Part 5: Is the "Get Checked" programme achieving the expected results?

Ministry of Health and district health boards: Effectiveness of the "Get Checked" diabetes programme.

5.1
In this Part, we report on whether:

  • the barriers to Māori and Pacific Island peoples accessing high quality care had decreased; and
  • the programme was improving how diabetes was managed.

Have barriers to accessing high quality care decreased?

5.2
Māori and Pacific Island peoples have prevalence rates for diabetes that are nearly three times higher than for Europeans, and their diabetes-related mortality rates in the 40-65 year age range are nearly ten times higher.

5.3
Diabetes 2000 notes that:

Barriers to accessing high-quality treatment and care are reported by Māori and Pacific Island people. These barriers arise due to the costs of treatment, difficulty accessing services from the community, and the lack of choice in the services provided.1

5.4
It also notes that Māori and Pacific Island peoples with diabetes are expected to benefit from the free annual review and treatment plans.

5.5
We expected that:

  • PHOs would have identified barriers to Māori and Pacific Island peoples accessing high quality care;
  • initiatives would have been put in place to remove these barriers; and
  • the numbers of Māori and Pacific Island peoples accessing the programme would have increased.

Have barriers for Māori and Pacific Island peoples been identified?

5.6
One of the main problems being experienced by the PHOs that we visited was getting the patients into the clinic to participate in a free annual review. The majority of PHOs had identified the reasons Māori and Pacific Island peoples were not attending. These reasons included:

  • difficulty in communication because English was a second language;
  • a preference for a Pacific Island or Māori provider;
  • lack of transport to clinics or specialist diabetes services (for example, if the podiatrist or ophthalmologist was located in the centre of Auckland);
  • the cost – PHOs noted that, although the annual check provided by the programme was free, there were downstream costs (for example, the costs of medication, taking time off work to attend appointments, and follow-up appointments); and
  • a feeling of denial or hopelessness about their ability to manage their diabetes.

Have initiatives been put in place to remove these barriers?

5.7
Many of the PHOs that we visited, especially those with Māori and Pacific Island peoples populations, were trying innovative methods to remove these barriers. These initiatives involved taking the programme to the community. The features they had in common included:

  • improving the level of education in the community about diabetes, which was often done in conjunction with community activities (for example, sports events, church groups, hui, and fairs);
  • supporting lifestyle changes for not only the person with diabetes but their whole family/whānau; and
  • making it easier for patients to attend clinics (for example, providing transport, extending the time that the clinic was open, or providing home visits).

5.8
During our visits, most PHOs were interested in learning about initiatives carried out by other PHOs. They were also interested in setting up a mechanism for sharing good practice more effectively.

5.9
Initiatives were being implemented at both DHB and PHO levels. For example, Counties Manukau DHB was conducting a DHB-wide initiative, as shown in Figure 8.

5.10
The Tumai mo te Iwi PHO provides an example of an initiative that involves a PHO and community organisation working together (see Figure 9).

5.11
A third example is provided by the Hawke’s Bay DHB, which recently funded a newly established PHO for two initiatives to improve access, as shown in Figure 10.

Figure 8
Counties Manukau District Health Board

Counties Manukau DHB is implementing its own “Let’s Beat Diabetes” programme, which aims to stop people getting diabetes, slow the disease’s progression, and increase the quality of life for people with diabetes. The programme focuses on:
  • including the community, institutions, and businesses that make up the social fabric of Counties Manukau;
  • supporting health and preventing and managing diabetes at all stages of disease progression; and
  • acknowledging that an individual is part of a family/whānau (or household) that has a direct influence on environmental risks, choices, and decisions. Wherever possible, working with families/whānau is central to the programme.
The DHB, in collaboration with the primary care sector, has identified four programme initiatives to:
  • provide consistent and persuasive information to “at risk” people to support lifestyle change;
  • improve the identification of people who have diabetes at an earlier stage of their disease’s progression;
  • improve the level of education given to people newly diagnosed with diabetes to support improved self-management of both their diabetes and their cardiovascular risk; and
  • trial a new approach to disease management in which the primary care team works with the whole family/whānau of a person with diabetes, to support better health for the whole family/whānau.
To date, Counties Manukau has commissioned the Whānau Support Evaluation Project, which was carried out from July to October 2006. The aim of this project is to work with Māori with diabetes and their family/whānau to investigate how the family/whānau can support:
  • the person with diabetes to lead a healthy lifestyle and manage their diabetes; and
  • the family/whānau members without diabetes to lead a healthy lifestyle and avoid developing diabetes.
Also, in December 2005 the implementation of a district-wide Self Management Education (SME) programme was endorsed with a staged implementation process with the initial focus on diabetes during 2006/07. Facilitators, who will deliver the structured SME programme to groups of people with a chronic condition (starting with diabetes), were trained in October 2006.

