Benchmarking can be a useful method to improve standards of health care. Comparisons of outcomesbetween different hospitals and regions, if performedand interpreted correctly, can be used to explore ways ofidentifying deficiencies in care and to help improveprocesses to benefit health care delivery. A new NHSAtlas of Variation for England has been published, and itstates: ‘Our aim is to put variations in activity, expendi-ture, quality, outcome, value, and equity firmly on thehealth service agenda for the next decade and to stimulate the NHS to search for unwarranted variationand, by extension, to tackle the causes and drivers of that variation.’ In terms of endocrine problems, the Atlasreported on diabetes-related amputations, the percent-age of people recorded as receiving nine key diabetescare processes, and rates of bariatic surgery.1 For ampu-tation the results show a variation from around 1.5 per1000 patients with type 2 diabetes undergoing lowerextremity amputation in South East England and theWest Midlands to 3 per 1000 patients in South WestEngland. The percentage of patients receiving nine keycare processes in diabetes varied from 2% to 70% acrossall primary care trusts in England. What factors may contribute to a two-fold variation in amputation and a35-fold variation in process of care?

Amputation rates: interpreting the dataFirstly, it should be asked whether the association is dueto artefact or is a real association that does not appear tobe explained by chance, bias or confounding. It is alsocrucial to consider whether the measurement is anappropriate reflection of quality of care. Using amputa-tions as an example (Atlas map 3) it is important torecognise that although amputations are a reasonableguide of foot care, early amputation can sometimes be abetter outcome than delayed or absence of amputation2

which may even precipitate early death. Secondly, the interpretation of the data needs exam-

ining. The data presented are adjusted for differences inthe distribution of age and sex between different popu-lations. However, other variables, such as deprivation,smoking status and ethnicity, which are known to beassociated with risk of amputation and vary by regionand could therefore confound the association, do notappear to have been considered in the comparisons ofamputation rates. It may be that regions with loweramputation rates have diagnosed more patients withearly onset in diabetes. In itself this is not a bad thing,but it will increase the denominator when calculatingthe rates of amputation. This results in a lowering ofrates due to a statistical quirk rather than anything to dowith improved foot care. It would thus be useful to knowthe adjusted prevalence of diagnosed diabetes in eachregion, or the rates of amputation per total population,as this would help in the interpretation of the data.

Additionally, many patients in hospital with diabetesand co-existing conditions are not recorded as having diabetes.3 Rayman showed that only 74% of patients with diabetes undergoing amputation were recorded as havingdiabetes,4 and recent data from Scotland indicate that theproportion of people with diabetes who had diabetesrecorded in routine hospital data varied from 34–88%between hospitals5 reflecting a large variation in a relativelysmall geographical area. In addition, many patients, who were diagnosed as having diabetes during the admis-sion that led to an amputation, may not be recorded ondischarge data as having diabetes. The use of routine collected clinical data to make comparisons betweenregions may also contribute to some of the variationobserved in analyses as data are collected in different ways.

How can best practice be shared?Thus, the data need to be interpreted with some caution.However, although part of the variation may be due toinaccuracy, it is likely that part is real and there is consen-sus that improving diabetes care and reducing amputationrates are desirable outcomes. The logical follow-on ques-tion is ‘how can best practice be shared?’ Initially, the focusshould be on evidence-based practice, as evidence-basedhealth care is most likely to be robust in the delivery ofbenefit over the long term.6,7 Multidisciplinary foot clinics(MDFCs) have been shown to reduce amputations.8,9 TheNHS Atlas reports the changes in amputation rates afterintroducing MDFCs in Ipswich and Torbay, with at least athree-fold reduction,10 and locally we report a reduction inamputations at a time when an MDFC was introduced.11

MDFCs are complicated to organise. Although an increasein resource is often required, more efficient use of currentresource and cross-disciplinary cooperation can con-tribute a great deal towards an effective service. One likelybenefit of an MDFC is that it acts as a focal point for manyof the other evidence-based benefits in foot care such astotal contact casting, negative pressure wound therapy and others.7,12 Screening has been shown to effectively identifythe patient at risk,7,13 thus allowing scarce resources to betargeted towards those at greatest need. The long-termbenefits of addressing risk factors, such as glycaemic control, hypertension, dyslipidaemia and smoking, shouldnot be underestimated.

Further considerationsPatients at greatest risk of amputation appear to be thosewith ischaemic feet and infection.14 Observational studies have demonstrated the benefit of early vascularintervention.15–17 Regions with higher rates of amputa-tion should be encouraged to explore the accessibility ofrapid vascular intervention services, and to see if theylink with diabetes services effectively. Unfortunately,there are few data on randomised control trials (RCTs)of vascular interventions in patients with diabetic foot

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Variation in practice: a useful measure or not?Looking at amputations and diabetes care

ulcers,7 and such an RCT is urgently required. Forinfected foot ulcers, empirical antibiotics should bestarted early using the knowledge of local microbiologi-cal sensitivities, and changing the antibiotic when theresults of specific sensitivities become available. Generalpractitioners and hospital practitioners need to be awareof the need for early use of high dose antibiotics, and inthis regard local antibiotic policies18 can be useful.

