NEW ZEALAND HEALTH S TRATEGY
DHB TOOLKIT
Diabetes
To reduce the incidence and impact of diabetes
2003
Edition 1: October 2001 Updated December 2003
Contents
Contents .......................................................................................................................... 2
Executive summary ......................................................................................................... 3
Summary of action points............................................................................................. 3
Development of this toolkit ............................................................................................... 6
Scope of the diabetes toolkit ........................................................................................ 6
Linkages ...................................................................................................................... 6
Introduction ...................................................................................................................... 8
What is diabetes? ........................................................................................................ 8
Burden of disease ........................................................................................................ 9
Control and treatment of diabetes .............................................................................. 10
The role of DHBs ....................................................................................................... 10
Strategic direction – disease management approach .................................................... 12
Reducing the incidence of type 2 diabetes .................................................................... 14
Community-based primary prevention in New Zealand .............................................. 14
Screening for type 2 diabetes .................................................................................... 15
Reducing the impact of diabetes .................................................................................... 17
National framework for diabetes services .................................................................. 17
Management and planning......................................................................................... 19
Primary care – free annual check............................................................................... 21
Diabetes education and self-management ................................................................. 22
Guidelines and reviews of evidence ........................................................................... 25
Hospital and other specialist diabetes services .......................................................... 25
Type 1 diabetes in children and young people ............................................................... 26
Guidelines and reviews of evidence ........................................................................... 26
The impacts of diabetes on body systems ..................................................................... 27
The impact of diabetes on the cardiovascular system ................................................ 27
The impact of diabetes on the eyes ........................................................................... 28
The impact of diabetes on the feet ............................................................................. 29
Modelling and quality assurance .................................................................................... 30
Modelling diabetes ..................................................................................................... 30
Evaluating the quality and performance of diabetes services ..................................... 30
APPENDIX 1: ............................................................................................................. 33
References .................................................................................................................... 36
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Executive summary
Diabetes presents a serious health challenge for New Zealand. It is a significant cause of ill health
and premature death. Reducing the incidence and impact of diabetes is therefore one of the 13
immediate action priority objectives for population health in the New Zealand Health Strategy.
This toolkit provides information and resources to assist District Health Boards (DHBs) and
Primary Health Organisations (PHOs) to work toward that objective.
Diabetes affects about 200,000 people in New Zealand but only half of these people have been
diagnosed. The prevalence of diabetes across the population of New Zealand is currently
estimated at around 4 percent. Within the New Zealand population, the prevalence of diabetes in
Maori and Pacific populations is around three times higher than among other New Zealanders.
Diabetes is defined by abnormalities in the regulation of blood glucose levels, but it is a chronic
condition causing kidney failure, eye disease, foot ulceration and a higher risk of heart disease.
Although there are other types of diabetes, the scope of this toolkit is restricted to type 1 and type
2 diabetes:

Type 1 is an autoimmune condition that typically develops in children and young adults
and absolutely requires insulin

Type 2 typically develops in middle or older ages but it is increasingly seen in overweight
children. Depending on the stage of development it is treated with a combination of drugs
and diet, although insulin may also be required.
Type 1 has the greatest impact on an individual and their family/whanau and is not preventable.
Type 2, representing about 90 percent of people with diabetes, is doubling every 15 years as a
result of the ageing population, increasing obesity and physical inactivity. Type 2 is substantially
preventable with lifestyle changes.
Primary prevention programmes aimed at reducing the risk factors for type 2 diabetes (ie,
reducing obesity and increasing physical activity) could have major benefits in reducing the
future impacts of type 2 diabetes. However, with little international evidence of primary
prevention programmes that have been effective, further research is required to develop effective
programme models. The National Diabetes Research Strategy, jointly funded by the Ministry of
Health and the Health Research Council, has funded research to develop and test communitybased programmes for preventing diabetes in high-risk people.
Once diabetes has been diagnosed, effective management, including treatment, education and
support, is required to maintain health and prevent the development of diabetes-related
complications. This toolkit cannot over emphasise the value of teamwork and collaboration
between health professionals, people with diabetes, local organisations and national agencies to
ensure that intersecting services work together for people with diabetes. To improve the quality
and effectiveness of treatment, services should work together to intervene earlier, intervene more
effectively and increase the uptake of interventions. Services must be structured and well coordinated, with effective information flows between care providers.
Summary of action points
General
The Ministry of Health will implement the Healthy Eating-Healthy Action strategy to improve
nutrition, increase physical activity and reduce obesity.
District Health Boards should implement the 2003 updated evidence based guideline
Management of Type 2 Diabetes (available from the NZGG website, www.nzgg.org.nz).
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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•
District Health Boards should develop a disease management approach to diabetes through
multidisciplinary services that have the information and knowledge to drive continuous
quality improvement at every stage in diabetes management.
•
District Health Boards and PHOs should use the “Get Checked” data to monitor the
number of people accessing free checks, the quality of care and the impact of diabetes in their
enrolled populations.
•
Personal health strategies should focus on identifying type 2 diabetes earlier, improving the
quality of all diabetes treatment, and improving the uptake of services by people with
diabetes.
Children and young people with diabetes
•
District Health Boards should review the specialist paediatric services that are available for
young people with diabetes. The review should cover access to specialist outpatient services
by ethnicity, and by children and young people in rural areas.
•
District Health Boards should work with key stakeholders to promote programs that
improve nutrition, increase physical activity and reduce obesity in children and young people
The impacts of diabetes on the cardiovascular system
•
Primary care organisations/PHOs offering free annual checks should review the prevalence
of all cardiovascular risk factors for people in their diabetes register by ethnicity. Specific
quality initiatives to optimise treatment in high-risk groups should be developed.
•
Hospitals should consider implementing systems to ensure people admitted (for any reason)
who have raised cardiovascular system (CVS) risk factors receive advice about reducing risk
factors. Risk factors and recommendations should be highlighted in discharge summaries or
plans for primary care.
•
Hospitals should ensure that all people admitted with potentially diabetes-related diseases
(and especially for CVS disease) are screened for diabetes. Hospitals may consider auditing a
sample of clinical records to establish coding accuracy for diabetes.
•
After primary care organisations have reported on CVS treatment and risk factors by
ethnicity, Local Diabetes Teams (LDTs) should review the information and consider
recommendations to the DHB for improving the quality and effectiveness of cardiovascular
treatment.
The impacts of diabetes on the eyes
•
Funding and performance staff of District Heath Boards should work with Local Diabetes
Teams to identify opportunities to improve retinal screening uptake in high-risk groups, and
establish targets for the DHB performance indicator.
•
Primary care organisations/PHOs should review the information about eye screening in
their diabetes registers, and work with eye screening services to identify geographic areas or
population groups in which screening uptake is low.
•
Hospitals providing hospital-based eye screening should consider implementing systems that
offer appropriate eye screening to people with diabetes who attend outpatients clinics or are
admitted for any reason. Such systems are particularly important for ‘hard to reach’ people
from rural areas or people who find transport to hospital difficult.
•
Hospitals should consider a clinical audit of cases of vitrectomy in people with diabetes, in
order to establish any opportunities for earlier intervention or improvements in eye screening
or laser treatment.
•
Eye screening services should work with LDTs, primary care organisations, and hospital
diabetes specialists to agree on the guidelines and processes for referral into diagnosis and
treatment.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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•
The Ministry of Health will facilitate – with existing eye screening services – the
development of a National Eye Screening Quality Programme.
The impacts of diabetes on the feet
•
Primary care organisations/PHOs should review with podiatry services the referral
guidelines for people with high-risk feet.
•
Local Diabetes Teams may choose to recommend retailers trained (perhaps by a local
podiatrist) in advising people with diabetes about shoes, foot protection (eg, insoles and
socks) and skin care for the feet.
•
Primary care organisations/PHOs, hospital diabetes services, and other organisations
providing formal education for people with diabetes should specify their foot-care education
syllabus and supporting education resources.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Development of this toolkit
The New Zealand Health Strategy has identified 13 immediate action priority areas for population
health. DHBs are required to report annually on progress in each of these priority areas.
This toolkit provides information and resources to assist DHBs to achieve the objective of
reducing the incidence and impact of diabetes in their communities. It will do so by providing:
•
a summary of the existing New Zealand strategies and the relevant international evidence
about the incidence and impact of diabetes
•
an outline of the existing national framework for diabetes services
•
links providing information about the most effective interventions, with practical suggestions
for quality improvement in New Zealand
•
nationally consistent clinical indicators for use by DHBs to monitor quality improvements
and diabetes trends over time.
This toolkit was developed by the Ministry of Health in association with the National Diabetes
Working Group, which is an expert group comprising clinicians, people with diabetes (and their
representatives), Maori and Pacific peoples.
