measurement for cardiovascular risk)
3 - Serum Cholesterol 
(blood test for cardiovascular risk)
4 - Serum Creatinine 
(blood test for kidney function)

## Responsibility Of Nhs Diabetes Eye Screening (Nhs England, Public Health England) (The Screening Registers Are Drawn From Practice Registers But The Outcomes Are Recorded In Screening Management Systems That Presently Cannot Export Data To The Nda)

5 - Urine Albumin/Creatinine Ratio 
(urine test for kidney function)
6 - Foot Risk Surveillance 
(foot examination for foot ulcer risk)
7 - Body Mass Index
(measurement for cardiovascular risk)
8 - Smoking History
(question for cardiovascular risk)

## Care Processes

Care process completion in England is similar between people with Type 1 using, and people with Type 1 not using, an insulin pump. In Wales, care process completion is generally worse in pump users.

care processes by care process, for those on insulin pump and those not on an 
|                      | England       | Wales        |
|----------------------|---------------|--------------|
| People  on an        | People  on an | People       |
| not                  |               |              |
| on an                | People        |              |
| not                  |               |              |
| on an                |               |              |
| insulin pump         | insulin pump  | insulin pump |
| HbA1c                |               |              |
| 93.0                 | 90.9          | 74.5         |
| Blood pressure       |               |              |
| 93.1                 | 91.9          | 90.3         |
| Cholesterol          |               |              |
| 85.6                 | 85.3          | 64.3         |
| Serum creatinine     |               |              |
| 91.2                 | 89.9          | 71.9         |
| Urine albumin        |               |              |
| 64.9                 | 62.6          | 32.7         |
| Foot surveillance    |               |              |
| 72.2                 | 72.7          | 55.6         |
| BMI                  |               |              |
| 83.4                 | 83.4          | 70.4         |
| Smoking              |               |              |
| 82.6                 | 83.8          | 68.4         |
| Eight care processes |               |              |
| 3                    |               |              |
| 42.2                 | 42.9          | 18.4         |

## 7. Treatment Target Achievement Treatment Targets

NICE recommends treatment targets for HbA1c (glucose control), blood pressure and serum cholesterol:

•
Target HbA1c reduces the risk of all diabetic complications.
•
Target blood pressure reduces the risk of vascular complications and 
reduces the progression of eye disease and kidney failure.
•
Target cholesterol* reduces the risk of vascular complications.

## Treatment Targets

All three treatment targets are more often achieved in people with Type 1 diabetes using an insulin pump. Figures have not been adjusted for age, although the age profile of people on insulin pumps is lower than for those not on a pump, and overall younger people are less likely to achieve the treatment targets1.

England and Wales
England
Wales
People  on an 
People  on an 
People not on an 
People not on an 
insulin pump
insulin pump
insulin pump
insulin pump
HbA1c < 58 mmol/mol
34.7
29.0
35.9
26.0
Blood Pressure < 140/80
73.1
70.7
73.3
73.3
Cholesterol < 5mmol/L
70.5
69.5
69.0
67.9
Meeting all three treatment targets
20.3
16.4
19.1
15.2

## Treatment Targets - Mean Hba1C

Mean HbA1c is lower for Type 1 patients treated with an insulin pump. Analysis for the first Insulin Pump Audit looked at the change in HbA1c after starting pump therapy: https://digital.nhs.uk/catalogue/PUB20436. 

## 8. Methodology Methodology

•
The National Diabetes Insulin Pump Audit supplements the core National Diabetes Audit. 
•
During the NDA collection window, the insulin pump data were collected 
alongside the NDA care processes and treatment target data. The local 
insulin pump teams were required to liaise with their wider diabetes teams and clinical audit/information departments to ensure that the correct information was submitted for all of their diabetes patients, not 
just insulin pump patients.
•
Welsh specialist services were allowed to submit only pump data, as 
100% GP practice participation in Wales should ensure that all other data for the patients were collected. However, this meant that for Wales comparisons are at Local Health Board level, whereas for England comparisons are at specialist service level. 
•
Within the proforma, the reason the person is on pump and the year 
pump was started, were mandatory fields. Achievement of treatment goals was optional. 
•
Pump data was linked to the core NDA data for all patients. For details of the NDA data please see the latest annual report: 
www.digital.nhs.uk/pubs/ndauditcorerep1617.

