Part 3: Is the "Get Checked" programme operating as intended?

3.1
In this Part, we report on:

• screening and coverage – whether those people who had been diagnosed with diabetes were being systematically screened (that is, whether they were being offered and encouraged to participate in the programme);
• treatment plans – whether an updated treatment plan was being discussed and agreed annually with each person participating in the programme; and
• treatment and referrals – whether participants were prescribed treatment and referred for specialist or other care if appropriate.

Screening and coverage

3.2
One of the main objectives of the programme is that people diagnosed with diabetes will be systematically screened for the risk factors and complications of diabetes to promote early detection and intervention. We expected that:

• general practices would be providing the programme and actively inviting all people diagnosed with diabetes to join the programme; and
• the numbers participating in the programme would be monitored.

Are all general practices offering the “Get Checked” programme?

3.3
In the PHOs that we visited, most general practices offered a free annual check to patients diagnosed with diabetes. Most general practices were also taking measures to ensure that people diagnosed with diabetes had been invited to join the programme.

3.4
PHOs and programme administrators were using a variety of methods to advertise the programme – for example, leaflets, flyers, and stalls at community events and sporting venues. In some areas, PHOs used local churches to raise awareness of diabetes and the programme. One PHO, AuckPAC Trust Health Board, was also using community radio.

3.5
In addition, GPs and diabetes nurses were inviting patients newly diagnosed with diabetes to join the programme, sending annual reminders to patients who had previously attended the programme, and following up non-responding patients by telephone. Some general practices provided after hours clinics for people who worked and a home-visiting service for those who preferred it.

3.6
Wairoa District Charitable Health Trust is an example of a PHO that increased participation in the programme from 4% to almost 95% of those people diagnosed with diabetes over a 12-month period (see Figure 4). The Trust achieved this by ensuring that there was funding for delivering the programme and working closely with its GPs.

Figure 4
Wairoa District Charitable Health Trust

Wairoa District Charitable Health Trust was set up on 1 January 2003 and has an estimated enrolled population of 8335. During the 2004/05 year, there was confusion over whether funding was available for the Trust to deliver the free annual check. Only 15 checks were carried out during the year ended 31 December 2005. The question of funding was resolved for the year ended 31 December 2006 when the Hawke’s Bay DHB awarded the Trust a contract to deliver the programme. The Trust worked closely with its GPs to increase the number of checks done. The Trust has the advantage of there being only four general practices in Wairoa. All used common patient management software, which allowed the Trust to: identify patients diagnosed with diabetes; monitor who has had the free annual check; and notify the general practices of patients who still need to be checked, so the practices, in turn, can notify the patients. This meant that, over a 12-month period, the Trust was able to increase its coverage from 4% to almost 95% of people diagnosed with diabetes.

3.7
Some of the other PHOs that we visited were also taking measures to increase participation in the programme. In some cases, PHOs provided resources – for example, community clinics – to increase participation in the programme. In other cases, it involved PHOs providing community co-ordinators or case managers to assist people who had proved “difficult to reach” to attend the free annual check. For example, Total Healthcare Otara had appointed two case managers with the aim of increasing attendance rates (see Figure 5).

Is the programme being offered within the intended funding?

3.8
The programme provides for a payment of $40 to GPs for each check. Some PHOs and programme administrators considered that this payment was insufficient and acted as a barrier for GPs to encourage their patients to participate in the programme.

3.9
We found that some general practices, especially in parts of Auckland and Counties Manukau, were not actively encouraging participation in the programme. We were told the main reason for their reluctance was that they believed the fee paid for carrying out the free annual check did not cover the costs of the check or the costs of completing the documentation that accompanied the check. In addition, problems with information technology (IT) systems sometimes resulted in the data not being submitted and the $40 claim not being received by the general practice, even though the check had been carried out.

