Targeting Diabetes and Cardiovascular Disease: Better Diabetes and Cardiovascular Services

Objectives

Improve diabetes and cardiovascular disease services through earlier detection, systematic risk assessment, effective management, updated treatment planning, appropriate referral and self-management support.[1][2]The national health target prioritises cardiovascular risk assessments for eligible adults, free annual diabetes checks and satisfactory or better diabetes management.[1]Address inequitable outcomes for Māori, Pacific peoples and people of South Asian origin, who experience a disproportionate burden of diabetes and cardiovascular disease.[1]

• Increase five-year cardiovascular disease risk assessments and use absolute risk to guide lifestyle advice, medication and clinical management.[1][2][3]
• Provide every person with diabetes access to a free annual check through a general practitioner or practice nurse.[2]
• Reduce five-year absolute cardiovascular risk to below 15 per cent where clinically achievable.[2]
• Improve retinal-screening access, with a local aim of 90 per cent coverage among people requiring screening.[4]
• Encourage Māori and Pacific men aged over 35 in high-need regions to obtain heart checks, adopt healthier lifestyles and use long-term heart medication when clinically indicated through the One Heart Many Lives programme.[5]
• Apply a Whānau Ora-based model that involves wider family in lifestyle change and long-term condition management.[6]
• Support evidence-based cardiovascular care while retaining professional clinical judgement.[3]

Implementation

Deliver improvement through coordinated primary care, district health boards, primary health organisations, community providers and locally adapted multidisciplinary initiatives.[7][6][8]Combine population data, proactive outreach, evidence-based guidelines, regular performance feedback and accessible community services to identify people at risk, close service gaps and improve care after risk is identified.[7][6][2]

• Coordinate the Ministry of Health, district health boards, primary health organisations, general practitioners and community health providers to identify people with, or at risk of, diabetes and cardiovascular disease and connect them with appropriate services.[7]
• Deliver the Get Checked programme through general practitioners and practice nurses, including systematic screening, treatment-plan updates, prescribing and referral to specialist or other care where appropriate.[2]
• Strengthen collaboration between Whanganui District Health Board and Whanganui Regional Primary Health Organisation to improve delivery for diabetes and other chronic illnesses.[6]
• Establish shared patient-data repositories and use Ministry of Health criteria, prescription records, laboratory tests, hospital records, medicines and treatment information to estimate the diabetes population and identify previously unrecognised patients.[6]
• Use Dr Info and Dashboard software to give general practices access to individual and enrolled-population results, while enabling primary health organisation monitoring.[6]
• Provide regular electronic practice ratings based on patient numbers and progress to raise awareness and stimulate improvement.[6]
• Maintain a Local Diabetes Team including district health board staff, diabetes nurse specialists, primary health organisation and community representatives, people with diabetes and a local diabetes service coordinator.[4]
• Bring retinal screening closer to communities through a mobile clinic operated by a Nelson optometrist travelling between towns quarterly; approximately 100 people are screened during each visit.[4]
• Provide diabetes checks, medical, eye and foot assessments, dietetic advice, nursing support and subsidised medicines through the Counties Manukau District Health Board diabetes programme.[4]
• Distribute cardiovascular guidelines, a handbook and related resources to general practitioners, practice nurses, pharmacists, Māori and Pacific health providers, and stroke and cardiac care workers.[2][3]
• Provide online resources, video clips, frequently asked questions and practitioner education sessions to support guideline implementation.[3]
• Use the Heart Age Forecast, developed by the National Heart Foundation of New Zealand and the University of Auckland, and a six-week personalised heart-health plan to communicate risk and encourage assessment and healthier choices.[3]
• Enable communities and local leaders to adapt and lead One Heart Many Lives activities, supported by social-marketing guidance, community-development expertise, a website and community events.[5]
• Monitor progress through national indicators for cardiovascular risk assessment coverage, annual diabetes-check attendance and satisfactory or better diabetes management.[1]
• Review regional performance quarterly, use screening coverage and practice feedback to identify gaps, and target high-risk and disadvantaged groups.[7][6]
• Evaluate health-target performance and report progress; the extract does not specify a comprehensive budget, financing mechanism or overall formal evaluation design.[8][1][7]

Monitoring & Evaluation

Monitoring combines national health-target measures, quarterly performance reporting, local service review and population-health data systems to improve diabetes and cardiovascular disease detection, management and equity.[1][7][6][8]

• Track three national indicators: eligible adults receiving a cardiovascular disease risk assessment within the previous five years; people with diabetes attending a free annual check; and people with diabetes achieving satisfactory or better management.[1]
• Monitor cardiovascular risk-assessment coverage, which exceeded 70 per cent of eligible adults and was increasing year on year.[7]
• Review local retinal-screening performance quarterly, including West Coast coverage of 80 per cent against an aim of 90 per cent among people requiring screening.[7][4]
• Record mobile retinal-screening activity, with approximately 100 people screened during each quarterly clinic visit.[4]
• Use Ministry of Health quarterly District Health Board performance reports and national targets to assess comparative service performance. Whanganui District Health Board improved from 21st of 21 boards in November 2009 to fifth nationally in November 2010.[6]
• Strengthen surveillance through data collection, matching and cross-checking of prescriptions, laboratory tests, hospital records, medicines and treatments.[6][2]
• Use a single patient-information repository, Ministry of Health criteria, Dr Info and Dashboard software, and electronic practice ratings to improve regional diabetes-population estimates, give practices patient and population-level results, and provide regular performance feedback.[6]
• Maintain data quality, with participating primary health organisations reporting accuracy above 95 per cent and identifying previously unrecognised patients through data matching.[6][2]
• Apply revised evidence-based criteria for diabetes screening, cardiovascular risk assessment, risk-factor management and reassessment using five-year absolute cardiovascular risk.[2]
• Use performance results to identify gaps, reach high-risk and disadvantaged populations, and improve management after risk identification. The Ministry of Health, District Health Boards and primary health organisations hold these implementation responsibilities.[7]
• Measure dissemination and professional-engagement activity, including 19,500 handbook copies distributed, more than 9,000 website visits and education sessions attended by more than 800 health practitioners.[3]
• Evaluate health-target performance and report progress, although the extract does not specify a full evaluation design, diabetes surveillance framework, reporting timetable or accountability structure beyond health-target reporting.[8]
• Use supporting contextual measures cautiously: One Heart Many Lives followed analysis showing lower statin use among Māori and Pacific men than among other New Zealanders, and cited a 10 to 14-year earlier age at death than Pākehā men.[5]
• Communicate cardiovascular risk through the Northland heart-risk card, using green for up to 10 per cent risk, amber for 10 to 15 per cent, and red for above 20 per cent.[5]

Costing & Financing

No explicit budget, expenditure, unit cost, funding allocation, funding gap, resource-mobilisation target or economic assumption is provided across the supplied extracts.[1][7][4][5][6][2][3]

• Provide free annual diabetes checks as a service entitlement, but no associated funding amount or financing mechanism is specified.[1][2]
• Deliver mobile retinal screening through contracted services and provide subsidised medicines through the Counties Manukau District Health Board diabetes programme, but neither the contract value, subsidy amount nor funding source is specified.[1][7][4]
• Improve quality and efficiency within a tight fiscal environment, without quantified savings, cost-effectiveness estimates or resource assumptions.[3]
• Use existing service and information-system arrangements, including general practice delivery, primary health organisation monitoring and population-health software, but the document does not specify their costs or funding sources.[6][2]