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NHS DigitalIndicator Supporting DocumentationIAP00049 Patient Experience of Community Mental Health ServicesFIELDCONTENTSIAP CodeIAP00049TitlePatient Experience of Community Mental Health ServicesPublished byNHS Outcomes FrameworkReporting periodQuarterlyGeographical CoverageEnglandReporting level(s)NationalBased on data fromNational Patient Experience Survey architectureContact Author NamePEPP team, NHS North WestContact Author EmailJanet.butterworth@northwest.nhs.ukRatingAssuredAssurance date06/10/11Review date06/10/14Indicator setNHS Outcomes Framework 2011/12Brief Description [This appears as a blurb in search results]The indicator is driven by policy priorities and is assured by the Patient Experience Policy Programme (PEPP) prior to entering the Indicator Governance Board Assurance process. The PEPP is a collaboration between the Department of Health, Patient and Public Engagement and Experience Division and NHS North West and seeks to produce an Excellence Framework for Patient Experience by March 2012.This will include strategic options for the future of the national patient experience survey architecture and information for Department of Health Policy Leads on best practice in the development of indicators for patient experience.PurposeThe purpose of this indicator is to be: * used by the NHSCB and SoS to hold commissioners and service providers to account for services provided by community mental health services. * transparent to all who use it drive continuous improvements in patient experience at local and national levels. DefinitionThis indicator is part of domain 4 which reflects the importance of providing a positive experience of care for patients, service users and carers. It is now standard practice in healthcare systems worldwide to ask people to provide direct feedback on the quality of their experience, treatment and care. This information will be used alongside additional information sources to provide local clinicians and managers with intelligence on the quality of local services from the patients’ and service users’ point of view. This information will help drive improvements in the quality of service design and delivery.Data SourceNHS Survey website (summary reports; historical comparison reports: ’s 2010 Community Mental Health Services survey NumeratorThe 2010 survey comprises a sample of service users aged 16 and over who had been in contact with NHS mental health services in the three-month period 1 July 2009 to 30 September 2009 and who were receiving specialist help for a mental health condition. A total of 17,199 questionnaires were returned, a response rate of 32%.DenominatorThe average weighted number of respondents to at least one of the 20 questions.Calculation[??????????????????????]×100Individual questions are scored according to a pre-defined scoring regime that awards scores between 0 and 100. Therefore, this indicator will take values between 0 and 100, where 0 is the worst score and 100 is the best score.Interpretation GuidelinesAs there is currently no indicator to measure patient experience of mental health services, this indicator will provide valuable information at both national and local levels to inform service improvement and development.CaveatsPrimary categoryMental health and dementiaIndicator Title, this is the short title, a concise concept. Do not include details of calculation, geography, time period or population characteristicsThe NHS Outcomes Framework 2011/12Domain 4 – Ensuring that people have a positive experience of care4.7 - Improving experience of healthcare for people with mental illnessApplication Code (IAP00049)Section A – Summary Application DetailsIndicator Definition, this is the longer description of the indicator. Include a description of the calculation, measurement units, geographical range, and characteristics of the population such as age and gender. OVERVIEW OF INDICATOR:This indicator forms part of the NHS Outcomes Framework, which is designed to provide national level accountability for the outcomes the NHS delivers, and act as a catalyst for driving transparency, quality improvement and outcome measurement throughout the NHS.The indicator is driven by policy priorities and is assured by the Patient Experience Policy Progrmame prior to entering the Information Centre Assurance process. The Patient Experience Policy Programme (PEPP) is a collaboration between the Department of Health Patient and Public, Engagement and Experience Division and NHS North West and seeks to produce by March 2012 an Excellence Framework for Patient Experience. This will include strategic options for the future of the national patient experience survey architecture and information for Department of Health Policy Leads on best practice in the development of indicators for patient experience. The Strategic Overview and Recommendations from PEPP are attached in the following draft embedded document ‘Strategic Overview and Recommendations, draft 6 May 2011. Indicators developed using data sources from the current national patient experience survey architecture are presented as short term solutions prior to consideration of PEPP recommendations for the future.Document available on request by email to indicators@.ukQuality assurance for the PEPP assurance process for Domain 4 indicator development has been sourced from the NHS North West INSPIRE training and development framework and particularly in the area of analytical and clinical review expertise in developing an understanding of experience data and analysis and creating a shared understanding of service experience values, language and terminology. In addition the development of indicators for Domain 4 will be included in the quality assurance process for PEPP which has been commissioned from academics experts in this field from Oxford University.This indicator is part of Domain 4, which reflects the importance of providing a positive experience of care for patients using community mental health services.IS A COMPOSITE MEASURE OR SINGLE MEASURE USED? – CompositeQUESTION(S):4. Thinking about the last time you saw this NHS health worker or social care worker for your mental health condition.....Did this person listen carefully to you?5. Did this person take your views into account?6. Did you have trust and confidence in this person?7. Did this person treat you with respect and dignity?47. Overall, how would you rate the care you have received from NHS Mental Health Services in the last 12 months?MEASUREMENT UNITS: Individual questions are scored according to a pre-defined scoring regime that awards scores between 0-100. Therefore, this indicator will also take values between 0-100).GEOGRAPHICAL RANGE: England AGE: The survey is for patients aged 16 and over. DISAGGREGATION:The Department of Health has made tackling health inequalities a priority. It is also under a legal obligation to promote equality across the equality strands protected in the Equality Act 2010. There is, therefore, a legal requirement and a principle that the design and introduction of the NHS Outcomes Framework will not cause any group to be disadvantaged. Where possible, all indicators in Domain 4 should be disaggregated by the equality and inequality strands. It should be noted that not all strands are covered in the surveys.The following strands are covered in the survey used to measure this indicator Religion or belief - NoGender - YesDisability – NoSexual orientation – noSocio-economic group (NS-SEC) – no\Deprivation (via postcode or area) - noAge – YesEthnicity - YesFor those strands that are covered, disaggregation is only possible at a national level. Disaggregation at trust level is unreliable due to sample size.Disaggregation is also required by age, using the following age bandings:16 to 3536 to 5051 to 6566 and overDoes this indicator measure a process or outcome including process as proxy? Answer: outcome including process as proxyThis measure is compared against a national average – NoThis measure is compared against an optimum value – YesThis measure is a comparison against an absolute evidence based standard – noThis measure is compared against self / baseline over time - yesThis measure is not compared against any other values - noList any indicators which overlap with the proposed indicator Are there other similar indicators currently in use? The IC will provide a library of existing indicators as a later part of this project development. For now, please list any indicator sources you have checked. In addition to Domain 4, mental health is also addressed in Domains 1 and 2 of the NHS Outcomes Framework:Domain 1, indicator 1.5Reducing premature death in people with serious mental illness Domain 2, indicator 2.5 Enhancing quality of life for people with mental illness During the consultation process for the NHS Outcomes Framework, wide checks were undertaken to identify overlaps with other indicators. It is recognised that there is some overlap between the NHS Outcomes Framework, the Public Health Outcomes Framework and the Adult Social Care Framework. Further work, including a consultation process, is currently being undertaken in this area.What value does the proposed indicator offer over existing indicators? As there is currently no indicator to measure patient experience of mental health services, this indicator will provide valuable information at both national and local levels to inform service improvement and development. How is the indicator to be derived from its source data? Existing raw data that require further calculation to answer the indicator question. Is this indicator linked to another that has been submitted to pipeline? Give the name and relationshipYes, this is indicator is part of the Domain 4 indicator set which is being developed as part of The NHS Outcomes Framework 2011/12.4a Patient experience of primary care 4b Patient experience of hospital care 4.1 Improving people’s experience of outpatient care 4.2 Improving hospitals’ responsiveness to personal needs 4.3 Improving people’s experience of accident and emergency services4.4 Improving access to primary care services 4.5 Improving women and their families’ experience of maternity services 4.6 Improving the experience of care for people at the end of their lives 4.7 Improving experience of healthcare for people with mental illness 4.8 Improving children and young people’s experience of healthcareIn addition, mental health is also addressed in Domains 1 and 2 of the NHS Outcomes Framework:Domain 1, indicator 1.5Reducing premature death in people with serious mental illness Domain 2, indicator 2.5 Enhancing quality of life for people with mental illness Section B – Application contact details (please note all contact details will be treated confidentially)Applicant NameName of person who is completing this application. PEPP teamApplicant Role / Job TitleApplicant OrganisationPEPP, NHS North WestApplicant EmailApplicant Telephone0161 625 7344Janet.Butterworth@northwest.nhs.ukSponsor nameName of the person who is paying for the production of the indicatorDavid DanielsSponsor Role / Job TitleMental Health Policy Lead, Department of HealthSponsor OrganisationDepartment of Health, Patient Experience Policy TeamAcknowledgements Please list any contributors to the development of the indicator you wish accreditedPlease list any other stakeholder groupsName specific groups of users who may wish to be involved in assurance of this indicatorSection C – Users of the Proposed IndicatorNational GovernmentSecondary userLocal GovernmentSecondary userGoverning Boards (NHS, local government etc)Secondary userProviding ManagersSecondary userCommissioning ManagersSecondary userRegulatorsSecondary userCliniciansSecondary userPatientsSecondary userPublicSecondary userOther (please specify) Secretary of State for HealthPrimary userOther (please specify)NHS Commissioning BoardPrimary userSection D – Rationale for IndicatorRelevant policies, strategies or programmes1. The NHS Outcomes Framework 2011-12 2. Patient Experience Policy Programme (PEPP)3. Excellence Framework for Patient Experience: Strategic Overview and recommendations, PEPP, NHS North West4. Refocusing the Care Programme Approach: policy and positive practice guidance 5. No health without mental health: a cross-government mental health outcomes strategy for people of all ages High level subject areaPreventing people from dying prematurelyEnhancing quality of life for people with long term conditionsHelping people recover from episodes of ill health or following injuryEnsuring people have positive experiences of careYesTreating and caring for people in a safe environment andprotecting them from avoidable harmHelping people to stay healthyEquitable