Figure 5
Total Healthcare Otara

Total Healthcare Otara was set up on 1 January 2003. At the time of our audit, the PHO had an enrolled population of 75,601, of which: 15% were Māori; 52.7% were Pacific Island peoples; 9.8% were European; 12.3% were Indian; and 10.2% were of other ethnicity. The PHO includes both a medical and a community provider – East Tamaki Healthcare, with 33 GPs and 150 staff, and Otara Health Incorporated, with 10 community health workers and three health promotion staff. This PHO is in the Counties Manukau DHB, and its practices therefore deliver a Chronic Care Management service to increase access. This service provides free quarterly visits to patients with chronic diseases. Diabetes is the second most prevalent chronic disease treated in the PHO. As at December 2006, 3718 people had been diagnosed with diabetes. The free annual check is built into the Chronic Care Management service. Three years ago, the PHO decided that it would focus on improving Chronic Care Management attendance rates. It aimed to increase the rates to more than 70%. The PHO identified the main problem as getting people with chronic conditions to keep appointments with their GPs. Letters and phone calls were not proving an effective means of doing this. At the end of July 2004, the PHO appointed two case managers to: establish how the PHO was managing diabetes; ensure that GPs and diabetes nurses had filled in the patient consultation templates; ensure that patients had their blood tests before they saw the GP; and remind patients of the benefits of attending for the free quarterly visits, including the free check. Before the initiative, only 51.5% of patients with diabetes enrolled in Chronic Care Management were up to date with quarterly visits to their GP and 30.6% of patients had not been seen in the previous six months. By August 2005, as a result of the actions taken by the case managers, 78.6% of patients were up to date with quarterly visits to their GP and only 6.5% of patients had not been seen in the previous six months. This initiative has also improved participation in the programme. The numbers participating in the programme increased from none at the beginning of 2004 to more than 2000 by 31 December 2005 (65.7% of patients diagnosed with diabetes). For the 12 months to December 2006, the number of annual checks increased to more than 2800 (75.5% of patients diagnosed with diabetes).

3.10
The Royal New Zealand College of General Practitioners and some PHOs and programme administrators told us that some GPs:

• saw the review as an information-collecting exercise; and
• believed that, as the free annual check was a health check with no immediately felt benefit, the number of people not attending for pre-arranged appointments was higher than patients with acute complaints needing treatment for relief. For some general practices, this can have an economic effect as GPs are not paid for appointments that are made but which patients do not keep.

3.11
When we discussed with Ministry staff whether the payment was enough, they advised us that they considered $40 to be enough to meet the cost of the review. We did not audit whether the payment was enough.

3.12
However, most DHBs allowed PHOs and programme administrators to increase or “top up” the payment out of their funding, so the amounts paid differed among PHOs and programme administrators. The Counties Manukau DHB had increased the fee paid for carrying out the free annual check for people who were not included in the Chronic Care Management service to $60 (plus GST).

3.13
In addition, the Hawkes Bay PHO and the Auckland PHO Ltd were using increased payments as an incentive to increase the number of free annual checks carried out – that is, the additional payment was conditional on an increase in the number of checks.

3.14
The Hawkes Bay PHO had increased the payment to GPs for the annual checks to $65, provided that:

• the higher payment to GPs was a pilot programme for one year;
• the GPs reached a target case detection rate of 65%; and
• the GPs focused on high needs Māori and Pacific Island peoples.

3.15
The Auckland PHO Ltd was also beginning a programme in 2007 – “Finding Diabetes” – that would identify the people diagnosed with diabetes in patient management systems and then work out the participation rate for practices. An extra $1,000 would be paid to practices that have checked 95% of their Māori and Pacific Island peoples and 90% of others.

Are numbers participating in the programme being monitored?

3.16
One of the programme’s main performance measures is the coverage of the programme – that is, the percentage of people diagnosed with diabetes who received a free annual check during the year.¹

3.17
Some programme administrators that we visited were measuring this percentage for each general practice (a few were doing it at GP level), and were reporting the aggregated figures for each PHO to the DHB and the LDT.

