Integrated diabetes care in Derby: new NHS organisations for new NHS challenges

Service user and community clinician design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence

INTRODUCTION

Design of an integrated diabetes service based on needs of service users (persons living with diabetes) and community clinicians in a semirural low-income health district of the UK.

RESEARCH DESIGN AND METHODS

One hundred and eighty-five service users engaged through public meetings, questionnaires and focus groups. General practice staff contributed views through workshops and questionnaires. Analysis of feedback indicated service user needs for better access to education, dietary advice and foot care. General practice staff endorsed these views and requested regular access to secondary care in the community. Seven hundred persons registered with diabetes attended eight well-being events in the community. From 2017 virtual practice multidisciplinary patient reviews, virtual referral of foot cases and non-face-to-face helplines were developed. A National Health Service (NHS) approved 'App' and web-based personalized education support for those recently diagnosed with diabetes was introduced.

RESULTS

Engagement in education for those recently diagnosed with diabetes increased from 5% to 71%. Weight and hemoglobin A1c (HbA1c) levels before and 6 months after starting the program were 99.4±25 and 95.5±24.2 kg and 59.3±16 and 54.8±12.9 mmol/mol, respectively, p=0.00003 and 0.003. Of those engaging at well-being events, 44 had missed regular follow-up. One hundred and seventy-five cases were reviewed virtually with practice staff by the secondary care team avoiding referral to the hospital diabetic clinic. One hundred and seventy-six referrals were made to the virtual multidisciplinary diabetic foot team clinic. Major amputation incidence declined from 13 to 3 major procedures/10 000 per annum and minor amputation from 26 to 18/10 000. Percentage bed day occupancy by persons with diabetes fell significantly in the district general hospital.

CONCLUSIONS

Integrated community-based diabetes care delivery has been achieved with partially virtual reviews. Patient education, secondary care in the community, access to dietetic advice and foot care outcomes have all improved.

Evaluation of a community diabetes initiative: Integrating diabetes care

AIMS

To evaluate the impact of a community diabetes initiative, aiming to improve the efficiency of type 2 diabetes (T2DM) care within the Cardiff and Vale Health Board.

METHODS

In 2012, a community diabetes initiative was introduced in Cardiff and Vale. Ten National Health Service (NHS) consultant diabetologists and three nurse specialists supported 69 general practices in this region. Here we evaluate the impact of this initiative by assessing the number and quality of secondary care diabetes clinic referrals before (2011-2012) and after implementation (2013-2014). Referrals pre and post initiative were audited against Cardiff and Vale T2DM referral guidelines in two 6-month periods.

RESULTS

In the 6-months prior to the initiative, 108 referrals were received, 78 of which were in line with local guidance. Approximately one year after embarking on the diabetes initiative (2013-2014) there was a 31% reduction (p<0.01) in the total number of T2DM clinic referrals and a 57% reduction (p<0.01) in referrals outside the guidelines. A decrease in referrals was not seen in the practice noted not to engage with the initiative.

CONCLUSIONS

The community diabetes initiative intervention has significantly improved the appropriateness of T2DM referrals from GP practices engaged with the initiative. As a result we advocate a move towards integrated diabetes care within the community.

Hospitalisation among patients with diabetes associated with a Diabetes Integrated Care Initiative: a mixed methods case study

Integrated care has been postulated to result in improvements to diabetes outcomes, including reduced hospitalisation. The Diabetes Integrated Care Initiative (DICI) aimed to integrate primary, secondary and community diabetes care in East Cambridgeshire and Fenland (ECF). The aims of this study were to describe changes in care and hospitalisation rates over the first 3 years of the initiative, 2009-2012. The evaluation involved a mixed-methods approach, including a before-after design with controls from adjacent geographical areas and from patients without diabetes, alongside a 30-month ethnographic study including interviews with patients and health professionals. Over the three years, admission rates among patients with diabetes in the intervention area continued to grow. In fact, the increases in admissions in ECF were 7.4% (95% CI 5.2-9.2) and 45.5% (95% CI 42.5-48.5) greater than in the neighbouring areas of Huntingdonshire and Greater Cambridge, respectively. The rates of increase in diabetic foot, non-elective or other hospital admissions were not reduced. In summary, the DICI was not associated with improved diabetes care or reduced diabetes hospitalisation over the 3 years studied, despite substantial investment. While the principle of integration remains an ideal, linking different providers in ECF, especially those that are positioned between primary and secondary care, created barriers rather than bridges to better diabetes outcomes.