Scope of the diabetes toolkit
Although there are several types of diabetes, the scope of this toolkit is limited to diabetes type 1
and type 2. The toolkit provides information on reducing the incidence of type 2 diabetes through
public health programmes. It also discusses reducing the impact of type 1 and type 2 diabetes
through treatment and management programmes delivered by primary/secondary care and allied
health professionals.
This toolkit has been developed for DHB funding and planning teams, LDTs, management staff
in health care provider organisations, clinicians, and people with diabetes. Given this broad
audience, the toolkit must balance technical detail and general explanations, requiring some
compromise. This toolkit will be updated periodically, and once a year the evidence and
guidelines will be systematically updated.
Linkages
This toolkit has clear links with other New Zealand Health Strategy priority areas including:
• reducing the incidence and impact of cardiovascular disease – Best Practice, Evidence-based
Guideline: The Assessment and Management of Cardiovascular Risk (available from the
NZGG website, www.nzgg.org.nz).
• improving nutrition – Healthy Eating - Healthy Action. Oranga Pumau – Oranga Kai: A
strategic framework
•
reducing the rate of obesity
•
increasing the level of physical activity
•
reducing smoking.
Links to cardiovascular disease
Even in healthy people before clinical diabetes has developed, there is evidence that blood
glucosei and HBA1cii may be independent risk factors for the development of cardiovascular
disease. Once diabetes has developed it is very strongly associated with other risk factors for the
development of cardiovascular disease, to the extent that lipid abnormalities, raised blood
pressure and type 2 diabetes may be regarded as features of a common metabolic syndrome.
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Links to nutrition
Ministry of Health publications relating to nutrition
Nutrition and the Burden of Disease
Nutrition influences weight. Diet and nutritional planning that prevents weight gain during adult
life will have the positive benefits of reducing the risk and improving the management of
diabetes.
Diet is also fundamentally important in managing insulin treatment for people with both type 1
and type 2 diabetes. There is substantial and mounting evidence that changes to diet and lifestyle
significantly reduce the incidence and impact of type 2 diabetes. In a recent United States study
of 3,234 people with impaired glucose tolerance (the Diabetes Prevention Program, DPP), the
risk of developing type 2 diabetes reduced by 58 percent for those who received intensive
lifestyle and nutrition counselling.iii For those on the drug arm of the study (850 mg Metformin
bd), risk of development reduced by 31 percent. These results are consistent with those of a 2001
prevention study undertaken in Finland.iv
Dietitians play a central role in the nutrition counselling and follow-up required in the ongoing
management of diabetes.
Links to obesity and physical activity
Prevention of Obesity and Type 2 Diabetes in New Zealand Children (available from the
Diabetes New Zealand website, www.diabetes.org.nz)
People who are overweight or physically inactive have a higher chance of developing type 2
diabetes than their contemporaries. Weight loss and/or increased physical activity will reduce the
chance of these people developing diabetes in future. In New Zealand and every comparable
country, increasing obesity rates have led to a significant increase in the proportion of people who
develop type 2 diabetes in any given age group. The term diabesity has been used to refer to this
combined epidemic.
For people with newly diagnosed type 2 diabetes, both weight loss and physical activity can be
very effective in managing diabetes – provided that they are sustained in the long term.
Links to smoking
People with diabetes who smoke are at significantly higher risk of developing cardiovascular
complications associated with diabetes, including coronary heart disease and stroke. It is of
particular concern that rates of smoking remain high in Maori, a population with a higher
prevalence of diabetes than the general population.
He Korowai Oranga – Maori Health Strategy
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Introduction
Key points
• Diabetes is defined by abnormalities in glucose levels in the blood, but it affects virtually
every organ in the body.
•
Both type 1 and type 2 diabetes are increasing in incidence. Type 2 diabetes is diagnosed
increasingly in children and teenagers.
•
Type 2 diabetes is a substantially preventable condition. The main factors contributing to the
increasing incidence of type 2 diabetes are rising levels of obesity and physical inactivity in
New Zealand populations.
Main actions for DHBs
• Public health strategies are crucial to reduce both the incidence and impact of type 2 diabetes.
•
A disease management approach to diabetes is needed, with multidisciplinary services that
have the information and knowledge to drive continuous quality improvement at every stage
in the development of diabetes and its complications.
•
Personal health strategies should focus on identifying type 2 diabetes earlier, improving the
quality of all diabetes treatment and improving the uptake of services by people with
diabetes.
•
Effective communication links among care providers from primary to tertiary level, including
allied health providers such as podiatrists and dietitians, are vital to ensure the co-ordination
of diabetes services.
What is diabetes?
Diabetes is characterised by raised blood glucose levels as a consequence of insulin undersecretion, insulin resistance, or both. Diagnostic criteria for diabetes have been agreed by the
World Health Organizationv and the major clinical diabetes organisations in Australasia.vi
Type 1 diabetes typically develops in children and young adults. It is an auto-immune disease in
which insulin-producing cells in the pancreas are destroyed. People who develop type 1 diabetes
will become dependent on balancing injected insulin, diet and exercise for control of blood
glucose levels.
The reported incidence of type 1 diabetes is ‘very high’ in New Zealand compared with other
countries. For reasons that are not yet clear, the incidence of the condition appears to be
increasing in New Zealand and internationally.vii
The provision of health care services for people with type 1 diabetes should reflect that its impact
on quality of life and long-term complications are substantially greater than for type 2 diabetes.
Type 1 diabetes is less common in Maori and Pacific peoples than in New Zealand Europeans.
Type 2 diabetes is caused by reduced insulin secretion and/or resistance to the action of insulin
on body tissues. In all people the ability of the pancreas to secrete insulin in response to body
needs falls progressively with age. Decreasing insulin secretion capacity results in impaired
glucose tolerance, which then leads to the development of type 2 diabetes. Strong links have been
established between type 2 diabetes and obesity. A hormone released by fat cells that exacerbates
the effects of falling insulin levels may mediate this relationship.viii
A range of oral diabetes medications is used in the treatment of type 2 diabetes. These
medications function by stimulating insulin release, decreasing insulin resistance or affecting
carbohydrate absorption. Many people with type 2 diabetes eventually require insulin to maintain
optimal treatment as diabetes progresses.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Burden of disease
Type 2 diabetes is about three times more common in Maori and Pacific peoples than in New
Zealand Europeans. Overall it represents about 95 percent of known diabetes in Maori and Pacific
peoples, and about 89 percent of known diabetes in New Zealand Europeans.
Type 2 diabetes typically develops in people over 40–50 years old, although the onset may be
earlier in overweight people and in Maori or Pacific peoples. In recent years, however, type 2
diabetes has increasingly been recognised in teenagers and even younger children. ix In the United
States of America the mean age of children at diagnosis of type 2 diabetes is between 12 and 14
years, and the condition is most common in females, non-Europeans, and people who are
overweight, inactive, have a family history of diabetes or were exposed to diabetes in utero. x This
trend is disturbing as these people are almost certain to develop the advanced complications of
diabetes during their lifetime, and will represent a significant burden of disease in future years.
Reducing the incidence and impact of diabetes through public health or any other health measures
will be extremely challenging as type 2 diabetes already represents a substantial burden of disease
for New Zealanders. Figure 1 reflects the extent to which diabetes relative to other major risk
factors contributes to disability adjusted life years.
Figure 1: Attributable burdens, total mortality, for different causes, 1997
Source of base data: compiled from multiple sources
Note: Diabetes – as a risk factor for other diseases as well as a disease in itself
Source: Ministry of Health (2003)xi
As well as representing a substantial burden of disease currently, the prevalence of type 2
diabetes is increasing in New Zealand. With the number of people with diabetes in New Zealand
predicted to increase 1.8 fold by 2011, the burden of diabetes and its complications will rise
significantly. A proportion of this increase in prevalence will be the result of the ageing
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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population and other demographic trends, but almost one third will be a consequence of more
common obesity.
Type 2 diabetes is a substantially preventable condition, at least in theory, given sustained
reduction of modifiable risk factors such as obesity, physical inactivity and smoking. The
challenge to health systems in New Zealand and around the world is to develop programmes that
achieve a sustained reduction of risk across the population.
Control and treatment of diabetes
In general, there are three kinds of opportunities to improve the quality and effectiveness of
personal health services.
1. Intervene earlier: Type 2 diabetes generally remains asymptomatic for several years.
Diagnosis, and therefore treatment, are often delayed. It is estimated that approximately half
the people with diabetes in New Zealand and Australiaxii have not been diagnosed. For these
people, by the time the diagnosis is made and treatment started, complications have already
developed in a significant proportion of people.
2. Intervene more effectively: There is substantial evidence from New Zealand and overseas
that the quality of treatment could be significantly improved. xiii To this end, structured
systems should include regular recall and review using evidence-based guidelines by
appropriately trained and experienced primary care clinicians.xiv Referral to appropriate
specialist services must use set clinical criteria to identify those at highest risk.
