Part 2: Knowing who has been diagnosed with diabetes and whether they are getting checked

Effectiveness of the Get Checked diabetes programme.

Identifying people who have been diagnosed with diabetes

2.1
In our Get Checked report, we considered that all DHBs should be able to identify the actual number of people who have been diagnosed with diabetes in their district.

2.2
The programme has now been running for more than nine years. It is important that DHBs know the actual number of people diagnosed with diabetes in their districts so they can accurately assess the coverage of the programme.

2.3
Without this information, DHBs cannot be certain that all people diagnosed with diabetes have been offered the opportunity to take part in the programme. Equally, DHBs might be overestimating the programme’s coverage. It is also important that DHBs know the actual number of people with diabetes so they can plan for the likely future demand for services, especially for treating complications from diabetes.

2.4
In 2009, most DHBs reported examples of work that they, their Get Checked programme administrators (programme administrators), or primary health organisations (PHOs) were carrying out to improve GPs’ coding and recording of patients diagnosed with diabetes. Figure 1 sets out the different ways that DHBs were doing this. See also the case studies in Figures 2 and 3.

Figure 1
Examples of work to improve GPs’ coding and recording of patients diagnosed with diabetes

Common action DHBs had taken included:
  • increasing the funding to general practices for annual checks to improve the recording of those checks;
  • funding information technology positions to support general practices;
  • assisting general practices to build their electronic patient management systems;
  • providing regular reports to general practices that benchmark their performance against other general practices;
  • introducing software into patient management systems to prompt GPs to code patients as having been diagnosed with diabetes; and
  • putting in place a local quality indicator programme, which includes diabetes coding as quality indicator.

2.5
Some DHBs reported that the national PHO Performance Programme provides an incentive for their PHOs to identify people diagnosed with diabetes in their GPs’ patient management systems.

2.6
The PHO Performance Programme, which started in 2006, was designed to improve the health of people enrolled with a PHO and reduce inequalities in health outcomes. If PHOs improve their performance against nationally consistent indicators, including two diabetes indicators, they receive incentive payments.

2.7
All but one PHOs participate in the diabetes part of the PHO Performance Programme.

2.8
Some DHBs told us that they check how complete their diabetes register is by comparing it to the Ministry’s register. The Ministry’s register includes a list of people who have had:

  • diabetes-specific medications dispensed;
  • a hospital discharge recorded;
  • four or more HbA1c tests2 in a two-year period; or
  • a diabetes-specific outpatient appointment.

2.9
We consider it good practice for DHBs to use this information to ensure that they have identified all those diagnosed with diabetes in their district.

Ensuring that diabetes registers are accurate and up to date

2.10
In our Get Checked report, we recommended that DHBs work to ensure that their diabetes registers are accurate and up to date, which is essential to identify patients who have been diagnosed with diabetes.

2.11
In 2009, many DHBs reported examples of work that they were carrying out to ensure that their diabetes registers were accurate and up to date. Much of this work was aimed at helping GPs correctly code those diagnosed with diabetes in their patient management system (see Figure 1).

Question to consider:
1. Have you identified all of the people in your district who have been diagnosed with diabetes by ensuring your diabetes register is accurate and up to date?

Identifying people diagnosed with diabetes who are not getting checked

2.12
In our Get Checked report, we considered that DHBs, their programme administrators, and PHOs should be able to identify those people diagnosed with diabetes who were not taking part in the programme. This would allow DHBs to know the real coverage of the programme in their district, rather than the coverage of the number of people estimated to have diabetes. Patients not taking part in the programme could then be asked to join, if they had not been asked already.

2.13
In 2009, some DHBs reported examples of work to identify those diagnosed with diabetes who were not attending the free annual health check that the programme offers. The case studies in Figures 2 and 3 show how two DHBs were carrying out this work.

Figure 2
Counties Manukau District Health Board – Known Diabetes project

Counties Manukau DHB set up the Known Diabetes project to identify the number of patients in its district diagnosed with diabetes. The DHB used several local databases to identify diabetes patients, including Counties Manukau DHB inpatients, diabetes and ophthalmology diabetes outpatients, diabetes waitlist and referrals, enrolees in the diabetes Chronic Care Management programme, enrolees in the Get Checked programme, and retinal screening patients.

