|Diabetes single map||PHO analysis||Consumer summary (164KB, pdf)|
The goal of this Atlas of Healthcare Variation domain is to investigate the quality of care given to people with diabetes. The data is not intended to form a basis for judgement or definitive statements of quality, rather to raise questions about potential areas for quality improvement.
The indicators were developed with the help of an expert advisory group.
Update to include 2019 data
(Data updated December 2020)
This Atlas domain has been updated using data from the updated Virtual Diabetes Register (VDR) for 2019.
Diabetes prevalence is markedly higher in some population subgroups than in others
The prevalence of diabetes increased significantly with age, from a mean of 0.3 percent in those aged 0–24 years to 17 percent in those aged 75 years and older. In 2019, diabetes prevalence varied three fold by DHB, from 9 percent to 27 percent of a DHB population aged 65–74 years, and more than three-fold in those aged 45–64 years (5–16 percent).
Pacific peoples had a significantly higher prevalence of diabetes than all other ethnic groups, while those identifying as European/other had a significantly lower rate. On average, 53 percent of Pacific peoples aged 65–74 years were estimated to have diabetes compared with 10.9 percent of people of European/other ethnicity aged 65–74 years.
People of Indo-Asian ethnicity are not presented separately in the data; however, rates of diabetes in this population group are close to those observed in Pacific peoples.
Good glycaemic control and cardiovascular risk factor management are important for positive outcomes
If haemoglobin A1c (HbA1c) in a person with diabetes does not meet an agreed target with dietary and lifestyle changes, drug therapy is recommended. Insulin and metformin are well proven. Evidence suggests good glycaemic control benefits microvascular outcomes.
The provision of comprehensive cardiovascular risk management for people with diabetes (such as blood pressure and lipid management) has been shown to improve macrovascular outcomes substantially while good glycaemic control has a smaller and very delayed effect.
Insulin and metformin use varied
Given both the lack of available data on clinical parameters and the inability to split data by diabetes type, the indicators of medication use are not intended to suggest an ‘ideal’ rate of use, rather they provide a high-level view. Wide variation may raise questions such as, do DHBs with lower-than-average rates of medication use have lower or higher rates of diabetes complications?
Without HbA1c results available, nationally, 59 percent of people with diabetes aged 25 years and over regularly received insulin and/or metformin. Use was highest in those aged 65–74 years. This varied 1.4-fold by DHB for all ages (46–69 percent).
People with either type 1 or 2 diabetes require insulin therapy. Overall, 23 percent of people with diabetes regularly received insulin in 2019. Across all ages, people of European/other ethnicity had the highest rate of insulin dispensing (26 percent) with people of Asian ethnicity having the lowest rate (13 percent). As might be expected, insulin use was highest in the 0–24-year age group with diabetes, with 61 percent of these regularly dispensed insulin.
Metformin remains the standard initial drug treatment for type 2 diabetes. As expected, use increased with age. On average, 24 percent of people with diabetes aged 25–44 years regularly received metformin compared with 56 percent of those aged 65–74 years in 2019. Males aged 25 and over (49 percent) were more likely to regularly receive metformin than females (44 percent).
Intensive management of high blood pressure and microalbuminuria
On average, 53 percent of people with diabetes received angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARB) medicines in 2019. This is a reduction from 55 percent in 2014. The 2019 rate varied 1.2-fold by DHB (49–58 percent). People of Asian ethnicity received the fewest ACEI or ARB medicines compared with all other ethnic groups.
Intensive management of blood pressure and microalbuminuria is recommended to prevent progression of renal disease in diabetes. ACEI and ARB medicines are first-line treatments.
The younger the age at diagnosis, the greater the impact of diabetes on life expectancy; this highlights the importance of glycaemic control, blood pressure management and prevention of kidney disease in younger people with diabetes.
Māori and Pacific peoples have higher rates of ACEI or ARB medicine use at a younger age, however some data also shows these populations have significantly higher rates of end-stage renal disease. A recent publication found Māori and Pacific peoples have a relative risk of 6.48 for developing end-stage renal disease due to type 2 diabetes compared with other New Zealanders.
Complications – hospital admissions for diabetic ketoacidosis and hypoglycaemia varied by age
Nationally, the rates for admission to hospital for diabetic ketoacidosis were eight times higher in those aged 0–24 years than in all other age groups. Māori experienced significantly higher admission rates at all ages.
The rates for admission to hospital as a result of hypoglycaemia was also highest in the youngest age group although the count of people was highest in those aged 65 years and over. It is pleasing to note there has been a consistent reduction in admissions to hospital for hypoglycaemia in those aged 0–24 years since 2014.
Complications – lower-limb amputations increased with age
Lower-limb amputation rates increased significantly with age, with 95 percent occurring in those aged 45 years and over. While this rare complication affected only 0.23 percent of the diabetes population in a year, in 2019 this meant 595 people lost part of a lower limb as a result of their diabetes. In 2019, males (0.3 percent) had statistically significantly more lower-limb amputations than females (0.1 percent).
Note this indicator counts people with diabetes who had one or more amputations in a year. The VDR is a register so people who died during the year are excluded. This means that people who had an amputation during the year and died are not included. The data is available on request: email@example.com.
People with diabetes occupied more bed-days for any reason
The number of medical and surgical bed-days occupied by people with diabetes was compared with the total occupied medical and surgical bed-days. Age had a significant effect on occupied bed-days. In 2019, age-specific rates varied over two-fold. For example, people with diabetes aged 45–64 years occupied 24 percent of total bed-days, compared with a population prevalence of 8.5 percent of people with diabetes in this age group.
