Diabetes management: shared care or shared neglect

Community-based management of complex type 2 diabetes: adaptation of an integrated model of care in a general practice setting

BACKGROUND

Overburdened hospital clinics can have adverse outcomes.

AIMS

To evaluate the effectiveness and patient acceptability of an integrated model of complex type 2 diabetes care delivered in a community-based general practice by upskilled general practitioners (GP) co-located with an endocrinologist and diabetes nurse educator.

METHODS

Patients transferred from hospital clinic lists or referred by local GP were assessed in two southern Perth practices. An upskilled GP and endocrinologist developed a management plan which was communicated to the participant's usual GP. Up to two follow-up visits over 6 months ensured that management was acceptable and effective.

RESULTS

A total of 464 people with type 2 diabetes (mean ± standard deviation age = 59.3 ± 13.7 years, 52.2% males) was enrolled. Their mean glycated haemoglobin (HbA_1c ) was 9.3% (78 mmol/mol) and their mean body mass index 33.7 kg/m² . Use of injectable blood glucose-lowering therapies increased between the initial and final visit in association with a median HbA_1c reduction of 1.2% (13 mmol/mol) which was sustained to 12 months in assessable participants. There were also reductions in blood pressure, and serum low-density lipoprotein cholesterol and triglyceride concentrations. Patient satisfaction with current treatment, time for self-management, time spent in diabetes-related appointments and diabetes knowledge increased significantly. Non-attendance for scheduled appointments was <10%. Local hospital referrals and waiting lists reduced over the study period.

CONCLUSIONS

This study confirms the value of integrated community-based care of complex type 2 diabetes which could represent a sustainable solution to overburdened hospital diabetes outpatient clinics.

Evolution of a register recall system to enable the delivery of better quality of care in general practice

Australian Divisions of General Practice have a key role to play in supporting general practitioners (GPs) to provide proactive, preventive care for their patients with cardiovascular disease (CVD) and diabetes. They can achieve this by providing them with quality improvement information generated by population health monitoring tools such as CARDIAB®™. CARDIAB®™ has prompted the development of standard minimum clinical datasets, enabled recording, monitoring and audit of quality of care and health outcomes for diabetes and cardiovascular patients who are locally enrolled in Division programs. It has also supported the improvement of services within general practice and local secondary care services. GPs have been able to audit their clinical performance and monitor quality of care and health outcomes in diabetes and cardiovascular disease. This article describes the evolution of the CARDIAB®™ database from the grass roots level to a nationally accepted database.

Care of patients with chronic disease: the challenge for general practice

General practice can provide good quality care for a range of high-prevalence chronic diseases, at the same time providing continuity of care and management of comorbidity. Although the quality of care for patients with chronic disease is improving in general practice, about half of patient care does not meet optimal standards. Factors contributing to the gap between optimal and current practice include the method of financing, the availability of other disciplines to participate in team care, limited engagement with self-management education, and lack of information and decision support systems. National initiatives and incentives have enhanced planned and systematic care in general practice, and some programs have been introduced to improve access to allied health care. The number and complexity of programs, and lack of integration between them are a significant administrative burden for general practice, and the financial incentives are small compared to overseas programs. A better integrated and more comprehensive strategy is required to achieve widespread and sustained improvements in the quality of care for people with chronic disease in general practice.

Challenges for IT-supported shared care: a qualitative analyses of two shared care initiatives for diabetes treatment in Denmark "I'll never use it" (GP5)

Purpose

To investigate the circumstances as to why it is so difficult in the primary care sector to implement IT based infrastructures supporting shared care.

Case study

The qualitative analysis includes two separate case studies of IT-supported shared care implemented in two different regions of Denmark throughout 2005. The study comprises 21 interviews and 35 hours of observations. The data were analysed through a coding process that led to the emergence of three main challenges impeding the organisational implementation of IT-supported shared care.

Discussion and conclusion

The two cases faced the same challenges that led to the same problem: The secondary care sector quickly adopted the system while the primary sector was far more sceptical towards using it. In both cases, we observe a discrepancy of needs satisfied, especially with regard to the primary care sector and its general practitioners which hinder bridging the primary sector (general practitioners) and the secondary sector (hospitals and outpatient clinics). Especially the needs associated with the primary sector were not being satisfied. We discovered three main challenges related to bridging the gap between the two sectors: (1) Poor integration with the general practitioners' existing IT systems; (2) low compatibility with general practitioners' work ethic; (3) and discrepancy between the number of diabetes patients and the related need for shared care. We conclude that development of IT-supported shared care must recognise the underlying and significant differences between the primary and secondary care sectors: If IT-supported shared care does not meet the needs of the general practitioners as well as the needs of the secondary care sector the initiative will fail.

