Targeting Diabetes and Cardiovascular Disease

Objectives

The strategic focus is to improve prevention, early detection, management and outcomes for diabetes and cardiovascular disease, using national health targets to improve health, independence and access to care across New Zealand.[1][2]The programme particularly seeks to reduce avoidable disability, premature mortality and inequities affecting Māori, Pacific peoples and people of South Asian origin.[1]

• Increase the proportion of eligible adults receiving a cardiovascular disease risk assessment within the previous five years.[1]
• Increase attendance at free annual diabetes checks and the proportion of people with diabetes achieving satisfactory or better management.[1]
• Prioritise earlier detection, integrated cardiovascular risk assessment, diabetes screening, effective treatment and prevention of complications.[1][3]
• Provide every person with diabetes access to a free annual check-up, including systematic screening, treatment-plan review and referral where needed.[4]
• Apply five-year absolute cardiovascular risk assessment and seek to reduce risk below 15 percent through lifestyle change, medicines and diabetes care.[4]
• Improve access to retinal screening, patient education, clinical advice, regular eye and foot checks, dietary support, lifestyle assistance and subsidised medicines for diabetes management.[5]
• Reduce cardiovascular risk among Māori and Pacific men aged over 35 in high-need regions by promoting heart checks, appropriate medical treatment, healthier lifestyles and sustained use of cholesterol-lowering and other cardiac medicines.[6]
• Address unequal access to cardiovascular medicines and earlier mortality among Māori and Pacific men, who were reported to receive statins less often and to die 10 to 14 years earlier than Pākehā men.[6]

Implementation

Implementation combines national evidence-based guidance and health-target monitoring with integrated, locally adapted primary and community care.[3][7][2]The Ministry of Health supports district health boards, primary health organisations, general practices and clinical teams to identify risk, improve chronic-care management, use data for performance improvement, and reach people least likely to receive routine services.[1][8]

• Link cardiovascular risk assessment with diabetes detection and management through evidence-based guidelines, reflecting the clinical overlap between the conditions.[3]
• Apply national cardiovascular guidance on risk assessment, diabetes screening, treatment targets and regular reassessment, while retaining clinical judgement and experience in individual care.[4][7]
• Use a consistently applied identification tool to find people with, or at risk of, diabetes and support comprehensive free annual diabetes checks.[3]
• Build patient- and family-centred Whānau Ora support, involving families in self-management and helping practices address lifestyle and treatment needs associated with long-term conditions.[8]
• Coordinate Local Diabetes Teams involving district health board representatives, diabetes nurse specialists, primary health organisation staff, private-practice nursing, community representatives, people with diabetes and a local service coordinator.[5]
• Provide diabetes information days, guest speakers, professional advice, preparation for appointments, dietary support, and regular medical, eye and foot checks.[5]
• Extend access through community-based provision, including quarterly mobile retinal screening between West Coast towns by a Nelson optometrist, which screened about 100 people at each visit.[5]
• Reach high-risk and disadvantaged people who have not received cardiovascular risk assessment through innovative programmes and locally tailored delivery.[3][2]
• Use a community-led model for One Heart Many Lives, supplying adaptable resources, social-marketing guidance and community-development expertise while allowing local groups to lead delivery.[6]
• Engage community organisations, local champions, Māori and Pacific communities, whānau and clinical providers through culturally relevant resources, community events, festivals and health checks.[6]
• Distribute cardiovascular resources to general practitioners, practice nurses, pharmacists, Māori and Pacific health providers, and stroke and cardiac-care workers.[4][7]A multifaceted dissemination programme supplied 19,500 handbook copies, online videos and frequently asked questions, and education sessions attended by more than 800 health practitioners.[7]
• Provide public risk-information tools, including the Heart Age Forecast developed by the National Heart Foundation of New Zealand and the University of Auckland, which estimates current and future heart disease or stroke risk and offers a tailored six-week heart-health plan.[7]
• Integrate information systems by storing patient data in a single repository, consistently applying Ministry of Health criteria, and using Dr Info and Dashboard software to give practice-level and population-level performance information.[8]
• Strengthen diabetes data by matching prescriptions, laboratory tests, hospital records, medicines and treatments; participating primary health organisations reported matching rates above 95 percent.[8][4]
• Review performance through quarterly district health board reports and local multidisciplinary review.[3][8]Whanganui District Health Board improved from 21st nationally in November 2009 to fifth in November 2010 for diabetes and cardiovascular services.[8]
• Track cardiovascular-risk-assessment coverage, annual diabetes-check attendance, diabetes-management outcomes and retinal-screening coverage.[1][5]Cardiovascular assessment coverage exceeded 70 percent of eligible adults and was increasing year on year, while the retinal service reported 80 percent coverage against an aim of 90 percent among those requiring screening.[3][5]

