HealthStats NSW
HealthStats NSW
HealthStats NSW

Diabetes hospitalisations: principal diagnosis or comorbidity

Males, 2016-17
161.4Males, 2015-16
158.5Males, 2014-15
158Males, 2013-14
160.9Males, 2012-13
153.1Males, 2011-12
140.9Males, 2010-11
144.4Females, 2016-17
122.5Females, 2015-16
124.7Females, 2014-15
122Females, 2013-14
122.2Females, 2012-13
115.6Females, 2011-12
114.3Females, 2010-11
121.3
  • + Source

    NSW Combined Admitted Patient Epidemiology Data and ABS population estimates (SAPHaRI). Centre for Epidemiology and Evidence, NSW Ministry of Health.

  • + Notes

    Coding rules for diabetes in hospital data have changed over time. Trends are presented for diabetes as a principal diagnosis since 2010-11 and as a comorbidity since 2012-13 as coding rules were consistent over this period; see Codes tab.

    Diabetes was the principal reason for hospitalisation when it was coded in the first diagnosis field; it was a comorbidity when it was coded in the 2nd-50th diagnosis fields and was not the principal diagnosis. Gestational and diabetes in pregnancy are included.  

    Only NSW residents are included. Rehabilitation episodes are excluded. Figures are based on where a person resides, rather than where they are treated. Hospital separations were classified using ICD-10-AM. Rates were age-adjusted using the Australian population as at 30 June 2001.

    A recent policy change (PD2017_015) resulted in patients treated solely within the emergency department being excluded from this indicator report. Please note that a minority of patients being managed in short stay areas of emergency departments are still included. Further information is found in a paper in the HealthStatsPLUS Methods tab on this website.

    Numbers for recent years include an estimate of the small number of hospitalisations of NSW residents in interstate public hospitals, data for which were unavailable at the time of production. Further details can be found in the Methods tab in the following HealthStats NSW indicator: http://www.healthstats.nsw.gov.au/Indicator/bod_hos_cat

     

  • + Commentary

    In NSW between 2010-11 and 2017-18, the hospitalisation rate for diabetes as a principal diagnosis did not change substantially. In 2017-18, the rate of hospitalisation for diabetes as a principal diagnosis was 149 per 100,000 population (171 per 100,000 population for males and 130 per 100,000 population for females). The rate of hospitalisation for diabetes as a comorbidity was 3,314 per 100,000 population (3,645 per 100,000 population for males and 3,053 per 100,000 for females) in 2017-18.

    In 2017-18 there was an average of 1.3 hospitalisations per person for diabetes in NSW. Diabetes is a chronic disease and, if not well managed, can lead to complications that result in repeated hospitalisation. These complications include eye and kidney problems and ulcers or gangrene, mainly to lower limbs. 

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  • + Methods
  • + Codes
    • Changes to coding of diabetes

      Changes to coding of diabetes in the Admitted Patient Data in NSW since July 1998 and the impact of these changes on the analysis of diabetes hospitalisation trends

      Summary

      • The coding of diabetes as a principal diagnosis was stable between July 2000 and June 2010. The records within this period are expected to reliably reflect hospitalisation for diabetes (with and without complications) as the primary reason for admission between 2000-01 to 2009-10 inclusive. A substantial change was however introduced in July 2010.

      • The coding of diabetes as an additional diagnosis has been very unstable from 1989-90 and the coding has changed 8 times between July 1998 and July 2012. Consequently, monitoring the trends in prevalence of diabetes in the community, or monitoring hospital admission practices by using hospital records of diabetes in additional diagnosis field is not appropriate.

      The period after July 2012, that is a period starting in financial year 2012-13, is the time when all admissions with diabetes are accounted for in both primary and additional diagnoses, as long as diabetes is documented in the patient file. In that period, the distinction between diabetes with and without complications reflects the true status of diabetes, as assessed during hospitalisation. Consequently, data from 2012-13 and following years can be used to estimate the burden of diabetes in the community and the distribution of hospitalisations for diabetes with and without complications in NSW.

      Details of changes

      There have been seven changes concerning the coding of diabetes in the Combined Admitted Patient Epidemiology Data (CAPED) in NSW since 1998.