3.18
All the DHBs that we visited (with the exception of Tairawhiti in 2005) had set annual targets (by ethnicity) for the percentage of people diagnosed with diabetes in their district who were expected to participate in the programme. The DHBs monitored achievement against the targets, and reported it in their annual reports.

Monitoring is based on predicted rather than actual figures

3.19
Because of the importance of measuring the coverage of the programme, we were concerned that only four of the PHOs that we visited were able to identify the number of patients enrolled in their practices who had actually been diagnosed with diabetes. This also meant that the DHBs did not know the number of people diagnosed with diabetes in their districts.

3.20
In place of actual figures, the Ministry had developed a model of diabetes² based on census data and diabetes prevalence data from the early and mid-1990s. DHBs were using this model to estimate the number of people diagnosed with diabetes in their populations and at the PHO level.

3.21
The staff from the programme administrators, PHOs, and DHBs that we spoke to said that they lacked confidence in the model. For example, one PHO noted that there were more people on its GP rolls than were recorded in census information. While some acknowledged that the model may have some validity across the total population, they believed that it was not accurate for district- and PHO-sized populations. The model itself states that:

The accuracy and precision of our forecasts are constrained by a number of data deficiencies as well as limitations in the design of the model and its necessary assumptions.³

3.22
One of the assumptions noted for the model is that:

The 1996 diabetes prevalence data used to initiate the model comes from a limited survey base. In particular, data for Pacific peoples was inadequate. More recent data suggests that 1996 prevalence may have been under-estimated for Pacific peoples, leading to forecasts for this ethnic group being too low.⁴

3.23
We acknowledge that it is difficult to identify people diagnosed with diabetes in GPs’ patient management systems. However, at the time of our audit, it was more than six years since the programme began, and most of the PHOs and programme administrators still did not know the actual number of people in the practices who had been diagnosed with diabetes. We consider that they should have known this information by this time. Without this information, the coverage of the programme cannot be accurately assessed, and PHOs, programme administrators, and GPs cannot be sure that all people diagnosed with diabetes have been offered the opportunity to participate in the programme. Conversely, they may be falsely assured that coverage is better than it really is.

3.24
In addition to there being a lack of confidence in the total number of people diagnosed with diabetes, there were also concerns, supported by the work that we carried out, about the accuracy of some of the data reported on the number of people receiving the free annual check. This is addressed in greater detail in paragraphs 4.9-4.19.

The programme is increasing its coverage

3.25
We acknowledge that estimates of the population eligible to participate in the programme may not be accurate. However, figures compiled by the Ministry show that the percentage of the estimated eligible population (those people diagnosed with diabetes) participating in the programme in the six DHBs that we visited had generally been increasing and targets for 2006 that DHBs set were being achieved in all but one DHB (Tairawhiti), as shown in Figure 6.

Figure 6
The percentage of the estimated eligible population participating in the programme

DHB	Dec 31 2002 %	Dec 31 2003 %	Dec 31 2004 %	Dec 31 2005 %	Dec 31 2006 %	Dec 31 2006 target %
Auckland	24	34	42	50	68	60
Capital & Coast	50	61	60	66	71	70
Counties Manukau	15	56	65	70	81	72
Hawke’s Bay*	77	50	41	41	59	58
Otago	72	77	78	72	81	81
Tairawhiti	21	20	41	52	52	62

* The Hawke’s Bay results for 2002/03 are likely to be overstated, reflecting data quality problems being experienced before 2003/04.

Conclusion

3.26
For the DHBs that we visited, the percentage of the estimated eligible population participating in the programme had generally increased over time. However, it was not possible to accurately assess the coverage of the programme because only four of the PHOs that we visited were able to identify the number of patients enrolled in their practices who had been diagnosed with diabetes. The true percentage of people diagnosed with diabetes participating in the programme was therefore not known. This makes it more difficult to ensure that people entitled to participate in the programme have been invited to do so.

