Does delay in planned diabetes care influence outcomes for aboriginal Australians? A study of quality in health care

Association of personalised care plans with monitoring and control of clinical outcomes, prescription of medication and utilisation of primary care services in patients with type 2 diabetes: an observational real-world study

OBJECTIVE

To study the association of personalised care plans with monitoring and controlling clinical outcomes, prescription of cardiovascular and antihyperglycaemic medication and utilisation of primary care services in patients with type 2 diabetes (T2D).

PATIENTS

Primary care T2D outpatients from the Rovaniemi Health Centre.

SETTING

The municipal health centre, Rovaniemi, Finland.

DESIGN

A cross-sectional, observational, retrospective register-based study. The patients were divided into three groups: 'no care plan entries' (usual care); '1-2 care plan entries'; and '3 or more care plan entries'.

MAIN OUTCOME MEASURES

Monitoring of clinical and biochemical measures, achievement of treatment targets, prescription of cardiovascular and antihyperglycemic medication, and use of primary care services.

RESULTS

A total of 5104 patients with T2D (mean age 65.5 years (SD 12.4)), of which 67% had at least one care plan entry. Compared to usual care, the establishment of a care plan (either care plan group) was associated with better monitoring of glycosylated haemoglobin A1c, low-density-lipoprotein cholesterol, systolic blood pressure (sBP), and renal function, and there was more frequent prescription of all cardiovascular and antihyperglycemic medication. Patients in either care plan group were more likely to achieve sBP target (p < 0.05). Patients without a care plan had more unplanned primary care physician contacts compared to patients in care plan groups (p < 0.001).

CONCLUSION

Establishment of a care plan is associated with more intensive and focussed care of patients with T2D. The appropriate use of primary care resources is essential and personalised care plans may contribute to the treatment of patients with T2D.Key PointsCare planning aims to empower patients with type 2 diabetes. This study demonstrates that personalised care planning is associated withmore frequent monitoring for clinical outcomes,more frequent prescription of cardiovascular and antihyperglycemic medication andmore frequent utilisation of planned diabetes consultations when compared to usual care.

Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study

BACKGROUND

Type 2 diabetes is rapidly becoming a significant challenge in Uganda and other low and middle-income countries. A large proportion of the population remains undiagnosed. To understand diagnostic delay, we explored the diagnostic pathways for diabetes among patients receiving care at a semi-urban district hospital in eastern Uganda.

METHODS

Eligible participants were patients aged 35-70 years receiving care at the diabetes clinic of Iganga district hospital between April and May 2019 and their healthcare providers. Patients were interviewed using an interview guide to collect information on patients' symptoms and their diagnostic experience. A separate interview guide was used to understand the organisation of the diabetes services and the diabetes diagnostic process at the hospital. Using maximum variation purposive sampling, we selected 17 diabetes patients aged 35-68 years, diagnosed within the previous three years, and the three health workers managing the diabetes clinic at Iganga hospital. The data was analysed using ATLAS.ti version 8 to code, organise and track the data segments. We conducted template analysis using a priori themes derived from the intervals of Walter's model of Pathways to Treatment to identify the factors influencing diagnostic delay.

RESULTS

We identified four typologies: a short diagnostic pathway, protracted appraisal pathway, protracted appraisal and diagnostic interval pathway, and delayed treatment pathway. The pathways of patients with protracted appraisal or diagnostic intervals demonstrated strong socio-cultural influences. There was a firm reliance on traditional healers both before and after diagnosis which deferred enrolment into care. Other health system barriers implicated in delayed diagnosis included stock-out of diagnostic supplies, misdiagnosis, and missed diagnosis. Denial of diagnosis was also found to lead to delayed initiation of care.

CONCLUSION

Reducing diagnostic delay requires addressing both negative socio-cultural influences and the adoption of system-wide interventions to address barriers to timely diagnosis.

Frequent avoidable admissions amongst Aboriginal and non-Aboriginal people with chronic conditions in New South Wales, Australia: a historical cohort study

BACKGROUND

Aboriginal and Torres Strait Islander people have high rates of avoidable hospital admissions for chronic conditions, however little is known about the frequency of avoidable admissions for this population. This study examined trends in avoidable admissions among Aboriginal and non-Aboriginal people with chronic conditions in New South Wales (NSW), Australia.

METHODS

A historical cohort analysis using de-identified linked administrative data of Aboriginal patients and an equal number of randomly sampled non-Aboriginal patients between 2005/06 to 2013/14. Eligible patients were admitted to a NSW public hospital and who had one or more of the following ambulatory care sensitive chronic conditions as a principal diagnosis: diabetic complications, asthma, angina, hypertension, congestive heart failure and/or chronic obstructive pulmonary disease. The primary outcomes were the number of avoidable admissions for an individual in each financial year, and whether an individual had three or more admissions compared with one to two avoidable admissions in each financial year. Poisson and logistic regression models and a test for differences in yearly trends were used to assess the frequency of avoidable admissions over time, adjusting for sociodemographic variables and restricted to those aged ≤75 years.

RESULTS

Once eligibility criteria had been applied, there were 27,467 avoidable admissions corresponding to 19,025 patients between 2005/06 to 2013/14 (71.2% Aboriginal; 28.8% non-Aboriginal). Aboriginal patients were 15% more likely than non-Aboriginal patients to have a higher number of avoidable admissions per financial year (IRR = 1.15; 95% CI: 1.11, 1.20). Aboriginal patients were almost twice as likely as non-Aboriginal patients to experience three or more avoidable admissions per financial year (OR = 1.90; 95% CI = 1.60, 2.26). There were no significant differences between Aboriginal and non-Aboriginal people in yearly trends for either the number of avoidable admissions, or whether or not an individual experienced three or more avoidable admissions per financial year (p = 0.859; 0.860 respectively).

CONCLUSION

Aboriginal people were significantly more likely to experience frequent avoidable admissions over a nine-year period compared to non-Aboriginal people. These high rates reflect the need for further research into which interventions are able to successfully reduce avoidable admissions among Aboriginal people, and the importance of culturally appropriate community health care.

Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia

Background: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies. Aims: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia. Methods: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013–2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)). Results: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as “discussed” (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes. Conclusion: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.