access to careOther (specify)Evidence base for the indicator Provide a paragraph summarising the evidence for the rationale, noting quality of evidence where appropriate. Please extract salient messages, list the relevant documents in Question 4.The purpose of this indicator is to be: used by the NHSCB and SOS to hold commissioners and service providers to account for services provided by community mental health services.transparent to all who use it drive continuous improvements in patient experience at local and national levels.This indicator has been selected as part of a set of indicators – developed through a consultation process – that will be used to hold the NHS Commissioning Board to account. The set of indicators consists of five domains:Preventing people from dying prematurelyEnhancing quality of life for people with long-term conditionsHelping people to recover from episodes of ill-health or following injuryEnsuring that people have a positive experience of careTreating and caring for people in a safe environment and protecting them from avoidable harmThis indicator is part of domain 4, which reflects the importance of providing a positive experience of care for patients, service users and carers. It is now standard practice in healthcare systems worldwide to ask people to provide direct feedback on the quality of their experience, treatment and care. This information will be used alongside additional information sources to provide local clinicians and managers with intelligence on the quality of local services from the patients’ and service users’ point of view. This information will help drive improvements in the quality of service design and delivery.Selected questions are to be used to develop a composite score from the existing Community Mental Health Survey. The selected questions will be used as a data source to demonstrate performance against the indicator. This methodology is in line with the recommendations of the NHS Outcomes Framework technical guidance. When selecting the questions to include in the composite, the following points were considered:Is the question a filter question or one which is answered by all respondents?Filter questions/optional questions were omitted. Is the question asking for demographic information (e.g. sex, age etc)?These questions were omitted. Can the information be obtained elsewhere?These questions were omitted. Does the question measure what really matters to patients? – evidence taken from King’s Fund, King’s College London work.Which elements of the patient experience frameworks does the question address? (Picker Institute, Institute of Medicine, Inspiration NW). Is the question relational or functional/transactional?How is the question scored? Does the question help to focus on continuous improvement for patient experience? A significant proportion of the questions were excluded on the basis that they were only answered by respondents on Care Programme Approach (CPA). Although deemed important in terms of policy, inclusion of these questions would mean that the composite would only measure the experience of one particular group of community mental health patients. The sample size would also be significantly reduced, making it difficult to use the indicator at the local level.Questions relating to day-to-day needs, such as physical health needs, alcohol or drug use, and caring responsibilities were also discounted as they are not relevant to all community mental health patients. For example, in 2010 only 21% of respondents said that they had care responsibilities.The questions which make up the composite are:4. Thinking about the last time you saw this NHS health worker or social care worker for your mental health condition.....Did this person listen carefully to you?5. Did this person take your views into account?6. Did you have trust and confidence in this person?7.Did this person treat you with respect and dignity?47. Overall, how would you rate the care you have received from NHS Mental Health Services in the last 12 months?Development of this indicator has also been guided by the core principles of the Patient Experience Policy Programme, and known best practice from academic research (See Strategic Overview and Recommendations Paper embedded earlier in the document). The questions include both transactional and relational aspects of care as recommended by the King’s Fund and King’s College London in their work, ‘What Matters to Patients’. However, in line with community mental health policy, the emphasis is on relational aspects. Questions 4, 5, 6 and 7 elicit information which can only be provided by the patient, and are classified as ‘loudspeaker’ questions.The questions chosen have been checked against and fit into the key dimensions of care identified in widely used frameworks for patient experience:Picker Institute Dimensions of CareInstitute of Medicine Dimensions of Patient Centred Care Inspiration NW’s framework for service experienceThe two key dimensions used from the frameworks are:Information, communication and educationRespect for patient values, preferences and expressed needs In particular, information, communication and education is central to the government’s policy No health without mental health, which aims to put people at the heart of services, and provide people with the information and support they need to exercise choice of provider and treatment.In addition, analysis of data from the 2010 survey has been conducted to ascertain:where there is genuine scope for improvement where there was a range of performance levels across UK TrustsBased on 2010 data for question 47, performance levels across UK trusts varied from 66.1% to 85.2%. This question, therefore, shows both scope for improvement, and a range of performance levels.Responses to the other questions showed much less variation (see figures 2-5) but have been included due to their policy importance. For example, question 7 which relates to respect and dignity shows high performance levels (90.5% - 97.8%) but has been included in the composite because it addresses a critical element of patient experience because mental health patients – particularly elderly patients and those with severe mental health problems – are often more vulnerable to discrimination or neglect than patients with other conditions.References List up to six key references or documents. If available on the internet, please give the URLWhat matters to patients?’ Developing the evidence base for measuring and improving patient experience, Kings Fund, March 2011Analysis of the current patient experience survey architecture’, unpublished research paper , PEPP Analysis, May 2011Clinical Advice Provide details of any clinical advice or support already given in development or preparation of indicator. Clinical advice, provided by Hugh Griffiths, Acting Clinical Director for Mental Health, was used to refine the long-list of questions to ensure that the composite reflected the Department of Health’s key policy aims with regards to community mental health.Section E – Management and production of IndicatorCommissioner Organisation This may be the same as the stakeholder in Section B, Question 8 - Department of HealthProducer of indicator This is the organisation who will publish or provide the indicator and may be the same as the proposer in Section B, Question 3 - NHS Information CentreExpected ‘improvement actions’ as a result of this indicator State where responsibility will lie, and what actions will be expected as the result of a ‘poor’ rating of this indicator. For example, poor performance will lead to letter being sent to Chief Executive of organisation, to stimulate them to take action. The NHS Outcomes Framework sets out the national outcome goals that the Secretary of State will use to monitor the progress of the NHS Commissioning Board. It does not set out how these outcomes should be delivered.It will be for the NHS Commissioning Board to determine how best to deliver improvements by working with GP commissioning consortia and making use of various tools and levers at their disposal.Have costs of collection, construction, dissemination and presentation been fully identified? Please provide, even if the indicator is not to be produced by the NHS IC. This is a useful measure of how committed the sponsor is to this indicator and helps us prioritise applications through the process. Funding statusSecuredBeing soughtNot identifiedN/AWhat are the timescales you envisage for developing / producing this indicator Give specific dates for key stages or publication or development of indicatorThe indicator needs to be produced by 31 March 2012. This will provide a baseline which the Secretary of State will use to hold the NHS Commissioning Board to account. Risks, assumptions and impact of producing indicator Are there any external factors that need to be understood, such as changes to policy, data collections, finances or political changes. Due to the limitations of the existing survey architecture, the composite does not measure the needs of all community mental health patients. In particular, questions relating to the Care Plan Approach (CPA) have been excluded. CPA and, more broadly, coordination of care for mental health patients, is a core element of community mental health policy. It is hoped that future development of indicators and methods to capture patient feedback will take a broader approach.Risks of perverse incentive and gaming by healthcare providers To what extent can organisations influence the value of the indicator in ways which may not benefit patients? As this is a survey based indicator, healthcare providers have little chance to influence the indicator value. There is, therefore, a low risk of perverse incentive or gaming by healthcare providers. Risks, assumptions and impact of not producing indicatorThis indicator is part of the NHS Outcome Framework 2011-12 indicator set. A public commitment has been made to developing this set of indicators by April 2012.Have costs of collection, construction, dissemination and presentation been fully identified? Please provide, even if the indicator is not to be produced by the NHS IC. This is a useful measure of how committed the sponsor is to this indicator and helps us prioritise applications through the process. Section F – MethodologySelect the calculation type:Mean This is the sum of all values divided by the number of values, or common ‘average’.Select the adjustment or standardisation type used Select all that apply:Direct standardisation Descriptions of the calculation Describe the calculation required in words. Where this is insufficient, please submit a document with formulae in addition to this applicationCleaning and scoringAll questions responses are converted to scores using the scoring scheme given.Missing values for age and gender are replaced with values from the sample file where available. Records without a valid age or gender or admission type are removed from the file.Records without any valid question responses are removed from the file.Ages are grouped into bands: 16 to 35, 36 to 50, 51 to 65, 66 plus.Survey filters are followed and inappropriate routing corrected (e.g. respondent answers Q42, which then says ‘go to Q46’, but respondent has also answered Q43-45. In this example, the answers to Q43-45 would be removed).Standardisation by age and genderEach individual is assigned to a group based on their age-band and gender. Totals for each such group (or strata) are calculated for each NHS Trust, and also nationally. A weight is then calculated for each individual as follows:Weighti=ntrust,innational,iWhere n is the number of valid records at Trust or national level in the same strata as patient i.Question scores at trust levelA mean score is then worked out for each of the relevant questions, within each trust. The Trust level mean score for question j and Trust k is given by:xjk=iWixijkiWiHere, the xijk represent the question scores from each individual patient and the Wi represents the weight for that individual.Note at this point how the method handles missing values. The relevant xijk would be ‘missing’ and therefore excluded from the numerator. To compensate, the Wi for those individuals is set to zero, so they do not contribute to the denominator either. Thus, the question score is a weighted mean of responses received, regardless of how many responses there were.Using question scores to calculate trust and national indicator scoresThe mean of the scores for each question is calculated for each trust to give the trust indicator score. The mean of the trust scores is calculated to give the national indicator score.Statistical Methods Type of analysis (any methods used), risk adjustment (predictive power of