INVESTING TO IMPROVE THE OUTCOMESOF DIABETES CARE

Ruth Colagiuri and Margaret WilliamsonCentre for Clinical Policy & PracticeMichael FrommerCentre for Research & DevelopmentPublic Health DivisionN$W Health Department

I n October 1994 the NSW Health Department began evolving a model orprototype for the development, planning and implementation of initiativesto improve the outcomes of health care, focusing on diabetes meffitus. Thisarticle outlines progress on this project, which is known as the Diabetes

Outcomes Project. Key principles of the project are wide consultation, theidentification and adoption of practices with evidence of effectiveness andefficiency, equity of access to health services, monitoring of health outcomesand the use of information obtained from monitoring in subsequent decisionmaking.

WHY DIABETES?Diabetes was chosen as the model for several reasons.

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It is a prevalent disorder which typifies many chronic conditions inthe NSW population. Diabetes affects 3-4 per cent of the Australianpopulation', at least 10 per cent of older people, up to 20 per cent ofsome Aboriginal communities', and has a high prevalence in peoplefrom the Pacific Islands, the Middle East, Southern Europe and someAsian countries.

Diabetes causes a substantial burden of morbidity and mortality.It is among the major causes of death and is the second most commonreason for commencing renal dialysis in Australia3. It is estimated thatup to 50 new cases of blindness and 775 non-traumatic lower extremityamputations are attributable to diabetes in NSW each year. Diabetesis also a major cause of ischaemic heart disease, stroke and impotence.The true burden in terms of health resources, personal suffering anddetriment to quality of life is immeasurable.

The care of people with diabetes spans the continuum from preventionand diagnosis, through initial arid ongoing treatment, to rehabilitationand palliation. People with diabetes encounter a wide range of healthprofessionals in the full spectrum of health care settings which arevariously supported by Commonwealth- and State-sourced paymentmechanisms. Thus diabetes care exemplifies all facets of the looselynetworked Australian health care system.

There is evidence that outcomes for people with diabetes can besubstantially improved by providing better access to quality diabetesservices. The focus is on preventing or mininiising complications of thedisease. It is estimated that the numbers of new cases of blindness andlower extremity amputations attributable to diabetes could be halved.

Contents

[II] Articles

99Investing to improve theoutcomes of diabetes care

102 A framework for applyinga health outcomesapproach

106 Waiting list reductionprogram: initial results

110 The Hunter-ilkuvarraStudy ofAirways andAir Pollution: refiningthe process

Infectious Diseases

1 l 3 No4fications

Correspondence

Please address allcorrespondence and potentialcontributions to:

The EditoNSWPublic Health Bulletin,Public Health Division,NSWHealth DepartmentLocked Bag No 961,North Sydney NSW2059Telephone: (02)3919191Facsimile: (02) 391 9029

Vol. 6/No. 10 99

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diabetes outcomes

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There had already been formal collaboration onthe measurement of diabetes outcomes betweenthe NSW Health Department and clinicians frommedical, nursing and allied health backgrounds,and consumers. This collaboration resulted in theidentification of process and outcome indicatorsfor diabetes care and the development of a systemto make clinical indicator information availablein different health care settings.

THE FRAMEWORK

The project initially concentrated on the development ofa generic planning framework which could be applied toimprove the health of people with diabetes as well as otherchronic conditions. It comprises a series of interdependent,interacting steps, as follows:

developing goals and targets for diabetes preventionand care;identifying and evaluating prevention andtreatment strategies and interventions;defining and evaluating standards of care;evaluating services and identifiing ways to improveservice delivery;developing indicators arid systems to monitor thequality and outcomes of services;identilying research needs for incorporation intoa strategic research plan;developing, piloting and evaluating models forprevention and care; anddeveloping a statewide plan for integrating diabetesservices.

The planning framework has since been further refined, andis described on page 102 in this issue of the Pubik HealthBulletin.

CONSULTATIONSince the inception of the project there has been anemphasis on the participation of people with diabetes,diabetes care providers and the orgariisation.s whichrepresent them. To this end there has been a broadconsultation process involving consumers, consumer groups,endocrinologists, general practitioners, diabetes educators,podiatrists and other relevant clinicians, health promotionpractitioners and Area and District planning groups. AnExpert Panel on Diabetes has been established to providescientific and clinical advice and consumer perspectives.Its membership represents consumers, medical andnon-medical clinicians, public health practitioners andrepresentatives from Aboriginal Medical Services (AMS)and rural arid conimunity health services. Working groupsof the Expert Panel have provided advice on guidelines andspecffic implementation issues.