Figure 9
Tumai mo te Iwi Primary Health Organisation

Tumai mo te Iwi PHO (Tumai) is a not-for-profit charitable trust providing primary health care services to the communities of Porirua, from Tawa to Pukerua Bay. Tumai was set up in April 2003, and, at the time of our audit, about 48,500 people were registered with a Tumai practice. About 15% of those registered were Māori, and 12% were Pacific Island peoples.

The PHO has set up several initiatives to break down barriers to accessing diabetes care. The PHO and Greater Wellington Health Trust provide for:

  • two free visits for people newly diagnosed with diabetes to help patients and their family/ whānau understand what diabetes is and how they can help themselves, as well as how others can support them to understand and live with the condition;
  • an outreach access nurse service in interim practices. This role is varied and includes chronic disease management, which for some patients includes weekly visits that monitor weight, blood glucose levels, blood pressure, and medications, and providing them with help liaising with the hospital, attending outpatient appointments, and co-ordinating care between services. From 1 July 2004 to 30 June 2005, 941 patients were visited for diabetes. In some cases impressive results were achieved.
  • free prescriptions for high need Māori, Pacific Island peoples, and low-income households within the Tumai area;
  • interpreting services for Tumai patients and general practice staff either on site or by telephone. This means that patients with English as a second language can seek the appropriate assistance for services if there is a language barrier;
  • free nurse and GP services at the Tumai health clinic. The clinic provides diabetes education, nutrition advice, and physical activity advice. The clinic focuses on the Tumai population who currently have no GP or are not enrolled with a PHO or who are not accessing health services in a timely manner. The clinic assists patients to enrol with a primary health provider for ongoing care;
  • specialist satellite clinics held in the Waitangirua Health Centre. The diabetes nurse educator and an access nurse support these clinics with patient follow-up. Building a rapport between the access nurse and patients attending the outpatient clinic is considered another means of removing barriers to health care and improved outcomes, especially for Pacific Island patients; and
  • a free taxi service for people who need it to access health care within Tumai. Ten trips are allowed over a three-month period.

Figure 10
Tu Meke Primary Health Organisation

Tu Meke, a PHO that provides low cost access to primary health care, was set up on 1 October 2005. At the time of our audit, Tu Meke had an enrolled population of 12,000 to 13,000 people, of which 48% were Māori and 15% were Pacific Island peoples. Most of the population were from low socio-economic areas. In addition, during the fruit and grape picking season, the population in the district increased by about 10,000. There were more than 700 patients diagnosed with diabetes in Tu Meke’s enrolled patient list.

The PHO has identified the following barriers to access:
  • patients are not aware that the free check is available;
  • there are problems contacting people;
  • patients have a blood test done but do not always attend follow-up appointments; and
  • some patients will not accept or acknowledge that they have diabetes in the first place.
Tu Meke recognises that most of their people diagnosed with diabetes have poorly managed diabetes, which could be improved if patients were able to better self-manage. The DHB has provided funding to the PHO for a project aimed at changing attitudes and behaviours through increased awareness and knowledge of diabetes.

The project has two phases.

The first phase, which started in June 2006, is aimed at identifying 50 patients with an HbA1c greater than 8% and offering them alternative treatments such as being seen by a nurse at home or in an appropriate community setting, or in a support group of other people with similar problems.