Recommendation 1
We recommend that district health boards work with programme administrators to identify those patients in patient management systems who have been diagnosed with diabetes.

Recommendation 2
We recommend that district health boards work with programme administrators to identify those people in the population diagnosed with diabetes who are not participating in the programme, ensure that they have been invited to join the “Get Checked” programme, and (if possible) note and address their reasons for declining.

Treatment plans

3.27
Improved blood glucose control can significantly reduce the risk of complications. The Evidence-based best practice guideline – Management of type 2 diabetes (see paragraph 3.49) noted that a 1% reduction in HbA1c is likely to reduce the risk of developing complications by:

• 37% for retinopathy and nephropathy;
• 14%-16% for heart attacks and heart failure;
• 12% for strokes; and
• 21% for any diabetes-related deaths.

3.28
Treatment plans are important for encouraging patients to effectively manage their diabetes and control their blood glucose levels. As Diabetes 2000 has noted, “people with diabetes are ultimately responsible for managing the lifestyle changes and medication required to avoid or control diabetes”.⁵

3.29
The programme aims to achieve lifestyle changes and self-management. As part of the programme, the GP or diabetes nurse should prepare a personalised treatment plan with the patient (and, if appropriate, their family/whānau). This plan should include not only medication but, just as importantly, goals for lifestyle improvements – for example, increasing exercise and eating less and healthier foods.

3.30
We were limited in the audit work that we were able to do on the treatment plans, as we were not able to view a sample of treatment plans because of patient privacy. We therefore:

• looked for evidence that treatment plans were being prepared;
• checked whether the PHOs or programme administrators monitored the preparation and quality of the treatment plans; and
• looked for evidence that the treatment plans were effective.

Are treatment plans being prepared?

3.31
We were told by the PHOs and programme administrators that we visited that treatment plans (also referred to as care plans or wellness plans) were being prepared and discussed with patients. We were shown templates of treatment plans that PHOs and programme administrators provided to GPs, and we were provided with details of templates in patient management systems. We were also told that the treatment plans were well received by patients.

3.32
The treatment plan templates that we looked at had some components in common, such as:

• a medication list (including the purpose of the medicine, the dosage, and the time it was to be taken);
• personal health goals – for example, exercise, healthy eating, stopping smoking (where relevant), and learning more about diabetes. Some plans included major and minor goals and the dates when they would be achieved;
• test results; and
• appointments.

3.33
However, we were concerned to note that an interim evaluation of the Chronic Care Management programme carried out by Counties Manukau DHB in April 2005 noted that the average percentage of patients reported as being given wellness plans was 44% and only one of the 10 practices interviewed was using wellness plans. The evaluation report noted that:

Since the wellness plan includes the development and recording of self management goals with patients this does call into question the extent to which the [CCM] programme has supported patients to improve their self management skills.⁶

3.34
In addition to the treatment plans, the PHOs and programme administrators that we visited were also providing patients with, or giving patients access to, other education resources to help them understand how to manage their diabetes and the importance of a healthy diet and exercise. For example, South Link Health Inc, which provides programme administration services for a number of PHOs, published a booklet for patients entitled Stay Well with Diabetes. This booklet explains diabetes, how to measure blood glucose, and the effect of high and low blood glucose levels. It also discusses the advantages of physical activity (including a guideline as to how this should be done) and healthy eating, the annual diabetes check, and the main measures that can be taken to prevent or reduce complications.

3.35
The booklets published by Diabetes New Zealand (about one million are printed yearly) and the National Heart Foundation were also popular resources.

Is the preparation and quality of treatment plans being monitored?

3.36
In the PHOs and programme administrators that we visited, we found only one example where treatment plans were being monitored as part of a wider quality improvement process. This was the Counties Manukau DHB, which was funding the Diabetes Care Support Service (DCSS) Audit in South and West Auckland (see Figure 7). This service was provided free to GPs. Waitemata DHB, which was not in our sample, was also funding this service.