model), special techniques (dealing with dispersion, constant risk), statistical process control See above Risk adjustment variables The purpose of risk adjustment is to remove the effect of aspects beyond the direct control of the organisation or group monitored. Where risk adjustment is used, summarise the application of risk adjustment and selection of relevant variables. If not used, state why. FORMTEXT ?????Quality assurance process Detail the quality assurance processes in place to check data, identify anomalies. Note any processes or arrangements in place to discuss issues with the suppliers of the raw data if required.Guidance published by the Care Quality Commission provides rigour to the process of collecting and analysing data. The data cleaning process described above ensures that the indicator is produced accurately. Test or sample data Test or sample data are required as proof of concept. Please submit a document or spreadsheet with this applicationInterpretation Describe how this indicator is planned to be used, what questions the indicator is planned to answer, and any known limitation(s)This indicator forms part of the NHS Outcomes Framework, which is designed to provide national level accountability for the outcomes the NHS delivers, and act as a catalyst for driving quality improvement and outcome measurement throughout the NHS.This indicator measures adult patients’ experience of community mental health services. Format of presentation Describe the final published format, such as interactive website, csv file etc. Please submit a document with an example or screenshot (or mock version) of how the final presentation of the data will appear. Include any interpretive text as well as figuresDepartment of Health have requested that the data be provided in CSV format.Section G – Data sources If you answered (a) in Section A Question 6, please complete only the numerator part of this section. If you answered (b) or (c) and the indicator is based on more than one data source answer both numerator and denominator parts. Numerator definition Word description of the cases or events to be counted. The numerator should be a subset of the denominatorThe indicator is a composite, calculated as the average of 5 survey questions. Each question describes a different element of the overarching theme: patient experience of mental health care.QUESTION(S):4. Thinking about the last time you saw this NHS health worker or social care worker for your mental health condition.....Did this person listen carefully to you?5. Did this person take your views into account?6. Did you have trust and confidence in this person?7. Did this person treat you with respect and dignity?47. Overall, how would you rate the care you have received from NHS Mental Health Services in the last 12 months?Individual questions are scored according to a pre-defined scoring regime that awards scores between 0-100. Therefore, this indicator will also take values between 0-100).Numerator source Organisation and data collection nameCommunity Mental Health Survey (part of the National Survey Programme) Numerator construction Which data fields (specify) and values (specify codes) are combined to arrive at the count. Include any special rules or filtersUsing question scores to calculate trust and national indicator scoresThe mean of the scores for each question is calculated for each trust to give the trust indicator score. The mean of the trust scores is calculated to give the national indicator score.Numerator completeness Are all relevant cases/ events counted. List any known exclusions, shortfalls or collection issues which will affect the required count. How do counts compare with other sources? The 2010 survey comprises a sample of service users aged 16 and over who had been in contact with NHS mental health services in the three month period 1 July 2009 to 30 September 2009 and who were receiving specialist help for a mental health condition. A total of 17,199 questionnaires were returned, a response rate of 32%. It is likely that the next survey will have a similar sample size and response rate.Numerator quality of data Issues with accuracy or known variability of recording. For example coding by untrained staff. Please list any indicators of data quality available (by field or whole numerator)NANumerator data availability Are the data publicly available / published? Are they available only upon request, or only to groups of people meeting specific criteria / conditions?Is survey data publicly available:Yes FORMCHECKBOX If Yes, please state where available, and in what format (If the data is published in multiple locations, please include all known locations, including URLs)No FORMCHECKBOX NHS Information Centre (available upon request in various formats)NHS Survey website (summary reports; historical comparison reports; Care Quality Commission.(data available at trust level; other data available upon request) FORMCHECKBOX If Yes, please state where available, and in what format (If the data is published in multiple locations, please include all known locations, including URLs)No FORMCHECKBOX NHS Information Centre (available upon request in various formats)NHS Survey website (summary reports; historical comparison reports; Care Quality Commission.(data available at trust level; other data available upon request) timeliness Frequency and timeliness of data. State how the publication / release of data relates to envisioned indicator productions timescalesSURVEY TIMING (frequency/how quickly is it published?)Lead sectorSurveyFieldwork timingExpected month of publicationNotes2010/11 surveys Mental Health TrustsCommunity mental health surveyWinter/Spring 20119th August 2011The Community mental health survey has now completed and will publish on 9th August 2011.2011/12 surveys Mental Health TrustsCommunity mental health surveyWinter/Spring 2012Approximately August 2012 (tbc)NHS providers will need to fund implementation on the same basis as in previous years.Will baseline data be available by March 2012?Yes FORMCHECKBOX No FORMCHECKBOX If No, please state why, and indicate when it will be availableNumerator ISB compliance Some data items used across the NHS and social care have been approved as an Information Standard by the Information Standard Board for health and social care, and is a measure of quality and consistency. Please give the Information Standard number and release version where appropriate FORMTEXT ?????Numerator ROCR approval Data collected by NHS and social care staff other than that required for day-to-day treatment of patients must be approved by the Review of Central Returns. Please give the ROCR Reference number and date for review where appropriate. FORMTEXT ?????Numerator comments Please detail any caveats not already covered FORMTEXT ?????Denominator definition Word description of the cases or events to be counted. N/ADenominator source Organisation and data collection nameN/ADenominator construction Which data fields (specify) and values (specify codes) are combined to arrive at the count. Include any special rulesN/ADenominator completeness Are all relevant cases/ events counted. List any known exclusions, shortfalls or collection issues which will affect the required count. How do counts compare with other sources? N/ADenominator quality of data Issues with accuracy or known variability of recording. For example coding by untrained staff. Please list any indicators of data quality available (by field or whole numerator)N/ADenominator data availability Are the data publicly available / published? Are they available only upon request, or only to groups of people meeting specific criteria / conditions?N/ADenominator timeliness Frequency and timeliness of data. State how the publication / release of data relates to envisioned indicator productions timescalesN/ADenominator ISB compliance Some data items used across the NHS and social care have been approved as an Information Standard by the Information Standard Board for health and social care, and is a measure of quality and consistency. Please give the Information Standard number and release version where appropriateN/ADenominator ROCR approval Data collected by NHS and social care staff other than that required for day-to-day treatment of patients must be approved by the Review of Central Returns. Please give the ROCR Reference number and date for review where appropriate. N/ADenominator comments Please detail any caveats not already coveredN/AApplication Checklist – Clinical Indicator Team use only Section A – Summary Application Details FORMCHECKBOX Requires additional information Section B – Application contact details FORMCHECKBOX Requires additional information Section C – Users of the Proposed Indicator FORMCHECKBOX Requires additional information Section D – Rationale for Indicator FORMCHECKBOX Requires additional information Section E – Management and production of Indicator FORMCHECKBOX Requires additional information Section F – Methodology FORMCHECKBOX Requires additional information Section G – Data sources FORMCHECKBOX Requires additional information Issues for consideration Record all major issues to be considered before indicator can be ‘assured’Area where issue resides Record of meetings Choose meeting type and add hyperlink to the meeting minutesMeeting type Date Caveats to apply to indicator Indicator Assurance Pipeline Process Methodology Review GroupApplications & Recommendations 14th March 2012Document Author:Chris WilsonCurrent Issue Date:29/03/2012Document Owner:Chris WilsonResponses expected by:n/aCreated Date:29/03/2012Version Number:V 1.1Contents TOC \o "1-3" \h \z \u 0.Document Control PAGEREF _Toc317165654 \h 20.1Version History PAGEREF _Toc317165655 \h 20.2Approvals PAGEREF _Toc317165656 \h 20.3Distribution PAGEREF _Toc317165657 \h 2 HYPERLINK \l "_Introduction" 1.Introduction PAGEREF _Toc317165658 \h 3 HYPERLINK \l "_New_indicators_for" 2.New indicators for consideration PAGEREF _Toc317165660 \h 4 HYPERLINK \l "_Recommendation_updates" 3.Recommendations update25 HYPERLINK \l "Appendix" 4.Appendices28Document ControlVersion HistoryVersionDateChanged BySummary of ChangesV 1.029/03/2012Chris WilsonDocument createdV1.129/03/12Chris WilsonPage numbering correctedApprovalsNameTitleDateVersionSignatureDistributionVersionDateDistribution ListHSCIC: John Varlow, Andy Sutherland, Azim Lakhani, Alyson Whitmarsh, Simone Chung, Peter Knighton, Helen Lewis, Alison Roe, Jonathon Hope, Chris Roebuck, Matt Curley Cc: Susie KingIntroductionMatters to discuss:New indicators for consideration:NHS Outcomes FrameworkIndicator 1.4vii - Under 75 mortality rate from cancerCommissioning Outcomes FrameworkDiabetesCOPD Recommendations / Indicator update:NHS Outcomes FrameworkIndicator 4.7 (IAP00049) Patient experience of community mental health servicesPresent at meeting: Andy Sutherland, Alyson Whitmarsh (chair), John Varlow, Chris Wilson (secretariat) Alison Roe, Helen Lewis, Helen Payne, Jonathon Hope (Diabetes), Ellen Cameron (Diabetes), Matt Curley (COPD), Chris Roebuck (COPD), Peter Knighton (NOF),Apologies:Azim Lakhani, Simone ChungNew indicators for considerationIndicatorNHS-OF 1.4.vii – Under 75 mortality rate from cancerConstruction and data sourceNumerator: Number of deaths under 75 from all cancers. Cancer is defined in terms of the following ICD10 codes: All ICD-10 codes for malignant Neoplasms in Chapter II – Neoplasms (C00-C97). ONS mortality data by cause.Denominator: Resident population under 75 years. ONS mid-year population estimates.Indicator format: Rate per 100,000 population directly age standardised to the European Standard Population (ESP).RationaleIntroduced to the NHS Outcomes Framework in December 2012. This shared indicator with Public Health has been introduced in addition to indicators of one-and five-year survival from the three main cancers to demonstrate that the NHS can make a contribution to improving preventable as well as amenable cancer mortality. Ref DocsThe NHS Outcomes Framework 2012/13 Technical Appendix issuesIndicators 1.1, 1.2 and 1.3 of the NHS OF use the same method with different ICD-10 codes.1.1 Under 75 mortality rate from cardiovascular disease 1.2 Under 75 mortality rate from respiratory disease 1.3 Under 75 mortality rate from liver diseaseThe indicator under consideration here and 1.1 are also calculated for the Compendium of Population Health IndicatorsESP used as international comparisons are a key element in setting the levels of ambition for the NHS Outcomes Framework.Diabetes Audit-Based COF IndicatorsDomain 2 - Enhancing the quality of live for people with long term conditionsThe following indicators are discussed below:NoDiabetesNDAHES2.53Of people with newly diagnosed diabetes, the proportion who