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

Abstract

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 (HbA1c) 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 HbA1c 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.

Effectiveness of a locality‐based integrated diabetes care service on clinical outcomes

“…This was possibly due to the project being a ‘horizontally’ integrated primary diabetes care approach, buying in specialist services, rather than a vertically integrated service as occurring in our service 5 . Other community‐based integrated care models between primary and secondary care (non‐RCT) have also shown similar improvements in HbA1c 6,7 (significant difference between baseline and follow up (median (IQR) HbA1c 89 mmol/mol (10.3%) (65–105) versus 81 mmol/mol (9.6%) (60–99); P = 0.002) 19 including those in rural and remote Indigenous communities 20,21 …”

Effectiveness of Diabetes Case Conferencing Program on Diabetes Management

“…Several studies have evaluated diabetes management provided by a multidisciplinary team with the patient present during the consultation. Both virtual/ videoconferencing and face-to-face consultations have reported improved glycaemic outcomes [7][8][9][10][11][12][13]. This is the first study to evaluate a diabetes case conferencing program without patients' presence/participation in a diabetes multidisciplinary consultation.…”

“…In Australia, funding is available to provide joint specialist consultations to manage complex and chronic cases [6] of which diabetes is one example. The role of GPs is crucial in diabetes management and a proactive review of patient care with a specialist has improved diabetes management in primary care in a number of local initiatives [10][11][12].…”

Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review

“…A multidisciplinary approach to care improves glycaemic control and is desirable due to the multifaceted nature of the disease and management required (60,61). A system whereby diabetes care is integrated within primary health care (PHC) could work in this setting, an approach that has been demonstrated for other chronic disease management (62,63). Although none of the included studies described the impact on mental health (e.g.…”