Are we measuring what matters in health technology assessment of disease management? Systematic literature review

OBJECTIVES

An overview was produced of indicators currently used to assess disease management programs and, based on these findings, provide a framework regarding sets of indicators that should be used when taking the aims and types of disease management programs into account.

METHODS

A systematic literature review was performed.

RESULTS

Thirty-six studies met the inclusion criteria. It appeared that a link between aims of disease management and evaluated structure, process, as well as outcome indicators does not exist in a substantial part of published studies on disease management of diabetes and asthma/chronic obstructive pulmonary disease, especially when efficiency of care is concerned. Furthermore, structure indicators are largely missing from the evaluations, although these are of major importance for the interpretation of outcomes for purposes of decision-making. Efficiency of disease management is mainly evaluated by means of process indicators; the use of outcome indicators is less common. Within a framework, structure, process, and outcome indicators for effectiveness and efficiency are recommended for each type of disease management program.

CONCLUSIONS

The link between aims of disease management and evaluated structure, process, and outcome indicators does not exist in a substantial part of published studies on disease management. The added value of this study mainly lies in the development of a framework to guide the choice of indicators for health technology assessment of disease management.

The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management

OBJECTIVE

Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management.

STUDY DESIGN AND SETTING

An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated.

RESULTS

Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions.

CONCLUSION

With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.

Social disadvantage: its impact on the use of Medicare services related to diabetes in NSW

OBJECTIVE

To use Medicare data to examine the impact of social disadvantage on the use of health services related to diabetes.

METHOD

Information on number of diabetic individuals and number of services for select Medicare item codes were retrieved by New South Wales postcodes using a Health Insurance Commission data file. The postcodes were graded into quintiles of social disadvantage.

RESULTS

People at most social disadvantage were significantly less likely to be under the care of a general practitioner (adjusted OR 0.41; 95% CI 0.40-0.41) or consultant physician (adjusted OR 0.50; 95% CI 0.48-0.53), despite this group having the highest prevalence of diabetes. The difference in attendance to other specialists was less marked but nevertheless significant (adjusted OR 0.71; 95% CI 0.68-0.75). Once under a doctor's care, patients at most disadvantage were slightly more likely to undergo HbA1c or microalbuminuria estimation (adjusted OR 1.04; 95% CI 1.00-1.10 and adjusted OR 1.22; 95% CI 1.12-1.33, respectively) but were less likely to undergo lipid or HDL cholesterol estimation (adjusted OR 0.81; 95% CI 0.48-0.53 and adjusted OR 0.85; 95% CI 0.79-0.90, respectively).

CONCLUSION

While access to medical care is decreased for people at most social disadvantage, once under a doctor's care they receive a level of monitoring that is relatively equal to that provided to people less disadvantaged.

IMPLICATION

Strategies are required to ensure equal access to medical services for all persons with diabetes, especially for persons who are at most social and medical disadvantage.

Differential shared care for diabetes: does it provide the optimal partition between primary and specialist care?

AIMS

To establish whether a system of differential shared care between general practitioners and specialists is compatible with patients receiving the level of care they require.

METHODS

We sought to trace 200 shared care patients whose care had been kept at the general practitioner level after initial referral and compared them with a group of patients who had been re-referred to the Royal Prince Alfred Hospital Diabetes Centre for specialist review.

RESULTS

There were no significant differences in glycaemic, blood pressure and lipid levels of returned and non-returned patients at initial assessment. However, non-returned patients were less likely to have a history of macrovascular disease or risk factor (adjusted odds ratio (OR) 0.4; 95% confidence interval (CI) 0.2-0.6). Their referral letter was also more likely to emphasize their type and/or duration of diabetes (adjusted OR 4.6; 95% CI 2.5-8.4). Nearly half (47.1%) of the non-returned group changed their doctor in the years following their initial specialist review, increasing their likelihood of not being re-referred five-fold (adjusted OR 5.0; 95% CI 2.9-8.8). At initial assessment, non-returned patients were given less treatment recommendations (adjusted OR 0.5; 95% CI 0.3-0.7). Doctors registered with the Diabetes Shared Care Programme referred more patients than their non-shared care counterparts. However, a higher proportion of these doctors (52.5% vs. 21.3%; chi(2) = 16.5, 1 d.f., P = 0.00005) were selective in whom they re-referred.

CONCLUSION

Differential shared care encourages appropriate referral to specialist services, without compromise to standards of care. Diabet. Med. 18, 554-557 (2001)