All together now: The transformation of primary care diabetes treatment and management

08 September 2022

Cathy Fraser, diabetes nurse Te Awamutu Medical Centre, accessing the diabetes dashboard.

A trifecta of newly funded medications, targeted dashboard technology and innovative training for primary care diabetes management is behind significant improvements for diabetes patients in Te Manawa Taki (Midland region). 
Pinnacle Midlands Health Network (MHN) diabetes clinical specialist, Kathy Knight, says this year is “the year of diabetes” in primary care. 
“Everything has come together all at once, which is amazing,” says Kathy. “The combination of all three – new medications, the dashboard and primary clinician education, means diabetes management is now happening in a cohesive, collective way that hasn’t been possible before.”  

New medications a game-changer

First came the new medication. In 2021, Pharmac began funding Trulicity (Dulaglutide) and Jardiamet/Jardiance (Empagliflozin with and without metformin). Both diabetes medications are used widely overseas with great effectiveness, but were previously unfunded in New Zealand.  
Now available and with equity funding for specific groups, Kathy Knight says the two medications are making a huge difference for eligible patients. She gives an example of improvements experienced by a young patient who really didn’t like taking injections.  
“This patient had high blood glucose levels. They started on Trulicity but were on mealtime insulin as well. Their nurse practitioner advised them to reduce insulin appropriately, and a month later they had beautiful blood glucose levels – at which point they sheepishly admitted they hadn’t taken insulin for the whole month.” 
It’s a story reflected in the number of insulin starts claimed through Primary Options in the Midlands region – essentially a count of how many people are being started on insulin in Pinnacle practices. Kathy says the numbers have dropped dramatically since Trulicity and Jardiance became funded. 
“We’re at 10 per cent of what we were doing 12 months ago – nowhere near the same rate.”  
“These two medications are working so well. They may prevent people from going into renal failure with diabetes and will certainly slow their renal decline. Independent of the diabetes, they both also reduce the risk of cardiovascular disease and death from heart attack and strokes.” 

Diabetes dashboard improves outreach and uptake

A new primary care diabetes dashboard rolled out to Pinnacle practices in December 2021 has increased uptake of Trulicity and Jardiance from 25 per cent of eligible patients, to 50 per cent. 
The dashboard makes proactive outreach easier, with fast, accurate data down to NHI level for patients in a practice. By applying filters, primary care teams can easily identify who is eligible for the new medications, see where there are gaps, and get people in to review their diabetes management and treatment.  
Te Awamutu Medical Centre diabetes nurse specialist, Cathy Fraser-Reading, uses the dashboard with her team and says it is a great clinical tool for outreach and review. 
“The dashboard is very easy and logical to use. We’ve had other systems doing query builds but the lists were so big and time consuming to scroll through people – I’ve done things like printed off 30 pieces of paper and stuck the corresponding HbA1cs against names.  
“Using the new dashboard we can drill down to identify population groups in the practice that are in need and would most benefit from the medication. We can draw out, for example, who in our 700+ diabetes patients have higher HbA1c levels and meet the criteria for the new medications, and put in place initiatives to engage them. Time-management-wise, it is amazing. 
“It also gives us a baseline of where we’re at, to help measure the outcomes and see progress in the future.”

Motivated, informed and having effective conversations

Further support for improved diabetes management comes from the establishment of a new, easily accessible education course run by Dr Ryan Paul, academic endocrinologist at Te Whatu Ora Waikato and the University of Waikato.  
The course is part of Dr Paul’s research project about how to improve diabetes knowledge in primary care while reducing the burden of time that education often requires. Run online, the programme provides short, engaging advice and knowledge backed up with mentoring and peer discussion.  
Around 350 primary care clinicians, allied health and practice nurses from across the Midlands region are currently enrolled in the first intake of the course, and webinars and mentoring sessions are still available for those who were unable to initially join the programme.   
At Te Awamutu Medical Centre, Cathy Fraser-Reading is enrolled along with several other clinicians in her team, and says the course has raised awareness of diabetes in the practice overall. 
“It’s sparking lots of good conversations between health professionals about diabetes care.  
“Case studies are presented back to the group for discussion and advice on different aspects of diabetes management. In our practice we also have a regular teaching session on a Friday lunch time and the dashboard is part of that. Patients are on the receiving end of that increased knowledge.” 
Kathy Knight says those who have engaged with the course are feeling motivated and more confident in their diabetes mahi and practice.  
"The primary care teams deserve so much praise. They are really on board with everything, have embraced the medications, using the dashboard technology, and are upskilling to have the most up-to-date knowledge.  
“By working cohesively as a team, diabetes management is happening in a way that means we are seeing benefits now, and we’ll see more further down the track.  

Looking to the long-term benefits

The significant positive outcomes already being seen channel hope for longer-term improvements in the future.  
“Individually these things have all been in the pipeline for a while. Seeing them all come together is fantastic,” says Kathy Knight. 
“While we are already seeing an overall improvement in things like glycaemic control and dropping blood glucose levels, the real long-term impacts and reductions in diabetes complications will be seen 5-10 years from now.” 
“We estimate that one third of the people with Type 2 diabetes in New Zealand are eligible for funding for one of the new medications. The more eligible people who get these drugs prescribed, the more benefits we will see further down the track.”