      A precursor to these changes was the change of the version of the classification system from International Classification of Diseases version 9 (NCC 1996) to version 10 (NCCH 1998) in July 1998. The coding of diabetes was not affected by this change.

      1. The first change was introduced in July 1999. It required that diabetes (with or without complications) was included in the case record as an em>additional diagnosis only if it affected the hospital admission (see in 1.1 below). This requirement applied to all conditions already from 1998 with the exception of hypertension, Parkinson disease and diabetes. In Australia in July 1999, this exception was removed [Australian Coding Standard (ACS) 0002] by the National Centre for Classification in Health.

      1.1. The Australian Coding Standard 0002, volume 5 [each edition from 1998 up to and including 2010 (NCCH 2010)]:

      For coding purposes, additional diagnoses should be interpreted as conditions that affect patient management in terms of requiring any of the following:

      • therapeutic treatment, (from July 2008 the following has been added: ‘commencement, alteration or adjustment of therapeutic treatment’ see point 6 for discussion)

      • diagnostic procedures

      • increased nursing care and /or monitoring.

      1.2 This change had some effect and the rate of diabetes in additional fields (both with and without complications) was reduced in NSW. At that time 20 diagnosis fields were available in the electronic Admitted Patient Data system in NSW.

      2. The second change, in July 2000 concerned only diabetes with complications (in principal and additional diagnosis fields). It stated (ACS 0401) that it was no longer necessary for clinicians to make a clear ‘cause – effect’ connection between diabetes and another co-existing condition for medical coders to be required to code diabetes with complication, as long as the complication was on the ‘approved ICD list in the Alphabetic Index’. The list comprises conditions classified to categories of diabetes E09-E14 in ICD-10-AM. A separate code for the co-existing condition was also to be used in order to describe the condition more fully.

      2.1. For example, a statement in clinical notes to the effect that there is increased intra-abdominal fat deposition leads to the use of code E1x.72: ‘diabetes mellitus with features of insulin resistance’. Renal diseases must be matched with ‘diabetes with renal complication’ (E1x.2x).

      2.2. This change had a considerable effect on rates. The rates for diabetes with complications (both in principal and additional diagnosis fields) rose and the rates for diabetes without complication decreased (both in principal and additional diagnosis fields).

      2.3. This effect, where records flowed from diabetes without complications to diabetes with complications resulted in improving the scope for monitoring the prevalence of cases of hospitalisations for diabetes with complications (co-existing, not necessarily caused by diabetes as well as those caused by diabetes, which often could not be definitively ascertained).

      3. The third change in July 2004 involved only NSW hospital records. It reversed the changes from July 1998 and July 1999 concerning the coding of additional diagnoses. That is, from July 2004 in NSW, all conditions diagnosed in a patient and recorded in a patient file when hospitalised, including diabetes, were coded in the hospital record regardless whether they impacted on the hospitalisation. At that time there were 55 diagnosis fields available in the electronic Admitted Patient Data system in NSW (although only the first 15 or so were ever filled in).

      3.1. This change had a dramatic effect on the rates for diabetes with complications (which increased) and without complications (which decreased) in additional diagnosis fields in NSW. The change achieved an improved accounting of diabetes with complications in hospitalised persons in NSW.

      3.2. In summary, prior to July 2004, coders coded diabetes without complications in cases where diabetes itself and not a co-existing complication was attended to during a hospitalisation and the hospitalisation occurred for another reason altogether, recorded as principal diagnosis, neither diabetes nor its complication.

      3.3 For example, a patient could have had insulin levels measured and medication could have been dispensed accordingly, but renal, neurological or any other complications were not attended to directly. Before July 2004, this was regarded as ‘diabetes without complications’ from the point of view of hospital stay. This confusing coding practice was employed to fulfil the requirement that only a diagnosis which impacted on a hospital stay should be acknowledged in the record.

      3.4. After July 2004, the increase in the number of records with diabetes with complications as an additional diagnosis included both records previously coded as diabetes without complications as well as additional records of diabetes with complications in cases where diabetes was previously excluded as not relevant to a hospital stay.

      4. The fourth change, in July 2005, reversed the change from July 2004 and concerned additional diagnoses only. The reversal was due to problems in distinguishing diagnoses of diabetes coded as relevant from those coded as not relevant to a hospitalisation.

