Diabetes. Service Plan

Transcription

1 Diabetes Service Plan July 2005

2 Cover photographs kindly supplied by Diabetes New Zealand (top), Diabetes Christchurch (middle), Diabetes Youth Manawatu (bottom)

3 Contents INTRODUCTION WHY DO WE NEED A DIABETES SERVICE PLAN? PURPOSE OF THE DIABETES SERVICE PLAN VISION FOR THE FUTURE OBJECTIVES PRINCIPLES OUTCOMES... 4 THE PLANNING FRAMEWORK - STRATEGIES MAORI HEALTH THE PACIFIC CONCEPT OF HEALTH MIDCENTRAL'S DIABETES MODEL OF CARE ACROSS THE HEALTH CONTINUUM CRITICAL SUCCESS FACTORS... 9 DEMOGRAPHIC PROFILE FOR MIDCENTRAL DISTRICT GEOGRAPHY POPULATION DEPRIVATION MAORI, PACIFIC AND ASIAN PEOPLES SMOKING PREVALENCE...15 DIABETES BURDEN PROFILE MAORI AND PACIFIC PEOPLES ASIAN PEOPLES THE IMPACT OF DIABETES ON FEET THE IMPACT OF DIABETES ON EYES IMPACT OF DIABETES ON THE KIDNEYS AND HEART DIABETES IN CHILDREN AND YOUNG PEOPLE IMPACT OF DIABETES ON WELLBEING OVERVIEW OF CURRENT SERVICES AND ISSUES MIDCENTRAL DISTRICT PROVIDERS PRIMARY HEALTH ORGANISATIONS "AOTEAROA GET CHECKED" - THE NATIONAL DIABETES SCREENING PROGRAMME FEET... 24

4 5. EYES KIDNEY AND HEART CHILDREN AND YOUNG PEOPLE WITH DIABETES NUTRITION AND PHYSICAL ACTIVITY EDUCATION SUPPORTING LONG-TERM LIFESTYLE CHANGE DIABETES PROGRAMME AND MEMBERSHIP CARD...30 THE WAY FORWARD - SUMMARY OF OBJECTIVES AND KEY ACTIONS OF THE DIABETES STRATEGY OBJECTIVE ONE Reduce the Incidence of Diabetes Through Prevention and Health Promotion Strategies OBJECTIVE TWO Ensure Effective Screening and Early Diagnosis to Reduce the Impact of Diabetes on Wellbeing OBJECTIVE THREE Ensure Effective Support, Treatment, and Palliative Care to Enhance Quality of Life...38 OBJECTIVE FOUR OBJECTIVE FIVE Improve Diabetes Services Through a Responsive Workforce Improve the Quality and Integration of Diabetes Services Through Planning, Innovation and Quality Monitoring INVESTMENT APPROACH GLOSSARY OF TERMS AND ABBREVIATIONS REFERENCES APPENDIX 1 THE NATIONAL FRAMEWORK FOR DIABETES APPENDIX 2 MIDCENTRAL DISTRICT PROVIDERS APPENDIX 3 KEY STAKEHOLDERS WHO HAVE PROVIDED COMMENT APPENDIX 4 SELECTED MINISTRY OF HEALTH PERFORMANCE INDICATORS... 61

5 Figures Figure 1: Levels of concern...5 Figure 2: The Primary Health Care Strategy...6 Figure 3: Te Whare Tapa Wha model of health...7 Figure 4: MidCentral s diabetes model of care across the health continuum...8 Figure 5: Ethnicity distribution for MidCentral District (2001) Figure 6: MidCentral District deprivation distribution (2001) Figure 7: MidCentral District by deprivation (NZDEP01) census Figure 8: Figure 9: MidCentral District type 2 diabetes prevalence by age and ethnicity (2004) Relationships among socio-economic deprivation, obesity and noncommunicable disease...18 Figure 10: Ideal primary situation...25 Figure 11: Percentage of people with diabetes on ACE inhibitor in MidCentral District by ethnicity 2002, Figure 12: Basal rate profile and physiological insulin needs...27 Figure 13: Components of the diabetes programme and membership card Figure 14: Key actions of the Diabetes Service Plan Tables Table 1: Clinical indicator targets for MidCentral...4 Table 2: Smoking prevalence (indirectly standardised) for selected regions Table 3: Diabetes mortality by ethnic group and sex (national population) 1997, 17 Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Table 10: Risk coefficients for diabetes for a 1kg/m² lower body mass index (BMI)...18 Standardised discharge ratios by DHB region for lower limb amputation in people with diabetes in 2002/ Prevalence rates of complications in people with known diabetes by ethnicity (national statistics) % Reduction of the risk of diabetic heart and kidney complications shown in recent studies (2001) Number of people with diabetes in MidCentral District who had annual check in Number of people who had their eyes screened in the last two years January - December Number of people with diabetes in MidCentral District with free annual checks who had poor diabetes control in 2003 (HBA1c>=8%)...26 Table 11: Diabetes Service Plan investment approach... 48

