Part 4: Checking the quality of the service

Effectiveness of the Get Checked diabetes programme.

Clinical audit of diabetes care

In our Get Checked report, we recommended that DHBs (or their programme administrators or PHOs) use information in diabetes registers to identify general practices that may need extra support to manage patients diagnosed with diabetes. We then expected DHBs to carry out a more focused audit of the diabetes care that these general practices provide, to discover what the issue was and what support the DHB needed to provide.

In 2009, some DHBs told us that they carry out audits like this. For example, Counties Manukau DHB reported that it was working with its local provider, the Diabetes Project Trust,5 to focus its audits of GPs on general practices that PHOs had highlighted as needing clinical assistance. The Diabetes Project Trust had initially identified those general practices with case management rates under 55% and those with retinal screening rates under 60% as needing clinical assistance.

We also understand that all PHOs are required to carry out clinical audits of their general practices under the DHB-PHO agreement. In our view, DHBs should use the information from these audits to identify general practices that need extra support to manage patients diagnosed with diabetes.

Many DHBs reported that they tend to provide support and education to general practices rather than auditing their clinical care to ensure that it is of an acceptable quality. Figure 4 sets out examples of this support and education.

Figure 4
Examples of quality improvement support that district health boards provided to general practices

DHBs have told us that they have:
  • resourced providers of local diabetes education to educate primary and secondary care clinicians;
    • increased resourcing of PHO diabetes nurse educators who work with general practices to improve their management of diabetes patients;
    • worked with the sector to prepare standardised assessment and care planning templates;
    • employed diabetes co-ordinators to work with general practices on diabetes planning and management;
    • funded software in general practices that supports diabetes assessment;
    • diabetes specialists working with primary health care practitioners to promote, educate, and support best practice care in line with the guidelines;
    • the LDT actively working with general practices and acting as a resource on effectively managing their diabetic population; and
    • provided national-guidelines-based education to primary and secondary health care nurses.

We consider this work appropriate, but note that it is also important to ensure that patients receive diabetes care in line with the evidence-based best practice guidelines and national referral guidelines. In our view, an audit component would strengthen this work.

An audit component would also allow DHBs to identify where general practices need support and education in their diabetes care. Providing support and education will be more effective if it addresses identified issues of quality.

Question to consider:
8. Have you considered whether you or your PHO(s) should inform and complement the support and education for general practices with more in-depth audits of their diabetes care?

Checking diabetes treatment plans

In our Get Checked report, we recommended that DHBs, their programme administrators, or their PHOs check that patients taking part in the programme were getting treatment plans and that the treatment plans were of an acceptable quality. Treatment plans can make a considerable contribution to the success of the programme. They encourage patients to effectively manage their diabetes and control their blood glucose levels.

Few DHBs reported to us in 2009 that they checked this. The ones that did told us that they have checked that patients were getting treatment plans, but have not checked the quality of those plans.

Question to consider:
9. Are you, your programme administrator, or your PHO(s) checking that diabetes treatment plans are of an acceptable quality?

Establishing the effectiveness of treatment plans

In our Get Checked report, we recommended that DHBs (or their programme administrators or PHOs) monitor the effectiveness of the treatment plans in improving self-management of diabetes through lifestyle changes. Indicators of improved self-management may include reducing body mass indexes, reducing the number of people smoking, and improving HbA1c levels.

After we published the Get Checked report, the Government introduced Health Targets for diabetes care. All DHBs must now record and report each year the proportion of people who have had a free annual health check with satisfactory or better diabetes control (as indicated by HbA1c levels).

A few DHBs reported using other indicators to monitor the effectiveness of treatment plans, such as lifestyle changes. For example, West Coast DHB told us that its PHO monitors the effectiveness of treatment plans by analysing information collected through the programme, such as smoking rates, medication rates, lipid levels, HbA1c levels, and blood pressure levels. This analysis is fed back to general practices with peer comparisons on a quarterly basis.

Auckland DHB also analyses information collected by its PHOs, such as smoking cessation rates, medication prescription rates, and HbA1c levels. The DHB shares this information with its PHOs and LDT annually.

Where the evidence indicates a lack of progress in improving self-management, DHBs (and their programme administrators or PHOs) need to work to improve it. In the Get Checked report, we reported examples of work to improve HbA1c levels. Figure 5 sets out these examples.

Figure 5
Examples of work to try to improve self-management of diabetes

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

South Link Health Incorporated introduced an Enhanced Diabetes Programme on 1 April 2005. The Enhanced Diabetes Programme provided an additional subsidised visit for patients who had an HbA1c level greater than 8% for two consecutive free annual health checks. The main purpose of this extra visit was to focus on lifestyle and medication changes.
Question to consider:
10. Are you, your programme administrator, or your PHO(s) working to improve the effectiveness of the treatment plans in improving self-management of diabetes where there is evidence of a lack of progress?

5: The Diabetes Project Trust is a non-governmental organisation that runs and manages the Diabetes Care Support Audit (see page 37 in the Get Checked report).

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