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Improving diabetes care in primary care

Improving diabetes care in primary care

What is diabetes?

Diabetes is diagnosed when a person has too much glucose (sugar) in the blood. This happens because the pancreas cannot make enough insulin or the insulin does not work in the way it should.

Glucose is an essential source of energy for the brain and is one of the sources of energy for the body. Glucose in the bloodstream comes from carbohydrate foods, which are changed into glucose after we have eaten them. Glucose also comes from the liver, where it has been previously stored. This ensures a constant supply even when we have not eaten recently.

Diabetes is the result of the body not creating enough insulin or the insulin does not work the way it should to keep blood glucose levels in the normal range. Glucose then stays in the blood and does not reach the body’s cells. Over time, diabetes can lead to serious problems with blood vessels, the heart, nerves, kidneys, mouth, eyes, and feet.

Diabetes cannot be cured but it can be controlled with medication or a modified diet and you can lead a full and active life.

For more information about diabetes please go to www.diabetes.org.nz.

What are we trying to achieve?

  • In 2011 the Northern Region Health Plan identified the need change the way we deliver services for people with long term conditions in order to improve their outcomes
  • The West Auckland Locality and Cluster Analysis[1] showed that diabetes related outcomes in West Auckland was poorer that other areas within the Waitemata district

Our goal is to improve diabetes care for people in the West Auckland area through achieving good glycaemic control.

What have we done?

  • A West Auckland Diabetes Working Group was formed to initiate a 2-year quality improvement pilot in primary care, commencing in December 2014
  • We carried out a stocktake of 10 GP practices in West Auckland around their existing practices for diabetes care
  • We identified the following clinical indicators to achieve good glycaemic control (good sugar control)[2]:
    • management of blood pressure
    • management of micro-albuminuria
    • management of cardiovascular risk
    • early intervention and classification
    • smoking cessation
  • We gathered baseline clinical indicator data for 8 practices in March 2015, and continued to collect data quarterly for all 10 practices

PDSA cycle of improvement with The FONO

The FONO logoWe engaged with The FONO to share their benchmarking data and stocktake. Using the PDSA cycle as their tool for improvement they set a focus targeting patients with HbA1c >90 with the aim of reducing HbA1c by 20% over 12 months.

A mini audit showed 79 registered patients with HbA1c >90. We also selected 12 patients for intensive case management. This involved a dedicated team with a GP and district nurse, intensified patient management and home visits.

Patients’ results were monitored regularly to check that activities, including education and insulin management options, were making a difference. If not the team would try a different approach with the patient to help manage their diabetes.

  1. West Auckland Integrated Care Project: Locality and cluster level analysis. Martin, S., Zhou, L. 2012. 
  2. Glycaemic control means good sugar control, and the measure of good glycaemic control is a blood test called the HbA1c:
    • the lower the score the better the control
    • the higher the score the worse the control and the greater the risk of complications (eyes, heart, kidneys and limbs)


Did we make a difference?

  • Overall we achieved our aim to reduce HbA1c by 20% or 22 mmol/mol (average 83 mmol/mol in March 2016 down form average 105 mmol/mol in June 2015)
  • 66% of patients with HbA1c >90 showed improvement over the 12 months
  • Of the patients who were intensively case managed, the average reduction in HbA1c was 27% or 29 mmol/mol

Where to from here?

  • We will extend the pilot to include other GP practices
  • We plan to carry out a final evaluation of the pilot in Jan 2017