6 INTRODUCTION As part of the MidCentral District Health Board s Primary Health Care Strategy, MidCentral District Health Board (MidCentral) is responsible for the development and implementation of a coordinated, district wide plan for the prevention and management of diabetes. This document is a strategic plan for the development of services over the next three years. It has been developed collaboratively with primary and secondary care providers and community stakeholders. 1. WHY DO WE NEED A DIABETES SERVICE PLAN? The New Zealand Health Strategy (2000) identifies 13 population health objectives for implementation in the short to medium term. One of these 13 objectives is to reduce the incidence and impact of diabetes. Diabetes carries a huge burden both in human and financial terms from complications including renal failure, stroke, foot ulceration, ischaemic heart disease, blindness and lower limb amputation In 2004, 69 deaths will be attributable to diabetes in the MidCentral District Both type 1 and 2 diabetes are increasing in incidence. Type 2 diabetes is diagnosed increasingly in children and teenagers. In the next 20 years, the prevalence of diabetes will increase in NZ by: - 90% in Maori (rising to approximately 47,000 people) - 109% in Pacific peoples (approximately 18,000) - 39% in Europeans (approximately 101,000 people) Source: PriceWaterhouseCoopers Background: Type 2 Diabetes Epidemic pg 1 Diabetes is a disease that is very responsive to effective management. To achieve better health outcomes, we need to move away from a system that is focused on episodic care in response to acute illness, towards a system that is proactive and emphasises health across a lifetime 1. The focus is on the journey that people take, and the support they need at each stage. 1 MoH (Sept 2002) Team Health Newsletter Issue 1, September

7 2. PURPOSE OF THE DIABETES SERVICE PLAN The overall purpose of MidCentral District Health Board s Diabetes Service Plan is to: Reduce the incidence and impact of diabetes Improve the health status of Maori Reduce inequalities in health outcomes. 3. VISION FOR THE FUTURE This service plan strives to enable people with diabetes to enjoy the best possible health and independence. The vision is to: Reduce the incidence of diabetes through prevention and promotion, and ensure people with diabetes, their family/whanau have the skills, confidence, support and care to stay well through their lifelong journey with diabetes. The aim is to reduce the risk of complications and, in the event of ill health, to provide expert and appropriate care across the continuum. 4. OBJECTIVES The objectives of the Diabetes Service Plan are to: reduce the incidence of diabetes through prevention and health promotion strategies ensure effective screening and early diagnosis to reduce diabetes impact on wellbeing ensure effective support, treatment and palliative care to enhance quality of life improve diabetes services through a responsive workforce improve the integration of diabetes services through planning, innovation and quality monitoring. 2

8 5. PRINCIPLES The vision and objectives of this plan are based on the following underlying principles: In the first instance, we should be trying to prevent the incidence of diabetes through health promotion and healthy environments Every person is unique and requires options from which they can select the services that best suit them The care provided to people with diabetes needs to be organised, and it needs to be coordinated across providers and the continuum of care Inequalities in health outcomes need to be addressed. In particular Maori, Pacific peoples and minority group health outcomes need to be improved through targeting in a manner that accounts for client needs All services need to be person-centred - actively ensuring participation of service users in care. Given the importance of self care, people with diabetes and their family/whanau can be considered a part of the health workforce and require appropriate skills. This includes people: making their own decisions and managing their own wellbeing participating in the delivery of services to others participating in the planning of services Service options must be consistent in terms of quality and best practice. Advice and support provided by services also needs to be consistent Where possible, programmes and services will be delivered in the community Diabetes services across the district need to be synchronised to ensure the best outcomes for the total population Diabetes services are accessible and affordable Continuous quality improvement (including auditing) is an underlying principle of all services The entire diabetes workforce should have access to development processes Wherever possible, in developing diabetes services, everyone will work together and build on existing resources to avoid duplication and to ensure the maximum benefits to our community Information sharing to ensure consistency and the best possible outcomes. 3

9 6. OUTCOMES Diabetes clinical indicators are well established and form part of the routine quality control in MidCentral District. Table 1 sets targets for the next three years, based on Ministry of Health performance indicators. Appendix 4 provides a detailed summary of some of these indicators. Table 1: Clinical indicator targets for MidCentral Actual % 2003 Target 05/06 Target 06/07 Target 07/08 All Ethnicities Case detection 49.7% 63% 78% 88% Case management (HBA1c >= 8%) 31.7% 31% 28% 22% Eye screening 81.0% 85% 85% 90% % on ACE Inhibitor/ A2 Agents % 58% 70% 75% Screening for peripheral neuropathy and - 100% 100% 100% peripheral vascular disease 3 Maori Case detection 29.9% 60% 75% 85% Case management (HBA1c >= 8 %) 50.2% 35% 30% 25% Eye screening 69.6% 85% 85% 90% % on ACE Inhibitor / A2 Agents 52.0% 60% 75% 80% Screening for peripheral neuropathy and - 100% 100% 100% peripheral vascular disease3 Pacific Peoples Case detection 47.7% 60% 75% 85% Case management (HBA1c >= 8 %) 51.2% 35% 30% 25% Eye screening 68.3% 85% 85% 90% % on ACE Inhibitor / A2 Agents 41.0% 60% 75% 80% Screening for peripheral neuropathy and - 100% 100% 100% peripheral vascular disease3 Others Case detection 54.5% 70% 85% 95% Case management (HBA1c >= 8 %) 28.9% 25% 23% 20% Eye screening 82.8% 85% 85% 90% % on ACE Inhibitor / A2 Agents 52.5% 55% 60% 65% Screening for peripheral neuropathy and peripheral vascular disease3-100% 100% 100% 2 The Ministry of Health clinical indicators include the % of Angiotensin Converting Enzyme (ACE) Inhibitors. This indicator has been adjusted for the service plan to include those on A2 Agents as this is an alternative drug therapy where ACE Inhibitors are contra indicated. 3 New indicator proposed by Diabetes Service Plan Reference Group 4

