Management of type 2 diabetes in Western Australian metropolitan general practice

Barreiras para a realização de oftalmoscopia direta por médicos de família e comunidade

A oftalmoscopia direta é um exame utilizado para diagnóstico e rastreamento de doenças da retina, do disco óptico e do humor vítreo no contexto da atenção primária à saúde. Estudos demonstram que é uma prática pouco utilizada regularmente por médicos de família e comunidade. O objetivo deste estudo é identificar barreiras para a realização da oftalmoscopia por médicos da referida especialidade. Este estudo utilizou metodologia qualitativa, baseada em entrevista semiestruturada com médicos de família e comunidade e posterior análise temática. Demonstrou-se que as barreiras para a realização de oftalmoscopia direta incluem dificuldade no manejo do oftalmoscópio e na dilatação pupilar, pouco conhecimento da anatomia ocular, sentimento de insegurança na realização e na interpretação de achados, percepção de que seria um exame mais bem realizado por um especialista, falta de formação e experiência prática na graduação e na residência médica, percepção de pouca utilidade ou resolutividade, dificuldade em adequar o ambiente para a realização do exame, ausência de aparelho e colírios midriáticos nas unidades de saúde, aumento no tempo de consulta, ausência de fluxos de encaminhamento mediante achados alterados, presença de serviços de teleoftalmologia e ausência de treinamento da equipe multiprofissional.

The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis

BACKGROUND

Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources.

METHODS

We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care.

DISCUSSION

Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.

Assessing the influence of health systems on Type 2 Diabetes Mellitus awareness, treatment, adherence, and control: A systematic review

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is reported to affect one in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries. Health systems play an integral role in responding to this increasing global prevalence, and are key to ensuring effective diabetes management. We conducted a systematic review to examine the health system-level factors influencing T2DM awareness, treatment, adherence, and control.

METHODS AND FINDINGS

A protocol for this study was published on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016048185). Studies included in this review reported the effects of health systems factors, interventions, policies, or programmes on T2DM control, awareness, treatment, and adherence. The following databases were searched on 22 February 2017: Medline, Embase, Global health, LILACS, Africa-Wide, IMSEAR, IMEMR, and WPRIM. There were no restrictions on date, language, or study designs. Two reviewers independently screened studies for eligibility, extracted the data, and screened for risk of bias. Thereafter, we performed a narrative synthesis. A meta-analysis was not conducted due to methodological heterogeneity across different aspects of included studies. 93 studies were included for qualitative synthesis; 7 were conducted in LMICs. Through this review, we found two key health system barriers to effective T2DM care and management: financial constraints faced by the patient and limited access to health services and medication. We also found three health system factors that facilitate effective T2DM care and management: the use of innovative care models, increased pharmacist involvement in care delivery, and education programmes led by healthcare professionals.

CONCLUSIONS

This review points to the importance of reducing, or possibly eliminating, out-of-pocket costs for diabetes medication and self-monitoring supplies. It also points to the potential of adopting more innovative and integrated models of care, and the value of task-sharing of care with pharmacists. More studies which identify the effect of health system arrangements on various outcomes, particularly awareness, are needed.

Temporal trends in the age-specific prevalence of diabetes and diabetic retinopathy in older persons: Population-based survey findings

PURPOSE

To compare the age-specific prevalence of diabetes and diabetic retinopathy (DR) over 6 years.

METHODS

The Blue Mountains Eye Study (BMES) examined 3654 residents (82.4% response) aged >49 years in BMES I (1992-1994). Survivors (n = 2335) and newly eligible residents (n = 1174) were examined in BMES II (1997-2000). Diabetes was defined by history or fasting plasma glucose > or =7.0 mmol/L. DR was graded from 6-field retinal photographs using the Airlie House Classification. Age-specific prevalence in 5-year intervals was compared, as samples of each age group were independent.

RESULTS

The overall diabetes prevalence increased from 7.8 to 9.9% (p = 0.002) while the age-specific prevalence increased in age groups 60-74 years, over 6 years. A slightly higher prevalence of mild levels of DR (p = 0.018) but lower prevalence of moderate-severe levels of DR (p = 0.049) was evident in BMES II compared to BMES I. Factors significantly associated with DR prevalence were diabetes duration > or =20 years (BMES I, OR 7.6 [2.9-20.5]; BMES II, OR 6.1 [2.5-15.4]) and blood glucose level (BMES I, OR 1.1 [1.0-1.2]; BMES II, OR 1.2 [1.1-1.3] per mmol/L increase).

