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Spring Update - DVLA, HbA1C & strip usage, and of course Libre stats

I was hoping that this update would include a discussion of the new national Libre policy, which I contributed to.  However, I should have known that the wheels of central NHS bureaucracy move glacially slowly and a month after the final draft was submitted for approval, the final version has still not been published.  I am hoping that the final version of the policy hasn't been appreciably watered-down as the version that was submitted was well thought-out and fair.

DVLA Update

At 22:30 on Valentines Day, without fanfare, the DVLA quietly released the new guidelines for those who use insulin and drive (fortunately, I had an alert for all DVLA document releases, so had an early notification of the release).  As mentioned previously in this blog, the law was changed over a year ago to allow for this change, but it's taken a long time for the new guidelines to be released.  This was in part because of a challenge from a pharma company who suggested this was unfair (it isn't!).

The key change is below (broadly, Group 1 drivers are those that drive cars and don't drive them for a living).

People have asked whether apps like Glimp and xdrip+ can be used.  This is also clarified in the guidance.
The Libre reader and the Librelink app both have CE marks (as does all the official Dexcom infrastructure), however third-party apps do not.  So, these third-party solutions cannot be used for this proof - however is this an academic issue?  

There is still a requirement to have a traditional testing method available as there are times where the CGM/Flash monitor result needs to be confirmed using a finger prick test.

There have also been questions whether you can use the Libre reader whilst driving.  I think this is clear, although I'm not sure I have the co-ordination to achieve this.  The law says that you cannot use a mobile communication device whilst driving.  So, Librelink is clearly off-limits.  However, is the official reader?  My interpretation is that the reader can be used, with an important caveat.  Here's what the law says defines a communication device
The reader performs none of the functions specified in (c) so therefore it is not covered in the "you must touch whilst driving" rules that apply to phones.

However, it is covered under the rules that includes actions like programming a satnav, re-tuning the radio, eating a sandwich etc.  If you're deemed not to be in full control of your vehicle, then you could be prosecuted.  As I said at the beginning though, I think scanning and driving would be a bit challenging anyway, but at least now you know the reality of what you technically are and aren't allowed to do!

This new regulation should make the prescribing of Libre most cost-effective as the number of required test strips should decline.

HbA1C and Strip Usage

HbA1C

My attendance at a DAFNE course in November 2016 had a profound effect not only on me personally, but it also opened my eyes to the world of T1 Diabetes outside the social media bubble.  The people on my course were lovely, but knew almost nothing about their condition.  I'm not going to apportion blame here, but did wonder how and why, and whether the people I'd met were representative of the wider T1 population.  As usual, I thought I'd dig into the stats to find out.  

As luck would have it, the National Diabetes Audit 2017/2018 was published recently.  It has a range of useful stats and has data that can be analysed down to each individual surgery - there are 55 T1s at my surgery, 44% of whom have an A1C under 7.5%...and the surgery aren't interested in engaging with me!!.  Here is the state of HbA1C levels across all T1s in England:

30% of T1s achieve an HbA1C less than 7.5% (58.5mmol/mol avg BG 9.4mmol/l)

8% of T1s achieve an HbA1C less than 6.5% (47.5mmol/mol avg BG 7.8mmol/l)

So nationally, just 8% of T1s achieve the target that the NHS has set for T1s.  It is easy to argue that this target is inappropriate both clinically and because so few achieve it, however that's the target.

It's possible then to look at those same figures, but at a CCG level to see the range of percentages achieving each level.

**EDIT** I thought the top segment was those under 8.5%, but actually, the level is under 10% (thanks for the tip-off).  To put that in perspective, in the area with the lowest percentage achieving that, 25% of T1s have an average blood glucose over 13mmol/l!
So, in one CCG, just 17% of T1s achieve an HbA1C less than or equal to 7.5%.  Why's 7.5% important?  It's the level above which microvascular complications have been proven to be more likely to occur. 