are offered [structured education] within 3 months of diagnosisX2.54Of people with established diabetes, the proportion who are offered [structured education]X2.55Of people with newly diagnosed diabetes, the proportion who start [structured education]X2.56Of people with established diabetes, the proportion who start [structured education]X2.57Of people with newly diagnosed diabetes, the proportion who complete [structured education]X2.58Of people with established diabetes, the proportion who complete [structured education]X2.59Of people with established diabetes, the proportion whose last [review] and [reinforcement] of the [structured education] was no longer than 15 months after the previous reviewX2.61The incidence of complications associated with diabetes per X people with diabetesX2.62The incidence rate of lower limb amputations per X people with diabetesXThe National Diabetes Audit (NDA) is the only source for some of the data elements required to construct many diabetes related indicators although GPES may be able to provide much of the required information given the correct data extraction business rules.The NDA is the largest annual clinical audit in the world. It has permission from NIGB to collect patient identifiable data under Section 251 of the NHS Act 2006.The audit is optional, so it is not mandated but data are collected from PCTs, Hospital Trusts, Specialist Paediatric Units and GP Practices. In 2009-10, 6507 of 8357 England GP Practices took part in the audit (77.86%) and significantly improved technical data extraction methods have resulted in far greater participation in the most recent audit whose results are imminent. For example, in 2009-10, there were 2.00 million patients recorded in the NDA; the 2010-11 dataset contains 2.24 million records. NDA has no exclusions, patient of all ages and all types of diabetes (apart from gestational which is temporary) are included.NDA encompasses all Primary care and all adults from Secondary care. Paediatric units and endocrinology units treating children with diabetes no longer return data to the NDA as their data are independently collected. However, the NDA team believes that the majority of children with diabetes will have type one diabetes and thus most will have this noted in their GP record - in the most recently published audit, 20,000 children had records of diabetes in paediatric units of which 18,000 were also recorded in the GP record. Since the NDA is the only source for the required data, given that secondary care records for children are not included in the dataset, there are several options:Use the NDA to cover primary care only, for patients of all ages, all types of diabetes (except gestational), no exclusions. This would include treatment delivered by primary or secondary care for these patients but exclude any records with no primary care match.Use the NDA and filter for adults only, exclude children’s records entirely but include records from secondary care.Use the NDA as is, accepting that child records from secondary care will not be included.The NDA team believes that the inclusion or otherwise of children in the secondary care dataset is not a relevant concern in view of the fact that the object of the indicator is to know and understand whether structured education is being offered and what the take up has been, i.e. whether healthcare providers are delivering what they should. Furthermore, the NDA team believes (as above) that most children receiving diabetes treatment in secondary care will be identified via their GP records instead. The team therefore recommends use of the NDA as is. The NDA takes place annually and has been completed every year since 2003-2004. Indicators can thus be reported no more frequently than on a yearly basis. Following the collection, date are validated, verified, processed and quality assured before analysis and reporting can begin. NDA 2010-2011 will be ready to commence reporting during May 2012.These indicators need to be reported at CCG level, which will be derived from GP practice registrations. Not all patients are registered with a GP and since some NDA data comes solely from secondary care, some patients will not be attributable to a CCG. The NDA team advises that three years ago, 2.8% of secondary care patient records had no GP recorded. Further investigation is needed to ascertain the spread of this. There may be issues around reporting small numbers at CCG level.Structured Education Indicators – Potential IssuesStructured education is poorly recorded in primary care e.g. NDA 2009-2010 showed only 1.8% of patients submitted to the NDA had a structured education offered Read code in their record. Read codes exist for referral, attendance and review of structured education (see Appendix 1) although in some instances the codes have a narrow focus and it is not necessarily clear which of these codes would constitute “structured education”.Data returned by Secondary Care includes two flags (01=Carried out , 02=Not done) for Structured Education Offered and Structured Education Attended; only 1.6% of records in the raw 2009-2010 dataset have an entry in the Education Offered field and there is no capacity in the current data collection for Structured Education Completed. The NDA and Clinical Indicators Teams have concerns about the completeness of data. It is suggested that the poor completion is due to the fact that there are no QOF points associated with the recording of this measure – for example, 90-95% of diabetes patients have a record of their blood sugar level because there is an incentive to record this information.As a consequence of the incomplete data and issues with the Read codes, the NDA team questions whether it is appropriate and meaningful to report structured education by offered, attended and completed and recommends that if included these would be included as an experimental statistic to encourage improved completion of these fields – contextual indicators may also be useful to drive this change. The NICE guidance considers that patients cannot attend or complete structured education unless it has first been offered, so specifies that indicators 2.55 and 2.57 would be a subset of the patients identified for 2.53 (newly diagnosed and offered structured education) and 2.56 and 2.58 would be a subset of 2.54 (patients with established diabetes and offered structured education). Because the Read codes for structured education do not support this and the data are infrequently recorded, this is not currently feasible and thus the indicators will have to use all newly or established patients in the denominator as applicable. Furthermore, it is possible that the audit data contained a patient who was not offered education during that data year (because it was offered before the start of the window) but went on to attend. This could conceivably mean that more than 100% of those offered education in that data year actually attended.NICE defined “newly diagnosed” as within 6 months. The NDA has historically recorded the year of diagnosis rather than the actual date. This has been changed for future collections but for the feasibility testing, “newly diagnosed” is defined as less than a year.IndicatorCOF 2.53 - Of people with newly diagnosed diabetes, the proportion who are offered [structured education] within 3 months of diagnosis Construction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with newly diagnosed diabetes offered a structured education Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients newly diagnosed with diabetes offered a structured education.Denominator: Patients newly diagnosed with diabetes as recorded in GP Adult Population Data and / or secondary care records.RationaleThe indicator is based on a NICE Quality Standard (refer to section 3, Evidence Base) and has been identified by the NICE COF Advisory Committee for use in the Commissioning Outcomes Framework. Indicators 2.53 to 2.64 have been identified as being a key component of high quality care as defined in the NICE quality standard for diabetes. For indicators 2.53 to 2.59, Statement 1 requires that “People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria at the time of diagnosis, with annual review and access to on-going education. ”Potential issuesNDA historically recorded year as opposed to date of diagnosis although the collection is being updated to record actual date. NICE defined “newly diagnosed” as within 6 months but this cannot yet be reported. Patients to be identified if first date of diagnosis is during the audit year.It is not yet possible to report offer of structured education within 3 months of diagnosis (see above), but it is possible to record whether an offer has been made.These constraints will be irrelevant by the time COF is live.NDA is able to collect only offered or attended and does not collect the Read codes. Any requirement to split attended into started and completed would require a change to the audit and may incur costs.IndicatorCOF 2.55 - Of people with newly diagnosed diabetes, the proportion who start [structured education] Construction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with newly diagnosed diabetes who attended a structured education Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients newly diagnosed with diabetes who attended a structured education.Denominator: Patients newly diagnosed with diabetes as recorded in GP Adult Population Data and / or secondary care records.RationaleSee 2.53Potential issuesAs for 2.53See points 7 - 9 in opening paragraph.It is not possible to report this indicator as a subset of patients offered a structured education because of the aforementioned data completeness and coding issues. Denominator therefore to be all newly diagnosed diabetes patients.Read codes to not record “Started” only attended or completed. Clarification required for which Structured Education Read codes to useIndicatorCOF 2.57 - Of people with newly diagnosed diabetes, the proportion who complete [structured education] Construction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with newly diagnosed diabetes who completed a structured education Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients newly diagnosed with diabetes who completed a structured education.Denominator: Patients newly diagnosed with diabetes as recorded in GP Adult Population Data and / or secondary care records.RationaleSee 2.53Potential issuesSee 2.55 aboveIndicatorCOF 2.54 - Of people with established diabetes, the proportion who are offered [structured education]Construction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with established diabetes offered a structured education.Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients with established diabetes offered a structured education.Denominator: Patients with established diabetes as recorded in GP Adult Population Data and / or secondary care records.RationaleSee 2.53Potential issuesIssues with year vs date of diabetes. Patients will be identified as having established diabetes if their first year of diagnosis is before the audit year.The NDA will soon record date of diagnosis so this should not be a problem in the future How often should structured education be offered? Once the patient is flagged as having attended / completed structured education, they should be removed from the denominator for “offered” and counted for indicator 2.59.How are patients processed if structured education is offered but refused or they do not attend? Should the offer be made repeatedly?Clarification required for which Structured Education Read codes to useIndicatorCOF 2.56 - Of people with established diabetes, the proportion who start [structured education]Construction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with established diabetes who attended a structured education.Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients with established diabetes who attended a structured education.Denominator: Patients with established diabetes as recorded in GP Adult Population Data and / or secondary care records.RationaleSee 2.53Potential issuesAs 2.54 above points 1 to 4See points 7 - 9 in opening paragraph.It is not possible to report this indicator as a subset of patients offered a structured education because of the aforementioned data completeness and coding issues. Denominator therefore to be all newly diagnosed diabetes patients.IndicatorCOF 2.58 - Of people with established diabetes, the proportion who complete [structured education]Construction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with established diabetes who completed a structured education.Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients with established diabetes who completed a structured education.Denominator: Patients with established diabetes as recorded in GP Adult Population Data and / or secondary care records.RationaleSee 2.53Potential issuesAs 2.54 above points 1 to 4See points 7 - 9 in opening paragraph.It is not possible to report this indicator as a subset of patients offered a structured education because of the aforementioned data completeness and coding issues. Denominator therefore to be all newly diagnosed diabetes patients.IndicatorCOF 2.59 - Of people with established diabetes, the proportion whose last [review] and [reinforcement] of the [structured education] was no longer than 15 months after the previous reviewConstruction and data sourceData source: National Diabetes Audit (NDA) and GP Population DataIndicator definition: the proportion of persons with established diabetes whose structured education is reviewed within the past 15 months.Indicator will be reported annually. This indicator will be a percentage.Numerator: The number patients with established diabetes whose structured education is reviewed within the past 15 months.Denominator: Patients with established diabetes as recorded in GP Adult Population Data and / or secondary care records who have already attended or completed a structured education.RationaleSee 2.53Potential issuesIssues with year vs date of diagnosis as aboveInclude only patients who have already attended / completed structured educationWhat happens with those patients who have refused to participate in structured education? Clarification required for which Structured Education Read codes to useThis would require linkage across data years, which doesn’t currently happen in the audit. It would therefore be a resource intensive piece of workCommissioning Outcomes Framework (COF) 2.53 -Of people with newly diagnosed diabetes, the proportion who are offered [structured education] within 3 months of diagnosis2.54 - Of people with established diabetes, the proportion who are offered [structured education]2.55 - Of people with newly diagnosed diabetes, the proportion who start [structured education]2.56 - Of people with established diabetes, the proportion who start [structured education]2.57 - Of people with newly diagnosed diabetes, the proportion who complete [structured education]2.58 - Of people with established diabetes, the proportion who complete [structured education]2.59 - Of people with established diabetes, the proportion whose last [review] and [reinforcement] of the [structured education] was no longer than 15 months after the previous reviewRecommendationsRec 2012/36Definitions in relation to what is being covered in the measurement, and what recording periods are being defined, to be made more precise within the indicator description. MRG suggested that the description could start as “of people included in the audit...”Rec 2012/37Further investigation is required to examine the impact on data quality that the recording levels described in point 9 of the summary of the MRG paper may have – ie for Secondary Care only 1.6% of records in the 2009-10 raw dataset have an entry in the Education Offered field. Further consideration is needed with regards to what measures of data quality could support the indicators for completeness of understandingRec 2012/38Consideration is to be given as to how to follow up the percentage of GP’s who don’t take part in the NDA. Additionally the rate at which people dissent from the audit will need to be reported back.Rec 2012/39The position on which GP is attributable for “offers”, “starts” and “completions”, when a patient changes GP practice within the defined indicator time periods needs clarifyingNoDiabetesNDAHES2.61Of people with newly diagnosed diabetes, the proportion who are offered [structured education] within 3 months of diagnosisX2.62Of people with established diabetes, the proportion who are offered [structured education]XIndicatorCOF 2.61 - The incidence of complications associated with diabetes per X people with diabetesConstruction and data sourceData source: HES, National Diabetes Audit (NDA) and GP Population DataIndicator definition: Rates of complications associated with diabetesNDA complication types are diagnoses or procedures as follow:KetoacidosisAnginaMyocardial InfarctionCardiac FailureStrokeDiabetic Retinopathy treatmentsRenal FailureAmputation minorAmputation major ICD-10 and OPCS-4 codes are provided (see Appendix 2)Indicator will be reported annually (April to March). This indicator will be a rate.Numerator: Number of people identified by NDA in the denominator with a HES record of NDA complications using (a) ICD-10 primary or secondary diagnosis codes (see below) or (b) OPCS-4 procedure codes Denominator: Number of people with diabetes collected by the NDA from Primary and / or Secondary CareRationaleThe indicator is based on a NICE Quality Standard (refer to section 3, Evidence Base) and has been identified by the NICE COF Advisory Committee for use in the Commissioning Outcomes Framework. NDA reports on complications prevalence in the NDA diabetes population annually, this is available publicly via the HSCIC website.Potential issuesComplicationprevalence is defined as the number of people who have had one or more records of a specific complication over the defined time periodincidence is defined as the total number of times a specific complication has occurred within the defined time periodClarify whether to count people with complications irrespective of number, or count of incidents (which theoretically could return a higher numerator than denominator)Complications incidence cannot be provided for renal failure, cardiac failure and angina.RecommendationsCommissioning Outcomes Framework (COF) 2.61 - The incidence of complications associated with diabetes per X people with diabetesRec 2012/40Further investigation of death rates connected to myocardial infarction is required to confirm this is not impacting on results.Rec 2012/41MRG recommended that an exercise take place to verify the number of instances where NDA/HES items don’t match, e.g where missing NHS numberRec 2012/42MRG recommended that a review of whether there is a necessity for age standardisation take place, for instance is the complication connected to age profile, with a risk model built as appropriate.IndicatorCOF 2.62 - The incidence rate of lower limb amputations per X people with diabetesConstruction and data sourceData source: HES, National Diabetes Audit (NDA) and GP Population DataIndicator definition: Rates of complications associated with diabetesNDA complication types are diagnoses or procedures as follow:Amputation major OPCS-4 codes are provided belowIndicator will be reported annually (April to March). This indicator will be a rate.Numerator: Number of people identified by NDA in the denominator with a HES record of lower limb amputation using the OPCS-4 procedure codes belowDenominator: Number of people with diabetes collected by the NDA from Primary and / or Secondary CareRationaleThe indicator is based on a NICE Quality Standard (refer to section 3, Evidence Base) and has been identified by the NICE COF Advisory Committee for use in the Commissioning Outcomes Framework. Statement 10 for indicator 2.62: People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours.” Potential issuesNHSIC Compendium Indicator reports incidence of lower limb amputations in diabetic patients using HES data and a general population denominator – this will use the NDA diabetic population as the denominator as reported by NDA.RecommendationsCommissioning Outcomes Framework (COF) 2.62 - The incidence rate of lower limb amputations per X people with diabetesRec 2012/43 Review the work previously done in relation to the compendium indicator and build a critique around why the current compendium indicator can’t be adapted for COF purposesHES or Diabetes Audit-Based COF IndicatorsNoDiabetesNDAHES2.60Readmission rates of people admitted with diabetic ketoacidosis within 12 months following discharge XX2.63Emergency admissions: diabetic ketoacidosis in people with diabetes XX2.64Emergency admissions: hypoglycaemia in people with diabetes XIndicatorCOF 2.60 HES - Of people discharged following admission to hospital with diabetic ketoacidosis, the proportion who are readmitted within 12 months Construction and data sourceData source: Hospital Episode Statistics Admitted Patient Care Data (HES APC), GP Patient Data.Indicator definition: the proportion of persons readmitted to hospital with a diagnosis of diabetic ketoacidosis following discharge (following a spell for the same cause) within the previous 12 months.Indicator will be annual. This indicator will be a rate of the total CCG population meeting the denominator criteria.NumeratorThe number finished and unfinished continuous inpatient spells (CIPS), excluding transfers with emergency admission, where the first episode contains a primary diagnosis of diabetic ketoacidosis (without coma) and the patient had a previous admission within the last 12 months (discharged before financial year 1011) with a primary diagnosis of diabetic ketoacidosis. See ICD-10 code descriptions below.DenominatorThe number of emergency admission spell records discharged before financial year 1011, where the first episode contains a primary diagnosis of diabetic ketoacidosis (without coma) and discharge method is not death.RationaleIndicators 2.53 to 2.64 have been identified as being a key component of high quality care as defined in the NICE quality standard for diabetes. In particular, statement 12 “People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team.”Potential issuesThis is for all people unless requested otherwise In the event that the patient has changed GP and CCG between discharge and readmission, it is recommended that results be matched to the GP Practice and CCG in the numerator rather than denominator. It would be unfair and inappropriate to record against the original GP and CCG once the patient has left their care, while the new GP is responsible for ensuring that the patient has adequate support and education to manage their long-term condition. However, there is some question about the reasonableness of timescales here – how quickly should a new GP ensure that this support and training are in place?Additional InformationApplied filters:The following filters are suggested for application to both numerator and denominator, unless stated otherwise:CLASSPAT = ‘1’ or ‘2’ to select ordinary and day case admissions only. Excluding regular day/night attenders, maternity and birthsEPISTAT = ‘1’ or ‘3’ (Selects finished episodes only) EPITYPE = ‘1’ (Selects general episodes only, excluding delivery and birth related episodes) SEX IN (‘1’,’2’) (Selects valid SEX)STARTAGE Between 0 AND 120 OR STARTAGE between 7001 AND 7007 (Valid ages)ADMIMETH = 21,22,23,24 or 28 (admission method)EPISTART >= 01/04/YYYY and EPISTART <= 31/03/YYYY+1 (episode start date within year)EPIORDER = 1 (episode order)DIAG-01 in the valid list for this indicator (primary diagnosis)NB Numerator date ranges 01-04-20XX to 31-03-20XX+1, and to qualify as a readmitted patient, there would need to be a diagnosis of diabetic ketoacidosis and a discharge date of between 02-04-20XX-1 and 31-03-20XX+1ICD-10 Codes E10-E14E10.1 Insulin-dependent diabetes mellitus with ketoacidosisE11.1 Non-insulin-dependent diabetes mellitus with ketoacidosisE12.1 Malnutrition-related diabetes mellitus with ketoacidosisE13.1 Other specified diabetes mellitus with ketoacidosisE14.1 Unspecified diabetes mellitus with ketoacidosis A query of 2010-2011 data found 9572 records of which 1640 were readmissions within the 12 month period.54 CCGs had no readmissions during this year.Alternatively NDA proposed methodology as followsIndicatorCOF 2.60 NDA - Of people discharged following admission to hospital with diabetic ketoacidosis, the proportion who are readmitted within 12 monthsConstruction and data sourceData source: Hospital Episode Statistics Admitted Patient Care Data (HES APC), GP Patient Data, NDAIndicator definition: the proportion of persons readmitted to hospital with a diagnosis of diabetic ketoacidosis following discharge (following a spell for the same cause) within the previous 12 months.Indicator will be annual. This indicator will be a rate of the total CCG population meeting the denominator criteria.NumeratorThe number of patients with diabetes who have had more than one DKA episode (E10.1, E11.1, E13.1, E14.1)DenominatorThe number of patients with diabetes who have had a one or more episodes of DKA (from NDA)RationaleAs abovePotential issuesThe NDA indicator will provide the percentage of patients with diabetes who have been admitted as in inpatient with more than 1 DKA episode within the audit year out of the total number of patients with diabetes who have been admitted as an inpatient with 1 or more episodes of DKA.This is not the same as reporting readmissions within 12 months of a previous admission.Why exclude E12.1?Additional CommentThe HES proposal seems more suitable for recording across years to calculate actual readmission rates within 12 months of discharge. RecommendationsCommissioning Outcomes Framework (COF) 2.60 - Readmission rates of people admitted with diabetic ketoacidosis within 12 months following dischargeRec 2012/44Feedback to NICE around clinical coding optionsRec 2012/45Use of QOF to produce the denominator would mean that the numerator would use a filter of people aged 17 and above.? A check that QOF can provide this at CCG level is needed.This is to be supplemented with further clarification on the definition of 17 used in QOF, and how this may impact on the denominator.Rec 2012/46Recommendation to use HES to calculate readmissions as NDA cannot span years.?IndicatorCOF 2. 