Mlemm HEALTH ?4 Database number: 20161937 Security classification: ln-Confidence File number: AD62-14-2016 Action required by: routine Update on the Implementation of Living Well with Diabetes To: Hon Dr Jonathan Coleman, Minister of Health Purpose This report updates you on progress in implementing Living Well with Diabete risk of, or iiving with, diabetes 2015-2020 (the Diabetes Plan). Progress is priority areas for action and the nine outcome measures in the Diabe? Key points . The Diabetes Plan sets out a vision that all New developing type 2 diabetes, are living well an- . high -centred health . Diabetes is New Zealand?s fast - . . poses a significant economic -.- .. the -- ing to increase each year. a .- 5? .- prioritised actions in the Diabetes Plan the Quality Standards for Diabetes Care across all try and . services; development of evidence?based advice on pre- come measures includes: completion of early work on premature - to diabetes; a decline in the number of major amputations in people with .- . ement in implementing the Diabetes Plan are: reducing the variation in diabetes - rose the country; developing innovative models of care that reach high-risk populations; ildi - . multi-disciplinary workforce capacity; and improving data collection and analysis. These - as are being addressed through intensified engagement with DHBs. sharing best-practice information, supporting innovative approaches and improving data capture and understanding. . The next progress report will be provided in mid?2017. Recommendations This report is for your information only and does not request any decisions. Jill Lane Minister?s signature: Director Service Commissioning Date: Dr Helen Rodenburg, Clinical Director LTC 8 Contacts: Clare Perry, Group Manager, Integrated Services Design 3 Page 1 of 7 HEALTH Database number: AD62-14-2016 The Diabetes Plan 1. The Diabetes Plan was developed in 2015 to respond to the serious health challenge of growing numbers of people with diabetes - an estimated 260,458 people in New Zealand at end-2015 with the number increasing each year. Diabetes (New Zealand's fastest growing long-term condition) poses a significant economic burden at individual and societal levels. 2. The Diabetes Plan builds on work already underway and sets out a vision that all New Zealanders with diabetes-or at high risk of developing type 2 diabetes, are living well and have access to high- quality, people-centred health services. The focus is on supporting people to mangir condition themselves, with the priority areas of action to: prevent high-risk people from developing type 2 diabetes enable effective self?management improve quality of services provide integrated care meet the needs of children and adults w' - 3. You launched the Diabetes Plan in Octob 2 2016 (HR20160382 refersbased advice for health providers on risk factor management for pre-diabetes. The advice includes guidance on dietary counselling, increased physical activity, weight management and behaviour modification, and was published on the Ministry website last month. Enable effective seif-management 7. A text messaging self-management support service (SMS4BG) is being trialled by the University of Auckland. The trial focuses on people with poorly controlled diabetes who are of Maori or Pacific ethnicity and/or who live in rural areas. There are 366 participants involved in the trial and the early results will be available in late 2017. 8. A weight management project aiming to reduce the risk of diabetes is in progress with Compass Health and Weight Watchers. To date, 170 people at risk of diabetes have been recruited by local practices for a three?month or six-month weight management programme. This includes a higher than expected proportion of Maori and Pacific people. The project is being evaluated with the early findings due mid-2017. Improve quaiity of services 9. The Ministry continues to work closely with DHBs to drive implementation of the Quaiity Standards for Diabetes Care and to address some ongoing national and local variability in diabetes services. DHBs are required to undertake a stocktake of their diabetes services against the standards and report progress on this and their associated actions in their Annual Plans and quarterly reports. Page 2 of 7 . . . a! Database number: AD62-14-2016 10. Diabetes indicators are also contributory measures within the System Level Measures library. including diabetes detection and follow-up, HbA1c test results, Diabetes Annual Reviews and delay of progression of diabetic retinopathy. 11. In addition to the growing numbers of people with diabetes (30 percent increase in prevalence over the last five years) reported service delivery challenges include: building sufficient multi-disciplinary workforce capacity; reaching high-risk people; and variation in data collection, sharing and analysis. Other challenges described are time constraints in providing effective support for people with diabetes (especially for those with lower health literacy) and increasing clinical complexities such as in children and young people with type 1 diabetes and in younger peeple with type 2 diabetes (those aged 25-45 years and especially Maori, Pacific. Indo-Asian). Detect diabetes early and reduce the risk of complications 12. Diabetes/mental health pilots in Northland and Tairawhiti DHBs are a and focusing on three key groups; adults, youth and children/whana 1' ty betes. DHB is adopting a kaiawhina model working with people wit 0. .-. ?ef practice. Malatest is evaluating the pilots with the results I?w .. ed fro en- . -guida a increased . 13. An update of the CVD risk guidance is in progres . focus on diabetes. 14. Significant improvements in foot scree DHBs. This includes increased nu bers 15. - ma! Screening, Grading, Monitoring and 'apital and Coast. Hutt Valley and Wairarapa ree-DHB model more efficiently uses existing health 'l sed . Research findings have been submitted forjournal publication i disseminated through normal Ministry channels. - des and Community Engagement project lead by Dr Tom Mulholland continues. people have had HbA1c, blood pressure and blood lipids tested thus far, and ave been made to general practices where appropriate. Ofthese, 130 people (24 - had undiagnosed pre-diabetes and 26 people (5 percent) had undiagnosed diabetes. Follow-up surveys with a subsample of 94 people revealed that 84 percent had taken action to address their test results; most people increased their physical activity and/or made dietary changes. Meet the needs of children and adults with type 1 diabetes 17. Work has commenced on developing a Virtual Diabetes Register (VDR) for type 1 diabetes to help estimate type 1 prevalence and guide local service provision. An updated version ofthe full VDR will be released in April 2017 which will support clinical and quality improvements. 18. Options for increased support for people with type 1 diabetes are being developed and these will be progressed in line with clinical and consumer guidance, dependent on available budget. These options include improved access to technology that provides more effective insulin therapy, additional support for self-management and up-skilling the health workforce. Progress against the identified measures 19. The Diabetes Plan includes nine specific measures that have been developed to track progress towards improving health outcomes for people with diabetes. These measures are framed within the themes of reducing the personal burden for people with diabetes. providing service consistency across the country and reducing the cost of type 2 diabetes. Page 3 of 7 HEALTH Database number: AD62-14-2016 20. A summary of progress against the measures using currently-available information is provided below. More detailed data tables are attached as Appendix 1. Comprehensive data is not yet available on all measures, however the Ministry is currently progressing this and more detailed information will be provided to you in 2017. Measure Progress A 20 percent reduction in complications A wide range of outcome measures for diabetes are in and disability experienced by people with advanced stage of development and will be completed in early- diabetes under the age of 75 years by mid 2017. 2020; with a 25?30 percent reduction for high risk population groups Reduce the rate of amputations per 1000 Between 2011 -2015 there was iwmin ae people with diabetes by 20 percent from of major amputations (abo - . w?knee) that over 2010?14 by 2019, and by 30 people with diabetes . percent for Maori and Paci?c peoples number of amputati . -- .. . 3emained portion of gement of ppendix 1. Reduce the rate of renal replaceme? Td?re?nu/mber of end stage renal disease from all 1000 people with diabetes by causes placement therapy was stable in New from that over 2010?14 Ze 14. For people with diabetes the rate of 30 percent for Maori an nt therapy was either stable or trending down in Appendix 1. A 20 perce prop his ata has not preVIously been reqwred from DHBs and people HOs, but is now requested as part of the quarterly reporting. It should be available from 2017 onwards. The Ministry does not currently have access to data to report on this measure. Work is underway to include reporting from PHOs on this measure in 2017. duction in the proportion of The Ministry hasjust completed initial work on this measure. mortality (at 75 years) due to for which there is little prior data. This shows that in calendar es by 2019, with a 20 percent year 2013, 59 percent of deaths attributable to diabetes were ecline for Maori and Pacific peoples. This in people aged under 75 years (1301 of 2201 deaths) and can is to be replaced when available by life thus be regarded as premature. Over 40 percent of these expectancy and DALY targets deaths were in people of working-age (25-64 years). See Table 4 in Appendix 1. According to 2012-2014 data, at age 25 years, the life expectancy for Maori and non-Maori people with diabetes is 45 years and 53 years, respectively. This compares with a life expectancy of 53 years and 59 years for Maori and non-Maori people who do not have diabetes, respectively. See Table 5 in Appendix 1. The disability-adjusted life year (DALY) is a measure of health loss (disease burden). Measuring DALY estimates is currently problematic because much of the necessary data is not yet available. The Ministry is working to improve the way DALY estimates for diabetes and other diseases are calculated. By 2020 DHBs will have implemented All DHBs are conducting or have completed stocktakes of quality standards for diabetes care diabetes services against the Quair'ty Standards; however, both DHB progress and reporting on this is still variable. Page 4 of 7 . . Database number: 4-2016 Reduce prevalence by a 20 percent Work is underway to develop a methodology to distinguish reduction in the rate of increase of new between type 1 and type 2 diabetes. This work should be cases of type 2 diabetes, by 2020; with a complete by mid-2017. Data from the VDR shows that the faster rate of reduction for high-risk prevalence of diabetes has increased year-on-year across all population groups (30 percent for Maori DHB regions and ethnic groups. See Tables 6 and in and Pacific) Appendix 1. Reduce the rate of hospital admissions In 201314, more than 15,000 hospitalisations in New Zealand primarily due to diabetes (per 1000 people had a primary diagnosis of impaired glucose regulation and with diabetes) by 20 percent from that in diabetes. Approximately one third of these admissions were for 2014, and by 30 percent for M?ori and Maori and Pacific peoples. See Table 8 in Ap ix 1. Pacific peoples by 2019 Next steps 21. The Ministry Diabetes team is meeting with DHB Chief Exe prioritisation of diabetes services. Key points emphasi . The growing burden of diabetes and the The Ministry?s expectation that pr vis diabetes will be prioritised. . impIe-- El - gve hig - sfor people with . The need for DHBs to deli ov odel eir partner organisations that reach high-risk popul The value of mul egrated ns self-management, primary and 3 to in their development and delivery of people- .