Effectiveness of joint specialist case conferences for building general practice capacity to enhance diabetes care: A pilot study in Western Sydney, Australia

Integrating point-of-care diabetes detection with lifestyle counselling in community settings: outcomes from Western Sydney, Australia

INTRODUCTION

Early detection and prevention of type 2 diabetes and its complications are global health priorities. Optimal outcomes depend on individual awareness and proactive self-management of health risks. This study evaluates the effectiveness of a community-based diabetes detection and intervention program in a high-risk area in western Sydney, Australia.

RESEARCH DESIGN AND METHODS

We collaborated with the Workers Lifestyle Group, Tamil Association Arts and Culture Association, and the National Aboriginal and Islanders Day Observance Committee to implement our program. Participants underwent HbA1C testing via point-of-care blood spot testing. They received personalized feedback, education on diabetes management, and were offered opportunities to enrol in lifestyle modification programs. Participants identified with pre-diabetes (HbA1C 5.7-6.4%) or diabetes (HbA1C > 6.4%) were advised to consult their General Practitioners (GPs). A follow-up questionnaire was distributed 3-8 months post-intervention to evaluate the programs usefulness and relevance and lifestyle changes implemented by the participants.

RESULTS

Over eight months, 510 individuals participated. Of these, 19% had an HbA1C > 6.4%, and 38% had levels between 5.7 and 6.4%. Among those with diabetes, HbA1C levels ranged as follows: 56% <7%; 20% 7-7.9%; 18% 8-8.9%; and 5% >9%. Post intervention survey indicated that the program was well-received, with 62.5% of responses reporting lifestyle changes and 36.3% seeking further advice from their local healthcare providers.

CONCLUSION

The study demonstrates a significant prevalence of pre-diabetes and diabetes in the community, similar to findings from larger-scale hospital and general practice studies. Point-of-care testing combined with personalized education effectively motivated participants toward healthier lifestyle choices and medical consultations. The paper discusses the scalability of this approach for broader population.

Qualitative and Quantitative Evaluation of an Innovative Primary and Secondary Diabetes Clinic in Western Sydney

Introduction

Western Sydney Diabetes (WSD) established an innovative diabetes service in May 2020, using virtual and in-person care, linking primary care with the diabetes specialist team. This study evaluated the service's feasibility using qualitative and quantitative methods.

Method

Evaluation included: 1) thematic analysis of interviews and workshops with patients and health professionals (n = 28); 2) quantitative analysis of records of patients admitted July 2020-June 2021 (n = 110).

Results

Key themes related to 1) benefits: convenient location, access to integrated care, advantages of virtual care; 2) challenges: hard for patients to ask questions, technology issues; 3) confidence: shared care decision making, multidisciplinary team; and 4) future directions: additional multidisciplinary services, expanded insulin stabilisation service, promotion.Improvements between baseline and 3 months included 1.3% reduction in HbA1c (p < 0.05). Sulfonylurea dropped by 25% between initial appointment and follow-up, and GLP1RA/SGLT2i use increasing by 30% (p < 0.05). The clinic covered costs using Medicare billings and Nationally Weighted Activity Units.

Discussion

The findings suggest this integrated care model was feasible and perceived as beneficial by both patients and providers. The clinic offers a promising model of practice that could be developed further to roll out in other regions for rural delivery of care.

Evaluating the Effectiveness of Joint Specialist Case Conferences in Improving Diabetes Control in Patients With Schizophrenia on Clozapine

ABSTRACT

Clozapine treatment for schizophrenia is typically long-term and is associated with a high rate of diabetes. Mental health and diabetes specialist teams at a local hospital in Australia have undertaken a series of joint specialist case conferences (JSCCs) where the diabetes team works with the psychiatry team to improve diabetes management. In this retrospective cohort study conducted between 2013 and 2018, we found that glycemic control in clozapine clinics linked with JSCCs was improved significantly compared with that in the non-JSCC clinics. In the non-JSCC clozapine clinics (control), the poor glycemic control rates stayed at a similar level: 23% in 2013 and 24% in 2018. In contrast, whereas the control patients' poor glycemic rate in JSCC clozapine clinics in 2013 was 24%, it decreased markedly in 2018 to 13%. This study indicates that JSCCs can improve diabetes outcomes in a group of patients with severe mental illness.

Diabetes during the COVID-19 pandemic: are people getting access to the right level of care?

INTRODUCTION

Avoidance of health services, in particular hospital and community services, is problematic for people with diabetes. Evidence has demonstrated that such missed attendances are associated with worse health, faster declines in functioning, and higher rates of mortality long-term. This paper investigated the impact of the pandemic on healthcare access across community and hospital care, including Virtual Care (VC) using several large datasets of General Practice (GP) and hospital services in western Sydney.

