Diabetes QI

Early identification of type 2 diabetes and prevention and management of pre-diabetes

Type 2 Diabetes is likely under-diagnosed across NSW, and earlier identification of those people at risk of developing type 2 diabetes, direction to lifestyle modification strategies and optimal management and care of those people with pre-diabetes, is crucial to preventing and delaying the onset of symptoms.  Sydney North Health Network is working towards to keeping people healthy, reducing the likelihood of the development of type 2 diabetes and the impact of its associated secondary complications.

Sydney North Health Network invites general practices to participate in a Quality Improvement initiative; A Quality Improvement Initiative: Early identification of type 2 diabetes and prevention and management of pre-diabetes in September 2025.

According to Diabetes Australia, early detection of pre-diabetes represents a vital step for initiating proactive intervention and support strategies for preventing or delaying the onset of type 2 diabetes and associated comorbidities including cardiovascular disease. The program aims to equip health care professionals and practices to identify at-risk patients, to create a database of their patients, increase their knowledge of lifestyle management and appropriate early intervention strategies.

Practices are supported to analyse available data via their clinical information system, Primary Sense and the PIP QI reports, identify eligible patients for AUSDRISK screening, and establish relevant, targeted quality improvement activities within their practice, with an aim to;

• reduce the impact of type 2 diabetes in the Northern Sydney region through prevention and early management, with a focus on those “at risk”,
• ensure that appropriate services and partnerships are in place across care settings to improve diabetes prevention and care,
• Use a coordinated whole of practice approach to reduce the impact of type 2 diabetes in our region.

Objectives:

• Increase the early identification of people at high risk of developing type 2 diabetes through the use of the AUSDRISK tool.
• Increase early management for people living with pre-diabetes, to delay progression to type 2 diabetes and prevent complications and other chronic condition sequelae.
• Increase referral pathways to the multi-disciplinary team and escalate care when required.
• Empower people to engage in lifestyle strategies that are sustainable and may reduce their risk of diabetes progression and increase their knowledge.
• Increase capability of clinicians in NSPHN to mobilise effective clinical management.

Benefits to the Practice:

• Support with planning and implementation of a QI activity and access to a suite of resources.
• Networking opportunities with other interested practices via a Community of Practice.
• Upskill in quality improvement processes.
• Improved health outcomes for patients.