The programme will attempt to affect change by:
  • increasing awareness among participants and their family/whānau around the issues for people with diabetes;
  • working with the participants and their family/whānau (as requested) within their cultural context/environment;
  • educating participants and their family/whānau around self-care, nutrition, physical activity, and use of medication;
  • motivating patients and their family/whānau to take responsibility for effective self-management of their condition; and
  • providing opportunities to enter into physical activity, diet, and nutritional programmes, either individually or in a group setting.
The programme will also attempt to:
  • monitor the patient’s current condition to prevent the disease from advancing further; and
  • enhance current quality of life (in the eyes of the participant).
The second phase of the programme will focus on 150 people who are at high risk of developing diabetes, with the intention of identifying undiagnosed or recently diagnosed people with diabetes and entering them into appropriate care.

The PHO told us that it was worried it may not have enough resources to deal with people diagnosed as a result of the screening programme. At the time of our audit, two of its general practices had closed their rolls because of the high demand for all health services, not only diabetes.

Are the numbers of Māori and Pacific Island peoples accessing the programme increasing?

5.12
The numbers of Māori and Pacific Island peoples participating in the programme have generally increased over the duration of the programme in the districts that we visited.

5.13
The coverage rates (the percentage of the estimated eligible population participating in the programme) for Pacific Island peoples were high in 2006, with rates exceeding the DHB targets. The coverage rates for Māori continued to fall short of the annual targets set by the DHBs. Figure 11 sets out the coverage targets and results for the year ended 31 December 2006.

Figure 11
Coverage targets and actual results for the year ended 31 December 2006

DHB Māori Pacific Island
Target % Actual % Target % Actual %
Auckland 60 31 60 105
Capital & Coast 45 39 80 83
Counties Manukau 63 53 100 125
Hawke’s Bay 45 42 65 74
Otago 41 29 66 98
Tairawhiti 60 46 90 163

Note: The target figures are based on population estimates derived from the Ministry of Health’s model of diabetes which has some data deficiencies discussed earlier (see paragraphs 3.20 to 3.22) that affect the accuracy and precision of the forecasts from it. This is one reason the actual figures for Auckland DHB, Counties Manukau DHB, and Tairawhiti DHB are more than 100% of the target.

5.14
We also noted during our audit that the New Zealand Health Survey 2002/03 recorded that the diabetes prevalence rate was 8.7% for Asian females and 8.1% for Asian males. The Asian Health Chart Book 20062 recorded the prevalence rates for each Asian ethnic group as:

  • 3.4% for Chinese;
  • 9.4% for Indians; and
  • 5.7% for other Asians.

5.15
Some of the PHOs that we visited, especially those in the Auckland area, noted this growing incidence of diabetes in these ethnic groups. They noted that these cultures also have barriers – for example, a reluctance to acknowledge to others that they have diabetes – that could affect the management of their diabetes.

Conclusion

5.16
Many of the PHOs that we visited, especially those with larger Māori and Pacific Island peoples populations, had identified barriers to these population groups using the programme, and had put in place initiatives to address these barriers. From the numbers and coverage rates reported by DHBs, it appears that these initiatives have been more successful with Pacific Island peoples. Although the numbers of Māori accessing the programme were increasing, the coverage rates continued to fall short of the target rate set by DHBs.

Recommendation 14
We recommend that district health boards work with primary health organisations to continue to focus on removing the barriers to Māori and Pacific Island peoples accessing the “Get Checked” programme.
Recommendation 15
We recommend that the Ministry of Health and district health boards work with primary health organisations to evaluate existing initiatives for removing barriers to accessing diabetes care, and ensure that there is a mechanism in place to disseminate successful initiatives throughout district health boards and primary health organisations.
Recommendation 16
We recommend that district health boards consider whether initiatives need to be put in place for populations within their districts other than Māori and Pacific Island peoples who also experience barriers to accessing diabetes care.

Is the programme improving how diabetes is managed?

5.17
One of the main benefits of the programme is the information that has been collected since the programme began, and the opportunity that this allows for analysis, reporting, and planning to better manage diabetes care.

5.18
In paragraphs 5.19 to 5.39, we discuss whether the data collected from the programme is being used to:

  • analyse and report how the programme is improving diabetes management to enable continuing improvements; and
  • plan for future diabetes services.

Is the data from the programme being used to measure improvements in diabetes management?