-. - and - ed services. roved data collection. sharing and analysis. iabetes services, including Annual Plans, quarterly reporting . ortunities for further investment in this financial year include: additional funding for DHB ini atives that address identified gaps in DHB services for people with diabetes; increased support and self?management capability. for people with type 1 diabetes; and potentially using social media options to enhance awareness 24. The next progress report will be provided in mid-2017. END. Page 5 of 7 MINIseror HEALTH HM UM Database number: AD62-14-2016 Appendix 1: Data tables to show progress against the measures in the Diabetes Plan Data is given as raw numbers and/or rates per 1,000 people with diabetes. Given the rapidly increasing prevalence of diabetes. a static total number represents a fall in the rate. 9- Table 1: Amputations data from the VDR 2011 2012 2013 2014 2015 Comment Total number of diabetes related 700 809 877 809 849 amputation procedures Rate per 1000 people with 3.32 3.60 3.67 3.22 32 - reducing diabetes 1 0 Major amputations 230 238 247 241 2&8 Rate per 1000 people with 1.09 1.06 1.03 :09 Ag diabetes A Table 2: Publicly funded diabetes related amputati U?v CIiil?$1? ear of vdischarge Amputation type \2011 1201592013 2014 2015 Amputation 0f toe 811315 315 336 Amputation 0f toe including metat 218 270 212 234 Amputation of ankle through 9d fib 1 1 0 0 Midtarsal amputation 6 8 10 13 9 Transmetatarsal 700 809 877 809 849 Ta?e??x nal replacement therapy in peeple with and without diabetes, 2010- 2015 2010 2011 2012 2013 2014 2015 Comment CEEeWcases of renal replacement 515 487 519 554 547 MA erapy Rate per million people 119 112 118 125 122 No change New cases of renal replacement 260 205 256 269 260 NM therapy from diabetes Rate per 1,000 people with diabetes 0.133 0.097 0.114 0.113 0.103 No change Table 4: Rates of diabetes-related deaths and deaths in people with diabetes, New Zealand 2013 25- 30- 35Total 159 251 413 618 806 1.036 1,272 1.273 977 6972 DRD 2201 Notes: number of deaths in diabetics, DRD number of diabetes-related deaths Page 6 of 7 MINISIRYOF HEALTH m1 mu ?4 4, Database number: AD62-14-2016 Table 5: Ethnic-specific life expectancies for VDR and non-VDR populations at exact age 25, 2012-14 LEzs (years) VDR Difference Maori 53.34 44.63 8.71 Non-Maori 58.63 53.30 5.33 Table 6: Diabetes prevalence 2010?2015 by DHB DHB of domicile 2010 2011 2012 2013 2014 Auckland 19,615 21,036 22,629 24,531 26,491 Bay of Plenty 10,162 10,634 11,076 11,462 11,872 Canterbury 18,625 19,357 20,308 21,076 21, Capital and Coast 9,798 11,225 12,408 13,145 Counties Manukau 28.565 30,941 33,507 36,508 Hawkes Bay 7,028 7,365 7,838 8,25 Hutt 6,112 6,880 7,508 7 ,078 Lakes 4,608 4,862 5 9 MidCentral 7,032 7,829 7 Nelson Marlborough 5,437 5,757 ,121 Northland 8,705 9,241 11 South Canterbury 2,952 3,371 Southern 12,534 14,959 Tairawhiti 2,824 4,089 Taranaki 6,58 7,396 Waikato 17, 21,493 Wairarapa 2,352 Waitemata 29,743 West Coast 28 1,321 Whanganui 32 3,809 4:9 398 (\196,13h,v\\) 210,759 224,908 238,890 251,478 260,458 0 iabet I 10-2015 by ethnic group Year? A (Vh?d? Pacific-peOple Indian EuropeanIOther Total 2010 \f2 >185 22,526 10,365 135,058 196,134 2 CQ 0,171 24,349 11,377 144,862 210,759 3 32,380 26,473 12,481 153,574 224,908 1 34,619 28,488 13,767 162,016 238,890 36,915 30,561 15,175 168,827 251,478 015 38,610 32,017 16,045 173.786 260,458 Table 8: Number of inpatient and day hospitalisations due to impaired glucose regulation and diabetes mellitus in 2013714, by ethnic group Maori Pacific Other All ethnic groups Inpatient Day Total In patient Day Total Inpatient Day Total Inpatient Day Total Total 1,758 1,282 3,040 906 1,000 1,906 5,488 4,842 10,330 8,152 7,124 15,276 Male 905 620 1,525 433 427 860 3,040 2,561 5,601 4.378 3,608 7,986 Female 853 662 1,515 473 573 1,046 2,448 2,281 4,729 3,774 3,516 7,290 Page 7 of 7 477ACHMENT Database number: 20170926 I '2 Security classification: ln-Confidence "r i? j? 3' File number: Action required by: rot. we Progress update on implementing Living Well with Diabetes Remap 7 a To: Hon Dr Jonathan Coleman, Minister of Health 1 .7 il . .v Ul?igL ~i Pu rpose This report provides you with an update on diabetes and a summary of progress tow implementing Living Well with Diabetes: A plan for people at high risk of or living with diabetes 2 0 (the Diabetes Plan). The last diabetes update was provided to you in Decembx 1937 $elid-201s, an 1. Diabetes poses a significant economic burden at indi . ?13) ietal .. . . . estimated 241,463 people in New Zealand had di - delle a Diabetes Register. 10-2016 especially in Key points 2. The prevalence of diabetes in New Zeal Pacific, lndo-Asian and Maori eth -s slowed over the last few years. 3. Over 2010-2016 there -. crease in diabetes prevalence in younger adults aged 25-50 - . ?ties except lndo-Asian and is most gh risk of developing type 2 diabetes, are living well and have -centred health services. - relatively stable. Although the personal burden of disease appears to have stabilised, ot yet seeing a turning of the curve. Key achievements over the last six months include ongoing visits to District Health Boards (DHBs) to support the implementation of the Diabetes Plan and the Quality Standards for Diabetes Care; delivery of a successful diabetes workshop for the sector to share best practice, innovative approaches and latest research; and continuing delivery of a range of projects that provide support to people with or at risk of diabetes. 7. Next steps for the Ministry include exploring future investment in initiatives targeted to enhance diabetes service delivery and meet the needs of high-risk populations; and investigating options to centralise laboratory test results. 8. The next progress report will be provided at end-2017. Contacts: Paul Drury, Clinical Advisor Diabetes 5 9(2lla) Clare Perry, Group Manager, Integrated SerVices Design 5 Page 1 of 11 MINISTRY or 3 HEALTH MPH-kit! R1. Recommendations Database number: 20170926 This report is for your information only and does not request any decisions. ?1 ?e ice Commissioning si s@ 63% Minister?s signatur ?2:7 <1 ?g i% Page 2 of 11 MANATEI HAUOM Database number: 20170926 The prevalence of diabetes continues to increase 1. Diabetes poses a significant and increasing economic burden at individual and societal levels. As at end-2016. an estimated 241,463 people in New Zealand had diabetes. The prevalence of diabetes in New Zealand. as measured by the latest Virtual Diabetes Register (VDR), has continued to rise over 2010-2016 especially in Pacific, lndo~Asian and Maori ethnicities, but the rate of increase has slowed over the last few years (Appendix 1, table 5). Over 2010?2016 there appears to have been a marked increase in type 2 diabetes prevalence in younger adults aged roughly 25?50 years. This increase has been seen internationally and this cohort typically experience complications, morbidity and mortality from diabetes at a younger age than in previous decades. International data and experience indicate these peo: a are more difficult to manage and less likely to engage with effective preventive clinica . 3g The increase in diabetes prevalence at a younger age is apparent itn?g1 xcept . . . . a th times more likely than European/Other to die from d?se - ated - - ages 40- 70 Years. Implementing the Diabetes Plan, Living Well with Diabetes (th the serious health challe that all New Zealander and have acces The focus is rting age their condition themselves, with the priority areas of ac?o . tes early and reduce the risk of complications integrated care To date implementation of the Diabetes Plan has been managed largely through baseline funding. This has been supported by $12.4 million allocated to district health boards (DHBs) as part of Budget 2013 to support implementation of Diabetes Care improvement Packages (DCIP). funding has been devolved to DHBs from 1 July 2017. it is difficult to ascertain if service funding has increased at the same rate as the increase in diabetes prevalence, as funding is now devolved to DHBs (HR20170360 refers). Key achievements and implementation progress areas over the last six months include: i. As part of the ?Understanding Diabetes' project, a review of consumer?focused, awareness- raising diabetes resources is now complete. The advisory group. chaired by a consumer, have reviewed the findings and made recommendations on appropriate resources to provide information on diabetes and to support healthy eating and physical activity. A final report summarising findings of the stocktake and recommendations of the advisory group is due July 2017. information from this report will be used to inform future work to raise awareness and make available information that is reliable, accessible and easily understood. ii. The weight management programme by Compass Health is nearing completion. Two hundred and six people at risk of developing diabetes or heart disease have been referred by their GPs to enrol in either a three?month or six?month Weight Watchers programme. Page 3 of 11 i MINISTRY or EALTH MANATO kuom 10. Other activities supporting the im . I. Database number: 20170926 Preliminary results show notable weight loss and reduced HbAic in this cohort. An evaluation is being conducted by Otago University, with a final report due July 2017. The Northland and Tairawhiti DHB projects to support people with diabetes and mild to moderate mental health issues are progressing well. The three Northland DHB projects support newly diagnosed children with type one diabetes and their whanau; use a theatre group to support rangatahi with type 1 diabetes; and provide a range of supports for adults with poorly controlled diabetes. The Tairawhiti DHB project utilises kaiawhina and social workers to provide support for adults with poorly controlled diabetes. Malatest is evaluating the projects, with a report due end-2017. The Healthy Attitudes and Community Engagement project led by Dr Tom Mulholland is due to be completed in July 2017. A key success over this six months has bee -ngaging with the South Indian community in South Auckland, who have responded - - care testing at the workplace or place of worship. Additionally, so A new electronic decision support tool and accomp providers to identify and manage chronic kidne the electronic tool has been launched in 18 utilisation of the tool, with a focus on - or needs populations. 8% e% Include: The Ministry continues - . upport the implementation of the Quality Standards - national and regional variability in diabetes service -i a: oetes services against the Quality Standards and rape in reports on actions to address any iden?f ii. th ix mon . stry diabetes team has visited three DHBs (Canterbury, aw - ?3 Bay 'scuss and review regional progress towards implementing the es 1 . perc u-fth . netes demographic in New Zealand. Most DHBs are making significant pro ds implementing the Quality Standards for Diabetes Care. A general limitation vi. is access to PHO and practice data, which is critical to equitable ntation. Further DHB visits are planned for the next six months. alf of the DHBs have identified diabetes?related contributory measures in their 2017/18 System Level Measures improvement plans. A further three DHBs have indicated their intention to include diabetes as a contributory measure in the 2017MB out years (see Appendix 2). Kidney Health New Zealand are developing a suite of contributory measures to be included in the System Level Measures library. This will enable DHBs to choose to focus on improving services for people with diabetic~related kidney disease. Development of the updated cardiovascular disease (CVD) consensus statement is continuing and is now being progressed by a multidisciplinary group involving the Heart Foundation and the New Zealand Society for the Study of Diabetes. A consensus was reached by stakeholders in June 2017'. A draft document is being finalised and is currently being reviewed. implementation work will link with IT stakeholders and also align with the DHB annual planning process. This will mean more accurate CVD risk prediction among people with diabetes and improved primary care promotion of appropriate management decisions. in collaboration with academic colleagues and the National Diabetes Leadership Group, the Ministry is examining data on transition from pre-diabetes to diabetes. Initial results suggest that it may be apprOpriate to better target intervention to those at highest risk of developing diabetes. Page 4 of 11 mum Database number: 20170926 11. The National Diabetes Leadership Group. comprising members with backgrounds in clinical leadership, primary care, DHB planning and funding, and consumers. continues to meet to provide advice to the Ministry and the sector. Key issues over this period have included: clarifying key messages on pre?diabetes; identifying steps to address complications for inpatients with diabetes; new technology for people with type 1 diabetes; and raising national awareness of the emerging issue of early onset diabetes. 