Careful writing and editing, and an equity lens, have been instrumental in updating the type 2 diabetes HealthPathways, helping to reduce unnecessary variation in treatment plans and outcomes, writes journalist Lisa Dick.
In mid-April, the Te Manawa Taki (Midland) region had cause for celebration. Updated HealthPathways covering best practice guidance on the use of non-insulin diabetes medications and insulin in type 2 diabetes went live.
Leading the update project was Te Manawa Taki Region Community HealthPathways, a collaborative venture covering the region’s five DHBs: Bay of Plenty, Lakes, Taranaki, Waikato and Hauora Tairāwhiti.
The group has been in operation since 2018 and began work on the diabetes pathways in mid-2020.
The pathways incorporate international best practice, the latest funded medication options from PHARMAC, and links to secondary health providers in each part of the region.
Pathways of Care Manager Chris Scott says the Region’s Pathways of Care Governance Group aims to prioritise areas of need – particularly around equity.
“The prevalence of diabetes across New Zealand is high and is growing,” Mrs Scott says. “Diabetes has significant inequities in health outcomes, especially for Māori, therefore the region’s governance group prioritised the development of these pathways.”
Kieran Holland clinical lead – HealthPathways Strategy, Streamliners says one of the strengths of the HealthPathways model is that it can accommodate necessary variation in care processes due to important local differences, while also helping to reveal unnecessary variation in care (see panel).
“Local variations are sometimes necessary to accommodate valid differences, such as population demographics, access to community services and proximity to tertiary hospitals. Distinguishing between the types of variation is the first step towards improving the quality and consistency of care.”
However, Dr Holland points out that consistency does not always lead to equity.
“Sometimes achieving equity means accommodating different care processes for different populations, and HealthPathways is a good way to formalise and share these processes.”
HealthPathways is an online platform that provides localised, specific guidance on the assessment, management and referral process of different health conditions.
It is linked to patient management systems so that with just one click, all health professionals in a region – from GPs, through to community pharmacists – have access to similar, locally-relevant information.
HealthPathways began in Canterbury in 2008, as a collaboration between technical writing company Streamliners and the Canterbury District Health Board. Since then, Streamliners has expanded, and the HealthPathways product is now used across New Zealand and most of Australia, and in parts of the UK.
As of April this year, HealthPathways is used by 45 regional sites collectively responsible for the care of 25 million people, say Kieran Holland, clinical lead – HealthPathways Strategy, Streamliners.
As treatment options, best practice and regional providers change, each pathway must be updated. And so that every region doesn’t need to write and update every pathway, HealthPathways communities are established to facilitate the sharing of pathways.
“Pathway sharing means that different regions take the lead on developing and updating different pathways so other regions can follow these updates with only minimal local changes – dividing the work across the country,” Dr Holland explains.
The first phase in pathways updates was to bring together a team.
“Our group covers five DHBs, so we had to make sure everyone was on board. Then we needed a clinical editor to write the pathway, together with a subject matter expert (SME)," Mrs Scott says.
Enter Fiona Campbell (Waikato DHB GP liaison) as clinical editor and Ryan Paul (Waikato DHB endocrinologist and executive member of the New Zealand Society for the Study of Diabetes) as SME.
The region’s diabetes HealthPathways suite will be made up of eight pathways, but the team chose to focus first on two: non-insulin diabetes medications and insulin in type 2 diabetes.
They began by bringing old pathways in line with current best practice guidelines.
This work coincided with PHARMAC funding empagliflozin (a sodium-glucose cotransporter-2 inhibitor), and proposing to fund dulaglutide (a glucagon-like peptide-1 agonist) following Medsafe approval. NZSSD correspondingly updated its guidelines to include these non-insulin medications for diabetes. The pathways also represent a paradigm shift moving away from focusing on blood glucose control, to reducing cardiovascular and renal disease, responsible for most of the morbidity and mortality in people with type 2 diabetes.