5.19
We do not consider that the measures currently being reported by DHBs are enough to establish whether and how diabetes management is improving. We consider that DHBs need to carry out robust analysis of the data collected through the programme to enable continuing improvements to diabetes management.

5.20
DHBs are required to report their performance on the programme in their annual reports. One of the indicators is diabetes management. This is an indicator of the quality or effectiveness of care, and measures the proportion of people with poor diabetes management (that is, people with an HbA1c level greater than 8%) among people who have had a free annual check. The results reported show that, as at December 2006, the proportion of people with poor diabetes management has increased in seven out of 21 DHBs since the programme began, decreased in three, and remained largely unchanged in 11.

5.21
However, the public can have little confidence that this means diabetes management has improved. We have concerns that the figures are misleading in some respects. Where there is an increase in programme participants, the reduction in the proportion of participants with poor diabetes management may not show that the actual number of participants with poor diabetes management has increased. For example, Auckland DHB reported that the proportion of participants with poor diabetes management reduced from 39% to 32.5% between 2001/02 and 2004/05. However, the number of people participating in the programme in the Auckland DHB increased by 5122 over the same time, and the number of participants with poor diabetes management actually increased by 1627. Nor do the figures show whether diabetes management has improved (that is, whether HbA1c levels have fallen) for people who have been participating in the programme for some time, or whether new people joining the programme simply have lower HbA1c levels.

5.22
The programme alone may not improve how effectively diabetes is managed. Rather, this may depend on both the effectiveness of the programme and a coordinated package of care: support for patients to self-manage their condition through lifestyle changes, appropriate medication, advice, and specialist care where required. The information gathered from the programme should, however, enable identification of where management of diabetes cases needs to be improved at GP, practice, PHO, and DHB level.

5.23
Better indicators are needed to gauge whether the programme is leading to more effective management of diabetes. These should be based on tracking the HbA1c levels of a consistent group of people over a number of annual checks to determine how and why they change over time. This type of analysis is known as cohort analysis.

5.24
Cohort analysis was being used by two of the programme administrators that we audited – Wellington Regional Diabetes Trust and South Link Health Inc. In addition, a research team that was using the programme’s data as part of the New Zealand Diabetes Cohort Study provided the Wellington Regional Diabetes Trust with cohort analysis. This study involved 3838 people who had been for four checks.

5.25
The analysis of the cohort data showed similar results, in that increased use of medication had meant better cholesterol and blood pressure levels. However, the HbA1c levels were at best remaining constant, but generally rising.

5.26
Two other evaluations had also been carried out in Otago which showed similar results.

5.27
The first was an evaluation of diabetes care for a six-year period from 1998 to 2003 using data from the Otago Diabetes Register which pre-dated the programme (see paragraph 3.39).

5.28
The study found that process measures (the proportion of patients completing the recommended clinical examinations and tests within time) could be improved and sustained. It also found that blood pressure and lipid levels could be improved and sustained by prescribing medications, which was likely to translate into considerable clinical benefit. However, the evaluation identified that it appeared more difficult to achieve reduced HbA1c levels. The mean HbA1c levels for both type 1 and type 2 diabetes patients increased over the six-year period. The study noted that the most likely explanation for the failure to improve glycaemic control, a pivotal component of diabetes management, was the failure to implement lifestyle changes. This was witnessed by the increase in body weight of both men and women.

5.29
The study noted that the following factors had played an important role in the improvement:

  • GP and practice nurse education;
  • guideline implementation;
  • the provision of timely information to enable monitoring of patients; and
  • information to enable the timely recall of patients.

5.30
The study also noted that:

A nationwide “Free Annual Get Checked’ programme implemented at the end of 2000 in Otago, may have contributed to improved diabetes care in the region, but much of the improvement occurred prior to its implementation. However, the nationwide programme may have facilitated further improvements and helped to sustain the improvements.3

5.31
The second study (see paragraph 3.40) was an evaluation of the health outcomes for diabetes patients returning for three annual checks. This study was carried out using data from patients enrolled on the South Link Health Inc diabetes register which covered those patients who had completed three diabetes reviews by December 2005 (840 type 1 patients and 9998 type 2 patients).