Processes of careFor processes of care (Atlas map 4), when the top andbottom 5% of primary care trusts (health care based population groupings of which there were approximately150 in England at the time of the analysis with popula-tions varying between 90 000 and 1.3 million people) areremoved from the analysis, the variability drops from 35-fold to five-fold. The appropriateness of these ‘measurements’ being assessed may be more debateablethan with amputation, but as some of these data arelinked to payments for general practitioners they may bemore accurate. It is notable that clinicians have a very varied response to incentivised target-based schemes.Furthermore, although there may be an improvement inthese measurements in all areas, with a mean improve-ment for the population as a whole, the differencesbetween the best and the worst areas, and hence the variation, may increase. Thus, increased variation shouldnot be mistaken for deteriorating levels of care.

ConclusionWe live in an era where guidelines proliferate, but theevidence is often limited and the implementation of therecommendations frequently fails. The NHS Atlas ofVariation1 is a pointer towards this, and such benchmark-ing should be used as a tool to spread best practice acrossall areas. The information should be used in a construc-tive dialogue and a genuine desire to resolve unneces-sary barriers to care. The temptation to use such data asa competitive league table needs to be strongly resisted,and areas with poorer outcomes need to be supported toidentify the explanations for their outcomes and to helpimprove their own services.

GP Leese, Consultant in Diabetes andEndocrinology, Department of Diabetes, Ninewells Hospital and Medical School, University of Dundee, UKSH Wild, Reader in Epidemiology and PublicHealth, Centre for Population Health Sciences,University of Edinburgh, UKME Edmonds, Consultant Physician, Diabetic FootClinic, King’s College Hospital, London, UK

Conflict of interest statementThere are no conflicts of interest.

References1. NHS Atlas of Variation in Healthcare (2010). www.

rightcare.nhs.uk/atlas/ [last accessed 7/12/2010].2. Jeffcoate WJ, van Houtum WH. Amputation as a marker of

the quality of foot care in diabetes. Diabetologia 2004; 47:2051–8.

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4. Rayman G, et al. Are we underestimating diabetes-relatedlower-extremity amputation rates? Diabetes Care 2004; 27(8):1892–6.

5. Anwar H, Wild S. Assessment of the underreporting of dia-betes related morbidity in hospital admission data. PublicHealth in Scotland 2010 abstracts book, Scottish HealthServices Centre, 2010, Edinburgh.

6. NICE guidance on type 2 diabetes – foot care (2004).www.nice.org.uk/nicemedia/live/10934/29242/29242.pdf[last accessed 7/12/2010].

7. SIGN guideline on diabetes (2010). www.sign.ac.uk/pdf/sign116.pdf [last accessed 7/12/2010].

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9. Larsson J, et al. Decreasing incidence of major amputation indiabetic patients: a consequence of a multidisciplinary footcare team approach? Diabet Med 1995; 12: 770–6.

10. Krishnan S, et al. Reduction in diabetic amputations over 11years in a defined U.K. population: benefits of multidiscipli-nary team work and continuous prospective audit. DiabetesCare 2008; 31: 99–101.

11. Schofield CJ, et al. Decreasing amputation rates in patientswith diabetes – a population based study. Diabet Med 2009; 26:773–7.

12. Hinchliffe RJ, et al. A systematic review of the effectiveness ofinterventions to enhance the healing of chronic ulcers of thefoot in diabetes. Diabetes Metab Res Rev 2008; 24(Suppl 1):S119–44.

13. Leese GP, et al. Predicting foot ulceration in diabetes: valida-tion of a clinical tool in a population-based study. Int J ClinPract 2006; 60: 541–5.

14. Prompers L, et al. Prediction of outcome in individuals with dia-betic foot ulcers: focus on the differences between individualswith and without peripheral arterial disease. The EURODIALEStudy. Diabetologia 2008; 51: 747–55.

15. Winell K, et al. The national hospital discharge register dataon lower limb amputations. Eur J Vasc Endovasc Surg 2006; 32:66–70.

16. Zayed H, et al. Improving limb salvage rate in diabeticpatients with critical leg ischaemia using a multidisciplinaryapproach. Int J Clin Pract 2009; 63: 855–8.

17. Uccioli L, et al. Long-term outcomes of diabetic patients withcritical limb ischemia followed in a tertiary referral diabeticfoot clinic. Diabetes Care 2010; 33: 977–82.

18. Leese G, et al. Use of antibiotics in people with diabetic foot dis-ease: A consensus statement. The Diabet Foot J 2009: 12: 62–78.

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CONFERENCE NOTICE

Diabetes UK Annual Professional Conference30 March – 1 April 2011, International Conference Centre, London

Contact website: www.diabetes.org.uk