      4.1. It should be noted that the 2004 change was contrary to the Australian Coding Standards and in the absence of appropriate filtering of records the NSW health system could not fulfil its national reporting obligations. The change introduced in 2005 was therefore necessary, to ensure that the data collection was properly supporting the system of Diagnosis Related Groups and financial monitoring although it was at the expense of improved reporting of diabetes prevalence in the population.

      4.2. The change from July 2005, that is the one that returned the NSW diabetes coding in hospital statistics to the national standard, did not bring the expected reduction in the numbers and rates of diabetes in additional diagnosis in the NSW hospital statistics. The rates in 2005-06 were higher than in 2004-05 and continued to rise afterwards.

      4.3. The reason for this lack of change in the trend was that the diabetes was still coded even if its impact on hospital stay was limited to monitoring. That is even if only blood glucose test was performed, diabetes was still coded as relevant to hospital stay.

      5. In July 2008 the Australian Coding Standard 0002 concerning additional diagnoses was revised (see the first dot point in point 2.1 above) and the requirement for relevancy to hospital stay was strengthened. This was the sixth change. The new definition of additional diagnosis directs coders to include diabetes as an additional diagnosis only if a substantial alteration to the treating regime took place (NCCH 2008). This change had a dramatic effect on the numbers and rates of diabetes in additional diagnosis field in the NSW hospital statistics, with a 54% reduction in comorbidity rates between 2007-08 and 2008-09.

      6. In July 2010 the Australian Coding Standard 0401 concerning diabetes mellitus and impaired glucose regulation was revised and a major change was introduced. The coding of diabetes was changed to follow the rules of coding of the principal (ACS 0001) and additional diagnoses (ACS 0002) applying to all other hospitalisations thus removing an anomaly known as ‘a reverse index pathway’ coding concerning diabetes up to that point. This change meant that the coding of the principal diagnosis was to take place first and additional diagnoses were to be coded then in all hospitalisations that involved diabetes. This change affected both the coding of the principal diagnosis and additional diagnoses. This was the sixth change.

      6.1. For example, a cataract or ulcer being treated as the main reason for the hospitalisation in a person with a history of diabetes would have previously been coded as diabetes with a matching complication in the principal diagnosis and a cataract or ulcer would have been included in additional diagnosis (‘a reverse index pathway’). Since July 2010 a cataract or ulcer are coded as principal diagnoses and diabetes is included as additional diagnosis if it fulfils the criteria of additional diagnosis under the rules of ACS 0002, that is if it substantially impacts on admission (as explained in point 2.1 and 5 above) or if a ‘cause and effect’ relationship between diabetes and a complication is clearly established in medical notes (see points 3. and 3.1) and diabetes can be classified as a problem or underlying condition to the condition in the principal diagnosis.

      6.2. This change affected diabetes in both principal and additional diagnoses. In the principal diagnosis the change had a dramatic effect on hospitalisation rates, with an almost 60% drop in rates between 2009-10 and 2010-11.

      6.3. This change had a negative impact on the use of hospital data to monitor the burden of diabetes in the population. The long term trend of hospitalisations for diabetes in the principal diagnosis no longer reflected the rising prevalence of Type 2 diabetes. Many cases of complications of diabetes could be still ascertained via additional diagnoses. However, many complications had not been included as additional diagnoses since July 2010. These complications were, for example, where the ‘cause and effect’ had not been specifically mentioned in the clinical notes, but did exist, or conditions where the ‘cause and effect’ did not apply but the principal cause of the hospitalisation had been worsened by co-existing diabetes.

      7. In July 2012 the rules of coding of diabetes in additional diagnosis were changed again. The direction to coders has been since that ‘Diabetes mellitus and intermediate hyperglycaemia should always be coded when documented’ (Rule 1 of ACS 0401). This was the eighth change to the coding of diabetes since 1998. This change reversed the sixth change contained in ACS 0002 in relation to diabetes (see point 6).

      7.1. The change in July 2012 has affected diabetes as an additional diagnosis by increasing the number of hospitalisations where the diabetes is coded in the record of hospitalisation. There was an almost 4.5 fold increase between 2011-12 and 2012-13. Before the July 2012 change, many cases of diabetes were not coded because they did not have a sufficient impact on treatment provided during a hospital stay (ACS 0002). After the change, diabetes is coded regardless of its impact on the course of hospitalisation (ACS 0401, Rule 1).