12. A successful two-day Diabetes and Long Term Conditions workshop was held for DHBs, PHOs and the sector on 5?6 April 2017. The intent of the workshops was to share best practice and innovative approaches, deliver updates on the latest research and provide a forum for networking. There were 100 attendees each day and sessions included consumer presentations, workshop discussions and presentations from DHBs and PHOs on innovative service provision. vr interventi 13. initial exploratory social investment work by the Ministry indicated potential . -.-. diabetes from deprived communities. The findings of this work will decisions for the 2017/18 budget. 14. implementation of the Diabetes Plan has been slower in having to prioritise a large work programme. As a m' 15. The Diabetes Plan includes - improving health outco reduction in the per .. betes; provision of consistent services across diabetes. 16. - . ..- -n summarised below, and more detailed data tables are ts an the recent change to the Virtual Diabetes Register (VDR). tly progressing this and more detailed information will be provided to -. ompared with numbers derived from any previous version the VDR algorithm has resulted in a reduction in totals. Any comparison artificial and inaccurate trends. Measure Progress A 20 percent reduction in complications and disability experienced by people with diabetes under the age of 75 years by 2020; with a 25?30 percent reduction for high risk population groups A wide range of outcome measures for diabetes are in advanced stage of development and will be completed in late 2017. Reduce the rate of amputations per 1000 people with diabetes by 20 percent from that over 2010-14 by 2019, and by 30 percent for Maori and Pacific peoples Between 2010-2016, the total number of amputations has increased across all ethnicities except Indian. The rate of amputations per 1,000 people with diabetes has remained relatively stable, with a decline for Maori and indian people. The number of major amputations (above-knee and below- knee) has remained relatively stable between 2010?2016, though the rate of major amputations per 1,000 people with diabetes has declined. The decreased proportion of major amputations might reflect earlier management of diabetes complications. See Tables 1 and 2 in Appendix 1. Page 5 of 11 MINISTRY OF HEALTH MAHATD moon Database number: 20170926 Reduce the rate of renal replacement per 1000 people with diabetes by 20 percent from that over 2010?14 by 2019, and by 30 percent for Maori and Pacific peoples No new data was available for this reporting period. Data on renal replacements will be updated at end-2017 and will be included in the next progress report. A 20 percent decrease in the proportion of people with HbAic levels >100, by 2020, with better improvement for high?risk population groups To date. this data has been provided from DHBs and PHOs for quarter one of 2016/17. Noting issues with the completeness of the data, less than half of Maori and Pacific peopie with diabetes met the glycaemic control target of HbA1c 5.64 mmol and just over half of European/Other people met this target. HbAic 2101 for all population groups was See Table 3 in Appendix 1. By 2020, 85 percent of people with diabetes will participate in an annual review across all population groups The Ministry is working with DHBs to a ?ssues in 4 providing complete and accurate l-ibA A The Ministry does not curren veggcb?s to on this measure. Work ne re requirements from is easure ffom 2 . A 10 percent reduction in the proportion of premature mortality (at 75 years) due to diabetes by 2019, with a 20 percent decline for Maori and Pacific peoples. This is to be replaced when available by life expectancy and DALY targets A By 2020 DHBs will have imple quality standards for diabe i) ii No new data .., . - or in an iod. Mortality data will . -nd 2 included in the next . ing or have completed stocktakes of against the Quality Standards. From 's are required to provide progress on their implementation of the Quality Standards. 20 per Reduce pr val reduct' 3i increase 0. a abetes, 2020; or Maori \SWork is underway to develop a methodology to distinguish between type 1 and type 2 diabetes. This work should be complete by late 2017/eariy 2018. VDR data from end~2016 shows that the prevalence of diabetes has continued to increase annually across all DHB regions and ethnic groups. See Tables 4 and 5 in Appendix 1. .- .- reducti percent for Maori and acific peoples by 2019 Since 2014i15, the total number of hospital admissions primarily due to diabetes has remained stable across all ethnic groups. See Table 6 in Appendix 1. Next steps 17. The Ministry Diabetes team is exploring opportunities for future thinking in the following: i. Support DHBs to identify and develOp targeted services to reach their high~risl< populations. ii. Update the 2014 Toolkit that accompanies the Quality Standards for Diabetes Care 2014 to ensure it remains current, fit for purpose and underpins service quality improvement. Consider a moderated social media campaign for diabetes that supports self-management to prevent high-risk people from developing type 2 diabetes and to detect diabetes early and reduce the risk of complications. Target implementation ofthe Gestational Diabetes Guidelines and service improvement by encouraging new models of care that are woman/wh?nau?centric and provide integrated maternity care with wrap around nutrition and physical activity support for pregnant mothers. v. improved services for children and young peeple with type 1 diabetes by reviewing current services and developing a programme that includes better access to technology. more effective insulin therapy management and improved data collection. Page 6 of 11 Er HAUOM Database number: 20170926 vi. Consider a national awareness programme that: targets high risk populations; supports services identified by DHBs in their gap analysis; and follows through on the current ?Understanding Diabetes' project. 18. The Ministry diabetes team has a data subgroup meeting twice annually to review available data and to improve/expand outcome measures. One favoured option deriving from the data group would be the central/regional collection of laboratory test results, as opposed to simply the fact of a test as currently happens. This would allow immediate quality monitoring and corrective action, rather than relying on local collection which is variable in quality, quantity and availability. 19. The next progress report will be provided to you at end-2017. END. Page 7 of 11 MINISTRY OF EALTH mum-O HAUOM Database number: 20170926 Appendix 1: Data tables to show progress against the measures in the Diabetes Plan Data is given as raw numbers and/or rates per 1,000 people with diabetes. Given the rapidly increasing prevalence of diabetes, a static total number represents a fall in the rate. Table 1: Publicly funded discharges that contain a diabetes related amputation procedure by ethnicity and year of dischargeI 2011 2016 Prioritised ethnicity Year of discharge 2011 2012 2013 2014 2015 2016 European/Other 358 406 454 431 445 438 Rate per 1,000 people with diabetes 2.62 2.34 3.06 2.34 4,237 223 lndian 13 15 11 \913 6% Rate per 1,000 people with diabetes 1.13 1.26 0.36 4 1.2a A 3 Maori 127 153 \22 1% 146 Rate per 1,000 people with diabetes 4.33 4.96 . 3.95 Pacific People 61 WW 1Q) 61 73 Rate per 1,000 people with diabetes 2.56 313V 2.454% 2.00 2.43 \g 3 Total 559 to 634 661 675 Rate per 1,000 people with diabetes 46?77% 2.98\ k. 2.77 2.80 2.80 Note: Diabetes related amputation proce counted 1- cs contains the procedures listed in table 2 and a diagnosis of diabetes mellitus. Furl i dures . - the discharge contains any diagnosis of trauma ora diagnosis of lower limb cancer Table 2: Publicly 11313de ation procedures by clinicai code and year of discharge Am putatio? WV Year of discharge A 2011 2012 2013 2014 2015 2016 . 223 311 315 315 335 339 5k al bone 203 218 270 212 235 244 - . - 1 Amputation - malleoli of tibia and fibula amputation 30 23 31 25 44 39 above knee 8? 105 107 94 95 102 iculation at knee 2 1 2 1 3 1 Amputation below knee 143 138 140 149 127 131 Amputation Hindquarter amputation 1 0 0 0 0 Disarticuiation through toe 5 2 1 0 0 1 Total 700 809 877 809 849 865 Notes: Diabetes reiated amputation procedures are only counted if the discharge contains the procedures listed in table 2 and a diagnosis of diabetes mellitus. Further to this, procedures are not counted if the discharge contains any diagnosis of trauma or a diagnosis of lower limb cancer. Multiple amputations occurring within the same hospital discharge are counted each time. Page 8 of 11 HANATEI moon). Database number: 20170926 Table 3: Number and proportion of people with HbA1c 2101 mmoisimol by ethnicity Ethnicity Proportion of people in each HbA1c category HbA1c ?64 HbA1c 65-80 HbA1c 81-100 HbA1c 2101 mmols mmols mmols mmols European/Other 54% 10% 4% 2% Maori 44% 1 1 8% 3% Pacific 41% 13% 1 1% 2% Total 51% 1 1% 6% 2% Notes: Data for HbA1c s64 mmols has been provided by all 20 DHBs, yet data for HbA1c 265 mmols has been provided by 18 of 20 DHBs. The following data collection issues have been reported by DHBs: unable to provide results from all ly able to rap on patients who have had an annual review. only providing data for the current month rather the or Iyeart and other data integrity issues. Source: 2016/17 Quarter 2 HbAtc report 5 Table 4: Number of people on the Virtual Diabetes Register by?iqlmf $8 DHB of domicile 2010 2011 2012 A?xxr??Av 2018 Auckland 18,573 19,647 20,85 1 6 \237887 24,508 Bay of Plenty 9507 9917 ,433 10.330 10,391 Canterbury 18,103 18,706 20,0 0, 4 21,261 21,959 Capital and Coast 9393 10,788 1 .805 13,119 13,350 Counties Manukau .092 .1 36.927 39,007 40,266 Hawkes Bay 7 8 5 8025 8181 8370 Hutt - 5 7457 7899 7888 7903 Lakes . 