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In 2009–10, 18% of Australians with diabetes completed an annual cycle of care.

Why is this an important indicator for diabetes?

Completing an annual cycle of care is an important indicator for diabetes as it provides a measure of the clinical management of diabetes according to national guidelines. An annual cycle of care is a detailed set of patient management steps that general practitioners (GPs) can claim through Medicare for the management of diabetes. An annual cycle of care is important for preventing complications associated with diabetes.

While many people have their diabetes clinically managed by a GP, they must have undertaken all of the steps listed below for their annual cycle of care to be considered complete (Table 1).

Table 1: Components of an annual cycle of care
Component At least
Measure HbA1c to assess diabetes control Once every year
Carry out a comprehensive eye examination (a) Once every two years
Measure weight and height and calculate BMI (b) Twice every cycle of care
Measure blood pressure Twice every cycle of care
Examine feet (c) Twice every cycle of care
Measure total cholesterol, triglycerides and HDL cholesterol Once every year
Test for microalbuminuria Once every year
Provide self-care education on managing diabetes As required
Review diet and encourage good dietary choices As required
Review levels of physical activity and encourage good levels of physical activity As required
Check smoking status and encourage stopping smoking (if relevant) As required
Review of medicines As required
  1. Not required if the patient is blind or does not have both eyes.
  2. Initial visit: measure height and weight and calculate BMI.
  3. Not required if patient does not have both feet.

Sources: DoHA 2007; DA & RACGP 2008

What are the results?

  • In 2009–10, 18% (over 169,000) of Australians with diabetes had Medicare claims for a completed annual cycle of care (SCRGSP 2011, Medicare Australia 2011).

What are the data sources?

There are two main data sources:

  • The Medicare Benefits Scheme (MBS), and
  • The National Diabetes Services Scheme (NDSS).

How is this indicator calculated?

This indicator compares:

  • numerator: the number of people with Type 1 or Type 2 diabetes who have had an annual cycle of care (based on data from the MBS), to
  • denominator: the total number of people with Type 1 or Type 2 diabetes (in the NDSS).

Are there any data limitations?

MBS data on people with annual cycles of care may be incomplete because:

  • Not all general practices participate in the Practice Incentives Program (PIP), which is a requirement to make these claims from Medicare. In 2002, PIP practices covered 78.2% of patients in general practice (NHPC 2004). Further, information based on PIP activity may not cover activity in Aboriginal Community Controlled Health Services.
  • GPs may carry out an annual cycle of care or other actions for a patient for diabetes but not claim it.
  • Data are currently unavailable for people who completed a partial annual cycle of care.

The NDSS is a voluntary scheme that people with medical practitioner- or nurse-diagnosed diabetes can enrol in. NDSS's coverage of the population with diagnosed diabetes is about 80–90%, but varies by region.

Where can I find more information?

AIHW (Australian Institute of Health and Welfare) 2007. National indicators for monitoring diabetes: report of the Diabetes Indicators Review Subcommittee of the National Diabetes Data Working Group. Diabetes series no. 6. Cat. no. CVD 38. Canberra: AIHW.

DA & RACGP (Diabetes Australia & Royal Australian College of General Practitioners) 2008. Diabetes Management in General Practice: Guidelines for Type 2 diabetes 2008/9, 14th edition. Canberra: Diabetes Australia.

DoHA (Department of Health and Ageing) 2007. Medicare Benefits Schedule Book. Canberra: DoHA.

Medicare Australia 2011. Medicare Item Reports. Canberra: Medicare Australia. Viewed 8 February 2011, <www.medicareaustralia.gov.au/statistics/mbs_item.shtml>

NHPC (National Health Performance Committee) 2004. National report on health sector performance indicators 2003. Cat. no. HWI 78. Canberra: AIHW.

Steering Committee for the Review of Government Service Provision (SCRGSP) 2011. Report on Government Services 2011. Canberra: Productivity Commission.


Australian Institute of Health and Welfare
Diabetes Australia & Royal Australian College of General Practitioners
Department of Health and Ageing
Medicare Benefits Scheme
National Diabetes Services Scheme
National Health Performance Committee
National Health Survey
National Integrated Diabetes Program Practice Incentives Program
Steering Committee for the review of Government Service Provision

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