63 HES - Admission rates for diabetic ketoacidosis in people with diabetesConstruction and data sourceData source: HES, QOF and GP Population DataIndicator definition: Admission rates for diabetic ketoacidosis in people with diabetesIndicator will be reported annually (April to March). This indicator will be a rate.NumeratorThe number of emergency admission spell records in adults (aged 17 or over) where the primary diagnosis code in the first episode is equal to one or more from the following ICD-10 codes which refer to diabetic ketoacidosis (without coma): E10.1, E11.1, E12.1, E13.1, E14.1. See descriptions below:DenominatorThe number of people registered to be diabetic aged 17 or over. Data source, QOF.Additional data filters: ordinary admissions only, ‘valid’ sex only, closed episodes only.RationaleThe indicator is based on a NICE Quality Standard (refer to section 3, Evidence Base) and has been identified by the NICE COF Advisory Committee for use in the Commissioning Outcomes Framework. NDA reports on complications prevalence in the NDA diabetes population annually, this is available publicly via the HSCIC website.Potential issuesSpecify ages – crucial to defining the denominator. QOF can only provide counts age 17 and above; DH seems to want 19+ for adults; NDA may provide more precise count.Should the source of the denominator be consistent across the diabetes indicators?Additional InformationCLASSPAT = ‘1’ or ‘2’ to select ordinary and daycase admissions only. Excluding regular day/night attender’s, maternity and birthsEPISTAT = ‘3’ (Selects finished episodes only)EPITYPE = ‘1’ (Selects general episodes only, excluding delivery and birth related episodes) checkSEX IN (‘1’,’2’) (Selects valid SEX)STARTAGE Between 0 AND 120 OR STARTAGE between 7001 AND 7007 (Valid ages)2010-11 HES data produced 7989 records for admissions for adults aged 17 and over.Alternatively NDA proposed methodology as followsIndicatorCOF 2. 63 NDA - Admission rates for diabetic ketoacidosis in people with diabetesConstruction and data sourceData source: Hospital Episode Statistics Admitted Patient Care Data (HES APC), GP Patient Data. NDAIndicator definition: the proportion of persons admitted to hospital with a diagnosis of diabetic ketoacidosis Indicator will be annual. This indicator will be a rate.Numerator: Number of people collected by the NDA who have a HES recording of (in primary and secondary diagnosis) of diabetic ketoacidosis as follows (E10.1, E11.1, E13.1, E14.1)Denominator: Number of people with diabetes collected by the NDA from primary and secondary careRationaleAs above.Potential issuesIdentifying denominator counts this way is consistent with other indicatorsUse same query filters as HES?Why exclude E12.1?RecommendationsCommissioning Outcomes Framework (COF) - Emergency admissions: diabetic ketoacidosis in people with diabetesRec 2012/47Recommendation that HES is used as the data source for indicator 2.63IndicatorCOF 2. 64 HES - The admission rate for hypoglycaemia in people with diabetes per X people with diabetesConstruction and data sourceData source: HES, QOF and GP Population DataIndicator definition: The admission rate for hypoglycaemia in people with diabetesIndicator will be reported annually (April to March). This indicator will be a rate.NumeratorThe number of emergency admission spell records in adults (age 17 or over) where either the primary or secondary diagnosis code is equal to one or more from the following ICD-10 codes below with a diagnosis code for hypoglycaemia, code E16.2DenominatorThe number of people registered to be diabetic aged 17 or over. Data source, QOF.RationaleThe indicator is based on a NICE Quality Standard (refer to section 3, Evidence Base) and has been identified by the NICE COF Advisory Committee for use in the Commissioning Outcomes Framework. NDA reports on complications prevalence in the NDA diabetes population annually, this is available publicly via the HSCIC website.Potential issuesSpecify ages – crucial to defining the denominator. QOF can only provide counts age 17 and above; DH seems to want 19+ for adults; NDA can provide more precise count.Should the source of the denominator be consistent across the diabetes indicators?Suggest using NDA for denominatorAdditional InformationIDC-10 CodesE10 Insulin-independent diabetes mellitusE11 Non-insulin-dependent diabetes mellitusE12 Malnutrition-related diabetes mellitusE13 Other specified diabetes mellitus E14 Unspecified diabetes mellitusO24.0 pre-existing diabetes mellitus, insulin-dependantO24.1 pre-existing diabetes mellitus, non-insulin-dependantO24.2 Pre-existing malnutrition-related diabetes mellitusO24.3 Pre-existing diabetes mellitus, unspecifiedO24.4 Diabetes mellitus arising in pregnancyO24.9 Diabetes mellitus in pregnancy, unspecifiedP70.2 Neonatal diabetes mellitusCLASSPAT = ‘1’ or ‘2’ to select ordinary and daycase admissions only. Excluding regular day/night attender’s, maternity and birthsEPISTAT = ‘3’ (Selects finished episodes only)EPITYPE = ‘1’ (Selects general episodes only, excluding delivery and birth related episodes) checkSEX IN (‘1’,’2’) (Selects valid SEX)STARTAGE Between 17 AND 120 (Valid ages)2010-11 HES data produced 8224 recordsNoCOPD3.7Of people admitted to hospital with [an exacerbation of COPD], the proportion who are under the [care of] a [respiratory consultant] within 48h of admission until discharge3.8Of those adults admitted to hospital following an exacerbation of COPD, the proportion who were readmitted within [x days] of dischargeIndicatorCOF 3.7 Of people admitted to hospital with [an exacerbation of COPD], the proportion who are under the [care of] a [respiratory consultant] within 48h of admission until dischargeConstruction and data sourceData source: Hospital Episode Statistics Admitted Patient Care Data (HES APC), GP Patient Data.Indicator definition: the percentage persons admitted to hospital with an exacerbation of COPD who are under the care of a respiratory consultant within two days of admission.Indicator will be quarterly. This indicator will be a percentage of the total CCG population meeting the denominator criteria.NumeratorNumber of spells where the first episode contains a primary or secondary diagnosis of exacerbation of COPD, code J44.1 and an episode that has an episode start date within two days of admission with the Main Specialty code of Thoracic\Respiratory Medicine, code 340DenominatorNumber of spells where the first episode contains a primary or secondary diagnosis of exacerbation of COPD, code J44.1RationaleIndicator 3.7 has been identified as being a key component of high quality care as defined in the NICE quality standard for COPD, statement 10: People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support.Potential issuesCannot report within 48 hours only because the data do not support this – can report more broadly “within 2 days”Specify age ranges – currently the proposal assumes all patients.Clarification regarding “until discharge”Additional InformationApplied filters:The following filters are suggested for application to both numerator and denominator, unless stated otherwise:MAINSPEF = ‘340’ (Respiratory consultant), applied to numerator onlyADMIDATE > DATEADD (DAY, -2, EPISTART) (EPISTART within 2 days of ADMIDATE), applied to numerator onlyEPIORDER = ‘1’ selects the first episode in a spell so only those admissions with COPD exacerbation recorded against the first episode in spell are counted which means that spells where exacerbation takes place whilst in hospital are excludedEPISTART >= ADMIDATE (DQ filter)CLASSPAT = ‘1’ or ‘2’ to select ordinary and daycase admissions only. Excluding regular day/night attender’s, maternity and birthsEPISTAT = ‘3’ (Selects finished episodes only)EPITYPE = ‘1’ (Selects general episodes only, excluding delivery and birth related episodes)SEX IN (‘1’,’2’) (Selects valid SEX)(STARTAGE Between 0 AND 120 OR STARTAGE Between 7001 AND 7007) (Valid ages)ICD-10 Codes J44.12010-11 data produced 31217 records of which 5942 were under the care of a respiratory consultant within 2 daysIndicatorCOF 3.8 - Of those adults admitted to hospital following an exacerbation of COPD, the proportion who were readmitted within [x days] of dischargeConstruction and data sourceData source: Hospital Episode Statistics Admitted Patient Care Data (HES APC), GP Patient Data.Indicator definition: 30 day readmissions for people who have been admitted following an exacerbation of COPDIndicator will be quarterly. This indicator will be a percentage of the total CCG population meeting the denominator criteria.NumeratorThe total number of emergency admission spell records in adults over the age of 18, where the first episode contains a primary diagnosis of exacerbation of COPD (ICD-10 code J44.1, Chronic Obstructive Pulmonary Disease with exacerbation, unspecified) and the patient has a previous admission in the previous 30 days, which also has a primary diagnosis code in the first episode relating to exacerbation of COPDDenominatorThe number of emergency admission spell records in adults over the age of 18, where the first episode contains a primary diagnosis of exacerbation of COPD and discharge method is not death.RationaleAs abovePotential issues30 day readmission recommended as this is increasingly becoming standard rather than 28 and also as 30 would be in line with Europe and Assuming adults are aged 19 and over as defined by DH.Additional InformationApplied filters:CLASSPAT = ‘1’ or ‘2’ to select ordinary and daycase admissions only. Excluding regular day/night attender’s, maternity and birthsEPISTAT = ‘3’ (Selects finished episodes only)EPITYPE = ‘1’ (Selects general episodes only, excluding delivery and birth related episodes) checkSEX IN (‘1’,’2’) (Selects valid SEX)STARTAGE Between 0 AND 120 OR STARTAGE between 7001 AND 7007 (Valid ages) (This came from original paperwork – indicator is adults only so should be >=19)ADMISORC <> ‘51’, ‘52’ ‘53’2010-11 data produced 31217 admissions of which 3145 were readmissions within 30 daysRecommendationsCommissioning Outcomes Framework (COF) 3.7 - Of people admitted to hospital with [an exacerbation of COPD], the proportion who are under the [care of] a [respiratory consultant] within 48h of admission until discharge3.8 - Of those adults admitted to hospital following an exacerbation of COPD, the proportion who were readmitted within [x days] of dischargeRec 2012/48Provide clarity on what is meant by “within two days” as per the indicator definition. In addition investigate further how a) patients who leave before 2 days have passed? b) patients who die? Are dealt with in the indicatorRec 2012/49Report back to NICE questions linked to data quality in which the preference of NICE is sought. This includes assurance around the use of specialist codes and whether the appropriate sub-specialities are being used.Recommendation updatesThe following indicator is presented for further consideration after previously being discussed at MRG (8th Sept 2011) and IGB (6th October 2011)IndicatorNHS-OF 4.7 (IAP00049) – Patient experience of community mental health servicesConstruction and data sourceMethod approved by MRG for use in CQC survey based indicators in the NHS Outcomes Framework – Sept 2011.Data source: CQC’s Community mental health services survey.Over 17,000 responses to 2010 survey – response rate of 33%.This is a composite indicator averaging scores from several questions. Individual questions are scored according to pre-defined scoring regime that awards scores between 0-100. Therefore the indicator will take values between 0-100. The questions have been selected by the Mental Health policy team at DH and assured by the Patient Experience Policy Team (PEPP).Full details of the selection and assurance