454 4928 51 78 5430 5589 MidCentral 97 7953 8120 8331 8448 Nelson Marlboroug 5888 5788 5933 8022 8080 Northland 9805 10,425 10,734 10,844 10,952 - - - 2989 3018 3040 3107 3150 13,208 13,525 13,578 13,804 14,145 3098 3241 3357 3444 3388 8510 8597 8859 6767 8781 18,548 17,398 18.125 18.895 19,837 20,408 20,998 1919 2075 2198 2218 2228 2223 2199 20,295 22,138 23,851 24,959 25,908 27,020 27,798 1195 1228 1213 1204 1192 1254 1305 - 3045 3255 3420 3471 3533 3818 3744 Unknown/Unassigned 285 272 259 224 200 174 142 Total 187,880 200,235 211,591 220,888 228,790 238,073 241,483 Note: People that were either not enrolled in a PHO or were not alive, as at 31712 of the relevant year, have been excluded. Source: VDR Dec Note that data from the VDR presented here should not be compared with numbers derived from any previous version of the VDR as a recent revision made to the VDR algorithm has resulted in a reduction in totals. Any comparison may result in arti?cial and Inaccurate trends. Table 5: Number of people on the Virtual Diabetes Register (VDR) by ethnic group, 2010 - 2016 Year Maori Pacific-people Indian Euro peanlOther Total 2010 27,257 22,143 10,086 128,374 187,860 2011 29,003 23,799 10,981 136,452 200,235 2012 30,827 25,649 11,924 143,191 211,591 2013 32,634 27,296 12,764 148,172 220,866 2014 34,355 29,001 13,750 151,684 228,790 2015 35,769 30,445 14,632 155,227 236,073 2016 36,978 31,480 15,383 157,622 241,463 Note: Peopie that were either not enrolled in a PHO or were not alive, as at 311'12 of the relevant year, have been excluded. Source: VDR Dec 2010?201 6 (1686) Page 9 of 11 MINISTRY or HEALTH MANATO 3?.qu Database number: 20170926 Table 6: Number of publicly funded hospital discharges due to diabetes mellitus by prioritised ethnic group, 2013/14 2015/16 European I Year Maori Pacific Asian other Total 2013/14 3,124 2,031 1,162 9,278 15,595 2014/15 1,268 601 281 3,835 5,985 2015/16 1,254 635 289 3,768 5.946 Notes: Discharges had a primary diagnosis of diabetes meilitus. As of 1 July 2014 diabetes mellitus did not need to be sequenced as the primary diagnosis anymore (it 3 previously required in some cases pre 1 July 2014). This change is clearly shown with the notable decrease betv@ 3/14 and 2014/15. Because of the clear administrative reason for this trend. please use this numbers with cautio gk Source: National Minimum Dataset (NMDS) 3; s63 @a Page 10 0111 MINISTRY or EALTH MAHATB HAUOM Database number: 20170926 Appendix 2: DHBs with diabetes-related contributory measures The following DHBs have identified diabetes?related contributory measures in their 2017/18 System Level Measures improvement plans: . Capital and Coast Hutt Valley Lakes Nelson Marlborough Southern Tairawhiti Taranaki Waikato Wairarapa Whanganui The following DHBs have indicated their intention to incl 6 ??elated measures in the 2017/18 out years: 69? goiggw Page 11 of11 OF EALTH mmt't?r HAUOM Health Report number: 20171873 1 5 APR 2018 Security classification: In-Confidence File number: Action required by: routine Progress update on implementing Living Well with Diabetes: A plan for people at high risk of or living with diabetes 2015-2020 To: Hon Dr David Ciark. Minister of Health Purpose This report provides you with a summary of progress towards implementin plan for people at high risk of or living with diabetes 2015-2020 (the dies made since the diabetes plan was launched in October 2015, with months. Key points . Diabetes is one of New Zealand?s fastest i contributor to the burden of disease ov th . Tack morbidities has the potential to too 3 and . you equity; and improve child wellb we would expect to see a cardiovascular diseas - . Following the la . ogress across the country has been slow due to system factors su - -- the past year there has been evidence of improved . ?3 rt the sector in delivering quality diabetes services. ugh the implementation of the diabetes plan, all DHBs have been asked . - . - against the Quality Standards for Diabetes Care by the end of April 2018. to se ?au Resul to measure their progress and determine priority areas for improvement. A su self-audits will be included in the next progress report. nd-2016, an estimated 241,463 people in New Zealand had diabetes, as modelled by the a Diabetes Register. - The prevalence of diabetes in New Zealand has risen by 29 percent between 2010?2016. This was most pronounced in people of Maori, Pacific and South-Asian ethnicities. However, the rate of increase in diabetes prevalence has slowed over the last few years, and has remained relatively static in all ethnic groups between 2014-2016. . The diabetes plan was co-developed with consumers and the sector and launched in October 2015. it provides a medium-term plan to tackle diabetes and has a vision that all New Zealanders with diabetes, or at risk of developing type 2 diabetes, are living well and have access to high?quality, people-centred health services. . The Ministry of Health diabetes team works with the health sector to oversee the implementation of the diabetes plan. DHBs report on progress to the Ministry every six months. . Most DHBs are showing better integration and collaboration across disciplines and levels of care. There are some efforts to improve HbAic levels across high risk populations, though success is variable across DHBs. Contacts: Clare Perry, Group Manager Integrated Service Design 3 Sue Riddle. Manager CVD Diabetes and Long Term Conditions 5 Page 1 of'l5 MINISTRY HEALTH Miami muons Health Report number: 20171873 - The diabetes team is working with the National Diabetes Leadership Group that includes clinicians and consumers to identify quality improvement opportunities to successfully implement the Diabetes plan by 2020. - Next steps for the Ministry diabetes team will focus on identifying and supporting opportunities to improve primary care readiness to drive diabetes improvements. and opportunities for people with diabetes to better self?manage their condition. . Where possible, available data has been provided for the measures in the diabetes plan. The measures indicate that amputations arising from diabetes have remained relatively stable but the rate of people with diabetes requiring renal replacement has declined since 2010. Between 2013?2015, diabetes was responsible for an average of 2,147 deaths per year. Of these, approxi ately 61 diabetes aged between 40 and 70 years are five to seven times more likelyt die from a diabetes-related cause. . The next progress report will be provided in September 2018. Recommendations This report is for your information only and doe? 'r any dew ?nders signature: ioninw Date: Page 2 of 15 MINISTRYOI HEALTH mnm?r HAUDM Health Report number: 20171873 Update on the implementation of Living Well with Diabetes - March 2018 The prevalence and impact of diabetes has continued to rise, but the increase in prevalence may have slowed 1. Diabetes is one of New Zealand?s fastest growing long-term conditions and poses a significant burden at individual, economic and societal levels. it is a major cause of renal failure, blindness and amputations, and a substantial contributor to premature stroke and cardiovascular disease Register 2016?). 3. Approximately 90-95 percent of people with diabetes have type preventable. About a quarter of New Zealanders are believeiabet an ?E-l a greater risk of all largely preventable and expensive conditions. 2. At the end of 2016, an estimated 241,463 people in New Zealand had diabe?@al Diabet preventative action. are likely to develop type 2 diabetes. 4. hree times more ing in the least deprived 5 i -nd other co-morbidities. This is a se diabetes self-care and poorer 6 aland has risen by 29 percent between 2010? a . of Maori, Pacific and South-Asian2 ethnicities. which 0 1 . sers. The aging population and people living longer with es also contributes to the increase in diabetes prevalence. 7. prevalence has slowed over the last few years and has remained - 0 groups (Appendix 3, Table 10). This slowing appears to be a global ronounced in New Zealand. an in previous decades and they may be less likely to engage with effective preventive clinical care. 9. The increase in diabetes prevalence at a younger age is apparent in people of all ethnicities except South-Asian, and is most pronounced in Maori and Pacific peoples. The lack ofan apparent parallel increase in South-Asian people is probably due to high recent immigration; the ?healthy migrant? effect. 10. According to recent diabetes mortality data from the Ministry (unpublished), Maori and Pacific peoples with diabetes aged between 40 and 70 years are five to seven times more likely than European/Other to die from a diabetes-related cause (Appendix 3, Table 11. Of all specific causes of health loss in New Zealand, diabetes has advanced the furthest since 1990. It is now the 7th leading cause of health loss for males of Disability Adjusted Life Years and 12th for females of 1 2 South-Asian peoples: Indian. including Fijian Indian, Sri Lankan. Afghani, Bangladeshi, Nepalese, Pakistani. Tibetan. 3 Page 3 of 15 MINISTRY 0" HEALTH ?mam muons Health Report number: 20171873 The costs of diabetes 12. The increased prevalence of diabetes has a major financial impact on the New Zealand health system. In 2014/15 diabetes-related pharmaceutical costs alone were estimated as $48.5 million and laboratory costs $23.4 million. Modelling by Price Waterhouse Coopers (PWC) (2008) estimated that type 2 diabetes would cost $1.3 billion in 2018/17 (or approximately $3,832 per person) and increase to $1.8 billion in 2021/22 with only basic diabetes health services in place. 13. If diabetes prevalence continues to increase, the financial and non-financial costs of diabetes and associated factors/complications are expected to continue to escalate. it is anticipated that more people will develop the associated co?morbidities of type 2 diabetes such as kidney disease, stroke, cardiovascular disease, mental illness, diabetic retinopathy/biindness and war limb amputations. This will probably result in: a. increased burden for the health system, including primary/commu' disparities in health outcomes. The Ministry?s response: Livin 14. Living Well with Diabetes: A diabetes plan)4 was co-d provides a medium-t rm diabetes, or at ri people-centr .- . ices. 15. The 0 in n. ctives of es plan are to: . burde of disease for pebble with diabetes by providing integrated a ools and support people need to manage their own health diabetes plan focuses on supporting people to manage their condition themselves, with the priority areas of action to: a. prevent high-risk people from developing type 2 diabetes b. enable effective self-management c. improve quality of services d. detect diabetes early and reduce the risk of complications e. provide integrated care i. meet the needs of children and adults with type 1 diabetes. 17. The diabetes plan is implemented in addition to a number of other Government initiatives that enable New Zealanders to live a healthy lifestyle, including Healthy Families NZ, Green Prescription and regional programmes delivered through DHBs, local government and the education sector. These initiatives will contribute to reducing the impact of obesity in New Zealand and help reduce the incidence of type 2 diabetes in the long term. 18. In 2013/14, the Ministry released the Quality Standards for Diabetes Care (the Quality Standards) and accompanying toolkit? The 20 Quality Standards provide guidance for the health sector to 4 5 Page 4 of 15 MINISTRY or HEALTH muoru Health Report number: 20171873 support planning high quality clinical services and comprehensive patient-centred care. The Quality Standards complement the diabetes plan and provide a benchmark for DHBs, PHOs and general practices. Progress towards implementing Living Well with Diabetes 19. Working with the health sector, the Ministry of Health diabetes team oversees the implementation of the diabetes plan. DHBs report on progress to the Ministry every six months. 20. Since November 2017 the Ministry diabetes team has visited six DHBs to meet with primary, specialist and community-based allied health services with DHB portfolio managers to discuss the regional implementation of the diabetes plan. DHB visits are very valuable for the DHBs. As a result, the Ministry has a greatly improved understanding of - 21. Most DHBs are progressing the implementation of the diabete integration and collaboration between primary and secon ?9 is some evidence of efforts to identify and reduce 0v-. 22. As we are now halfway team is asking all eir progress and determine priority areas for inistry to understand any national trends that may i? 'ts have indicated that there is wide variation in the implementation of the diabetes ?a es the country. Services require a greater level of national consistency to achieve equity Q: It New Zealanders with or at risk of diabetes. Results from the stocktake against the Quality Standards will be used by the Ministry team to identify and prioritise support for key areas. 25. The diabetes team is working with the National Diabetes Leadership Group that includes clinicians and consumers to identify quality improvement opportunities to successfully implement the Diabetes plan by 2020. 