      7.2. From July 2012, the distinction between diabetes with and without complications reflects the true status of diabetes, as assessed during hospitalisation. The equivalent period in the first half of 2010s was the financial year 2004-05 (and only 2004-05). Data from this year can be used for comparisons with 2012-13 and subsequent years, if desired.

      7.3 The July 2012 change affected the coding of diabetes as an additional diagnosis and there is no evidence of an effect on the numbers and rates of hospitalisations for diabetes as a principal diagnosis in the first year after the change.

      References

      National Centre for Classification in Health. The International statistical classification of diseases and related health problems, 10th Revision, Australian Modification (ICD-10-AM). Seventh edition. Australian Coding Standards Sydney: NCCH, 2010.

      National Centre for Classification in Health. The International statistical classification of diseases and related health problems, 10th Revision, Australian Modification (ICD-10-AM). Sixth edition. Australian Coding Standards Sydney: NCCH, 2008.

      National Centre for Classification in Health. The International statistical classification of diseases and related health problems, 10th Revision, Australian Modification (ICD-10-AM). First edition. Sydney: NCCH, 1998.

      National Coding Centre. The Australian version of the International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM). Sydney: University of Sydney, 1996.

      University of Wollongong. Casemix and Coding Matters Newsletter available at http://nccc.uow.edu.au/productservices/casemixmatters/index.html

    • Codes: Diabetes hospitalisations

      The International Statistical Classification of Diseases and Related Health Problems

      National Centre for Classification in Health, Australia; CM - Clinical Modification; AM - Australian Modification
      DescriptionICD-10 & ICD-10-AMComments
      Diabetes E10-E14, O24 All records are included except those involving rehabilitation, NSW residents only, all ages. 

      Episodes that are entirely within an emergency department are excluded.

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  • + Associated Information
    • Key points: Diabetes

      Latest available information

      Latest available data for adults in NSW

      Prevalence

        • 11.1% of adults aged 16 years and over (12.6% of men and 9.7% of women) had diabetes or high blood glucose as estimated from the 2018 NSW Adult Population Health Survey (self-reported using Computer Assisted Telephone Interviewing or CATI). It is likely that there are many people with diabetes in NSW who are unaware they have it.

        • Prevalence estimates have been increasing over time.

        • Diabetes prevalence increases with age and socioeconomic disadvantage and diabetes is more prevalent among Aboriginal people.

      Hospitalisation

        • In NSW between 2010-11 and 2017-18, the hospitalisation rate for diabetes as a principal diagnosis did not change substantially. In 2017-18, the rate of hospitalisation for diabetes as a principal diagnosis was 148.8 per 100,000 population (171.2 per 100,000 population for males and 129.7 per 100,000 population for females). In 2017-18, there was an average of 1.3 hospitalisations for diabetes per person in NSW.

        • While Type 2 diabetes accounts for up to 90% of all diabetes cases in the community, it accounted for around 65% of all hospitalisations for diabetes in 2017-18. Type 1 diabetes accounted for around 29% of hospitalisations and gestational diabetes for around 5%.

      Deaths

        • While diabetes was the principal (underlying) cause of around 3% of all deaths in NSW in 2017 (1,609 deaths), around 6% of all deaths in that year were directly related to diabetes (2,930 deaths) and 11% (5,922) involved diabetes in some way. Cardiovascular disease was the most common cause of death among people with diabetes.

      Latest available data for adults in Australia

      As estimated from the 2017-18 National Health Survey: First Results, 4.9% of adults aged 18 years and over (5.5% of men and 4.3% of women) had diabetes.

    • Introduction: Diabetes

      Diabetes definition and burden of disease

      Diabetes mellitus is a group of closely related chronic conditions characterised by high blood sugar (glucose) levels. In uncontrolled diabetes, glucose builds up in the bloodstream and leads to a range of short- and long-term problems, including damage to vital organs.

      Diabetes and its associated complications contribute significantly, both directly and indirectly, to mortality, morbidity, poor quality of life of sufferers and carers and the cost of health care. Experts agree that diabetes now represents one of the most challenging public health problems of the 21st century worldwide (Tanamas et al. 2013). Diabetes and cardiovascular conditions together are the causes of about one-third of all years of life lost due to premature death and about one-fifth of all years lost to premature death or years lived with a disability in NSW. The contribution of diabetes to the total disease burden in Australia in 2011 was 2.3% (AIHW 2016).

