A preliminary study of the relationship between general practice care and hospitalisation using a diabetes register, CARDIAB.

BACKGROUND: Diabetes can be effectively managed in general practice (GP). This study used record linkage to explore associations between diabetes care in GP and hospitalisation. METHODS: Data on patients with type 2 diabetes were extracted from a Division of GP diabetes register (CARDIAB) for 2002-05 and were linked to the New South Wales Admitted Patient and Emergency Department (ED) Data Collection to create a unit record data collection containing demographic, clinical and health service records. Rates of admission and ED presentation per patient-year of follow up were calculated for the year following CARDIAB record. RESULTS: The study included 1178 diabetic patients with 2959 patient-years of follow up. Their mean age was 65.7 years and duration of diabetes was 5.9 years. All-cause admission and ED presentation rates were 0.7 and 0.2 per patient-year of follow up respectively and length of admission 3.2 days (s.d. 11.7 days). Admission was associated with age, duration of diabetes and prior admission. The number of processes of care recorded for each patient-year was associated with admission. Admission and length of stay were not associated with achievement of clinical targets. CONCLUSIONS: These data suggest that receipt of processes of care, rather than clinical targets, will prevent admission. One explanation may be that continuity of care in GP provides opportunity for early intervention and treatment. WHAT IS KNOWN ABOUT THE TOPIC? Diabetes is a serious public health problem that is largely managed in primary care. Health care planners use health service use (hospital admissions) for diabetes as an indicator of primary care. Guidelines for diabetes care are known to be effective in reducing diabetes-related complications. WHAT DOES THIS PAPER ADD? This paper created a linked data collection comprising demographic and clinical data from general practice and administrative health records of hospital admissions and emergency department presentations. The paper explores the associations between processes of primary care and control of diabetes and cardiovascular risk factors, and use of health services for a general practice population with diabetes. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? The study suggests that processes of care and not technical control of diabetes and cardiovascular risk factors are important in preventing hospital admission. Continuity of care in general practice that ensures implementation of processes of care provides opportunity for early intervention and treatment.

A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia.

BACKGROUND: Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines. METHODS: Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation, and the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model, to project outcomes for 40 years from the time of diagnosis and from 5 years post-diagnosis. Cost information was obtained from a range of sources. While program costs are directly available, and costs of complications can be estimated from the UKPDS model, other costs are estimated by comparing costs in the Division with average costs across the state or the nation. The outcome and cost measures are used derive incremental cost-effectiveness ratios. RESULTS: The clinical data show that the program is effective in the short term, with improvement or no statistical difference in most clinical measures over 5 years. Average HbA1c levels increased by less than expected over the 5 year period. While the program is estimated to generate treatment cost savings, overall net costs are positive. However, the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life-year saved and $A9,730 per year of QALE gained. CONCLUSIONS: The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available. Based on this methodology, integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness, which suggests that similar outcomes may be obtained elsewhere.

Investigation of cardiovascular risk factors in type 2 diabetes in a rural Australian Division of General Practice.

OBJECTIVE: To examine the changes in cardiovascular disease (CVD) risk factors for a cohort of patients with type 2 diabetes in general practice. DESIGN AND SETTING: A 4-year retrospective cohort study using extracted data from an active Division of General Practice diabetes register in Australia. PARTICIPANTS: 628 patients (297 female; 331 male) with type 2 diabetes who participated in the diabetes program of the Southern Highlands Division of General Practice and for whom evaluation data were recorded each year from 2002 to 2005. MAIN OUTCOME MEASURES: Changes in the following CVD risk factors over time: body mass index (BMI), serum lipid levels (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], total triglycerides [TG]), systolic and diastolic blood pressure (BP), and glycated haemoglobin (HbA(1c)) level. RESULTS: After adjusting for age, sex, duration and clustering, there was significant improvement in serum lipid levels (TC and LDL-C; P < 0.05) over time; and there was no significant change in BP, HbA(1c) level or BMI. Older patients had significantly worse systolic BP, but significantly better BMI and lipid levels than younger patients. Longer duration of diabetes was associated with worse systolic BP and HbA(1c) level, but better HDL-C level. People with higher BMI were likely to have worse systolic BP, and HDL-C and HbA(1c) levels, but better TC level than those with lower BMI. CONCLUSIONS: Improving BP, HbA(1c) level and BMI may be more difficult than improving lipid levels. There is a need for more intensive and comprehensive interventions to reduce the total risk of CVD.

Quality of care provided by general practitioners using or not using Division-based diabetes registers.

OBJECTIVE: To compare the quality of care provided by general practitioners participating in diabetes shared-care registers with that provided by GPs not using registers. DESIGN: Cross-sectional comparison using Health Insurance Commission (HIC) data for patients attending the GPs. PARTICIPANTS AND SETTING: 155 GPs using diabetes registers, 459 GPs not using registers, and their patients with diabetes (as identified by HIC criteria). The study analysed data for the period January 1996 to December 1998 and was based on Divisions of General Practice within the South Western Sydney Area Health Service. MAIN OUTCOME MEASURES: Frequency of visits to GPs and tests ordered within each of six six-month periods. RESULTS: GPs using the registers had more patients with diabetes, and saw those patients more frequently, than GPs not using registers. "Register" GPs also ordered tests (for HbA(1c) and microalbuminuria) more frequently than "non-register" GPs. CONCLUSION: GPs who participated in diabetes registers were more likely to provide patient care that more closely adhered to evidence-based guidelines than those who did not. Further research is needed to determine whether this was the result of characteristics of the GPs themselves, or their practices, or a was a consequence of their participation.