24. Next steps for 2018 26. Two main areas of focus are: opportunities to improve support for people with diabetes to better self?manage; and supporting opportunities to improve primary care readiness to drive diabetes improvements. The Ministry team will work closely with the sector to improve equity in outcomes for Maori and Pacific people and better support people with diabetes to self-manage. This may include SMS messaging, better coordination of culturally-appropriate diabetes self~management education, enhanced services for young people with type 1 diabetes and making a wider range of languages available in patient information resources. 27. In addition. the future of primary care in sopporting diabetes improvements and building a better platform for services may emerge from the Primary Care Review. END. Page 5 of15 MINISTRY OF EALTH uwou Health Report number: 20171873 Appendix 1: Ministry initiatives and projects to support the implementation of the diabetes plan, 2015?2018 Initiatives 1. Implementation of the diabetes plan has been managed almost entirely through baseline funding. This has been supported by $12.4 million allocated to district health boards (DHBs) as part of Budget 2013 to support implementation of Diabetes Care Improvement Packages (DCIP). funding was devolved to DHBs from 1 July 2017 (HR20170360 refers). The total value of funding remains unchanged million across all DHBs for 2017/18). 2. More Heart and Diabetes Checks funding from Budget 2013 was also made avai . sle to DHBs to 4. Each year the Ministry releases national estimates . which is used to monitor the prevalence of di. 0 5. . dicated one-day diabetes workshop for ices and share innovations. updates and challenges to tly delivered a two-day long term conditions conferen How do we Transform?) which was held 27?28 Febr . programme of the conference. 8. 1i? 0 Health published a Consensus Statement on Cardiovascular it .. .-. - nd Management for Primary Care to update and refresh the CVD neline Zea/and Primary Care Handbook 2012. For Maori, Pacific and South-Asian pop dividuals with known significant CVD risk factors. screening should now begin at or men and 40 years for women. 15 years earlier than other populations. There is an emphasis on diabetes in the Consensus Statement, specific risk calculations for tea and clear updated advice on management. 2018 the Ministry released the Diabetic Retinal Screening, Grading, Monitoring and Referral Guidances, which provides an update to the previous guidelines on diabetic retinal screening (2006, updated 2008). The guidance represents a statement of best practice, based on evidence and expert consensus. and is intended to inform and guide the delivery of a nationally consistent retinal screening programme. Additional guidance on chronic kidney disease and gestational diabetes has been published in collaboration with the relevant teams within the Ministry. 8. Before the diabetes plan, a More Heart and Diabetes Checks health target was launched in 2012, and ran until July 2016?. The goal was for 90 percent of people in specified age and ethnicity cohorts to have their cardiovascular risk assessed in the past five years. The check includes a risk assessment (CVDRA) and a blood test for diabetes (HbA1c) delivered in primary care settings. Attaining this health target has meant that more people are aware of their risk, with some making appropriate health behaviour changes to reduce that risk. Additionally, people with undiagnosed diabetes have been identified and should now be receiving optimised care. 9. The Ministry holds a contract with Diabetes New Zealand that represents and supports peeple with diabetes. Diabetes New Zealand provides health promotion activities and access to information 5 7 Page 6 of 15 MINISTRY OF HEALTH MANATCI HAUOM Health Report number: 20171873 and resources to support and promote better understanding of people with diabetes, including maintenance of the Diabetes New Zeaiand website and provision of an 0800 information line. it also leads initiatives and advocates for people with diabetes to enhance self?management. The Ministry diabetes team is working with Diabetes New Zealand to coordinate resources and information and improve access for hard to reach populations. 10. The Ministry team has met with Brandon Orr-Walker, chairperson of the New Zealand Society for the Study of Diabetes is committed to working with the Ministry to improve coordination and services for people with diabetes. Projects 11. A two-year community-based project to raise awareness of risk factors for i 12. 13. 1 15. 16. rural communities with low levels of primary care engagement has be Mulholland and the Healthy Families teams, the project featured: . . The evaluation also lifestyle messages with ealthy eating and physical activity. A final ommendations was received in July 2017. The raising campaign embedded in behaviour change . messages to meet the needs of a range of users. The - pport the ongoing work of the Ministry. needs of young people (and their carers) with type 1 diabetes. conducted by means of: an online survey for young people with type 1 iews with key informants, such as clinicians and diabetes support agencies; focus groups with young people with type 1 diabetes. Preliminary findings that support services vary significantly across the regions, and that access to social a project delivered by Compass Health PHO, 206 people at risk of developing diabetes or heart disease were referred from general practices to enrol in either a three-month or six-month commercial weight loss programme (Weight Watchers). An evaluation report showed that at follow up. which was conducted three to six months following completion of the programme, participants? average weight loss was 4.2kg. Participants reported that meeting with a practice nurse provided them with support and motivation to engage with the weight management programme, and the programme was helpful in improving participants' understanding of their own health and ways they could decrease their risk of developing diabetes. Approximately one third of those who enrolled in the Weight Watchers programme did not complete it. We have subsequently contracted with Compass Health to further examine approaches to weight management for adults in primary practice. This will address: routine weight monitoring for adults attending general practice; trialling a tool to facilitate weight management conversations with patients; and follow-up of patients in the Weight Watchers study. A team~based weightless competition for Maori and Pacific peoples living in Northland, Manawatu and Auckland is being trialled by Massey University's School of Public Health. Seven teams of seven people at risk of developing type 2 diabetes or CVD participated in the WEHI trial. The teams received information on how to lose weight and earned points for achieving daily and weekly goals aimed at increasing physical activity and adopting healthier eating habits. The programme will provide much-needed information to design interventions and future trials for obesity Page 7 of 15 17. 18. 19. MINISTRY OF HEALTH MANMFJ muons Health Report number: 20171873 prevention and/or treatment. Results, including changes in participants? weight. HbAtc and eating and dieting habits, will be made available in April 2018. The Ministry supported a randomised controlled trial to evaluate the effectiveness of a text message self-management programme for blood glucose (SMS4BG), for adults with poorly controlled diabetes. The programme was devei0ped by the National Institute for Health Innovation in conjunction with Waitemata DHB and is designed to increase motivation for good blood glucose control. The text messages provide diabetes education and information to support behaviours required for successful diabetes self-management with modules tailored to individual patients. The provisional results at nine months showed a small but significant decrease in HbAtc in the intervention group and also improved foot care behaviour, perceived diabetes support and quality of life. Participants found SMS4BG to be culturally appropriate and it had high is of satisfaction and acceptability amongst Maori and Pacifica participants. An economic anal investigat' of potential implementation methods and alignment with other e-health programmes are planned. The Ministry funded two projects that aimed to improve acce . .. gple - a - . in and diabetes control were those that issues . . and holistic support. There is great potential for non~clinicai ro the outreach services practical solutions. They can and managing their diabe -. . with Careerforce and partner Action Plan. The Ministry fu tl? a .- opme electronic clinical decision support tools to support healt ortant areas for patients with diabetes in primary care ee cot and chronic kidney disease provide standard te referral documents, and link to patient support and advice. Page 8 of 15 MINISTRY or EALTH 1.1mm} HAUUM Health Report number: 20171873 Appendix 2: Progress against the identified measures 1. The diabetes plan included nine measures that were developed to track progress towards improving health outcomes for people with diabetes. These measures are focused on: measuring a reduction in the personal burden for people with diabetes; provision of consistent services across the country; and a reduction in the cost of type 2 diabetes. Several of these have required extensive and continuing work to develop meaningful data. Progress against these measures has been summarised below, and more detailed data tables are included in Appendix 3. Measure Progress A (5 1. A 20 percent reduction in Data on amputations and renak? In pe pl wIt complications and disability diabetes has been provi - a . 2 and experienced by people with below). ?gf? diabetes under the age of 75 years by 2020; with a 25?30 percent reduction for high risk population groups 2. Reduce the rate of amputations per 1000 people with diabet- .. by 20 percent from that 0% total number of major amputations (above- -knee and 2010? 14 by 2019. an percent for Maor' peoples below-knee) has remained relatively stable between 2011? vx 2016 while diabetes prevalence has increased, thus giving a progressively reducing rate. The number of minor amputations has risen. though this is roughly in proportion with the increase in diabetes prevalence. The proportion of major to total amputations has reduced progressively from 34 to 28 percent. See Tables 1 and 2 and Figure 1 in 3 0r all ethnicities except Indian. Appendix 3. 4'2] Reduce the rate of renal People with diabetes account forjust over half of all people replacement per 1000 people having renal replacement therapy (RRT). Between 2010 with diabetes by 20 percent and 2016, the rate of RRT per 1,000 people with diabetes from that over 2010?~14 by has reduced by 28 percent. See Table 3 and Figure 2 in 2019, and by 30 percent for Appendix 3. Maori and Pacific peoples 4. A 20 percent decrease in the Between Quarter 2 2016/17 and Quarter 2 2017/18, the proportion of people with HbA1c proportion of people with HbA1c 2101 mmol has not levels >100, by 2020, with better changed substantially. This is true across all ethnic groups. improvement for high-risk See Table 4 in Appendix 3. population groups 5. By 2020, 85 percent of people Data received from all DHBs for Quarter 2 2017/18 shows with diabetes will participate in that an average of 87 percent of the total population of an annual review across all people with diabetes nationwide had an HbA1c result population groups recorded within the past 12 months. This represented an average of 81 percent, 82 percent and 89 percent for Maori, Pacific and Other ethnicities, respectively. See Table 5 in Appendix 3. Page 9 of 15 MINISTRY OF HEALTH Health Report number: 20171873 6. A 10 percent reduction in the Table 6 shows that diabetes was responsible for an average proportion of premature of 2,147 deaths per year in 2013-2015. This accounts for mortality (at 75 years) due to 31 percent of all deaths occurring among people living with diabetes by 2019, with a 20 diabetes. This proportion varies from 64 to 72 percent of percent decline for Maori and people living with diabetes aged 25?59 years, and then Pacific peoples. This is to be declines steadily down to 12 percent of deaths in the 85-89 replaced when available by life year age group. Of the 2,147 deaths attributable to expectancy and DALY targets diabetes, around 61 percent were premature (aged less than 75 years at the time of death). Approximately 29 percent of diabetes-related deaths occurred in the ?working a 3, 7- BY 2020 DHBS WWV be) 9n on progress made towards self- implement dard diabetes services against the Quality Standards for di e$ iabetes Care. As at Quarter 2 2017/18, 19 DHBs have completed their stocktake against the Quality Standards, and a further DHB is currently completing their stocktake. The most common services that DHBs have chosen to self-management education and retinal screening. prioritise in their upcoming work programmes are: podiatry, The Ministry diabetes team has asked all DHBs to review 3 and update their self-assessment against the Quality Standards by end of April 2018. to mark the halfway point of implementing the diabetes plan. This information will be used to generate a national picture of diabetes services and indicate future direction of improvement initiatives. 