1
|
Acharya S, Taylor R, Parsons M, Attia J, Leigh L, Oldmeadow C, Wynne K, Rowe C, Joseph M, Luu J, Philcox A, Jackel D, Quach T, Sankoorikal C, Dagg S, Hure A. Spillover effects from a type 2 diabetes integrated model of care in 22,706 Australians: an open cohort stepped wedge trial. BMC Endocr Disord 2024; 24:183. [PMID: 39256722 PMCID: PMC11384678 DOI: 10.1186/s12902-024-01692-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/15/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Many Australian adults are not receiving timely or effective diabetes management to prevent or delay the onset of diabetes related complications. Integrated care, a worldwide trend in healthcare reform, aims to reduce the fragmented delivery of health services and improve outcomes. This study aimed to test whether a specialist-led integrated model of care provided to a small subset of patients in general practices leads to spillover clinical improvements in all patients of the practice with type 2 diabetes. METHODS Seventy-two general practice sites (clusters) in New South Wales, Australia received the Diabetes Alliance intervention, creating a non-randomised open cohort stepped wedge trial. The intervention comprised of case conferencing, delivered directly to a small proportion of adults with type 2 diabetes (n = 1,072) of the general practice sites; as well as practice feedback, education and training. Spillover clinical improvements were assessed on all adults with type 2 diabetes within the general practice sites (n = 22,706), using practice level data recorded in the MedicineInsight electronic database, compared before and after the intervention. Outcome measures included frequency of diabetes screening tests in line with the Annual Cycle of Care, and clinical results for weight, blood pressure, HbA1c, lipids, and kidney function. RESULTS Compared to before Diabetes Alliance, the odds of all practice patients receiving screening tests at or above the recommended intervals were significantly higher for all recommended tests after Diabetes Alliance (odds ratio range 1.41-4.45, p < 0.0001). Significant improvements in clinical outcomes were observed for weight (absolute mean difference: -1.38 kg), blood pressure (systolic - 1.12 mmHg, diastolic - 1.18 mmHg), HbA1c (-0.03% at the mean), total cholesterol (-0.11 mmol/L), and triglycerides (-0.02 mmol/L) (p < 0.05). There were small but significant declines in kidney function. CONCLUSIONS Integrated care delivered to a small subset of patients with type 2 diabetes across a large geographic region has spillover benefits that improve the process measures and clinical outcomes for all practice patients with type 2 diabetes. TRIAL REGISTRATION ACTRN12622001438741; 10th November 2022, retrospectively registered: https://www.anzctr.org.au/ACTRN12622001438741.aspx .
Collapse
Affiliation(s)
- Shamasunder Acharya
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia.
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.
| | - Rachael Taylor
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Martha Parsons
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
| | - John Attia
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Clinical Research Design IT and Statistical Support (CReDITSS) Unit, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Clinical Research Design IT and Statistical Support (CReDITSS) Unit, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Katie Wynne
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Christopher Rowe
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Morag Joseph
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- Hunter New England Central Coast Primary Health Network, PO Box 2288, Dangar, NSW, 2309, Australia
| | - Judy Luu
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Annalise Philcox
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Damien Jackel
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Tuan Quach
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Christy Sankoorikal
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Simone Dagg
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Alexis Hure
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| |
Collapse
|
2
|
Serrano J, Meyerowitz-Katz G, Dawson J, Ratnayake A, Ravi S, Dick H, Bramwell S, Scott M, Jayaballa R, Maberly G. Integrating point-of-care diabetes detection with lifestyle counselling in community settings: outcomes from Western Sydney, Australia. BMC Health Serv Res 2024; 24:926. [PMID: 39138433 PMCID: PMC11323375 DOI: 10.1186/s12913-024-11335-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/22/2024] [Indexed: 08/15/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Jaybee Serrano
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia.