APPLYING THE FRAMEWORKThe goals of the diabetes outcomes project are to prevent orminimise the complications of diabetes, enable people withdiabetes to have the best possible quality of life and preventnon-insulin-dependent diabetes.

It is not possible to prevent insulin-dependent diabetes.But there is evidence that factors such as improvednutrition and adequate physical activity contribute to

the prevention of non-insulin-dependent diabetes mellitus(NIDDM). Because community strategies for optimalnutrition and physical activity (which are already beingimplemented to prevent cardiovascular disease) mayalso prevent NIDDM, the Diabetes Outcomes Projecthas concentrated on diabetes care issues, as follows:

describing the current state of diabetes care;identifying key elements of quality diabetes careand opportunities for improving outcomes;defining and disseminating evidence-basedstandards of care, including the development ofmethods for evaluating the quality of evidence;defining indicators and developing informationsystems to monitor progress; andencouraging service integration aimed at enhancingaccess and promoting a comprehensive, collaborative,population-based approach to diabetes care.

CURRENT STATE OF DIABETES SERVICES IN NSWA statewide survey of Area and District Health Services,community health services, specialist diabetes centres andservices and private specialist physicians was conducted inDecember 1994 to determine the nature, scope and locationof diabetes services in NSW.

Before the survey it was known that diabetes ambulatorycare centres were established in all Area Health Servicesbut one. It was acknowledged that a high standard ofspecialised diabetes care was provided by the multi-disciplinary teams in these centres and by endocrinologistsin private practice, with an estimated 80 per cent ofdiabetes care taking place in general practice.

The survey results confirmed the variable nature of diabetesservices and identified lack of access to specialist services asa major issue in rural and remote regions and for Aboriginaland non-English speaking people.

ELEMENTS OF DIABETES CARE AND OPPORTUNITIESFOR IMPROVEMENTThere is a consensus of expert opinion, supported bypublished literature, that diabetes care and outcomes can beimproved by providing access for all people with diabetes to:

information about their condition and educationfor self care;ongoing clinical care to provide optimal metaboliccontrol; aridscreening for and appropriate treatment ofcomplications.

Seven guidelines have been prepared to aid clinical decisionmaking and assist the practitioner in the management ofdiabetes in people over the age of 18 years. A group ofpaediatric endocrinologists is adapting these guidelinesfor application to children and adolescents with diabetes.Principles and recommendations for diabetes education andthe promotion of self-care skills are also being developed.

As far as possible the guidelines are based on publishedevidence which has been evaluated using criteria andmethods established for this purpose by Irwig, Liddle andWilliamson4. Grading of the quality of the evidence for threeguidelines (blood glucose control, diabetic eye disease andfoot problems) is complete. The evidence supporting therecommendations for the blood glucose control and diabeticeye disease guidelines is strong. However, the evidence thatscreening for and treating foot problems results in improved

VoI.6INo.10 100

outcomes is variable or unavailable. This is partly due to theethical difficulties of randomised allocation of people with aserious foot problem to receive no treatment. Whereevidence is weak or absent, guidelines are based onconsensus expert opinion.

FROM PRINCIPLES TO PRACTICEIntegrated care has been identified as a model that iscapable of improving access to care, quality of care andoutcomes for people with diabetes. Shared care schemeshave pioneered the integration of public specialist andgeneral practitioner services for diabetes and have improvedaccess to quality diabetes care and outcomes. However,many shared care schemes have not addressed the needto formalise communication, speciey responsibilities andincorporate auditing mechanism&.

Integrated care builds on and ex±ends the concept of sharedcare by incorporating a population-based approach toimprove access to uniform standards of quality carethrough:

commitment to local collaboration;development of an agreed Area- or District-wideservice plan based on local needs;incorporating identified guidelines into clinicalpractice;the provision of training;enhanced communication mechanisms; andmonitoring and feeding information into clinicalpractice.

The involvement of general practitioners, other medicaland non-medical clinicians and consumers is central to thesuccessful implementation of principles of diabetes care andguidelines into practice.