## 9. Definitions, Footnotes, Data Sources And Further Reading Definitions Diabetes

Diabetes is a condition where the amount of glucose in the blood is too high because the pancreas doesn't produce enough insulin.  Insulin is a hormone produced by the pancreas that allows glucose to be used as a body fuel and other nutrients to be used as building blocks. There are two main types of diabetes: Type 1 diabetes (no insulin); Type 2 diabetes (insufficient insulin)

## Care Processes (Nice Recommends All Of These At Least Once A Year)

Blood Pressure is a measurement of the force driving the blood through the arteries. Blood pressure readings contain two figures, e.g.130/80. The first is known as the systolic pressure which is produced when the heart contracts. The second is the diastolic pressure which is when the heart relaxes to refill with blood.

BMI measurement - Body Mass Index calculated from weight and height to classify under, normal and over-weight Serum creatinine - this blood test is used as a measure of kidney function Urinary albumin - this urine test detects the earliest stages of kidney disease Cholesterol - this blood test measures a type of fat that can damage blood vessels Foot check - this examination checks the blood supply and sensation (feeling) in the feet. Loss of either is a risk for foot disease Smoking Status - this records whether the person is a smoker. Smoking increases the diabetic risk for heart attacks and stroke HbA1c - this is a blood test for average blood glucose levels during the previous two to three months.

## Definitions Treatment Targets (Nice Defines Target Levels To Reduce Risks Of Complications For People With Diabetes) Hba1C - The Closer This Is To Normal (Less Than 42Mmol/Mol) The Lower Is The Risk Of All Long Term Complications Of Diabetes Cholesterol - Reducing Cholesterol Levels Lowers The Risk Of Heart Attacks And Strokes Blood Pressure - High Levels Are A Risk For Heart Attacks And Strokes; They Also Drive Progression Of Eye And Kidney Disease Specialist Service

This is a service (often hospital based but sometimes delivered in a community setting) which includes diabetes specialists working in multidisciplinary teams. These teams usually comprise physicians (Diabetologists), Diabetes Specialist nurses and dieticians; it may also include clinical psychologists.

## Insulin Pump Therapy

Insulin pumps are portable devices attached to the body that continuously deliver amounts of rapid or short acting insulin via a catheter placed under the skin. Insulin pump therapy is also referred to as continuous subcutaneous insulin infusion therapy.

## Footnotes

1.
NICE recommended care processes http://www.nice.org.uk/guidance/conditions-anddiseases/diabetes-and-other-endocrinal--nutritional-and-metabolic-conditions/diabetes
2.
National Service Framework (NSF) for Diabetes https://www.gov.uk/government/publications/national-service-framework-diabetes NICE Clinical Guidelines - NG17: Type 1 diabetes in adults: diagnosis and management 
http://www.nice.org.uk/guidance/ng17
NICE Clinical Guidelines - NG28: Type 2 diabetes in adults: management 
http://www.nice.org.uk/guidance/ng28 NICE - Diabetes in Adults Quality Standard http://guidance.nice.org.uk/QS6
3.
The eye screening care process is not included; therefore 'eight care processes' 
comprises of eight care processes excluding eye screening.

## Additional Information

The following documents are available from http://www.digital.nhs.uk/pubs/ndapump1617

•
Supporting data in Excel
–
National Summary: Tables and Charts
–
Interactive report for participating Specialist Services in England
–
Interactive report for Local Health Boards in Wales
•
PowerPoint version of this report
# National Diabetes Insulin Pump Audit, 2016-2017 Published By Nhs Digital Part Of The Government Statistical Service

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