3. Improve the uptake of interventions: Many people with diagnosed diabetes do not reliably
access treatment available to them. This group includes some of the people at highest risk of
developing diabetes complications. The technical quality of diabetes treatment services may
be excellent but, to be effective, they must reach those most in need of them. It is generally
agreed that the core barriers to increasing uptake in New Zealand include:
– difficulty accessing specialist services from the community
– the cost of services and medications
– lack of choice of culturally appropriate services
– psychosocial factors related illness perception and beliefs.
The three kinds of opportunities to improve the quality and effectiveness of personal health
services, as identified above, require multidisciplinary care teams, in which clinicians from
primary through to tertiary care, people with diabetes, and people from related consumer support
organisations work together.
Primary health organisationsxv are pivotal in co-ordinating and providing a more comprehensive
range of services that are:
•
easily accessed by people most in need
•
at a cost that they can afford
•
in a setting that is culturally safe and effective in motivating self-management and lifestyle
change.15, 16, 17
Major complications of diabetes are managed largely through specialist care in hospital and
other settings. This toolkit provides information on the treatment of diabetes from primary to
tertiary care.
The role of DHBs
Both the incidence and impact of type 2 diabetes are strongly linked to socioeconomic
deprivation in our communities. Strategies to control diabetes should therefore extend well
beyond the health sector. DHBs are well placed to co-ordinate local, multisector programmes that
target the gaps between those most and least advantaged in our society.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Moreover, DHBs are in an excellent position to integrate public health, primary health and
specialist hospital services in their areas to ensure that the programmes to reduce the risk of
diabetes, and the services available to people with diabetes, are as effective as possible. This
integrative potential will be especially evident when both personal and public health are included
in population-based funding.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Strategic direction – disease management
approach
In 1997 the Ministry of Health set out its strategic direction for diabetes management in
Strategies for the Prevention and Control of Diabetes. That document advocates a disease
management approach to diabetes. Such an approach would focus on people with diabetes and
their experience of the complete clinical course of the condition, rather than viewing diabetes care
as a series of discrete episodes within different parts of the health system.
The aims of Strategies for the Prevention and Control of Diabetes are to improve co-ordination
and information flows among stakeholders in diabetes care and to improve diabetes services
through integrating primary, secondary and allied health services.
To that end, in managing diabetes services DHBs should consider the three fundamental
components proposed for disease management by Hunter and Fairfield:xvi
‘Research, performance measurement, and quality improvement.’
The Ministry of Health’s strategic direction for diabetes addresses the full course of diabetes from
primary prevention of type 2 diabetes to the treatment of diabetes and its complications. In
summary, the strategies focus on four areas of action:
1. primary prevention of type 2 diabetes
2. identification of people with diabetes, and enrolment into structured programmes in primary
care
3. monitoring of the health of people with diabetes through free annual checks, and the use of
population-health information from these checks for quality improvement and service
planning
4. treatment planning, including the full spectrum of care from community- to hospital-based,
and including allied health services (eg, podiatry and dietetics).
While including the primary prevention of type 2 diabetes through increasing physical activity,
improving nutrition and reducing obesity, Strategies for the Prevention and Control of Diabetes
notes that influencing such lifestyle changes was difficult and was largely reliant on factors
beyond the control of the health sector. One of the key strategies in the 1997 document is to fund
research and develop integrated pilot programmes to prevent diabetes, especially in high-risk
populations such as Maori and Pacific peoples.
The 1997 strategy document was followed in 2000 with the Health Funding Authority’s Diabetes
2000 implementation plan. Diabetes 2000 describes services and structures to be put in place to
deliver on the strategy. It also provides a framework for service delivery (see ‘Reducing the
impacts of diabetes’). The initiative at the centre of the framework is the implementation of the
free annual check, which provides an opportunity for people with diabetes to check, with their
general practitioner or practice nurse, that the important diabetes tests and examinations have
been completed each year, and agree on a treatment plan for the coming year.
In addition, Diabetes 2000 established the LDTs, with representation from practitioners at all
levels of diabetes care, along with consumer representatives.
LDTs provide:

a local integrated group to oversee diabetes care within each region

analysis of data from primary care

advice to DHBs on service planning.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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(These services are described in greater detail in ’Reducing the impacts of diabetes’.)
 Download Diabetes 2000
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Reducing the incidence of type 2 diabetes
Key points
• The scope of this section is limited to reducing the incidence of type 2 diabetes.
•
The global epidemic of type 2 diabetes is having an increasing impact on disability,
premature mortality, and consumption of finite health resources.
•
Maori and Pacific populations are amongst the highest risk groups for diabetes and for
cardiovascular disease and related conditions.
•
Effective primary prevention programmes for type 2 diabetes are largely based around
programmes for the reduction of diabetes risk factors.
•
Research sentinel sites will be established to gather evidence on community-based primary
prevention programmes for type 2 diabetes.
•
Opportunistic screening in primary care has the potential to provide an effective system for
earlier detection of diabetes.
Type 1 diabetes is an auto-immune condition. As its cause is unknown, it is not possible at
present to implement services to reduce its incidence. For that reason, the scope of this section is
limited to reducing the incidence of type 2 diabetes.
In New Zealand by 2011, the prevalence of diabetes is predicted to increase by 58%, 132% and
146% in European, Maori and Pacific populations respectively. This increase reflects changing
demographic factors (including increased population size and changes in population age
structure) and epidemiological factors (such as obesity and physical inactivity).
The above figures highlight the substantial challenge represented by the New Zealand Health
Strategy. The changes in our population mean that the prevalence of diabetes would not be
reduced absolutely even if the increase in obesity and physical inactivity were completely halted
over the next 20 years.
The increasing incidence of diabetes will inevitably mean that diabetes has a greater impact in
New Zealand. However optimally applied, no treatment exists that can compensate (by
preventing diabetes complications) for even a twofold increase in the number of people with
diabetes. In summary, without reducing the incidence we will not be able to reduce the total
impact of diabetes either.
Fortunately New Zealand has the experience and infrastructure to lead the world in developing
effective and validated interventions to reduce the incidence of diabetes in future. In review of the
international evidence around potentially modifiable risk factors, J Mann xvii summarises the
limitations of approaches targeting people with impaired glucose tolerance (IGT), endorses the
essential role of community-based primary prevention programmes, and highlights the critical
importance of applied research.
Community-based primary prevention in New Zealand
Effective primary prevention programmes for type 2 diabetes are largely based around
programmes to reduce diabetes risk factors, such as be reducing overweight/obesity, stopping
smoking and increasing physical activity. Such programmes extend beyond the health sector,
involving local government, employers, education and community groups, amongst others.
Maori and Pacific populations are amongst the highest risk groups for diabetes and for
cardiovascular disease and related conditions. These populations traditionally have strong
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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community links, which are important to the success of health programmes targeting the above
risk factors.
There is little New Zealand evidence for community-based primary prevention interventions,
while international evidence is equivocal with regard to whether such programmes can reduce
diabetes incidence in the longer term. The Diabetes 2000 implementation plan proposes that
research sentinel sites be established to develop community-based programmes for primary
prevention of type 2 diabetes in a New Zealand setting (see ‘Research into primary prevention
and screening’).
Dr Andrew Lindsay from Auckland Public Health has reviewed the evidence for primary
prevention from New Zealand and overseas studies. He concluded that community-based primary
prevention programmes were justified.xviii Subsequently international studies have given more
support to this conclusion.
 Download Dr Lindsay’s full paper - Primary Prevention of Type 2 Diabetes - A Critical
Appraisal of Community Based Primary Prevention Programmes
Screening for type 2 diabetes
Type 2 diabetes generally remains asymptomatic for several years. For this reason it is estimated
that half the people with diabetes in New Zealand and Australia have not been diagnosed and
therefore remain untreated. International evidence suggests that in determining whether screening
programmes are implemented, their potential benefits should be carefully weighed against the
costs and ethical considerations. A recent review from the United Kingdomxix reached the
following conclusions:
• Universal screening for diabetes is unmerited, but targeted screening in specific high-risk
subgroups may be justified
• The benefits of early detection and treatment of undiagnosed diabetes have not yet been
proven. The potential disadvantages of screening should be quantified
• Effectiveness of diabetes screening in reducing cardiovascular disease depends of disease
prevalence, background cardiovascular risk, and risk reduction in those screened and treated
• Clinical management of people with established diabetes should be optimised before a
screening programme is considered.
Experience from other countries shows that the effective implementation of broad-scale
community screening programmes is fraught. For example, the American Diabetes Association
recently withdrew its recommendations about community screening in the absence of evidence of
cost-effectiveness.
Although current international evidence does not support broad-scale community screening, it
does indicate that screening targeted at high-risk populations or groups may be effective.
Targeted screening in Maori and Pacific populations may therefore be effective provided that it is
carefully planned and that services ensure that people who screen positive are referred reliably for
diagnosis and treatment. Any screening programmes developed should screen for cardiovascular
disease and diabetes together, given the extremely close association between these conditions.