10 THE PLANNING FRAMEWORK - STRATEGIES Diabetes has reached epidemic proportions throughout the world. The World Health Organization and the International Diabetes Federation, representing 125 countries, are concerned about the comparable trends worldwide 4. Chronic conditions such as diabetes are increasing such that by the year 2020 developing countries can expect 80% of their disease burden to come from chronic problems 5. Diabetes is also a growing concern both nationally and regionally in New Zealand. The following section highlights the levels of concern (figure 1) and strategies in place to reduce the effect of diabetes upon the health and wellness of people and their family/whanau and community. Figure 1: Levels of concern In terms of diabetes, the key government strategies are the New Zealand Health Strategy (December 2000); The Primary Health Care Strategy (February 2001); The Youth Health Strategy, Plan to Action (2002); Child Health Strategy (June 1998); 4 PriceWaterhouseCoopers (April 2001) Diabetes New Zealand Inc Type 2 Diabetes Managing for Better Health Outcomes 5 Ministry of Health (Sept 2002) Team Health: Health and Disability News Primary Focus Aims to Improve Chronic Disease Management Issue 1, September

11 and He Korowai Oranga Maori Health Strategy (November 2002). The National Framework for Diabetes is set out in Appendix 1. Chronic Disease Management A global health needs assessment completed during 2001 indicated that diabetes illness (morbidity) and death (mortality) rates for people living within MidCentral District s boundaries needs to be addressed adequately in primary health care 6. Such issues are goals of the local Primary Health Care Strategy 7. Figure 2 highlights the new approach of the strategy. Figure 2: The Primary Health Care Strategy Old Focus on individuals Provider focused Doctors are principal providers Fee for service Service delivery monocultural Providers tend to work alone New Population based Community/people focused Education and prevention Needs based funding for population Cultural competence Connection to other health and nonhealth agencies Teamwork The Primary Health Care Strategy has six objectives: Access People will have ease of access to health care services throughout the district Community participation The community will actively contribute to shaping primary health care services Coordination of services There will be seamless follow through of services for all people Infrastructure development Primary health care services are supported by planned infrastructure development Integration between primary and secondary care People receive care that is not interrupted between primary and secondary care events Quality People can expect the best possible quality when receiving primary health care services. PHOs are critical to chronic disease management the expertise of general practice teams will enable us to manage effectively the prevention, primary treatment and ongoing care in diseases such as diabetes. Diabetes will be one of the great challenges for at least the next two decades, but New Zealand now has the right foundation to build on, and PHOs will carry forward the next steps in community outreach and disease management. Ministry of Health Clinical Advisor, Dr John Marwick Ministry of Health Team Health: Health and Disability News Issue 1 September MidCentral District Health Board (2004) Primary Health Care Strategy pg 35 7 Adapted from TADS Training Programme presentation July

12 1. MAORI HEALTH The need to address diabetes among Maori has been emphasised in strategic health policy documents including The New Zealand Health Strategy (2000), The New Zealand Public Health and Disability Act 2000, and He Korowai Oranga (2002). It is essential that the principles of the Treaty of Waitangi are followed: Partnership Participation Protection Working together with iwi, hapu, whanau/family and Maori communities. Involving Maori at all levels including planning, development and the delivery of health care programmes and services. Striving for equal levels of health as non Maori and caring for the cultural concepts and values of Maori 8. The Maori world view places greater emphasis on the group dynamic as opposed to the individual. In keeping with this belief the Maori view of health is that personal wellbeing is based upon a balance of spiritual, whanau, mental and physical wellbeing. This is encapsulated in the Whare Tapa Wha model, a concept recognised by the World Health Organization. Te Whare Tapa Wha likens the four dimensions of health (taha wairua, taha hinengaro, taha tinana, taha whanau) to the walls of a house (figure 3). Symmetry of these four dimensions gives strength and balance to a person in much the same way that walls contribute to a house. This concept, together with upholding the principles of the Treaty of Waitangi ie, partnership, participation and active protection, needs to be carefully considered when developing and implementing strategies to address diabetes in the Maori population. Figure 3: Te Whare Tapa Wha model of health Taha Wairua Taha Hinengaro Taha Tinana Taha Whanau Focus Spiritual Mental Physical Extended Key Aspects The capacity for faith and wider communion The capacity to communicate, to think, and to feel The capacity for physical growth and development The capacity to belong, to care, and to share Themes Health is related to unseen and unspoken energies Mind and body are inseparable Good physical health is necessary for optimal development Individuals are part of wider social systems Durie, M. (1994) Whaiora: Māori Health Development. Auckland, Oxford Press 8 Ministry of Health Addressing Maori Health 7

13 2. THE PACIFIC CONCEPT OF HEALTH For Pacific peoples, health is a holistic concept which encompasses spiritual, emotional, mental, physical and social wellbeing. The emphasis is on total wellbeing of the individual within the context of the family. The family includes both the nuclear family and the extended family MIDCENTRAL'S DIABETES MODEL OF CARE ACROSS THE HEALTH CONTINUUM Following the continuum of care framework, the vision for MidCentral s diabetes services sees the person with diabetes on a collaborative journey from diagnosis to treatment across the lifespan. As figure 4 illustrates, primary and secondary health professionals will work together in a coordinated and unified way to deliver the best possible programmes across the health continuum. Figure 4: MidCentral s diabetes model of care across the health continuum Keeping Healthy Improving Health Maintaining Health Restoring Health Maximising Wellbeing Health Professionals Prevention and early detection Family and Community services PHOs - Tararua, Otaki, Horowhenua & Manawatu General practice teams, pharmacy, Maori providers, disease state management nurses, residential care, podiatry, Diabetes Trust, Diabetes Manawatu, community workers Person with diabetes and their whanau/ family Diabetes Specialist Team Endocrinology, Obstetrics, Paediatrics, Podiatry, Diabetes Lifestyle Centre, Dietetics, Specialist Nursing End-oflife Care Longterm Care GP and Specialist Services Pharmacies Behavioural Healthcare Nursing Emergency Care Specialist Medical Homecare Rehabilitation CRITICAL SUCCESS FACTORS A skilled and experienced workforce Health and wellness plans across the health continuum Ongoing co-ordination of diabetes programmes across the District Shared information Shared policy, procedure and guidelines 9 Ministry of Health (2003) Healthy Eating - Healthy Action, Oranga Kai Oranga Pumau: A Background pg 61 8

