Australian National

Diabetes Audit

ANDA-AQSMA 2016

FINAL REPORT

ANDA-AQSMA 2016

Australian National Diabetes Audit - Australian Quality Self-Management Audit

Acknowledgement

ANDA-AQSMA 2016 was funded by the Australian Government Department of Health

Monash Centre for Health Research and Implementation

This activity is coordinated by the Monash Coordinating Centre led by Professor Sophia Zoungas and includes Dr Natalie Nanayakkara -Diabetes Clinical Research Fellow, Sanjeeva Ranasinha - Biostatistician, Trieu-Anh Truong - Data Management Officer, Elspeth Lilburn - ANDA Secretariat and Natalie Wischer - NADC CEO

Table of contents

Foreword ........................................................................................................................................ A

Executive Summary ........................................................................................................................ C

Overview ....................................................................................................................................... C

Methodology ................................................................................................................................D

Main Findings ................................................................................................................................ E

Patient Characteristics, Diabetes Type and Management ........................................................ E

Glycaemic Control ..................................................................................................................... E

Lifestyle Management and Preventive Health Care .................................................................. E

Medication Use and Monitoring ............................................................................................... F

Health Services Utilisation ....................................................................................................... G

Patient Wellbeing and Quality Of Life Assessment .................................................................. G

Summary ........................................................................................................................................ I

Audit: Future Directions ................................................................................................................. J

Clinical Directions ....................................................................................................................... J

Process Directions ...................................................................................................................... J

Background .................................................................................................................................... 3

What is an NADC Member Centre? .......................................................................................... 3

Who will access the various Diabetes Services? ....................................................................... 5

Development of ANDA-AQSMA ................................................................................................ 5

ANDA-AQSMA 2016 ........................................................................................................................ 6

How the project can improve the care of patients with diabetes ............................................. 6

How efficiency of ANDA-AQSMA will be assessed .................................................................... 6

Ethics Approval ......................................................................................................................... 6

Governance ............................................................................................................................... 6

1. Methodology............................................................................................................................. 7

1.1 The Dataset ......................................................................................................................... 8

1.2 The Software ....................................................................................................................... 8

1.3 ANDA-AQSMA Coordination ............................................................................................... 9

1.4 Participants ....................................................................................................................... 10

1.5 Data Verification and Validation ....................................................................................... 11

1.6 Data Assumptions and Decisions ...................................................................................... 11

1.7 Site Data Reports .............................................................................................................. 12

1.8 Pooled Data Report .......................................................................................................... 12

1.9 Questionnaires ................................................................................................................. 13

2. Findings and Results ............................................................................................................... 14

2.1 Introduction ...................................................................................................................... 14

2.2 Patient Characteristics and Management Methods ......................................................... 14

2.3 Lifestyle ............................................................................................................................ 17

2.4 Medication Use ................................................................................................................ 20

2.5 Patient Self Care Practices ................................................................................................ 21

2.6 Health Services Utilisation (in the last 12 months) ........................................................... 22

2.7 Self Rated Wellbeing ........................................................................................................ 24

2.8 Questionnaire Results ...................................................................................................... 31

2.9 Missing Data ..................................................................................................................... 32

3. Discussion ............................................................................................................................... 35

4. Conclusion .............................................................................................................................. 36

5. Acknowledgements ................................................................................................................ 37

References ....................................................................................................................................38

Appendix 1 – ANDA-AQSMA Documents ………… ............................................................................. 41

Appendix 2 – ANDA-AQSMA Questionnaires… ................................................................................ 87

Appendix 3 – Frequency Count Data………… .................................................................................... 93

Appendix 4 – NADC’S Guide to Quality Improvement ................................................................... 107

Appendix 5 – NADC’s Diabetes Publications & Resource List 2016 ............................................... 115

Appendix 6 – Descriptive Report………………………………………………………………………………………………..129

Figures

Figure 1 - Mean HbA1c (% by Diabetes Type) ........................................................................................... E

Figure 2 - Physical Activity ........................................................................................................................ F

Figure 3 - BCD©: Likely Depression by Diabetes Type ............................................................................. H

Figure 4 - Diabetes Type ........................................................................................................................ 15

Figure 5 - Initial Visit by Diabetes Duration ........................................................................................... 16

Figure 6 - Management Methods in patients with Type 2 Diabetes ...................................................... 17

Figure 7 - Physical Activity ..................................................................................................................... 18

Figure 8 - Influenza Vaccination in the Last 12 Months ......................................................................... 18

Figure 9 - Pneumococcal Vaccination in the Last 12 Months by Age Group .......................................... 19

Figure 10 - Vaccination Status in Last 12 months by Diabetes Type ...................................................... 19

Figure 11 - Smoking Status .................................................................................................................... 19

Figure 12 - Methods of Smoking Cessation ........................................................................................... 20

Figure 13 - Health Services Utilisation ................................................................................................... 22

Figure 14 - Number of Health Services Utilised (other than diabetes specialist) ................................... 22

Figure 15 - Percentage Seen by Diabetes Educator by Diabetes Duration & Initial or Follow-up Visit .. 23

Figure 16 - Percentage Seen by Dietitian by Duration of Diabetes & Initial or Follow-up Visit .............. 23

Figure 17 - BCD: ‘Likely Depression’ by Diabetes Type .......................................................................... 25

Figure 18 - Mean Own Health State Rating ........................................................................................... 26

Figure 19 - Mean Own Health State Rating & Management Method in Type 2 Diabetes ..................... 26

Figure 20 - Total DDS 17 Score by Diabetes Type .................................................................................. 30

Figure 21 - Emotional Burden Score by Diabetes Type .......................................................................... 30

Figure 22 - Physician-related Distress by Diabetes Type ....................................................................... 30

Figure 23 - Regimen Related Distress by Diabetes Type ........................................................................ 31

Figure 24 - Interpersonal Distress by Diabetes Type ............................................................................. 31

Abbreviations

ANDA Australian National Diabetes Audit AQCA Australian Quality Clinical Audit AQSMA Australian Quality Self-Management Audit BCD© Brief Case-Find for Depression CVD Cardiovascular Disease DDS Diabetes Distress Scale DM Diabetes Mellitus DVA Department of Veterans Affairs GDM Gestational Diabetes Mellitus HbA1c Glycated Haemoglobin IQR Interquartile Range NADC National Australian Diabetes Centres NDSS National Diabetes Services Scheme OTC Over the Counter QoL Quality of Life SD Standard Deviation T1DM Type 1 Diabetes Mellitus T2DM Type 2 Diabetes Mellitus

A

Foreword

The Australian National Diabetes Audit - Australian Quality Self-Management Audit provides an overview of the clinical status of people with diabetes attending services for diabetes care. Participating diabetes centres, endocrinologists and diabetes health care professionals can evaluate their data against their peers, enabling them to identify and implement mechanisms to improve outcomes for their patients. There has long been a perceived need for a more ‘Education and Patient Self-care’ focused initiative than the more ‘medically’ focused ANDA-AQCA. This was piloted successfully in 2005 as ANDIAB2, and run again in 2010, 2012, 2014 and 2016. It had been seen as an appropriate initiative to run in the alternate years between ANDA-Australian Quality Clinical Audit surveys. This document reports on ANDA-AQSMA 2016, the fifth ‘Education and Patient Self-care' focused diabetes data collection facilitated by the National Association of Diabetes Centres (NADC). This year 50 data collection sites participated, with de-identified clinical process and outcomes data collected on 3930 individuals attending services for diabetes care mainly during the months of May or June 2016. We believe the information contained in this report of pooled data from all sites provides i) a unique snapshot of the current wellbeing, education and health care utilisation of people with diabetes attending services for diabetes care in 2016; and ii) a comparison with past collections. We hope this report will be widely disseminated. The outcome of ANDA-AQSMA has resulted in the collection of substantial data that provides a framework by which strategies to care for people with diabetes could be developed both within our diabetes centres and nationally. Feedback from participating sites indicates that changes and refinements to services have been made in response to this national benchmarking activity. In this undertaking we acknowledge the very generous support of the Australian Government Department of Health, who have provided the funding to undertake ANDA-AQSMA 2016. The NADC is proud of the work ANDA-AQSMA is doing and would like to thank all the dedicated multidisciplinary teams who have participated. Steering Committee National Association of Diabetes Centres December 2016 E-mail: anda@nadc.net.au Website: www.nadc.net.au

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Executive Summary

Overview The Australian National Diabetes Audit - Australian Quality Self-Management Audit (ANDA-AQSMA) is a well-established, important biennial quality activity facilitated by the National Association of Diabetes Centres (NADC) in services providing care for people with diabetes across Australia, in all States and Territories. The 2016 collection is the largest to date, with 3930 patients from 50 diabetes centres audited. The pooled national report is an important source of cross-sectional data on the self- management practices and wellbeing of people attending services in diabetes care across the country. Participating diabetes centres receive an individualised report of their patient data to compare with other diabetes centres.

ANDA-AQSMA

Quality Improvement

Disease Burden

Trends Over Time

Benchmarking

D

Methodology In 2016, 56 diabetes centres (members of the NADC) responded to an expression of interest invitation. Of these:

• 50 provided de-identified data on a total of 3930 individuals all aged over 18 years seen mainly during the one-month survey period of May or June 2016

• 6 sites were unable to participate in the audit due to shortage of staff or not being able to meet the minimum requirement of patients

The ANDA-AQSMA dataset is derived from the ANDIAB2 data set developed for the ANDIAB2 2005 Pilot, and revised for 2010 and the following biennial collections. It contains demographic, clinical, self -management and wellbeing data items that have standardised definitions, and has been promulgated for collection in all clinical practice settings. The participants in the ANDA-AQSMA 2016 survey completed a one page scannable form. Based on feedback from participants from previous collections, several enhancements were made to the process and data fields to be collected for ANDA-AQSMA in 2016. These included:

• Reformatting of the scannable paper form • Reformatting of the past smoker cessation method from single Yes/No to tick all

that applies • A change to the wording ‘Do you have difficulties following your prescribed diet?’

to ‘Do you have difficulties following your recommended diet? NOTE: Analysis of the pooled data from all participating centres forms the basis of this report. Every effort was made to ensure data were complete and correct prior to pooling and analysis. Centres were given an opportunity to supply any missing data and to validate questionable data. Unless otherwise stated, results are reported as the percentage of those who answered the question, not the percentage of the total patient group. This is a change from the previous method of reporting percentages and considered to reflect the most clinically relevant information.

E

Main Findings

Patient Characteristics, Diabetes Type and Management

In ANDA-AQSMA 2016: • Males and females were equally represented • The mean (±SD) age was 55.3 (± 17.4) years • 5% of patients identified as Aboriginal/Torres Strait Islander • 69% of patients reported that they were born in Australia • 4% of patients required an interpreter for completion of the survey • 65% of patients had type 2 diabetes and 28% had type 1 diabetes • The median (±IQR) duration of diabetes was 13 (± 12) years

Glycaemic Control

Improving glycaemic control is known to reduce the risk of complications of diabetes. The Australian Diabetes Society recommends a general target HbA1c of less than or equal to 7.0%, although targets should be individualised.1

• The mean (±SD) HbA1c of all patients was 8.3% (±1.9) and slightly higher in those with type 1 diabetes (mean HbA1c 8.4%±1.7) than those with type 2 diabetes (mean HbA1c 8.3%±1.9) (Figure 1)

• The mean HbA1c over time has varied very little (8.1% in 2010, 8.3% in 2012, 8.2% in 2014)

Figure 1 - Mean HbA1c (% by Diabetes Type)

Lifestyle Management and Preventive Health Care

Physical Activity and Nutrition Lifestyle modification is the foundation for management of diabetes, with physical activity and a healthy diet important for both weight management and glycaemic control. Even where comorbidities such as ischaemic heart disease are present, access to safe and appropriate physical activity advice or programs should be made available to patients2.

02468

1012

Type 1 Type 2Diabetes Type

HbA1c (%)

F

CVD Risk Factors Cardiovascular disease is the primary cause of death and disability for people with diabetes.3 Control of cardiovascular risk factors forms a fundamental part of management of people with diabetes.

• Over half of patients reported that they do not engage in sufficient physical activity (150 total minutes per week) (54%) (Figure 2)

• One third of patients reported they have trouble following their recommended diet. For these patients, barriers to appropriate food choices were: time to prepare meals (33%) cost of food (30%) they did not know what foods are best to eat (28%)

• Only half of all patients had attended a dietitian in the last 12 months • Current smoking was reported by 13% of patients, the same as 2014 (13%) • Of those who were currently smoking, three quarters (78%) reported that they

had tried to stop smoking Figure 2 - Physical Activity

Vaccination Annual influenza vaccination is recommended for people with diabetes.4

• 63% of patients reported that they had been vaccinated against influenza in the

last 12 months • In those aged 60 years and over, 76% reported vaccination against influenza in the

last 12 months

Medication Use and Monitoring

Regular monitoring of blood glucose levels and adherence to prescribed medications are two important aspects in the self-management of diabetes.

• Of those using insulin or other injectable medications (incretin mimetics), the majority (96%) reported that they rotate their injections sites

46%39%

15%

Sufficient Insufficient Sedentary

G

• The majority (92%) of patients reported that they usually take all of their medications and 73% reported that they do not ever forget to take their medications

• 26% of patients reported that they do not test their blood glucose levels as often as recommended. However, only 6% of patients were unsure of how often they should monitor their blood glucose levels

• 28% of patients reported use of complementary therapy or dietary supplements, and most of them (86%) had reported this use to their health care provider

Health Services Utilisation

Comprehensive care of people with diabetes requires a multi-disciplinary approach. This facilitates optimal diabetes control for prevention of complications and early identification and management of complications when present. In the last year:

• 76% had attended a diabetes educator and 71% a diabetes specialist • 65% reported that they had attended an optometrist, 39% an ophthalmologist

and 27% had seen both an optometrist and ophthalmologist • 55% reported that they and attended a podiatrist, 52% a dietitian, 44% a dentist,

14% a psychologist, 8% a social worker and 9% an exercise physiologist • Health service utilisation in 2016 appears similar to previous years (2014, 2012

and 2010)

Patient Wellbeing and Quality Of Life Assessment

Depressive symptoms and diabetes related distress are thought to have an impact on diabetes outcomes and optimal self-management.5

‘Likely Depression’ (Brief Case Find Tool)

• 27% of patients were found to have ‘likely depression’, using the Brief Case Find tool (BCD©i)6

• This proportion was similar in patients with type 1 and type 2 diabetes (Figure 3) and unchanged over the last 4 ANDA-AQSMA surveys

• Of those with ‘likely depression’ on the BCD: • 34% were on antidepressants • 11% were currently seeing a psychologist/psychiatrist • 27% had reported previous psychologist/psychiatrist treatment

i BCD©1993 Monash University Department of Psychological Medicine

H

Figure 3 - BCD©: Likely Depression by Diabetes Type

Diabetes Distress (Diabetes Distress Scale 17)

All patients audited were asked to answer two Diabetes Distress Scale screening questions which identify with high accuracy those at risk of diabetes distress and those who should complete a thorough assessment using the Diabetes Distress Scale 17 (DDS17 Appendix 1).7-9

• 37% of patients were identified as at risk of diabetes distress and completed the full DDS17 questionnaire

• Assessment of diabetes distress using the DDS screening questions and full DDS17 questionnaire showed that: 8% of all patients experience overall high diabetes distress (22% of those who

completed the DDS17) 12% of all patients experience moderate diabetes distress (35% of those who

completed the DDS17) Emotional burden was the DDS 17 sub-scale area in which the greatest

proportion of patients experienced high distress, affecting 14% of all patients (40% of those who completed the DDS17)

Self-Assessed Health Status (Own Health State Rating)

Patient self-assessed health status was measured using the Visual Analogue Scale of the EQ-5D, as in previous collections. Patients indicated their ‘Own Health Status’ rating on the day of completion on a scale of 0 to 100.

• The mean (±SD) ‘Own Health Status’ rating was 66.0 (±20.1) in all patients, similar in patients with type 1 diabetes (68.3±19.5) and type 2 diabetes (64.7±20.1)

0%

10%

20%

30%

40%

50%

Type 1 Type 2Diabetes Type

I

Summary

Australian National Diabetes Audit – Australian Quality Self-Management Audit (ANDA-AQSMA) 2016 has built on the successful, well-established ANDIAB2 initiative, and has provided data on people attending services in diabetes care across Australia. The key findings from ANDA-AQSMA 2016 were:

• The majority of patients reported the correct use of insulin or other injectable medications as well as good adherence to their prescribed medication

• One third of patients do not monitor their blood glucose level as often as is recommended

• 54% of patients with diabetes do not engage in sufficient physical activity • One third of patients have trouble following their recommended diet, but only

half of all patients audited had attended a dietitian in the last 12 months • Of the 13% of patients who are current smokers, three-quarters had tried to quit

smoking • Reduced wellbeing and diabetes distress was identified in a considerable number

of people (37%) • 27% of patients with diabetes were found to have ‘likely depression’ • 45% of patients had not seen a podiatrist in the last year

We believe that this initiative has been successful on several fronts:

• The ANDA-AQSMA 2016 Final Report provides a snapshot of the education, self-care and wellbeing of patients with diabetes being managed in services specialising in diabetes care

• Additionally it provides information for comparison with previous collections • Data quality is significantly improved with very little missing data compared with

previous surveys, a tribute to the diligence of those diabetes centres and patients who participated, and to ANDA-AQSMA follow up processes

• Each centre received an individual report benchmarking their findings against other centres to allow them to identify areas of service or patient self-care that can be improved and for which changes or educational strategies may need to be instituted through quality improvement initiatives

J

Audit: Future Directions Clinical Directions

• Routine access to psychological support may improve wellbeing in those patients attending diabetes centres

• Assessing for diabetes distress using a tool such as the Diabetes Distress Scale is a key part of standard care. We encourage sites that are not routinely assessing for diabetes distress, to incorporate the Diabetes Distress Scale into their practice

• Improved access to appropriate professional advice and education on lifestyle modification may increase engagement with lifestyle measures. This should focus on counselling patients on safe strategies to achieve sufficient physical activity, and on consumption of healthy meals which are affordable and easy to prepare

• Uptake of lifestyle modification may be enhanced by improved routine access to dietitian consultation and exercise programs in diabetes centres

• Ongoing support for smoking cessation remains a priority in the care of patients with diabetes who continue to smoke

• Utilisation of podiatry services, which play an important role in education on foot care, screening for and management of diabetes related foot disease appeared inadequate

• Patients with diabetes should be regularly asked whether medication is being taken, and blood glucose levels measured as often as is recommended. Clinicians should assist patients to identify barriers to meeting recommendations and facilitate improvements in patient self-care practices

• Diligence is recommended in clinical assessment of important aspects of patient self-care such as those highlighted in this report, to identify areas where patients may need to be educated/re-educated and supported

Process Directions

We recommend that:

• ANDA-AQSMA continue as a regular diabetes audit activity in services providing diabetes care, to be run in alternate years to ANDA-AQCA. This will allow centres to measure the impact of health care improvement initiatives

• The information provided in this report and the individual site reports be used to reinforce successful strategies where areas of strength are identified, and to facilitate clinical practice improvements in areas which need improvement

• The NADC facilitates development of useful resources to assist with clinical practice improvements on the NADC website and links to evidenced based quality improvement programs, especially focussing on lifestyle modification, diabetes distress and ‘likely depression’

• ANDA could be extended to include data from other relevant clinical practice settings

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ANDA-AQSMA 2016 Australian National Diabetes

Audit FINAL REPORT

This report details the analysis of self-management practices and wellbeing of people referred to services specialising in diabetes care, collected over a one-month period. The results build on those from the inaugural ANDIAB2 pilot data collection in 2005, ANDIAB2 2010, 2012 and ANDA-AQSMA 2014. This activity was coordinated by the Monash Coordinating Centre led by Professor Sophia Zoungas and included Dr Natalie Nanayakkara - Diabetes Clinical Research Fellow, Sanjeeva Ranasinha - Biostatistician, Trieu-Anh Truong - Data Management Officer, Elspeth Lilburn - ANDA Secretariat and Natalie Wischer - NADC CEO. The following Background and Aims formed the basis of the ANDIAB2 2005 Pilot, and represent the format under which that Pilot, thence ANDIAB2 2010, 2012 and ANDA-AQSMA 2014, 2016 were conducted.

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Background The National Association of Diabetes Centres (NADC) is a national collective of diabetes centres brought together by a common desire to see improvement in the standard of diabetes care in Australia. With the focus being on proactive maintenance of good health and complications prevention, NADC diabetes centres aim to bridge the gap between the acute care hospital system, and the long-term chronic care of primary care and community services. Supported by the Australian Diabetes Society (ADS), the NADC facilitates the ANDA initiative as part of monitoring and improving quality of care after considering the outcomes of the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS). The DCCT found that maintenance of good glycaemic control significantly reduces diabetes related complications in patients with Type 1 diabetes, while the UKPDS showed that maintenance of good glycaemic and blood pressure control, in people with Type 2 diabetes, reduced the long term complications of the disease. Both strategies require a multidisciplinary team approach including specialist care to achieve better outcomes for people with diabetes. As a consequence, the NADC was created to establish and promote effective health care practice and ultimately achieve better outcomes for people with diabetes. In particular, key strategies were identified including the development of standards of care and quality review initiatives, information provision, and training and support for health professionals in specialist multidisciplinary settings.

What is an NADC Member Centre?

The National Association of Diabetes Centres (NADC) is a national collective of Diabetes Services established in 1994 to promote mechanisms for improving the standard of care available to people with, or at risk, of diabetes through services specialising in diabetes care. In 2016 there were 111 NADC member diabetes centres across Australia and these are found working in a range of locations and facilities from major metropolitan adult and children’s hospitals, as well as in the community, and include primary health care providers, i.e. local general practitioners and community health staff.

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Are there differences between the diabetes centres that participate in ANDA? There are 4 membership levels of NADC: 1. Centres of Excellence

Recognised diabetes centres that have demonstrated excellence in education, research, service delivery, practice/policy development and education. These centres must be Tertiary level facilities.

2. Tertiary Diabetes Centres

NADC centres that have the full range of diabetes service providers including endocrinologists, diabetes nurse educators, dietitians and podiatrists on staff full time and who have demonstrated a high standard of care through service delivery and organisational capacity and have been accredited by the NADC.

3. Diabetes Care Centres

These services have a range of full and/or part-time diabetes staff but often do not have an endocrinologist as part of their usual team. They may be working toward accreditation as a Tertiary centre.

4. Affiliate Centres

These centres have part-time staff and work closely with the local general practitioners to provide care for people with diabetes.

The membership distribution in 2016:

Centre Types Registrations Centres of Excellence 4 Tertiary Centres 32 Diabetes Care Centres 15 Affiliate Centres 23 Unknown* 37

*Unknown members have not identified themselves as any of the eligible categories There were a variety of centres participating in the 2016 ANDA audit:

Centre Types Participating Sites Centres of Excellence and Tertiary Diabetes Centres 26 Diabetes Care Centres and Affiliate Centres 13 Unknown 11

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Who will access the various Diabetes Services?

Most patients referred to Tertiary diabetes centres, including centres of excellence, are referred by their general practitioners so that they may receive specialist assessment and treatment. Given this role, it is important to recognise that it is most likely that people attending Tertiary diabetes centres will be those whose diabetes is less likely to be managed well. In considering the outcomes of this data collection, it is important to remember that whilst Tertiary diabetes centres will provide assessment and treatment, ongoing responsibility for management of most people remains with the individual and their general practitioner. Therefore, patients with diabetes referred to specialist Tertiary level diabetes services and specialist endocrinologists in private practice, are likely to be those with newly diagnosed type 1 diabetes requiring education, and those with uncontrolled type 1 or 2 diabetes or complications of the disease requiring specialist assessment and management. As such the latter patients, in particular, likely represent those patients with more complicated diabetes and/or poorer blood glucose control.

Development of ANDA-AQSMA

The following formed the basis of the ANDIAB2 2005 Pilot10,11 and represented the format under which that Pilot, thence ANDIAB2 2010,12,13 201214 and ANDA-AQSMA 201415 and now 2016 were conducted. In Australia, diabetes remains a serious health problem associated with significant morbidity and long-term complications, with associated increased mortality. Diabetes education is a major component in assisting individuals to self-manage their diabetes, however measurement of patient practices and the effects of care delivered in services specialising in diabetes care have not been widely canvased. Diabetes data collection is essential for monitoring the quality of diabetes care, and in Australia there have been two national diabetes data collections undertaken:

• The National Divisions Diabetes Program (NDDP) data collection: Data collected on people with diabetes attending primary care physicians. This has been assessed twice, in 1999-2000 and 2002-2003

• The ANDIAB data collection

Clinical data collected on people with diabetes attending Specialist Diabetes Services commenced in 1998 and has been performed on 10 occasions. This has a strong ‘medicine’ driven focus targeting physical examination findings, laboratory data and health outcomes.

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ANDA-AQSMA 2016

How the project can improve the care of patients with diabetes

The results of ANDA-AQSMA are expected to provide an indication of the patient care practices and the process of care found amongst participating centres throughout Australia. There will likely be wide variation in these findings which may inform areas of practice or knowledge deficit amongst patients, or need for service development or revision. Sharing this information in a Final Report will assist in identifying processes that may be adopted to improve education and clinical care which (once implemented) should result in improved outcomes for people attending those centres.

How efficiency of ANDA-AQSMA will be assessed

Efficiency of ANDA-AQSMA 2016 will be assessed in 2 ways:

• The participation rate in ANDA-AQSMA itself • The assessment of responses to the questionnaires

Ethics Approval

This is a quality audit exercise utilising de-identified patient data from de-identified sites transmitted through a ‘trusted third party’ (the ANDA Secretariat). There is no disclosure of individual patient data. The usual ethics approval for the ANDA-AQSMA data collection will apply, which is, that each site determine how to address this within their individual setting.

Governance

In 2015, an Advisory Committee was established to provide strategic guidance to ensure the objectives, outcomes and deliverables of ANDA, as specified by the Department of Health are achieved. This committee consists of representatives of key stakeholder organisations including endocrinologists, diabetes nurse educators and the NADC CEO and is working to agreed Terms of Reference with the ultimate vision of assisting ANDA to maintain high visibility, appropriate engagement and relevance for diabetes service delivery.

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1. Methodology

The ANDA-AQSMA 2016 Australian National Diabetes Audit data collection process is summarised below:

1. Initial call for expressions of interest from all currently registered NADC diabetes centres (potential sites)

2. Formal invitations to participate and site acceptances (participating sites) 3. Allocation of unique site codes by the ANDA Secretariat in a double blind manner

and distribution of data collection forms 4. Data collection by participating sites 5. Data entry, cleaning, collation and validation (including missing data query

resolution) 6. Data analysis and reporting

The ANDA Secretariat invited diabetes centres (all levels of NADC membership) and specialist endocrinologists in private practice to participate in the ANDA-AQSMA collection for 2016. All contact and correspondence with participating centres occurs through the ANDA Secretariat. The ANDA Secretariat provides participating centres with their unique site code and holds the only copy of this code. Sites that have participated in past surveys use their previously allocated unique site code. Sites that have not participated in past surveys have been allocated a new unique site code. The central data management/analysis unit generated ‘Master Copies’ of the forms uniquely numbered for each site. The forms were then provided to the ANDA Secretariat who uploaded them onto Basecamp Classic, a project management and collaboration system, in a secure file transfer web folder which was set up for each individual site. Each participating site was instructed to make copies (as many as required) of their unique form for use in the survey. Each site’s web folder contained the following documentation:

• ANDA-AQSMA Protocol • ANDA-AQSMA 2016 Data Collection Form • Self-Assessment of Health Status • How to complete ANDA-AQSMA forms • Diabetes Distress Scale 17 Scoring Sheet • Diabetes Distress Scale 17 • Data Definitions • ANDA-AQSMA Post Data Collection Questionnaire • ANDA-AQSMA Individual Site Report Questionnaire

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Centres with computerised databases could choose to provide the data electronically, however none did so in 2016.