Figure 7
The Diabetes Care Support Audit in South and West Auckland

The Diabetes Care Support Audit is run and managed by the Diabetes Project Trust, and 156 GPs participate in the programme, with over 10,000 records viewed in 2006. The voluntary audit is free to practices, and involves trained nurses identifying all patients with diabetes, reviewing patient records, and filling out an audit tool. The audited practice receives: a patient register listing all patients with diabetes, pre-diabetes, or gestational diabetes; summary information about patients with diabetes in the practice; an individual report for each patient, with up-to-date “prompts”; personal feedback from the audit nurse (in some circumstances); special interest confidential reports; and Maintenance of Professional Standard credits for participating GPs. The audit is designed as a quality improvement process. Its primary purpose is to help GPs to identify improvement opportunities in their practice, encourage GP behaviour change, and promote contemporary research-based practice, through feedback and clinical support from a specialised executive committee. It also gathers non-identifiable patient information for research and service development.

Is there evidence that treatment plans are improving self-management?

3.37
Indicators of improved self-management through lifestyle changes include reducing BMIs, decreasing numbers of people smoking, and improving HbA1c levels. We looked at these indicators in the DHB districts that we visited.

3.38
Two cohort studies have been conducted in the Otago DHB district to assess changes in diabetes care.

3.39
The first study, an evaluation of diabetes care for a six-year period from 1998 to 2003, was carried out using data from the Otago diabetes register.⁷ The regional diabetes register was established in 1998, as part of the Otago Diabetes Project, to monitor diabetes care in the Otago region.

3.40
The second study measured changes in the health status of patients returning for three annual general practice checks,⁸ using data from the diabetes register established by South Link Health Inc in August 2000. This register records the data from the annual checks.

3.41
We discuss the results of these reviews in more detail in paragraphs 5.26 to 5.33. In summary, these reviews established that there was no overall improvement in glycaemic control. HbA1c levels were, at best, remaining constant, but generally rising. BMIs were also constant at best but generally rising, and there was little evidence that people were giving up smoking. Some programme administrator staff that we spoke to considered that the HbA1c and BMI levels remaining constant and not increasing was a good result in most cases.

3.42
We note that one of the DHBs (Counties Manukau DHB) and one of the programme administrators (South Link Health Inc) that we visited were trying to improve HbA1c levels by providing incentive schemes.

3.43
Counties Manukau DHB had recently offered a payment to general practices for a trial period as an incentive to reduce HbA1c levels. The incentive covered patients who had been enrolled in the Chronic Care Management programme because of their poor glycaemic control (that is, because they had an HbA1c greater than 9% when enrolled) and who had been in the programme for at least one year. For each general practice, the DHB planned to calculate the average HbA1c for the group of qualifying patients at the time of their enrolment and pay an incentive payment of $20 for each patient in the group whose HbA1c level decreased by at least 1.5%.

3.44
South Link Health Inc introduced an Enhanced Diabetes Programme on 1 April 2005. The programme provided an additional subsidised visit for patients who had an HbA1c greater than 8% for two consecutive free annual visits. The main purpose of this extra visit was to focus on lifestyle and medication changes.

Conclusion

3.45
We have some confidence that the general practices covered by the PHOs and programme administrators that we visited were preparing treatment plans. However, we are concerned that the quality and consistency of treatment plans (which are an important part of the diabetes management strategy for promoting and encouraging beneficial lifestyle changes) is not being adequately monitored. We are also concerned that analysis of the data obtained from the programme that has been carried out in some districts has highlighted few positive lifestyle changes.

Recommendation 3
We recommend that district health boards work with primary health organisations to monitor the preparation and audit the quality of treatment plans, and establish the effectiveness of these plans over time.