14 4. CRITICAL SUCCESS FACTORS Achieving the vision of the diabetes service plan requires the attainment of five critical success factors. 1. Health and wellness plans across the continuum People with diabetes and their family/whanau are individuals. The multiple daily self-care decisions that diabetes requires mean that being adherent to a predetermined care programme is generally not adequate over the course of a person s life Improved People with diabetes health and their with diabetes 10. Individuals should be able to and whanau/family plan their own treatment and management wellbeing requirements in conjunction with health professionals who provide them with information tailored for optimum support. People need to review their clinical status and Other health professionals General practice plan the year ahead. Health and wellness teams plans are a comprehensive assessment of each person s health condition and needs. These health and wellness plans should be easy for the person with diabetes to understand, so they are able to set themselves targets and learn how to achieve them. People with diabetes and their family/whanau need a range of choices. They need advice and support from health professionals who are engaged in multi-disciplinary, multi-agency approaches, including the involvement of iwi/maori providers. Strengthening of clinical alliances improves co-ordination and collaboration across services and has the ability to reduce diabetes complications in the future 11. Nurses Maori / iwi providers Community Organisations Patients are the primary decision-makers in control of the daily self-management of their diabetes. As providers, we have to give up the illusion that we have control of our patients diabetes self-management decisions and outcomes. Martha M. Funnell and Robert M. Anderson Empowerment and Self-Management of Diabetes Such an approach would focus on people with diabetes and their experience through the complete clinical course of the condition, rather than viewing diabetes care as a series of discrete episodes within different parts of the health system. Ministry of Health (2003) Diabetes Toolkit 10 Funnell, M and Anderson R Empowerment and Self-Management of Diabetes Clinical Diabetes Volume 22, Number 3, 2004, pg Ministry of Health (Sept 2002) Team Health: Health and Disability News Primary Focus Aims to Improve Chronic Disease Management Issue 1, September

15 2. Shared Information Enhancing communication and collaboration across the health care continuum is necessary to give enhanced understanding of diabetes and optimise management strategies. Sharing information helps to standardise practice and assist in the best possible health care being delivered across the continuum. The ultimate future goal would be a single clinical record. 3. Shared policy, procedure and guidelines Shared policy, procedure and guidelines across the District are necessary to provide optimum care. Evidence-based best practice guidelines should be used to help health care practitioners and consumers make decisions about health care needs. Clinical workers should participate in the planning of services including the involvement of Maori health providers and they should engage in multi-disciplinary, multi-agency approaches to screening and reviews. There is currently no diabetes competency framework for health workers and health professionals. Establishment of a competency framework will assist health professionals to promote appropriate standards of care delivery across the continuum of care. It will minimise risk by encouraging all health professionals to be aware of the standards required and to be competent in providing that care. A positive example of coordination is the Primary Health Care Nursing Professional Framework. The nursing framework is a conceptualised, tiered approach to nursing expertise and requires teamwork at every level. Such teamwork has enabled the nursing workforce to be self training, encouraging expertise to be filtered downwards. 4. A skilled and experienced workforce It is important to have a skilled and experience workforce, including appropriate resourcing numbers and expertise. People with diabetes and their family/whanau also need regular opportunities to upskill on how best to manage diabetes and maintain their quality of life. 5. Ongoing coordination of diabetes programmes across the district There is a need for continued and strengthened management of services for quality assurance and surveillance. The establishment of a Collaborative Diabetes Health 10

16 Improvement Group focused on diabetes will assist in identifying barriers to the implementation of the continuum of care model. The group will provide ongoing coordination of diabetes programmes across the District, resolve problems and deliver on quality improvement through the utilisation of consumer surveys. The Diabetes Health Improvement Group will comprise representatives of Maori providers, specialists, general practice teams, primary health organisations, members of Diabetes Trusts, and people with diabetes. 11

17 DEMOGRAPHIC PROFILE FOR MIDCENTRAL DISTRICT MidCentral District Health Board services a wide geographical and demographic district, through which we aim to improve, promote and protect the health of the approximately people we serve. 1. GEOGRAPHY Territorial Local Authorities (TLAs) are local council areas. In MidCentral District there are five TLAs: Manawatu, Palmerston North, Tararua, Horowhenua and part of the Kapiti Coast. In the Kapiti Coast TLA, the Census Area units (CAU)s included within MidCentral District are Otaki, Otaki Forks and Te Horo. These CAUs make up 20 % of the population of Kapiti Coast TLA. While public transport is generally available in Palmerston North City and Feilding, public transport in the more rural areas is less available making it difficult to use public transport to access health services 13. MidCentral District has a significant rural population; 28% of the population live outside a major urban or secondary urban area. 2. POPULATION MidCentral District s population comprises 15.3% Maori, 2.0% Pacific peoples, 3.5% Asian peoples, and 79.3% other ethnicities including European - evenly distributed across gender: males 49% and females 51% The following is a breakdown of population (2001 Census) by TLA. Horowhenua District The Horowhenua TLA has the second largest population grouping at 20% of the MidCentral District ( people), with the highest proportion of Maori at 20%, and is the most socio-economically deprived of the five TLAs. 12 District Health Board 2005/2006 Population Projections (as at 30/6/2004) 13 MidCentral District Health Board (2001) An Assessment of Health Needs in the MidCentral District Health Board Region Census 15 MidCentral District Health Board (2001) An Assessment of Health Needs in the MidCentral District Health Board Region pg 8 12