Opportunistic screening in primary care (where patients presenting for other reasons, but
exhibiting risk factors for diabetes are screened for diabetes) has the potential to provide an
effective system for earlier detection of diabetes. The New Zealand Health Survey found that
over 80 percent of people had seen their general practitioner or nurse in the previous year, which
implies that primary care organisations working within set screening criteria would have the
opportunity to detect people with a high diabetes risk. Diagnostic testing should be offered to
anyone exhibiting hypertension, lipid abnormalities, or possible diabetes symptoms who presents
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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to a general practitioner or nurse in primary care. Opportunistic diabetes screening criteria would
extend beyond such symptoms and include general risk factors.
An evidence-based review commissioned for New Zealandxx reached the following conclusions:
•
No single test can distinguish people with diabetes from those without diabetes
•
Several screening tests are available, and all are more accurate at distinguishing diabetes from
non-diabetes in high-risk populations
•
Within the first two groups assessed, the authors preferred fasting glucose and random
glucose as the cheapest and most widely used screening tests practised internationally
•
The authors discouraged the use of urine testing for screening
•
The authors recommended screening the following groups:
– non-Europeans > age 30, and Europeans > age 40 if other risk factors present (retest
three-yearly following negative screening test)
– non-Europeans > age 40, and Europeans > age 50 in the absence of other risk factors
(retest three-yearly after negative screening test)
– all people (regardless of age) with a past history of impaired glucose tolerance or
impaired fasting glucose (retest yearly following negative screening test).
•
General practice is the preferred venue for screening as 80–90 percent of people who may
need screening attend a general practice annually.
•
All parties involved in screening should be educated and trained to correctly test, interpret
results and ensure appropriate follow-up of tests.
 See the full paper of the review www.nzgg.org.nz/working_groups/diabetes.cfm - Screening
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Reducing the impact of diabetes
Key points
• Effective diabetes care requires a collaborative and integrated team approach. DHBs are well
placed to ensure diabetes services are delivered consistently and effectively.
•
A framework has been developed for the delivery of diabetes care and the promotion of
continuous quality improvement.
•
The foundation for diabetes services is the free annual check, delivered at primary care level
to reduce the risk of developing diabetes complications.
•
How people with diabetes manage their condition is a significant factor in determining the
long-term outcomes of diabetes. Diabetes education is therefore extremely important, but
there are major challenges to delivering effective education programmes.
•
The already high levels of morbidity and mortality caused by diabetes complications are
likely to become higher as more people get diabetes. It is therefore vital that specialist
services preventing and treating diabetes complications are effective.
National framework for diabetes services
Unstructured care in the community is associated with poorer follow-up, greater
mortality, and worse glycaemic control than hospital care. Computerised central recall,
with prompting for patients and their family doctors, can achieve standards of care as
good or better than hospital outpatient care, at least in the short term. This evidence
supports provision of regular prompted recall and review of people with diabetes by
willing general practitioners and demonstrates that this can be achieved, if suitable
organisation is in place.
Cochrane Review (Nov 1997)
The national framework for diabetes services was developed to ensure that a structured quality
system for delivering diabetes care – including regular recall and review of all people with
diabetes – is available.
Effective diabetes care requires a multidisciplinary team. In addition, to effectively deliver the
full spectrum of services to those people with diabetes who require them, diabetes care must
ensure that clinical services, including podiatry and dietetics, are aligned with primary and
hospital-based clinicians. In New Zealand non-medical clinical services have typically been
accessed through referral of the patient by primary care to hospital outpatient diabetes services.
There is a national framework for hospital services (including those for diabetes) separate to this
framework for diabetes in primary care. It is recommended that the framework for diabetes
services in primary care and the framework for outpatient services should be streamlined to
enable the seamless delivery of diabetes services within a district.
Figure 2 shows the relationships between people with diabetes, health care providers and other
organisations involved in the care of people with diabetes. It shows the types of services provided
through primary, secondary and allied health services, as well as illustrating the flow of
information among organisations.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
17
Figure 2
The national framework for diabetes
Free Annual Check
Person
with
Diabetes
With general practitioner and/or
primary care diabetes nurse
• Reviews treatment against
guidelines
• Undertakes any outstanding
tests
• Agrees on a treatment plan for
the year
Primary health organisation
• Maintains register of data from free
annual checks
• Promotes quality improvement
• Provides feedback to general
practices
• Reports aggregated diabetes data to
Local Diabetes Team
• Refers to other services if
required
• Passes data to primary health
organisation
Local Diabetes Team
• Includes clinical and consumer
representation
Diabetes retinopathy eye
screening
Hospital (and non-hospital-based)
specialist services
• Provides feedback to referring
practice
• Provides feedback to referring
practice
• Provides information to Local
Diabetes Team
• Provides information to Local
Diabetes Team
• Combines information from all public
health organisations in DHB area
• Collects information from hospital
and other specialist services
• Analyses information and develop
recommendations for service
improvements
• Prepares an annual report and
provides it to DHB
District Health Board
• Conducts health needs assessment, including consideration of recommendations in the Local
Diabetes Team report, when planning diabetes services
• Includes diabetes in annual plan
• Communicates with DHB population
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 2
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Management and planning
The framework in Figure 2 describes the information flows among the key stakeholders involved
in diabetes care. This section outlines the role of a number of people and organisations involved
in diabetes care.
People with diabetes
People with diabetes are clearly the primary stakeholders in diabetes care. A number of consumer
groups represent and support people with diabetes.
Diabetes New Zealand is the largest of these organisations with membership of over 13,500
people. Diabetes New Zealand, through its network of 36 regional diabetes societies, raises
awareness and provides resources to assist people with diabetes to learn about their condition and
how it should be managed. Diabetes New Zealand also manages a mail-based supply scheme
(Diabetes Supplies Ltd) for blood glucose meters, testing strips, other diabetes products and
educational resources.
 Diabetes New Zealand can be contacted through www.diabetes.org.nz
The prevalence of type 2 diabetes is significantly higher in Maori than in the general population.
Te Roopu Mate Huka is a Maori consumer organisation established to support Maori people with
diabetes and to raise awareness of diabetes amongst Maori.
Diabetes Youth New Zealand (DYNZ) is a national group representing children and youth with
diabetes. Most children and youth with diabetes have type 1 diabetes and have quite different
needs from adults, both medically and socially. DYNZ provides support for the child and family,
produces educational resources, runs camps for children and adolescents with diabetes, and
advocates for the needs of its members. In addition to this work at the local level, the DYNZ
committee organises national fund-raising, provides a national newsletter and provides
representation on the National Diabetes Forum and the International Diabetes Federation.
District Health Boards
DHBs are ideally placed to ensure that diabetes prevention and treatment services in a district are
planned and delivered consistently and effectively. DHBs will be in the best position to foster a
collaborative and integrated team approach to diabetes prevention and care involving consultation
with provider and consumer organisations. DHBs and the Ministry of Health will work together
to promote continuous quality improvement for diabetes services.
Diabetes status as one of the 13 priority areas noted in the New Zealand Health Strategy should
be reflected in DHB planning and in documentation prepared by DHBs. The Ministry of Health
expects that strategic plans prepared by DHBs will contain specific information about diabetes,
and that DHBs will prepare a comprehensive annual plan identifying priorities and targets for
diabetes services.
DHB annual plans should specify:
•
priorities identified for diabetes
•
targets for diabetes, including targets for the clinical indicators specified in this toolkit (see
‘Modelling and quality assurance’)
•
the services available for people with diabetes, which must include a free annual check for
people with diabetes, first specialist and follow-up attendances, and multidisciplinary
education and management services as presently funded from public hospitals
•
the workforce resources input into diabetes
•
the workforce development that will be provided.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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It is anticipated that DHBs will make one person accountable for the planning and co-ordination
of diabetes services within the district. This person should be available to co-ordinate planning in
provider organisations and will be the DHB’s representative on the LDT. Annual plans for
primary care organisations/PHOs and the hospitals in a DHB should also include specific sections
on diabetes services, and the priorities and targets should be consistent with DHB plans.
It is expected that the DHB, or one of its mandated subcommittees, will consider the
recommendations of the LDT when developing its strategic and annual plans.
A recent paper by Klonoff and Schwartz, who examine the costs and benefits of 17 diabetes
interventions, may provide useful guidance to DHB management.xxi These interventions are
discussed in more detail throughout this toolkit.
Local Diabetes Teams
LDTs were established to meet the need, as identified in Diabetes 2000, for a team of local
stakeholders to oversee the planning, implementation and integration of diabetes services in their
district. The Ministry of Health views LDTs as a vital local asset and well placed to provide
advice to DHBs on the state of diabetes services across the district.
The service specification for LDTs identifies the minimum set of organisations that should be
represented on them. LDTs should include representatives from the DHB, diabetes providers
(from primary to tertiary care), diabetes consumer organisations, and Maori and Pacific
communities. The major output of LDTs, as stated in the service specification, is the preparation
of an annual report summarising the free annual check data from primary care organisations
throughout the district, and recommending improvements to diabetes services.