1.1 The Dataset

As with previous collections, data items selected used current agreed, preferably national definitions (where in existence), or original National Diabetes Outcomes Workshop (NDOW, now METeOR) dataset definitions.16,17 Data items included were intended to provide relevant information for services specialising in diabetes care about their patients, with a view to instituting change in areas where opportunity for improvement was identified. The dataset used in the ANDIAB2 2005 pilot was placed on the Australian Diabetes Educators Association (ADEA) website, and feedback sought, and incorporated where possible. This process was not repeated for ANDIAB2 2010, 2012 or ANDA-AQSMA 2014, 2016. The following changes were made in 2016:

• The method of reporting smoking cessation (from single answer to selecting as many options as applicable)

• Wording changed from ‘Do you have difficulties following your prescribed diet?’ to ‘Do you have difficulties following your recommended diet?’

The data dictionary (indicating field type, size and transfer protocol requirements) was updated and made available to all sites (Appendix 1).

1.2 The Software

An application of Teleform© scannable/faxable software has been integrated with a Microsoft SQL Server 2010 running under a Windows 7 operating system11,12. The Teleform© Designer module allows paper forms to be designed and printed. Once completed by sites, forms are mailed to the ANDA Secretariat at 43-51 Kanooka Grove, Clayton, VIC 3168. The Teleform© Reader module assesses each form and either accepts the form (transferring data to an intermediate Access© data file), or suspends the form for verification of one or more data items that the Reader software cannot confidently identify. The Teleform© Verifier module allows an on screen version of the scanned (or faxed) image to be viewed, and corrections made where necessary. Once such corrections are made and accepted, data from these forms are also transferred to the intermediate file. Data in this file are then appended to the permanent database file. Concurrent Operating System and Software Versions are Windows 7, Access 2003 & Teleform V10.9.

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The software has been written to allow individual practitioners or sites (eg a diabetes centre) to be registered, and for unique forms to be generated for completion by that practitioner (or site). Reports have been developed and attached to menu buttons on a user-friendly interface to enable data reporting. This includes data verification reports to ensure complete and valid data capture. Any data extracted from practitioner or site in-house databases was transferred to via a secure file transfer protocol (SFTP) for collation and analysis alongside scanned form data. Data were stored in the central ANDA Database, a Microsoft Access© database held in password protected files on computers stored in a locked room at the School of Public Health and Preventive Medicine, Monash University.

1.3 ANDA-AQSMA Coordination

ANDA coordination and conduct is overseen by Monash Health, Diabetes and Vascular Medicine Unit, Clayton, Victoria. The ANDA Secretariat based at Monash Health coordinated ANDA-AQSMA which was conducted in a ‘double blind’ fashion. The ANDA Data Management and Analysis Centre based at the Monash Centre for Health Research and Implementation, Monash University in partnership with Monash Health, oversaw and managed the ANDA database and completed the data analysis and reporting. The major Project Milestones are summarised in Table 1. Table 1 -ANDA-AQSMA Project Milestones

• Revise ANDA-AQSMA Dataset • Initial call for expressions of interest, March 2016 • Formal invitations received, collation of site acceptances, April 2016 • Allocation of site codes, April 2016 • Generation and distribution of Data Collection Forms, April 2016 • Data collection, May – June 2016 • Study assessment: Post Data Collection Questionnaire • Data received from sites with in-house databases, June – July 2016 • Data entry and validation, July – September 2016 • Missing Data reports forwarded to sites, July – September 2016 • Integration of returned missing data, September 2016 • Final Data Analysis, October 2016 • Draft Pooled Data Report , December 2016 • Final Site Data Analysis Reports forwarded to sites, January 2017 • Final Pooled Data Report, January 2017 • Study assessment: Site Report Assessment Questionnaire

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1.4 Participants

In 2016, 56 diabetes centres (members of the NADC) expressed an interest in participating. Of those expressing interest, 50 provided de-identified data on a total of 3930 individuals seen during the one-month survey period mainly in May or June 2016 (Table 2). Six sites were unable to participate in the audit due to shortage of staff or not being able to meet the minimum requirement of patients. The state and territory breakdown for the location of participating sites was: Australian Capital Territory: 1 New South Wales: 10 Queensland: 10 South Australia: 2 Tasmania: 3 Victoria: 22 Western Australia: 2 Table 2- ANDA-AQSMA 2016 Participating Centres

ACT Health Diabetes Service Albury Wodonga Health Alexandra District Health Baker IDI Heart & Diabetes Institute Ballarat Health Services – Diabetes Education Clinic Ballina Byron Diabetes Centre Bankstown-Lidcombe Hospital – Diabetes Centre Barwon Health – Diabetes Referral Centre Beechworth Health Service Benalla Community Health Blacktown Diabetes Centre Cairns Diabetes Centre Castlemaine District Community Health Chronic Disease Diabetes Logan Cobram District Health Eastern Health Gateway Health, Wangaratta Gateway Health, Wodonga GNS Diabetes Service Goulburn Valley Health Diabetes Centre GP Plus Noarlunga, Intermediate Care, Diabetes Services Ipswich Diabetes Service John Morris Diabetes Centre, Northern Integrated Care Lyell McEwin Hospital – North Adelaide Local Health Network

Mater Health – Queensland Diabetes & Endocrine Centre Monash Health, Clayton – Diabetes Centre Monash Health, Dandenong – Diabetes Centre Monash Health Community Mt Druitt Diabetes Centre Murrumbidgee Local Health North West Diabetes Centre Northern Health Numurkah District Health Service (NDHS) Princess Alexandra Hospital Redland Hospital & Health Service Rockingham General Hospital Royal Hobart Hospital Royal Perth Hospital Seymour Health, Yea Hospital South West Hospital & Health Service St Vincent’s Public Hospital, Melbourne St Vincent’s Hospital, Sydney – Diabetes Service Sunshine Coast Diabetes Centre The Alfred – Dept. of Endocrinology & Diabetes Toowoomba Diabetes Service Townsville Hospital Tweed Valley Diabetes Service Werribee Mercy Hospital Endocrinology in Pregnancy Clinic Western Health Westmead Hospital – Diabetes & Endocrinology Ambulatory Care Centre

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1.5 Data Verification and Validation

As in previous years every effort was made to ensure data completeness and correctness, with specific ‘validation reports’ generated for each site. All missing data, invalid entries and out-of-range values were queried. Attempts were made to provide sites with the opportunity to improve their data with the generation of these specific reports containing lists of missing or potentially invalid data, as well as possible duplicate individual entries. These were forwarded to the sites through the ANDA Secretariat and returned to the data management centre once reviewed. All sites were sent data queries, one site had no data queries and six sites did not respond. All additional or corrected data items were entered/corrected respectively, in the pooled database, prior to final data analysis. For duplicate data, where duplicates were identified, these were reviewed and the first entered record retained, supplemented by any additional data in the second record that was missing in the original. The second entered record was then deleted.

1.6 Data Assumptions and Decisions

In analysing the data, as in previous years, the following data assumptions and decisions were made based on the following ‘rules’: Missing data were calculated conditionally where relevant:

• Pregnancy (Yes/No) only if female and aged 18 to 50 years

Clearly invalid data were excluded, and for all dependency questions:

• Date of Birth greater than date of data analysis, if not corrected after site validation requested

• Date of visit not from May – September 2016 • Pregnancy if male or female aged less than 18 or greater than 50 years • Male and GDM • GDM, but diagnosis year not within 12 months of visit • Insulin duration if management method does not include insulin • Tried to stop smoking when not a current smoker • Cessation methods when not a past smoker • Told doctor of complementary use when not taking any complementary therapy • Reasons for difficulty with diet (data collection form fields 5.1.1 - 5.1.5) when

patients reported no difficulty with diet • Rotation of injection site when management method does not include injection or

insulin

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Data calculations were necessary:

• Age • BCD score and likely depression • Duration of diabetes

1.7 Site Data Reports

A report providing comparison data for their site/practice versus all other sites is generated for each site. Pooled data analysis addressing the outcome findings for all data fields enable sites to compare and benchmark their practice findings against other participating sites. Individual site data reports were generated for all participating sites and included:

• Variable frequency counts (including % missing data) • Variable descriptive statistics • Comparative statistics by year of collection

Reports are presented in a standard format as tables and figures divided into the following sections:

1. Site Report at a Glance 2. Historical Comparison Report 3. National Benchmarking Report 4. Descriptive Report 5. NADC’s Guide to Quality Improvement 6. NADC’s Diabetes Publications & Resource List 2016 7. ANDA-AQSMA Data Collection Documents

1.8 Pooled Data Report

As in previous years, the ANDA-AQSMA 2016 final analysis report of pooled data follows the pattern:

• Pooled Data – all sites, including missing data report • Descriptive Report (de-identified) (Appendix 6)

Unless otherwise stated, results are reported as the percentage of those who answered the question, not the percentage of the total patient group. This methodology was introduced in 2014, where results from past years have been recalculated to be directly comparable. This change reflects the most clinically relevant information. Results in written text are rounded to the nearest whole number. Missing Data for ANDA-AQSMA 2016 are shown as the number of patients and the percentage missing data of those who should have answered that field (for example:

13

percentage missing data on Currently Pregnant is the percentage missing data of those patients who are female).

1.9 Questionnaires

Participating sites were asked to complete the first of two questionnaires at the completion of the data collection phase (June - September), to assess the project overall. The second questionnaire will be forwarded in January with their Site Report, to assess the individual site report they received. (See Appendix 2 for copies of Questionnaires used in 2016).

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2. Findings and Results 2.1 Introduction

There were data provided on a total of 3930 individuals. All were submitted as paper forms, with no electronic data transferred.

2.2 Patient Characteristics and Management Methods Patient characteristics are summarised in Tables 3 and 4. Important findings include:

• The mean±SD age of patients was 55±17 years • Males and females were equally represented • 5% of patients identified as Aboriginal/Torres Strait Islander • An interpreter was required for 4% of patients • 31% of patients were born outside of Australia

Table 3- Patient Characteristics

Category 2010 2012 2014 2016 n 2131 1892 2681 3930 Age (years) 53.6 ± 17.6 54.0 ± 16.8 55.0 ± 17.5 55.3 ± 17.4 Sex % Male 50.7% 47.1% 50.7% 49.7% DM Duration (years) 11.5 ± 10.8 10.1 ± 10.4 12.3 ± 11.3 13.0 ± 11.7 DM Duration (years)* 13.2 ± 11.2 13.7 ± 11.6 Diabetes Type

Type 1 27.5% 21.2% 26.0% 28.0% Type 2 67.3% 70.3% 67.2% 64.9% GDM 3.7% 6.7% 5.0% 5.3% Don't Know 0.6% 0.3% 0.2% 0.5% Other 0.7% 1.2% 1.5% 1.0% Unstated 0.2% 0.3% 0.1% 0.2%

Initial Visit 25.7% 27.3% 17.0% 19.8%

Aboriginal/Torres Strait Islander

2.1% 9.7% 4.0% 4.5%

DVA Patient 2.1% 0.7% 1.1% 1.3% Interpreter Required 4.0% 3.5% 4.4% 3.9% NDSS Member 92.2% 92.6% 93.4% 93.0% Pregnant† 24.8% 34.1% 28.1% 29.6%

*Excluding patients with GDM † Of females aged 18-50

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Australia was the country of birth in most patients (Table 4). Table 4 - Country of Birth

Country n % Australia 2723 69.3% England 158 4.0% New Zealand 105 2.7% India 86 2.2% Italy 76 1.9% Philippines 50 1.3% Greece 45 1.1% United Kingdom 45 1.1% Sri Lanka 32 0.8% Germany 27 0.7% Other 607 15.5% Total 3927

Most patients (65%) had type 2 diabetes. Just over one in four patients had type 1 diabetes (Figure 4). Figure 4 - Diabetes Type

0%10%20%30%40%50%60%70%80%90%

100%

Unstated Type 1 Type 2 GDM Don't Know Other

Diabetes Type

2010 2012 2014 2016

16

Table 5- Treatment by diabetes type

Category 2010 2012 2014 2016 Type 1

Unstated 0.0% 0.7% 0.0% 0.5% Nil 0.0% 0.0% 0.0% 0.1% Diet Only 0.3% 0.0% 0.1% 0.0% Tablets 0.2% 0.5% 0.4% 0.3% Non-insulin injectables† NA NA 0.3% 0.9% Non-insulin injectables & Tablets NA NA 0.0% 0.1% Insulin 95.4% 93.8% 93.0% 90.9% Insulin & Tablets 4.1% 5.0% 5.5% 6.9% Insulin, Tablets & Non-insulin injectables NA NA 0.7% 0.4%

Type 2 Unstated 0.4% 0.7% 0.1% 0.0% Nil 0.2% 0.3% 0.1% 0.0% Diet Only 8.4% 10.4% 7.6% 4.5% Tablets 37.2% 37.0% 30.7% 31.4% Non-insulin injectables NA NA NA NA Non-insulin injectables & Tablets NA NA 5.0% 5.2% Insulin 16.0% 13.0% 15.4% 15.1% Insulin & Tablets 37.7% 38.5% 39.1% 36.1% Insulin, Tablets & Non-insulin injectables NA NA 1.9% 7.2%

GDM Unstated 0.0% 3.2% 0.0% 0.0% Nil 2.5% 0.0% 0.0% 0.5% Diet Only 70.9% 73.0% 54.9% 62.5% Tablets 0.0% 1.6% 4.5% 2.9% Non-insulin injectables NA NA NA NA Non-insulin injectables & Tablets NA NA 1.5% 0.0% Insulin 26.6% 20.6% 33.8% 27.4% Insulin & Tablets 0.0% 1.6% 5.3% 6.7% Insulin, Tablets & Non-insulin injectables NA NA 0.0% 0.0%

† Injectable therapies other than insulin, i.e. incretin mimetics

Figure 5 - Initial Visit by Diabetes Duration

0%

10%

20%

30%

40%

50%

<1 1 2-4 5-9 10+Duration of Diabetes (years)

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A total of 0.6% were on non-insulin injectables alone, 3.4% on non-insulin injectables plus tablets, and 4.8% on non-insulin injectables with insulin and tablets. In 2014, the results were 0.1%, 3.5% and 1.5% respectively. In patients with type 2 diabetes, the majority of patients were on insulin (58%), either alone (15%), in combination with tablets (36%) or in combination with tablets and non-insulin injectables (7%) (Figure 6). A smaller proportion of patients are managed with diet alone (5% vs 8%) compared to 2014. The use of tablets alone and insulin alone have remained unchanged (31% and 15% respectively).

Figure 6 - Management Methods in patients with Type 2 Diabetes

2.3 Lifestyle

2.3.1 Physical Activity

Less than half (46%) of patients reported that they engage in sufficient physical activity, where sufficient physical activity is 150 total minutes per week (as classified by The National Physical Activity Guidelines for Australians, see data definitions (Appendix 1)). Insufficient physical activity (0-150 total minutes per week) was recorded by 39% and 15% identified as sedentary (0 total minutes per week). There has been little change compared to the last 3 collections (Figure 7).

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Figure 7 - Physical Activity

2.3.2 Vaccination Status

In 2016 63% of patients reported that they had been vaccinated against influenza in the last 12 months. Those aged 60 years and over were most likely to be vaccinated against influenza, with over three quarters (76%) in this age group reporting vaccination. There has been a small increase in vaccination rates across age groups <20-39 years and a slight decrease in age groups 40-59 years and ≥60 years compared to 2014 (Figure 8). Figure 8 - Influenza Vaccination in the Last 12 Months

12% of patients reported that they had received the pneumococcal vaccination in the last 12 months. There was a large spike in vaccination in 2010, particularly in patients over 60 years, with rates subsequently falling (Figure 9). In the last 12 months more patients with type 2 diabetes were vaccinated against influenza and pneumococcal than those with type 1 diabetes, which is likely to be reflective of the age difference between patients with type 1 and type 2 diabetes (Figure 10).

0%

10%

20%

30%

40%

50%

2010 2012 2014 2016Year

Sedentary Insufficient Sufficient

0%

20%

40%

60%

80%

100%

<20 20-39 40-59 60+Age Group

2010 2012 2014 2016

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Figure 9 - Pneumococcal Vaccination in the Last 12 Months by Age Group

Figure 10 - Vaccination Status in Last 12 months by Diabetes Type

2.3.3 Smoking Status

In 2016 13% of patients identified as current smokers, 36% as past smokers, and 50% as never having smoked. The percentage of current smokers was similar to 2014, but there was a slight decrease in past smokers (40% vs 36%) (Figure 11). Figure 11 - Smoking Status

0%

10%

20%

30%

40%

50%

<20 20-39 40-59 60+Age Group

2010 2012 2014 2016

0%10%20%30%40%50%60%70%80%90%

100%

2010 2012 2014 2016Year

Influenza Vaccination - Type 2

Influenza Vaccination - Type 1

Pneumococcal Vaccination - Type 2

Pneumococcal Vaccination - Type 1

0%10%20%30%40%50%

2010 2012 2014 2016Year

Never Smoked Past Smoker Current Smoker

20

Of the current smokers, the majority (78%) stated that they had tried to stop smoking. The most common method of cessation in past smokers was stopping with no intervention (80%), followed by medication (7%) and nicotine replacement therapies (7%). Hypnosis was infrequently used, and acupuncture not used at all (2% and 0% respectively) (Figure 12). Figure 12 - Methods of Smoking Cessation

2.4 Medication Use

The majority of patients report that they usually take all of their medications (92%). A minority reported that they ‘ever forget to take their medications’ (27%), with few patients stopping when they feel better (6%), or stopping when they feel worse (7%) (Table 6). These results are essentially the same as in 2014. Table 6 - Medication Use

2012

n = 1892 2014

n = 2681 2016

n = 3930 Category n % n % n %

Do you ever forget to take your medications? 433 23.9% 720 27.3% 1051 26.8%

Do you usually take all of your medications? 1565 87.7% 2393 91.9% 3569 92.1%

Do you sometimes stop taking your medications when you feel better?

142 8.0% 161 6.2% 236 6.1%

Do you sometimes stop taking your medications when you feel worse?

142 8.0% 187 7.2% 274 7.1%

Over one in four patients use complementary therapy, dietary supplements or over the counter treatments. Of patients reporting this, only (86%) had told their doctor about use of complementary therapy, dietary supplements or over the counter (OTC) treatments (Table 7).

0%10%20%30%40%50%60%70%80%90%

100%

Just stopped -No

Intervention

Hypnosis Medication Acupuncture NicotineReplacement

Other

2012 2014 2016

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Table 7 - Use of Complementary Therapy

2012 n = 1892 2014 n = 2681 2016 n = 3930 Category n % n % n %

Are you using a complementary therapy or dietary supplement or OTC treatment?

585 32.9% 703 26.9% 1069 27.6%

Have you told your Dr/Educator about complementary, dietary supplement, OTC treatment?

502 86.7% 579 82.6% 915 86.0%

2.5 Patient Self Care Practices Almost one third of patients reported having difficulties following their recommended diet (36%), with the most common reason in all patients being ‘I don’t have enough time to prepare healthy meals’ and ‘It costs too much to eat well’. More than half of those with type 1 diabetes who reported difficulties in following their recommended diet, stated that it is too hard to count carbohydrates and weigh food (Table 8).

Table 8 - Patient Dietary Practices

2012

n = 1892 2014

n = 2681 2016

n = 3930 Category n % n % n %

Do you have difficulties following your recommended diet? 724 39.6% 797 30.2% 1400 35.7%

I don't have enough time to prepare healthy meals 258 37.0% 261 33.7% 460 33.2% It costs too much to eat well 313 45.0% 256 32.7% 422 30.4% I don't know what foods are best to eat 230 33.2% 233 29.8% 392 28.2% I eat out a lot and find it hard to eat well 163 23.5% 178 22.9% 312 22.5% If Type 1 - It is too hard to count carbs- weigh food 97 74.0% 87 52.7% 176 56.6%

While 69% of patients reported that they check their blood glucose as often as recommended, 26% do not, and 6% were unsure of how often they should be monitoring. Of those using insulin and injectable medications 96% reported that they rotate their injection sites (Table 9). Table 9 - Patient Self Care Practices

2012 n = 1892 2014 n = 2681 2016 n = 3930 Category n % n % n %

Do you check your blood glucose level as often as recommended?

NA NA 1915 72.4% 2677 68.5%

Do you rotate your injection site? NA NA 1776 95.6% 2680 95.6%

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2.6 Health Services Utilisation (in the last 12 months)

Reporting on Health Professional Attendance in the last 12 months revealed 76% attended a diabetes educator and 71% a diabetes specialist. Only 55% had seen a podiatrist, and 52% had attended a dietitian. Less than half had seen a dentist (44%) and very few patients had seen a psychologist (14%), social worker (8%) or exercise physiologist (9%). There has been an increase in attendances to a diabetes specialist, optometrist, dietitian, dentist and exercise physiologist compared with previous collections (Figure 13). A total of 78% had seen either an optometrist or an ophthalmologist, and 27% had seen both an optometrist and ophthalmologist. Figure 13 - Health Services Utilisation

A total of 75% of patients utilised the services of three or more health professionals for the care of their diabetes, other than a diabetes specialist (Figure 14).

Figure 14 - Number of Health Services Utilised (other than diabetes specialist)

0%10%20%30%40%50%60%70%80%90%

100%

Health Service

2010 2012 2014 2016

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9

Number of Health Services

2010 2012 2014 2016

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Of those attending a Diabetes Centre, 69% of those attending an initial visit, and 78% of those attending a follow up visit, had seen a diabetes educator in the last year. Among patients with a duration of diabetes of less than one year, 69% of those attending for an initial visit, compared to 95% of those attending for a follow-up visit, had seen a diabetes educator in the last year (Figure 15). Of patients attending follow up visits at the time of survey, patients with diabetes duration <1 year were more likely to have seen a diabetes educator in the last year, compared to those with a longer duration of diabetes. There did not appear to be a difference for those attending initial appointments. Figure 15 - Percentage Seen by Diabetes Educator by Diabetes Duration & Initial or Follow-up Visit

Of those attending a Diabetes Centre for their initial visit at the time of survey, 46% had seen a dietitian in the last year, while 54% of those attending for a follow up visit had seen a dietitian in the last year.

Among patients with diabetes duration of less than 1 year, dietitian review in the last year was more frequent in those attending a Diabetes Centre for a follow-up visit (84%) than initial visit (56%) (Figure 16).

Figure 16 - Percentage Seen by Dietitian by Duration of Diabetes & Initial or Follow-up Visit

0%

20%

40%

60%

80%

100%

<1 1 2-4 5-9 10+Duration of Diabetes (years)

Initial Visit Follow-up visit

0%

20%

40%

60%

80%

100%

<1 1 2-4 5-9 10+Duration of Diabetes (years)

Initial Visit Follow Up

24

The proportion of patients attending various health professionals in the last 12 months was highest for those with diabetes duration of >10 years (4.4%-42.8%) and lowest for those with diabetes duration of 1 year (0.3%-2.7%). The proportion of patients attending various health professionals in the last 12 months was generally low (<14%) for all other diabetes durations (Table 10).

Table 10: Health Professional Attendance by Duration of Diabetes

Category

Total Population

Diabetes Duration <1 year 1 year 2-4 years 5-9 years >10 years

n % n % n % n % n % Educator 3927 524 13.3% 105 2.7% 258 6.6% 510 13.0% 1578 40.2% Diabetes Specialist 3928 304 7.7% 85 2.2% 237 6.0% 482 12.3% 1683 42.8% Optometrist 3921 297 7.6% 90 2.3% 251 6.4% 463 11.8% 1457 37.2% Ophthalmologist 3920 82 2.1% 39 1.0% 92 2.3% 222 5.7% 1096 28.0% Podiatrist 3925 172 4.4% 67 1.7% 187 4.8% 383 9.8% 1360 34.6% Dietitian 3924 453 11.5% 81 2.1% 176 4.5% 337 8.6% 991 25.3% Dentist 3920 243 6.2% 50 1.3% 147 3.8% 301 7.7% 985 25.1% Psychologist 3922 68 1.7% 21 0.5% 59 1.5% 106 2.7% 303 7.7% Social Worker 3922 40 1.0% 11 0.3% 34 0.9% 48 1.2% 172 4.4% Exercise Physiologist 3921 45 1.1% 16 0.4% 36 0.9% 73 1.9% 185 4.7%

2.7 Self Rated Wellbeing

Wellbeing was assessed using: i) The Brief Case Find For Depression (BCD©ii) ii) Antidepressant and psychiatric/psychological treatment iii) Own Health State Rating and iv) Diabetes Distress Scale 17 (DDS17) 2.7.1 Brief Case Find For Depression

The BCD© is a tool used to calculate whether depression is ‘likely’ or ‘unlikely.’ Using the four questions seen in Section 6A on the ANDA-AQSMA 2016 Data Collection Form (Appendix 1): Relating to the last two weeks: 6A.1 Have you been having restless or disturbed nights? 6A.2 Have you been feeling unhappy or depressed? 6A.3 Have you felt unable to overcome your difficulties? 6A.4 Have you been dissatisfied with the way you have been doing things? ii BCD© 1993 Monash University Department of Psychology Medicine (used with permission)

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Depression is considered likely if ‘Yes’ is answered to either or both of the first two questions (6A.1 and/or 6A.2) AND ‘Yes’ is answered to either or both of the second two questions (6A.3 and/or 6A.4). Depression was ‘likely’ in 28% of all patients, essentially unchanged over the past 3 collections (29% in 2014, 28% in 2012 and 28% in 2010). ‘Likely depression’ affected the 26% of patients with type 1 and 30% of patients with type 2 diabetes (Figure 17).

Figure 17 - BCD: ‘Likely Depression’ by Diabetes Type

2.7.2 Mental Health Treatment

Of patients with likely depression based on the BCD, 34% reported current use of antidepressant medications (19% of all patients), 11% were currently receiving psychologist/psychiatrist treatment, while 27% stated that they had received psychologist/psychiatrist treatment in the past. Both these numbers have increased compared to previous collections (Table 11). Table 11 - Current or Previous Psychology/Psychiatry Treatment and/or Counselling

Category 2010 n = 2131 2012 n = 1892 2014 n = 2681 2016 n = 3930 n % n % n % n %

Current 137 7.2% 128 7.8% 236 8.9% 410 10.5% Previous 409 21.4% 381 23.2% 601 22.7% 1039 26.5%

2.7.3 Self-Assessment of Health Status

The mean Own Health State Rating was based on the EQ-5D instrument developed by the EuroQol Group © 2000 (used with permission).18 Individuals were asked to rate their ‘Own Health State Today’ on a visual scale from 0 to 100, where 0 is the ‘Worst imaginable health state’ and 100 is the ‘Best imaginable health state’ (Appendix 1). Diabetes Centre staff then transcribed the result on to the one page ANDA-AQSMA 2016 data collection form.