The results from the project were then triangulated with other surveys, databases, and data sets, such as the Let’s Beat Diabetes baseline survey that interviewed 2500 adults living in the Counties Manukau DHB district. Counties Manukau DHB told us that this triangulation showed that the data from the Known Diabetes project aligned closely with the other data sets.

The results of the Known Diabetes project identified that there were about 25,000 people diagnosed with diabetes living in the Counties Manukau DHB district. The data also showed a very high prevalence of diabetes for the Pacific and Indian populations (at 11% and 9% respectively of those aged over 15). Overall, of the Counties Manukau DHB population over the age of 60, around 20% have been diagnosed with diabetes.

Because of the Known Diabetes project, Counties Manukau DHB was able to provide all its PHOs with lists of patients (by National Health Index number* at general practice level) who were on its “known diabetes” list but who were not enrolled in the Get Checked programme. PHOs have used these lists to update their registers and to contact individual patients and encourage them to have the free annual health check. Counties Manukau DHB told us that it employed two medical students to update registers for its largest PHO and contact these patients to off er them the free annual health check.

* The National Health Index number is an alphanumeric unique identifier used in the New Zealand health system.

Figure 3
Otago District Health Board – Data matching project

Otago DHB reported that its LDT was carrying out a data matching project that included the PHOs, general practices, and the DHB. The data matching project compares the Ministry’s 2008 diabetes data for Otago against the programme data for the same period to identify people with diabetes who have not accessed the programme during 2008.

Otago DHB told us that it intended to review the results of the matching process, and that each PHO would discuss the findings with the relevant general practice and determine how each general practice would investigate those who had not accessed the programme.

Otago DHB hoped that, once this was completed, the PHOs and general practices would have a much better understanding of who was not accessing the programme and how they might increase the number of eligible people accessing the programme.
Question to consider:
2. Have you identified those patients diagnosed with diabetes who are not taking part in the programme and made sure they have been asked if they would like to take part?

2.14
In paragraphs 5.1-5.5, we discuss identifying why people diagnosed with diabetes are not taking part in the Get Checked programme.

Encouraging people to participate in the programme

2.15
In our Get Checked report, we identified that some GPs were not encouraging patients to take part in the programme. The main reason for their reluctance was that the GPs believed that the fee paid for carrying out the free annual health check was not enough to cover the costs of the check or the costs of completing the documentation that accompanied it. Other issues reported to us included:

  • some GPs saw the reviews as an information-collecting exercise;
  • technology problems sometimes meant that data from the free annual health check was not submitted to the PHO or DHB and the fee was not paid to the general practice; and
  • a higher proportion of people failed to attend the pre-arranged appointment for the free annual health check than failed to attend appointments made for existing conditions.

2.16
In our view, all people diagnosed with diabetes should be offered a chance to take part in the programme. DHBs and their programme administrators or PHOs need to work with general practices to address concerns about the programme, where possible.

2.17
In our 2009 survey, one DHB told us that low participation in the programme by general practices was still an issue. This DHB reported to us that its GPs view the checks as an administrative data collection exercise and the wrong driver for better diabetes management. Although the GPs see the individual measures in the review as valid, they do not support the concept of an annual review about a single disease when people with diabetes may have other conditions, and need ongoing management of all of them.

2.18
Some DHBs reported that they had taken some steps to encourage GPs to promote and support the programme. Several DHBs reported to us that they have increased the funding to general practices for each free annual health check to better reflect the work involved. Waikato DHB told us that it has encouraged its PHOs to ensure that patients diagnosed with diabetes, especially Māori and Pacific Island patients, are encouraged to join the programme by way of its local quality indicator programme.

Question to consider:
3. Where GPs may not be promoting and supporting those diagnosed with diabetes to take part in the programme, have you (or your programme administrator or PHOs) considered whether you need to address concerns that GPs in your district might have about the Get Checked programme?

2: An HbA1c test is a blood test to measure a person’s glycosylated haemoglobin level. The test indicates how well a person has been managing their blood glucose levels, and the results are given as a percentage.

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