The re-written pathways were circulated throughout the Te Manawa Taki DHBs, with relevant changes, local information and suggestions added.
Tokoroa primary care pharmacist Helen Cant was one of many health professionals who examined some of the proposed pathways before they were published. She says, given diabetes management is strongly focused on medication as opposed to other conditions where surgery or scans might form much of the treatment, it is important healthcare professionals familiarise themselves with both the NZSSD guidelines and their local pathways as they are introduced.
Mrs Scott says the process to update the pathways was rather involved, but now they should be easily localised by other regions.
“At the top level, the pathway reflects national guidelines and shouldn’t need to be changed, but each area may have different local service agreements, and the pathway guides the GP to services for their locality.
“For example, in Eastern Bay of Plenty there is a referral to Kaupapa Māori services that support people in the community to manage their diabetes; and in Hauora Tairāwhiti, GPs can navigate their patients to a Kaupapa Māori provider who provides lifestyle management.”
A point of difference in the new pathways is that they have been written with an equity lens.
“Māori and Pacific patients are at a higher risk of developing diabetes, have increased mortality and morbidity once it has developed, and receive inequitable delivery of healthcare,” Dr Campbell says. “The new pathways highlight these inequities and provide a standardised framework to try and eliminate variation in care caused by location or ethnicity.”
For example, the Non-insulin Diabetes Medications pathway opens with a pointed statement appealing to healthcare providers to “address inequity by prescribing appropriately for Māori patients.”
Weaved throughout the pathways is equity information; for example, in the Insulin for Type 2 Diabetes pathway is a reminder to “Arrange insulin education and support – Māori and Pacific patients receive inequitable delivery of healthcare. Make sure all patients get the support and education they need to help them with their insulin regimens.”
Coupled with this guidance is a link to He Ako Hiringa’s EPiC Dashboard which allows the user to monitor their own prescribing practises across ethnicity, age, gender and deprivation quintile.
This overt attempt to address inequity has been applauded by other regions. In Northland, HealthPathways and eReferral clinical leader Dianne Davis has already circulated the new pathways to nursing and specialist clinical leads asking them to “review them with an eye to adopt”.
“I think we are often overwhelmed into inactivity by the complexity of inequity. This shows us a way forward by tackling one aspect we know exists. By taking this approach I have hope we can start to ‘eat the elephant’ or perhaps in this case, ‘eat the taniwha’.”
While the publication of the diabetes pathways has been widely welcomed, their development has not been without challenges.
Dr Paul, who also convened the development of the NZSSD guidance on the management of type 2 diabetes, is excited about disseminating the national guidance via HealthPathways. But, he says, converting that guidance to the format and language of the platform was often slow-going.
“Additionally, SMEs do not typically get dedicated time to contribute to HealthPathways, so must find time out of hours given the importance of the project.”
Mrs Scott acknowledges there can be considerable effort and, at times, frustration in presenting national guidelines into a localised pathway.
“New Zealand-led pathway development can generate extra work, with the costs covered by the DHBs involved,” she says. “However, as more pathways are developed by regions and adopted across New Zealand, the overall costs can be reduced.”
Dr Holland says the challenge of maintaining pathways over time is something Streamliners is addressing.
“It is important that local teams are adequately resourced, and we are providing guidance to help DHBs match their resourcing to the number of pathways they need to maintain. We are also working to increase pathway-sharing across the New Zealand community.”
This activity has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for up to 0.25 CME credits for continuing professional development purposes (1 credit per learning hour). To claim your CPD credits, log in to your Te Whanake dashboard and record these activities under the appropriate learning category.
This editable PDF helps you to delve into the EPiC data, contemplate your prescribing, reflect on your current practice, and set goals and actions.
*New audit section*
An additional audit/CQI section allows you or your practice team to repeat the process, completing activities that may be used for Foundation Standard or the Cornerstone CQI or Equity modules.