18 Kapiti Coast District - Otaki Ward The smallest population cluster in the MidCentral District resides in the Kapiti Coast CAUs (7 761 people). This group makes up 5% of the District s population, and comprises a large aged population reflective of retirees settling on the Coast. Manawatu District The Manawatu TLA makes up 18% of the District s population ( people). It has low socio-economic deprivation, and has, proportionally, a lower Maori population at 13%. Palmerston North City Forty-eight percent of the MidCentral District s population resides in the Palmerston North TLA ( people). Tararua District The Tararua TLA makes up 12% of the District s population ( people), and has, proportionately, the second highest number of Maori within its population at 18%. It has a measure of high socio-economic deprivation but overall tends towards moderate to low deprivation 16. Figure 5 shows the ethnicity distribution for MidCentral District. Figure 5: Ethnicity distribution for MidCentral District (2001) Ethnicity Distribution MidCentral DHB Region 2001 Number of people 60,000 50,000 40,000 30,000 20,000 10,000 *NB: The Otaki Ward comprises approximately 20% of the Kapiti Coast District figures shown. - Manawatu District Palmerston North City Tararua District Horowhenua District Kapiti Coast District European Ethnic Groups Maori Ethnic Group Pacific Peoples Ethnic Groups Asian Ethnic Groups Source: Sex by Ethnic Group (Grouped Total Responses) for the Census Usually Resident Population Count DEPRIVATION Lower socio-economic status is associated with difficulties in accessing health (and many other services). Overall, MidCentral District presents a slightly more deprived picture when compared to the national average. 16 MidCentral District Health Board (2004) Cancer Service Plan Discussion Document pg 10 13

19 Figure 6 is a breakdown of deprivation by territorial area. Figure 6: MidCentral District deprivation distribution (2001) Raw Number of Persons in Deprivation Decile NB: 1=Low deprivation 10=High deprivation DEP 1 DEP 2 DEP 3 DEP 4 DEP 5 DEP 6 DEP 7 DEP 8 DEP 9 DEP Horowhenua District Otaki Ward Manawatu District Palmerston North City Tararua District TLA Name Maori incomes in MidCentral District are approximately 60% of non-maori incomes, and lower than Maori incomes nationally. The Maori unemployment rate in MidCentral District is two or three times higher than the non-maori rate. This paints a picture of marked socio-economic disadvantage for Maori in MidCentral District 18. As figure 7 illustrates, a greater proportion of Maori and Pacific peoples in MidCentral District live in areas of higher deprivation than other ethnicities. Figure 7: MidCentral District by deprivation (NZDEP01) census Volume Maori Other Pacific Peoples Deprivation Score 1=Low Deprivation 10= High Deprivation 17 Technical Advisory Service (TAS) District Health Board, Territorial Authority & Ward Deprivation Profiles (2001) 18 MidCentral District Health Board (2001) An Assessment of Health Needs in the MidCentral District Health Board Region pg Census Population Data by DHB 14

20 4. MAORI, PACIFIC AND ASIAN PEOPLES The proportion of Maori living in MidCentral District is 15%, which is slightly higher than the total New Zealand population (14%). MidCentral District has a small, relatively stable population of Pacific peoples (1.9% of MidCentral District s 2001 population). Although they are a relatively small portion of the population, their morbidity and mortality rates are over represented. At 3.4%, MidCentral District s Asian population is significant. There is currently no data available on Asian health in MidCentral District. However anecdotal evidence suggests they have significant health issues. 5. SMOKING PREVALENCE People with existing chronic diseases such as diabetes are at relatively higher risk of smoking-related hospitalisations and premature death. As table 2 shows, MidCentral District s smoking prevalence is slightly above the national average for both females and males. Table 2: Smoking prevalence (indirectly standardised) for selected regions Selected DHB Region % Male % Female Waitemata Auckland Waikato Bay of Plenty Tairawhiti Taranaki Whanganui MidCentral Hawkes Bay Wairarapa Hutt Capital and Coast National Average Prevalence was calculated by multiplying crude NZ gender specific rates (male 26% and female 25%) by the indirectly age standardised DHB region rate ratio. The matching of TLAs to DHB regions is approximate only. 20 Ministry of Health (2003) Tobacco Toolkit pg 7 15