METHODS

A retrospective cohort study using a time-series database of 173,805 HbA_1c tests done at Blacktown and Mt Druitt hospitals and 1.8 million recorded consultations at GP clinics in the region was undertaken.

RESULTS

The average rate of diabetes in Emergency Department fell from 17.8% pre-pandemic to 11% after January 2020 (p < 0.001). This rate varied substantially over time, and correlated well with large outbreaks of COVID-19 in the state. Conversely, attendances of people with diabetes to GP clinics, especially using VC services, increased substantially over the pandemic period.

DISCUSSION/CONCLUSION

During the pandemic there was a substantial avoidance of hospital care by patients with diabetes. However, this may have been replaced by VC offered in the community for those with less severe diseases.

Effectiveness of Integrated Diabetes Care Interventions Involving Diabetes Specialists Working in Primary and Community Care Settings: A Systematic Review and Meta-Analysis

Introduction:

Evidence that integrated diabetes care interventions can substantially improve clinical outcomes is mixed. However, previous systematic reviews have not focussed on clinical effectiveness where the endocrinologist was actively involved in guiding diabetes management.

Methods:

We searched EMBASE, COCHRANE, MEDLINE, SCOPUS, CINAHL, Google Scholar databases and grey literature published in English language up to 25 January 2021. Reviewed articles included Randomised Controlled Trials (RCTs) and pre-post studies testing the effectiveness on clinical outcomes after ≥6 months intervention in non-pregnant adults (age ≥ 18 years) with type 1 or type 2 diabetes mellitus. Two reviewers independently extracted data and completed a risk of bias assessment. Appropriate meta-analyses for each outcome from RCTs and pre-post studies were performed. Heterogeneity was assessed using the I² statistic and Cochran’s Q and publication bias assessed using Doi plots. Studies were not pooled to estimate the cost-effectiveness as the cost outcomes were not comparable across trials/studies.

Results:

We reviewed 4 RCTs and 12 pre-post studies. The integrated care model of diabetes specialists working with primary care health professionals had a positive impact on HbA1c in both RCTs and pre-post studies and on systolic blood pressure, diastolic blood pressure, total cholesterol and weight in pre-post studies. In the RCTs, interventions reduced HbA1c (–0.10% [–0.15 to –0.05]) (–1.1 mmol/mol [–1.6 to –0.5]), versus control. Pre-post studies demonstrated improvements in HbA1c (–0.77% [–1.12 to –0.42]) (–8.4 mmol/mol [–12.2 to –4.6]), systolic blood pressure (–3.30 mmHg [–5.16 to –1.44]), diastolic blood pressure (–3.61 mmHg [–4.82 to –2.39]), total cholesterol (–0.33 mmol/L [–0.52 to –0.14]) and weight (–2.53 kg [–3.86 to –1.19]). In a pre-post study with no control group only 4% patients experienced hypoglycaemia after one year of intervention compared to baseline.

Conclusions:

Integrated interventions with an active endocrinologist involvement can result in modest improvements in HbA1c, blood pressure and weight management. Although the improvements per clinical outcome are modest, there is possible net improvements at a holistic level.

Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes

To translate improvements in diabetes management into improved outcomes, it is essential to improve care delivery. To help guide clinicians and health organizations in their efforts to achieve these improvements, this article briefly describes key components underpinning effective diabetes care and six categories of innovations in approaches to improve diabetes care delivery: (1) team-based clinical care; (2) cross-specialty collaboration/integration; (3) virtual clinical care/telehealth; (4) use of community health workers (CHWs) and trained peers to provide pro-active self-management support; (5) incorporating screening for and addressing social determinants of health into clinical practice; and (6) cross-sectoral clinic/community partnerships.

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

AIMS

To evaluate the effectiveness of a new locality-based integrated diabetes care service for people with Type 2 diabetes in an inner regional area.

METHODS

A quasi-experimental evaluation comparing baseline and follow up clinical data collected from general practices and specialist services participating in an integrated diabetes care programme in an inner-regional area. Patients had at least one specialist service consultation. The primary outcome was glycated haemoglobin (HbA1c).

RESULTS

Clinical data were collected for 178/239 patients (74.5% participation; aged 65± 11(SD) years, 46% female; median [interquartile range (IQR)] diabetes duration 19 (11.0-24.0) years from seven general practices over 33 months (median 18.5 months). There were reductions in HbA1c -0.7±1.6 % (8±18 mmol/mol) (p<0.001), systolic blood pressure -5.8±19.5 mmHg (p<0.001), diastolic blood pressure -2.4±14.3 mmHg (p=0.04), total cholesterol -0.5±1.3 mmol/l (p<0.001), low-density lipoprotein (LDL) -0.4±0.9 mmol/l (p<0.001), Body Mass Index -0.5±1.6 kg/m² (p<0.001), weight -1.8±4.7 kg (p<0.001). Urine albumin creatinine ratio [median (IQR)] at baseline was 3.0 mg/mmol (0.7-7) vs follow up 1.9 mg/mmol (0.8-5.5) p< 0.54).