Treatment and referral

3.46
One of the objectives of the programme is that participants are prescribed treatment and referred for specialist or other care if appropriate. We expected that:

• treatment and national referral guidelines would be available for GPs;
• adequate specialist diabetes services would be available; and
• the DHB would collect information on the numbers of patients, the type of specialist diabetes service that they were referred to, and when the specialist diabetes service was accessed.

Are guidelines available?

Guidelines for diabetes treatment

3.47
We found that comprehensive guidance was available to GPs for the treatment of diabetes.

3.48
Guidelines were first developed in 1998 when the Otago Diabetes Team, Comprehensive Health Services Limited, Mangere Health Resources Trust, and the South Auckland Diabetes Project developed best practice guidelines for four core aspects of diabetes management⁹ as part of the Diabetes Health Information Project. These guidelines for the management of core aspects of diabetes care were launched as part of the programme.

3.49
The Ministry and the New Zealand Guidelines Group¹⁰ issued an Evidence-based best practice guideline – Management of type 2 diabetes in December 2003. The guideline covered important aspects of the management of people with type 2 diabetes, including lifestyle management, glycaemic control, cardiovascular¹¹ disease, diabetic renal¹² disease, diabetic eye disease, and diabetic foot disease.

3.50
In addition to the Evidence-based best practice guideline, the Best Practice Advocacy Centre¹³ has issued:

• Diabetes POEMs (Patient Orientated Evidence that Matters);
• Laboratory Testing in Diabetes; and
• Diabetes Clinical Audit.

3.51
As the Evidence-based best practice guideline is 117 pages long, both South Link Health Inc and Counties Manukau DHB have tried to make it more user-friendly for GPs. Aspects of the Evidence-based best practice guideline are also being incorporated into patient management systems to assist GPs.

Referral guidelines

3.52
The Ministry has issued national referral guidelines for diabetes, which set out when patients need to be referred to secondary care diabetes services, a dietician, diabetes nurse education services, the ophthalmology service, and the diabetes podiatry service.

3.53
The secondary care diabetes specialists that we spoke to considered that GPs were not referring patients on all occasions recommended by the national referral guidelines. However, they considered that patients were being referred to them in an appropriate and timely manner, and that strict adherence to the guidelines would result in a number of unnecessary referrals. This suggests that the guidelines need to be reviewed to ensure that they still reflect good practice.

Are there enough specialist diabetes services available?

3.54
Most of the specialist diabetes services that we spoke to felt under pressure. We were unable to conduct an analysis of the adequacy of the specialist diabetes services in all the DHBs we visited because the information required was not available. However, we found evidence that specialist diabetes services in the Hawkes Bay and Tairawhiti DHBs were under pressure.

3.55
In Hawkes Bay, there had been two specialist diabetes physicians but this had been cut to one, who covered diabetes, endocrinology, and general medicine for a population of 150,000. The waiting time for a visit to the specialist diabetes physician had been 24-26 weeks. This pressure had been managed by ensuring that patients had an interim visit with the specialist diabetes nurse, and the waiting time had reduced to 14-16 weeks.

3.56
The specialist diabetes physician also took the opportunity to educate GPs when he referred patients back to primary care, by making recommendations that could be applied to other patients. The specialist diabetes nurse also liaised with GPs, especially if insulin was being used.

3.57
In Tairawhiti, the district did not have a diabetes specialist, and acute admissions were dealt with by the general medical service. The secondary diabetes services in this district were being run by a 0.6 full-time equivalent specialist diabetes nurse. In other districts, this service included a specialist diabetes physician. The nurse noted that she was able to get advice from the Hawkes Bay and Waikato DHBs. There was also a shortage of ophthalmology services, which were provided by the Hawkes Bay DHB. However, we were advised that a permanent ophthalmologist had been employed in March 2007. The laser treatment clinics were behind schedule and were doing only urgent work. The renal service had one physician available for 16 hours every three months, and the service was able to do only peritoneal dialysis.¹⁴ For haemodialysis,¹⁵ patients had to shift to the Waikato DHB.