 Download the Local Diabetes Team service specification
Ministry of Health
During 2003/04 the Ministry of Health will continue to focus on:

collaborating with the sector to ensure all people with diabetes can access primary health
care

ensuring people get quality advice on self-management of their diabetes.
Included in the Ministry of Health programmes are the following:
•
The Ministry of Health will work with primary health organisations and practice management
system vendors to further improve diabetes information systems. The priorities identified are
to improve user friendliness, improve decision support linked to evidence-based guidelines
and develop customisable treatment plans
•
A National Diabetes Database that could be used to link encrypted data uploaded from
primary care organisations to mortality and hospitalisation data
•
The Ministry will continue to fund diabetes awareness and support services provided by
Diabetes New Zealand. This includes free glucose meters and test strips for people with
Community Services Cards.
Applied research: The Ministry has established the National Diabetes Research Strategy in
association with the Health Research Council of New Zealand. The first priority is to fund the
community-based projects for primary prevention and screening (see Diabetes 2000). Other
research areas will be addressed where funding permits.
The Ministry of Health will continue to support the New Zealand Guidelines Group in updating
clinical guidelines. The latest diabetes guideline update is November 2003.
In regard to evaluation and quality improvement:
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
20
•
an evaluation tool for use by DHBs to assess the quality and integration of diabetes services
has been developed with DHBs
•
the Ministry of Health is funding and will support the establishment of a national quality
assurance programme for retinopathy screening.
Toolkit maintenance: Ongoing development and updating of this diabetes toolkit will be
required. The benefits and costs of specific diabetes treatments will be reviewed and published in
later editions of this toolkit.
The Ministry of Health will also continue to provide support for DHBs and LDTs.
Primary care – free annual check
A free annual check is funded through the national Get Checked programme for all people with
an established diagnosis of type 1 or type 2 diabetes. People with gestational diabetes, or those
who have never met the diagnostic criteria for diabetes, are not funded for free annual checks.
The free annual check is delivered at primary care level by a general practitioner or appropriately
trained primary care nurse with access to primary care notes. The primary care provider may be a
primary care organisation, or a Maori or Pacific provider organisation.
A key objective of the free annual check is to decrease the barriers to accessing high quality care for
Maori and Pacific peoples. For that reason, services should be provided at venues that are
appropriate to maximise access by Maori and Pacific peoples.
Primary care organisations must maintain electronic registers of information collected through the
free annual checks, using a minimum dataset defined in the service specification. Aggregated
(non-identifiable) summaries of that information must then be transferred to LDTs for each DHB.
The free annual check is the foundation for diabetes services. It is designed to improve the coordination of services delivered by all health care providers.
The objectives of the free annual check are to:
•
systematically screen for the risk factors and complications of diabetes to promote early
detection and intervention. Note the free annual check is to check that the screening has
occurred in the previous year, and does not require all tests or examinations are repeated at
the time of the annual check
•
agree on an updated treatment plan for each person with diabetes. The treatment plan (or
equivalent) should be provided in writing and verbally for the person with diabetes, and any
other providers of diabetes support (eg, whanau)
•
update the information in the diabetes register used as a basis for clinical audit and planning
improvements to diabetes services in the area
•
prescribe treatment and refer for specialist or other care if appropriate.
The free annual check must include:
•
a review of symptoms and concerns of the person with diabetes or their whanau
•
an examination for risk factors and complications, which must include a foot examination and
advice about basic foot care (for clinical guidelines see ‘Additional information and resources
for diabetes primary care’)
•
a fasting blood test for cholesterol, HDL and triglycerides
•
a blood test for HBA1c
•
a urine test for early nephropathy, as clinically indicated
•
prescription for medications, glucose test strips or glucose monitors (as required)
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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•
information for the person with diabetes and their consent for the use of information by the
primary care organisation. Specific consent must be obtained from the patient if the primary
care organisation proposes to forward identifiable contact or clinical information from the
primary care organisation to other diabetes service providers
•
forwarding of the minimum information from the practice to the primary care organisation for
analysis and reporting
•
the development and agreement of a treatment plan that includes feedback to the person with
diabetes and their whanau, an agreed self-management plan (including any changes to
medication) and plans for referral to specialist services.
The 2002 national Get Checked results are available here as a PDF.
Additional information and resources for diabetes primary care
•
A range of resource materials was developed for the Get Checked programme, including
posters and pamphlets in different languages, and a video targeting Maori. These resources
are available from public health information outlets.
•
For the guidance of general practitioners and primary care nurses, the New Zealand,
evidence-based guidelines for diabetes interventions are available at www.nzgg.org.nz/.
•
The National Waiting Times project developed referral guidelines. Those guidelines are
available from www.nzgg.org.nz/ for the information of general practitioners and primary
care nurses.
Diabetes education and self-management
The choices that people with diabetes make about managing their lifestyle and treatment options
are significant factors in the long-term outcome of the condition. It is therefore vital that their
choices are informed. Informing people with diabetes requires effective and accessible education
and management programmes.
Multidisciplinary teams in hospitals or in community settings currently deliver diabetes education
and management services. The composition of teams, and the services/programmes they provide,
should be flexible, responding to the specific needs of the population and individuals. The
diabetes education and management team should incorporate dietetic and podiatry services as
well as more general diabetes education.
Improving the effectiveness of diabetes education and self-management is a major challenge for
diabetes educators. Effective self-management is also a major challenge for the people who
matter most – people with diabetes.
Type 1 diabetes
For people with type 1 diabetes and their families/whanau, formal education is essential for
maintaining quality of life and reducing the risk of poor health outcomes.
Formal education occurs at the time of diagnosis and is sustained thereafter by specialist teams
and primary care. For people with type 1 diabetes informal education occurs every day through
experience with self-testing and adjusting insulin dosage, diet, exercise and the other complex
variables in their lives. Professional support for the informal learning process is also important. It
can be delivered in a variety of ways, for example through telephone support.
In New Zealand and internationally, youth camps can be an appropriate venue for diabetes
continuing education in young people. They may be a very effective and cost-effective method
for delivering services.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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Type 2
For people with type 2 diabetes, education around the treatment and control of diabetes is
important. However, the challenges for motivating weight loss, physical activity and compliance
with medication are perhaps even more significant than in type 1 diabetes. The extent of the
challenge arises because the rewards of self-management and healthy lifestyles in people with
type 2 diabetes are typically difficult to achieve, and may never be apparent to the asymptomatic
individual. Thus the programmes developed need to be effective in motivating sustained
behaviour change.
Current international evidence (outlined in the reviews of evidence below) challenges the
underlying premise that knowledge about diabetes is reliable in motivating changes in lifestyle or
the ability to sustain these changes.
The Alberta Heritage Foundation for Medical Research in Canada recently published a systematic
review of the evidence for patient diabetes education (PDE).xxii The review found that it was not
possible to identify consistent factors that made the many types of patient education programmes
effective. That is not to say that education is ineffective, rather that no one approach is
necessarily more effective than another. This finding illustrates the complexities of patient
diabetes education, and indicates that more research should be undertaken to fill knowledge gaps.
DHBs should specifically consider the recommendations for administrators of PDE programmes
in the abridged summary of the Alberta Heritage Foundation for Medical Research review, which
is provided below.
Abridged summary of the Alberta Heritage Foundation For Medical Research Review of
Patient Diabetes Education (PDE)
The published reports on the effectiveness of PDE as a tool to promote self-management in
adults with type 2 diabetes produced mixed results in terms of improved metabolic control
and reduced risks for diabetes-associated complications in the long term. The results are not
directly comparable since investigators have used different designs. Inadequate data
presentation also limited the interpretation of the available evidence.
The main finding of the review was that the long-term diabetes control outcomes of formal PDE,
when used to promote self-management in adults with type 2 diabetes, have yet to be defined.
Appropriate measures are also not yet established.
The available evidence did not permit reliable conclusions to be drawn on:
•
which types of programmes or what components are most effective in improving the
ability of adults with type 2 diabetes to self-manage their disease
•
which category of patients might benefit most.
This review confirmed results of previous reviews:
•
there is no consistent pattern of effect across outcomes based on type of intervention,
length of educational intervention, core team composition or type of educational setting
•
there is no standard method to describe formal PDE programmes and interventions, thus
making it difficult to replicate studies.
Findings from qualitative research studies were useful in illuminating the findings from
quantitative research studies, by helping to better understand the context in which formal
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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PDE should be applied to be successful in promoting self-management behaviours in adults
with type 2 diabetes.