      Types of diabetes

      There are three main forms of diabetes mellitus: Type 1 diabetes, Type 2 diabetes and gestational diabetes. Type 1 diabetes is estimated to be present in 10-15% of people with diabetes and is caused by a combination of genetic and environmental factors, but there are no known modifiable risk factors for this form of diabetes. Type 2 diabetes accounts for about 85-90% of all diabetes cases and primarily affects people older than 40 years. Several modifiable risk factors play a role in the onset of Type 2 diabetes, including obesity, physical inactivity and poor nutrition, as does genetic predisposition and ageing. Gestational diabetes mellitus occurs during pregnancy in about 3-8% of females not previously known to have diabetes. It is a temporary form of diabetes and usually resolves after the baby is born (Beers et al. 1999). The fourth, minor group, includes diabetes secondary to other conditions, for example diseases of the pancreas or drug-induced or chemical-induced diabetes.

      Complications of diabetes

      Diabetes can lead to acute and chronic complications. Acute metabolic disturbances can lead to coma. Chronic high blood glucose levels (hyperglycaemia) are associated with long-term damage, dysfunction and failure of virtually every body organ, especially the heart and blood vessels, eyes, kidneys and nerves. Consequently, diabetes predisposes those suffering from it to many severe conditions, including cardiovascular disease, as well as visual loss, amputations and renal failure.

      Management of diabetes

      Sustained, individualised management substantially reduces the risk of complications in people with diabetes. A combination of diet, exercise and medication (including insulin injections) is used in combination with very frequent monitoring of blood glucose levels and other risk factors (for example blood lipids and blood pressure) and regular screening for complications.

      Explanations of nomenclature

      In the past, Type 1 diabetes was called 'insulin-dependent diabetes mellitus' (IDDM) or 'juvenile-onset' and Type 2 diabetes was called 'non-insulin-dependent diabetes mellitus' (NIDDM). However, as insulin is often used to treat patients with Type 2 diabetes, the old terminology has been discouraged by the WHO since 2000 (NCCH Volume 5 2000).

      Diabetes mellitus and diabetes insipidus are completely different conditions.  Diabetes insipidus (DI, Central diabetes insipidus) is a temporary or chronic disorder that causes sufferers to excrete excessive quantities of otherwise normal urine and excessive thirst. Excessive urination and thirst are the features in common with diabetes mellitus , hence a Greek word for syphon (diabetes) is used in the name of both conditions. Diabetes insipidus is caused by deficiency of hormone called vasopressin (ADH) and is much less common than diabetes mellitus (Beers MH et al. 1999). This topic and data in the Report refer to diabetes mellitus.

      References

      Tanamas SK et al. The Australian diabetes, obesity and lifestyle study (AusDiab). Baker IDI Heart and Diabetes Institute, 2013.

      Beers MH, Berkow R. The Merck manual of diagnosis and therapy. West Point: Merck & Co, 1999.

      Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4. Canberra: AIHW, 2016. 

      National Centre for Classification in Health. The International statistical classification of diseases and related health problems, 10th Revision, Australian Modification (ICD-10-AM). Volume 5. Sydney: NCCH, 2000.

    • Interventions: Diabetes and Preventive Health

      The best way to reduce the harm caused by diabetes is by preventing the onset of Type 2 diabetes. Diabetes shares many modifiable risk factors with other lifestyle-related chronic diseases such as cardiovascular diseases. These include smoking, physical inactivity, poor diet, too much alcohol and being overweight. This means that strategies related to the prevention, early detection and optimal management of these risk factors will lead to better health outcomes for people with Type 2 diabetes and other lifestyle-related chronic diseases.

      NSW Health provides support for the prevention and optimal management of Type 2 diabetes through a broad range of programs:

      Healthy Eating Active Living

      The NSW Healthy Eating and Active Living (HEAL) Strategy 2013-2018 provides a whole of government framework to promote and support healthy eating and active living in NSW and to reduce the impact of lifestyle-related chronic disease. Further information on the NSW HEAL strategy is available from http://www.health.nsw.gov.au/heal/Pages/default.aspx.