CONCLUSIONS

An increased prevalence of diabetes, but decreased prevalence of severe levels of DR, was documented in two survey samples from the same region over 6 years.

Diabetic foot screening: why is it neglected?

Understanding reasons for the neglect of foot screening during the annual review of people with diabetes enables the development of solutions for this omission. This study explores the reasons within the context of health care delivery systems in terms of the professional, social, political and economic aspects of this screening. Information was obtained through reviewing publications on diabetic foot and health care reform. The omission of annual foot examination for people with diabetes is attributed to the nature of diabetes-related foot problems, people with diabetes, health care professionals and the current structure of health care delivery systems. Increasing the adherence to foot screening for those with diabetes requires short- and long-term strategies. Short- and long-term strategies for reminding patients and staff about foot screening are suggested.

How should peripheral neuropathy be assessed in people with diabetes in primary care? A population-based comparison of four measures

AIMS

To test the accuracy of four measures of peripheral diabetic neuropathy in a primary care population.

METHODS

Type 2 diabetic (n = 544) and 544 non-diabetic participants aged 45-76 years were randomly selected from general practice registers. Neuropathy was assessed using vibration threshold (VT) and scores for light touch, thermal sense and modified Michigan Neuropathy Screening Instrument questionnaire. These measures were assessed for variation with diabetes status, age, diabetes duration, HbA1c, and presence of retinopathy and nephropathy. Light touch, thermal sense and questionnaire scores were assessed against VT using ROC curve analysis.

RESULTS

Only VT and light touch were different between diabetic and non-diabetic groups (P = 0.02 and < 0.0001, respectively). All measures were significantly associated with diabetes duration and retinopathy, and all except questionnaire score (P = 0.14) with age. None was associated with nephropathy and only questionnaire score was associated with HbA1c (P = 0.033). VT varied as expected across scores of light touch (chi2 = 41.65, P = 0.0001), thermal sense (chi2 = 15.86, P = 0.015) and questionnaire (chi2 = 21.22, P = 0.047). Area under the curve values for light touch, thermal and questionnaire scores were 0.72 (95% confidence interval (CI) 0.63, 0.82), 0.63 (95% CI 0.52, 0.73) and 0.64 (95% CI 0.53, 0.74), respectively.

CONCLUSIONS

All measures had associations with risk factors for neuropathy, but light touch score (monofilament) had the strongest association with vibration threshold (the chosen gold standard) and thus appeared the most appropriate tool for use in primary care, because of its validity and simplicity of use.

Evidence-based medicine in general practice: beliefs and barriers among Australian GPs

If implemented, evidence-based medicine (EBM) in general practice will improve health outcomes for patients. This paper examines the views of 60 Australian general practitioners about EBM. While 57% of respondents had a computer in their surgery, 15% had Internet access and only 3% had access to the Cochrane Library at work. The most commonly cited barrier to EBM was 'patient demand for treatment despite lack of evidence for effectiveness' (45%). The next three most highly rated barriers related to lack of time. For each of three tasks of EBM, namely searching for evidence, appraising evidence and discussing the implications of evidence with patients, lack of time was rated as a 'very important barrier' by significantly more participants than lack of skills (McNemar's tests: chi2(1) = 7.1, P = 0.008, chi2(1) = 14.0, P = 0.001 and chi2(1) = 9.0, P = 0.003, respectively). Preferred resources for EBM included clinical practice guidelines (rated as 'very useful' by 55%) and journals that summarize research evidence, for example Evidence-based Medicine (52%). Systematic reviews were considered 'very useful' by only 15% of respondents, consistent with our finding that 30% did not understand the term 'systematic review'. Furthermore, 43% did not understand 'meta-analysis'. A minority indicated they understood the terms 'relative risk' (23%), 'absolute risk' (28%) and 'number needed to treat' (15%) sufficiently to explain to others. Skills development is crucial to achieve EBM in general practice.

Effectiveness of changes in the delivery of diabetes care in a rural community

Diabetes has a significant impact upon health in rural Maori communities. A diabetes club was established to support self-care and improve diabetes management in a rural community in Northland, New Zealand. A structured approach to care and an associated audit were also introduced. Patient involvement and ownership of the condition were considered important issues. Monitoring of care processes increased by 79%. The first year of audit was associated with a reduction in mean fructosamine from 369 +/- 85 micromol L-1 to 321 +/- 65 micromol L-1 and this was sustained for a further 3 years. The number of people using insulin increased from 15 to 22%. The audit process facilitated the implementation of changes in the delivery of care. We conclude that the data indicate that the enthusiastic delivery of care in general practice, with a devolution of power to the patient, linked to an audit service can result in improved management among patients with Type 2 diabetes.

