Key findings: Diabetes Equity Explorer indicators

What was already known from the diabetes Atlas domain

• Diabetes Atlas domain

The proportion of regular HbA1c testing[1] was similar across ethnic groups. Variation between district health boards (DHBs) was not significant.

Overall, 53 percent of the diabetic population received angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARB) medicines[2]. The proportion was similar for different ethnic groups. Variation between DHBs was not significant.

People with diabetes occupied a high proportion of medical–surgical bed-days in hospital:[3] 17.4 percent of bed-days (range 7–28 percent). The national population prevalence of diabetes is around 5 percent, although it would be expected that diabetic bed-days would be higher than 5 percent due to diabetes leading to ill-health directly and indirectly through other conditions. Age was a significant factor, with older diabetics occupying more bed-days than younger diabetics. Asian, Māori and Pacific peoples with diabetes also occupied more bed-days than their non-diabetic counterparts.

No information on deprivation was available in the diabetes Atlas domain.

What the equity indicators for diabetes add

• HbA1c testing showed little inequity between ethnic or socioeconomic groups
• Some DHBs have inequity in angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) medicine dispensing between ethnic and deprivation groups
• Asian, Māori and Pacific peoples with diabetes occupied comparatively more days in hospital compared with European people with diabetes. Likewise, socioeconomically deprived diabetics occupied comparatively more days in hospital than socioeconomically advantaged diabetics

HbA1c testing showed little inequity between ethnic or socioeconomic groups

HbA1c testing showed little variation in regular testing between the major ethnic groups, compared with the European/Other ethnic group. This means that, for most DHBs, there is little or no equity gap – even with our more sophisticated analyses. The standardised rate ratio compared with NZ European varied from 0.96–1.32 for Māori, 0.95–1.43 for Pacific peoples and 0.92–1.46 for Asian populations (2014 data). In most cases this ratio was not statistically significant from 1.0, and showed little change over five years of measurement.

Most DHBs also showed little variation in HbA1c testing between socioeconomic groups (NZDep2013 quintiles). The ratio for quintile 5/quintile 1 was between 0.97 and 1.1 for most DHBs. We did not find a strong relationship between increasing levels of deprivation and HbA1c testing.

Some DHBs have inequity in angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) medicine dispensing between ethnic and deprivation groups

The number of diabetics dispensed ACEI or ARB medicines in 2014 varied between 35 percent and 57 percent depending on the population group.

Asian, Māori and Pacific diabetic populations received fewer ACEI or ARB medicines than European/Other ethnicities in some DHBs (ratio less than 1.0), but more medicines in other DHBs (ratio more than 1.0). The DHB dispensing ratios compared with the European/Other ethnic group varied: 0.81–1.52 for Asian populations, 0.94–1.45 for Māori and 0.89–1.57 for Pacific peoples (2014 data). Māori and Pacific peoples were dispensed significantly more ACEI and ARB medicines in many DHBs. There was minor fluctuation in the numbers over the five years of data. Few ethnic groups changed ‘position’ within their DHB over this time. This indicates that in those DHBs where ethnic inequities existed, they were generally persistent over time.

For socioeconomic groupings, the ratio of dispensing in the most deprived quintile compared with the least deprived quintile varied between 0.82 and 1.84.

For most DHBs, ACEI or ARB medicine dispensing did not show a strong relationship to deprivation. Looking at the national data, ACEI and ARB medicines were more likely to be dispensed to those diabetics in more deprived socioeconomic groups. This relationship is affected by ethnic group, and ethnicity-specific deprivation data is shown for each DHB.

Asian, Māori and Pacific peoples with diabetes occupied comparatively more days in hospital compared with European people with diabetes. Likewise, socioeconomically deprived diabetics occupied comparatively more days in hospital than socioeconomically advantaged diabetics

The Equity Explorer found diabetic bed-days varied from 2.4–66 percent of the total number of bed-days for the same population (for example, (Māori diabetic bed-days)/(all Māori bed-days)). The difference compared with the 7–28 percent range for the diabetes Atlas domain is largely due to age-standardisation of the 40 years and over population only, and total response ethnicity which corrects Pacific peoples and Asian undercounting.

Almost all Asian, Māori and Pacific populations showed higher diabetic bed-day occupancy proportions than the European/Other ethnic group, which is consistent with the higher diabetes prevalence for these ethnicities. DHB ratios compared with European/Other ranged from 0.32–2.69 for Asian populations, 1.38–2.75 for Māori and 2.35–4.30 for Pacific peoples (2014 data). In many DHBs, there was an observable increase over five years of data, which reflects the rapidly increasing number of people with diabetes.

Deprivation analyses showed a trend in nearly all DHBs, with diabetics from increasingly deprived populations occupying proportionately more hospital bed days than diabetics from less deprived populations. This is consistent with diabetes prevalence, which is higher for more-deprived populations.[4] 

Limitations

The HbA1c indicator does not show whether diabetes was well controlled or not. We do not know whether the testing is showing poorer diabetes control for some populations.

Note that the deprivation analyses do not control for confounding by ethnicity, due to insufficient power to present analyses differently. Instead, ethnic-specific deprivation quintile data is shown.

How to use the Equity Explorer

Download the Equity Explorer

Below is a video about how to use the Equity Explorer, including a case study example from Northland DHB.

Notes

1. Haemoglobin A1c (HbA1c) is a blood test that measures whether blood sugars are under control over the medium term. It should be tested at least yearly in diabetic people.
2. Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are two classes of medicine that help prevent long-term complications of diabetes. They are recommended as long-term medicines.
3. Diabetic medical–surgical bed-days are the total number of days in hospital for all diabetic patients, as a proportion of all medical–surgical bed-days. It includes medical and surgical admissions, but not other admission types (for example, maternity or mental health). All admissions are included – including those not related to diabetes. 
4. Ministry of Health. 2015. Annual Update of Key Results 2014/15: New Zealand Health Survey. Wellington: Ministry of Health.