are provided in document entitled ‘Mental Health D4 4.7 PEPP ASSURANCE SIGNED OFF’.Construction:Overall score of five separate questions. Data is standardised by age and sex. For each trust, an average weighted score is calculated for each of the relevant questions. Missing values are excluded from analysis. These scores are aggregated into the overall value using a simple weighted average. National domain scores are calculated by a simple average of the Trust scores.RationaleIt is now standard practice in healthcare systems worldwide to ask people to provide direct feedback on the quality of their experienceAdditional InformationOriginal submission was for the use of five questions:Thinking about the last time you saw this NHS health worker or social care worker for your mental health condition Did this person listen carefully to you?Did this person take your views into account?Did you have trust and confidence in this person?Did this person treat you with respect and dignity?Overall, how would you rate the care you have received from NHS Mental Health Services in the last 12 months?The last question in this list is no longer going to be used for the following reasons,CQC will be removing this question from next year, so no comparison over time would be possible.The DH NHS Outcomes Framework team did not wish to use an overarching question in a composite indicator.The mental health team at the department of health are proposing that question be replaced with the following three:Has anyone in the NHS mental health services ever asked you about your use of non-prescription drugs?In the last 12 months, have you received support from anyone in the NHS mental health services in getting help with your physical health needs?In the last 12 months, have you received support from anyone in the NHS mental health services in getting help with your care responsibilities (including looking after children)?The argument for the use of these replacement questions is given in the attached paper.Document available on request by email to indicators@.ukPotential issuesThe questions forming the original indicator were selected by the DH Mental Health team with support from the Patient Experience Policy programme (PEP).PEP has concerns over the proposed question selection:‘We now have 7 questions as data sources which relate to a range of different things and really question the transparency of the indicator.’?‘This indicator now sits outside the model we had adopted for the CQC data source indicators.’RecommendationsIt is recommended that the concerns raised in the meeting about the suitability of the 3 additional questions, and the apparent disconnect with the original 4 questions in the indicator is fed back to DHAppendix 1 – Read CodesRead codes – Structured Education Referral, Attendance or CompletionTypev2CTv3Term DescriptionReferral679R.679R.Patient offered diabetes structured education programmeReferral8Hj0XaKGyReferral to diabetes structured education programmeReferral8Hj3.8Hj3.Referral to DAFNE diabetes structured education programmeReferral8Hj4.8Hj4.Referral to DESMOND diabetes structured education programmeReferral8Hj5.8Hj5.Referral to XPERT diabetes structured education programmeReferral8I81.8I81.Did not complete diabetes structured education programmeReferral8I82.8I82.Did not complete DAFNE diabetes structured education programReferral8I83.8I83.Did not complete DESMOND diabetes structured education programmeReferral8I84.8I84.Did not complete XPERT diabetes structured education programmeReferral9NiA.9NiA.Did not attend diabetes structured education programmeReferral9NiC.9NiC.Did not attend DAFNE diabetes structured education programmeReferral9NiD.9NiD.Did not attend DESMOND diabetes structured education programmeReferral9NiE.9NiE.Did not attend XPERT diabetes structured education programmeReferral9OLM.9OLM.Diabetes structured education programme declinedReferral?8Hj0Referral to diabetes structured education programmeReferral?XaKSp Patient offered diabetes structured education programmeReferral?XaNTaDid not attend diabetes structured education programmeReferral?XaNTdDid not complete diabetes structured education programmeReferral?XaNTeDid not complete DAFNE diabetes structured education programReferral?XaNTfDid not complete DESMOND diabetes structured education programmeReferral?XaNTgDid not complete XPERT diabetes structured education programmeReferral?XaNTHDiabetes structured education programme declinedReferral?XaNTQReferral to dose adjustment for normal eating diabetes structured education programmeReferral?XaNTSReferral to diabetes education and self management for ongoing and newly diagnosed diabetes structured programmeReferral?XaNTTReferral to expert patient education versus routine treatment diabetes structured education programmeReferral?XaNU1Did not attend DAFNE diabetes structured education programmeReferral?XaNU2Did not attend DESMOND diabetes structured education programmeReferral?XaNU3Did not attend XPERT diabetes structured education programmeReferral?XaX49Referral to type I diabetes structured education programme????Attendance9OLB9OLBAttended diabetes structured education programmeAttendance9OLE.9OLE.Attended diabetes education and self management for ongoing and newly diagnosed structured programmeAttendance9OLG.9OLG.Attended expert patient education versus routine treatment diabetes structured education programmeAttendance9OLH.9OLH.Attended dose adjustment for normal eating diabetes structured education programmeAttendance?XaKH0Attended diabetes structured education programmeAttendance?XaN1zAttended diabetes education and self management for ongoing and newly diagnosed structured programmeAttendance?XaNT8Attended expert patient education versus routine treatment diabetes structured education programmeAttendance?XaNTAAttended dose adjustment for normal eating diabetes structured education programmeAttendance9OLF.9OLF.Diabetes structured education programme completedAttendance9OLJ.9OLJ.Dose adjustment for normal eating diabetes structured education programme completedAttendance9OLK.9OLK.Diabetes education and self management for ongoing and newly diagnosed structured programme completedAttendance9OLL.9OLL.Expert patient education versus routinetreatment diabetes structured education programme completedAttendance?XaNHWDiabetes structured education programme completedAttendance?XaNTBDose adjustment for normal eating diabetes structured education programme completedAttendance?XaNTCDiabetes education and self management for ongoing and newly diagnosed structured programme completedAttendance?XaNTDExpert patient education versus routine treatment diabetes structured education programme completedAttendance?XaX5DDiabetes structured education programme completed????Review66Af66AfPatient Diabetes Education ReviewReview679L.XaJ7DHealth education - diabetesReview679L0679L0Education in self management of diabetesReview?XaKGsPatient diabetes education reviewReview?XaR8LEducation in self management of diabetesRead Codes – Diabetes Diagnosisv2CTv3Diabetes Read Code DescriptionC10..C10..Diabetes mellitusC100.C100.Diabetes mellitus with no mention of complicationC1000C1000Diabetes mellitus: [juvenile type, with no mention of complication] or [insulin dependent]C1001C1001Diabetes mellitus: [adult onset, with no mention of complication] or [maturity onset] or [non-insulin dependent]C100zC100zDiabetes mellitus NOS with no mention of complicationC101.C101.Diabetic ketoacidosisC1010C1010Type 1 diabetes mellitus with ketoacidosisC1011C1011Type 2 diabetes mellitus with ketoacidosiC101yC101yOther specified diabetes mellitus with ketoacidosis specified manifestationC101zC101zDiabetes mellitus NOS with ketoacidosisC102.C102.Diabetes mellitus with hyperosmolar comaC1020C1020Diabetes mellitus, juvenile type, with hyperosmolar comaC1021C1021Diabetes mellitus, adult onset, with hyperosmolar comaC102zC102zDiabetes mellitus NOS with hyperosmolar comaC103.C103.Diabetes mellitus with ketoacidotic comaC1030C1030Type 1 diabetes mellitus with ketoacidotic comaC1031C1031Type 2 diabetes mellitus with ketoacidotic comaC10FP?Type 2 diabetes mellitus with ketoacidotic comaC103yC103yOther specified diabetes mellitus with comaC103zC103zDiabetes mellitus NOS with ketoacidotic comaC104.C104.Diabetes mellitus: [with renal manifestation] or [nephropathy]C1040C1040Diabetes mellitus, juvenile type, with renal manifestationC1041C1041Diabetes mellitus, adult onset, with renal manifestationC104yC104yOther specified diabetes mellitus with renal complicationsC104zC104zDiabetes mellitis with nephropathy NOSC105.C105.Diabetes mellitus with ophthalmic manifestationC1050C1050Diabetes mellitus, juvenile type, with ophthalmic manifestationC1051C1051Diabetes mellitus, adult onset, with ophthalmic manifestationC105yC105yOther specified diabetes mellitus with ophthalmic complicationsC105zC105zDiabetes mellitus NOS with ophthalmic manifestationC1060C1060Diabetes mellitus, juvenile type, with neurological manifestationC1061C1061Diabetes mellitus, adult onset, with neurological manifestationC106yC106yOther specified diabetes mellitus with neurological complicationsC106zC106zDiabetes mellitus NOS with neurological manifestationC107.C107.Diabetes mellitus with: [gangrene] or [peripheral circulatory disorder]C1070C1070Diabetes mellitus, juvenile type, with peripheral circulatory disorderC1071C1071Diabetes mellitus, adult onset, with peripheral circulatory disorderC1072C1072Diabetes mellitus, adult with gangreneC1073C1073IDDM with peripheral circulatory disorderC1074C1074NIDDM with peripheral circulatory disorderC107yC107yOther specified diabetes mellitus with peripheral circulatory complicationsC107zC107zDiabetes mellitus NOS with peripheral circulatory disorderC1080C1080Type I diabetes mellitus with renal complicationsC10E0?Type 1 diabetes mellitus with renal complicationsC1081C1081Type I diabetes mellitus with ophthalmic complicationsC10E1?Type 1 diabetes mellitus with ophthalmic complicationsC1082C1082Type I diabetes mellitus with neurological complicationsC10E2?Type 1 diabetes mellitus with neurological complicationsC1083C1083Type I diabetes mellitus with multiple complicationsC10E3?Type 1 diabetes mellitus with multiple complicationsC1085C1085Type I diabetes mellitus with ulcerC1086C1086Type I diabetes mellitus with gangreneC1087C1087Type I diabetes mellitus with retinopathyC1088C1088Type I diabetes mellitus - poor controlC1088C1088Type I diabetes mellitus - poor controlC1089C1089Type I diabetes mellitus maturity onsetC108yC108yOther specified diabetes mellitus with multiple complicationsC108zC108zUnspecified diabetes mellitus with multiple complicationsC1090C1090Type II diabetes mellitus with renal complicationsC1091C1091Type II diabetes mellitus with ophthalmic complicationsC1092C1092Type II diabetes mellitus with neurological complicationsC10F2?Type 2 diabetes mellitus with neurological complicationsC1093C1093Type II diabetes mellitus with multiple complicationsC10F3?Type 2 diabetes mellitus with multiple complicationsC1094C1094Type II diabetes mellitus with ulcerC1095C1095Type II diabetes mellitus with gangreneC1096C1096Type II diabetes mellitus with retinopathyC1097C1097Type II diabetes mellitus - poor controlC1097C1097Type II diabetes mellitus - poor controlC10A.C10A.Malnutrition-related diabetes mellitusC10A0C10A0Malnutrition-related diabetes mellitus with comaC10A1C10A1Malnutrition-related diabetes mellitus with ketoacidosisC10A2C10A2Malnutrition-related diabetes mellitus with renal complicationsC10A3C10A3Malnutrition-related diabetes mellitus with ophthalmic complicationsC10A4C10A4Malnutrition-related diabetes mellitus with neurological complicationsC10A5C10A5Malnutrition-related diabetes mellitus with peripheral circulatory complicationsC10A6C10A6Malnutrition-related diabetes mellitus with multiple complicationsC10A7C10A7Malnutrition-related diabetes mellitus without complicationsC10B0C10B0Steroid-induced diabetes mellitus without complicationC10C.C10C.Diabetes mellitus autosomal dominantC10D.C10D.Diabetes mellitus autosomal dominant type 2C10E.C10E.Type I diabetes mellitusC10E4C10E4Unstable type I diabetes mellitusC10EAC10EAType I diabetes mellitus without complicationC10EBC10EBType 1 diabetes mellitus with mononeuropathyC10ECC10ECType I diabetes mellitus with polyneuropathyC10EDC10EDType I diabetes mellitus with nephropathyC10EEC10EEType I diabetes mellitus with hypoglycaemic comaC10EFC10EFType I diabetes mellitus with diabetic cataractC10EGC10EGType I diabetes mellitus with peripheral angiopathyC10EHC10EHType I diabetes mellitus with arthropathyC10EJC10EJType I diabetes mellitus with neuropathic arthropathyC10EKC10EKType 1 diabetes mellitus with persistent proteinuriaC10ELC10ELType 1 diabetes mellitus with persistent microalbuminuriaC10EPC10EPType 