      Get Healthy at Work

      Get Healthy at Work is a new NSW Government initiative that aims to improve the health of working adults. It focuses on healthy weight, physical activity, healthy eating, active travel, smoking and harmful alcohol consumption. Further information on the NSW Get Healthy at Work initiative is available from http://www.health.nsw.gov.au/healthyworkers/pages/default.aspx

      Get Healthy Information and Coaching Service

      This free, confidential telephone-based coaching service supports NSW adults to make sustained improvements in healthy eating, physical activity, and achieving and maintaining a healthy weight. Further information on the Get Healthy Information and Coaching Service is available from http://www.gethealthynsw.com.au

      Find Your Ideal Figure

      This initiative is intended to support informed, healthier food choices in NSW. As of 1 February 2012, major food retailing outlets with 20 or more stores in NSW and more than 50 stores nationally are required to include information about the kilojoule (kj) content of standard products on their menu boards. The 8700 Find Your Ideal Figure website provides information, links, tips, online calculators and tools, including a mobile phone application. Further information is available from www.8700.com.au.

      Healthy Built Environments Program

      The built environment can play an important role in promoting and supporting healthy behaviours. Research demonstrates the link between the modern epidemic of lifestyle-related chronic diseases such as cardiovascular diseases and Type 2 diabetes, and the way we live in the built environment. Car-dominated transport, coupled with a lack of active transport options (walking, cycling and public transport), reduce opportunities for physical activity. Sprawling low-density residential developments with poor access to amenities including healthy, fresh food and poor connectivity can negatively impact on both mental and physical health.

      NSW Agency for Clinical Innovation’s Endocrine Network

      The NSW Agency for Clinical Innovation established the Endocrine Network in 2007 to assist clinicians working with patients who have diabetes or obesity to develop best practice guidelines for treatment and to provide direction for diabetes and obesity research, education and management. The Endocrine Network has a number of priority areas including the development of the NSW Model of Care for Diabetes Mellitus covering the identification, treatment and management of people with Type 1 and 2 diabetes, gestational diabetes and diabetes in pregnancy. Further information on the Endocrine Network is available from http://www.aci.health.nsw.gov.au/networks/endocrine

      NSW Chronic Disease Management Program (Connecting Care in the Community)

      The NSW Chronic Disease Management Program (CDMP) aims to deliver an integrated, patient focused, whole person approach to effective health management to improve the quality of life of people with chronic and complex conditions, their carers and families and to prevent unplanned and avoidable hospital admissions. It achieves this by coordinating a statewide chronic disease management approach. The CDMP focuses on the five major chronic diseases recognised as having a major impact on the burden of disease in NSW: diabetes, chronic obstructive pulmonary disease (mainly emphysema and chronic bronchitis), coronary artery disease (also known as coronary or ischaemic heart disease), hypertension (high blood pressure), and congestive heart failure. It is overseen by the Chronic Disease Management Office. Further information on the NSW Chronic Disease Management Program (Connecting Care in the Community) is available from http://www.health.nsw.gov.au/cdm/pages/default.aspx

      NSW Chronic Care for Aboriginal People Program

      The NSW Chronic Care for Aboriginal People (CCAP) Program is managed by the NSW Agency for Clinical Innovation. The aim of the CCAP is to prevent and manage conditions including diabetes, heart disease, stroke, hypertension and kidney disease among Aboriginal people. These conditions share common risk factors, and common approaches are needed to address them in Aboriginal communities. Further information on the NSW Chronic Care for Aboriginal People Program is available from https://www.aci.health.nsw.gov.au/networks/ccap

    • For more information: Diabetes

      Useful websites include:

      NSW Ministry of Health at www.health.nsw.gov.au

      Diabetes Australia at http://www.diabetesaustralia.com.au/

      Australian Bureau of Statistics at http://www.abs.gov.au

      Australian Institute of Health and Welfare and its National Centre for Monitoring Diabetes at http://www.aihw.gov.au

      Australian Diabetes Society and its National Association of Diabetes Centres at http://www.diabetessociety.com.au/nadc.asp

      healthdirect at http://www.healthdirect.gov.au

Last Updated At: Tuesday, 14 May 2019