Quality Standards for Diabetes Care Toolkit

Introduction

Most patients with diabetes are at high risk for developing cardiovascular disease (Buse et al 2007), which is responsible for close to 50% of diabetes-related deaths (Robinson et al 2012). This risk is greater for Māori and people of Pacific and Southeast Asian origin. While the current New Zealand guidelines for cardiovascular risk assessment are based on those developed from the Framingham Heart Study in the United States, Robinson et al (2012) note that the application of the Framingham predictive risk equation to the New Zealand context has several disadvantages: the Framingham cohort did not include the ethnic groups relevant to New Zealand and included few people with diabetes; and the equation excludes a number of diabetes-specific variables known to predict cardiovascular disease, namely duration of diabetes, glycaemic control and albuminuria. In response to these concerns, a New Zealand adaptation has been developed which accommodates these requirements and has been tested (Elley et al 2010) and validated (Robinson et al 2012) using a diabetes-specific sample in the Diabetes Cohort Study (DCS). The results of these studies suggest that application of the DCS model would require more people with diabetes to be treated with medication than the Framingham model would suggest, but that more cardiovascular events would potentially be avoided. The cardiovascular disease (CVD) risk calculator for people with diabetes can be found on the NZSSD website (www.nzssd.org.nz/cvd/) and requires the following information:

age

duration of diabetes

sex

smoking status

systolic blood pressure

ethnicity

total cholesterol

HDL

albuminuria

BP medication status.
The output provides a combined cardiovascular risk assessment incorporating known risk factors including diabetes. ‘By knowing the combined risk, the clinician and patient can make decisions on more effective prevention and treatment of cardiovascular disease (CVD). These decisions include making choices about appropriate lifestyle change (principally diet, exercise and smoking), lipid-lowering and blood pressure (BP) lowering medication, antiplatelet medication, diabetes care, and medication after myocardial infarction (MI), stroke and other cardiovascular events’ (NZ Primary Care Handbook Cardiovascular Update 2013, p 3).