Diabetes Detection and Follow Up
- 1 Basic Facts
- 2 Brief overview of the measure
- 3 Application and interpretation of the measure
- 4 Calculation of the measure
- 5 Appraisal of the measure
- 6 Other items
- 7 Owner details
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
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
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.
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)
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.
Number of enrolled people in the PHO with a record of a diabetes annual review
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
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
This measure was developed by the PHO Performance Programme (which consists of an Advisory Group and support team).
Date of entry to library
Owner (Organisation name)
PHO Performance Programme
Creator (Organisation name)
PHO Performance Programme