It is interesting to look at the best and lowest performing areas in terms of this measure to see whether that tells us anything:
The top 5 are in southern areas, some, but not all fairly affluent.  The lowest 5 seem to be less affluent, in more northern areas.  I'm guessing this may not be a surprise.  However, the audit also details the deprivation index, so I looked at the rank of deprivation against the HbA1C measures.  There were some like Richmond CCG which followed the expected pattern of affluence being a good marker of HbA1C success, but there were some striking differences - one in particular was very different.  

City & Hackney CCG is the 193rd out of 195 in terms of deprivation, but 8th in terms of HbA1C measures.  55% of surgeries in the CCG have all of their T1 patients achieving an HbA1C less than 7.5%.  It would be interesting to know what's behind these figures.  Is there something within this CCG that means it is bucking the trend, or is there another explanation?

Test Strip Usage

In terms of strip usage, I managed to get hold of a scientific paper about this.  It was from 2014, but I've no reason to believe it is different today.  Unfortunately, it's behind an expensive paywall, but with some persistence, I managed to get a copy.  The paper reports data about test strip usage amongst people with Type 1 Diabetes on different insulin regimes.  I'm interested in basal-bolus users and those using pumps.  Here were the stats reported (some of which I've derived using statistical analysis):

Average strip usage all T1 per day - 2.11 strips a day. (2.68 for MDI, 3.14 for pump users)

Average of over 8 finger pricks a day on MDI - 0.64% of the T1 population

Average over 8 finger pricks a day on pump - 2.4% of the T1 population

Is this shocking?  Not to me, but I think I've had a glimpse of the world outside the rarefied environment of the online diabetes community.  I extrapolated the over 8 figure, mainly because that's the target for many of the previous Libre policies.  I think it will surprise people to know the tiny percentage of PWD that test that often - I could never achieve that level of testing, or really see the point...but I know many do.

I think there are two important messages from this analysis:
  • Tech is all well and good and we should be pushing to get the best tech possible...but we need to remember there are many people (possibly the majority) for whom tech isn't the most important intervention.  The results above sadden me and I wish I could do more to address that.  I strongly believe that engagement through primary care is one such key to this and why I am so frustrated that my particular surgery isn't interested.
  • Hopefully the data should give a boost to anyone who looks at the amazing results on display across many online forums and thinks they are perhaps not achieving. Just by being involved with diabetes social media or attending off-line groups in order to understand more about their condition they are already doing better than most.

Libre Update

Prescribing continues across all of the UK with an increase of around 20% each month in England.  The increases in Northern Ireland have now slowed and for three of the last four months, there has been almost no change, indeed in Wales and Scotland, the last two months have seen a plateauing of prescribing.
There's still lots of misunderstanding about what is going to happen post-April and the publishing of the new policy.  I've explained my thoughts on it to our group members many times, trying to dispel the fake news floating around - particularly from the East of England CCGs who seem especially obstreperous towards Libre.  Here's a concise summary I posted earlier this week:

There will be a new policy released. It has been formulated, but there's a delay in getting it approved. It should be this week or next...but the wheels of the central NHS move slowly. It will apply from 1st April.

There is funding for a maximum of 25% of T1s to get Libre on prescription. The new policy will aim to meet that 25%.  It's an imprecise science, but the thought is that if applied efficiently, more than 25% will get it. Some areas will undoubtedly be slower than others and in some areas.  I don't think as many as 25% will want it/make best use of it in all areas either. 

Therefore around 60k T1s will get Libre. It's not perfect, some people won't be happy, but that's a long way from the around 4.5% that get it funded currently.

And finally, as it's always good to end with a nice table of figures, here are the top 10 CCGs by estimated percentage of T1s with Libre on prescription from primary care taking into account the size of the CCG (data is for December 2018):


Fingers crossed that the next update will have the detail of the new national Libre policy.

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