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

2. 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. 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

4. Outcomes of improved diabetes management (NPCC) 1 percentage point reduction in HbA1c DCCT. N Engl J Med 1993; 329(14):977-986 UKPDS 33. Lancet 1998; 352(9131):837-853 25-30% reduction in micro- vascular complications vascular complications 10 mm Hg reduction in blood pressure UKPDS 38. BMJ 1998; 317(7160):703- 713 37% 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):614-620 39% reduction of coronary heart disease heart disease 43% reduction in death

5. Cholesterol control

6. Diabetic cholesterol control

7. 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%

8. 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.

9. Patients on statins have doubled

10. More active management

11. Blood Pressure Control

12. Diabetic Blood Pressure Control <130/80

13. 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

14. More BP’s being done

15. Percentage of patients on medications has increased

16. Need more active BP management

17. Renal Disease

18. ACR / eGFR

19. More active management

20. Brief Interventions for smoking and alcohol

21. Smoking brief interventions

22. Increased referrals for alcohol

23. Nutrition and Physical Activity Advice

24. Eyes, Feet and BMI

25. Eyes and Feet

26. BMI

27. 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