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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