8. Reduce prevalence by a 20 VDR data from end~2016 shows that the prevalence of percent reduction in the rate of diabetes has continued to increase annually across all increase of new cases of type 2 ethnic groups. Data on the rates of prevalence show that diabetes. by 2020; with a faster the increase in prevalence has progressively slowed since rate of reduction for high-risk 2010. While this is encouraging, it is too soon to claim a halt population groups (30 percent in the rising prevalence. See Tabies 9 and 10 in Appendix 3. for Maori and Pacific) 9. Reduce the rate of hospital Since 2014/15, the total number of hospital admissions admissions primarily due to primarily due to diabetes is trending downwards. This is diabetes (per 1000 peeple with apparent in the overall rate of admissions per 1,000 people diabetes) by 20 percent from with diabetes and for Pacific people. For Maori the rate of that in 2014, and by 30 percent admissions per 1,000 people with diabetes has remained for Maori and Pacific peoples stable. See Table 11 in Appendix 3. by 2019 Page 10 of15 MINISTRY or HEALTH MAHATCI muons Health Report number: 20171873 Appendix 3: Data tables to show progress against the measures in the diabetes plan Note: The following data provides a snapshot of figures over time and provides a measure of progress since the launch of Living Well with Diabetes. Most of the data is updated annually, at year end. Updated data will be provided in subsequent health reports when available. Table 1: Publicly funded discharges that contain a diabetes-related amputation procedure by ethnicity and year of discharge, 2011?2016 Prioritised ethnicity Year of discharge 2014 2011 2012 2013 20m European/Other 358 406 454 3 Rate per 1,000 people with diabetes 2.6 2.8 3.1 A436 Indian 13 15 1\l> 18 13 Rate per 1,000 people with diabetes 10.9 Maori 127 WK kg) 137 146 Rate per 1,000 people with diabetes 4.4 A 3.8 4.0 Pacific People \2 \2 $95 70 e1 73 Rate per 1,000 people with diabetes/?I? 22:3 . 2.4 2.0 2.5 Total (Figs 65? 034 661 675 Rate per 1,000 people with die 3dures untEEl?if the discharge contains the procedures listed in table not counted if the discharge contains any diagnosis of trauma or a -related amputation procedures by clinical code and year of discharge 2011-20 Ampu rigidigv Year of discharge A 2011 2012 2013 2014 2015 2016 i cites 223 311 315 315 335 339 lion of ice including metatarsal bone 203 218 270 212 235 244 DI rticulation through ankle 1 Amputation of ankle through malleoli of tibia and fibula 0 1 1 0 0 Midtarsal amputation 6 8 10 13 9 7 Transmetatarsal amputation 30 23 31 25 44 39 Amputation above knee 8? 105 107 94 95 102 Disarticulation at knee 2 1 2 1 3 1 Amputation below knee 143 138 140 149 127 131 Amputation Hindquarter amputation 1 0 0 0 0 Disarticulation through toe 5 2 1 0 1 Total 700 809 877 809 849 865 Notes: Diabetes related amputation procedures are only counted if the discharge contains the procedures listed above and a diagnosis of diabetes mellitus. Further to this. procedures are not counted if the discharge contains any diagnosis of trauma or a diagnosis of lower limb cancer. Multiple amputations occurring within the same hospital discharge are counted each time. Source: NMDS Page11of15 MINISTRY OF HEALTH MANMCI moon Health Report number: 20171873 Figure 1: Rates of total, minor and major amputations in people with diabetes, 2011?2016 Amputation rates total, minor and major, 2011- 2016 Total procedures as a percentage of people with diabetes 0.4024 0.3594 M?w?w'?mee?m 0.30% 0 25% 0.20% a 0.10% 0.05% 0.00% 2011 2012 20@ 0 W@?ple with and without diabetes, 2010?4016 2011 2012 2013 2014 2015 2016 New cese?m?T?Weopie wifi'xdiabeteev 287 241 296 313 332 290 265 New age peo it 228 247 224 243 220 23? 268 magma AQW if Total A 515 488 520 550 552 527 533 Rate per 1.5 1.2 1.4 1.4 1.5 1.2 1.1 Source: chessed January 2018) ates of renal repiacement therapy per 1,000 people with diabetes, 2010-2016 Table 3: Rates of re CKD new patient incidence rate NZ 2010?2016 Rate per 1,000 people with diabetes 1.80 1.60 A 1.40 120 1.00 0.30 0.60 0.40 0.20 0.00 2010 2011 2022 2013 2014 2015 2016 Page 12 of 15 or EALTH mama 1111qu Health Report number: 20171873 Table 4: Proportion of people with HbA1c 301 mmols in 2016117 and 2017118, by ethnicity 2016117 Quarter 2 2017113 Quarter 2 Ethnicity Proportion of people in each HbA1c Proportion of people in each HbA1c category category :64 65-80 81-100 2101 :64 65-80 81-100 2101 mmols mmols mmols mmols mmols mmols mmols mmols European/Other 540/o Maori 44Pacific 41Total 51 ?1 1 5% 20/0 51 0/0 1 3% 770A 2% Notes: 2016117 Quarter 2 data for ?64 mmols has been provided by all 20 DHBs, data for HbA1c 265 has been provided by 18 of 20 DHBS. The following data collection issues have been reported by DHBs: unable to provide results fr on patients who have had an annual review only providing data for the curre and other data integrity issues. Source: 2016117 Quarter 2 HbA1c report and 2017118 Quarter 2 HbAlc report. Table 5: Proportion of people with diabetes who had an December 2017, by ethnicity and DHB of domicile able 1 nt month rath? ?Manor/Car Ex. 7 and 31 DHB warty? \{gig? Maori A??c Total Auckland 77 79 Bay of Plenty 91 Canterbury 6 9 89 Capital and Coast 91 91 Counties Manukau 94 96 Hawkes Bay 73 67 Hutt Valle 85 84 Lake? 86 86 Mid 91 90 Nelso norou 75 73 Northlanda 1 52 46 South Waitemata 79 76 75 West Coast 100 100 100 100 Whanganui 87 92 91 90 All DHBs 81 82 89 87 Source: 2017118 Quarter 2 HbAtc report. Table 6: Rates of diabetes-related deaths and deaths in people with diabetes, New Zealand 2013-2015 Tma159 257 394 619 793 1,034 1,247 1.265 992 9.919 DRD 2,147 Notes: DID number of deaths in people with diabetes. DRD number of de aths attributable to diabetes Source: Diabetes Surveillance 2012-2014 and 2013?2015: Mortality. Ministry of Health Page13of15 MINISTRY or HEALTH mum?: muons Health Report number: 20171873 Table 7: Diabetes?related deaths rate ratios (RR). Comparison of ethnic groups with the EuropeanlOther category, 2013-2015 25Asian 0.4 0.2 0.4 0.5 0.9 0.8 1.1 1.0 1.1 0.9 1.1 1.0 1.3 1.2 Maori 4.3 5.0 4.8 7.8 5.5 6.7 4.3 6.0 5.2 4.1 3.3 2.4 1.8 1.4 Paci?c 2.5 5.7 9.2 7.1 7.6 5.6 6.8 6.4 5.2 4.0 3.0 2.3 2.1 Notes: Rate ratio ethnicity rate of diabetes-related deaths! European or Other rate of diabetes-related deaths All rates are per 100.000 people Source: Diabetes Surveillance 2012?2014 and 2013?2015: Mortality, Ministry of Health Age Tabie 8: Life expectancies for VDR and non-VDR populations at age 25 years, 201 2 Ethnicity Life expectancy at age 25 (years) 3 VDR Difference .4 Maori 54.5 44.8 9.3 Non-Maori 58.8 52.9 5.9 Note: VDR number of people with diabetes as estimated by the Virt Meter Source: Diabetes Surveillance 2012?2014 and 2013-2015: M011 1 Health?x Table 9: Number of peeple on the Virtualgrab?teggter (mg?group. 2010-2016 Year Maori Pagi??p?g?N/ InctI/arp Total 2010 27,257 1 3' . a 128. 374 187.860 2011 29, 003 136 452 200.235 2012 30, 827 :649 24 143.191 211.591 2013 63 27.1.2 764 148.172 220.866 2014 55 13 750 151.684 228.790 2015 0.4 14 632 155.227 236.073 314815 383 157 622 241,463 Note: PW ere geit%?w a PHO or were not alive. as at 31712 of the relevant year. have been excluded. Source: so 20 Table of abetes per 100 people, by ethnicity, 2010?2016 Year 2010 2011 2012 2013 2014 2015 2016 European/Other 2.6 2.7 2.8 2.8 2.8 2.8 2.8 Indian 9.2 9.5 9.7 9.9 10.1 10.1 10.1 Maori 6.2 6.4 6.6 6.8 6.9 7.0 6.9 Pacific 9.6 9.9 10.3 10.7 11.1 11.3 11.3 Total 3.3 3.5 3.6 3.7 3.7 3.8 3.8 Increase year-on~year - 0.2 0.1 0.1 0.1 0 Note: Rate has been standardised using the WHO popuiation and is per every 100 peopie. Source: VDR Dec 2010-2016. NHI Page 14 of 15 mmr? HAUOM Health Report number: 20171873 Table 11: Number of publicly funded hospital discharges due to diabetes mellitus by prioritised ethnic group, 2014l15-2016I17 European Year Maori Pacific Asian I other Total 2014/15 1.277 606 152 4,057 6,092 Rate per 1,000 people with diabetes 37.2 20.9 11.1 26.7 26.6 2015/16 1,274 638 152 3.993 6.05? Rate per 1,000 people with diabetes 35.6 21.0 10.4 25.7 25.7 2016/17 1,371 554 132 3,800 Rate per 1,000 people with diabetes 37.1 17.6 8.6 PHO and were dead as at 31 st December of each VDR year. Source: National Minimum Dataset (NMDS) and Virtual Diabetes Page 15 of 15 riff/icHMEA/T if Health Report number: 20181817 Security classification: ln-Confidence Quill record number: File number: Action required by: routme Progress update on implementing Living Well with Diabetes: A plan for people at high risk of or living with diabetes 2015-2020 September 2018 To: Hon Dr David Clark, Minister of Health KP) Purpose This report provides you with a summary of progress towaw . - - ?Siabetes. A plan for people at high risk of or living with diabetes 201 . . 3' nvers progress refers Key points . The prevalence of dia ber - crease in New Zealand between 2010 and 2017, overall by tcentr.n te of Increase has slowed over the past few years %fdia ms ofthe WHO standardised population? has ptateaued in an est 245 680 people in New Zealand had diabetes as modelled by of 201 - Th Ministry diabetes team has met with 19 of 20 DHBs since mid-2016 to discuss their progress xt stages of improvement have been identified by DHBs as a result of this work. towards implementing the diabetes plan. . There has been a dramatic improvement in the ascertainment of diabetes in almost all primary health organisations (PHOs) and DHBs, with practice register numbers closely aligned to VDR predictions. This is an essential prerequisite for systematic quality care, though in many DHBs there is evidence of 10 percent or more of the diabetes population not receiving regular care. . Most DHBs continue to work towards improving collaboration and integration. There is some evidence of greater focus on unstable diabetes and the need to improve HbA1c in vulnerable groups, though the effort varies across DHBs. 1 The WHO age-corrected standard population removes the effect of different aged populations on disease prevalence that show significant changes with age - as with diabetes. ll is used to compare countries with different age structures and where a population age :iro?les are changing because of ageing, immigration and differential birth rates. Contacts: Grant Pollard, Group Manager, Population Health and Prevention 8 Sue Riddle. Manager, CVD Diabetes Long Term Conditions, 8 Population Health, Population Health and Prevention Page 2 of 13 MINISTRY or EALTH Progress update on implementing Living Well with Diabetes: A plan for peOpIe at high risk of or living with diabetes 2015-2020 September 2018 Health Report number: 20181817 Recommendations This report is for your information only and does not request any decisions. Dr William Rainger Minis?r? te. $3 Population Health and Pr??n? o} <93? (93% Page 3 of 13 MINISI 0f 41 Health Report number: 20181817 EALTH )1 \l Update on the implementation of Living Well with Diabetes September 2018 1. At the end of 2017. an estimated 245,680 people in New Zealand had diabetes (Virtual Diabetes Register 2017).2 2. Over the period 2010?2017 the prevalence of diabetes has increased by 31 percent nationwide (ranging from 10 to 48 percent across DHBs and highest in Counties Manukau and Capital Coast DHBs). 