0%

10%

20%

30%

40%

50%

Type 1 Type 2 GDM Don't Know OtherDiabetes Type

26

The Own Health State Rating was recorded in 99% of patients, with a mean 66.0±20.1. The Own Health State Rating was similar for patients with type 1 diabetes (68.3±19.5) and type 2 diabetes (64.7±20.2) and highest in those with GDM (mean 70.2±20.4). In patients with type 1 diabetes the mean (±SD) Own Health State rating was slightly greater compared to the past 3 collections (2010: 65.6±19.2, 2012: 65.1±19.8, 2014: 66.9±19.2).

In patients with type 2 diabetes the mean (±SD) Own Health State rating (64.7±20.2) was higher in 2016 than in previous collections except for 2014 indicating a general trend towards improved health state as perceived by patients (2010: 62.0±21.1 (p<0.001), 2012:63.7±20.1 (p=0.025), 2014:65.8±20.3 (p=0.89) (Figure 18).

Figure 18 - Mean Own Health State Rating

Patients using non-insulin injectable therapies alone reported the lowest Own Health State Rating (52.3±26.5), however due to the small sample size (n=11), no further statistical analysis was performed. Those using insulin, tablets and non-insulin injectable therapies reported the second lowest Own Health State Rating (59.0 ±20.6), however it was not appreciably lower compared to patients using insulin (61.8±20.3, p=0.1). Own Health State for patients using insulin was significantly lower than for those using diet alone (7 patients using insulin 71.4±19.2 p<0.001). Those using insulin reported a lower rating than those using tablets alone (68.0±19.3 p=<0.001) and those using insulin and tablets (63.1±20.0 p=0.22) (Figure 19)

Figure 19 - Mean Own Health State Rating & Management Method in Type 2 Diabetes

0102030405060708090

100

Diet Only Tablets Injectables Injectables& Tablets

Insulin Insulin &Tablets

Insulin &Tablets &

Injectables

27

2.7.4 Diabetes Distress Scale 17

The validated Diabetes Distress Scale 17 (DDS 17)7,8,9 was used to assess diabetes-related distress, as in 2014, 2012 and 2010 allowing comparison across years. Detailed instructions on conducting the DDS 17 can be found in ‘How to Complete ANDA-AQSMA 2016 Forms’ (Appendix 1). Summary on how DDS 17 was completed:

• Two screening questions are first asked • If one or both screening questions are positive; scored as a moderate problem or

above (score ≥3), the patient is asked to proceed to the complete DDS 17 questionnaire

• The DDS 17 yields a ‘Total DDS 17’ diabetes distress score, and 4 sub-scores each addressing a different kind of diabetes distress; Emotional Burden, Physician-related Distress, Regimen-related Distress, Interpersonal Distress

• An automated DDS 17 Calculator was available for calculation of the mean Total DDS 17 score and the mean subscale scores

We use the revised criteria for interpretation of DDS 179 where a mean score of:

• Less than 2.0 indicates little or no distress • 2.0 to 2.9 indicates moderate distress • Equal to or above 3.0 indicates high distress in the relevant fields

Once DDS 17 questionnaires had been completed and the DDS 17 scores calculated (Appendix 1), the Diabetes Centre staff transcribed the results on to the one page ANDA-AQSMA 2016 data collection form. Results of the DDS Screening Questions and DDS 17:

• 1512 patients (39%) had positive DDS screening questions (one or both ≥3), indicating that these patients should complete the full DDS 17 questionnaire

• Of these, 1372 (91%) completed the DDS 17, representing 35% of all patients • Additionally, 67 patients, who should not have completed the DDS 17 (both

screening scale scores <3) went on to complete the DDS 17 (results not included in analysis)

• The DDS screening questions were shown to be an effective screening tool, given that 47% of those with positive screening questions had at least one individual DDS 17 score in the high distress range

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Table 12 - DDS 17 Questionnaire Data by Screening Question Score

2010

n = 2131 2012

n = 1892 2014

n = 2681 2016

n = 3930 Category % n % n % n % n

DDS 17 Questionnaire completed 57.9% 1061 50.9% 790 48.8% 998 46.1% 1441 Screening questions > 3 and DDS 17 Questionnaire completed

60.1% 638 71.0% 561 96.6% 964 95.4% 1374

Screening questions < 3 and DDS 17 Questionnaire completed

39.2% 416 20.3% 160 3.4% 34 4.6% 67

Screening questions both not completed and DDS 17 Questionnaire completed

0.5% 5 8.7% 69 0.0% 0 0.1% 2

Screening questions > 3 and DDS 17 Questionnaire NOT completed

22.3% 183 10.4% 65 6.6% 68 9.1% 138

Individual DDS Scores > 3 where Screening questions > 3

48.4% 397 56.4% 353 53.7% 554 50.2% 759

Individual DDS Scores > 3 where both Screening questions < 3

4.2% 44 1.1% 10 0.3% 4 0.2% 4

Table 13 details the DDS 17 findings and the results by diabetes type and year of collection, in those who completed the DDS 17 questionnaire: • The mean (±SD) Total DDS 17 was 2.3 (± 0.9) indicating a mean score in the

moderate distress range • For the subscale scores, mean Emotional Burden score was highest (2.8 ± 1.2),

followed by Regimen-related Distress (2.6 ± 1.), Interpersonal Distress (2.0 ± 1.2) and Physician-related distress (1.5 ± 0.9)

• Table 13 shows the mean Total DDS 17 scores and sub-scale scores for all patients and by diabetes type for 2010, 2012, 2014 and 2016

• There has not been a significant change in diabetes distress from 2014 to 2016 as indicated by the mean Total DDS 17 score for all patients (2.3±0.8 vs 2.3 ±0.9 p<0.74)

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Table 13 - Mean DDS 17 Scores by Diabetes Type and Year

2010 n = 2131 2012 n = 1892 2014 n = 2681 2016 n = 3930 Category Mean ± SD n Mean ± SD n Mean ± SD n Mean ± SD n

DDS 17 Questionnaire Completed 57.9% 638 50.9% 561 48.8% 964 46.0% 1372 Total DSS 17 Score All 2.4 ± 0.9 637 2.4 ± 0.9 556 2.3 ± 0.8 963 2.3 ± 0.9 1364 Type 1 2.2 ± 0.7 216 2.3 ± 0.7 185 2.3 ± 0.8 301 2.4 ± 0.9 464 Type 2 2.5 ± 1.0 399 2.5 ± 0.9 355 2.3 ± 0.9 625 2.3 ± 0.9 835 GDM 1.8 ± 0.8 9 1.9 ± 0.6 9 1.8 ± 0.5 26 2.0 ± 0.9 43 Emotional Burden All 2.9 ± 1.2 638 2.9 ± 1.2 355 2.8 ± 1.2 625 2.8 ± 1.2 1370 Type 1 2.8 ± 1.1 217 2.8 ± 1.1 185 3.0 ± 1.2 301 2.9 ± 1.2 466 Type 2 3.0 ± 1.3 399 2.9 ± 1.3 355 2.8 ± 1.2 625 2.8 ± 1.2 839 GDM 2.4 ± 1.1 9 2.8 ± 1.0 9 2.2 ± 0.9 26 2.3 ± 0.8 43 Physician-related Distress All 1.6 ± 1.1 637 1.6 ± 1.0 556 1.5 ± 0.9 963 1.5 ± 0.9 1369 Type 1 1.4 ± 0.8 216 1.5 ± 0.8 185 1.4 ± 0.7 301 1.5 ± 0.9 465 Type 2 1.7 ± 1.2 399 1.6 ± 1.1 355 1.5 ± 0.9 625 1.5 ± 0.9 839 GDM 1.3 ± 0.8 9 1.0 ± 0.0 9 1.1 ± 0.5 26 1.2 ± 0.5 43 Regimen-related Distress All 2.7 ± 1.1 638 2.8 ± 1.2 555 2.6 ± 1.2 963 2.6 ± 1.1 1371 Type 1 2.7 ± 1.0 217 2.7 ± 1.2 185 2.7 ± 1.1 301 2.7 ± 1.1 466 Type 2 2.7 ± 1.2 399 2.8 ± 1.3 354 2.6 ± 1.2 625 2.6 ± 1.1 840 GDM 2.2 ± 1.1 9 1.9 ± 0.8 9 2.1 ± 0.8 26 1.9 ± 0.7 43 Interpersonal Distress All 2.0 ± 1.3 636 2.2 ± 1.3 555 2.0 ± 1.2 963 2.0 ± 1.2 1371 Type 1 1.8 ± 1.0 217 2.1 ± 1.1 185 2.0 ± 1.2 301 2.0 ± 1.2 466 Type 2 2.2 ± 1.4 397 2.2 ± 1.4 354 2.0 ± 1.2 625 2.0 ± 1.2 840 GDM 1.5 ± 0.9 9 1.9 ± 0.9 9 1.6 ± 0.7 26 1.7 ± 0.9 43

Key findings regarding high distress (score≥3) in each field: • Of the patients who completed the DDS 17 in 2016, 22% had a mean Total DDS 17

score in the high distress range. This represents 8% of all Diabetes Centre patients audited (Figure 20)

• Emotional Burden was the area in which the greatest proportion of patients experienced high distress (40% of those who completed the DDS 17, 14% of all patients) (Figure 21)

• Physician-related Distress was reported least frequently (9% of those who completed the DDS 17, 3% of all patients) (Figure 22)

• There was a significant difference in the proportion of patients with a Total DDS17 score in the high distress category between those with type 1 (24%) and type 2 diabetes (21%) (p<0.001)

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Figure 20 - Total DDS 17 Score by Diabetes Type

Figure 21 - Emotional Burden Score by Diabetes Type

Figure 22 - Physician-related Distress by Diabetes Type

0%

20%

40%

60%

80%

100%

Type 1 Type 2 GDM

Little/No Distress Moderate Distress High Distress

0%

20%

40%

60%

80%

100%

Type 1 Type 2 GDM

Little/No Distress Moderate Distress High Distress

0%

20%

40%

60%

80%

100%

Type 1 Type 2 GDM

Little/No Distress Moderate Distress High Distress

31

Figure 23 - Regimen Related Distress by Diabetes Type

Figure 24 - Interpersonal Distress by Diabetes Type

2.8 Questionnaire Results

Results of feedback from participating sites to the specific questions related to the data collection project (Questionnaire 1) are summarised in Table 15, from responses measured on a Likert Scale (Appendix 2).

• Questionnaire 1 relates to the data collection process • Questionnaire 2 relates to the comments on the Individual Site Reports (to be

administered after reports are distributed) • Free text responses to questions and to other items were reviewed individually

and will be utilised to refine the data collection instrument and reporting process to assist in running future audits

0%

20%

40%

60%

80%

100%

Type 1 Type 2 GDM

Little/No Distress Moderate Distress High Distress

0%

20%

40%

60%

80%

100%

Type 1 Type 2 GDM

Little/No Distress Moderate Distress High Distress

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The results in Table 14 from 34 respondents indicate that there was approval of the data collection process from ANDA-AQSMA 2016, including information, data definitions, formatting, ease of completion and time to complete the form. Responses showed higher satisfaction with the 2016 process compared to previous collections. This is particularly encouraging given that a number of the participating sites in 2016 were new to the audit. The time to complete the form, and the format generated the lowest satisfaction. Ongoing review will be undertaken to facilitate further improvements in future collections. Table 14 - Questionnaire 1 (Data Collection Process) Responses

Likert Scale (1=Poor 5=Excellent) Data Collection Process

2010 Mean ± SD

(n=19)

2012 Mean ± SD

(n=29)

2014 Mean ± SD

(n=32)

2016 Mean ± SD

(n=34) Information Package/Letters

3.6±1.1 3.6±1.0 3.9±0.8 4.1±1.1

Data Definitions Forms 3.7±1.1 3.6±1.1 4.0±0.9 4.3±0.9 Format (layout of data items)

3.4±1.1 3.2±1.3 3.5±1.2 3.9±0.8

Ease of completion 3.1±0.9 3.3±1.1 3.6±0.9 3.6±0.9 Time to complete the form

2.2±1.1 2.9±1.0 3.5±0.9 3.0±1.4

2.9 Missing Data

Missing Data for ANDA-AQSMA 2016 is shown in Table 15, as the number of patients and the percentage of the patients missing data who should have answered that field. It is arranged in increasing frequency of missing data. The item number on the left of Table 15 indicates the correlating section on the ANDA-AQSMA 2016 Data Collection Form. All data were collected for a number of items. For the remainder, missing data for compulsory collection items ranged from 0.1% (smoking status) to 11.1% (HbA1c in mmol/mol). In the 2014 data collection, missing data ranged from 0.0% to 7.6%. The higher rate of missing data in 2016 may reflect the dual reporting for HbA1c, as many sites reported HbA1c as either percentage or mmol/mol rather than reporting in both units.

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Table 15- Missing Data

2012 n = 1892 2014 n = 2681 2016 n = 3930

Item Field n % n % n % 1.1 Date of Birth (Based on year) 23 1.2% 1 0.0% 0 0.0% 1.3 Visit Date 0 0.0% 11 0.4% 0 0.0%

Age 23 1.2% 12 0.4% 0 0.0% BCD Depression likely 236 12.5% 45 1.7% 0 0.0%

2.7 Smoking Status 10 0.5% 18 0.7% 2 0.1% 4.6 Attended Diabetes Specialist 60 3.2% 35 1.3% 2 0.1% 4.2 Attended Diabetes Educator 60 3.2% 6 0.2% 3 0.1% 1.9 Country of birth NA NA 7 0.3% 3 0.1%

5.1 Diet - Difficulties following recommended diet

62 3.3% 40 1.5% 3 0.1%

2.3 Management Method 17 0.9% 1 0.0% 5 0.1% 4.1 Attended Podiatrist 61 3.2% 47 1.8% 5 0.1% 4.3 Attended Dietitian 63 3.3% 8 0.3% 6 0.2%

6B.1 On antidepressants 242 12.8% 30 1.1% 7 0.2% 1.2.1 Currently pregnant (only if female) 99 9.9% 4 7.5% 9 0.2%

1.2 Sex of Individual 9 0.5% 3 0.1% 8 0.2% 2.2 Type of Diabetes 5 0.3% 4 0.1% 8 0.2% 1.6 Interpreter required 212 11.2% 6 0.2% 8 0.2%

6B.3 Psychiatric treatment/counselling - current

246 13.0% 36 1.3% 8 0.2%

6B.2 Psychiatric treatment/counselling - previous 247 13.1% 39 1.5% 8 0.2%

4.4 Attended Psychologist 64 3.4% 45 1.7% 8 0.2% 4.5 Attended Social Worker 72 3.8% 46 1.7% 8 0.2% 2.4 Physical Activity 45 2.4% 179 6.7% 8 0.2% 1.4 Initial Visit 22 1.2% 7 0.3% 9 0.2% 4.8 Attended Optometrist 101 5.3% 48 1.8% 9 0.2%

4.10 Attended Exercise Physiologist 83 4.4% 49 1.8% 9 0.2% 4.7 Attended Ophthalmologist 70 3.7% 44 1.6% 10 0.3% 4.9 Attended Dentist 62 3.3% 51 1.9% 10 0.3% 1.5 Indigenous - ATSI 145 7.7% 2 0.1% 11 0.3%

6A.1 BCD - had restless or disturbed nights

238 12.6% 44 1.6% 11 0.3%

3.1 Medications - ever forget to take medications

78 4.1% 48 1.8% 11 0.3%

6A.2 BCD - Unhappy or feeling depressed

240 12.7% 44 1.6% 12 0.3%

6A.3 BCD - Felt unable to overcome difficulties 240 12.7% 46 1.7% 13 0.3%

6A.4 BCD - Been dissatisfied with their way of doing things

246 13.0% 48 1.8% 14 0.4%

7.4 DDS 17 Questionnaire completed 4 0.6% 4 0.4% 6 0.4% 2.1 Year of Diagnosis 19 1.0% 7 0.3% 16 0.4%

Duration of diabetes 19 1.0% 7 0.3% 16 0.4% 1.7 DVA patient 158 8.4% 19 0.7% 16 0.4%

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2012 n = 1892 2014 n = 2681 2016 n = 3930

Item Field n % n % n %

2.5.1

Complementary Therapy - told Dr or educator of use (only patients who are on complementary therapy)

6 1.0% 2 0.3% 5 0.5%

2.7.2 Past Smoker Method of Cessation NA NA NA NA 7 0.5%

5.2 Check blood glucose as recommended

NA NA 35 1.3% 24 0.6%

5.1.2 Diet - It costs too much to eat well 28 3.9% 14 1.8% 11 0.8% 7.2 DDS Screening Scale Q1 332 17.5% 87 3.2% 33 0.8% 7.3 DDS Screening Scale Q2 332 17.5% 90 3.4% 33 0.8%

5.1.3 Diet - Don't know what best foods are to eat

31 4.3% 16 2.0% 12 0.9%

5.1.4 Diet - Eat out a lot and find it hard to eat well

30 4.1% 21 2.6% 12 0.9%

2.5 Vaccination - Flu in past 12 months 32 1.7% 26 1.0% 36 0.9%

5.1.1 Diet - Not enough time to prepare healthy meals

27 3.7% 22 2.8% 13 0.9%

2.6 Vaccination - Pneumococcal in past 12 months

50 2.6% 55 2.1% 37 0.9%

7.1 QoL - Own Health State Rating (0-100)

271 14.3% 93 3.5% 40 1.0%

2.7.1 Tried to stop smoking (current smokers only)

6 2.2% 0 0.0% 6 1.2%

3.2 Medications - Usually take all your medications 107 5.7% 77 2.9% 54 1.4%

3.3 Medications - do you stop taking when feeling better

116 6.1% 75 2.8% 57 1.5%

3.4 Medications - do you stop taking when feeling worse

117 6.2% 74 2.8% 58 1.5%

2.3.1 Insulin duration NA NA 9 0.5% 41 1.5%

3.5 Complementary therapy or dietary supplement used

114 6.0% 71 2.6% 61 1.6%

5.3 Rotate injection site NA NA 35 1.8% 51 1.8% 1.8 NDSS Member 240 12.7% 22 0.8% 78 2.0%

5.1.5 Diet - too hard to count carbohydrates (only if Type 1)

7 5.1% 5 2.9% 7 2.2%

3.1.1 Medications - How many times forget medications per week (only patients who forget)

3 0.7% 32 4.4% 42 4.0%

2.8 HbA1c (%) 350 18.5% 195 7.3% 335 8.5% 7.4.4 DDS Regimen-related Burden 71 11.3% 69 6.7% 141 9.3% 7.4.5 DDS Interpersonal Distress 71 11.3% 69 6.7% 141 9.3% 7.4.2 DDS Emotional Burden 70 11.2% 69 6.7% 142 9.4% 7.4.3 DDS Physician-related Burden 70 11.2% 69 6.7% 143 9.5% 7.4.1 DDS Total DDS Score 70 11.2% 69 6.7% 148 9.8%

2.8 HbA1c (mmol/mol) NA NA 203 7.6% 438 11.1% Staff ID (optional) 0 0.0% 1661 62.0% 2169 55.2%

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3. Discussion The aim of the Australian National Diabetes Audit (ANDA) is to provide a high quality audit program. This is achieved by the collection, collation, analysis, audit and reporting of clinical diabetes data in specialist diabetes services and, in so doing, the underlying objectives have remained: • Provide an individual audit report for participants • Utilise different technologies to collect and collate data • Assess participant responses • Generate a pooled data collection report of standardised data • Encourage progress towards annual collection • Constantly update and refine This cross-sectional audit provides a ‘snapshot’ of the self-management and wellbeing of patients being cared for in services specialising in diabetes care in Australia. Owing to the success of the validation process and the diligence of those involved in the collection in 2016 there were minimal missing data. It is important to note that no difficulties with respect to the technical aspects of ANDA-AQSMA were encountered. A comparison with previous years’ data reveals a degree of ‘stability’ of the findings which suggests that these data do reliably reflect the clinical status of individuals with diabetes and could be used as a basis on which to gauge the effectiveness of diabetes management or intervention strategies aimed at improving health outcomes. There were minimal missing data, owing to the success of the validation process and the diligence of those involved in the collection. As this audit is based on de-identified data, longitudinal data analyses is not possible. Another limitation is that the audit captures data regarding consecutive patients with diabetes who present to their centre during the audit month rather than a random sample of patients. Data collection is carried out during the same time of year for each audit. Given that HbA1c is known to demonstrate seasonal change, this provides consistency for comparisons between years, however the variability in HbA1c experienced by patients with diabetes may not be captured. Administration of the questionnaire by medical professionals may introduce bias, especially in relation to the Physician-related Distress section of the Diabetes Distress Scale. A number of fields rely on patient self-reporting, which may introduce recall bias. There were a quarter of the patients (27.3%) for whom this was an initial visit and the possibility exists that the reduced prevalence findings for many of the items assessed may in some part be related to no (or minimal) previous diabetes education.

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4. Conclusion ANDA-AQSMA provides a ‘snapshot’ of education and self-care practices in individuals attending Specialist Diabetes Services across Australia. This is the largest ANDA self-management audit to date which collected data on 3930 adult patients from 50 diabetes centres across Australia. Only the Northern Territory did not participate in 2016. This audit focuses on lifestyle management, health service access, education and wellbeing of people with diabetes. These findings indicate that whilst patients are generally adherent to medication advice, areas for improvement include physical activity, dietary advice, cardiovascular risk factor modification and blood glucose monitoring. Encouragingly, the majority of patients reported the correct use of insulin or other injectable medications as well as good adherence to their prescribed medications. However, 54% of patients did not engage in the recommended 150 minutes of physical activity a week. One third of patients reported trouble following their recommended diet. The majority of patients were aware of the importance of blood glucose monitoring, but a third of patients did not test their blood glucose levels as often as recommended. Current smoking was reported by 13% of patients, unchanged since 2014. Interestingly, of those who were currently smoking, three quarters reported that they had tried to stop (and thus may be receptive to further attempts to assist smoking cessation). The above issues may be addressed by increased access to a range of health care professionals, including diabetes educators, dietitians, podiatrists and exercise physiologists or specialised exercise programs within services specialising in diabetes care to educate patients with diabetes regarding the importance of preventive care. Such multi-disciplinary initiatives may be most effective in promoting education and self-care measures in people with diabetes, thereby minimising the incidence and severity of diabetes related complications and associated morbidity and mortality in the future. As in previous collections, there was demonstrated a high prevalence of ‘likely depression’ as measured by the BCD© and notable diabetes-specific distress related to ‘Emotional Burden’ as measured by the Diabetes Distress Scale 17. Of concern, amongst patients with likely depression, only one tenth reported current counselling and one third reported currently taking antidepressant therapy. This highlights the importance of addressing emotional and psychological health in people with diabetes managed in services specialising in diabetes care.

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5. Acknowledgements ANDA-AQSMA 2016 has been supported by funding from the Australian Government Department of Health. This funding also supported the conduct of ANDA-AQCA in 2015. We would like to thank the participating diabetes centres and patients for their time and generous contribution to this work. We would also like to thank the members of the ANDA Scientific Advisory Committtee which was established in 2015 to provide strategic guidance to ensure the objectives, outcomes and deliverables of ANDA, as specified by the Department of Health, were achieved.

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References 1. Position statement of the Australian Diabetes Society: individualisation of glycated

haemoglobin targets for adults with diabetes mellitus. N Wah Cheung, Jennifer J Conn, Michael C d’Emden, Jenny E Gunton, Alicia J Jenkins, Glynis P Ross, Ashim K Sinha, Sofianos Andrikopoulos, Stephen Colagiuri and Stephen M Twigg. Med J Aust 2009; 191 (6): 339-344.

2. National Heart Foundation of Australia physical activity recommendations for

people with cardiovascular disease. Briffa T, Maiorana A, Allan R, et al. On behalf of the Executive Working Group and National Forum Participants. Sydney (Australia): National Heart Foundation of Australia; January 2006.

3. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium:

International Diabetes Federation, 2013.

4. http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-influenza#flu

5. Speight J. Managing diabetes and preventing complications: what makes the

difference? MJA 2013; 198(1):17.

6. Clarke D.M., McKenzie D.P., Marshall R.J., Smith G.C. The construction of a brief case-finding instrument for depression in the physically ill. Integrative Psychiatry 1994; 10: 117-123.

7. Assessing Psychosocial Distress in Diabetes Development of the Diabetes Distress

Scale. William H .Polonsky, Lawrence Fisher, Jay Earles, R. James Dudl, Joel Lees, Joseph Mullan, Richard A. Jackson. Diabetes Care 28:626–631, 2005.

8. Development of a Brief Diabetes Distress Screening Instrument. Lawrence Fisher,

Russell E. Glasgow, Joseph T. Mullan, Marilyn M. Skaff, William H. Polonsky. Ann Fam Med. May 2008; 6(3): 246–252.

9. When Is Diabetes Distress Clinically Meaningful? Establishing cut points for the

Diabetes Distress Scale. Lawrence Fisher, Danielle M Hessler, William H Polonsky, Joseph Mullan. Diabetes Care 35:259-264, 2012.

10. Australian National Diabetes Information Audit and Benchmarking [ANDIAB] 2011.

A/Prof Jeff Flack and Prof Stephen Colagiuri on behalf of the National Association of Diabetes Centres.

11. Pilot NADC ANDIAB patient Review Project 2004 [Follow-up Data 2000 to 2003]

A/Prof Jeff Flack and Prof Stephen Colagiuri on behalf of the National Association of Diabetes Centres. Final Report June 2004.

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12. Quality Assurance of Patient Practices and Diabetes Centre Care: ANDIAB2. A/Prof Jeff Flack and Prof Stephen Colagiuri on behalf of the National Association of Diabetes Centres. Final Report June 2006.

13. Quality Assurance of Patient Practices and Diabetes Centre Care: ANDIAB2. A/Prof

Jeff Flack and Prof Stephen Colagiuri on behalf of the National Association of Diabetes Centres. Final Report June 2010. http://www.health.gov.au/internet/main/publishing.nsf/Content/publications-Diabetes

14. Quality Assurance of Patient Practices and Diabetes Centre Care: ANDIAB2. A/Prof

Jeff Flack et al on behalf of the National Association of Diabetes Centres. Final Report 2012. http://www.health.gov.au/internet/main/publishing.nsf/Content/publications-Diabetes

15. Australian National Diabetes Audit ANDA-AQSMA 2014. Prof Sophia Zoungas et al on behalf of the National Association of Diabetes Centres. Final Report 2014. http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-diabetes-pubs

16. Diabetes dataset (clinical) [National Health Data Dictionary {NHDD}] National

Health Data Committee 2003.Other Data Set Specification, Diabetes(clinical), National Health Data Dictionary.Version12.AIHWcat.No.HWI47.Canberra:Australian Institute of Health and Welfare.