1 diabetes mellitus with exudative maculopathyC10EQC10EQType 1 diabetes mellitus with gastroparesisC10ERC10ERLatent autoimmune diabetes mellitus in adultC10F.C10F.Type II diabetes mellitusC10F9C10F9Type II diabetes mellitus without complicationC10FAC10FAType II diabetes mellitus with mononeuropathyC10FBC10FBType II diabetes mellitus with polyneuropathyC10FCC10FCType II diabetes mellitus with nephropathyC10FDC10FDType II diabetes mellitus with hypoglycaemic comaC10FEC10FEType II diabetes mellitus with diabetic cataractC10FFC10FFType II diabetes mellitus with peripheral angiopathyC10FGC10FGType II diabetes mellitus with arthropathyC10FHC10FHType II diabetes mellitus with neuropathic arthropathyC10FJC10FJInsulin treated Type 2 diabetes mellitusC10FLC10FLType 2 diabetes mellitus with persistent proteinuriaC10FMC10FMType 2 diabetes mellitus with persistent microalbuminuriaC10FQC10FQType 2 diabetes mellitus with exudative maculopathyC10FRC10FRType 2 diabetes mellitus with gastroparesisC10FSC10FSMaternally inherited diabetes mellitusC10G.C10G.Secondary pancreatic diabetes mellitusC10G0C10G0Secondary pancreatic diabetes mellitus without complicationC10H.C10H.Diabetes mellitus induced by non-steroid drugsC10H0C10H0Diabetes mellitus induced by non-steroid drugs without complicationC10J.C10J.Insulin autoimmune syndromeC10J0C10J0Insulin autoimmune syndrome without complicationC10L0C10L0Fibrocalculous pancreatopathy without complicationC10N.C10N.Secondary diabetes mellitusC10N0C10N0Secondary diabetes mellitus without complicationC10y.C10y.Diabetes mellitus with other specified manifestationC10y0C10y0Diabetes mellitus, juvenile type, with other specified manifestationC10y1C10y1Diabetes mellitus, adult onset, with other specified manifestationC10yyC10yyOther specified diabetes mellitus with other specified complicationsC10yzC10yzDiabetes mellitus NOS with other specified manifestationC10z.C10z.Diabetes mellitus with unspecified complicationC10z0C10z0Diabetes mellitus, juvenile type, with unspecified complicationC10z1C10z1Diabetes mellitus, adult onset, with unspecified complicationC10zyC10zyOther specified diabetes mellitus with unspecified complicationsC10zzC10zzDiabetes mellitus NOS with unspecified complication?XaOPuLatent autoimmune diabetes mellitus in adult?XaOPtMaternally inherited diabetes mellitus?XaJUHInsulin autoimmune syndrome?XaJlNInsulin autoimmune syndrome without complicationC108.X40J4Type I diabetes mellitusC1084Xa4g7Unstable type I diabetes mellitus?X40JYInsulin-dependent diabetes mellitus secretory diarrhoea syndromeC108DXaF04Type I diabetes mellitus with nephropathy?XaIzMType 1 diabetes mellitus with persistent proteinuria?XaIzNType 1 diabetes mellitus with persistent microalbuminuriaC108FXaFm8Type I diabetes mellitus with diabetic cataract?XaJSrType 1 diabetes mellitus with exudative maculopathyC108BXaEnnType I diabetes mellitus with mononeuropathyC108CXaEnoType I diabetes mellitus with polyneuropathy?L1805Pre-existing diabetes mellitus, insulin-dependentC108AXaELPType I diabetes mellitus without complicationC108EXaFWGType I diabetes mellitus with hypoglycaemic comaC108GXaFmKType I diabetes mellitus with peripheral angiopathyC108HXaFmLType I diabetes mellitus with arthropathyC108JXaFmMType I diabetes mellitus with neuropathic arthropathyC109.X40J5Type II diabetes mellitusC109CXaF05Type II diabetes mellitus with nephropathy?XaIzQType 2 diabetes mellitus with persistent proteinuria?XaIzRType 2 diabetes mellitus with persistent microalbuminuriaC109EXaFmAType II diabetes mellitus with diabetic cataract?XaJQpType 2 diabetes mellitus with exudative maculopathyC109AXaEnpType II diabetes mellitus with mononeuropathyC109BXaEnqType II diabetes mellitus with polyneuropathy?L1806Pre-existing diabetes mellitus, non-insulin-dependentC1099XaELQType II diabetes mellitus without complicationC109DXaFWIType II diabetes mellitus with hypoglycaemic comaC109FXaFn7Type II diabetes mellitus with peripheral angiopathyC109GXaFn8Type II diabetes mellitus with arthropathyC109HXaFn9Type II diabetes mellitus with neuropathic arthropathyC109JX40J6Insulin treated Type 2 diabetes mellitus?X40J7Malnutrition-related diabetes mellitus?X40J8Malnutrition-related diabetes mellitus - fibrocalculous?X40J9Malnutrition-related diabetes mellitus - protein-deficientC10AXCyu21Malnutrition-related diabetes mellitus with other specified complicationsC10AWCyu22Malnutrition-related diabetes mellitus with unspecified complications?L1807Pre-existing malnutrition-related diabetes mellitus?X40JASecondary diabetes mellitus?X40JBSecondary pancreatic diabetes mellitus?XSETIFibrocalculous pancreatic diabetes?XaJlPFibrocalculous pancreatopathy without complication?XaJlLSecondary pancreatic diabetes mellitus without complication?X40JCSecondary endocrine diabetes mellitus?XSETKDrug-induced diabetes mellitus?XaJUIDiabetes mellitus induced by non-steroid drugs?XaJlMDiabetes mellitus induced by non-steroid drugs without complicationC10B.C11y0Steroid-induced diabetes?XaJlRSecondary diabetes mellitus without complication?Q441.Neonatal diabetes mellitus?X40JFTransitory neonatal diabetes mellitus?Xa08aSmall for gestation neonatal diabetes mellitus?X40JGGenetic syndromes of diabetes mellitus?X40JIDiabetes mellitus autosomal dominant?X40JJDiabetes mellitus autosomal dominant type 2?X40JKPolyglandular autoimmune syndrome - type II?X40JOCongenital lipoatrophic diabetes?X40JSHyperproinsulinemia?XSETHMaturity onset diabetes mellitus in young?66AJ1Brittle diabetes?X40JaAbnormal metabolic state in diabetes mellitus?Xa3eeDiabetes with ketoacidosis - no coma?XaCJ2Diabetic hyperosmolar non-ketotic stateC109KXaIrfHyperosmolar non-ketotic state in type 2 diabetes mellitus?X40JbDiabetic severe hyperglycaemia?X40JcPoor glycaemic control?66AJ0Chronic hyperglycaemia?X40JeAcute hyperglycaemia?X40JZDiabetes-deafness syndrome maternally transmitted?XSETpDiabetes mellitus due to insulin receptor antibodies?XE12GDiabetes + eye manifestation (& [cataract] or [retinopathy])?Cyu20Other specified diabetes mellitus?Cyu23Unspecified diabetes mellitus with renal complications?Lyu29Pre-existing diabetes mellitus, unspecified?XE10EDiabetes mellitus, juvenile type, with no mention of complication?XE10FDiabetes mellitus, adult onset, with no mention of complication?XE10GDiabetes mellitus with renal manifestationC106.XE10HDiabetes mellitus with neurological manifestation?XE10IDiabetes mellitus with peripheral circulatory disorder?XE12KDiabetes: [peripheral circulatory disease] or [gangrene]?XE12MDiabetes with other complications?XM1QxDiabetes mellitus with gangrene?XM1XkUnstable diabetes?XE128Diabetes mellitus (& [ketoacidosis])?XE12ADiabetes mellitus: [adult onset] or [noninsulin dependent]?XE12CDiabetes mellitus: [juvenile] or [insulin dependent]?XaKyWType 1 diabetes mellitus with gastroparesis?XaKyXType 2 diabetes mellitus with gastroparesisC10N1C10N1Cystic fibrosis related diabetes mellitusC10M0?Lipoatrophic diabetes mellitus without complicationC10M.?Lipoatrophic diabetes mellitusC10L.?Fibrocalculous pancreatopathyC10E5?Type 1 diabetes mellitus with ulcerC10E6?Type 1 diabetes mellitus with gangreneC10E7?Type 1 diabetes mellitus with retinopathyC10E8?Type 1 diabetes mellitus - poor controlC10E9?Type 1 diabetes mellitus maturity onsetC10EM?Type 1 diabetes mellitus with ketoacidosisC10EN?Type 1 diabetes mellitus with ketoacidotic comaC10F0?Type 2 diabetes mellitus with renal complicationsC10F1?Type 2 diabetes mellitus with ophthalmic complicationsC10F4?Type 2 diabetes mellitus with ulcerC10F5?Type 2 diabetes mellitus with gangreneC10F6?Type 2 diabetes mellitus with retinopathyC10F7?Type 2 diabetes mellitus - poor controlC10FK?Hyperosmolar non-ketotic state in type 2 diab mell C10FN?Type 2 diabetes mellitus with ketoacidosisC10K.?Type A insulin resistanceC10K0?Type A insulin resistance without complication?XaMzICystic fibrosis related diabetes mellitusAppendix 2 – Complications CodesNDA Complications – Diagnosis: ICD 10 CodesCodesComplication typeDescriptionI20.0AnginaUnstable anginaI20.1AnginaAngina pectoris with documented spasmI20.8AnginaOther forms of angina pectorisI20.9AnginaAngina pectoris, unspecifiedE10.1DKAInsulin-dependent diabetes mellitus with ketoacidosisE11.1DKANon-insulin-dependent diabetes mellitus with ketoacidosisE13.1DKAOther specified diabetes mellitus with ketoacidosisE14.1DKAUnspecified diabetes mellitus with ketoacidosisI50.0Heart FailureCongestive heart failureI50.1Heart FailureLeft ventricular failureI50.9Heart FailureHeart failure, unspecifiedI21.0MIAcute transmural myocardial infarction of anterior wallI21.1MIAcute transmural myocardial infarction of inferior wallI21.2MIAcute transmural myocardial infarction of other sitesI21.3MIAcute transmural myocardial infarction of unspecified siteI21.4MIAcute subendocardial myocardial infarctionI21.9MIAcute myocardial infarction, unspecifiedI22.0MISubsequent myocardial infarction of anterior wallI22.1MISubsequent myocardial infarction of inferior wallI22.8MISubsequent myocardial infarction of other sitesI22.9MISubsequent myocardial infarction of unspecified siteN18.0Renal FailureEnd-stage renal diseaseZ49.0Renal FailurePreparatory care for dialysisZ49.1Renal FailureExtracorporeal dialysisZ49.2Renal FailureOther dialysisZ99.2Renal FailureDependence on renal dialysisI61.0StrokeIntracerebral haemorrhage in hemisphere, subcorticalI61.1StrokeIntracerebral haemorrhage in hemisphere, corticalI61.2StrokeIntracerebral haemorrhage in hemisphere, unspecifiedI61.3StrokeIntracerebral haemorrhage in brain stemI61.4StrokeIntracerebral haemorrhage in cerebellumI61.5StrokeIntracerebral haemorrhage, intraventricularI61.6StrokeIntracerebral haemorrhage, multiple localizedI61.8StrokeOther intracerebral haemorrhageI61.9StrokeIntracerebral haemorrhage, unspecifiedI63.0StrokeCerebral infarct due to thrombosis of precerebral arteriesI63.1StrokeCerebral infarction due to embolism of precerebral arteriesI63.2StrokeCereb infarct due unsp occlusion or stenos precerebrl artsI63.3StrokeCerebral infarction due to thrombosis of cerebral arteriesI63.4StrokeCerebral infarction due to embolism of cerebral arteriesI63.5StrokeCerebrl infarct due unspec occlusion or stenos cerebrl artsI63.6StrokeCereb infarct due cerebral venous thrombosis, nonpyogenicI63.8StrokeOther cerebral infarctionI63.9StrokeCerebral infarction, unspecifiedI64.XStrokeStroke, not specified as haemorrhage or infarctionI67.9StrokeCerebrovascular disease, unspecifiedNDA Complications – Procedures: OPCS4 Codes CodesProcedure typeDescriptionX09.3Major AmputationAmputation of leg, Amputation of leg above kneeX09.4Major AmputationAmputation of leg, Amputation of leg through kneeX09.5Major AmputationAmputation of leg, Amputation of leg below kneeX09.8Major AmputationOther specified amputation of legX09.9Major AmputationUnspecified amputation of leg?X10.1Minor AmputationAmputation of foot, Amputation of foot through ankleX10.2Minor AmputationAmputation of foot, Disarticulation of tarsal bonesX10.3Minor AmputationAmputation of foot, Disarticulation of metatarsal bonesX10.4Minor AmputationAmputation of foot, Amputation through metatarsal bonesX10.8Minor AmputationAmputation of foot, Other specifiedX10.9Minor AmputationAmputation of foot, UnspecifiedX11.1Minor AmputationAmputation of toe, Amputation of great toeX11.2Minor AmputationAmputation of toe, Amputation of phalanx of toeX11.8Minor AmputationAmputation of toe, Other specifiedX11.9Minor AmputationAmputation of toe, UnspecifiedM01.1Renal FailureTransplantation of kidney, Autotransplantation of kidneyM01.2Renal FailureTransplantation of kidney, Allotransplantation of kidney from live donorM01.3Renal FailureTransplantation of kidney, Allotransplantation of kidney from cadaverM01.4Renal FailureAllotransplantation of kidney from cadaver heart beatingM01.5Renal FailureAllotransplantation of kidney from cadaver heart non-beatingM01.8Renal FailureTransplantation of kidney, Other specifiedM01.9Renal FailureTransplantation of kidney, UnspecifiedX40.1Renal FailureCompensation for renal failure, Renal dialysisX40.2Renal FailureCompensation for renal failure, Peritoneal dialysisX40.3Renal FailureCompensation for renal failure, Haemodialysis necX40.4Renal FailureHaemofiltrationX40.5Renal FailureAutomated peritoneal dialysisX40.6Renal FailureContinuous ambulatory peritoneal dialysisX40.7Renal FailureHeamoperfusionX40.8Renal FailureCompensation for renal failure, Other specifiedX40.9Renal FailureCompensation for renal failure, UnspecifiedC82.1Retinopathy TreatmentsDestruction of lesion of retina, Cauterisation of lesion of retina C82.5Retinopathy TreatmentsPanretinal laser photocoagulation to lesion of retina NECC82.6Retinopathy TreatmentsLaser photocoagulation to lesion of retina NEC ................
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