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Enhancing proactive management of Type 2 Diabetes in General Practice

Diabetes remains a critical health challenge in Australia. Between 2000 and 2021, the age-standardised incidence rate for type 2 diabetes declined by 43%1 reflecting significant advancements in prevention through improved screening, increased public awareness, and educational programs fostering behavioural change.2 However, despite these gains, the absolute burden of diabetes continues to grow. 

The number of Australians living with diabetes has surged nearly 2.8-fold during the same period, rising from 460,000 to 1.3 million.1 By 2024, type 2 diabetes accounted for around 128,000 years of healthy life lost,1 highlighting the persistent toll on individuals and the healthcare system.

Primary care is at the forefront of diabetes prevention, early identification and management. Through focusing on optimal, person-centred care, general practices can continue to significantly improve outcomes and quality of life for people living with diabetes.

This QI toolkit empowers your practice to review data, refine procedures and processes and drive better outcomes for patients on the diabetes care continuum.

This QI Toolkit relates to the following PIP QI Quality Improvement Measures (QIMs): 

  1. QIM #1: Proportion of regular clients with diabetes with an HbA1c result recorded in their GP record within the previous 12 months.
  2. QIM #5, the proportion of regular clients with diabetes with an influenza immunisation status recorded in their GP record within the previous 15 months. 

QIM #1: HbA1c recorded (Type 1 diabetes)

As of July 2024, the CCQ region reported 59.4% of regular clients of all ages who had a recorded diagnosis of Type 2 diabetes had an HbA1c result recorded within the previous 12 months in their GP record, higher than the 57.3% across Queensland and 56.9% nationally.

Click image to enlarge.
Source: AIHW (accessed April 2025)

QIM #1: HbA1c recorded (Type 2 diabetes)

As of July 2024, the CCQ region reported 72.7% of regular clients of all ages who had a recorded diagnosis of Type 2 diabetes had an HbA1c result recorded within the previous 12 months in their GP record, higher than the 71.5% across Queensland and 71.8% nationally.

Click image to enlarge.
Source: AIHW (accessed April 2025)

QIM #1: HbA1c recorded
(undefined diabetes)

As of July 2024, the CCQ region reported 68.6% of regular clients of all ages who had a recorded diagnosis of Type 2 diabetes had an HbA1c result recorded within the previous 12 months in their GP record, higher than the 64.3% across Queensland and 65.4% nationally.

Click image to enlarge.
Source: AIHW (accessed April 2025)

QIM #5: Influenza vax recorded (diabetes)

As of July 2024, the CCQ region reported 50.6% of regular clients with diabetes had an influenza immunisation status recorded in their GP record within the previous 15 months in the CCQ region, higher than the 49.7% across Queensland and 48.4% nationally.

Click image to enlarge.
Source: AIHW (accessed April 2025)

Improve the early detection, diagnosis, and management of type 2 diabetes in general practice.

To achieve this goal, you can access a range of resources:

  1. Review current best practice.
  2. HealthPathways: Explore locally tailored approaches to diabetes management. Simply enter “Diabetes” to get started.
  3. Self-Management of Chronic Conditions (SMoCC): Delivers the COACH program, a free telephone chronic disease program aiming to improve self-management skills, thereby improving quality of life and reducing hospitalisations.
  4. National Diabetes Services Scheme (NDSS) provides a range of information resources and education events for both patients and health professionals.
  5. Diabetes Australia has a range of resources for clinicians and consumers.

Kickstart your quality improvement activity by bringing together a quality improvement team. Together, you’ll identify the key challenges and come up with innovative solutions, ensuring you all share a clear understanding of the improvement objectives and strategies.

  1. Engage with your Primary Health Coordinator from CCQ; they can offer tailored support, resources and guidance to enhance your QI efforts wherever you are in your QI journey. Your Primary Health Coordinator can support your practice to:
    • Bring a QI team together to decide on an improvement idea
    • Plan, start and finish a QI activity
    • Facilitate QI meetings
    • Create practice-wide systems improvement
  1. Gather data and information. Review current practice data and processes for detection and management of diabetes.
  2. Identify and discuss any common barriers to engagement to optimal diabetes management. Consider using process maps, flow charts or driver diagrams to generate change ideas and improve processes.

What data might you need? You’ll need data to understand the problem and measure your outcomes. We suggest you start with:

  1. Primary Sense can provide insight, detailed reports and targeted guidance on improving data quality, specifically for diabetes management. The following reports are available within Primary Sense:
    • Diabetes Mellitus: Identifies patients with possible diabetes who have not had a HbA1c, patients who may have diabetes but who have not been coded and patients with a coded diagnosis of diabetes who may be eligible for chronic care occasions of service.

To achieve your goal, you can consider several improvement ideas such as:

  1. Incorporate the AUSDRISK into practice procedure and processes to screen for diabetes in at-risk patients. Tip: Promote the My Health 4 Life program to eligible patients.
  2. Utilise the Primary Sense report ‘Diabetes Mellitus’ to find gaps in diabetes management and recall patients due for various chronic care occasions of service. Tip: Ensure your team is familiar with the eligibility and use of the practice nurse MBS item number 10997 for chronic disease monitoring and support.
  3. Utilise the Primary Sense prompt ‘Due microalbumin pathology’ to opportunistically provide and increase ACR tests.
  4. Run a diabetes coding audit to ensure all people with diabetes are coded correctly in the clinical software.

Improve monitoring of diabetic patients by establishing a diabetes register based on the Annual Diabetes Cycle of Care. Tip: It may be more effective to appoint one person to centrally create and maintain this register.

Remember to self-report your QI project as a CPD activity. QI is a great tool for measuring tangible outcomes and demonstrating improvement in patient care!

Share your results with your CCQ practice support team and with your patients. Ensure you document your quality improvement activity to meet PIP QI guidelines and for CPD purposes.

References

  1. Australian Institute of Health and Welfare (2024) Diabetes: Australian facts, AIHW, Australian Government, accessed 16 December 2024. 
  2. Magliano DJ, Islam RM, Barr EL, Gregg EW, Pavkov ME, Harding JL, Tabesh M, Koye DN and Shaw JE (2019) ‘Trends in incidence of total or type 2 diabetes: systematic review- external site opens in new window‘, BMJ, 366:I5003.
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