17. Meta data Online Registry [‘METeOR’]-Diabetes (clinical) Data Set Specification. [see

AIHW website]: http://meteor.aihw.gov.au/content/index.phtml/itemId/304865

18. A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments. Hawthorne G, Richardson J and Atherton Day N. Annals of Medicine 33; 358-370, 2001.

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Australian National Diabetes Audit ANDA-AQSMA 2016

Appendix 1

Protocol Data Collection Sheet

Data Definitions Data Dictionary

Form Completion Instructions Self-Assessment of Health Status

Diabetes Distress Scale 17

Final Report

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Page 1 of 10

ANDA-AQSMA PROTOCOL

Australian National Diabetes Audit – Australian Quality Self-Management Audit

Protocol Final Protocol Version 1 dated March 2016

Email: anda@nadc.net.au

An initiative of the National Association of Diabetes Centres (NADC)

Email: anda@nadc.net.au Web: www.nadc.net.au

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Page 2 of 10

TABLE OF CONTENTS : 1. Background 3 2. The Dataset 5 3. ANDA Software/Database 6 4. ANDA Coordination 6 5. ANDA Methodology 6

5.1 Survey period 7

5.2 Ethics 7 5.3 Survey population 7

5.4 Data Verification and Validation 7 5.5 Data analysis/reporting 8

5.6 Post survey/reporting feedback 8

6. Funding 8 7. Milestones 9 8. References 9

Acknowledgement

ANDA-AQSMA 2016 is funded by the Australian Government Department of Health

Monash Centre for Health Research

and Implementation This Activity is coordinated by the Monash Coordinating Centre led by Professor Sophia Zoungas and including Dr Natalie Nanayakkara, Diabetes Clinical Research Fellow, Sanjeeva Ranasinha, Biostatistician, Trieu-Anh Truong, Data Management Officer, Elspeth Lilburn, ANDA Secretariat and Natalie Wischer, NADC CEO

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Page 3 of 10

ANDA-AQSMA PROTOCOL Australian National Diabetes Audit –

Australian Quality Self-Management Audit Synopsis The Australian National Diabetes Audit - Australian Quality Self-Management Audit is a well-established, important biennial, quality activity led by the National Association of Diabetes Centres (NADC), in specialist diabetes centres across Australia, in all States and Territories, (although in some years, some States and Territories have not submitted data). Participating specialist diabetes services (Diabetes Centres and specialist endocrinologists in private practice), receive an individualised report of their diabetes practice processes and patient outcome data compared with their peers. In addition to the site audit report received by participating services, the pooled national report is an important source of cross-sectional data on the clinical status and outcomes of individuals attending specialist diabetes services across the country. ANDA-AQSMA is undertaken in services specialising in diabetes care and other clinical practice settings including primary care. In 2015, an advisory committee was established to provide strategic guidance to ensure the ANDA program successfully achieves the outcomes and deliverables as specified by the Department of Health. This committee consists of representatives of key stakeholder organisations, including Endocrinologists, Diabetes Nurse Educators, Data experts and the NADC CEO. 1. Background The National Association of Diabetes Centres (NADC) is a national collective of Diabetes Centres brought together by a common desire to see improvement in the standard of diabetes care in Australia. With the focus being on proactive maintenance of good health and complications prevention, NADC Diabetes Centres aim to bridge the gap between the acute care hospital system, and the long-term chronic care of primary care and community services. Supported by the Australian Diabetes Society (ADS), the NADC facilitates the ANDA initiative as part of monitoring and improving quality of care after considering the outcomes of the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS). The DCCT found that maintenance of good glycaemic control significantly reduces diabetes related complications in individuals with Type 1 diabetes, while the UKPDS showed that maintenance of good glycaemic and blood pressure control, in people with Type 2 diabetes, reduced the long term complications of the disease. Both strategies requiring a multidisciplinary team approach including specialist care to achieve better outcomes for people with diabetes. As a consequence, the NADC was created to establish and promote effective health care practice and ultimately achieve better outcomes for people with diabetes. In particular, key strategies were identified including the development of standards of care and quality review initiatives, information provision, and training and support for health professionals in specialist multidisciplinary settings.

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Page 4 of 10

What is an NADC Member Centre? The National Association of Diabetes Centres (NADC) is a national collective of Diabetes Services established in 1994 to promote mechanisms for improving the standard of care available to people with, or at risk, of diabetes through services specialising in diabetes care. In 2015 there were 103 NADC member diabetes centres across Australia and working in a range of locations and facilities ranging from major metropolitan adult and children’s hospitals, community based, and primary health care providers, i.e. local general practitioners and community health staff. Are there differences between the Diabetes Centres that participate in ANDA? There are 4 membership levels of NADC: 1. Centres of Excellence

Recognised diabetes centres that have demonstrated excellence in education, research, service delivery, practice/policy development and education. These centres must be Tertiary level facilities.

2. Tertiary Diabetes Centres

NADC centres that have the full range of diabetes service providers including endocrinologists, diabetes nurse educators, dietitians and podiatrists on staff full time and who have demonstrated a high standard of care through service delivery and organisational capacity and have been accredited by the NADC.

3. Diabetes Care Centres

These services have a range of full and/or part-time diabetes staff but often do not have an endocrinologist as part of their usual team. They may be working toward accreditation as a tertiary centre.

4. Affiliate Centres

These centres have part-time staff and work closely with the local general practitioners to provide care for people with diabetes.

Who will access the various Diabetes Services? Most patients attending Tertiary Diabetes Centres, including centres of excellence, for specialist assessment and treatment are referred by general practitioners. Given this, it is important to recognise that people attending Tertiary Diabetes Centres will be those more likely to have complex disease or needs. In considering the outcomes of this data collection, it is important to remember that whilst Tertiary Diabetes Centres will provide assessment and treatment, ongoing responsibility for management of most people remains with the individual and their general practitioner. Development of ANDA Quality Clinical Indicators There has been long standing worldwide interest in attempting to define suitable diabetes datasets and methods of data collection to reflect appropriate diabetes outcomes. As a result, collection, analysis and reporting of standardised diabetes datasets is now widely practised. The European Association for the Study of Diabetes (EASD) Study Group DO IT (Diabetes care Optimisation through Information Technology)1 undertook much work aimed at improving the quality of diabetes care through the appropriate use of information technology, including promoting the collection, analysis and reporting of the DiabCare dataset2,3 for audit and benchmarking purposes. From this has come the DiabCare Q-Net initiative4.

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A similar initiative in Australia, in September 1993, was the NSW Diabetes Outcomes Workshop (NDOW), sponsored by the NSW Health Department as one of its Health Outcomes Funded Projects5,6. Forty five diabetes health professionals, Health Department officials and consumers met for a one day workshop and agreed on a dataset of 59 health outcome data elements that covered demographic, acute and chronic complications and self-care practice areas of diabetes care. These items became known as the NDOW dataset, and subsequently these data items have become widely promulgated for collection (using standardised definitions) across Australia. In 1997 the Australian Diabetes Society (ADS) Council accepted a recommendation to adopt the NDOW dataset as its Diabetes Outcomes dataset, and formed a sub-committee (now named the National Diabetes Data Working Group (NDDWG)). This sub-committee managed the dataset and promoted quality diabetes care in Australia, through the National Diabetes Outcomes Quality Review INitiative, (NDOQRIN)). The NDDWG has taken a subset of the NDOW dataset and has promoted its collection as a minimum dataset (for quality diabetes care) in a variety of clinical practice settings. After diabetes was named the 5th National Health Priority Area in 1996, work followed to improve diabetes care in Australia including the commissioning of the National Diabetes Strategy to update and replace the National Action Plan. One aspect reviewed was the need for local data on which appropriate planning could be carried out and assessment of the effect of initiatives could be undertaken. Consequently, several initiatives indicated the need for reliable data in Australia (including diabetes indicators work), as noted in the National Health Priority Areas Report: Diabetes Mellitus 19987. However, data on clinical aspects of diabetes, including outcomes data, were deficient in Australia as highlighted in The National Diabetes Strategy and Implementation Plan report (Colagiuri et al)8. The NDDWG continued to promulgate the NDOQRIN dataset, and in 2002 was successful in having it accepted as the first clinical dataset to be included in the National Health Data Dictionary and Knowledgebase, Version 12. This dataset has since been enhanced, and is now online as part of the AIHW – Metadata Online Registry (‘METeOR’) as the Diabetes (clinical) Data Set Specification at – (see AIHW website). http://meteor.aihw.gov.au/content/index.phtml/itemId/304865 2. The Dataset The NDOQRIN diabetes dataset has considerable compatibility with similar international datasets including the DiabCare dataset. The NDOQRIN dataset was enhanced and used as the basis of this national initiative, aimed at improving diabetes care through a structured approach to patient management9. This was achieved by linking the minimum dataset to the NSW Clinical Management Guidelines for Diabetes10, thence enhanced over the years. This minimum dataset is suitable for use in primary care (where it is known as the ‘Recommended GP Subset of the NDOQRIN Dataset’11), Specialist practice and Diabetes Centre settings. Enhancements and deletion/addition of data fields have occurred over the years with feedback from participating centres on collections. Currently the dataset remains a one page scannable form with required written data kept to a minimum, most fields being yes/no or other choice options (Appendix Data Collection Form). The data definitions provide definitions for each data field, including all valid field types. (Appendix Data Definitions). The data dictionary (indicating field type, size and transfer protocol requirements) has been updated and is made available to all sites including sites contemplating electronic data transfer from in-house databases.

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3. ANDA Software/Database An application of Teleform© scannable/faxable software has been integrated with a Microsoft SQL Server 2010 running under a Windows XP© operating system. The Teleform© Designer module allows paper forms to be designed and printed (or faxed out). Once completed, forms can be mailed to the ANDA Secretariat at 43-51 Kanooka Grove, Clayton, VIC 3168. The Teleform© Reader module assesses each form and either accepts the form (transferring data to an intermediate Access© data file), or suspends the form for verification of one or more data items that the Reader software cannot confidently identify. The Teleform© Verifier module allows an on screen version of the scanned (or faxed) image to be viewed, and corrections made where necessary. Once such corrections are made and accepted, data from these forms are also transferred to the intermediate file. Data in this file are then appended to the permanent database file. Concurrent Operating System and Software Versions are Windows 7, Access 2003 & Teleform V10.1. The software has been written to allow individual practitioners or sites (eg a Diabetes Centre) to be registered, and for unique forms to be generated for completion by that practitioner (or site). Reports have been developed and attached to menu buttons on a user-friendly interface to enable data reporting. This includes data verification reports to ensure complete and valid data capture. Any data extracted from practitioner or site in-house databases will be transferred to via a secure file transfer protocol (SFTP) for collation and analysis alongside scanned form data. Data will be stored in the central ANDA Database, a Microsoft Access© database held in password protected files on computers stored in a locked room at the School of Public Health and Preventive Medicine, Monash University. 4. ANDA Coordination ANDA coordination and conduct will be overseen by Monash Health, Diabetes and Vascular Medicine Unit, Clayton, Victoria. The ANDA Secretariat based at Monash Health will coordinate the conduct of ANDA and distribution of reports.

The ANDA Data Management and Analysis Centre based at the Monash Centre for Health Research and Implementation, Monash University in partnership with Monash Health, will oversee and manage the ANDA database and complete the data analysis and reporting.

5. ANDA Methodology

ANDA will consist of the following steps:

1. Initial call for expressions of interest from all currently registered NADC Diabetes Centres (potential sites).

2. Formal invitations to participate and site acceptances (participating sites). 3. Allocation of unique site codes by the ANDA Secretariat in a double blind manner and

distribution of data collection forms. 4. Data collection by participating sites. 5. Data entry, cleaning, collation and validation (including missing data query resolution). 6. Data analysis and reporting.

The ANDA Secretariat will invite Diabetes Centres (all levels of NADC membership) and specialist endocrinologists in private practice to participate in the ANDA-AQSMA collection for 2016.

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Specialist endocrinologists, may participate in one of two ways:

(i) as part of a Diabetes Centre receiving either a ‘pooled’ report for all doctors, or an individual report covering patients seen by each doctor (identified uniquely within that Centre); or

(ii) as an individual specialist in private practice independent of a Diabetes Centre.

All contact and correspondence with participating centres/specialist endocrinologists will only occur through the ANDA Secretariat. The ANDA Secretariat will provide participating centres and specialist endocrinologists with their unique site code and hold the only copy of this code. Sites that have participated in past surveys will use their previously allocated unique site code. Sites that have not participated in past surveys will be allocated a new unique site code. The central data management/analysis unit will generate ‘Master Copies’ of the forms uniquely numbered for each site and/or doctor. The forms will then be provided to the ANDA Secretariat who will distribute them to each of the participating sites. All sites will receive a “How to Fill in ANDA-AQSMA Forms” with instructions on how the forms should be completed and the data field definitions (Appendix “How to fill in ANDA-AQSMA Forms”). Each participating site will be instructed to make copies (as many as required) of their unique form for use in the survey. 5.1 Survey period Centres will conduct the survey over 4 consecutive weeks during the month of May or June. 5.2 Ethics As this is a doubly de-identified quality assurance activity it does not require formal ethics, however, the onus is on each centre to seek advice re local ethics requirements. 5.3 Survey population All consecutive patients attending the centre/service over the 4-week survey interval (recommended 100 patients per site). Sites using paper forms will be advised to complete a data collection form for each patient attending the centre/service. All completed forms will be copied by the sites and stored locally in a secure place. The original forms will then be sent to the ANDA Secretariat at 43-51 Kanooka Grove, Clayton VIC 3168. The ANDA Secretariat will check and collate the original forms and deliver them to the data management centre for processing. Sites with computerised databases will have the alternative option of extracting the appropriate data in an electronic and de-identified form and providing it directly to the ANDA Secretariat through a secure web based data transfer process. 5.4 Data Verification and Validation As in previous years every effort will be made to ensure data completeness and correctness, with specific “validation reports” generated for each site.

49

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These validation reports will contain lists of missing or potentially invalid data, as well as possible duplicate individual entries and will be forwarded to the sites by the ANDA Secretariat. Sites will then have 4 weeks to respond to these validation reports. Once returned to the ANDA Secretariat, they will be forwarded to the data management centre where any additional or corrected data items will be entered/corrected respectively, in the pooled database, prior to final data analysis. Where duplicates are identified, these will be reviewed and the first entered record retained, supplemented by any additional data in the second record that was missing in the original. The second entered record will then be deleted. 5.5 Data analysis/reporting In analysing the data, as in past surveys, the previous specified data assumptions, decisions and data ‘manipulations’ will be observed. Data analysis and reporting will include: Pooled data report • Variable frequency counts (including % missing data) • Variable descriptive statistics • Comparative statistics by site (de-identified) • Comparative statistics by year of collection • Comparative statistics by type of centre Site/doctor individual data report • Variable frequency counts (including % missing data) • Variable descriptive statistics Comparative statistics by year of collection Site reports will be presented in a standard format as tables and figures divided into the following sections: 1. Site Report at a Glance 2. Historical Comparison Report 3. National Benchmarking Report 4. Comparative statistics by site 5. NADC’s Guide to Quality Improvement 5.6 Post survey/reporting feedback Participating sites will be asked to complete two questionnaires: one in July/August, (at completion of the data collection phase), to assess the project overall, and the other in January, (after receipt of the reports) to assess the adequacy of the individual site/doctor report(s). (Appendix Post survey/reporting Questionnaires). 6. Funding

ANDA conduct has been funded by the Department of Health since 2013.

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7. Milestones

The major project milestones are summarised below:

ANDA-AQSMA Milestones

Revise ANDA-AQSMA Dataset Initial call for expressions of interest, March 2016

Formal invitations received, collation of site acceptances, April 2016

Allocation of site codes, April 2016 Generation and distribution of Data Collection Forms, April 2016

Data collection, May 2016– June 2016

Study assessment: Post Data Collection Questionnaire Data received from sites with in-house databases June 2016– July 2016

Data entry and validation July – September 2016

Missing Data reports forwarded to sites July – September 2016 Integration of returned missing data September 2016

Final Data Analysis October 2016

Draft Pooled Data Report December 2016 Final Site/Doctor Data Analysis Reports forwarded to sites January 2017

Final Pooled Data Report January 2017

Study assessment: Site Report Assessment Questionnaire

8. References

[1] DO IT Study Group. Report of the EASD Study Group DO IT 1990/1991. Diabetologia 1991; 34 (Suppl 2): I.

[2] Monitoring the targets of the St Vincent Declaration and implementation of quality

management in diabetes care: the DiabCare initiative. Piwernetz K, Home PD, Snorgaard O, Antsiferov M, Staehr-Johansen K, Krans M, for the DiabCare Monitoring Group of the St Vincent Declaration Steering Committee. Diabetic Med 1993; 10:371-377.

[3] Monitoring instruments for quality improvement in diabetes care. In Diabetes care and

research in Europe. The St Vincent Declaration action programme. Krans HMJ, Porta M, Keen H. G Ital Diabetologia 1992; 12 (suppl 2) 32-36.

[4] DiabCare Quality Network in Europe.

Piwernetz K, Bruckmeier A, Staehr Johansen K, Krans HMJ. Diabetes, Nutrition & Metabolism 1993; 6: 311-314.

[5] Report on the 1993 NSW Diabetes Outcomes Workshop [NDOW]. Diabetes Australia NSW &

NSW Department of Health.

[6] NSW diabetes outcomes workshop [NDOW] data collection. A. Rattray, S. Colagiuri, T. Churches, J. Flack. Abstract 113, Proceedings of the Australian Diabetes Society Meeting, September 1995 Melbourne.

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[7] National Health Priority Areas Report: Diabetes Mellitus 1998. Australian Health Ministers Conference August 1999. Commonwealth Department of Health and Aged Care, and the Australian Institute of Health and Welfare [1999].

[8] The National Diabetes Strategy and Implementation Plan 1998. Colagiuri S, Colagiuri R, Ward J. Diabetes Australia, Canberra 1998.

[9] National Divisions Diabetes Program Modules (Version 1 1998), Integration Support and Evaluation Resource Unit.

[10] Principles of Care and Guidelines for the Clinical Management of Diabetes Mellitus v1.3. NSW Department of Health 1996.

[11] Recommended GP Subset of the NDOQRIN Dataset. National Divisions Diabetes Program, Integration Support and Evaluation Resource Unit.

52

2.5 Have you had a flu vaccination in the last 12 months?

4.2 Diabetes Educator

Diet Only

Tablets

Insulin

Insulin+Tablets Nil

Injectables

Injectables+

Insulin+Tablets+Injectables

ANDA-AQSMA 2016

Section 1. Patient Demographics

Section 2. Diabetes Type & Management & Lifestyle Issues

1.3 Date of visit

Centre ID Site StaffIdentifier

MedicalRecord No.

1.1 Date of birth

No Yes1.4 Initial visit

No Yes

No Yes1.5 Aboriginal/Torres Strait Islander

Male Female1.2 Sex

d d m m y y y y

if FEMALE 1.2.1 Currently pregnant

Type 1 Type 2 GDM Don't Know Other2.1 Year of

diagnosisy y y y

2.2 Type of diabetes

2.3 Management method

Current smoker

Past smoker

Never smoked

2.7 Smoking status

d d m m y y y y

ANDA-AQSMA 2016 Data Collection Form Version 1.1

/ /

/ / 2 0 1 6

No Yes1.6 Interpreter required No Yes1.7 DVA patient

No Yes

2.6 Have you had a pneumococcal vaccination in the last 12 months? No Yes

if CURRENT 2.7.1 Have you tried to stop smoking?

if PAST 2.7.2 Which of the following methods did you use?

No Yes

Australian National Diabetes Audit - Australian Quality Self Management Audit

No Yes1.8 NDSS mem ber

1.9 Country of birth

3.2 Do you usually take all your medications?

3.3 Do you sometimes stop taking your medications when you feel better?

3.5 Are you using a complementary therapy or dietary supplement or over the counter (OTC) Rx?

3.5.1 Have you told your doctor or educator about usingcomplementary, dietary supplement or OTC Rx?

3.4 Do you sometimes stop taking your medications when you feel worse?

3.1 Do you ever forget to take your medications?

if YES 3.1.1 How many times per week?

Section 3. Medication Use

5.1 Do you have difficulties following your recommended diet?

5.1.1 I don't have enough time to prepare healthy meals

5.1.2 It costs too much to eat well

Section 5. Patient Self Care Practices

5.1.3 I don't know what foods are best to eat5.1.4 I eat out a lot and find it hard to eat wellwell

No Yes

if YES Do the following apply?

5.1.5 If Type 1 - it is too hard to count carbs/weigh food

Has the patient attended any of the following in the last 12 months?

No Yes

4.8 Optometrist

4.7 Ophthalmologist

4.6 Diabetes Specialist

4.5 Social Worker

4.4 Psychologist

4.3 Dietitian

4.1 Podiatrist

Section 4. Health Professional Attendances

4.10 Exercise Physiologist

4.9 Dentist

Section 7. Quality of Life Assessment

Part A: Self-assessment of health status

7.2 Screening Scale Q1

7.3 Screening Scale Q2

7.1 Own health state rating (0-100)

} if Q1 or Q2 is > 3,complete Part B

No Yes7.4 DDS 17 Questionnaire done

Part B: Diabetes Distress Scale 17

if YES complete 7.4.1 - 7.4.5 below:

7.4.1 Total DDS 17 Score .7.4.2 Emotional

Burden (A) .

7.4.3 Physician-related distress (B) .

7.4.4 Regimen-related distress (C) .

7.4.5 Interpersonal distress (D) .

No Yes

Over the last couple of weeks has the patient been:No Yes

6A.4 Dissatisfied with their way of doing things

6A.3 Feeling unable to overcome difficulties

6A.2 Feeling unhappy or depressed

6A.1 Having restless or disturbed nights

Section 6A. BCD

6B.2 Psych. treatment/counselling - past

6B.1 Is the patient taking antidepressants

6B.3 Psych. treatment/counselling - now

No Yes

Section 6B. Treatment

%.2.8 Glycated Hb result ANDmmol/mol

Tablets

Just stopped - no intervention

Medication

Nicotine replacement

Hypnosis

Acupuncture

Other

<1yr

1-5yrs

>5yrs

2.3.1 How long agow as insulin started?

if INSULIN

Sufficient Insufficient Sedentary2.4 Physical activity sufficiency

if YES

No Yes

5.2 Do you check your blood glucose level as often as recommended?

No Yes Unsure of recommended testing

5.3 If you are on injectables or insulin, do you rotate your injection site? No Yes

17780

53

ANDA‐AQSMA 2016 DATA DEFINITIONS

Section 1. Patient Demographics Medical Record No. (Compulsory field). Enter some identifier such as record number or first the 2 letters of the first name and surname and month

and year of birth (e.g. FFSSMMYY) to enable you to check your records if there is a question regarding the data. Centre ID Site Identifier. Site Staff Identifier Site staff ID. Date of Birth Record as DD/MM/YYYY. [If unknown other than year: Record as 01/01/YYYY]. Sex Mark Male or Female indicating phenotypic (physical) sex at birth. Currently pregnant If Sex is female, mark Yes or No if the patient is currently pregnant. Date of Visit Record the date the patient attended as DD/MM/2014. Initial Visit Mark No or Yes indicating if this is an initial visit assessment. Indigenous Mark No or Yes indicating Aboriginal / Torres Strait Islander background (or neither). Interpreter required Record No or Yes for the requirement for interpreter services as perceived by the patient. DVA Patient Eligible people whose medical care charges are met by the Dept of Veterans’ Affairs (DVA). NDSS Member Record No or Yes if a member of the NDSS. Country of Birth Enter the patient’s country of birth. Section 2. Diabetes Type & Management & Lifestyle Issues Year of Diagnosis Record as YYYY of first diagnostic blood glucose estimation. Type of Diabetes Mark Type1 [IDDM] or Type2 [NIDDM] or GDM or Don't Know, or Other to indicate the clinical classification of diabetes. Management Method Record as Diet Only or Tablets or Injectables or Insulin or Insulin & Tablets or Nil to indicate the management method.

Injectables includes injected anti‐hyperglycaemic agents not including insulin (eg GLP‐1 analogues). If on insulin: How long ago was insulin started

<1 year insulin was started within the past year. 1‐5 years insulin was started between 1 and 5 years ago. > 5 years insulin was started more than 5 years ago.

Flu vaccination Has the patient had a flu vaccination in the last 12 months? (No/Yes). Pneumococcal vaccination Has the patient had a pneumococcal vaccination in the last 12 months? (No/Yes). Physical Activity Physical activity is calculated in ‘total minutes per week’ by summing the total minutes of walking, moderate and/or vigorous

physical activity in a usual 7‐day period. Vigorous physical activity is weighted by a factor of two to account for its greater intensity.Intensity of physical activity is defined by The National Physical Activity Guidelines for Australians: Moderate physical activity causes a slight but noticeable increase in breathing and heart rate, the person can comfortably talk but not sing. Vigorous physical activity causes the person to ‘huff and puff,’ talking in full sentences between breaths is difficult. Sufficient physical activity for health benefit is equal to or more than 150 total minutes per week. Insufficient physical activity is more than 0 minutes, but less than 150 total minutes per week. Sedentary is where there has been no moderate and / or vigorous physical activity per week.

Smoking Status Mark Current Smoker or Past Smoker or Never Smoked to indicate smoking of any tobacco material. Current Smoker = regular smoking over the past 3 months, Past Smoker = no regular smoking for 1 month or more, Never smoked = never smoked any tobacco material.

If Current Smoker Has tried in ANY WAY to stop smoking (No/Yes). If Past Smoker Indicate whether the method (No intervention or Medication or Nicotine replacement or Hypnosis or Acupuncture or Other)

was used to stop smoking. Glycated Hb Result Record absolute result [%] and mmol/mol of the most recent HbA1c result in the last 6 months. Section 3. Medication Use Medication use practices Ask patient questions as listed and indicate response (No/Yes). Complementary therapy Is the patient using a complementary therapy [herbal/homeopathic/ vitamin or mineral supplement or dietary supplement or

‘over the counter’ [OTC] Rx]? (No/Yes). Told doctor / DE Has the patient told their diabetes doctor or diabetes educator about using complementary therapy or OTC? (No/Yes). Section 4. Health Professional Attendances Health professional attendances Record if the patient attended (last 12 months) (No/Yes) for each health professional. Section 5. Patient Self Care Practices Do you have difficulties following your recommended diet?

Indicate whether patient has difficulties following recommended diet (No/Yes). If YES ask the patient whether the following options apply to them. Mark No/Yes to each of the options.

Do you check your blood glucose level as often as recommended?

Mark which one of the options describes the patient’s usual practice (No/Yes/Unsure of recommended monitoring).