1. Involvement of general practitionersIn view of the central role of GPs in providing andco-ordinating the care of people with diabetes, there wasearly involvement of GPs in the project. In addition to GPmembership of the Expert Panel, all Divisions of GeneralPractice in NSW were invited to participate in a workshopsponsored by the NSW Health Department and DiabetesAustralia- NSW in April 1995. The aim of the workshopwas to inform GPs about the health outcomes approach,present the clinical management guidelines and seek GPs'input on the implementation of the guidelines. Sixty-threeparticipants represented the Divisions of General Practiceand the Royal Australian College of General Practitioners,the Australian Medical Association, the Aboriginal MedicalServices in NSW and the NSW Corrections Health Service,as well as the General Practice Branch of theCommonwealth Department of Human Services andHealth, Diabetes Australia and the NSW HealthDepartment. The workshop was instrumental in buildinga partnership between the Divisions and the NSW HealthDepartment and opened the way for frank dialogue on suchissues as GPs' training needs in relation to diabetes and theavailabifity of public non-medical clinical services (e.g.podiatry). Subsequently the Divisions of General Practiceagreed to participate in pilots of integrated diabetes care.

2. Consumer involvementConsumer advice is being provided to the Expert Panelby Diabetes Australia - NSW, the Juvenile DiabetesFoundation Australia and representatives of people withinsulin-dependent and non-insulin-dependent diabetes.

Other rural and metropolitan groups of consumers are alsobeing consulted. The consumer groups are being asked toidentifr:

• the main issues and concerns for people withdiabetes; and

• expectations of access to and standards of healthservices.

Based on this information, a working group is drafting aconsumer charter to encourage and empower people withdiabetes to request appropriate quality of care, and promotetheir involvement in the management of their condition.This working group has also provided advice on theprinciples of diabetes care and the clinical managementguidelines.

PILoTING INTEGRATED DIABETES CARETo assess the feasibility, effectiveness and cost of integratedcare, a call for expressions of interest in piloting integrateddiabetes care systems was distributed in June 1995 to Areaand District Health Services, Divisions of General Practice,Aboriginal Medical Services, diabetes centres and servicesand Public Health Units in NSW. It invited joint proposalsfrom Areas/Districts, Divisions of General Practice and theother services.

Monitoring of service provision and outcomes will make useof the NDOW information system developed by cliniciansand NSW Health Department staff and named after the1993 NSW Diabetes Outcomes Workshop which hasgenerated a minimum dataset of diabetes process andoutcome indicators.

Three pilot sites have been selected, encompassing theWestern Sydney Area, the Orana and Far West Districtsand the Macleay-Hastings District. The pilots will be runover a two-year period with funding provided jointly by theNSW Health Department and the General Practice Branchof the Commonwealth Department of Human Services andHealth. An evaluation committee will oversee the process,including final assessment of the effectiveness, efficiency,cost, feasibility and wider application of integrated care.

INFORMATION SYSTEMS FOR MONITORING CAREAND OUTCOMESThe September 1993 NSW Diabetes Outcomes Workshop(NDOW) identified 59 consensus indicators, includingmeasures of metabolic control, modifiable risk factors andmorbidity relating to individual patients. These indicatorsare known as the N])OW dataset. A NSW Health Outcomesgrant awarded in 1994 developed a data collection systemfor the NDOW dataset, enabling the data to be transferredbetween clinical settings electronically, by facsimile or aspaper copy. The NDOW Data System has been trialledat the Prince of Wales Hospital arid Lidcombe Hospitaldiabetes centres and is being piloted by a group of GPsin the Central Coast Area.

Throughout the project, gaps in the documented evidencefor some areas of clinical practice, the relative efficacy ofmodels of care and prevention, and morbidity data havebeen flagged. The implementation of the NDOW datasystem in the three integrated care pilots will provideaccurate information on morbidity and will assist in

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A FRAMEWORK FOR APPLYING A HEALTH OUTCOMES APPROACH

Margaret Williamson, Cait Lonie, Ruth Colagiuri, DianneKelleher, Elizabeth Terracini, Kym Scanlon, MagnoliaCardona, Hanna Noworytko, Julianne Brown, AndrewWilson, Glen Close and Helen MoorePublic Health DivisionNSW Health Department

aditionally the performance of the health system hasbeen assessed by measuring the number, type, length

and cost of interactions with patients. With the focus onoutcomes, attention is turning to measuring the impactof health services on the health of people. Health outcomesinitiatives in NSW have concentrated on the developmentof indicators to monitor services and their effect on health,and on the use of indicator data to improve the quality andoutcomes of health services.