The excerpts do not specify a consolidated governance structure, dedicated budget, funding source, total programme cost or resource-mobilisation plan.[1][3][5][6][8][4][7][2]They also do not set out a single formal evaluation framework beyond health-target reporting, performance data and local review mechanisms.[3][6][7][2]

Monitoring & Evaluation

Monitoring centres on national health-target performance for cardiovascular disease and diabetes, supported by district health board reporting, practice-level data, service-coverage measures and locally coordinated review. The available material describes several operational indicators and data sources, but not a single comprehensive evaluation or surveillance framework.[1][8][2]

• Measure the proportion of eligible adults who have received a cardiovascular disease risk assessment within the preceding five years, the proportion of people with diabetes attending free annual checks, and the proportion achieving satisfactory or better diabetes management.[1]
• Monitor cardiovascular risk-assessment coverage, reported as exceeding 70 percent of eligible adults and increasing favourably year on year.[3]
• Track retinal-screening access for people with diabetes, with West Coast coverage reported at 80 percent and a target of 90 percent for people requiring screening.[3][5]
• Record mobile screening activity, with approximately 100 people screened during each quarterly retinal-screening clinic visit.[5]
• Use quarterly district health board performance reports and electronic practice ratings to monitor national-target progress and identify opportunities for service improvement.[8]
• Review performance locally through multidisciplinary clinical meetings, illustrated by quarterly West Coast reviews of service performance and potential improvements.[3]
• Use integrated patient and service data, including prescriptions, laboratory tests, hospital records, medicines and treatments, to improve diabetes-data accuracy; participating primary health organisations reported matching rates above 95 percent.[8][4]
• Use data from the Get Checked programme to improve diabetes services and help primary health organisations identify people with previously unrecognised diabetes.[4]
• Assess service performance comparatively across district health boards: Whanganui District Health Board was reported as lowest of 21 boards for diabetes and cardiovascular services in November 2009, and subsequently improved to fifth nationally in November 2010.[6][8]
• Monitor implementation reach for cardiovascular guidance through resource distribution, online engagement and practitioner education: 19,500 handbook copies were distributed, the online resource received more than 9,000 hits, and education sessions reached more than 800 health practitioners.[7]
• Use heart-risk categories in community-facing tools, including categories of up to 10 percent, 10 to 15 percent, and above 20 percent in Northland’s traffic-light card.[6]
• Continue to evaluate health-target performance and report progress, while using targets to focus action within broader aims of improving health, independence and access to care.[2]

The material does not specify a unified evaluation methodology, indicator definitions or denominators, a national surveillance architecture, independent evaluation arrangements, or formal sanctions and accountability mechanisms. It identifies quarterly Ministry of Health reporting and local performance review, but does not provide a complete reporting timetable or governance structure for all programmes.[1][3][5][6][7][2]

Costing & Financing

No explicit budgets, expenditure totals, funding allocations, funding gaps, financing sources, resource-mobilisation targets or economic assumptions are provided. The material identifies care inputs and delivery mechanisms that may require resources, but does not quantify their cost or state how they are financed.[1][3][8][4][7][2]

• Provide free annual diabetes checks, systematic screening, treatment-plan updates and referrals where appropriate, without specifying the budget or funding source for these services.[4]
• Include subsidised medicines as part of diabetes care and long-term cholesterol-lowering and other heart medicines within cardiovascular risk management, without specifying medicine prices, subsidy levels or allocations.[5][6]
• Resource mobile retinal screening, quarterly service visits, Local Diabetes Teams, patient-information activities, clinical advice and regular medical, eye and foot checks, but provide no associated staffing, capital, operating or programme costs.[5]
• Support information infrastructure and performance management through a single patient-information repository and the Dr Info and Dashboard software, without identifying procurement, maintenance, data-management or training expenditure.[8]
• Distribute cardiovascular guidelines and resources, maintain an online handbook and deliver practitioner education sessions, but provide no costs for printing, digital delivery, workforce education or public communication.[7]
• Use community-led engagement, adaptable resources, social marketing guidance and community-development expertise for the One Heart Many Lives programme, without specifying grants, commissioning arrangements, partner contributions or total programme funding.[6]

Although the initiatives involve district health boards, primary health organisations, general practices, community organisations, health professionals, Māori and Pacific providers, and national agencies, the material does not distinguish central-government, local-provider, pharmaceutical, charitable or community funding responsibilities. It also does not state whether available resources were sufficient, identify any affordability constraints, or provide cost-effectiveness, return-on-investment, demand, inflation or other economic assumptions.[5][6][8][7]