21 DIABETES BURDEN PROFILE There are estimated to be people in MidCentral District with diagnosed diabetes. Poorly controlled diabetes, whether Type 1 or Type 2, can result in debilitating complications including blindness, kidney failure, heart disease, neuropathy, lower limb amputations and male impotence. While diabetes takes a number of forms, Type 1 and Type 2 diabetes predominate. Type 1 Diabetes Type 1 is an absolute deficiency in insulin secretion and has the greatest impact on an individual and their family/whanau 21. It is not preventable % of all people with diabetes have this type of diabetes. Approximately 450 people in MidCentral District have Type 1 diabetes 22. Type 2 Diabetes 85-90% of all people with diabetes have Type 2 diabetes. Type 2 diabetes generally remains asymptomatic for several years. For this reason it is estimated that half the people with diabetes in New Zealand have not been diagnosed and therefore remain untreated. Type 2 diabetes results from insulin resistance, usually accompanied by a deficiency in insulin secretion 23. In MidCentral District, people have been diagnosed with Type 2 diabetes. However it is estimated that approximately have Type 2 diabetes. Figure 8 shows the prevalence of diabetes in MidCentral District by ethnicity. Type 2 diabetes typically develops in middle or older ages but it is increasingly seen in overweight children 24. Type 2 diabetes is strongly correlated with obesity, physical inactivity and a family history of the disease; it also has a strong genetic association. Although there are many different risk factors associated with this form of diabetes, obesity seems to be the most prominent 25. The chances of getting Type 2 diabetes can be reduced by up to 50% by making simple lifestyle changes, for example staying physically active and maintaining a healthy body weight and up to 75% by controlling obesity. Ninety percent of people diagnosed with Type 2 diabetes are obese Ministry of Health (2003) Diabetes Toolkit 22 Ministry of Health (2001) Implementing the New Zealand Health Strategy Mag, Nicole (April 2004) Exercise and Type 2 Diabetes Mellitus: Implications for the Young Trinity Student Medical Journal, Volume 5, pg 6 24 Ministry of Health (2003) Diabetes Toolkit pg 3 25 Nicole (April 2004) Exercise and Type 2 Diabetes Mellitus: Implications for the Young Trinity Student Medical Journal, Volume 5, pg 7 26 Ministry of Health (2004) Obesity Toolkit 16

22 Figure 8: MidCentral District type 2 diabetes prevalence by age and ethnicity (2004) Number of people with diabetes in each age group Maori Pacific Other MAORI AND PACIFIC PEOPLES The burden of diabetes in New Zealand is unequally distributed between ethnic groups, with an increased burden in Maori and Pacific peoples. As a population group, Maori have, on average, the poorest health status of any group in New Zealand 27. The incidence rates for Maori and Pacific peoples are more than three times higher than the European rates, with Maori and Pacific peoples more than five times more likely to die from diabetes 28. Table 3 shows the diabetes mortality rates for Maori and non-maori by sex, highlighting the significant burden of diabetes on Maori. Table 3: Diabetes mortality by ethnic group and sex (national population) Sex Ethnicity Deaths (Count) Years of Life lost (count) Deaths (Rate)* Years of Life Lost (rate)* Males Non-Maori 554 6, Maori 238 3, ,324 Females Non-Maori 428 5, Maori 274 4, ,975 Pacific peoples in New Zealand are estimated to have more than a 25% lifetime risk of developing diabetes, and lose on average 12 years of life as a result Ministry of Health Addressing Maori Health 28 MidCentral District Health Board (2001) An Assessment of Health Needs in the MidCentral District Health Board Region Pg Rate per , age standardised to WHO world population 30 Ministry of Health (August 2003) Nutrition and the Burden of Disease: New Zealand pg Ministry of Health (2002) Modelling Diabetes: A Summary 17

23 Maori obesity rates are higher than those for the general population - 27 % of adult Maori men and 28% of Maori women are obese. A further 30% of all Maori adults are overweight. Table 4 shows the risk coefficients for diabetes for a 1kg/m² lower body mass index (BMI). A 1kg/m² lower body mass index (BMI) is associated with a risk reduction for Type 2 diabetes of 32% in younger adults, dropping to a 17% lower risk in adults aged 75 years and over. These risk coefficients are much higher than those for any other BMI-disease association, highlighting the importance weight reduction has on reducing the burden of diabetes. Table 4: Risk coefficients for diabetes for a 1kg/m² lower body mass index (BMI) 32 Males Females Age group (years) Risk coefficient Risk reduction (%) Risk coefficient Risk reduction (%) Figure 9 illustrates the relationship between socio-economic deprivation and disease. Figure 9: Relationships among socio-economic deprivation, obesity and noncommunicable disease 33 Cardiovascular diseases Some cancers Low socioeconomic / deprivation status Diabetes Obesity Poor nutrition Physical inactivity In 20 years the number of Maori and Pacific peoples with diabetes will nearly double, even if lifestyle risk factors do not deteriorate Ministry of Health (August 2003) Nutrition and the Burden of Disease: New Zealand pg Ministry of Health (2004) Obesity Toolkit 34 Health Funding Authority (2000) Diabetes 2000 pg 3 18