CONCLUSIONS

Glycaemia and cardiovascular risk factors can be reduced in patients with long-standing Type 2 diabetes by moving to a locality based integrated primary-secondary care diabetes care service. This article is protected by copyright. All rights reserved.

Challenges to Introducing Integrated Diabetes Care to an Inner-Regional Area in South Western Sydney, Australia

Introduction

Diabetes care often requires collaboration between general practitioners, allied health professionals, nurses, and/or medical specialists. This study aimed to describe the establishment of an integrated diabetes prevention and care approach in an area with limited access to primary and secondary care, and the challenges faced in its initial development.

Description

A qualitative research approach to identify challenges was taken. Data included meeting minutes, observational data and reports involving local clinical and non-clinical stakeholders from June 2016- December 2018 and were thematically analysed.

Discussion

Key challenges were low patient attendance in general practice, healthcare professional time, low participation at health promotion activities/peer support groups and diabetes education reflecting a low priority among people with and at risk of diabetes. Coordination between services remained a challenge.

Conclusion

This study highlights the need to integrate new diabetes services with existing health activities in the community and the importance of allowing flexibility and regular contact with local healthcare professional and community to encourage their involvement. Regular meetings with the funders, internal and external stakeholders are key for sustainability and to adapt programmes to the local situation. Further work is needed to identify and implement strategies to overcome these challenges.

Hunter and New England Diabetes Alliance: innovative and integrated diabetes care delivery in general practice

Evidence-based standardised diabetes care is difficult to achieve in the community due to resource limitations, and lack of equitable access to specialist care leads to poor clinical outcomes. This study reports a quality improvement program in diabetes health care across a large health district challenged with significant rural and remote geography and limited specialist workforce. An integrated diabetes care model was implemented, linking specialist teams with primary care teams through capacity enhancing case-conferencing in general practice supported by comprehensive performance feedback with regular educational sessions. Initially, 20 practices were recruited and 456 patients were seen over 14 months, with significant improvements in clinical parameters. To date 80 practices, 307 general practitioners, 100 practice nurses and 1400 patients have participated in the Diabetes Alliance program and the program envisages enrolling 40 new practices per year, with a view to engage all 314 practices in the health district over time. Diabetes care in general practice appears suboptimal with significant variation in process measures. An integrated care model where specialist teams are engaged collaboratively with primary care teams in providing education, capacity enhancing case-conferences and performance monitoring may achieve improved health outcomes for people with diabetes.

Evaluating the Diabetes-Cardiology interface: a glimpse into the diabetes management of cardiology inpatients in western Sydney's 'diabetes hotspot' and the establishment of a novel model of care

BACKGROUND

Approximately two-thirds of individuals presenting to emergency departments in Western Sydney have glucose dysregulation, accelerating their risk of cardiovascular disease (CVD). We evaluated the prevalence and management of type 2 diabetes (T2D) in cardiology inpatients in Western Sydney. A novel model of care between diabetes and cardiology specialist hospital teams (joint specialist case conferencing, JSCC) is described herein and aimed at aligning clinical services and upskilling both teams in the management of the cardiology inpatient with comorbid T2D.

METHODS

Cardiology inpatients at Blacktown-Mount Druitt Hospital were audited during a 1-month period.

RESULTS

233 patients were included, mean age 64 ± 16 years, 60% were male, 27% overweight and 35% obese. Known T2D comprised 36% (n = 84), whereas 6% (n = 15) had a new diagnosis of T2D, of which none of the latter were referred for inpatient/outpatient diabetes review. Approximately, 27% (n = 23) and 7% (n = 6) of known diabetes patients suffered hyper- and hypoglycaemia, respectively, and 51% (n = 43) had sub-optimally controlled T2D (i.e. HbA1c > 7.0%); over half (51%, n = 51) had coronary artery disease. Only two patients were treated with an SGLT2 inhibitor and no patients were on glucagon like peptide-1 receptor analogues. The majority were managed with metformin (62%) and therapies with high hypoglycaemic potential (e.g., sulfonylureas (29%)) and in those patients treated with insulin, premixed insulin was used in the majority of cases (47%).

CONCLUSIONS

Undiagnosed T2D is prevalent and neglected in cardiology inpatients. Few patients with comorbid T2D and CVD were managed with therapies of proven cardiac and mortality benefit. Novel models of care may be beneficial in this high-risk group of patients and discussed herein is the establishment of the diabetes-cardiology JSCC service delivery model which has been established at our institution.