Rotate injection sites Does the patient routinely change the site of injection for injectables or insulin? (No/Yes). Section 6A. Brief Case Find For Depression (BCD) Copyright 1993 Monash University Department of Psychology Medicine Been having restless or disturbed nights? (No/Yes). Been feeling unhappy or depressed? (No/Yes). Been feeling unable to overcome difficulties? (No/Yes). Problems of life that have been worrying you. Been dissatisfied with the way of doing things? (No/Yes). Things that you’ve had to do at home or at work. Section 6B. Treatment Is the patient taking antidepressants? Is the patient taking antidepressant medication (not prescribed for peripheral neuropathy)? (No/Yes). Psych treatment/counselling – now Is the patient currently having psychiatric treatment/counselling? (No/Yes). Psych treatment/counselling – past? Has the patient had psychiatric treatment/counselling in the past? (No/Yes). Section 7. Quality of Life Assessment Own Health State Rating Record the absolute result of the patient’s Own Health State Rating (0‐100) from Self Assessment of Health Status Screening Scale Q1 & Q2 All patients to do on Self Assessment of Health Status. Record the ACTUAL SCORE reported in the Screening Scale Q1 & Q2. DDS17 Questionnaire Done Was the DDS 17 Questionnaire done by the patient? (No/Yes). Only if screening scale Q1 or Q2 ≥3 administer DDS17. Total DDS Score Record the ‘Mean Item SCORE calculated on the DDS17 Scoring Sheet. Emotional Burden (A) Record the ‘Mean Item SCORE calculated on the DDS17 Scoring Sheet. Physician‐related distress (B) Record the ‘Mean Item SCORE calculated on the DDS17 Scoring Sheet. Regimen‐related distress (C) Record the ‘Mean Item SCORE calculated on the DDS17 Scoring Sheet. Interpersonal distress (D) Record the ‘Mean Item SCORE calculated on the DDS17 Scoring Sheet.

54

ANDA ‐ AQSMA Data Definitions

Item No. Question Field name Field Type Format Code Constraints Notes

Medical Record Number PatientID TEXT alphanumeric Compulsory field

Centre ID SiteID TEXT NNN Compulsory field

Site Staff Identifier GPID TEXT alphanumeric Optional field

1.1 Date of Birth DOB DATE DD/MM/YYYY Must be before CreatD

1.2 Sex Sex NUMERIC N1 = Male2 = Female Compulsory field

1.2.1 Currently Pregnant Pregnant_Current NUMERIC N1 = Yes2 = No Required only if Sex = 2

1.3 Date of Visit CreatD DATE DD/MM/YYYY Must be between May and June this year

1.4 Initial Visit Initial_Visit NUMERIC N1 = Yes2 = No Compulsory field

1.5 Aboriginal/Torres Strait Islander Indigen NUMERIC N1 = Yes2 = No Compulsory field

1.6 Interpreter required Interpret NUMERIC N1 = Yes2 = No Compulsory field

1.7 DVA Patient DVA NUMERIC N1 = Yes2 = No Compulsory field

1.8 NDSS Member NDSS NUMERIC N1 = Yes2 = No Compulsory field

1.9 Country of birth Country TEXT alphanumeric Compulsory field Introduced in 2014

Section 1. Patient Demographics

55

ANDA ‐ AQSMA Data Definitions

Item No. Question Field name Field Type Format Code Constraints Notes

2.1 Year of Diagnosis YearDx NUMERIC NNNN Must be between DOB and CreatD

2.2 Type of Diabetes DiabType NUMERIC N

1 = Type 12 = Type 23 = GDM4 = Don't know5 = Other Compulsory field

2.3 Management Method RxMethod NUMERIC N

1 = Diet2 = Tablets3 = Insulin4 = Insulin & Tablets5 = Nil6 = Injectables7 = Injectables & Tablets8 = Insulin, Tab, Inj. Compulsory field

2.3.1 How long ago was insluin started InsStarted NUMERIC N

1 = <1yr2 = 1‐5yrs3 = >5yrs Required only if RxMethod = 3, 4 or 8

2.4 Physical Activity Sufficiency PhysicalActivity_Sufficiency NUMERIC N

1 = Sufficient2 = Insufficient3 = Sedentary Compulsory field

2.5 Flu vaccination in last 12 months Vaccination_Flu NUMERIC N1 = Yes2 = No Compulsory field

2.6Pneumococcal vaccination in last 12 months Vaccination_Pneumococcal NUMERIC N

1 = Yes2 = No Compulsory field

2.7 Smoking Status Smoking_Status NUMERIC

1 = Current2 = Past3 = Never Compulsory field

2.7.1 Tried to stop smoking Smoker_TriedToStop NUMERIC N1 = Yes2 = No Required only if Smoking_Status = 1

2.7.2Cessation Method: Just Stopped ‐ no intervention Smoker_Past_JustStopped NUMERIC N

1 = Yes0 = No Required only if Smoking_Status = 2

2.7.2 Cessation Method: Medication Smoker_Past_Medication NUMERIC N1 = Yes0 = No Required only if Smoking_Status = 2

2.7.2Cessation Method: Nicotine replacement Smoker_Past_Nicotine NUMERIC N

1 = Yes0 = No Required only if Smoking_Status = 2

2.7.2 Cessation Method: Hypnosis Smoker_Past_Hypnosis NUMERIC N1 = Yes0 = No Required only if Smoking_Status = 2

2.7.2 Cessation Method: Acupuncture Smoker_Past_Acupuncture NUMERIC N1 = Yes0 = No Required only if Smoking_Status = 2

2.7.2 Cessation Method: Other Smoker_Past_Stopped_Other NUMERIC N1 = Yes0 = No Required only if Smoking_Status = 2

2.8 Glycated HbA1c % HbA1cPercent NUMERIC NN.N Must be between 5 ‐ 20

2.8 Glycated HbA1c mmol/mol HbA1cMmol NUMERIC NNN Optional field. If provided, must be between 31 ‐ 195 Introduced in 2014

Section 2. Diabetes Type & Management & Lifestyle Issues

56

ANDA ‐ AQSMA Data Definitions

Item No. Question Field name Field Type Format Code Constraints Notes

3.1 Forget to take medications Medications_Forget NUMERIC N1 = Yes2 = No Compulsory field

3.1.1 How many times per week Forget_Meds_HowManyTimes NUMERIC NN Required only if Medications_Forget = 1

3.2 Usually take all medications Medications_Careless NUMERIC N1 = Yes2 = No Compulsory field

3.3Sometimes stop taking when feeling better Medications_Better_Stop NUMERIC N

1 = Yes2 = No Compulsory field

3.4Sometimes stop taking when feeling worse Medications_Worse_Stop NUMERIC N

1 = Yes2 = No Compulsory field

3.5Using complementary therapy or dietary supplement or OTC Rx ComplementaryRxUsed NUMERIC N

1 = Yes2 = No Compulsory field

3.5.1

Told doctor or educator about using complementary, dietary supplement or OTC Rx ComplementaryRxToldDr NUMERIC N

1 = Yes2 = No Required only if ComplementaryRxUsed = 1

Item No. Question Field name Field Type Format Code Constraints Notes

4.1 Podiatrist Podiat NUMERIC N1 = Yes2 = No Compulsory field

4.2 Diabetes Educator DiabEduc NUMERIC N1 = Yes2 = No Compulsory field

4.3 Dietitian Dietitn NUMERIC N1 = Yes2 = No Compulsory field

4.4 Psychologist Psychologist NUMERIC N1 = Yes2 = No Compulsory field

4.5 Social Worker SocialWorker NUMERIC N1 = Yes2 = No Compulsory field

4.6 Diabetes Specialist DiabetesSpecialist NUMERIC N1 = Yes2 = No Compulsory field

4.7 Ophthalmologist Ophthalmologist NUMERIC N1 = Yes2 = No Compulsory field

4.8 Optometrist Optometrist NUMERIC N1 = Yes2 = No Compulsory field

4.9 Dentist Dentist NUMERIC N1 = Yes2 = No Compulsory field

4.10 Exercise Physiologist Exercise_Physiologist NUMERIC N1 = Yes2 = No Compulsory field

Section 3. Medication Use

Section 4. Health Professional Attendances

57

ANDA ‐ AQSMA Data Definitions

Item No. Question Field name Field Type Format Code Constraints Notes

5.1 Difficulties following prescirbed diet Diet_Difficulty NUMERIC N1 = Yes2 = No Compulsory field

5.1.1don't have enough time to prepare healthy meals Diet_Difficulty_Time NUMERIC N

1 = Yes2 = No Required only if Diet_Difficulty = 1

5.1.2 costs too much to eat well Diet_Difficulty_Cost NUMERIC N1 = Yes2 = No Required only if Diet_Difficulty = 1

5.1.3 don't know what foods are best to eat Diet_Difficulty_BestFoods NUMERIC N1 = Yes2 = No Required only if Diet_Difficulty = 1

5.1.4 eat out a lot and find it hard to eat well Diet_Difficulty_EatOut NUMERIC N1 = Yes2 = No Required only if Diet_Difficulty = 1

5.1.5 if type 1 ‐ too hard to count carbs Diet_Difficulty_Type1 NUMERIC N1 = Yes2 = No Required only if Diet_Difficulty = 1 & DiabType = 1

5.2Check blood glucose as often as recommended Check_glucose NUMERIC N

1 = Yes2 = No3 = Unsure Compulsory field Introduced in 2014

5.3 Rotate injection site Rotate NUMERIC N1 = Yes2 = No Required only if RxMetrhod = 3, 4, 6, 7 or 8 Introduced in 2014

Item No. Question Field name Field Type Format Code Constraints Notes

6A.1 Restless or disturbed nights RestlessNight NUMERIC N1 = Yes2 = No Compulsory field

6A.2 Feeling unhappy or depressed FeelingDepressed NUMERIC N1 = Yes2 = No Compulsory field

6A.3 Feeling unable to overcome difficulties FeltUnable NUMERIC N1 = Yes2 = No Compulsory field

6A.4Dissatisfied with their way of doing things BeenDissatisfied NUMERIC N

1 = Yes2 = No Compulsory field

Item No. Question Field name Field Type Format Code Constraints Notes

6B.1 Is the patient taking antidepressants OnAntidepressant NUMERIC N1 = Yes2 = No Compulsory field

6B.2 Psych. Treatment/counselling ‐ past PsychiatricTreatmentPrev NUMERIC N1 = Yes2 = No Compulsory field

6B.3 Psych. Treatment/counselling ‐ now PsychiatricTreatmentCurrent NUMERIC N1 = Yes2 = No Compulsory field

Section 6A. BCD

Section 6B. Treatment

Section 5. Patient Self Care Practices

58

ANDA ‐ AQSMA Data Definitions

Item No. Question Field name Field Type Format Code Constraints Notes

7.1 Own Health State Rating OwnHealthStateRating NUMERIC NNN Compulsory field

7.2 Screening Scale Q1 DDS_Screen_Q1 NUMERIC N Compulsory field

7.3 Screening Scale Q2 DDS_Screen_Q2 NUMERIC N Compulsory field

7.4 DDS 17 Questionnaire Done DDS17Q_Done NUMERIC N1 = Yes2 = No

Required only if either DDS_Screen_Q1 or DDS_Screen_Q2 > 3

7.4.1 Total DDS 17 Score Total_DDS_Score NUMERIC N.N Required only if DDS17Q_Done = 1

7.4.2 Emotional Burden Emot_Burden NUMERIC N.N Required only if DDS17Q_Done = 1

7.4.3 Physician‐related distress Phys_rel_Burden NUMERIC N.N Required only if DDS17Q_Done = 1

7.4.4 Regimen‐related distress Regimen_rel_Burden NUMERIC N.N Required only if DDS17Q_Done = 1

7.4.5 Interpersonal distress Interpers_Distress NUMERIC N.N Required only if DDS17Q_Done = 1

Item No. Question Field name Field Type Format Code Calculation Notes

Patient Age Age NUMERIC NN.NN (CreatD‐DOB)/365.25

Current Year Year NUMERIC NNNN 2016 Prepopulated

Duration of diabetes Duration NUMERIC NNYear‐YearDx‐1recode Duration (‐1=0)

BCD Depression Likely ‐ part A LikelyDepA NUMERIC N

LikelyDepA=1 if RestlessNight==1 | FeelingDepressed==1LikelyDepA=2 if RestlessNight==2 & FeelingDepressed==2

BCD Depression Likely ‐ part B LikelyDepB NUMERIC NLikelyDepB=1 if FeltUnable==1 | BeenDissatisfied==1LikelyDepB=2 if FeltUnable==2 & BeenDissatisfied==2

BCD Depression Likely BCDCalc NUMERIC N1 = Yes2 = No BCDCalc=1 if LikelyDepA=1 & LikelyDepB=1

Either DDS screening questions have a score of 3 or more DDS_Over2 NUMERIC N

1 = Yes2 = No DDS_Over2=1 if DDS_Screen_Q1>2 | DDS_Screen_Q2>2

Any of the DDS17 scores is equal to or more than 3 DDS_Indiv_over2 NUMERIC N

1 = Yes2 = No

DDS_Indiv_over2=1 if Total_DDS_Score >=3 | Emot_Burden >=3|Phys_rel_Burden>=3| Interpers_Distress>=3| Regimen_rel_Burden>=3

Derived Fields

Section 7. Quality of Life Assessment

59

60

1. The Forms2. Printing and Copying3. Completing the Forms4. Data Field Definitions5. Section 7: Quality of Life Assessment

Part A: Self Assessment of Health StatusPart B: Diabetes Distress Scale 17

61

62

63

Section 7 Part B (Diabetes Distress Scale 17)

ONLY needs to be completed in select patients.

Further details to follow.

!

Appendix 2 Appendix 2

64

65

For scanning purposes it is vital that copies of the ANDA‐AQSMA Data Collection Form are of perfect quality.

Correct Size

Straight on the Page

Centred

66

To avoid shrinkage when printing, please ensure the Page Scaling option is set to ‘None’

67

Forms should be completed for each patient with a black biro.Writing should be upright, clear and within the boxes.Do not use dashes or other symbols if data is missing or not required‐leave these boxes blank. The N/Y boxes can be filled in with

an ‘X’. Please ensure markings go through the centre of the box, not the edge.This is important so that the forms

can be automatically scanned. !

68

If a mistake is made please put a line through the error and

clearly mark the correct choice.

Do not use leading zeros in number fields.

Correct

69

The Data Field Definitions sheet indicates the interpretation of each field and the valid entries for each.

When required, please reference these definitions.

70

Each patient should complete a separate ‘Self Assessment of Health Status’ Form (Appendix 1).

Own Health State Rating Patient draws a line from

‘Your Own Health State Today’ box to area on scale which best describes their current health

state.

71

Transpose Own Health State Rating (0 ‐100) onto Data Collection Form 7.1

72

Transpose answer to Screening Scale Questions

Q1 and Q2 onto Data Collection Form 7.2 and 7.3

73

Section 7 Part B (Diabetes Distress Scale 17)ONLY needs to be completed

IF ONE OR BOTH of the answers to 7.2 and 7.3 is greater than or equal to 3.

23

74

75

Patients to indicate score for all 17 questions by circling relevant

number 1 – 6 1 = not a problem

6 = a very serious problem

Section 7 Part B (Diabetes Distress Scale 17)ONLY needs to be completed

IF ONE OR BOTH of the answers to 7.2 and 7.3 is greater than or equal to 3.

!

76

A mean Total DDS 17 score is calculated by: 1. Summing answers to Q1 to Q172. Divide this by 173. Transpose this result onto the

Data Collection Form 7.4.151 3

77

Mean Subgroup Scores are also calculated by

1. Summing the results to relevant questions

2. Divide by the number of relevant questions

3. Transpose this to the Data Collection Form item 7.4.2 to 7.4.5

15 3

78

An electronic calculator is also available.Transpose results from DDS 17 Form into calculator.This automatically generates mean total and subscale scores.Transpose results onto Data Collection Form 7.4.2 to 7.4.5

79

We consider a mean item score of 3 or higher (moderate distress) as a level of distress worthy of clinical attention.

We also suggest reviewing the patient’s responses across all items, regardless of mean item scores.

If any single item scored 3 or greater we recommend making time to address this with the patient, and make referral to additional services as

appropriate, e.g. psychology, social work, pharmacy, or physician.

!

80

PLEASE RETAIN FOR YOUR OWN RECORDS: A copy of the Data Collection Forms Self Assessment of Health Status (Appendix 1)Diabetes Distress Scale 17 Questionnaire (Appendix 2)DDS17 Scoring Sheet (Appendix 3)

Please photocopy and retain a copy of the ANDA‐AQSMA Data Collection Forms in a secure place at your site.

Forward the ORIGINAL Data Collection Forms to the ANDA secretariat. !

PLEASE RETURN TO THE ANDA SECRETARIAT: ONLY the original one page ANDA‐AQSMA Data

Collection Forms.

81

Thank you very much for your efforts in participating in ANDA – AQSMA 2016!

If you have any questions please do not hesitate to contact the ANDA Secretariat,

Elspeth Lilburn on anda@nadc.net.au

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ANDA-AQSMA 2016

SELF ASSESSMENT OF HEALTH STATUS

Appendix 1

Date:

Name:

Own Health State Rating (0-100)

We would like you to indicate on the scale to the right how good or bad your own health state is today, in your opinion.

Please do this by drawing a line from the grey box below to whichever point on the scale indicates how good or bad your health state is today.

Best imaginable health state

Screening Scale Questions

Listed in the table below are two potential problem areas that people with diabetes may experience. Consider the degree to which each of the two items may have distressed or bothered you during the past month and circle the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that particular item is not a bother or problem for you, you would circle “1”. If it is very bothersome to you, you might circle “6”.

Your Own Health State

Today

Not a Problem

A Slight Problem

A

Moderate Problem

Somewhat

Serious Problem

A Serious Problem

A Very Serious

Problem

Q1. Feeling overwhelmed by the demands of living with diabetes.

1

2

3

4

5

6

Q2. Feeling that I am often failing with my diabetes routine.

1

2

3

4

5

6

ANDA-AQSMA 2016

Worst imaginable health state

83

ANDA‐AQSMA 2016

DIABETES DISTRESS SCALE 17

Page 1 of 2

DIRECTIONS: Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Listed below are 17 potential problem areas that people with diabetes may experience. Consider the degree to which each of the 17 items may have distressed or bothered you DURING THE PAST MONTH and circle the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would circle “1”. If it is very bothersome to you, you might circle “6”.

Patient Name: Date:

Appendix 2

84

ANDA‐AQSMA 2016

DIABETES DISTRESS SCALE 17

Page 2 of 2

Appendix 2

85

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86

Australian National Diabetes Audit ANDA-AQSMA 2016

Appendix 2

Post Data Collection Questionnaire Individual Site Report Questionnaire

Final Report

87

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88

ANDA-AQSMA 2016 (Australian National Diabetes Audit) Post Data Collection Questionnaire

Thank you for completing the data collection phase of the project. We would now greatly appreciate your anonymous comments to the following brief questionnaire. Please mark your response to each question on the 1 – 5 “Lickert” Scale or circle N/A (Not Applicable). [A] Please comment on the “How to fill in ANDA-AQSMA Forms” information package/letters you received about the data collection project:

N/A [1] Poor / Insufficient [5] Excellent / Fully explained

Information Package/Letters 1________2________3________4________5 Comments: _________________________________________________________________ ___________________________________________________________________________ [B] Please comment on the Data Definitions Forms:

N/A [1] Unclear / Confusing [5] Clear / Concise

Data Definitions Forms 1________2________3________4________5 Comments: _________________________________________________________________ ___________________________________________________________________________ [C] Please comment on the following aspects of the Data Collection Forms: [C1] Format (layout of data items) [1] Unclear / Confusing [5] Clear / Concise 1________2________3________4________5 Comments: _________________________________________________________________ ___________________________________________________________________________ [C2] Ease of completion [1] Difficult [5] Easy 1________2________3________4________5 Comments: _________________________________________________________________ ___________________________________________________________________________

89

[C3] Time to complete the form [1] Took too long [5] Time not excessive 1________2________3________4________5 Comments: _________________________________________________________________ ___________________________________________________________________________ [D] Please list any Data items you feel should have ALSO been collected in ANDA-AQSMA. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ [E] Please list any Data items you feel should NOT have been collected in ANDA-AQSMA. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ [G] Any other comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Thank you for taking the time to complete this questionnaire. Please email to: Elspeth Lilburn anda@nadc.net.au

90

ANDA-AQSMA 2016 [Australian National Diabetes Audit] Individual Site Report Questionnaire

Thank you again for participating in the ANDA-AQSMA 2016 data collection project. We would now greatly appreciate your anonymous comments to this brief questionnaire. Please mark your response to each question on the 1 - 5 Lickert Scale. [A] Please comment on your overall impression of the Individual Site Final Report you received: Individual Site Final Report

[1] Poor/Limited Use [5] Excellent/Useful

1_________2_________3_________4_________5 Comments: _______________________________________________________________ _________________________________________________________________________ [B] Please comment on the following aspects /sections of the REPORT: [i] Explanatory Information

[1] Unclear/Confusing [5] Clear/Concise/Instructive

1_________2_________3_________4_________5 Comments: ________________________________________________________________ __________________________________________________________________________ [ii] 3 Year Comparative Data If Applicable Yes / No / N/A Is the comparative 2012, 2014 & 2016 Patient Outcomes and Missing Data Useful?

[1] Unclear/Confusing [5] Clear/Concise/Instructive

1_________2_________3_________4_________5

Comments: _________________________________________________________________ ___________________________________________________________________________ [iii] Worked Examples

[1] Unclear/Confusing [5] Clear/Concise/Instructive

1_________2_________3_________4_________5 Comments: ___________________________________________________________________ _____________________________________________________________________________

91

[iv] National Benchmarking Report [1] Unclear/Confusing [5] Clear/Concise/Instructive

1_________2_________3_________4_________5

Comments: __________________________________________________________________ ____________________________________________________________________________ [v] Comparative Statistics by Site

[1] Unclear/Confusing [5] Clear/Concise/Instructive

1_________2_________3_________4_________5

Comments: __________________________________________________________________ ____________________________________________________________________________ [C] Please list any Data / Information you feel should have ALSO been reported. _____________________________________________________________________________ _____________________________________________________________________________ [D] Please list any Data / Information you feel should NOT have been reported. _____________________________________________________________________________ _____________________________________________________________________________ [E] Any other comments [in particular, how are you making use of your report?]. _____________________________________________________________________________ _____________________________________________________________________________ Thank you for taking the time to complete this questionnaire. Please email to: Elspeth Lilburn anda@nadc.net.au

92

Australian National Diabetes Audit ANDA-AQSMA 2016

Appendix 3

Frequency Count Data

Final Report

93

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94

Item Field Name Category Total % Relative %* Median Mean SD Min Max

1.1

DOB 3930 100.0% 100.0%

Missing 0 0.0%

Sum 3930 100.0% 100.0%

Age 3930 100.0% 100.0% 58.0 55.3 17.4 18.0 95.0

Missing 0 0.0%

Sum 3930 100.0% 100.0%

1.2

Male 1950 49.6% 49.7%

Female 1972 50.2% 50.3%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

1.2.1

Yes 242 29.5% 29.6%

No 576 70.2% 70.4%

Missing 3 0.4%

Sum 821 100.0% 100.0%

1.3

Visit Date 3930 100.0% 100.0%

Missing 0 0.0%

Sum 3930 100.0% 100.0%

1.4

Yes 775 19.7% 19.8%

No 3146 80.1% 80.2%

Missing 9 0.2%

Sum 3930 100.0% 100.0%

1.5

Yes 175 4.5% 4.5%

No 3744 95.3% 95.5%

Missing 11 0.3%

Sum 3930 100.0% 100.0%

1.6

Yes 152 3.9% 3.9%

No 3770 95.9% 96.1%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

1.7

Yes 51 1.3% 1.3%

No 3863 98.3% 98.7%

Missing 16 0.4%

Sum 3930 100.0% 100.0%

SECTION 1. PATIENT DEMOGRAPHICS

Date of Birth

Age

Sex of Individual

Date of Visit

Initial Visit

Indigenous

Interpreter Required

DVA Patient

*Relative % = % of the total excluding the missing values

Currently Pregnant (for females aged between 18‐50 years)

95

Item Field Name Category Total % Relative %* Median Mean SD Min Max

1.8

Yes 3581 91.1% 93.0%

No 271 6.9% 7.0%

Missing 78 2.0%

Sum 3930 100.0% 100.0%

1.9

Country 3927 99.9% 100.0%

Missing 3 0.1%

Sum 3930 100.0% 100.0%

SECTION 1. PATIENT DEMOGRAPHICS (cont)

NDSS Member

Country of Birth

*Relative % = % of the total excluding the missing values

96

Item Field Name Category Total % Relative %* Median Mean SD Min Max

2.1

Year 3914 99.6% 100.0% 2004 2002 11.9 1944 2016

Missing 16 0.4%

Sum 3930 100.0% 100.0%

Duration 3914 99.6% 100.0% 11.0 13.0 11.7 0.0 71.0

Missing 16 0.4%

Sum 3930 100.0% 100.0%

2.2

Type 1 1101 28.0% 28.1%

Type 2 2552 64.9% 65.1%

GDM 208 5.3% 5.3%

Don't know 20 0.5% 0.5%

Other 41 1.0% 1.0%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

2.3

Diet Only 251 6.4% 6.4%

Tablets 816 20.8% 20.8%

Injectables 23 0.6% 0.6%Injectables & Tablets

133 3.4% 3.4%

Insulin 1477 37.6% 37.6%Insulin & Tablets

1032 26.3% 26.3%

Insulin & Tablets & Injectables

190 4.8% 4.8%

Nil 3 0.1% 0.1%

Missing 5 0.1%

Sum 3930 100.0% 100.0%

2.3.1

<1 year 390 14.4% 14.7%

1‐5 years 686 25.4% 25.8%

>5 years 1582 58.6% 59.5%

Missing 41 1.5%

Sum 2699 100.0% 100.0%

SECTION 2. DIABETES TYPE & MANAGEMENT & LIFESTYLE ISSUES

Year of Diagnosis

Duration of Diabetes

Type of Diabetes

Management Method

How long ago was insulin started

*Relative % = % of the total excluding the missing values

97

Item Field Name Category Total % Relative %* Median Mean SD Min Max

2.4

Sufficient 1811 46.1% 46.2%

Insufficient 1510 38.4% 38.5%

Sedentary 601 15.3% 15.3%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

2.5

Yes 2445 62.2% 62.8%

No 1449 36.9% 37.2%

Missing 36 0.9%

Sum 3930 100.0% 100.0%

2.6

Yes 484 12.3% 12.4%

No 3409 86.7% 87.6%

Missing 37 0.9%

Sum 3930 100.0% 100.0%

2.7

Current 514 13.1% 13.1%

Past 1426 36.3% 36.3%

Never 1988 50.6% 50.6%

Missing 2 0.1%

Sum 3930 100.0% 100.0%

2.7.1

Yes 397 77.2% 78.1%

No 111 21.6% 21.9%

Missing 6 1.2%

Sum 514 100.0% 100.0%

2.7.2

Yes 1145 80.3% 80.3%

No 281 19.7% 19.7%

Sum 1426 100.0% 100.0%

2.7.2

Yes 103 7.2% 7.2%

No 1323 92.8% 92.8%

Sum 1426 100.0% 100.0%

Physical Activity

SECTION 2. DIABETES TYPE & MANAGEMENT & LIFESTYLE ISSUES (cont)