3. Since 2010 there has a gradual slowing of the rate of increase of prevalence. wit teau reached over the past two-to-three years when expressed as the WHO corr ct tion rate. This applies to total prevalence, and also for Maori, Pacific and lndo-Asi European/Other (Figure 3 in Appendix 1). In their recent self?assessment of services against the 20 Qu . iving with diabetes 2015?2020 (the . -s a medium-term plan for tackling .i . ith diabetes, or at risk of developing type 2 people to manage their condition themselves, with the eo le om developing type 2 diabetes anagement . meet the needs of children and adults with type 1 diabetes. In 2013/14, the Ministry released the Quality Standards for Diabetes Care and an accompanying The 20 quality standards provide guidance for the health sector to support planning of high-quality clinical services and comprehensive patient-centred care. The quality standards and toolkit complement the diabetes plan and provide a benchmark for DHBs, PHOs and general practices. Progress against the identified measures in the diabetes plan 8. The diabetes plan included nine measures that were developed to track progress towards improving health outcomes for people with diabetes. These measures are focused on: measuring a reduction in the personal burden for people with diabetes; provision of consistent services across the country; and a reduction in the cost of type 2 diabetes. Several of these have required extensive and continuing work to develop meaningful data. 2 3 4 5 Page 4 of 13 9. HEALTH IIALPUKA Health Report number: 20181817 Progress against these measures has been summarised below, and more detailed data tables are included in Appendix 1. a. Measure: A 20 percent reduction in complications and disability experienced by people with diabetes under the age of 75 years by 2020; with a 25?30 percent reduction for high risk population groups. Progress: Data on amputations and renal replacement in people with diabetes has been provided for measures and (see below). We have commenced work exploring the development of new measures for the progress of diabetic disease and foot disease. Results are likely to be available in 12-18 months. Progress: Between 2011 and 2017 the rate of amputation proce diabetes has reduced by 33 percent for Indian people. The . minor amputations, which could be indicative remained static despite the increase in nu and Figure 1 in Appendix 1. c. Measure: Reduce the rate of re re -. percent from that over 20 I 14 . I peoples. ccount f-rgp .. ~nt. See Table 3 and Figure 2 in Appendix 1. - - proportion of people with HbA1c levels 100, tfor high?risk population groups. 16/17 and Quarter 4 2017/18, the proportion of people with not changed substantially overall. However, for Pacific peoples, 2 percent to 6 percent. See Table 4 in Appendix 1. - .13. 0, 85 percent of people with diabetes will participate in an annual gs! ol/mol - 3: Data was provided by 19 DHBs for Quarter 4 2017/18, which shows an average of percent of the national population with diabetes had an HbA1c result recorded within the i past 12 months. This was a small decrease from the data received for Quarter 2, though this may be due to some inaccuracies in data reporting. See Table 5 in Appendix 1. f. Measure: A 10 percent reduction in the proportion of premature mortality (at 75 years) due to diabetes by 2019, with a 20 percent decline for Maori and Pacific peoples. This is to be replaced when available by life expectancy and DALY targets. Progress: Table 6 shows that diabetes was responsible for an average of 2,058 deaths per year in the period 2014-2016. This accounts for 29 percent of all deaths occurring among people living with diabetes. This proportion varies from 64 to 73 percent of people living with diabetes aged 25?59 years, and then declines steadily down to 8 percent of deaths in the 85?89 year age group. Of the 2,058 deaths attributable to diabetes, around 64 percent were premature (aged less than 75 years at the time of death). Approximately 31 percent of diabetes?related deaths occurred in the ?working age? population aged 25?64 years. Mortality data from 2014 to 2016 shows that overall, diabetes accounts for around 7 percent of all adult deaths in New Zealand. See Tables 6 and 7 in Appendix 1. 9. Measure: By 2020 DHBs will have implemented quality standards for diabetes care. Progress: To mark the halfway point of implementing the diabetes plan, the Ministry diabetes team asked all DHBs to review and score their services against the Quality Standards for Diabetes Care in April 2018. This was completed by 19 DHBs, and the remaining DHB will undertake this by the end of the year. All DHBs reported they are progressing with Page 5 of 13 - HEALTH DHB self-assessments against the quality stand 10. 11. 12. MANN ll Health Report number: 20181817 implementing the quality standards, and they have identified their highest priority quality standards. See points 9?14 of this health report for more detail. h. Measure: Reduce prevalence by a 20 percent reduction in the rate of increase of new cases of type 2 diabetes, by 2020; with a faster rate of reduction for high-risk population groups (30 percent for Maori and Pacific). Progress: VDR data for 2010?2017 shows that total diabetes prevalence has continued to increase. However, the rate corrected to a WHO standardised population has plateaued since 2014/15. This is true for all ethnicities. See Tables 8 and 9 and Figure 3 in Appendix 1. i. Measure: Reduce the rate of hospital admissions primarily due to diabetes (per 1,000 people with diabetes) by 20 percent from that in 2014, and by 30 perce Maori and Pacific peoples by 2019. iabet bete a VII Progress: Since 2014/15 the total number of hospital admissions has shown little change. The total rate of admissions per 1,000 decreased by 4 percent. For Maori and Pacific peoples th people with diabetes has remained stable. See Table I To mark the halfway point of the diabetes pl were asked to self-assess their services 9 asked to provide ratings for both quality assessment. A total of 19 DHBs - one remaining ic care, self-management and assessment: People with diabetes should be assessed for the presence of problems with expert help provided if needed. They should receive high quality structured self-management education that is tailored to their individual and cultural needs. They and their families/whanau should be informed of, and provided with, support services and resources that are appropriate and locally available. They should be offered, as a minimum, an annual assessment for the risk and presence of diabetes-related complications and for cardiovascular risk. They should participate in making their own care plans, and set agreed and documented goals/targets with their health care team. b. Management of diabetes complications i. All people with diabetes should have regular checks of renal function and proteinuria (ACR) with appropriate management and/or referral if abnormal. ii. They should be assessed for the risk of foot ulceration and, if required, receive regular review. Those with active foot problems should be referred to and treated by a multidisciplinary foot care team within recommended timeframes. Page 6 of 13 14. nerable older adults living at home or in supervised care. 1 Mi try diabetes team has written feedback letters to each DHB providing a summary of 16. MINISTRY OF HEALTH Health Report number: 20181817 Management of diabetes and cardiovascular risk i. Those who do not achieve their agreed targets should have access to appropriate expert help. Special groups i. Vulnerable patients, including those in residential facilities and those with mental health or cognitive problems, should have access to all aspects of care, tailored to their individual needs. Other key findings from the self-assessments include: The best performing and responsive services are those with a high-functioni integrated leadership group with representation from primary care, PHOs, 5 services Across the country many of the greatest improvements in prim .- . -r ance - ines re . wwever l' - evidence deprivation. . In niabetes who now ic on of people with . . diabetes is close to complete . There is great potential - u: . . inform quality improvement at practice and individu in which this dat -ars with type 2 diabetes iv early renal disease ults ag 25 t% . 0} port for people with diabetes I- it a nal results and individualised responses to address areas of interest for each district. All HBs have been encouraged to share the findings amongst their local diabetes team, alliance or leadership group and to consider these as they develop and enhance services for people with diabetes. The Ministry is exploring ways to support DHBs to address service needs and gaps identified in the self?assessments. This includes facilitating peer relationships and options to connect with other Ministry work programmes. For example, a possible link with the mental health team to support the prioritised quality standard on providing assessment and support for people with problems. A workshop for the sector to review and discuss key findings from the self- assessments is being planned for the next long term conditions conference in February 2019 (refer point 20 below). Implementation of the diabetes plan is variable across the sector 17. Since March 2018, the Ministry diabetes team has visited two further DHBs and teleconferenced with one where travel was not possible. The team has now met with 19 out of 20 DHBs since mid- 2016 to discuss and support the implementation of the diabetes plan. We will visit the final DHB in October 2018. DHB visits have proved invaluable in objectively assessing progress and establishing good working relationships with the sector. There has been a substantial improvement in the quality and completeness of quarterly reports and annual plans. Page 7 of 13 MINISIRYUF . . Health Report number: 20181817 18? DHB visits and the self-assessments have indicated there continues to be a wide variation across the country in implementing the diabetes plan. Although there is an improved focus on improving services and outcomes for vulnerable groups, there remains an equity gap in terms of measures of care and diabetes-related outcomes for some DHBs. Overall progress in implementing the diabetes plan has been slow for four DHBs in particular. 19. Over the next six months the Ministry plans to work closely with DHBs where challenges implementing the diabetes plan remain. Paper-based reviews to support the higher performing DHBs will continue over 2019. The Ministry will facilitate mechanisms to improve collaboration and integration for DHBs to enable them to meet the objectives of the diabetes plan by 2020. 20. The Ministry diabetes team has reviewed the draft DHB 2018/19 Annu- -- - 21. In February 2018, the Ministry of Healt Disease Risk Assessment (CVDRAteam is currently planning a conference on 1- cians. This aims to showcase innovative work from -- andk . rvices with an emphasis on improving equity There will be three $0 - You have agreed to open the conference issioned exploratory work to identify the support needs of young people (and type 1 diabetes with a focus on support needed to enable a seamless transition a . etes is challenging for young people and their parents/caregivers, though especially for those aged 18 to 20 years as they move out of home and away from paediatric services. Emotional and support becomes increasingly important with age but is not always available. Diabetes services vary across the country, and young people would benefit most from regular face? to-face contact, judgement-free services that assess a young person?s holistic wellbeing. END. Page 8 of 13 MINISTRY OF HEALTH ?9.5le Health Report number: 20181817 Appendix 1: Data tables to show progress against the measures in the diabetes plan Table 1: Number of diabetes-related amputation procedures by ethnicity and year of discharge, 2011?2017 Ethnicity Year of discharge 2011 2012 2013 2014 2015 2016 2017 European/Other 440 509 576 532 558 550 653 Rate per 1,000 people with diabetes 3.1 3.5 3.8 3.4 3.5 3.4 4.0 Indian 15 18 28 15 25 15 Rate per 1,000 people with diabetes 1.2 1.4 2.0 1.0 125?