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Diabetes Detection and Follow Up

Basic Facts

Stage of development


Potential or current usage

This measure has been part of the PHO Performance Programme's National Indicator Set since 1 July 2008 and is used to determine what proportion of the population expected to have diagnosed diabetes have had a diabetes annual review.

Brief overview of the measure

General description

This measure focuses on what proportion of the population expected to have diagnosed diabetes have had a diabetes annual review.

Rationale for selection

An appropriate Diabetes review (follow up) gives people with Type 1 or Type 2 Diabetes the opportunity for their GP or nurse to review their treatment and lifestyle advice, and update their care plans. The expected service requirements that constitute a diabetes review include, through the year, the measurement of certain blood and urine tests, retinal (eye) screening (every two years), review of cardiovascular risk, examination of the feet and review and updating of the patient’s care plan. The care plan may include patient-specific goals related to diabetes control, exercise, diet etc. In some areas much of this service is provided at an “annual review”. In other areas the service may be provided in parts at each quarterly visit.

Domain(s) of quality

Effectiveness, Efficiency

Application and interpretation of the measure

Stated intent of the measure

Ensuring people diagnosed with diabetes are reviewed amnually.

Caveats - Considerations

Currently there are technical difficulties in collecting this data from PHOs who do not use the Get Checked Programme to provide diabetes reviews; these difficulties are being addressed by the Programme on a case by case basis. The indicator measures the percentage of people estimated to have diabetes who have had a review, rather than the percentage of those identified and recorded in general practices as having diabetes who have had a review. This may result in some regions having higher than expected diabetes review rates. Conversely if a region has not identified and recorded all their people who are estimated to have diabetes, they will not be able to achieve high diabetes review rates. Revised prevalence estimates were introduced in 2010. This makes comparison with previous periods difficult. In future, historic performance will be recalculated to reflect performance against the current prevalence estimates and provide an accurate representation of progress in improving diabetes detection and follow-up.

Links to other measures


Level of health care delivery/setting

This measure is currently reported by the PHO Performance Programme to PHO level although use of this measure to monitor practice and patient level performance is also possible.

Target population

All people aged 15 to 79 years All people aged 15 to 79 years who are within the high need population (identified as Māori, Pacific Island and/or Decile 9 or 10)

Stratification by vulnerable populations

The PHO Performance Programme currently uses this measure to monitor at both a total PHO enrolled population level (all PHO enrolled eligible patients) and a high need PHO enrolled population level (whereby high need is identified as Māori, Pacific Island and/or Decile 9 or 10)

Associated incentives

This measure is currently funded through the PHO Performance Programme both at a total population level and a high need level.

Calculation of the measure

Output of calculation

Percentage of patients enrolled in a PHO that have diagnosed diabetes that have had an annual review.

Numerator description

Number of enrolled people in the PHO with a record of a diabetes annual review

Denominator description

Number of enrolled people in the PHO who would be expected to have diagnosed diabetes, using the Diabetes Prevalence Estimate Data.

Criteria/standard for optimal performance

Every practice within a PHO should have a process in place for identifying / recalling patients with diagnosed diabetes. The PHO Performance Programme goal is: 80% or more of those estimated to have diabetes have had a diabetes review

Data source

PHO Clinical Performance Indicator Report and Diabetes Prevalence Estimate Data provided by the Ministry of Health.

Method of extraction

The link below will take you to the document that defines how the measure is calculated - see 'Diabetes Detection and Follow Up' section of the Indicator Definitions for PHOs document.

Appraisal of the measure

Development approach

This measure was developed by the PHO Performance Programme (which consists of an Advisory Group and support team).

Other items

Owner details

Reference number


Date of entry to library

2012-05-31 10:14:51

Owner (Organisation name)

PHO Performance Programme

Creator (Organisation name)

PHO Performance Programme

Creator (Email contact)