3.58
The secondary care diabetes specialists that we spoke to also commented that, if the national referral guidelines were strictly adhered to, they would not have enough resources at the secondary care level to deal with the increased demand. They believed that they only had enough resources to deal with complex, difficult-to-manage cases.

Are district health boards collecting information on the demand for specialist diabetes services?

3.59
The information that was provided to us on the demand for specialist diabetes services and waiting times varied between DHBs. It was not possible to conduct a comprehensive analysis of demand for specialist diabetes services against those available for the DHBs that we visited. The data for this type of analysis was not readily available in the majority of the DHBs.

Conclusion

3.60
Treatment guidelines and national referral guidelines were available for GPs.

3.61
Our interviews with some specialist diabetes services suggested that referrals to specialist diabetes services were timely, but that the national referral guidelines were not always being followed. If they were followed, specialist diabetes services believe they might not be able to cope with the extra demand.

3.62
The information that specialist diabetes services were able to give us on their resources, the demand for their services, and waiting times was not adequate to comprehensively analyse whether shortfalls existed in all the DHBs. However, we did find evidence that specialist diabetes services in Hawkes Bay DHB and Tairawhiti DHB were under pressure. Specialist diabetes services will come under more pressure if the numbers of people participating in the programme increase or more people are diagnosed with diabetes.

Recommendation 4
We recommend that the Ministry of Health review and, if necessary, update the national referral guidelines.

Recommendation 5
We recommend that district health board specialist diabetes services maintain enough data on the numbers of patients attending their clinics, the complexity of patients’ conditions, and waiting times to enable the district health board to identify and plan for the funding and resources needed to provide adequate diabetes services at this level.

Recommendation 6
We recommend that those district health boards where there are shortfalls in specialist diabetes services investigate the shortfalls and provide additional services as considered necessary.

---

1: The percentage of people participating in the programme is calculated by taking the number of people who have received the free annual check for the period 1 January to 31 December and dividing it by the expected number of people diagnosed with diabetes.

2: Ministry of Health (2002), Modelling Diabetes: A multi-state life table model, Public Health Intelligence Occasional Bulletin No. 9, Wellington.

3: Ibid., page 20.

4: Ibid., page 21.

5: Page 6.

6: Counties Manukau District Health Board (2005), Chronic Care Management Programme Interim Programme Evaluation Report, page 25.

7: Coppell, Kirsten J, et al. (2006), “Evaluation of diabetes care in the Otago region using a diabetes register, 1998-2003”, Diabetes Research and Clinical Practice, Vol. 71, Issue 3, pages 345-352.

8: Tomlin, Andrew, et al. (2007), “Health outcomes for diabetes patients returning for three annual general practice checks”, The New Zealand Medical Journal, Vol. 120, No. 1252.

9: The guidelines covered primary care for glycaemic control, retinal screening, micro-albuminurea screening (for early detection of kidney problems), and foot screening.

10: A not-for-profit organisation set up to promote effective delivery of health and disability services, based on evidence.

11: Cardiovascular refers to the heart (cardio) and the blood vessels (vascular). The cardiovascular system includes arteries, veins, arterioles, venules, and capillaries. Heart disease and stroke are the most common cardiovascular diseases.

12: The term “renal” refers to kidney, and renal failure means kidney failure.

13: An independent organisation that promotes healthcare interventions which meet patient needs and are evidence-based, cost effective, and suitable for the New Zealand context.

14: Peritoneal dialysis works by using the body’s peritoneal membrane, which is inside the abdomen, as a semipermeable membrane. Special solutions that help remove toxins are infused into the abdomen, remain in there for a time, and then are drained out. This form of dialysis can be performed at home, but must be done every day.

15: Haemodialysis works by circulating blood through special filters outside the body. The blood flows across a semipermeable membrane (the dialyzer or filter), along with solutions that help remove toxins.

page top