The administrators of formal PDE programmes need to consider that the trends in formal PDE
delivery call for:
•
an ongoing, patient-centred PDE approach, described as a step-by-step process that
involves the diabetes care and education providers, the patients and their caregivers
•
focus on meeting the patient’s needs and overcoming patient’s barriers to self-management
behaviours, and continuous reinforcement of patient’s positive behaviours, in addition to
transmission of knowledge and skills
•
the development of trustful patient–educator relationships and the existence of a good
partnership with the other members of the diabetes management team
•
measurement of PDE success in terms of both long-term outcomes and short-term
outcomes, regardless of PDE approach
•
data collected for each outcome by using a more standardised set of validated instruments.
None of the Canadian studies published over the last 10 years met the criteria in the working
definitions and inclusion criteria for review. Canadian investigators can build upon the
research described in this report and should attempt to overcome the methodological
limitations of the reviewed studies.
Approaches to learning programmes for people with diabetes
There are three broad categories of interventions to support behaviour change in people with
diabetes: information and skills programmes, cognitive behavioural interventions, and patient
empowerment. Programmes can be delivered individually, or through group sessions, and there is
no reliable evidence to suggest that any of these methods is superior to any other.
The core module for type 2 diabetes education must include nutrition, physical exercise, footcare, diabetes awareness, the importance of eye screening, annual screening for complications,
and compliance with prescribed medication. The programme should be integrated with treatment,
which occurs largely in primary care.
There are many providers of education in communities around New Zealand, and there are a
variety of programmes. Examples of new or novel means of delivering information include:
•
Internet-based advice (eg, the Diabetes New Zealand web site)
•
telephone support
•
group sessions, which may include supermarket or market tours, cooking sessions, exercise
programmes, practical sessions on what to look for in buying shoes and socks.
The role of DHBs and LDTs
DHBs and LDTs are best able to identify the information needs of people with diabetes in their
area. They are also well placed to develop core learning modules or educational programmes with
a range of choices to suit the needs of different people. The quality of the educators involved is of
the greatest importance in determining the success of programmes. Criteria for the evaluation of
the effectiveness of programmes should be determined and programmes should be monitored
against them.
There should be ongoing improvement to systems to support and involve people with diabetes.
Diabetes registers in primary care organisations provide the potential to monitor the longer-term
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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changes in factors that predict health outcomes for groups that have completed education
programmes, and the educators themselves will then have a better opportunity to learn, and
demonstrate, what is effective.
Guidelines and reviews of evidence
There is currently no evidence-based guideline in New Zealand for formal patient diabetes
education.
The Alberta Heritage Foundation for Medical Research review of the evidence for education and
self-management is available in full at http://www.ahfmr.ab.ca/.
The NHS Centre for Reviews and Dissemination has systematically reviewed the evidence on
promoting self-management as part of developing national clinical practice guidelines for
nephropathy treatment. That review is available at www.qualityhealthcare.com.
Hospital and other specialist diabetes services
As discussed above, for the ongoing management of diabetes, community-based primary care
services are important. In addition to management at primary care level, many people with
diabetes will also require ongoing specialist care. Much of this specialist care is delivered through
outpatient clinics.
The National Service Framework (Ministry of Health Data Dictionary v8: National Service
Framework, Hospital Specific and Public Health Purchase Units for Services provided by
District Health Boards) specifies the outpatient diabetes services available from hospitals.
Historically specialist physician clinics have been purchased differently depending on the hospital
resources. Smaller hospitals without diabetologists have received diabetes funding bundled with
funding for general medical outpatient attendances, but some larger hospitals have received
funding for diabetes clinics as part of endocrinology services. Traditionally, paediatric diabetes
services have been funded separately from adult diabetes services, and the transition from the
paediatric to adult services occurred at different ages, depending on the needs of the individual
concerned.
Acute hospital care will also be required for people with diabetes in a number of situations,
including (but not limited to):
•
acute cardiovascular events
•
acute renal failure
•
episodes of ketoacidosis
•
hypoglycaemic coma.
Hospital services required to manage such acute situations and the treatment of non-acute
diabetes complications include (but are not limited to): general medical, surgical and acute
services, intensive care, renal services and ophthalmology.
The co-ordination of hospital diabetes services and acute general medical/surgical services
accessed by people with diabetes with primary care and supporting services (such as dietetics and
podiatry) is an important factor in determining the outcome of care for the patient. Discharge
planning is an area that highlights the importance of effective communication and co-ordination
of care for effective ongoing management and treatment following discharge of the patient into
primary care and/or rehabilitation services.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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Type 1 diabetes in children and young people
Type 1 diabetes is one of the most common serious diseases in children and young people. The
reported incidence of type 1 diabetes is rising, both in New Zealand and other countries for
reasons that are not known. Type 1 diabetes is not curable and research has not yet produced any
evidence that preventing it is possible.
Type 1 diabetes has a major impact on individuals and their families or caregivers. The
management of type 1 diabetes includes meticulous attention to diet and exercise, frequent selftesting and insulin injections. Type 1 diabetes has the potential to affect every aspect of social and
physical development in children and young people, and brings a constant risk of ill health. The
impacts of type 1 diabetes in young people extend beyond the family, as teachers and friends
must understand the condition and its implications, particularly for very young children who are
unable to manage the condition on their own.
Diabetes care should be delivered through multidisciplinary teams that include specialised
paediatric services and primary care clinicians. Each team should share information and coordinate support for individuals and their families. Diabetes services for young people can be
structured in a range of ways including through mobile specialist clinics, youth camps, one-stop
youth shops, and specific telephone or Internet support.
Few evaluations have compared or assessed the quality and quantity of care available for children
with type 1 diabetes and their families in different areas of New Zealand.
Type 1 diabetes is less common in Maori and Pacific peoples than in other New Zealanders.
Paediatricians, however, report that on average young Maori and Pacific peoples achieve poorer
diabetes control than other young New Zealanders. More targeted, accessible services and
culturally appropriate education are required to improve the outcomes for those groups.
Guidelines and reviews of evidence
The Australian Paediatric Endocrine Group Handbook on Childhood and Adolescent Diabetesxxiii
includes useful information on the management of diabetes in children and adolescents. The
chapter on ambulatory care provides guidelines for services required for the child and family and
the checks that should form part of a comprehensive evaluation at least once a year.
The International Society for Paediatric and Adolescent Diabetes produced the ISPAD consensus
guidelines in 2000.
The Diabetes Research Foundation in Australia in association with the Juvenile Diabetes
Association produced The National Needs Assessment of Children and Adolescents with
Diabetes. It reflects many of the ISPAD guidelines from a consumer viewpoint.
Suggested action points
• The Ministry of Health will work with Diabetes Youth New Zealand and other stakeholders
to review paediatric diabetes services and to develop a national service framework.
•
District Health Boards should review the specialist paediatric services that are available for
young people with diabetes. This review should cover access to specialist outpatient services
by ethnicity, and by children and young people in rural areas.
•
Hospital paediatric services should use the National Paediatric Diabetes Database available
from Starship Hospital to capture data in a nationally consistent manner.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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The impacts of diabetes on body systems
The Ministry of Health has prepared papers detailing the impacts of diabetes on the
cardiovascular system, on eyes and on feet, describing the evidence supporting the treatment
interventions indicated. A summary of the key points and actions from the three papers is
presented here and the full papers can be downloaded by clicking on the links indicated. Further
papers on the impacts of diabetes on other body systems will be added to the toolkit in the future.
A summary of the key points and actions from the three papers is presented here. Links are also
given to the full papers.
The impact of diabetes on the cardiovascular system
 Download the full paper on the impact of diabetes on the cardiovascular system
The relationship between diabetes and cardiovascular system disease has long been recognised.
For a significant proportion of people the two conditions co-exist as part of a metabolic
syndrome.
Key points
•
Cardiovascular disease is the leading cause of death in people with diabetes.
•
The presence of diabetes increases the risks of coronary artery disease two- to threefold in
men, and four- to fivefold in women when compared to people without diabetes.
•
In people with diabetes the risk of death, stroke, microvascular complications, and lower leg
amputation are all associated with high blood pressure. For those with type 2 diabetes,
intensive control of blood pressure is at least as effective as intensive control of blood glucose
in reducing the impact of diabetes complications.
•
A 10 mmHg reduction in blood pressure reduces diabetes-related death by 15 percent (95%
CI 12–18%), diabetes complications by 12 percent (95% CI 10–14%), microvascular
complications by 12 percent (95% CI 10–16%) and myocardial infarction by 11 percent (95%
CI 7–14%).
•
The evidence linking diabetes and cardiovascular disease has been comprehensively reviewed
in Australia (see ‘Guidelines and reviews of evidence’).
Suggested action points
•
Primary care organisations/PHOs offering free annual checks should review the prevalence
of all cardiovascular risk factors for people in their diabetes register by ethnicity. If the
prevalence of hypertension, abnormal lipids, micro-albumin (raised albumin:creatinine ratio)
or smoking is higher in Maori or Pacific peoples, then specific quality initiatives to optimise
treatment in these groups should be developed by the primary care organisation, hospital
specialists, LDT and/or DHB management staff.
