Quality improvement in non Quality improvement in non glycaemic targets in diabeticglycaemic targets in diabeticpatients at Central Australian patients at Central Australian

Aboriginal CongressAboriginal Congress

John BoffaJohn Boffa

Public Health Medical OfficerPublic Health Medical Officer

IntroductionIntroduction

1.1. A historical perspectiveA historical perspective

2.2. NPCC and prioritising outcomesNPCC and prioritising outcomes

3.3. Cholesterol controlCholesterol control

4.4. BP controlBP control

5.5. Treatment for renal diseaseTreatment for renal disease

6.6. Brief interventions for SNAPBrief interventions for SNAP

7.7. Eyes and Foot ChecksEyes and Foot Checks

8.8. What has led to the improvements?What has led to the improvements?

3 historical periods in Diabetes 3 historical periods in Diabetes Care in Central AustraliaCare in Central Australia

Period 1 “Denial”Period 1 “Denial” 1988: diabetes but no complications1988: diabetes but no complications

Period 2 “Treatment nihilism”Period 2 “Treatment nihilism” 1994: Scrimgeour and Rowse, Menzies – 1994: Scrimgeour and Rowse, Menzies – telling an Aboriginal person they had telling an Aboriginal person they had diabetes was the equivalent of telling a non diabetes was the equivalent of telling a non Aboriginal person they had cancerAboriginal person they had cancer

Period 3 “Hope”Period 3 “Hope”1999: diabetes is preventable and 1999: diabetes is preventable and

effective effective treatment from a well resourced treatment from a well resourced PHC sector PHC sector can make a big differencecan make a big difference

Outcomes of improved diabetes Outcomes of improved diabetes management (NPCC)management (NPCC)

11 percentage point percentage point reduction in HbA1creduction in HbA1cDCCT. N Engl J Med 1993; 329(14):977-DCCT. N Engl J Med 1993; 329(14):977-986 986

UKPDS 33. Lancet 1998; 352(9131):837-UKPDS 33. Lancet 1998; 352(9131):837-853853

25-30%25-30% reduction in micro- reduction in micro-

vascular complicationsvascular complications

1010 mm Hg reduction in mm Hg reduction in blood pressureblood pressureUKPDS 38. BMJ 1998; 317(7160):703-UKPDS 38. BMJ 1998; 317(7160):703-

713713

37%37% reduction in micro- reduction in micro-

vascular complications;vascular complications;

44%44% reduction in strokes; reduction in strokes;

32%32% reduction in deaths reduction in deaths

Improved blood lipid Improved blood lipid controlcontrolPyorala K, et al. Diabetes Care 1997; Pyorala K, et al. Diabetes Care 1997;

20(4):614-62020(4):614-620

39% reduction of coronary39% reduction of coronary

heart diseaseheart disease

43% reduction in death43% reduction in death

Cholesterol controlCholesterol control

Diabetic cholesterol controlDiabetic cholesterol controlCentral Australian Aboriginal Congress: Percentage of Patients with Diabetes with Cholesterol

<4mmol/l. Practice vs. Divisional and National Trends. Wave 1 Month 17 (August 2006)

0

5

10

15

20

25

30

35

BaselineApril May June July

AugustSeptember

OctoberNovemberDecemberJanuary_06February_06

March_06April_06May_06June_06July_06

August_06

Report Period

Percentage

Central Australian AboriginalCongress

GP & Primary Health Care,Top End, Central Aust andKimberley DGPsNational MEAN

Results: Cholesterol 2006Results: Cholesterol 2006

Total diabetic population n=541Total diabetic population n=541

Total cholesterol recorded in 75.8% Total cholesterol recorded in 75.8% (n=410)(n=410)

Of those recorded:Of those recorded:– 76% Total Cholesterol <5.5 mmol/L76% Total Cholesterol <5.5 mmol/L– 30% Total Cholesterol ≤4.0 mmol/L30% Total Cholesterol ≤4.0 mmol/L– Mean Total Cholesterol 4.7 mmol/L.Mean Total Cholesterol 4.7 mmol/L.

CAAC (541)CAAC (541) Remote NT (194)Remote NT (194) Cape York (252)Cape York (252) Torres Strait (921)Torres Strait (921)

TC <5.5TC <5.5 76%76% 60%60% 67%67% 46%46%

Results: Cholesterol 2009Results: Cholesterol 2009

Total diabetic population n = 734Total diabetic population n = 734

Total cholesterol recorded in 79.8% Total cholesterol recorded in 79.8% (n=610)(n=610)

Of those recorded:Of those recorded:– 79% Total Cholesterol <5.5 mmol/L79% Total Cholesterol <5.5 mmol/L– 35% Total Cholesterol ≤4.0 mmol/L35% Total Cholesterol ≤4.0 mmol/L– Mean Total Cholesterol 4.5 mmol/L.Mean Total Cholesterol 4.5 mmol/L.

Patients on statins have doubledPatients on statins have doubled

More active managementMore active management

Blood Pressure ControlBlood Pressure Control

Diabetic Blood Pressure Control Diabetic Blood Pressure Control <130/80<130/80

Central Australian Aboriginal Congress: Percentage of Patients with Diabetes with BP <130/80mm Hg. Practice vs. Divisional and National Trends. Wave 1 Month 17 (August 2006)

0

10

20

30

40

50

60

BaselineApril May June July

AugustSeptember

OctoberNovemberDecemberJanuary_06February_06

March_06April_06May_06June_06July_06

August_06

Report Period

Percentage

Central Australian AboriginalCongress

GP & Primary Health Care,Top End, Central Aust andKimberley DGPsNational MEAN

2009 BP outcomes2009 BP outcomes

67% of Diabetic patients (n = 492) 67% of Diabetic patients (n = 492) have had a BP recorded in the last 6 have had a BP recorded in the last 6 monthsmonths

Of these patients, 231 or 47% have a Of these patients, 231 or 47% have a BP < 130/80BP < 130/80

2006 baseline of about 38% < 130 2006 baseline of about 38% < 130 /80/80

More BP’s being doneMore BP’s being done

Percentage of patients on Percentage of patients on medications has increasedmedications has increased

Need more active BP managementNeed more active BP management

Renal DiseaseRenal Disease

ACR / eGFRACR / eGFR

More active managementMore active management

Brief Interventions for Brief Interventions for smokingsmoking

and alcoholand alcohol

Smoking brief interventionsSmoking brief interventions

Increased referrals for alcoholIncreased referrals for alcohol

Nutrition and Physical Activity Nutrition and Physical Activity AdviceAdvice

Eyes, Feet and BMIEyes, Feet and BMI

Eyes and FeetEyes and Feet

BMIBMI

What has led to these What has led to these improvements?improvements?

1.1. An evidence based focus on prioritised outcomes An evidence based focus on prioritised outcomes and scheduled services and scheduled services

2.2. Regular feedback to practitioners about our Regular feedback to practitioners about our performanceperformance

3.3. Improved PIRS functionality: annual cycle of care, Improved PIRS functionality: annual cycle of care, recalls, queries, data quality, electronic recordsrecalls, queries, data quality, electronic records

4.4. An improved pharmacy system ensuring better An improved pharmacy system ensuring better access to medicationsaccess to medications

5.5. An improved clinic system ensuring better access An improved clinic system ensuring better access to regular GP for chronic disease management to regular GP for chronic disease management with excellent GP retentionwith excellent GP retention

6.6. Access to a diabetes educator and diabetes Access to a diabetes educator and diabetes nursenurse

7.7. Regular physician clinicsRegular physician clinics