The pattern of diabetes care in New South Wales: a five-year analysis using Medicare occasions of service data

OBJECTIVE

To use Medicare occasions of service data to establish the pattern and standard of care received by people with diabetes.

METHOD

Information about visits to medical practitioners as well as utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997 was retrieved using a Health Insurance Commission data file. Individuals were deemed to have diabetes if an HbA1c which can only be ordered for a person with known diabetes, had been performed over the five-year period.

RESULTS

On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. A large proportion of patients also received care at the specialist and consultant physician level, 51.2% and 38.6% respectively, a three to four fold increase when compared with their non-diabetic counterparts. There was also a 1.3 to 1.8 fold increase in the mean number of attendances to the various medical practitioners. Surveillance of diabetes parameters was inadequate but small improvements were seen over the 5 year study period (proportion of persons with diabetes with a HbA1c performed: 48.8% to 56.8%; Lipids: 49.4% to 52.0%; HDL cholesterol: 18.3% to 18.8%; microalbuminuria: 4.7% to 11.6%).

CONCLUSION

This study has highlighted the heavy burden imposed by diabetes on our health care system.

IMPLICATIONS

The use of Medicare occasions of service data represents a cost efficient way of monitoring health service utilisation.

Management of type 2 diabetes: a challenge for patient and physician

Type 2 diabetes mellitus is a chronic disease, associated with serious complications and co-morbidity and considerable costs. The number of people with diabetes mellitus is expected to increase with 40% in the next decade, due to prolonged life expectancy, the ageing of the population and developments in the health care sector, including more active screening strategies. The majority (40-60%) of type 2 diabetes patients in routine GP practice have a poor metabolic control (HbA1c > 8% or fasting blood glucose > 11 mmol/l). In this paper the obstacles in routine clinical practice for optimal type 2 diabetes care are discussed. Long-term complications are the major cause of morbidity and mortality in type 2 diabetes patients. Therefore, the primary aim of type 2 diabetes management is the prevention of complications, by lowering blood glucose levels and reducing the cardiovascular risk profile. An important component of type 2 diabetes management is an active role of the patient: diet, smoking habits, physical exercise and self-care behavior often need to change. In addition, the patient has to adhere to life long medical therapy. Motivating the patient for this active role is the challenge for health care providers. A complicating factor is that changes in lifestyle do not give immediate benefit for the patient, as the effects are seen in the reduction of the development of long-term complications. The cornerstones of health care to support active patient participation are: to guarantee the continuity of care, to integrate education in health care and to encourage the patient's attendance. It is the challenge for physicians to give type 2 diabetes patients the tools for active participation in the management of the disease.

Management of insulin-treated diabetes in Tasmania

OBJECTIVE

To evaluate patterns of self-management, healthcare utilisation and screening for major complications among Tasmanians with insulin-treated diabetes.

MAIN OUTCOME MEASURES

Frequency of self-monitoring of blood glucose, health care utilisation and screening for diabetic complications.

DESIGN AND SETTING

A questionnaire survey of 1517 people listed on the Tasmanian Diabetes Register in 1995-1997.

RESULTS

Response rate was 79.5%. Self-monitoring of blood glucose was reported by 98% of respondents, daily self-monitoring by 74%. About 41% of respondents were being managed jointly by GPs and diabetes specialists, 29% solely by GPs and 25% solely by diabetes specialists. Over 96% visited the doctor treating their diabetes more than once a year, but 21% reported they had never visited a diabetes educator and 43% reported they had never visited a dietitian. Most respondents aged > or = 25 years (90%) reported having an eye examination within the past two years, almost all by an eye specialist. Blood pressure was commonly assessed, but most adults indicated that the doctor treating their diabetes did not routinely examine their feet. Nearly 19% of respondents smoked cigarettes.

CONCLUSIONS

Some aspects of diabetes self-care and medical care have improved in Tasmania since the 1984 survey (eg, frequency of self-monitoring of blood glucose rose from 50% to 98%). However, our findings suggest that further improvements are needed to increase daily self-monitoring of blood glucose, attendance at diabetes educator and dietitian services, and foot examinations by doctors. Additional efforts are also needed to lower the prevalence of smoking.