•
Hospitals should consider implementing systems to ensure that people admitted (for any
reason) who have raised cardiovascular system (CVS) risk factors receive initial advice about
reducing risk factors, assessment or treatment as appropriate. Risk factors and
recommendations should be highlighted in discharge summaries or plans for primary care.
•
Hospitals should ensure that all people admitted with potentially diabetes-related diseases
(and especially for CVS disease) are screened for diabetes, if the diagnosis has not already
been made or recently excluded. Diabetes should also be reliably recorded in the clinical
records and coded as a diagnosis in the national minimum dataset (NMDS) record for these
admissions. Hospitals may consider (as part of their coding quality control systems) auditing
a sample of clinical records to establish coding accuracy for diabetes.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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•
After primary care organisations have reported on CVS treatment and risk factors by
ethnicity, LDTs should review the information and consider recommendations to the DHB
for improving the quality and effectiveness of cardiovascular treatment. The development of
recommendations is likely to require specialist advice.
•
LDTs may recognise barriers to CVS risk factor control in people with diabetes. They will be
well placed to ensure that all stakeholders in diabetes care are working to address those
barriers and to monitor the effectiveness of those efforts through analysis of primary care
data.
•
Community laboratories may be able to develop a formatted report for all diabetes and CVS
results (as in Auckland) that may improve the integration of diabetes and cardiovascular risk
factors in treatment decisions for primary care or hospital outpatient units. LDTs or DHB
management staff should consult community laboratories to review the options for presenting
clinical information more effectively.
The impact of diabetes on the eyes
 Download the full paper in the impact of diabetes on the eyes
Diabetes is associated with several eye conditions. Most important in causing avoidable loss of
vision are its effects on the retina and the retinal blood vessels, causing a condition known as
diabetic retinopathy. Diabetic retinopathy is present at diagnosis for a significant proportion of
people with type 2 diabetes. In people with type 1 diabetes, it generally develops some years after
diagnosis.
Key points
•
Diabetes is widely accepted as the most common cause of avoidable loss of vision in people
of working age in developed countries.
•
No country has reliable measures of the incidence of loss of vision from diabetes.
International studies suggest that about 70 people in New Zealand become legally blind every
year as a result of diabetes.
•
Diabetic retinopathy can be detected reliably by screening programmes.
•
Retinopathy screening with referral for laser treatment is effective in reducing loss of vision.
It is either cost-effective or cost-saving to the health funder.
•
The uptake of screening, especially in high-risk populations, is relatively low in New Zealand
and comparable countries. Uptake in high-risk groups is as important to maximise the
effectiveness of screening programmes.
•
Technology for retinopathy screening is improving. For delivering screening to high-risk
populations, there are several international models that use mobile cameras.
•
A National Eye Screening Quality Programme will be developed. Eye screening services will
be required to enrol in this programme.
•
An upgraded national service specification has been developed and agreed.
Suggested action points
• Funding and performance staff of DHBs should work with LDTs to identify opportunities to
improve screening uptake in high-risk groups, and establish targets for the DHB performance
indicator.
•
Primary care organisations should review the information about eye screening in their
diabetes registers, and work with eye screening services to identify geographic areas or
population groups in which screening uptake is low.
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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•
Hospitals providing hospital-based eye screening should consider implementing systems that
offer appropriate eye screening to people with diabetes who attend outpatients or are admitted
for any reason. Such systems are particularly important for ‘hard to reach’ people from rural
areas or people who find transport to hospital difficult.
•
Hospitals should consider a clinical audit of their cases of vitrectomy in people with diabetes
with a view to establishing any opportunities for earlier intervention or improvements in eye
screening or laser treatment.
•
Eye screening services should work with Local Diabetes Teams, primary care organisations
and hospital diabetes specialists to agree on the guidelines and processes for referral into
diagnosis and treatment.
•
The Ministry of Health will facilitate – with existing eye screening services – the
development of a National Eye Screening Quality Programme.
The impact of diabetes on the feet
 Download the full paper on the impact of diabetes on the feet
 Download graph of lower limb amputations in people with diabetes in New Zealand (PDF
file)
Foot complications in people with diabetes are a consequence of peripheral neuropathy,
peripheral blood vessel disease, or a combination of both. Diabetic foot complications impact
upon quality of life, causing pain and reduced mobility. In addition, they have the potential to
lead to lower limb amputation.
Key points
•
Diabetes-related foot complications are common and potentially disabling.
•
Nationally there are about 500 hospital admissions each year for lower limb amputations in
people with diabetes. Funding for the inpatient costs of these cases alone is around $6 m per
year.
•
The increased hospital admission rate for Maori and Pacific can be explained largely by
differences in age distribution and socioeconomic deprivation.
•
Hospital admission rates vary for each DHB. These differences merit further investigation
locally.
•
Treatment interventions have been reviewed extensively (see ‘Guidelines and evidence
reviews’). In general, preventing foot complications using intensive glycaemic, lipid, and
blood pressure control is likely to be more effective than high technology interventions aimed
at preventing amputation in people with diabetes with very high-risk feet.
•
The importance of foot-care programmes, including patient education and podiatry, is
emphasised.
Suggested action points
• With podiatry services primary care organisations should review the referral guidelines for
people with high-risk feet.
•
Local Diabetes Teams may choose to recommend retailers trained (perhaps by a local
podiatrist) in advising people with diabetes about shoes, foot protection (eg, insoles and
socks) and skin care for the feet.
•
Primary care organisations, hospital diabetes services and other organisations providing
formal education for people with diabetes should specify their foot-care education syllabus
and any supporting education resources.
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Modelling and quality assurance
Modelling diabetes
There are major limitations to undertaking randomised, controlled trials to develop ways of
improving the balance of comprehensive care for people with diabetes. Namely, such trials
require a large sample size to provide the necessary statistical power, and extensive time to reach
reliably measured end-points. The cost of these research trials can therefore be substantial.
Given these limitations, mathematical modelling is a useful tool for estimating the future impact
of diabetes and changes in diabetes care. With modelling, the impact of changes to the underlying
variables can be investigated to estimate the benefits and the cost of different combinations of
interventions.
Modelling is inherently dependent on the accuracy of the underlying assumptions. Typically,
people developing models change underlying assumptions or variables, and observe how
sensitive the model is to the accuracy of these assumptions. The outcome of modelling, and of
testing model assumptions, may be the identification of areas where further research is required.
To quantify model assumptions more accurately, randomised controlled trials may then be used
to gather that data. Mathematical models are therefore complimentary to, but not a replacement
for, randomised controlled trials.
There are also valuable opportunities for the use of models to explore the effectiveness of
changes in different disease risk factors in reducing the future incidence and impact of diabetes.
In this role, models provide decision support for setting priorities and targets.
Ministry of Health model
The Ministry of Health has developed a multistate Incidence, Prevalence, Remission, Mortality
(IPRM) model for forecasting the incidence and future prevalence of diabetes. The forecast
extends to 2011. The model has recently been updated with 2003-03 data.
Reducing the incidence of diabetes is one aspect of the New Zealand Health Strategy priority
statement for diabetes. However, given the variability in case detection (as described
elsewhere in this toolkit), it is not practical currently to measure the incidence of type 2
diabetes directly. The Ministry of Health model therefore estimates incidence from the
observed prevalence (in community studies) and observed all-cause mortality in people with
diabetes.
A C TI O N P O I N T F O R D H B S AN D L D TS
A number of clinical indicators have been defined for diabetes against which DHBs will be
required to report (for further detail see ‘Evaluating the quality and performance of diabetes
services’). To access the denominator figure for the Case Detection indicator from the Ministry of
Health model's estimate of expected diabetes prevalence please download the following Excel
file.
Evaluating the quality and performance of diabetes services
For the Ministry of Health and DHBs to ensure that the quality of diabetes services is being
maintained or improved over time, it is vital that services can be monitored in a robust and
consistent fashion throughout the country. Monitoring the performance of services can be
undertaken on a number of levels. Performance indicators have been developed for diabetes and
are linked to monitoring contract performance for DHBs.
Full detail of the indicators for diabetes, including those related to the measurement of DHB
performance in 2001/02, is available from the Ministry of Health’s 2003 –04 Indicators of DHB
performance
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 Download Final Indicators of DHB Performance 2003/04 (available on the Ministry of
Health website)
This section summarises these diabetes indicators.
Indicator 1: Diabetes detection and follow up
The indicator measures the effectiveness of the health care system in identifying the population
with diabetes and monitoring the profile of risk factors for diabetic complications. This indicator
is related to DHB performance measurement in 2003/04.
NUMERATOR: (DATA SOURCE: DHB)
The number of unique individuals with type 1 or type 2 diabetes on a diabetes register with a free
annual check during the reporting period (calendar year)
DENOMINATOR: (DATA SOURCE: MINISTRY OF HEALTH)
The expected number of unique individuals to have type 1 or type 2 diabetes, as at the end of the
reporting period.