24 2. ASIAN PEOPLES Although there is very little data concerning Asian peoples and diabetes in New Zealand, studies from overseas have outlined a significant burden of disease in Asian peoples living outside of Asia. Most Asian peoples have traditionally been fairly small and slender, but changes in diet and less physical activity may be contributing to increased numbers of overweight and obese people in these populations. A Ministry of Health Report on Asian health needs in the Auckland region (February 2003) identified that language and cultural barriers are the biggest obstacles to better utilisation of health services. Asian people, particularly new migrants, face language and economic barriers to improved health status. Miscommunication can impact on the quality of health care services in terms of costs, incorrect assessments or interventions, and inefficiencies. 3. THE IMPACT OF DIABETES ON FEET Foot complications for people with diabetes impact upon quality of life by causing pain and reduced mobility. About 15% of people with diabetes will have foot ulcers at some time in their life - 40% will be a result of neuropathy, 24% peripheral blood vessel disease, and 36% of mixed causes. Ulcers and infection can potentially lead to lower limb (LL) amputation 35. In 2002/03 there were 23 LL amputations (one in Maori) in MidCentral District. As table 5 shows, MidCentral is slightly above the national average for LL amputations. Table 5: Standardised discharge ratios by DHB region for lower limb amputation in people with diabetes in 2002/ Standardised Discharge Ratio DHB Region Total DHB Region Total Northland 1.39 MidCentral 1.08 Waitemata 0.80 Whanganui 1.15 Auckland 0.72 Capital and Coast 0.81 Counties Manakau 1.04 Hutt 0.82 Waikato 1.76 Wairarapa 1.71 Lakes 0.43 Nelson Marlborough 1.27 Bay of Plenty 0.54 West Coast - Tairawhiti 0.97 Canterbury 1.00 Taranaki 0.96 South Canterbury 1.49 Hawkes Bay 0.71 Otago 1.15 New Zealand 1.00 Southland 0.83 Notes: 1 Data source: NMDS public hospital data, maintained by the NZ Health Information Service (NZHIS). 2 Time period covered - 12 months to 30 June 2003 (Provisional data). 3 Discharges are for people from each DHB region of domicile. 4 Standardised discharge ratio is the ratio of observed to expected discharge rates. Expected rates are calculated on the age structure of the population with diabetes in each DHB region. 5 All diabetic populations are based on medium series population projections for 2002/03 (assuming medium levels of mortality, fertility and migration), and are based on the 2001 census, and projected 2003 type I and type II prevalence rates for diabetes by age and ethnicity. 6 "_" implies that the number of discharges are less than five. Using survival information for the three-year period only 51% of people would be expected to survive three years after a lower limb amputation. 35 Ministry of Health (2003) Diabetes Toolkit 36 Ibid pg 29 19

25 4. THE IMPACT OF DIABETES ON EYES Diabetes is the most common cause of avoidable loss of vision in people of working age in developed countries. International studies suggest that about 70 people in New Zealand become legally blind every year as a result of diabetes 37. The most significant effects of diabetes on vision are its effects on the retina and the retinal blood vessels, causing a condition known as diabetic retinopathy. Diabetic retinopathy is present at diagnosis for a significant proportion of people with Type 2 diabetes. In people with Type 1 diabetes, diabetic retinopathy generally develops some years after diagnosis of diabetes 38. After 10 years with diabetes all people will have some degree of retinopathy and about 40% - 50% will develop complications which can affect on vision 39. The impact of diabetes on the eyes is much more widespread in Maori and Pacific peoples as is shown in table 6. Table 6: Prevalence rates of complications in people with known diabetes by ethnicity (national statistics) 40 MAORI PACIFIC PEOPLES EUROPEAN (%) (%) (%) Smoking rates (pop n) Blindness Heart attack Renal failure 4-8 x increased risk for Maori and PI with type 2 Diabetic foot disease Diabetic retinopathy can be detected reliably by screening programmes. New Zealand best practice guidelines for diabetes management recommend retinal screening every two years. 5. IMPACT OF DIABETES ON THE KIDNEYS AND HEART Diabetes is now the most common cause of kidney failure in New Zealand 41. Approximately 40% of people with Type 1 and 5-10% of people with Type 2 diabetes will eventually develop progressive kidney failure 42. The prevalence of microalbuminuria, overt diabetic nephropathy and end-stage renal failure is higher among Maori and Pacific peoples compared with New Zealand Europeans. 37 Ministry of Health (2003) Diabetes Toolkit pg Ibid New Zealand Health Information 40 Statistics were obtained from Simmons, D, The Epidemiology of Diabetes and its Complications in New Zealand 1996, Diabetic Medicine, 3, (with the exception of smoking rates which were obtained from The 1996/97 New Zealand Health Survey Taking the Pulse 1999, Ministry of Health) New Zealand Health information 42 Kidney Disease and Diabetes 20

26 Controlling high blood pressure is very important for people with diabetes, to reduce the risk of developing both cardiovascular (CVD) and renal complications. Even if nephropathy has started to develop, controlling blood pressure can substantially slow its progression 43. Cardiovascular disease is the leading cause of death in people with diabetes. The presence of diabetes increases the risks of coronary artery disease two to threefold in men, and four to fivefold in women when compared to people without diabetes 44. Several possible interventions may contribute to better management of risk factors and consequently reduce the actual number of CVD events among people with diabetes over the next five years. ACE inhibitors are an important tool for reducing the incidence of cardiovascular disease and renal failure. Table 7 highlights the reduction of the risk of diabetic heart and kidney complications possible through improved blood glucose and blood pressure control. Table 7: Percentage reduction of the risk of diabetic heart and kidney complications shown in recent studies (2001) 45 Strategy Type 1 diabetes Type 2 diabetes Improved blood glucose control (HBA1c) - nephropathy 34%-57% reduction 70% reduction - cardiovascular & peripheral vascular disease 54% reduction - myocardial infarction 16% reduction - all diabetes related complications 12% reduction Improved blood pressure control Microvascular disease 37% reduction Cardiovascular disease 51% reduction Heart failure 56% reduction Stroke 44% reduction All diabetes related complications 24% reduction Diabetes related deaths 32% reduction Each 1% reduction in HbA1c is associated with a 21% (95% CI, 15-27%) reduction in the risk of diabetes related death and a 14% reduction in the risk of myocardial infarction over 10 years DIABETES IN CHILDREN AND YOUNG PEOPLE In 2004 there were 121 children/young people (0-25 years of age) throughout MidCentral District under the care of diabetes services. Of those, 73 were under the age of 18-98% of these had Type 1 diabetes. It is well recognised that Type 1 diabetes is unique in that the services, treatment and needs are vastly different from those required for the management of Type 2 diabetes. Care of this group requires integration of diabetes care and clinical management with the complicated physical 43 PriceWaterhouseCoopers (2001) Diabetes NZ Inc Type 2 Diabetes Managing for Better Health Outcomes pg Ministry Of Health (2003) Diabetes Toolkit 45 PriceWaterHouseCoopers (2001) Diabetes NZ Inc Managing for Better Health Outcomes pg Evidenced Best Practice Guidelines (2004) Management of Type 2 Diabetes pg 39 21