As described on page 99 of the NSW Public Health Bulletin,the NSW Health Department has developed and applied aplanning framework designed to improve the outcomes ofcare for people with diabetes mellitus. The planningframework is being adapted for application to the nationalpriority areas of cardiovascular disease, cancer, injury andmental health. This article describes the planningframework and outlines the steps in its application toimprove the quality and outcomes of health services.

WHAT IS MEANT BY 'HEALTH OUTCOMES APPROACH'?The objective of the health outcomes approach is to ensurethat the structures and processes of health care andprevention have a positive impact on people's health.Although the emphasis is on improving health and healthstatus, the approach is also concerned with the quality,delivery and organisation of services, the examinationand evaluation of evidence for existing and proposedinterventions, consumer acceptability, resourcemanagement, and equity of access mid outcomes. It dependson the availability of systems to monitor these factors aswell as changes in the health of individuals and populations.By linking information on process and outcomes withinformation on costs, the health outcomes approach can

assist in setting priorities for the planning and deliveryof health services at a local level, across the spectrumfrom prevention through early diagnosis, treatment andmanagement to continuing care, rehabilitation andpalliation.

The emphasis on equity of access to services and equity ofoutcomes is especially important for disadvantaged groups,such as rural communities, Aboriginal and Torres StraitIsland people, and people from non-English speakingbackgrounds.

WHAT IS NEW ABOUT THE HEALTH OUTCOMESAPPROACH?Health professionals have for many years applied a similarapproach, using evidence-based practice in health care andmeticulously monitoring patient outcomes. Many healthservices and orgamsations have incorporated programs toimprove the quality of their services and to meet the needsof their patients. The reorientation of ambulance andemergency department services to improve outcomes fortrauma patients is an example of how a health outcomesapproach has been applied to improve patient care in NSW.

The health outcomes approach is innovative in that it relieson the systematic application of a cycle of defining outcomesand indicators, developing systems to provide indicatorinformation, monitoring processes and outcomes, linkingoutcome information to cost information, and using thisinformation in decision making.

How is THE HEALTH OUTCOMES APPROACH APPUED?The health outcome approach is essentially problem-based,and can be posed in relation to a specific health problem.The following list of nine questions encompasses thepractical application of the health outcomes approach.They represent the components of a reiterative process.

• What is the problem?• What do we aim to achieve?• What is the best thing to do?• How can we measure what we achieve?• Are we doing the best thing now?

diabetes outcomes

Continued from page 101

identifying the processes and service configurationswhich lead to the best outcomes.

LESSONS TO DATEThere have been two important lessons from the diabetesoutcomes project.

The first has been the importance of wide consultationfrom an early stage. The contribution from people with aconsumer or professional interest in diabetes is remarkableand their collaboration has generated a wide ownership ofthe process.

The second lesson has been the value of moving the debateon health outcomes from a conceptual level to one ofpractical implementation. The focus on diabetes as a modelfor implementation has enabled the health system to define

objectives and to identify opportunities for attainingclearcut, quantifiable improvements in health.1. Glatthaar C, Welborn TA, Stenhouse NS, et at Diabetes and impairedglucose tolerance: a prevalence estimate baaed on the Busselton 1981survey. Med JAust 1985; 143:436-440.2. McGrath M, Collins V, Zimmet P, Dowse G. Lifestyle disorders inAustralian Aborigines: diabetes and cardiovascular disease risk factors:a review. International Diabetes Institute, for ATSI Better HealthProgram. 1991.3. Disney APS (Ed). Sixteenth Report of the Australia and New ZealandDialysis and Transplantation Registry (ANZDATA) 1993. The QueenElizabeth Hospital, Woodville, South Australia.4. Irwig L, Liddle J, Williamson M. Evaluation checkliat for evidence-based guidelines. NSW Health Department. May 1995.5. Colagiuri K, Williamson M. Report on the 1995 NSW DiabetesOutcomes Workshop for General Practitionera, Epidemiology Branch,NSW Health Department, April 1995.6. Diabetes Integrated Care Evaluation Team. Integrated care fordiabetes: clinical, psychological and economic evaluation. Br Med J 1994;308:1208-1212.7. Baksi AK. To fulfil a defect in primary health care: in Gatekeeper andProviders of Primary Care in Diabetes Mellitus Symposium, 15thInternational Diabetes Federation Congress. Japan, 1994 (in press).8. Waters J, Churches T. Report on the 1993 NSW Diabetes OutcomesWorkshop. Epidemiology Branch, NSW Health Department. January1994.

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