Indicator 2: diabetes management
This indicator provides an estimate of the present and future impact of diabetes. HBA1c remains
the most commonly used predictor of microvascular complications and diabetes control. It is one
indicator of the effectiveness of the overall health care system in reducing the population
attributable risk for diabetes complications. This indicator is related to DHB performance
measurement in 2003/04/
NUMERATOR: (DATA SOURCE: DHB)
The number of people with type 1 or type 2 diabetes on a diabetes register that have had a HBA1c
blood test in the previous 12 months with an HBA1c equal or less than 8 percent, as at the end of
the reporting period.
DENOMINATOR: (DATA SOURCE: DHB)
The number of people with type 1 or type 2 diabetes on a diabetes register that have had a HBA1c
blood test in the previous 12 months, as at the end of the reporting period.
Indicator 3: Retinal screening of people with diabetes in last two years
Blindness from diabetic retinopathy is substantially preventable with effective screening and
appropriate use of laser treatment. Retinopathy prevention is clearly established as cost-saving.
This measure of screening uptake is responsive to short-term changes in the performance of the
health care system. Reducing barriers to screening for those at highest risk, for example Maori
and Pacific peoples, is a priority. This indicator is related to DHB performance measurement in
2003/04.
NUMERATOR: (DATA SOURCE: DHB)
The number of people with type 1 or type 2 diabetes on a diabetes register that have had retinal
screening or an ophthalmologist examination in the last two years, as at the end of the reporting
period.
DENOMINATOR: (DATA SOURCE: DHB)
The number of people with type 1 or type 2 diabetes on a diabetes register, as at the end of the
reporting period.
Diabetes service evaluation tool
As well as collecting data against indicators, it is possible to assess the progress of DHBs toward
improving diabetes health outcomes by monitoring statistics from the New Zealand Health
Information Service, such as lower limb amputation rates. These measures, however, are not
New Zealand Health Strategy • DHB Toolkit: Diabetes • Edition 1
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highly sensitive to change in the short term and do not identify the origin of any problems that
arise.
To make possible more finely focused evaluation of diabetes services, the Ministry of Health has
developed an interview-based evaluation tool. It can be used in conjunction with indicators to
provide an overall view of diabetes service planning and provision in DHB areas.
The Ministry of Health developed the evaluation tool to ensure nationally consistent evaluation
that will enable comparison among DHBs and within each DHB over time. It is envisaged that
DHBs or their shared support agencies will use the tool for evaluation and that the Ministry of
Health will only be involved where particular problems or successes are identified in a given
area.
The design of the tool focuses strongly on encouraging DHBs and providers to strive for quality
improvement. It is hoped that evaluation will enable DHBs to learn from the successes of others
and thus avoid unnecessary duplication in the development of new services or systems. It is also
intended that evaluation will encourage communication and cohesion among providers within a
DHB area, in line with the theme of delivering services via seamless, multidisciplinary teams.
The draft evaluation tool has been developed in consultation with the Waikato DHB. A pilot
evaluation has been undertaken with providers and consumers within that area. The Ministry of
Health will undertook a further pilot evaluation in the Whanganui DHB area during 2001/02
before releasing the final evaluation tool to DHBs for implementation.
Download evaluation tool
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APPENDIX 1:
Glossary of terms and abbreviations
Blood glucose: the main sugar that the body makes, mostly from carbohydrates, as well as from
the other two elements of food – proteins and fats. Glucose is the major source of energy for
living cells and is carried to each cell through the bloodstream.
BMI: body mass index. It is a measure of body weight that also takes account of a person’s
height. Expressed as weight (in kg) divided by the square of height (in metres). Desirable: 20–25,
overweight >25, obese >30.
Cardiovascular disease (CVD): disease of the heart or vessels of the circulation.
Coronary heart disease: also known as ischaemic heart disease.
DHB: District Health Board.
Diabetes mellitus: a disease involving a disturbance of metabolism, the underlying cause of
which being the defective production or action of the hormone insulin. There are several
manifestations of the disease, the most common being type 1 and type 2 (see below).
Diabetologist: a specialist doctor who sees and treats people with diabetes mellitus.
Dietitian: an expert in nutrition who helps people with special health needs plan the kinds and
amounts of foods to eat.
End-stage renal failure: the final phase of kidney disease; treated by dialysis or kidney
transplantation.
Epidemiology: study of the distribution and determinants of health-related states or events in
specified populations.
Gangrene: the death of body tissue. It is most often caused by a loss of blood flow, especially in
the legs and feet.
Goal: a general aim for which to strive.
HbA1c: a blood test used to measure glycosylated haemoglobin levels which indicate glycaemic
control.
HDL/LDL: high-density lipoprotein and low-density lipoprotein make up cholesterol. The levels
and ratios of HDL and LDL are predictors of cardiovascular disease.
Health status: a set of measurements that reflect the health of populations. The measurements
may include physical function, emotional wellbeing, activities of daily living.
Hyperglycaemia: elevation of blood glucose. Over an extended duration it is associated with the
development of diabetes complications.
Hypoglycaemia: a low level of blood glucose. Associated with an elevated level of insulin in
insulin-dependent diabetics, it can lead to performance changes, but is not always symptomatic.
Incidence: the number of new cases or deaths in a given period in a specified population.
Insulin: a hormone that helps the body use glucose (sugar) for energy. The beta cells in the
pancreas (in areas called the Islets of Langerhans) make the insulin. When the body cannot make
enough insulin on its own, a person with diabetes can inject insulin made from other sources.
Intersectoral: between sectors.
Intervention: a specific prevention measure or activity designed to meet a programme objective.
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Intrasectoral: within a sector.
LDT: Local Diabetes Team. A local group of stakeholders in diabetes care and prevention.
Lipid: a term for some forms of fat.
Ketoacidosis: A serious condition caused by an accumulation of ketoacids in the blood resulting
from the body deriving energy from non-glucose sources during hyperglycaemia. Usually seen in
type 1 diabetes, ketoacidosis can lead to coma if not immediately treated with insulin.
Macrovascular complications: diabetes complications from large blood vessel disease. Includes
coronary heart disease, stroke, peripheral vascular disease, hypertension.
Maori: indigenous people of New Zealand.
Microvascular complications: diabetes complications from small blood vessel disease; includes
retinopathy (damage to eye), nephropathy (damage to kidneys), neuropathy (damage to nerves)
Morbidity: illness.
Mortality: death.
Nephropathy: disease of the kidneys caused by damage to the small blood vessels or to the units
in the kidneys that clean the blood. People who have had diabetes for a long time may have
kidney damage.
Neuropathy: disease of the nervous system. Many people who have had diabetes for a while
have nerve damage. The most common form is peripheral neuropathy, which mainly affects the
feet and legs. Nerve damage in the feet and legs causes diabetic gangrene.
Obesity: when people have 20 percent (or more) extra body fat for their age, height, sex and bone
structure, fat works against the action of insulin. BMI > 30 (see BMI).
Objective: the end result a programme seeks to achieve.
Ophthalmologist: a doctor who sees and treats people with eye problems or diseases.
Ottawa Charter: the Charter developed and adopted by the first International Conference on
Health Promotion held in Ottawa, Canada in November 1986. This Charter defines health
promotion as the process of enabling people to increase control over, and to improve, their health.
Health promotion action means building healthy public policy, creating supportive environments,
strengthening community action, developing personal skills, and reorienting health services.
Overweight: body weight that is above the recommended level, due to increased body fat. 25 <
BMI > 30 (see BMI).
Pacific peoples: the population of Pacific Island ethnic origin (eg, Tongan, Niuean, Fijian,
Samoan, Cook Islands Maori and Tokelauan), incorporating people born in New Zealand as well
as overseas.
Podiatrist: a health professional who treats and takes care of people’s feet.
Prevalence: the number of instances of a given disease or other condition in a population at a
designated time. Prevalence includes both new (incidence) and existing instances of a disease.
Retinopathy: a disease of the small blood vessels in the retina of the eye.
Risk factor: an aspect of personal behaviour or lifestyle, an environmental exposure, or an
inborn or intended characteristic that is associated with an increased risk of a person developing a
disease.
Target: an intermediate result towards the objective that a programme seeks to achieve.
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Treaty of Waitangi: the founding document of New Zealand.
Type 1 diabetes: Otherwise known as insulin-dependent diabetes mellitus (IDDM), type 1
diabetes is found most often in childhood, with secondary peaks in early and late adulthood. It is
characterised by rapid onset of clinical symptoms and requires prompt medical treatment and
regular use of insulin for survival. It is also termed juvenile-onset diabetes.
Type 2 diabetes: Otherwise known as non-insulin-dependent diabetes mellitus (NIDDM), type 2
diabetes is found primarily in adults and which accounts for most cases of diabetes. It is
characterised by a gradual onset of symptoms. It is also termed mature-onset or adult diabetes.
Urologist: a doctor who sees people for treatment of the urinary tract and for treatment of the
(male) genital organs.
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