*Relative % = % of the total excluding the missing values

Influenza Vaccination

Pneumococcal Vaccination

Smoking Status

Current Smoker ‐ Tried to stop smoking

Past Smoker Method of Cessation ‐ No Intervention

Past Smoker Method of Cessation ‐ Medication

98

Item Field Name Category Total % Relative %* Median Mean SD Min Max

2.7.2

Yes 104 7.3% 7.3%

No 1322 92.7% 92.7%

Sum 1426 100.0% 100.0%

2.7.2

Yes 22 1.5% 1.5%

No 1404 98.5% 98.5%

Sum 1426 100.0% 100.0%

2.7.2 Past Smoker Method of Cessation ‐ AcupunctureYes 5 0.4% 0.4%

No 1421 99.6% 99.6%

Sum 1426 100.0% 100.0%

2.7.2 Past Smoker Method of Cessation ‐ OtherYes 64 4.5% 4.5%

No 1362 95.5% 95.5%

Sum 1426 100.0% 100.0%

2.8 Glycated Hb Result %HbA1c % 3595 91.5% 100.0% 8.0 8.3 1.9 4.4 17.4

Missing 335 8.5%

Sum 3930 100.0% 100.0%

2.8 Glycated Hb Result mmol/molHbA1c mmol/mol

3492 88.9% 100.0% 64.0 66.6 20.5 5.0 167.0

Missing 438 11.1%

Sum 3930 100.0% 100.0%

Past Smoker Method of Cessation ‐ Hypnosis

SECTION 2. DIABETES TYPE & MANAGEMENT & LIFESTYLE ISSUES (cont)

Past Smoker Method of Cessation ‐ Nicotine Replacement

*Relative % = % of the total excluding the missing values

99

Item Field Name Category Total % Relative %* Median Mean SD Min Max

3.1

Yes 1051 26.7% 26.8%

No 2868 73.0% 73.2%

Missing 11 0.3%

Sum 3930 100.0% 100.0%

3.1.1

Times forget 1009 96.0% 100.0% 1.0 1.9 16.6 1.0 14.0

Missing 42 4.0%

Sum 1051 100.0% 100.0%

3.2

Yes 3569 90.8% 92.1%

No 307 7.8% 7.9%

Missing 54 1.4%

Sum 3930 100.0% 100.0%

3.3

Yes 236 6.0% 6.1%

No 3637 92.5% 93.9%

Missing 57 1.5%

Sum 3930 100.0% 100.0%

3.4

Yes 274 7.0% 7.1%

No 3598 91.6% 92.9%

Missing 58 1.5%

Sum 3930 100.0% 100.0%

3.5

Yes 1071 27.3% 27.7%

No 2800 71.2% 72.3%

Missing 59 1.5%

Sum 3930 100.0% 100.0%

3.5.1

Yes 917 85.6% 86.0%

No 149 13.9% 14.0%

Missing 5 0.5%

Sum 1071 100.0% 100.0%

SECTION 3. MEDICATION USE

Ever forget to take medications

How many times forget medications per week

Medications ‐ Usually take all your medications

Medications ‐ Stop taking when you feel better

Medications ‐ Stop taking when you feel worse

Medications ‐ Using complementary therapy or dietary supplement

Medications ‐ Told Dr or educator of use of complementary therapy

*Relative % = % of the total excluding the missing values

100

Item Field Name Category Total % Relative %* Median Mean SD Min Max

4.1

Yes 2176 55.4% 55.4%

No 1749 44.5% 44.6%

Missing 5 0.1%

Sum 3930 100.0% 100.0%

4.2

Yes 2987 76.0% 76.1%

No 940 23.9% 23.9%

Missing 3 0.1%

Sum 3930 100.0% 100.0%

4.3

Yes 2047 52.1% 52.2%

No 1877 47.8% 47.8%

Missing 6 0.2%

Sum 3930 100.0% 100.0%

4.4

Yes 558 14.2% 14.2%

No 3364 85.6% 85.8%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

4.5

Yes 305 7.8% 7.8%

No 3617 92.0% 92.2%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

4.6

Yes 2798 71.2% 71.2%

No 1130 28.8% 28.8%

Missing 2 0.1%

Sum 3930 100.0% 100.0%

4.7

Yes 1536 39.1% 39.2%

No 2384 60.7% 60.8%

Missing 10 0.3%

Sum 3930 100.0% 100.0%

4.8

Yes 2565 65.3% 65.4%

No 1356 34.5% 34.6%

Missing 9 0.2%

Sum 3930 100.0% 100.0%

Attended Psychologist in last year

Attended Social Worker in last year

SECTION 4. HEALTH PROFESSIONAL ATTENDANCES

Attended Podiatrist in last year

Attended Diabetes Educator in last year

Attended Dietitian in last year

Attended Diabetes Specialist in last year

Attended Ophthalmologist in last year

Attended Optometrist in last year

*Relative % = % of the total excluding the missing values

101

Item Field Name Category Total % Relative %* Median Mean SD Min Max

4.9

Yes 1729 44.0% 44.1%

No 2191 55.8% 55.9%

Missing 10 0.3%

Sum 3930 100.0% 100.0%

4.10

Yes 358 9.1% 9.1%

No 3563 90.7% 90.9%

Missing 9 0.2%

Sum 3930 100.0% 100.0%

Attended Dentist in last year

SECTION 4. HEALTH PROFESSIONAL ATTENDANCES (cont)

Attended Exercise Physiologist in last year

*Relative % = % of the total excluding the missing values

102

Item Field Name Category Total % Relative %* Median Mean SD Min Max

5.1

Yes 1400 35.6% 35.7%

No 2527 64.3% 64.3%

Missing 3 0.1%

Sum 3930 100.0% 100.0%

5.1.1

Yes 460 32.9% 33.2%

No 927 66.2% 66.8%

Missing 13 0.9%

Sum 1400 100.0% 100.0%

5.1.2

Yes 422 30.1% 30.4%

No 967 69.1% 69.6%

Missing 11 0.8%

Sum 1400 100.0% 100.0%

5.1.3

Yes 392 28.0% 28.2%

No 996 71.1% 71.8%

Missing 12 0.9%

Sum 1400 100.0% 100.0%

5.1.4

Yes 312 22.3% 22.5%

No 1076 76.9% 77.5%

Missing 12 0.9%

Sum 1400 100.0% 100.0%

5.1.5

Yes 176 55.3% 56.6%

No 135 42.5% 43.4%

Missing 7 2.2%

Sum 318 100.0% 100.0%

5.2 Check blood glucose level as often as recommended

Yes 2677 68.1% 68.5%

No 995 25.3% 25.5%

Unsure 234 6.0% 6.0%

Missing 24 0.6%

Sum 3930 100.0% 100.0%

5.3 Rotate injection siteYes 2680 93.9% 95.6%

No 124 4.3% 4.4%

Missing 51 1.8%

Sum 2855 100.0% 100.0%

SECTION 5. PATIENT SELF CARE PRACTICES

Diet ‐ Difficulties following recommended diet

Diet ‐ Not enough time to prepare healthy meals

Diet ‐ It costs too much to eat well

Diet ‐ I don't know what foods are best to eat

Diet ‐ I eat out a lot and find it hard to eat well

*Relative % = % of the total excluding the missing values

Diet ‐ If Type 1, it is too hard to count carbs/weigh food

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Item Field Name Category Total % Relative %* Median Mean SD Min Max

6A.1 Having restless or disturbed nightsYes 2001 50.9% 51.1%

No 1918 48.8% 48.9%

Missing 11 0.3%

Sum 3930 100.0% 100.0%

6A.2 Feeling unhappy or depressedYes 1238 31.5% 31.6%

No 2680 68.2% 68.4%

Missing 12 0.3%

Sum 3930 100.0% 100.0%

6A.3

Yes 785 20.0% 20.0%

No 3132 79.7% 80.0%

Missing 13 0.3%

Sum 3930 100.0% 100.0%

6A.4

Yes 959 24.4% 24.5%

No 2957 75.2% 75.5%

Missing 14 0.4%

Sum 3930 100.0% 100.0%

Likely 1078 27.4% 27.4%

Unlikely 2852 72.6% 72.6%

Missing 0 0.0%

Sum 3930 100.0% 100.0%

6B.1

Yes 755 19.2% 19.2%

No 3168 80.6% 80.8%

Missing 7 0.2%

Sum 3930 100.0% 100.0%

6B.2

Yes 1039 26.4% 26.5%

No 2883 73.4% 73.5%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

6B.3

Yes 410 10.4% 10.5%

No 3512 89.4% 89.5%

Missing 8 0.2%

Sum 3930 100.0% 100.0%

Taking Antidepressants

Psych. Treatment/counselling ‐ past

Psych. Treatment/counselling ‐ now

Feeling unable to overcome difficulties

SECTION 6. BCD & TREATMENT

Dissatisfied with their way of doing things

*Relative % = % of the total excluding the missing values

Depression Likely

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Item Field Name Category Total % Relative %* Median Mean SD Min Max

7.1 Own Health StateRating 3890 99.0% 100.0% 70.0 66.0 20.1 0.0 100.0

Missing 40 1.0%

Sum 3930 100.0% 100.0%

7.2 Screening Scale Q1Rating 3897 99.2% 100.0% 2.0 2.1 1.2 1.0 6.0

Missing 33 0.8%

Sum 3930 100.0% 100.0%

7.3 Screening Scale Q2Rating 3897 99.2% 100.0% 2.0 2.2 1.3 1.0 6.0

Missing 33 0.8%

Sum 3930 100.0% 100.0%

7.4

Yes 1372 90.9% 91.2%

No 132 8.7% 8.8%

Missing 6 0.4%

Sum 1510 100.0% 100.0%

7.4.1

Total Score 1364 90.2% 100.0% 2.0 2.3 0.9 1.0 6.0

Missing 148 9.8%

Sum 1512 100.0% 100.0%

7.4.2

Score 1370 90.6% 100.0% 2.6 2.7 1.2 1.0 6.0

Missing 142 9.4%

Sum 1512 100.0% 100.0%

7.4.3 DDS 17 Physician‐related distressScore 1369 90.5% 100.0% 1.0 1.5 0.9 1.0 6.0

Missing 143 9.5%

Sum 1512 100.0% 100.0%

7.4.4 DDS 17 Regimen‐related distressScore 1371 90.7% 100.0% 2.2 2.5 1.1 1.0 6.0

Missing 141 9.3%

Sum 1512 100.0% 100.0%

7.4.5 DDS 17 Interpersonal distressScore 1371 90.7% 100.0% 1.6 1.9 1.2 1.0 6.0

Missing 141 9.3%

Sum 1512 100.0% 100.0%

DDS 17 Total Score

DDS 17 Emotional Burden

*Relative % = % of the total excluding the missing values

SECTION 7. QUALITY OF LIFE ASSESSMENT

DDS 17 Questionnaire Done

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Australian National Diabetes Audit ANDA-AQSMA 2016

Appendix 4

NADC’s Guide to Quality Improvement

Final Report

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NADC GUIDE TO QUALITY IMPROVEMENT

What should you do with the ANDA results?

Quality improvement is a critical factor in all levels of healthcare and plays an important part in the

provision of service. The onus of quality improvement in health is now the responsibility of all health

care providers and not just those in the Quality departments of our organisations. However, unless we

measure what we do, and the outcomes of our care, it will be difficult to know exactly what needs to

improve and what impact our improvements have had over time. Efforts to improve systems or

processes must be driven by reliable data.

Data not only allows us to accurately identify problems, it also assists us in prioritising quality

improvement initiatives and enables objective assessment of whether change and improvement have

indeed occurred after change. Data helps us to understand, focus and improve our service by allowing

us to compare our performance, either against known standards or against our own prior results.

Collecting and analysing data are therefore critical to the function of quality improvement in any health

service.

This guide demonstrates the fundamentals of using your data for quality improvement. The concepts

are logical and simple, and should apply to any practice.

The NADC encourages you and your organisation to take this opportunity to utilise the valuable

information provided to you in the final report of the 2016 ANDA-AQSMA audit.

The NADC hopes that the following guideline will aid the development of quality

improvement initiatives that can be reflected in your organisation's future results and patient

outcomes.

To access NADC quality improvement tool templates including the PDSA worksheet and a

detailed action plan, please click the following link or go to: http://nadc.net.au/quality-

improvement/

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THE STEPS OF QUALITY IMPROVEMENT Step 1: What is your centre aiming for?

You need to be clear, you need to be focused.

“If you aim at nothing, that’s what you will hit!”

Step 2: Assess your ANDA data

Where do you sit in comparison to other organisations?

• Can you do better? • Are you an outlier? • Why?

Again, reflect on what your centre aims for and is it achieving this aim?

Step 3: Deciding on your projects

Possible criteria for your Quality Improvement projects could be:

• Improvements that will be of most benefit to patients • Improvement actions that will have the biggest impact across the greatest number of areas • Improvement that are aligned with organisational strategic goals • Improvements that are most likely to succeed when all barriers are considered

Step 4: Rapid Cycle Model questions

The following is the rapid cycle model which gets you started by asking 3 questions:

1) What are you trying to accomplish? Using the questions of:

• What does the centre want to achieve? • How does this align with the organisation’s overall strategic goal?

Most organisations will align this with the following 6 overarching aims for improvement in health care:

• Safe • Effective • Patient-centred • Timely • Efficient • Equitable

As you answer this question you will develop your Aim Statement.

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2) How will you know that a change is an improvement?

The answer to this question helps determine your measures.

3) What changes can you make that will result in an improvement?

• What would give you the biggest bang for the organisation’s time and dollar investment? • Are there a few changes you can make that would be simple but effective that may be best

to do first? • Answering these questions moves you into testing the cycles as you begin to find solutions

and then make improvements upon them. • But remember: All improvement requires making changes but not all changes result in

improvement! Plan wisely!

4) How will you know that a change is an improvement? • Simple – ANDA data! You have it already! • Think about what other sources of information you have available • Benchmark with other NADC Centres

Step 5: Deploy the PDSA cycle

After answering the previous key questions, move into the PDSA cycle.

The PDSA system is a simple but effective tool to guide your activity through the essential improvement elements (see Appendix 1)

ACT PLAN

STUDY DO

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Plan:

In the planning section you decide:

• What exactly you will do • Who will carry out the plan • When will it take place • Where • What do you predict will happen • What data/information will you collect to know whether there is an improvement? What will

you measure?

Do

So what do you do in the “DO” section?

• You carry out the plan • You document any unexpected events or problems • You begin analysis of data

Study

The STUDY component is where you:

• Complete the analysis of the data • Review and reflect on the results • Compare the data to predictions • Summarise what was learned

Act

The “A” step in the PDSA cycle is where you ACT on what you have planned, done and studied.

You decipher:

• What changes are to be made • What is the next cycle • And can you grow the improvements that have been made • The cycle doesn’t necessarily stop here!

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5

BARRIERS TO CHANGE Sometimes despite our best efforts we have barriers to change.

Be alert to the following change blocker?

• Absence of relevant data • Negative attitude • Fixed routines • Lack of quality improvement skills • Unsupportive culture re innovation, team work, change and short term clinical focus • Money • And the big issue for everyone = TIME!

CHANGE PRACTICE INVOLVES • Keeping it simple • Starting small and build slowly • Being clear about what you want and how it can be achieved • Planning well • Involving key people • Selling your ideas and plans • Getting help!

CONCLUSION

Every system is perfectly designed to get the results it gets, so design your system for the results you want.

ANDA gives us an opportunity, an amazing resource that needs to be more than a file on your PC or a wad of papers in your filing cabinet. It needs to be brought to life and be the catalyst for improvement in your organisation.

“If we always do what we have always done, then we will always get what we have always got”

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6

Appendix 1

PDSA WORKSHEET Organisation: __________________________________________ Date: _________________________ Department: __________________________________________ Coordinator: ___________________ AIM: (What is the overall goal you wish to achieve?) ____________________________________________________________________________ PLAN: (List the tasks that need to be made to made the change)

ACTION How will you achieve the goal? What steps do you need to take?

WHO Who is involved?

MEASURABLE How will you know that you have achieved the goal

ACHIEVABLE What resources and time to do this?

REALISTIC Are you sure you can really do this?

TIME LIMITED When can this realistically be achieved?

Do: Describe what actually happened when the changes were implemented ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Study: Describe the measured results and how they compared to the predictions. Were goals met? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Act: Based on this PDSA cycle, what are the next steps to achieve the Goal/Aim statement? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Australian National Diabetes Audit ANDA-AQSMA 2016

Appendix 5

NADC’s Diabetes Publications & Resource List 2016

Final Report

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Diabetes Publications & Resource List 2016

There are many resources available nationally that provide evidence based guidelines on how care should be provided and what outcomes should be achieved for people living with diabetes.

The following is a list of commonly used resources in Australia. The list also includes health care organisations involved in the provision of diabetes care. These links have been divided into topics. Please click on the topic of interest.

Title Description / Link Prevention, Prediabetes & Diagnostics

National Evidence Based Guideline for Case Detection and

Diagnosis of Type 2 Diabetes

To read or download your copy, please click here

National Evidence Based Guideline for the Primary

Prevention of Type 2 Diabetes

To read or download your copy, please click here

The Australian Diabetes Educators Association (ADEA)

and the Australian Diabetes Society (ADS) Position

Statement on Prediabetes

To read or download your copy, please click here

Hospital Guidelines

ADS Guidelines for Routine Glucose Control in Hospital To read or download your copy, please click here

ADS Peri-Operative Diabetes Management Guidelines These guidelines are primarily intended to provide assistance for

those practitioners whose primary focus is not diabetes or who

do not have the support of local diabetes expertise in their

management of patients with diabetes undergoing surgical

procedures. To read or download your copy, please click here

Obesity Management Australian Obesity Management Algorithm This statement has been developed by a working group with

representatives from the Australian Diabetes Society, the

Australian and New Zealand Obesity Society and the Obesity

Surgery Society of Australian and New Zealand.

The aims of the document are to:

1) Assist general practitioners (GPs) in treatment decisions for

non-pregnant adults with obesity

2) Provide a practical clinical tool to guide the implementation of

existing guidelines for the treatment of obesity in the primary

care setting in Australia.

To read or download your copy, please click here (Posted:

October, 2016)

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Metabolic Surgery in the Treatment Algorithm for Type 2

Diabetes: A Joint Statement by International Diabetes

Organizations

The ADS has recently endorsed international guidelines that

recommend metabolic surgery for patients with type 2 diabetes

and class III (BMI ≥40 kg/m2) obesity and patients with type 2

diabetes with class II (BMI 35.0–39.9 kg/m2) obesity who have

had inadequate glycaemic control with lifestyle and

pharmacotherapy.

To read or download your copy, please click here (Posted: June,

2016)

Type 1 Diabetes

Alcohol and type 1 diabetes To view or download your copy, please click here

Diabetes in Pregnancy booklet for women with type 1 –

Having a Healthy Baby

To view or download your copy, please click here

Drug use and type 1 diabetes To view or download your copy, please click here

Guidelines for Sick Day Management for People with

Diabetes

Provides readily accessible nformation recommending strategies

for managing sick days in diabetes. To view the technical

document for health professional, please click here

To view the sick day management of adults with type 1 diabetes

consumer resources, please click here

Information for young women with type 1 or type 2

diabetes planning a pregnancy now or in the future

To view or download your copy, please click here

National Evidence Based Clinical Care Guidelines for Type

1 Diabetes in Children, Adolescents and Adults

To view or download your copy, please click here

Pregnancy & Diabetes Information To view or download your copy, please click here

Travelling and type 1 diabetes To view or download your copy, please click here

Type 2 Diabetes

ADS Position Statement on A New Blood Glucose

Management Algorithm for Type 2 Diabetes

This position statement developed by the Australian Diabetes

Society outlines the risks, benefits and costs of the available

therapies and suggests a treatment algorithm incorporating the

older and newer agents. Summary of this ADS Position

Statement is as follows:

To read or download the full version of the ADS A New Blood

Glucose Management Algorithm for Type 2 Diabetes Position

Statement please click here (Updated: October, 2016)

The Position Statement was also published in the MJA (Med J

Aust 2014; 201 (11): 650-653.). You can read the MJA article

online

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Diabetes Management in General Practice 2016/18 General practitioners continue to provide most of the medical

support to people with type 2 diabetes. This guide plays an

important role in providing a readable summary of current

guidelines and recommendations from various sources on the

management of type 2 diabetes in the general practice setting.

To read or download your copy, please click here

Guidelines for Sick Day Management for People with

Diabetes

Provides readily accessible nformation recommending strategies

for managing sick days in diabetes. To view the technical

document for health professional, please click here

To view the sick day management of adults with type 2 diabetes

consumer resources, please click here

Metabolic Surgery in the Treatment Algorithm for Type 2

Diabetes: A Joint Statement by International Diabetes

Organisations

The ADS has recently endorsed international guidelines that

recommend metabolic surgery for patients with type 2 diabetes

and class III (BMI ≥40 kg/m2) obesity and patients with type 2

diabetes with class II (BMI 35.0–39.9 kg/m2) obesity who have

had inadequate glycaemic control with lifestyle and

pharmacotherapy.

To read or download the full version of the 'Metabolic Surgery in

the Treatment Algorithm for Type 2 Diabetes: A Joint Statement

by International Diabetes Organizations' Guidelines please click

here (Posted: June, 2016)

National Evidence Based Guideline for Blood Glucose

Control in Type 2 Diabetes

To read or download your copy, please click here

National Evidence Based Guideline for Diagnosis,

Prevention and Management of Chronic Kidney Disease in

Type 2 Diabetes

To read or download your copy, please click here

National Evidence Based Guidelines for the Management

of Type 2 Diabetes

These guidelines comprise a suite of Type 2 Diabetes

Guidelines developed in 2009 under a funding agreement

between the Department of Health and Ageing and the Diabetes

Australia Guideline Development Consortium. The five

Guidelines in the series, when combined, present a

comprehensive set of evidence-based guidelines for the

prevention, diagnosis and management of Type 2 Diabetes. To

read or download your copy, please click here

Elderly / Aged Care / End of Life Diabetes Management in Aged Care: A practical handbook This is an updated version of the resource developed in 2012

and is aimed at care staff. To read or download your copy of the

E-book, please click here

To read or download your PDF copy, please click here

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Diabetes Management in Aged Care: Fact sheets for care

workers

The diabetes management in aged care fast facts for care

workers is a booklet of quick reference sheets that aim to give

care staff basic information on how to manage diabetes in a

residential care setting: To read or download your copy of the E-

book, please click here

To read or download your PDF copy, please click here

Guidelines for the Management and Care of Diabetes in the

Elderly

Focuses on the ‘healthy’ person over 65 years of age. Provides

readily accessible information about diabetes prevention,

diagnosis, treatment and long term management option for

elderly people at risk of or living with diabetes. To view or

download your full copy, please click here. To view a summary

version, click here

Guidelines for Managing Diabetes at the End of Life These guidelines were developed in 2014 to assist with the

management of Diabetes at the End of Life. To access these

guidelines, search for these on the ADMA website. Click this link

to access the ADMA website

Older People – Healthy Eating Guide To read or download your copy, please click here

Older People – Managing Diabetes as You Age To read or download your copy, please click here

Older People – You and your Health Care Team To read or download your copy, please click here

The McKellar guidelines for Managing Older people with

Diabetes in Residential and Other Care Settings

These Guidelines were developed in 2014 to assist with the

management of Diabetes in Residential Care Facilities. To

access these guidelines, search for these on the ADMA website.

Click this link to access the ADMA website

Consulting / Diabetes Education

A new language for diabetes – Improving communications

with and about people with diabetes

Diabetes Australia has released an updated version (May 2016)

of their position statement on language around diabetes. To view

or download your copy, please click here

Enhancing your consulting skills “Enhancing Your Consulting Skills” was developed by the ADS

for the NDSS. It is now available in electronic format through the

ADS website. Please click here to access this. It can be

downloaded free of charge for individual use. Please note that

you will be required to submit a request for download and obtain

your password prior to receiving the download link. Hard copies

of the resource are available from the ADS Secretariat.

National Evidenced Based Guideline for Patient Education

in Type 2 Diabetes

This document provides minimum standards for development

and facilitation of diabetes education programs. To view or

download your copy, please click here

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Outcomes and Indicators for Diabetes Education: National

Consensus Position Information and Education for People

with Diabetes: a ‘Best Practice’ Strategy

This report details a systematically derived framework of

nationally agreed goals, outcomes and indicators for diabetes

education. It provides a benchmark and policy platform for

refining and evaluating the consistency, quality and

effectiveness of diabetes education services which can be

applied nationally and/or at a regional or local service level. To

view or download your copy, please click here

Person Centred Care & Health Literacy ADEA project In 2013-2014 ADEA completed a revision of the information

sheet ‘Person Centred Care for people with diabetes’ and

developed an information sheet on Health literacy for people

with diabetes. To view or download your copy, please click here

Renal Information National Evidence Based Guideline for Diagnosis,

Prevention and Management of Chronic Kidney Disease in

Type 2 Diabetes

To view or download your copy, please click here

Foot Care

• Australasian Podiatry Council

• Limbs 4 Life

National Evidence Based Guidelines on Prevention,

Identification and Management of Foot Complications in

Diabetes

Approved by the NHMRC, the full guideline, clinical guide,

consumer guides and technical report can be downloaded here

Eye Care

• Optometrists Association of Australia

Diabetes Educators

National Core Competencies for Credentialed Diabetes

Educators

Provides a reference and a framework for guiding policy on the

training and credentialing of diabetes educators. To view or

download your copy, please click here

National Standards of Practice for Diabetes Educators One of the strategies developed by ADEA to promote a quality

professional diabetes education practice. To view or download

your copy, please click here

The Credentialed Diabetes Educator in Australia – Role and

Scope of Practice

Reflects the position of their unique and integral role in enabling

people with diabetes manage their condition and as part of the

multidisciplinary diabetes care team. To view or download your

copy, please click here

The Role of Credentialed Diabetes Educators and

Accredited Practising Dietitians in the Delivery of Diabetes

Self-Management and Nutrition Services for People with

Diabetes

To view or download your copy, please click here

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Fact Sheets / Patient Resources

Baker IDI Fact Sheets These materials have been developed by Baker IDI experts for

use by clients and health professionals for patient education.

The Institute is committed to providing credible, evidence-based

health information regarding optimum approaches to the

prevention and management of disease. To view or download

these resources, please click here

Diabetes Australia patient information and resources

To view or download these resources, please click here

National Diabetes Services Scheme (NDSS) resources

including fact sheets

35 facts sheets including those in other languages are available

through the NDSS website. To view or download these

resources, please click here

Nutrition / Diet • Dietitians Association of Australia (DAA)

• Food Standards Australia New Zealand (FSANZ)

• Glycemic Index Ltd

• Nutrition Australia

• Coeliac Australia

• Diabetes Australia recipes

Healthy Eating Guide for Older Australians with Diabetes To view or download your copy, please click here

Pregnancy

• The Australasian Diabetes in Pregnancy Society (ADIPS)

• Pregnancy and Diabetes

Diabetes in Pregnancy booklet for women with type 1 –

Having a Healthy Baby

To view or download your copy, please click here

Diabetes in Pregnancy booklet for women with type 2 –

Having a Healthy Baby

To view or download your copy, please click here

Gestational Diabetes - Caring for Yourself and Your Baby To view or download your copy, please click here

Information for young women with type 1 or type 2

diabetes planning a pregnancy now or in the future

To view or download your copy, please click here

New ‘Life After Gestational Diabetes’ booklet for women

produced in 5 languages – Arabic, Turkish, Vietnamese,

Chinese Mandarin and Chinese Cantonese

To view or download your copy, please click here

An English version is available here as well.