5.32
The study concluded that the introduction of a structured and systematic general practice review process aimed at improving diabetes care and patient outcomes resulted in significant improvements in mean blood pressure, cholesterol levels, and albumin:creatinine ratio.4 There was, however, no overall improvement in glycaemic control (HbA1c levels).

5.33
The study also noted that there were significant increases in the proportion of patients prescribed antihypertensive and lipid-lowering medication. Statin5 use more than doubled from the first to the third diabetes review.

5.34
Counties Manukau DHB also carried out an interim programme evaluation of its Chronic Care Management programme in April 2005. The results of the evaluation showed that, for a cohort of 1544 patients enrolled in the programme for a year, their average HbA1c decreased by 0.34. Data for the cohort of 647 patients who had reviews at the end of two years showed an average decrease in the HbA1c of 0.32.

5.35
The University of Auckland and the University of Otago are carrying out a further diabetes cohort study. They expect to report the results of this study during 2007. The study aims to establish the relationship between risk factors and medical outcomes for people with diabetes in New Zealand, and develop ways to calculate cardiovascular and microvascular risk for people of different ethnic origins.

Is the data from the programme being use to plan future diabetes services?

5.36
We noted in paragraphs 4.50 to 4.53 that the information the LDTs were giving to the DHBs was not enough to establish whether the levels of specialist diabetes services meet the demand for these services.

5.37
We consider that the information and analysis of the data from the programme is not enough for DHBs to plan future diabetes services.

5.38
The information the LDTs were giving to DHBs included:

  • the number of people who had a free annual check over the past three years;
  • whether these people have had a retinal screen over the last two years;
  • the number of people with HbA1c levels between 7% and 8% and over 8%;
  • the number of smokers;
  • the number of people on ACE inhibitors6 and statins; and
  • the number of people whose cholesterol has been reported and whether the level of cholesterol was greater than nine7.

5.39
Although the HbA1c level is the best single measurement of the management of diabetes, and reducing this level significantly reduces the risk of getting complications, the measure in itself is not a good indicator of the type and volume of the potential complications from poor diabetes management. For example, data on the levels of potential diabetic kidney disease is one of the items being collected through the programme that was not generally being reported back to LDTs and therefore not being reported to DHBs. We consider that it is important DHBs receive analysis of this sort of data to inform their planning for the likely growth in diabetic kidney disease.

Conclusion

5.40
No clear conclusions can be drawn from current Ministry indicators on whether and to what extent the programme is improving the effectiveness of diabetes management.

5.41
The current indicator measuring the proportion of people with poor diabetes management (as indicated by an HbA1c level greater than 8%) among people who have had a free annual check could be misleading. This is because it is not based on a consistent population of people, and potentially disguises the increased numbers of people with poor diabetes management.

5.42
Not enough use is being made of the information available from the programme to inform future planning for diabetes services. Although the HbA1c level is an important indicator of the management of diabetes, further indicators of the types and volumes of likely complications need to be used to inform future planning for diabetes services at both the primary and secondary care levels.

Recommendation 17
We recommend that district health boards and the Ministry of Health carry out further analysis (for example, cohort analysis) of the effect that the “Get Checked” programme has had on diabetes care and management, to better understand how the programme and other factors contributing to diabetes care are linked and to identify what further improvements can be made in diabetes care and management.
Recommendation 18
We recommend that district health boards work with local diabetes teams and programme administrators to make more use of the data available from the ”Get Checked” programme to plan their diabetes services.

1: Page 17.

2: Ministry of Health (2006), Asian Health Chart Book 2006, Public Health Intelligence Monitoring Report No. 4, page xvi.

3: Coppell, Kirsten J., et al., page 350.

4: The urine albumin:creatinine ratio is a measure of kidney function used in diabetic kidney disease.

5: Statin or HMGCo-A reductase inhibitors are a class of hypolipidemic agents used as pharmaceutical agents to lower cholesterol levels in people with, or at risk of, cardiovascular disease.

6: ACE inhibitors, or inhibitors of Angiotensin-Converting enzyme, are a group of pharmaceuticals that are primarily used to treat hypertension and congestive heart failure.

7: Nine = ratio of total cholesterol to HDL cholesterol.

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