On an unadjusted basis, people with diabetes occupied 18.9 percent of total bed-days, despite a population prevalence of diabetes of 5.4 percent. However, some of the differences here are partially explained by the fact that increasing age is strongly associated with bed-day use and the age structure of people with diabetes is older than the general population. However, the extent of the bed occupancy remains large.
In 2019, people of Māori, Pacific and Asian ethnicities aged 25 and over with diabetes occupied significantly more bed-days than those of European/other ethnicity – 26 percent on average compared with 16 percent. Males aged 45–74 years who identified as Māori or Pacific occupied statistically significantly more bed-days than Māori or Pacific females.
Regular laboratory testing was lowest for screening renal disease (ACR)
We analysed rates for people with diabetes who received one or more laboratory tests in a year for HbA1c, albumin:creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR). On average in 2019, 87 percent received an HbA1c test, 65 percent an ACR test and 85 percent an eGFR test.
Rates differed by ethnicity for certain tests. In ACR testing, people of European/other and Māori ethnicity received 62 percent on average compared with those of Asian and Pacific ethnicity, who received 74 percent on average. From 2014 through to 2019 for all age groups, men were more likely to have regular ACR testing compared with women.
Table 1 shows the percentage of people with diabetes receiving all three tests by age and ethnic group (2019).
Table 1: Percentage of people with diabetes receiving all three tests for HbA1c, ACR and eGFR, by age and ethnic group, New Zealand, 2019
|Age group (years) (%)|
- How many of these results can be explained by the predominant type of diabetes?
- Are rates for specific indicators lower or higher than might be expected?
- Is there room for improvement in any of the indicators?
- Do results reflect local differences in care?
Method and data source
This Atlas domain draws on data contained in the VDR, which was developed by the Ministry of Health to estimate and track the number of people diagnosed with diabetes.
The VDR combines and filters various sources of health information, including the National Minimum Dataset, the National Non-admitted Patients Collection (outpatients), the Pharmaceutical Collection, the Laboratory Claims Collection and the Primary Health Organisation Enrolment Collection.
The VDR was used to estimate the prevalence of diabetes. The data is based on health service utilisation data that is consistent with diabetes care rather than formal clinical diagnosis or laboratory results, so should be interpreted with some caution. The Atlas does not use any patient-identifiable data.
The Pharmaceutical Collection contains claim and payment information from community pharmacists for subsidised dispensing. This collection does not indicate whether a medicine was taken or whether the dose was effective. Over-the-counter medicines are not included.
In selecting indicators for oral hypoglycaemic medication use, the expert advisory group for this Atlas domain decided to focus only on metformin, as the first-line agent for people with type 2 diabetes and insulin as the key medication for people with type 1 diabetes.
There is no ideal rate of medicine use in people with diabetes because it depends on clinical need. However, wide variation between DHBs or ethnic groups raises questions as to why the rate of medicine use varies.
The Laboratory Claims Collection includes tests performed in the community. The exclusion of hospital and point-of-care tests will under-count testing and may affect results more in some DHBs than in others.
Analysis does not split by type of diabetes
There were some limitations as to what measures could be presented. It was not possible to reliably split people by type of diabetes; hence the indicators represent a combination of those with type 1 and type 2 diabetes. Generally, most people with diabetes aged 0–24 years will have type 1 diabetes, while around 90 percent and over of those aged 25 years and above are expected to have type 2 diabetes.
The method used in the VDR to identify people with diabetes is less accurate at identifying children than adults with diabetes. A recently published survey highlights that local DHB data may be a better source for identifying prevalence in children. More work is being done in this area.
Some important outcome indicators could not be included
Due to limitations in currently available data we could not explore certain outcome indicators, including screening for diabetic retinopathy, retinopathy rates and end-stage renal failure. Outcome indicators, including myocardial infarction rates, stroke and other cardiovascular outcomes, are not included in this version of the diabetes Atlas domain, but are likely to be included in future updates. We encourage users to investigate local data in relation to these outcomes to promote improvement and equity initiatives at primary health organisation and practice level.
Relationship with other Ministry of Health activities
The diabetes Atlas domain links with the current (2015–20) strategy for diabetes, Living Well with Diabetes, which provides an overall package of measures to improve care for people with diabetes in New Zealand. This includes work towards each DHB meeting the 20 quality standards published in 2014 (with an accompanying toolkit). The standards link with many of the measures presented in the diabetes Atlas domain, so the two are complementary.
Recommended reading/suggested links
- Ministry of Health. 2014. Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline. Wellington: Ministry of Health.
- International Diabetes Federation diabetes Atlas (eighth edition)
- Ministry of Health and New Zealand Society for the Study of Diabetes. 2021. Type 2 Diabetes Management Guidance. Dunedin: New Zealand Society for the Study of Diabetes.
- Ministry of Health. 2020. Diabetes. Wellington: Ministry of Health.
- Hill K, Ward P, Grace BS, et al. 2017. Social disparities in the prevalence of diabetes in Australia and in the development of end stage renal disease due to diabetes for Aboriginal and Torres Strait Islanders in Australia and Maori and Pacific Islanders in New Zealand. BMC Public Health 17(1): 802.
- Jefferies C, Owens N, Wiltshire E for the Clinical Network for Children with Diabetes in New Zealand, on behalf of the Paediatric Society of New Zealand diabetes clinical network. 2015. Care for children and adolescents with diabetes in New Zealand District Health Boards: Is the clinical resourcing ready for the challenge? NZMJ 128 (1424): 20–7.
- Ministry of Health. 2015. Living Well with Diabetes: A plan for people at high risk of or living with diabetes 2015–2020. Wellington: Ministry of Health.
- Ministry of Health. 2014. Quality Standards for Diabetes Care Toolkit. Wellington: Ministry of Health.