Pregnancy & Diabetes Information To view or download your copy, please click here

Aboriginal and Torres Strait Islander

• HealthInfoNet

Aboriginal and Torres Strait Islander Resources – NDSS To view or download resources, please click here

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Online Diabetes Education Training Manual for Aboriginal

Health Workers

An online training manual has been developed to increase

diabetes knowledge among Aboriginal Health Workers to better

support Aboriginal and Torres Strait Islander people with

diabetes and assist them in self-managing their diabetes.

This training is targeted to Aboriginal and Torres Strait Islander

Health Practitioners and Aboriginal and Torres Strait Islander

Health Workers who have completed a minimum of Certificate IV

in Aboriginal and/or Torres Strait Islander Primary Health Care

(Community Care) or (Practice).

This course is available through the ADEA Learning

Management System at: learning.adea.com.au

CALD / Multilingual • NDSS translated resources

• Health Translations by the Victorian Government includes translated health information

• Multicultural Health by the Queensland Government

• Multicultural Health Communication by NSW Health

New ‘Life After Gestational Diabetes’ booklet for women

produced in 5 languages – Arabic, Turkish, Vietnamese,

Chinese Mandarin and Chinese Cantonese

To view or download your copy, please click here or access the

multicultural diabetes portal

An English version is available here as well.

Translated resources for CALD groups All of the NDSS's translated resources are now also available on

our Multicultural Diabetes Portal. The portal provides access to a

broad range of diabetes resources for people from culturally and

linguistically diverse (CALD) backgrounds.

Resources contained on the site have been sourced from

Diabetes Australia and its agents and from other reputable

sources. All content has undergone a quality assessment

process and guidelines are in place to ensure periodic review.

To view or download this content, please click here

Web portal for information about diabetes for people from

culturally and linguistically diverse backgrounds

To view or download your copy, please click here

Data / Research • Diabetes Australia Research Program

• Juvenile Diabetes Research Foundation (JDRF)

• The Australian Centre for Behavioural Research in Diabetes

• The Diabetes Research Centre

• The Diabetes Research Foundation Western Australia

• The John Curtin School of Medical Research

• The NHMRC Centre of Clinical Research Excellence on Clinical Science in Diabetes (Diabetes CCRE)

• Baker IDI

• The Walter and Eliza Hall Institute of Medical Research

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Australian National Diabetes Audit (ANDA) reports The primary aim of ANDA is to:

•conduct a survey that will assess a standardised set of

predefined clinical (AQCA) and self-management diabetes

(AQSMA) indicators including demographic and biological

variables, and clinical outcomes;

•enable specialist diabetes services to benchmark their practice

processes and clinical outcome data against that of other

centres;

•enable specialist diabetes services to compare their practice

processes and clinical outcome data over time (where

participation in previous collections has occurred); and

•provide pooled national data and data grouped by state and

metropolitan/regional/ remote location on the clinical status of

people with diabetes attending specialist diabetes services.

This important quality assurance activity promotes continuous

improvement in the standard of service provided by Diabetes

Centres and is the primary quality assurance activity of the

NADC.

To view this data please click here

Data Snapshots NDSS national diabetes data snapshots are updated every three

months, and provide key statistics for all types of diabetes, type

1 diabetes, type 2 diabetes, gestational diabetes, and insulin

therapy. To view or download these snapshots, please click here

Diabetes Map Australia The Australian Diabetes Map is the only national map monitoring

the prevalence of diabetes in Australia.

The data contained in the Australian Diabetes Map is derived

from the National Diabetes Services Scheme (NDSS) Registrant

database* and the Australian Bureau of Statistics (ABS) and

shows people diagnosed with diabetes that are registered on the

Scheme.

It shows the numbers of people diagnosed with diabetes in all

parts of Australia with information on age, gender, type of

diabetes, ATSI status and socio-economic disadvantage.

To view the Australian Diabetes Map, please click here

2015 Miles Youth Report To view or download your copy, please click here

HbA1c

ADEA Position Statement on HbA1c Reporting The ADEA supports the change in routine laboratory HbA1c

reporting from the NGSP % units to International Federation of

Clinical Chemists (IFCC) units (mmol/mol). To view ADEA’s

position statement, please click here

Individualisation of HbA1c targets for Adults with Diabetes

Mellitus.

To view or download the full version of this guideline, please

click here

To view or download the short version, please click here

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Subcutaneous Devices / Techniques

ADEA Clinical Guiding Principles for Subcutaneous

Injection Technique

The ADEA Clinical Guiding Principles for Subcutaneous Injection

Technique identifies a number of broad clinical issues including

optimal needle length and angle of needle insertion for

children/adolescents and adults of varying anatomical size.

These clinical recommendations reinforce the importance of

documenting the process of teaching and reviewing injection

technique. To view or download your copy, please click here

Use of subcutaneous insulin delivery devices This position statement outlines ADEA recommendations for use

of subcutaneous insulin delivery devices. To view or download

your copy, please click here

Driving ADEA Fitness to Drive

The goal of the roll out of the Support for Health Professionals in

the assessment of a person with diabetes and their fitness to

drive program is to ensure a large percentage of health

professionals are exposed to the online program and are aware

of their obligations under Austroad’s Assessing Fitness to Drive

for commercial and private drivers; Medical Standards for

Licensing and Clinical Management Guidelines.

Templates have been developed to assist general practice in

implementing discussions around diabetes and driving during

consultations:

Rich text format template GPMP721_Diabetes_MD3

Rich text format template GPMP721_Diabetes_BP

Annual Cycle of Care

Assessing Fitness to Drive The National Transport Commission and Austroads have released Assessing Fitness to Drive 2016, a new edition of national medical standards for driver licensing. To view or download a copy, please click here

Workplace

An Employee’s Guide to Diabetes in the Workplace This booklet was developed in response to questions, concerns

and suggestions Diabetes Australia received from members of

the diabetes community about diabetes in the workplace. To

view or download your copy, please click here

NDSS

Blood Glucose Test Strip Six Month Approval - NDSS To download your copy, please click here

Medication Change Form - NDSS To download your copy, please click here

Registration Form – NDSS

To download your copy, please click here

125

Diabetes Related Organisations In Australia

• Australian Diabetes Society

• Australian Diabetes Educators Association

• Diabetes Australia

• National Diabetes Services Scheme

• National Association of Diabetes Centres

Diabetes Australia Position Statements To view or download all current Diabetes Australia position

statements, please click here

Australian Government Departments • Australian Department of Health

• Australian Institute of Health and Welfare

• Federation of Ethnic Communities Council Australia

• Healthdirect Australia

• Food Standards Australia and New Zealand

• Medicare Australia

• National Health and Medical Research Council (NH&MRC)

• Pharmaceutical Benefits Scheme

• Therapeutic Goods Administration

Professional Associations & Organisations

• Australian Diabetes Society (ADS)

• Australian Diabetes Educators Association (ADEA)

• Australian Medicare Local Alliance (AMLA) - formerly AGPN

• Australian Practice Nurses Association

• Australasian Diabetes In Pregnancy Society (ADIPS)

• Australasian Paediatric Endocrine Group (APEG)

• Australasian Podiatry Council

• Cancer Council Australia

• Dietitians Association of Australia

• National Heart Foundation

• Kidney Health Australia

• National Aboriginal Community Controlled Health Organisation

• National Stroke Foundation

• Optometrists Association of Australia

• Palliative Care Australia

• Pharmaceutical Society of Australia

• The Royal Australian College of General Practitioners

International Diabetes Associations

• International Diabetes Federation

• American Diabetes Association

• Canadian Diabetes Association

• Diabetes New Zealand

• Diabetes United Kingdom

• Glycosmedia

126

Support • Children with Diabetes (part of the Johnson & Johnson Diabetes Franchise)

• Diabetes Counselling Online

• Kids and Teens with Diabetes

• Munted Pancreas

• Reality Check Inc.

Last updated 11.11.16

127

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128

Australian National Diabetes Audit ANDA-AQSMA 2016

Appendix 6

Descriptive Report

Final Report

129

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130

Table of Contents

Section 1. Patient Characteristics Currently Pregnant………………………………………………………………………………………. 133

Initial Visit……………………………………………………………………………………………………. 134

Indigenous Status………………………………………………………………………………………… 135

NDSS Member……………………………………………………………………………………………… 136

Country of Birth……………………………………………………………………………………………. 137

Section 2. Lifestyle Issues

Physical Activity Status…………………………………………………………………………………. 138

Influenza Vaccination..…………………………………………………………………………………. 141

Pneumococcal Vaccination.……………………………………………………………….………… 142

Smoking Status…………………………………………………………………………………………….. 143

Tried to Stop Smoking (current smokers)…………………………………………………….. 146

Method of Cessation (past smokers)………………..………………………………………….. 147

HbA1c (%)…………………………………………………………………………………………………….. 149

HbA1c (%) & Patient Gender…..……….……………………………………………………..…… 150

HbA1c (%) & Initial Visit……………………………………………..………………………………… 151

Section 3. Medication Use

Medication Use – Forget to Take…………………………………………………………………. 153

Medication Use – Careless………..…………………………………………………………………. 154

Medication Use – Stop Taking When Feeling Better….…………………………………. 155

Medication Use – Stop Taking When Feeling Worse.…………………………..………. 156

Medication Use – Frequency of Forgetting Medication….……………………………. 157

Medication Use – Use of Complementary Therapy…….….……………………………. 158

Medication Use – Told Dr or Diabetes Educator………….….……………………………. 159

Section 4. Health Professional Attendances

Attended Podiatrist………………………………….….………………………………………………. 160

Attended Diabetes Educator..………………….….………………………………………………. 161

Attended Dietician……………………………….….………..…………………………………………. 162

Attended Psychologist….………………………….….………………………………………………. 163

Attended Social Worker….……………………….….………………………………………………. 164

Attended Diabetes Specialist..………………….….………………………………………………. 165

Attended Ophthalmologist……………………….….………………………………………………. 166

Attended Optometrist….………………………….….………………………………………………. 167

Attended Dentist….………………………………….….………………………………………………. 168

Attended Exercise Physiologist…..…………….….………………………………………………. 169 131

Section 5. Patient Self Care Practices

Difficulty Following Prescribed Diet…….……………………………………………………….. 170

Blood Glucose Monitoring As Recommended…..…………………………………………. 172

Rotation of Injection Site…………………………………..…………………………………………. 175

Section 6. BCD

BCD Depression……………………….…………………………………………………………………… 176

On Antidepressants..……………………………………………………………………………………. 177

Previous Psychiatric Treatment/Counselling...……………………………………………… 178

Current Psychiatric Treatment/Counselling ………….…………………………………….. 179

Section 7. Quality of Life Assessment

Own Health State Rating..……………………………………………………………………………. 180

Either Screening Scale ≥3…………………………………………………………………………….. 181

Total DDS 17 Score………………………………………………………………………………………. 182

Emotional Burden..………………………………………………………………………………………. 184

Physician-related Distress….……………………………………………………………………….. 186

Regimen-related Distress……………………………………………………………………………… 188

Interpersonal Distress…………………………………..……………………………………………… 190

132

n % n % n % n % n % n % n %

Yes 18 4.8% 14 6.3% 208 100.0% 1 20.0% 1 16.7% 242 29.6% 242 29.6%

No 358 95.2% 209 93.7% 0 0.0% 4 80.0% 5 83.3% 576 70.4% 576 70.4%

*Females aged 18‐50 years

X‐axis: All sites (Descending order)

Currently Pregnant* by Diabetes TypeTotalMissingType 1 Type 2 GDM Don't know Other

0%

20%

40%

60%

80%

100%

Currently Pregnant ‐ All Patients

0%

20%

40%

60%

80%

100%

Currently Pregnant ‐ Type 1

0%

20%

40%

60%

80%

100%

Currently Pregnant ‐ Type 2

0%

20%

40%

60%

80%

100%

Currently Pregnant ‐ GDM

133

n % n % n % n % n % n % n %

Yes 124 11.3% 534 21.0% 99 47.6% 7 35.0% 10 24.4% 1 14.3% 775 19.8%

No 977 88.7% 2010 79.0% 109 52.4% 13 65.0% 31 75.6% 6 85.7% 3146 80.2%

X‐axis: All sites (Descending order)

GDM Don't know Other Total

Initial Visit by Diabetes TypeMissingType 1 Type 2

0%

20%

40%

60%

80%

100%

Initial Visit ‐ All Patients

0%

20%

40%

60%

80%

100%

Initial Visit ‐ Type 1

0%

20%

40%

60%

80%

100%

Initial Visit ‐ Type 2

0%

20%

40%

60%

80%

100%

Initial Visit ‐ GDM

134

n % n % n % n % n % n % n %

Yes 28 2.6% 129 5.1% 14 6.7% 0 0.0% 1 2.4% 3 42.9% 175 4.5%

No 1070 97.4% 2416 94.9% 194 93.3% 20 100.0% 40 97.6% 4 57.1% 3744 95.5%

X‐axis: All sites (Descending order)

Indigenous Status by Diabetes TypeType 1 Type 2 MissingGDM Don't know Other Total

0%

10%

20%

30%

40%

50%

Indigenous ‐ All Patients

0%

10%

20%

30%

40%

50%

Indigenous  ‐ Type 1

0%

10%

20%

30%

40%

50%

Indigenous ‐ Type 2

0%

10%

20%

30%

40%

50%

Indigenous ‐ GDM

135

n % n % n % n % n % n % n %

Yes 1053 98.2% 2311 92.3% 157 75.5% 18 90.0% 35 87.5% 7 100.0% 3581 93.0%

No 19 1.8% 194 7.7% 51 24.5% 2 10.0% 5 12.5% 0 0.0% 271 7.0%

X‐axis: All sites (Descending order)

NDSS Member by Diabetes TypeTotalType 1 Type 2 GDM Don't know Other Missing

0%

20%

40%

60%

80%

100%

NDSS Member ‐ All Patients

0%

20%

40%

60%

80%

100%

NDSS Member ‐ Type 1

0%

20%

40%

60%

80%

100%

NDSS Member ‐ Type 2

0%

20%

40%

60%

80%

100%

NDSS Member ‐ GDM

136

n % n % n % n % n % n % n %

Australian born 896 81.4% 1648 64.6% 125 60.1% 14 73.7% 32 78.0% 8 100.0% 2723 69.3%

Non‐Australian born 205 18.6% 902 35.4% 83 39.9% 5 26.3% 9 22.0% 0 0.0% 1204 30.7%

X‐axis: All sites (Descending order)

Type 2 GDM Don't know TotalType 1 Other Missing

Country of Birth by Diabetes Type

0%

20%

40%

60%

80%

100%

Australian Born ‐ All Patients

0%

20%

40%

60%

80%

100%

Australian Born ‐ Type 1

0%

20%

40%

60%

80%

100%

Australian Born ‐ Type 2

0%

20%

40%

60%

80%

100%

Australian Born ‐ GDM

137

n % n % n % n % n % n % n %

Sufficient 700 63.7% 955 37.5% 125 60.1% 9 45.0% 21 51.2% 1 12.5% 1811 46.2%

Insufficient 304 27.7% 1120 44.0% 61 29.3% 4 20.0% 15 36.6% 6 75.0% 1510 38.5%

Sedentary 95 8.6% 471 18.5% 22 10.6% 7 35.0% 5 12.2% 1 12.5% 601 15.3%

X‐axis: All sites (Descending order)

Missing

Physical Activity Status by Diabetes TypeType 1 Type 2 GDM Don't know Other Total

0%

20%

40%

60%

80%

100%

Sufficient ‐ All Patients

0%

20%

40%

60%

80%

100%

Sufficient ‐ Type 1

0%

20%

40%

60%

80%

100%

Sufficient ‐ Type 2

0%

20%

40%

60%

80%

100%

Sufficient ‐ GDM

138

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Insufficient ‐ All Patients

0%

20%

40%

60%

80%

100%

Insufficient ‐ Type 1

0%

20%

40%

60%

80%

100%

Insufficient ‐ Type 2

0%

20%

40%

60%

80%

100%

Insufficient ‐ GDM

139

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Sedentary ‐ All Patients

0%

20%

40%

60%

80%

100%

Sedentary ‐ Type 1

0%

20%

40%

60%

80%

100%

Sedentary ‐ Type 2

0%

20%

40%

60%

80%

100%

Sedentary ‐ GDM

140

n % n % n % n % n % n % n %

Yes 610 56.0% 1707 67.5% 85 41.3% 9 45.0% 28 68.3% 6 75.0% 2445 62.8%

No 480 44.0% 822 32.5% 121 58.7% 11 55.0% 13 31.7% 2 25.0% 1449 37.2%

X‐axis: All sites (Descending order)

Type 2 GDM Don't know OtherType 1 TotalMissing

Influenza Vaccination by Diabetes Type

0%

20%

40%

60%

80%

100%

Influenza Vaccination ‐ All Patients

0%

20%

40%

60%

80%

100%

Influenza Vaccination ‐ Type 1

0%

20%

40%

60%

80%

100%

Influenza Vaccination ‐ Type 2

0%

20%

40%

60%

80%

100%

Influenza Vaccination ‐ GDM

141

n % n % n % n % n % n % n %

Yes 90 8.3% 371 14.7% 13 6.3% 1 5.0% 8 19.5% 1 12.5% 484 12.4%

No 998 91.7% 2160 85.3% 192 93.7% 19 95.0% 33 80.5% 7 87.5% 3409 87.6%

X‐axis: All sites (Descending order)

Type 1 Type 2 GDM

Pneumococcal Vaccination by Diabetes TypeDon't know Other Missing Total

0%

20%

40%

60%

80%

100%

Pneumococcal Vaccination ‐ All Patients

0%

20%

40%

60%

80%

100%

Pneumococcal Vaccination ‐ Type 1

0%

20%

40%

60%

80%

100%

Pneumococcal Vaccination ‐ Type 2

0%

20%

40%

60%

80%

100%

Pneumococcal Vaccination ‐ GDM

142

n % n % n % n % n % n % n %

Current 165 15.0% 314 12.3% 19 9.1% 5 25.0% 11 26.8% 0 0.0% 514 13.1%

Past 301 27.4% 1050 41.2% 47 22.6% 7 35.0% 15 36.6% 6 75.0% 1426 36.3%

Never 634 57.6% 1187 46.5% 142 68.3% 8 40.0% 15 36.6% 2 25.0% 1988 50.6%

X‐axis: All sites (Descending order)

Type 1 Type 2 Missing

Smoking Status by Diabetes TypeGDM Don't know Other Total

0%

20%

40%

60%

80%

100%

Current Smoker‐ All Patients

0%

20%

40%

60%

80%

100%

Current Smoker ‐ Type 1

0%

20%

40%

60%

80%

100%

Current Smoker ‐ Type 2

0%

20%

40%

60%

80%

100%

Current Smoker ‐ GDM

143

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Past Smoker ‐ All Patients

0%

20%

40%

60%

80%

100%

Past Smoker ‐ Type 1

0%

20%

40%

60%

80%

100%

Past Smoker ‐ Type 2

0%

20%

40%

60%

80%

100%

Past Smoker ‐ GDM

144

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Never Smoked ‐ All Patients

0%

20%

40%

60%

80%

100%

Never Smoked ‐ Type 1

0%

20%

40%

60%

80%

100%

Never Smoked ‐ Type 2

0%

20%

40%

60%

80%

100%

Never Smoked ‐ GDM

145

n % n % n % n % n % n % n %

Yes 123 75.9% 247 79.4% 16 84.2% 3 60.0% 8 72.7% NA NA 397 78.1%

No 39 24.1% 64 20.6% 3 15.8% 2 40.0% 3 27.3% NA NA 111 21.9%

X‐axis: All sites (Descending order)

GDM

Tried to Stop Smoking (current smokers) by Diabetes TypeType 1 Type 2 Don't know Other TotalMissing

0%

20%

40%

60%

80%

100%

Tried to Stop Smoking ‐ All Patients

0%

20%

40%

60%

80%

100%

Tried to Stop Smoking ‐ Type 1

0%

20%

40%

60%

80%

100%

Tried to Stop Smoking ‐ Type 2

0%

20%

40%

60%

80%

100%

Tried to Stop Smoking ‐ GDM

146

n % n % n % n % n % n % n %

Just Stopped ‐ no intervention

238 79.1% 844 80.4% 41 87.2% 5 71.4% 12 80.0% 5 83.3% 1145 80.3%

Medication 25 8.3% 73 7.0% 4 8.5% 0 0.0% 1 6.7% 0 0.0% 103 7.2%

Nicotine replacement

24 8.0% 77 7.3% 0 0.0% 1 14.3% 1 6.7% 1 16.7% 104 7.3%

Hypnosis 2 0.7% 17 1.6% 1 2.1% 1 14.3% 1 6.7% 0 0.0% 22 1.5%

Acupuncture 1 0.3% 4 0.4% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 5 0.4%

Other 13 4.3% 50 4.8% 1 2.1% 0 0.0% 0 0.0% 0 0.0% 64 4.5%

X‐axis: All sites (Descending order)

Don't know Other TotalType 1 Type 2 GDM

Method of Cessation (past smokers) by Diabetes TypeMissing

0%

20%

40%

60%

80%

100%

Just Stopped ‐ All Patients

0%

20%

40%

60%

80%

100%

Medication ‐ All Patients

147

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Nicotine Replacement ‐ All Patients

0%

20%

40%

60%

80%

100%

Hypnosis ‐ All Patients

0%

20%

40%

60%

80%

100%

Acupuncture ‐ All Patients

0%

20%

40%

60%

80%

100%

Other ‐ All Patients

148

T1DM T2DM GDMDon't know

Other Missing Total

n 1082 2366 90 15 35 7 3595

Mean HbA1c (%) 8.4 8.3 5.3 8.8 7.9 7.9 8.3

SD 1.7 1.9 0.7 2.8 2.1 1.1 1.9

Min 4.8 4.4 4.4 5.2 5.1 6.2 4.4

Max 15.0 16.3 10.7 15.0 17.4 9.3 17.4

X‐axis: All sites (Descending order)

HbA1c (%) by Diabetes Type

0.02.04.06.08.010.012.014.016.0

Mean HbA1c ‐ All Patients

0.02.04.06.08.010.012.014.016.0

Mean HbA1c ‐ Type 2

0.02.04.06.08.010.012.014.016.0

Mean HbA1c ‐ Type 1

0.02.04.06.08.010.012.014.016.0

Mean HbA1c ‐ GDM

149

n Mean SD Min Max n Mean SD Min Max

Type 1 510 8.5 1.8 4.9 15.0 572 8.4 1.6 4.8 14.9

Type 2 1299 8.3 1.8 4.4 16.1 1060 8.4 1.9 4.7 16.3

GDM NA NA NA NA NA 90 5.3 0.7 4.4 10.7

Don't know 8 8.6 3.0 5.2 15.0 7 9.1 2.6 6.1 13.4

Other 20 7.8 1.1 5.9 9.8 15 8.0 3.0 5.1 17.4

Missing 2 8.8 0.7 8.3 9.3 5 7.5 1.1 6.2 8.9

Total 1839 8.3 1.8 4.4 16.1 1749 8.2 1.9 4.4 17.4

X‐axis: All sites (Descending order)

Diabetes Type by HbA1c (%) and Patient GenderHbA1c ‐ FemaleHbA1c ‐ Male

0.02.04.06.08.010.012.014.016.0

Mean HbA1c ‐Male

0.02.04.06.08.010.012.014.016.0

Mean HbA1c ‐ Female

150

n Mean SD Min Max n Mean SD Min Max

Type 1 963 8.4 1.6 4.8 15.0 119 9.1 2.2 5.4 15.0

Type 2 1895 8.2 1.8 4.6 16.3 464 8.7 1.8 4.4 16.1

GDM 60 5.4 0.8 4.4 10.7 30 5.2 0.3 4.4 5.9

Don't know 10 7.9 1.6 6.1 10.6 5 10.7 3.8 5.2 15.0

Other 28 7.7 1.3 5.4 9.8 7 8.8 4.0 5.1 17.4

Missing 5 7.7 1.2 6.2 8.9 1 7.6 NA 7.6 7.6

Total 2961 8.2 1.8 4.4 16.3 626 8.6 2.3 4.4 17.4

X‐axis: All sites (Descending order)

Diabetes Type by HbA1c (%) and Initial VisitHbA1c when Initial Visit = YesHbA1c when Initial Visit = No

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = No ‐ All Patients

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = No ‐ Type 1

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = No ‐ Type 2

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = No ‐ GDM

151

X‐axis: All sites (Descending order)

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = Yes ‐ All Patients

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = Yes ‐ Type 1

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = Yes ‐ Type 2

0.02.04.06.08.010.012.014.016.0

Mean HbA1c & Initial Visit = Yes ‐ GDM

152

n % n % n % n % n % n % n %

Yes 297 27.0% 703 27.6% 42 20.7% 3 15.8% 5 12.2% 1 12.5% 1051 26.8%

No 803 73.0% 1845 72.4% 161 79.3% 16 84.2% 36 87.8% 7 87.5% 2868 73.2%

X‐axis: All sites (Descending order)

Medication Use ‐ Forget to Take by Diabetes TypeType 1 TotalType 2 GDM Don't know Other Missing

0%

20%

40%

60%

80%

100%

Forget Medications ‐ All Patients

0%

20%

40%

60%

80%

100%

Forget Medications ‐ Type 1

0%

20%

40%

60%

80%

100%

Forget Medications ‐ Type 2

0%

20%

40%

60%

80%

100%

Forget Medications ‐ GDM

153

n % n % n % n % n % n % n %

Yes 1017 92.6% 2317 92.1% 169 86.7% 18 94.7% 40 97.6% 8 100.0% 3569 92.1%

No 81 7.4% 198 7.9% 26 13.3% 1 5.3% 1 2.4% 0 0.0% 307 7.9%

X‐axis: All sites (Descending order)

Type 2 GDMType 1 Missing

Medication Use ‐ Careless by Diabetes TypeDon't know Other Total

0%

20%

40%

60%

80%

100%

Usually take all medications ‐ All Patients

0%

20%

40%

60%

80%

100%

Usually take all medications ‐ Type 1

0%

20%

40%

60%

80%

100%

Usually take all medications ‐ Type 2

0%

20%

40%

60%

80%

100%

Usually take all medications ‐ GDM

154

n % n % n % n % n % n % n %

Yes 52 4.7% 157 6.2% 23 11.8% 2 10.5% 2 4.9% 0 0.0% 236 6.1%

No 1044 95.3% 2357 93.8% 172 88.2% 17 89.5% 39 95.1% 8 100.0% 3637 93.9%

X‐axis: All sites (Descending order)

