Quality improvement in non glycaemic targets in diabetic patients at Central Australian Aboriginal Congress John Boffa Public Health Medical Officer

Introduction 1. A historical perspective 2. NPCC and prioritising outcomes 3. Cholesterol control 4. BP control 5. Treatment for renal disease 6. Brief interventions for SNAP 7. Eyes and Foot Checks 8. What has led to the improvements?

3 historical periods in Diabetes Care in Central Australia Period 1 “Denial” 1988: diabetes but no complications Period 2 “Treatment nihilism” 1994: Scrimgeour and Rowse, Menzies – telling an Aboriginal person they had diabetes was the equivalent of telling a non Aboriginal person they had cancer Period 3 “Hope” 1999: diabetes is preventable and effective treatment from a well resourced PHC sector can make a big difference

Outcomes of improved diabetes management (NPCC) 1 percentage point reduction in HbA1c DCCT. N Engl J Med 1993; 329(14): UKPDS 33. Lancet 1998; 352(9131): % reduction in micro- vascular complications vascular complications 10 mm Hg reduction in blood pressure UKPDS 38. BMJ 1998; 317(7160): % reduction in micro- vascular complications; vascular complications; 44% reduction in strokes; 32% reduction in deaths Improved blood lipid control Pyorala K, et al. Diabetes Care 1997; 20(4): % reduction of coronary heart disease heart disease 43% reduction in death

Cholesterol control

Diabetic cholesterol control

Results: Cholesterol 2006  Total diabetic population n=541  Total cholesterol recorded in 75.8% (n=410)  Of those recorded: –76% Total Cholesterol <5.5 mmol/L –30% Total Cholesterol ≤4.0 mmol/L –Mean Total Cholesterol 4.7 mmol/L. CAAC (541) Remote NT (194) Cape York (252) Torres Strait (921) TC <5.5 76%60%67%46%

Results: Cholesterol 2009  Total diabetic population n = 734  Total cholesterol recorded in 79.8% (n=610)  Of those recorded: –79% Total Cholesterol <5.5 mmol/L –35% Total Cholesterol ≤4.0 mmol/L –Mean Total Cholesterol 4.5 mmol/L.

Patients on statins have doubled

More active management

Blood Pressure Control

Diabetic Blood Pressure Control <130/80

2009 BP outcomes  67% of Diabetic patients (n = 492) have had a BP recorded in the last 6 months  67% of Diabetic patients (n = 492) have had a BP recorded in the last 6 months  Of these patients, 231 or 47% have a BP < 130/80  2006 baseline of about 38% < 130 /80

More BP’s being done

Percentage of patients on medications has increased

Need more active BP management

Renal Disease

ACR / eGFR

More active management

Brief Interventions for smoking and alcohol

Smoking brief interventions

Increased referrals for alcohol

Nutrition and Physical Activity Advice

Eyes, Feet and BMI

Eyes and Feet

BMI

What has led to these improvements? 1. An evidence based focus on prioritised outcomes and scheduled services 2. Regular feedback to practitioners about our performance 3. Improved PIRS functionality: annual cycle of care, recalls, queries, data quality, electronic records 4. An improved pharmacy system ensuring better access to medications 5. An improved clinic system ensuring better access to regular GP for chronic disease management with excellent GP retention 6. Access to a diabetes educator and diabetes nurse 7. Regular physician clinics