\5\ . 0.5/4 Maori 166 204 174 ?vg? 2@j Rate per 1,000 people with diabetes 5.4 6.2 5.1 511 ($55.3 Pacific People 79 78 9 KW 82 U109 Rate per 1,000 people with diabetes 3.0 2.8 . A .7 3.0 Notes: Diabetes related amputation procedures are only count diagnosis of diabetes mellitus. Further to this, procedures ar-. diagnosis of lower limb cancer. Rates per thousand people on the VDR, including those 1 Source: National Minimum Dataset (NMDS), abe .- 17 (uses) diagnosis of trauma or a listed in table 2 and a 'n the start and end of the year. Table 2: Publicly funded diab utation r?e clinical code and year of discharge, 2011-2017 Amputation type @Kgi Year of discharge A b; 2011 2012 2013 2014 2015 2016 2017 223 311 315 315 335 339 399 metata 203 218 270 212 235 244 302 ibia and fibula amputation iculation through toe otal 700 809 877? 809 849 864 989 Notes: Diabetes related amputation procedures are only counted if the discharge contains the procedures listed above and a diagnosis of diabetes mellitus. Further to this, procedures are not counted if the discharge contains any diagnosis of trauma or a diagnosis of tower limb cancer. Multiple amputations occurring within the same hospital discharge are counted each time. Source: NMDS Page 9 of 13 Health Report number: 20181817 Figure 1: Rates of total, minor and major amputations in people with diabetes, 2011-2017 Amputation rates total, minor and major Total procedures 0.151;. 0.107;. 00522:, ?x 0.00?5 2011 3013 3013 Table 3: Rates of renal repla??et 1. -- . and without diabetes, 2010-2016 A 20:10 20110) 2012 2013 2014 2015 2016 New cases of pbe?pch?abete \2?60) 9134 249 270 293 269 269 New cases of ithout 281 264 287 262 289 290 1 ?@1393 A ?515 485 513 557 555 558 559 me?fmpeoplemtwhabetes 1W2018) . WT eplacement therapy (RRT) in people with and without diabetes, 2010-2016 new patient incidence rate NZ 2010-2016 Rate per 1,000 people with diabetes 1.40 LOO 000 000 040 020 000 2010 2011 2013 2013 2034 2015 2010 Page100f13 MINISTRY or HEALTH Health Report number: 20181817 Table 4: Proportion of people with HbA1c 2101 mmols in 201611? and 2017118, by ethnicity 2016117 Quarter 2 2017118 Quarter 4 Ethnicity Proportion of people in each HbA1c Preportion of people in each HbA1c category category 564 65-80 81-100 2101 564 65-80 81 -1 00 2101 mmols mmols mmols mmols mmols mmols mmols mmols EuropeaniOther 54Maori 44Pacific 41% 13% 1 1% 2% 45% 17% Total 51% 1 1% 6% 2% 52% 14% Notes: 2016/17 Quarter 2 data for 64 mmols has been provided by all 20 DHBs, data for HbA1c 2 5 provided by 18 0f 20 DHBS. The following data collection issues have been reported by DHBs: unable to provide results Ii on patients who have had an annual review. data is not restricted to patients within the ceified for the current month rather than for the quarteriyear to date, and other data integr' 53$ . Source: 2016117 Quarter 2 HbA1c report and 2017MB Quarter 4 HbA1c report Table 5: Proportion of people with diabetes who had an 7 June 2018, by ethnicity and DHB of domicile DHB saw my Maori Pagi?c Other tal Auckland Plenty 91 Canterbury - 90 Capital and Coast 92 Counties Manukau 87 Hawkes Bay 69 Hutt Valley Whanganui 90 All DHBs 83 Note: The following data collection issues have been reported by DHBs: unable to provide results from all PHOs, only able to report on patients who have had an annual review, data is not restricted to patients within the speci?ed age range, only providing data for the current month rather than for the quanerryear to date. and other data integrity issues. Source: 2017118 Quarter 4 HbA1c report. Table 6: Rates of diabetes-related deaths and deaths in people with diabetes, New Zealand 2014-2016 25T?ta178 259 405 821 814 1098 1287 1319 1058 7207 DRD 5 9 14 27 85 119 165 238 326 380 370 272 108 -17 2058 Notes: DID number of deaths in people with diabetes, DRD number of deaths attributable to diabetes Source: VDR and Mortality collection, 2014-2016; Ministry of Health Page 11 of 13 stimulator HEALTH llkl?l??k Health Report number: 20181817 Table 7: Diabetes-related deaths rate ratios (RR). Comparison of ethnic groups with the EuropeanIOther category, 2014-2016 Age 25Asian 0.3 0.2 0.7 0.4 0.8 0.7 1.0 1.1 1.4 1.1 1.0 1.2 1.9 1.5 Maori 3.2 3.8 6.0 9.2 5.1 7.2 5.5 6.5 5.9 4.5 3.4 2.7 2.0 Pacific 4.0 3.4 5.2 11.4 7.4 8.5 5.9 7.1 6.5 5.3 4.2 3.4 2.7 2.2 Notes: Rate ratio ethnicity rate of diabetes-related deaths 7 European or Other rate of diabetes-related deaths All rates are per 100,000 population Source: VDR and Mortality collection. 2014-2016; Ministry of Health Table 8: Number of people on the Virtual Diabetes Register (VDR) by ethnic grcM), got?lg? Year Maori Pacific-people Indian EuropeanIthe? VA 53 2010 27.257 22.143 10.088 128 187 0 2011 29.003 23.799 10.981 52 20 2012 30.827 25.849 11.924 1 211 2013 32.834 27.296 12.784 0, 8 2014 34.355 29.001 13.750 .684 8,790 2015 35.769 30,445 1552 236,073 2018 36,978 31.480 1 . 241,483 2017 38,820 32,408 A Res A 245,680 5 Note: People that were either not enrolled Wnt?ar. have been excluded. N) Source: VDR Dec 2010?2017 (1.1585) Figure 3: Diabetes prevalence and ye rdised population2010 2011 2012 3013 2014 2015 3010 2017 + ndmn - Maori d-Total Source: VDR Dec 2010?2017 (V686), NHI Page 12 of 13 MINISTRY or HEALTH l' Health Report number: 20181817 Table 9: Rate of diabetes per 100 people, by ethnicity, 2010-2017 Ethnicity Year 2010 2011 2012 2013 2014 2015 2016 2017 European10ther 2.6 2.7 2.8 2.8 2.8 2.8 2.8 2.8 lndian 9.2 9.5 9.7 9.9 10.1 10.1 10.0 9.8 Maori 6.2 6.4 6.6 6.8 6.9 6.9 6.9 6.8 Pacific 9.6 9.9 10.3 10.7 11.1 11.3 11.3 11.1 Total 3.3 3.5 3.6 3.7 3.7 3.8 3.8 3.8 Increase year-onyear Table 10: Number of publicly-funded hospital discharges due to diabetes by @er 2 Year Maori Pacific lnd? er with 2014115 1278 606 v' v40? W) 16324.7 Rate per 1,000 people with diabetes 29.6 .7 2015116 1,280 152 6,133 Note: rate has been standardised using the WHO population and is per every 100 people Source: VDR Dec 2010?2017 (uses) 3% i i 1' 15?2 1@ Rate per 1,000 people with diabetes 24.1 2016/17 5,894 Rate per 1,000 people with d? . 7.6 22.7 2017118 166 6,273 i etes A Qa. 7.5 8.9 23.6 . 'rhary diagn ?a?et mellitus. ellitus did sequenced as the primary diagnosis. This resulted in a notable decrease - bet 1 - -n 2013 2014115. Due to this administrative trend, hospital discharges are shown calculate rates is only available by calendar year. The VDR year to produce . table above. This includes people who were alive the January before the financial 10?2017 (vase) Page 13 of 13 #772? CHMENT J- MINISIRYUI HEALTH MANAI 2nd May 2016 Diabetes Workshop Summa 'y epor Gift 1 Aw 1.. . '0 Health Navigator Prepared by: Health Navigator Charitable Trust "i i Health @Vigator Contents 1. Background 2 2. Evaluation process 2 3. Workshop Attendees 2 4. Workshop organisation, venue. facilitator, presentations and group discussions 3 5. Learnings and district collaboration 4 6. T. 8. 9. AC) 12. Report prepared by Dr Janine Bycroft and Charmaine Vaughan Health Navigator Charitable Trust. Contact: ianine@healthnavigatororq.nz, Ph: 021 869 869 Diabetes Workshop 2"d May 2016 Evaluation Report Draft 1.0 '0 - Health @vigator 1. Background A one-day Diabetes Workshop was held on Monday May 2016 in Rotorua by the Ministry of Health with organisational support provided by Health Navigator Charitable Trust. The main purpose of this workshop was to bring DHB and PHO funders, planners and clinical leaders together, to hear from national experts involved in recent guideline development and move towards improved consistency in the purchase and provision of diabetes services across the country. In support of this purpose the workshop aimed to: Bring diverse groups of management and clinicians together . Discuss a number of resources, guidelines and supporting frameworks that developed 0 Provide advice to assist with the annual planning process . View and discuss variance reports about current service prov] . Discuss the barriers and enablers for optimising care and 2. Evaluation process An evaluation questionnaire was provided to sh ic ants with the end of the day as hard copiesused as the of Health staff were excluded from A total of 59 response denominator since responding). The total number registered was 95 people with 90 attending. Reasons for attending are shown in the ?gure below with participants able to select multiple options: Diabetes Workshop 2"d May 2016 Evaluation Report- Draft 1.0 xi Health Navigator Figure 1: Reasons for attending this workshop Answer Count Percent 20% To Improve our planning process 39 24 5311. For notwolking 30 18 Interest Il?r the workshop lop-organisation 31 19 Ezperldlion to 4 2 52'? in he itillt'? In In national (?surgeon-5 nhuiil 26 H3 35 semres Other . . Total For other, reasons given were: . clarity around position. expectation forf invited as consumer . to better understand national direction a . to find out what others are doi . learning from other nati . Taken on new role SJJISTIITI V?ry Amau A In For this tabie, 2 peopte ticked very unsatisfactory for 5 responses yet there were no negative comments anywhere eise on their forms and their overaii satisfaction with the day was ticked as very satisfied or somewhat satisfied. Their resuits have been inciuded however such responses wouid suggest they may have ticked very unsatisfactory in error. Workshop venue, timing location: . One person commented that the "Venue very said on ieft hand side of the room? . Rotorua was seen at difficult to get to by a number of respondents ?a chaiienge to get to Rotorua. Up at 4.30am, home after 8.30pm? Diabetes Workshop May 2016 Evaluation Report? Draft 1.0 Health Navigator "Needs to be at easily accessible city - make flights and was still late and had to leave early. "Programme needs to consider flight availability. if finishing earlier. most could have caught last flight out tonight." "Please have these meetings in more accessible locations. Rotorua difficult and expensive. "the Ministry of Health workshop - is vital the location of Rotorua or Tauranga because it is central NZ. would like to see it run over two days instead of one. 0 Workshop organisation (registration process) 0 83% or respondents were very satis?ed or satis?ed. . "Notification of workshop would have been better earlier. . "Please don?t keep sending invite tickets 4 times. Organisation on the day 0 95% or respondents were very satisfied or satis?ed. . One person commented that "the site registration not straig@ Facilitator style and approach . Facilitator for the day was Dr Janine Bycro link conversation and presentations to the country. 92% or respo . ?Mornin I roup disc Over sponde were . always I get the right balance between group discussions. group feedback and f0 rmation read today was just read from the so no real discussion" Learnings and district collaboration When asked, ?Will learnings from this workshop encourage greater collaboration between stakeholders in your district/region on diabetes integration planning . 81.5% answered Yes or Possibly, (this is comparable with the 82% reported for the Diabetes Workshop from 2014) . Two people chose No chose No, and 0 Eight participants said they are already doing this well. Diabetes Workshop 2"'1 May 2016 Evaluation Report Draft 1.0 1? Health Navigator Finn-Tm Count 20.3 1m? 50'" Mal 5-1 100 6. Patient participation in service planning organisation invoives patients in diabetes service pianning?? More attendees were positive about including patients in service plan 'n workshop in 2014. (88.8% this year compared to 81.2% in 2014 . 80.4% responded ?Yes? (up from 45.4% in 2014) . 28.3% responded ?Maybe' (down from 35.4%) . 11.3% selected 'No? (down from 18.75% in ZI .. rowan-oi '2 bit: . '33 r: emiml ihe