Type 1 Type 2 GDM Don't know Other

Medication Use ‐ Stop Taking When Feeling Better by Diabetes TypeMissing Total

0%

10%

20%

30%

40%

50%

Stop Medications When Feeling Better ‐ All Patients

0%

10%

20%

30%

40%

50%

Stop Medications When Feeling Better ‐ Type 1

0%

10%

20%

30%

40%

50%

Stop Medications When Feeling Better ‐ Type 2

0%

10%

20%

30%

40%

50%

Stop Medications When Feeling Better ‐ GDM

155

n % n % n % n % n % n % n %

Yes 58 5.3% 195 7.8% 16 8.2% 3 15.8% 2 4.9% 0 0.0% 274 7.1%

No 1039 94.7% 2318 92.2% 178 91.8% 16 84.2% 39 95.1% 8 100.0% 3598 92.9%

X‐axis: All sites (Descending order)

GDM Don't know Other Missing

Medication Use ‐ Stop Taking When Feeling Worse by Diabetes TypeType 1 Type 2 Total

0%

20%

40%

60%

80%

100%

Stop Medications When Feeling Worse ‐ All Patients

0%

20%

40%

60%

80%

100%

Stop Medications When Feeling Worse ‐ Type 1

0%

20%

40%

60%

80%

100%

Stop Medications When Feeling Worse ‐ Type 2

0%

20%

40%

60%

80%

100%

Stop Medications When Feeling Worse ‐ GDM

156

n % n % n % n % n % n % n %

1‐2 times/week 211 73.5% 574 84.8% 32 86.5% 2 66.7% 4 80.0% NA NA 823 81.6%

> 3 times/week 76 26.5% 103 15.2% 5 13.5% 1 33.3% 1 20.0% NA NA 186 18.4%

X‐axis: All sites (Descending order)

Don't know Other Missing TotalType 1 Type 2 GDM

Medication Use ‐ Frequency of Forgetting Medication by Diabetes Type

0%

20%

40%

60%

80%

100%

Forget Medications > 3 times ‐ All Patients

0%

20%

40%

60%

80%

100%

Forget Medications > 3 times ‐ Type 1

0%

20%

40%

60%

80%

100%

Forget Medications > 3 times ‐ Type  2

0%

20%

40%

60%

80%

100%

Forget Medications > 3 times ‐ GDM

157

n % n % n % n % n % n % n %

Yes 270 24.6% 691 27.5% 92 47.2% 4 21.1% 12 29.3% 2 25.0% 1071 27.7%

No 826 75.4% 1821 72.5% 103 52.8% 15 78.9% 29 70.7% 6 75.0% 2800 72.3%

X‐axis: All sites (Descending order)

Medication Use ‐ Use of Complementary Therapy by Diabetes TypeGDM Missing TotalDon't know OtherType 1 Type 2

0%

20%

40%

60%

80%

100%

Use of Complementary Therapy ‐ All Patients

0%

20%

40%

60%

80%

100%

Use of Complementary Therapy ‐ Type 1

0%

20%

40%

60%

80%

100%

Use of Complementary Therapy ‐ Type 2

0%

20%

40%

60%

80%

100%

Use of Complementary Therapy ‐ GDM

158

n % n % n % n % n % n % n %

Yes 222 82.8% 590 85.6% 89 97.8% 3 75.0% 11 91.7% 2 100.0% 917 86.0%

No 46 17.2% 99 14.4% 2 2.2% 1 25.0% 1 8.3% 0 0.0% 149 14.0%

X‐axis: All sites (Descending order)

Medication Use ‐ Told Dr or Diabetes Educator by Diabetes TypeOther Missing TotalType 1 Type 2 GDM Don't know

0%

20%

40%

60%

80%

100%

Told Dr About Using Complementary Therapy ‐ All Patients

0%

20%

40%

60%

80%

100%

Told Dr About Using Complementary Therapy ‐ Type 1

0%

20%

40%

60%

80%

100%

Told Dr About Using Complementary Therapy ‐ Type 2

0%

20%

40%

60%

80%

100%

Told Dr About Using Complementary Therapy ‐ GDM

159

n % n % n % n % n % n % n %

Yes 473 43.0% 1664 65.3% 3 1.4% 11 55.0% 17 41.5% 8 100.0% 2176 55.4%

No 627 57.0% 884 34.7% 205 98.6% 9 45.0% 24 58.5% 0 0.0% 1749 44.6%

X‐axis: All sites (Descending order)

Missing

Attended Podiatrist by Diabetes TypeTotalType 1 Type 2 GDM Don't know Other

0%

20%

40%

60%

80%

100%

Attended Podiatrist ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Podiatrist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Podiatrist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Podiatrist ‐ GDM

160

n % n % n % n % n % n % n %

Yes 901 81.9% 1861 73.0% 173 83.2% 15 75.0% 30 73.2% 7 87.5% 2987 76.1%

No 199 18.1% 689 27.0% 35 16.8% 5 25.0% 11 26.8% 1 12.5% 940 23.9%

X‐axis: All sites (Descending order)

Attended Diabetes Educator by Diabetes TypeType 1 TotalType 2 GDM Don't know Other Missing

0%

20%

40%

60%

80%

100%

Attended Diabetes Educator ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Diabetes Educator ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Diabetes Educator ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Diabetes Educator ‐ GDM

161

n % n % n % n % n % n % n %

Yes 571 51.9% 1280 50.3% 159 76.4% 8 40.0% 23 56.1% 6 75.0% 2047 52.2%

No 529 48.1% 1267 49.7% 49 23.6% 12 60.0% 18 43.9% 2 25.0% 1877 47.8%

X‐axis: All sites (Descending order)

GDM Don't know Other Missing Total

Attended Dietitian by Diabetes TypeType 1 Type 2

0%

20%

40%

60%

80%

100%

Attended Dietitian ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Dietitian ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Dietitian ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Dietitian ‐ GDM

162

n % n % n % n % n % n % n %

Yes 203 18.5% 322 12.6% 17 8.2% 4 20.0% 11 26.8% 1 12.5% 558 14.2%

No 896 81.5% 2225 87.4% 190 91.8% 16 80.0% 30 73.2% 7 87.5% 3364 85.8%

X‐axis: All sites (Descending order)

Attended Psychologist by Diabetes TypeType 1 Type 2 GDM Don't know Other Missing Total

0%

20%

40%

60%

80%

100%

Attended Psychologist ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Psychologist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Psychologist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Psychologist ‐ GDM

163

n % n % n % n % n % n % n %

Yes 58 5.3% 228 9.0% 11 5.3% 1 5.0% 6 14.6% 1 12.5% 305 7.8%

No 1041 94.7% 2319 91.0% 196 94.7% 19 95.0% 35 85.4% 7 87.5% 3617 92.2%

X‐axis: All sites (Descending order)

Type 1 Type 2 GDM Don't know Other Missing Total

Attended Social Worker by Diabetes Type

0%

20%

40%

60%

80%

100%

Attended Social Worker ‐ All Patients 

0%

20%

40%

60%

80%

100%

Attended Social Worker ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Social Worker ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Social Worker ‐ GDM

164

n % n % n % n % n % n % n %

Yes 990 89.9% 1657 65.0% 97 46.6% 17 85.0% 32 78.0% 5 62.5% 2798 71.2%

No 111 10.1% 893 35.0% 111 53.4% 3 15.0% 9 22.0% 3 37.5% 1130 28.8%

X‐axis: All sites (Descending order)

Other Missing TotalDon't knowAttended Diabetes Specialist by Diabetes Type

Type 1 Type 2 GDM

0%

20%

40%

60%

80%

100%

Attended Diabetes Specialist ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Diabetes Specialist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Diabetes Specialist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Diabetes Specialist ‐ GDM

165

n % n % n % n % n % n % n %

Yes 470 42.9% 1041 40.9% 1 0.5% 8 40.0% 12 29.3% 4 50.0% 1536 39.2%

No 626 57.1% 1506 59.1% 207 99.5% 12 60.0% 29 70.7% 4 50.0% 2384 60.8%

X‐axis: All sites (Descending order)

Other Missing TotalType 1 Type 2 GDM Don't knowAttended Ophthalmologist by Diabetes Type

0%

20%

40%

60%

80%

100%

Attended Ophthalmologist ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Ophthalmologist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Ophthalmologist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Ophthalmologist ‐ GDM

166

n % n % n % n % n % n % n %

Yes 720 65.7% 1764 69.2% 39 18.8% 9 45.0% 26 63.4% 7 87.5% 2565 65.4%

No 376 34.3% 784 30.8% 169 81.3% 11 55.0% 15 36.6% 1 12.5% 1356 34.6%

X‐axis: All sites (Descending order)

Type 2Attended Optometrist by Diabetes Type

Other Missing TotalGDM Don't knowType 1

0%

20%

40%

60%

80%

100%

Attended Optometrist ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Optometrist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Optometrist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Optometrist ‐ GDM

167

n % n % n % n % n % n % n %

Yes 564 51.5% 1060 41.6% 71 34.1% 9 45.0% 19 46.3% 6 75.0% 1729 44.1%

No 532 48.5% 1487 58.4% 137 65.9% 11 55.0% 22 53.7% 2 25.0% 2191 55.9%

X‐axis: All sites (Descending order)

Attended Dentist by Diabetes TypeType 1 Type 2 GDM Don't know Other Missing Total

0%

20%

40%

60%

80%

100%

Attended Dentist ‐ All Patients 

0%

20%

40%

60%

80%

100%

Attended Dentist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Dentist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Dentist ‐ GDM

168

n % n % n % n % n % n % n %

Yes 87 7.9% 250 9.8% 7 3.4% 2 10.0% 10 24.4% 2 25.0% 358 9.1%

No 1012 92.1% 2295 90.2% 201 96.6% 18 90.0% 31 75.6% 6 75.0% 3563 90.9%

X‐axis: All sites (Descending order)

Attended Exercise Physiologist by Diabetes TypeType 1 Type 2 GDM Don't know Other Missing Total

0%

20%

40%

60%

80%

100%

Attended Exercise Physiologist ‐ All Patients

0%

20%

40%

60%

80%

100%

Attended Exercise Physiologist ‐ Type 1

0%

20%

40%

60%

80%

100%

Attended Exercise Physiologist ‐ Type 2

0%

20%

40%

60%

80%

100%

Attended Exercise Physiologist ‐ GDM

169

n % n % n % n % n % n % n %

318 28.9% 999 39.2% 63 30.4% 7 35.0% 12 29.3% 1 14.3% 1400 35.7%

132 42.4% 296 29.8% 26 41.3% 3 42.9% 2 16.7% 1 100.0% 460 33.2%

87 27.9% 316 31.8% 15 24.2% 2 28.6% 2 16.7% 0 0.0% 422 30.4%

68 21.9% 289 29.0% 28 45.2% 3 42.9% 3 25.0% 1 100.0% 392 28.2%

69 22.2% 223 22.4% 16 25.8% 1 14.3% 3 25.0% 0 0.0% 312 22.5%

176 56.6% NA NA NA NA NA NA NA NA NA NA 176 56.6%

X‐axis: All sites (Descending order)

Difficulty Following Recommended Diet by Diabetes TypeType 1 Type 2 GDM Don't know

Too hard to count carbs (Type 1)

Eat out a lot and find it hard to eat well

Don't know what foods are best to eat

Difficulties following recommended diet

Other Missing Total

Insufficient time to prepare healthy meals

Costs too much to eat well

0%

20%

40%

60%

80%

100%

Difficulties Following Prescribed Diet ‐ All Patients

0%

20%

40%

60%

80%

100%

Insufficient Time to Prepare Healthy Meals ‐ All Patients

170

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Costs Too Much To Eat Well ‐ All Patients

0%

20%

40%

60%

80%

100%

Don't Know What Foods Are Best To Eat ‐ All Patients

0%

20%

40%

60%

80%

100%

Eat Out A Lot ‐ All Patients

0%

20%

40%

60%

80%

100%

Too Hard To Count Carbs ‐ Type 1

171

n % n % n % n % n % n % n %

Yes 780 71.0% 1693 66.8% 156 75.7% 12 63.2% 29 72.5% 7 87.5% 2677 68.5%

No 280 25.5% 689 27.2% 12 5.8% 6 31.6% 8 20.0% 0 0.0% 995 25.5%

Unsure of recommended testing

39 3.5% 152 6.0% 38 18.4% 1 5.3% 3 7.5% 1 12.5% 234 6.0%

X‐axis: All sites (Descending order)

TotalType 1 Type 2 Don't know Other

Blood Glucose Monitoring As Recommended by Diabetes TypeGDM Missing

0%

20%

40%

60%

80%

100%

Check Blood Glucose As Recommended ‐ All Patients

0%

20%

40%

60%

80%

100%

Check Blood Glucose As Recommended ‐ Type 1

0%

20%

40%

60%

80%

100%

Check Blood Glucose As Recommended ‐ Type 2

0%

20%

40%

60%

80%

100%

Check Blood Glucose As Recommended ‐ GDM

172

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Do Not Check Blood Glucose as Recommended ‐ All Patients

0%

20%

40%

60%

80%

100%

Do Not Check Blood Glucose as Recommended ‐ Type 1

0%

20%

40%

60%

80%

100%

Do Not Check Blood Glucose as Recommended ‐ Type 2

0%

20%

40%

60%

80%

100%

Do Not Check Blood Glucose as Recommended ‐ GDM

173

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Unsure of Recommended Glucose Testing ‐ All Patients

0%

20%

40%

60%

80%

100%

Unsure of Recommended Glucose Testing ‐ Type 1

0%

20%

40%

60%

80%

100%

Unsure of Recommended Glucose Testing ‐ Type 2

0%

20%

40%

60%

80%

100%

Unsure of Recommended Glucose Testing ‐ GDM

174

n % n % n % n % n % n % n %

Yes 1021 95.1% 1539 95.9% 69 97.2% 16 94.1% 32 94.1% 3 100.0% 2680 95.6%

No 53 4.9% 66 4.1% 2 2.8% 1 5.9% 2 5.9% 0 0.0% 124 4.4%

X‐axis: All sites (Descending order)

TotalType 1 Type 2 GDM Don't know Other Missing

Rotation of Injection Site by Diabetes Type

0%

20%

40%

60%

80%

100%

Rotate Injection Site ‐ All Patients

0%

20%

40%

60%

80%

100%

Rotate Injection Site ‐ Type 1

0%

20%

40%

60%

80%

100%

Rotate Injection Site ‐ Type 2

0%

20%

40%

60%

80%

100%

Rotate Injection Site ‐ GDM

175

n % n % n % n % n % n % n %

Depression Likely 281 25.5% 754 29.5% 24 11.5% 5 25.0% 13 31.7% 1 12.5% 1078 27.4%

Depression Unlikely 820 74.5% 1798 70.5% 184 88.5% 15 75.0% 28 68.3% 7 87.5% 2852 72.6%

X‐axis: All sites (Descending order)

TotalType 1 Type 2 GDM Don't know Other Missing

BCD Depression by Diabetes Type

0%

20%

40%

60%

80%

100%

BCD Depression Likely ‐ All Patients

0%

20%

40%

60%

80%

100%

BCD Depression Likely ‐ Type 1

0%

20%

40%

60%

80%

100%

BCD Depression Likely ‐ Type 2

0%

20%

40%

60%

80%

100%

BCD Depression Likely ‐ GDM

176

n % n % n % n % n % n % n %

Yes 189 17.2% 539 21.2% 13 6.3% 4 20.0% 8 19.5% 2 25.0% 755 19.2%

No 910 82.8% 2008 78.8% 195 93.8% 16 80.0% 33 80.5% 6 75.0% 3168 80.8%

X‐axis: All sites (Descending order)

Type 1 Type 2 GDM TotalDon't know Other

On Antidepressants by Diabetes TypeMissing

0%

20%

40%

60%

80%

100%

Taking Antidepressants ‐ All Patients

0%

20%

40%

60%

80%

100%

Taking Antidepressants ‐ Type 1

0%

20%

40%

60%

80%

100%

Taking Antidepressants ‐ Type 2

0%

20%

40%

60%

80%

100%

Taking Antidepressants ‐ GDM

177

n % n % n % n % n % n % n %

Yes 328 29.9% 638 25.0% 47 22.6% 6 30.0% 19 46.3% 1 12.5% 1039 26.5%

No 769 70.1% 1910 75.0% 161 77.4% 14 70.0% 22 53.7% 7 87.5% 2883 73.5%

X‐axis: All sites (Descending order)

Previous Psychiatric Treatment/Counselling by Diabetes TypeType 1 Type 2 GDM Don't know Other Missing Total

0%

20%

40%

60%

80%

100%

Previous Psychiatric Treatment ‐ All Patients

0%

20%

40%

60%

80%

100%

Previous Psychiatric Treatment ‐ Type 1

0%

20%

40%

60%

80%

100%

Previous Psychiatric Treatment ‐ Type 2

0%

20%

40%

60%

80%

100%

Previous Psychiatric Treatment ‐ GDM

178

n % n % n % n % n % n % n %

Yes 130 11.9% 259 10.2% 9 4.3% 3 15.0% 9 22.0% 0 0.0% 410 10.5%

No 967 88.1% 2289 89.8% 199 95.7% 17 85.0% 32 78.0% 8 100.0% 3512 89.5%

X‐axis: All sites (Descending order)

Don't know Other

Current Psychiatric Treatment/Counselling by Diabetes TypeType 1 Type 2 GDM Missing Total

0%

20%

40%

60%

80%

100%

Current Psychiatric Treatment ‐ All Patients

0%

20%

40%

60%

80%

100%

Current Psychiatric Treatment ‐ Type 1

0%

20%

40%

60%

80%

100%

Current Psychiatric Treatment ‐ Type 2

0%

20%

40%

60%

80%

100%

Current Psychiatric Treatment ‐ GDM

179

T1DM T2DM GDMDon't know

Other Missing Total

n 1091 2526 207 20 38 8 3890

Mean Own Health State Rating

68.3 64.7 70.2 68.5 64.0 75.6 66.0

SD 19.5 20.2 20.4 18.9 22.0 14.6 20.1

Min 0.0 0.0 5.0 30.0 0.0 50.0 0.0

Max 100.0 100.0 100.0 90.0 100.0 98.0 100.0

X‐axis: All sites (Descending order)

Own Health State Rating by Diabetes Type

0

20

40

60

80

100

Mean Own Health State Rating ‐ All Patients

0

20

40

60

80

100

Mean Own Health State Rating ‐ Type 1

0

20

40

60

80

100

Mean Own Health State Rating ‐ Type 2

0

20

40

60

80

100

Mean Own Health State Rating ‐ GDM

180

n % n % n % n % n % n % n %

Either Screening Scale > 3

506 46.0% 939 36.8% 45 21.6% 9 45.0% 12 29.3% 1 12.5% 1512 38.5%

X‐axis: All sites (Descending order)

Type 2 GDM Don't know Other Missing

Either Screening Scale  > 3 by Diabetes TypeTotalType 1

0%

20%

40%

60%

80%

100%

Either DDS17 Screening Scale >3 ‐ All Patients

0%

20%

40%

60%

80%

100%

Either DDS17 Screening Scale >3 ‐ Type 1

0%

20%

40%

60%

80%

100%

Either DDS17 Screening Scale >3 ‐ Type 2

0%

20%

40%

60%

80%

100%

Either DDS17 Screening Scale >3 ‐ GDM

181

n  % n % n % n  % n % n % n  %n 489 871 48 9 13 1 1431

Mean Score ± SD 2.3  ± 0.9 2.2  ± 0.9 2.0  ± 0.9 1.7  ± 0.5 2.2  ± 0.9 NA  ± NA 2.3  ± 0.9

Little/no distress 203 41.5% 405 46.5% 32 66.7% 6 66.7% 6 46.2% 1 100.0% 653 45.6%

Moderate distress 174 35.6% 288 33.1% 11 22.9% 3 33.3% 5 38.5% 0 0.0% 481 33.6%

High distress 112 22.9% 178 20.4% 5 10.4% 0 0.0% 2 15.4% 0 0.0% 297 20.8%

X‐axis: All sites (Descending order)

Total DDS 17 Score by Diabetes TypeT1DM T2DM GDM Don't know Other Missing Total

0.0

1.0

2.0

3.0

4.0

5.0

Mean Total DDS 17 Score ‐ All Patients

0.0

1.0

2.0

3.0

4.0

5.0

Mean Total DDS 17 Score ‐ Type 1

0.0

1.0

2.0

3.0

4.0

5.0

Mean Total DDS 17 Score ‐ Type 2

0.0

1.0

2.0

3.0

4.0

5.0

Mean Total DDS 17 Score ‐ GDM

182

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Total DDS 17 Score: High Distress ‐ All Patients

0%

20%

40%

60%

80%

100%

Total DDS 17 Score: High Distress ‐ Type 1

0%

20%

40%

60%

80%

100%

Total DDS 17 Score: High Distress ‐ Type 2

0%

20%

40%

60%

80%

100%

Total DDS 17 Score: High Distress ‐ GDM

183

n  % n % n % n  % n % n % n  %n 491 874 48 9 13 1 1436

Mean Score ± SD 2.8  ± 1.2 2.7  ± 1.2 2.3  ± 0.8 2.0  ± 0.8 2.9  ± 1.3 NA  ± NA 2.7  ± 1.2

Little/no distress 124 25.3% 250 28.6% 16 33.3% 4 44.4% 2 15.4% 0 0.0% 396 27.6%

Moderate distress 164 33.4% 295 33.8% 24 50.0% 3 33.3% 5 38.5% 1 100.0% 492 34.3%

High distress 203 41.3% 329 37.6% 8 16.7% 2 22.2% 6 46.2% 0 0.0% 548 38.2%

X‐axis: All sites (Descending order)

Emotional Burden by Diabetes TypeT1DM T2DM GDM Don't know Other Missing Total

0.0

1.0

2.0

3.0

4.0

5.0

Mean Emotional Burden ‐ All Patients

0.0

1.0

2.0

3.0

4.0

5.0

Mean Emotional Burden ‐ Type 1

0.0

1.0

2.0

3.0

4.0

5.0

Mean Emotional Burden ‐ Type 2

0.0

1.0

2.0

3.0

4.0

5.0

Mean Emotional Burden ‐ GDM

184

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Emotional Burden: High Distress ‐ All Patients

0%

20%

40%

60%

80%

100%

Emotional Burden: High Distress ‐ Type 1

0%

20%

40%

60%

80%

100%

Emotional Burden: High Distress ‐ Type 2

0%

20%

40%

60%

80%

100%

Emotional Burden: High Distress ‐ GDM

185

n  % n % n % n  % n % n % n  %n 490 874 48 9 13 1 1435

Mean Score ± SD 1.5  ± 0.9 1.5  ± 0.9 1.2  ± 0.5 1.1  ± 0.3 1.3  ± 0.5 NA  ± NA 1.5  ± 0.9

Little/no distress 392 80.0% 690 78.9% 44 91.7% 9 100.0% 10 76.9% 1 100.0% 1146 79.9%

Moderate distress 57 11.6% 97 11.1% 2 4.2% 0 0.0% 3 23.1% 0 0.0% 159 11.1%

High distress 41 8.4% 87 10.0% 2 4.2% 0 0.0% 0 0.0% 0 0.0% 130 9.1%

X‐axis: All sites (Descending order)

Physician‐related Distress by Diabetes TypeT1DM T2DM GDM Don't know Other Missing Total

0.0

1.0

2.0

3.0

4.0

5.0

Mean Physician‐related Distress ‐ All Patients

0.0

1.0

2.0

3.0

4.0

5.0

Mean Physician‐related Distress ‐ Type 1

0.0

1.0

2.0

3.0

4.0

5.0

Mean Physician‐related Distress ‐ Type 2

0.0

1.0

2.0

3.0

4.0

5.0

Mean Physician‐related Distress ‐ GDM

186

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Physician‐related Distress: High Distress ‐ All Patients

0%

20%

40%

60%

80%

100%

Physician‐related Distress: High Distress ‐ Type 1

0%

20%

40%

60%

80%

100%

Physician‐related Distress: High Distress ‐ Type 2

0%

20%

40%

60%

80%

100%

Physician‐related Distress: High Distress ‐ GDM

187

n  % n % n % n  % n % n % n  %n 491 876 48 9 13 1 1438

Mean Score ± SD 2.6  ± 1.1 2.5  ± 1.1 1.9  ± 0.7 2.0  ± 0.8 2.6  ± 1.4 NA  ± NA 2.5  ± 1.1

Little/no distress 163 33.2% 311 35.5% 28 58.3% 3 33.3% 4 30.8% 1 100.0% 510 35.5%

Moderate distress 158 32.2% 269 30.7% 13 27.1% 5 55.6% 5 38.5% 0 0.0% 450 31.3%

High distress 170 34.6% 296 33.8% 7 14.6% 1 11.1% 4 30.8% 0 0.0% 478 33.2%

X‐axis: All sites (Descending order)

Regimen‐related Distress by Diabetes TypeT1DM T2DM GDM Don't know Other Missing Total

0.0

1.0

2.0

3.0

4.0

5.0

Mean Regimen‐related distress ‐ All Patients

0.0

1.0

2.0

3.0

4.0

5.0

Mean Regimen‐related distress ‐ Type 1

0.0

1.0

2.0

3.0

4.0

5.0

Mean Regimen‐related distress ‐ Type 2

0.0

1.0

2.0

3.0

4.0

5.0

Mean Regimen‐related distress ‐ GDM

188

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Regimen‐related Distress: High Distress ‐ All Patients

0%

20%

40%

60%

80%

100%

Regimen‐related Distress: High Distress ‐ Type 1

0%

20%

40%

60%

80%

100%

Regimen‐related Distress: High Distress ‐ Type 2

0%

20%

40%

60%

80%

100%

Regimen‐related Distress: High Distress ‐ GDM

189

n  % n % n % n  % n % n % n  %n 491 875 48 9 13 1 1437

Mean Score ± SD 2.0  ± 1.2 2.0  ± 1.2 1.6  ± 0.8 1.5  ± 0.5 1.4  ± 0.7 NA  ± NA 1.9  ± 1.2

Little/no distress 292 59.5% 511 58.4% 34 70.8% 7 77.8% 11 84.6% 1 100.0% 856 59.6%

Moderate distress 104 21.2% 184 21.0% 10 20.8% 2 22.2% 1 7.7% 0 0.0% 301 20.9%

High distress 95 19.3% 180 20.6% 4 8.3% 0 0.0% 1 7.7% 0 0.0% 280 19.5%

X‐axis: All sites (Descending order)

T1DM T2DM GDM Don't know Other Missing Total

Interpersonal Distress by Diabetes Type

0.0

1.0

2.0

3.0

4.0

5.0

Mean Interpersonal Distress ‐ All Patients

0.0

1.0

2.0

3.0

4.0

5.0

Mean Interpersonal Distress ‐ Type 1

0.0

1.0

2.0

3.0

4.0

5.0

Mean Interpersonal Distress ‐ Type 2

0.0

1.0

2.0

3.0

4.0

5.0

Mean Interpersonal Distress ‐ GDM

190

X‐axis: All sites (Descending order)

0%

20%

40%

60%

80%

100%

Interpersonal Distress: High Distress ‐ All Patients

0%

20%

40%

60%

80%

100%

Interpersonal Distress: High Distress ‐ Type 1

0%

20%

40%

60%

80%

100%

Interpersonal Distress: High Distress ‐ Type 2

0%

20%

40%

60%

80%

100%

Interpersonal Distress: High Distress ‐ GDM

191