27 and emotional growth needs of children, adolescents and their families. Historically, Type 2 diabetes was uncommon before middle age, but it is now being diagnosed with increasing frequency in young adults and even adolescents, especially among Maori and Pacific ethnic groups 47. In children, as in adults, Type 2 diabetes is more highly associated with obesity than with any other clinical condition. In 2000, the American Diabetes Association (ADA) stated that obesity is a hallmark of Type 2 diabetes with up to 85% of affected children being overweight or obese 48. While 98% of children in MidCentral District currently have Type 1 diabetes, worldwide the overall rate for new Type 2 diabetes cases in children is increasing. Evidence suggests that Type 2 diabetes may account for nearly half of all newly reported diabetes cases in paediatric populations between the ages of 10 and In the management of diabetes, it is important to recognise that there are different needs and various developmental stages associated with young people compared to children. What works for young people aged 12 and 13 years may be inappropriate for those aged 16, let alone those over Until the mid-1980s Type 2 diabetes was considered as a disease of the middle-aged and elderly, developed after years of poor diet and lack of exercise. These same causes have led to a rise in the disease in children and adolescents as young as five. International Diabetes Federation (25 June 2004) Diabetes and Obesity Epidemic in Children: International Call to Action 7. IMPACT OF DIABETES ON WELLBEING Like all chronic and progressive problems, diabetes has social, psychological, emotional, and spiritual aspects which require attention. Psychological support with the aim of facilitating and supporting self-management is extremely important for people with diabetes. Coming to terms with a diagnosis of diabetes and its ongoing requirements can lead to many different feelings, such as grief over the loss of wellness, shame and guilt about causing or deserving diabetes, resentment at dependence on medical assistance and the expense that goes with it, and anger that there is no cure. 51 Psychological support can assist people to come to terms with their diagnosis much more quickly, which in turn will enable them to cope better with their condition. 47 Ministry of Health (Aug 2003) Nutrition and Burden of Disease NZ ISBN: Mag, Nicole (April 2004) Exercise and Type 2 Diabetes Mellitus: Implications for the Young Trinity Student Medical Journal, Volume 5, pg 6 49 Ibid 50 Ministry of Health (Sept 2002) Youth Health - A Guide to Action pg 9 51 Diabetes Spectrum Volume 13 Number 4, 2000, Page 201 Diabetes Through the Life Span: Psychological Ramifications for Patients and Professionals 22

28 OVERVIEW OF CURRENT SERVICES AND ISSUES 1. MIDCENTRAL DISTRICT PROVIDERS In MidCentral District there are a number of providers caring for people with diabetes and their family/whanau: General practice teams Other nursing workforce primary nursing, secondary nursing, district nursing Secondary care Palmerston North Hospital, Horowhenua Hospital, Clevely Health Centre, and Dannevirke Community Hospital Diabetes Lifestyle Centre Health promotion services Maori health providers Diabetes societies Podiatrists Pharmacists Medlab. More detail on providers is set out in Appendix PRIMARY HEALTH ORGANISATIONS Funded by District Health Boards, Primary Health Organisations (PHOs) work with their communities to provide primary health care services at a local level for their enrolled populations. PHOs will improve coordination between primary and secondary care and develop closer links between communities and primary health care providers such as general practitioners (GPs), practice nurses and Maori health providers. GPs have shown a very positive movement towards PHOs. Currently there are four established PHOs in MidCentral District: Tararua PHO - Established 1 July 2003, it has an estimated enrolled population of Otaki PHO - Established on 1 April 2004, it has an estimated enrolled population of Horowhenua PHO - Established on 1 July 2004, it has an estimated enrolled population of

29 Manawatu PHO Established on 1 January 2005, it has an estimated enrolled population of "AOTEAROA GET CHECKED" - THE NATIONAL DIABETES SCREENING PROGRAMME Funded by MidCentral and run by the Manawatu/Horowhenua/Tararua Diabetes Trust, the Get Checked programme gives people with diabetes access to free yearly health checks. This yearly check provides the opportunity to ensure all important checks have been completed for the year and to plan for the year ahead. The check is delivered at primary care level by general practice teams and/or primary care nurses operating in a community setting with access to primary care notes. Data collected from the Get Checked programme are potentially useful in the provision of care and planning of diabetes services. Privacy is vigorously protected but currently the information on the diabetes programme database is not easily accessible to key diabetes workers such as the Diabetes Lifestyle Centre, general practice teams, Independent Practice Associations, Primary Health Organisations, community pharmacies and Maori health providers. Table 8 shows that while 49.7% of people with diabetes had an annual check in 2003 the proportion of Maori checked was substantially lower than other ethnic groups at 30.0%. Table 8: Number of people with diabetes in MidCentral District who had annual check in People % of expected Maori Pacific peoples All others Total FEET Community podiatry services are limited. The majority of people with diabetes have their foot care needs attended to by only one podiatrist based in Palmerston North. This podiatrist is thus responsible for the majority of MidCentral District. Currently people with diabetes and foot problems or wounds are seen in separate clinics in the Palmerston North Hospital with limited communication and 52 Ministry of Health (2004) Diabetes Model 2004 MC 24