| | - Gideon Meyerowitz-Katz
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
- School of Nursing, University of Wollongong, Wollongong, Australia
| | - Janine Dawson
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
| | - Aruni Ratnayake
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
| | - Sumathy Ravi
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Helen Dick
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
| | - Sian Bramwell
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
| | - Mark Scott
- Novo Nordisk Australia, Sydney, Australia
| | - Rajini Jayaballa
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
- School of Medicine, Macquarie University, Sydney, Australia
| | - Glen Maberly
- Western Sydney Diabetes (WSD), Western Sydney Local Health District (WSLHD), Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| |
Collapse
|
3
|
Ravi S, Meyerowitz-Katz G, Murugesan A, Ayre J, Jayaballa R, Rintoul D, Sarkis M, McCaffery K, Maberly G, Bonner C. Qualitative and Quantitative Evaluation of an Innovative Primary and Secondary Diabetes Clinic in Western Sydney. Int J Integr Care 2024; 24:13. [PMID: 38406628 PMCID: PMC10885848 DOI: 10.5334/ijic.7548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Sumathy Ravi
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gideon Meyerowitz-Katz
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
- School of Health and Society, University of Wollongong, Wollongong, NSW, Australia
| | - Anandhi Murugesan
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Julie Ayre
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rajini Jayaballa
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
| | | | - Marina Sarkis
- Agency for Clinical Innovation, St Leonards, NSW, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Glen Maberly
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Carissa Bonner
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
4
|
Zheng Y, Meyerowitz-Katz G, Bramwell S, Jayaballa R, Assur Y, Vasani D, Ganapathy R, Maberly G, Brakoulias V. Evaluating the Effectiveness of Joint Specialist Case Conferences in Improving Diabetes Control in Patients With Schizophrenia on Clozapine. J Nerv Ment Dis 2023; 211:221-225. [PMID: 36108285 DOI: 10.1097/nmd.0000000000001590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Sian Bramwell
- Western Sydney Diabetes, Western Sydney Local Health District, Blacktown
| | - Rajini Jayaballa
- Western Sydney Diabetes, Western Sydney Local Health District, Blacktown
| | | | | | | | | | | |
Collapse
|
5
|
Meyerowitz-Katz G, Ferdousi S, Maberly G, Astell-Burt T. Diabetes during the COVID-19 pandemic: are people getting access to the right level of care? BMC Health Serv Res 2023; 23:167. [PMID: 36797704 PMCID: PMC9933792 DOI: 10.1186/s12913-023-09168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
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 HbA1c 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.
Collapse
Affiliation(s)
- Gideon Meyerowitz-Katz
- Western Sydney Local Health District, Blacktown Hospital, 18 Blacktown Road, Blacktown, NSW, 2148, Australia. .,Population Wellbeing and Environment Research Lab, School of Health and Society, Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, Australia.
| | - Shahana Ferdousi
- Wentwest, Western Sydney Primary Health Network, Campbelltown, NSW Australia
| | - Glen Maberly
- grid.460687.b0000 0004 0572 7882Western Sydney Local Health District, Blacktown Hospital, 18 Blacktown Road, Blacktown, NSW 2148 Australia ,grid.1013.30000 0004 1936 834XBoden Initiative, Charles Perkins Centre, University of Sydney, Camperdown, NSW Australia
| | - Thomas Astell-Burt
- grid.1007.60000 0004 0486 528XPopulation Wellbeing and Environment Research Lab, School of Health and Society, Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW Australia ,grid.1013.30000 0004 1936 834XMenzies Centre for Health Policy and Economics, University of Sydney, Camperdown, NSW Australia
| |
Collapse
|
6
|
Effectiveness of Integrated Diabetes Care Interventions Involving Diabetes Specialists Working in Primary and Community Care Settings: A Systematic Review and Meta-Analysis. Int J Integr Care 2022; 22:11. [PMID: 35634254 PMCID: PMC9104489 DOI: 10.5334/ijic.6025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/19/2022] [Indexed: 11/20/2022] Open
Abstract
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.
Collapse
|
7
|
Jackson CL, O'Halloran D. Reforming our health care system: time to rip off the band-aid? Med J Aust 2021; 215:301-303.e1. [PMID: 34519047 DOI: 10.5694/mja2.51261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Claire L Jackson
- University of Queensland, Brisbane, QLD.,MRI-UQ Centre for Health System Reform and Integration, University of Queensland, Brisbane, QLD
| | | |
Collapse
|
8
|
Heisler M, Simmons D, Piatt GA. Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes. Endocrinol Metab Clin North Am 2021; 50:e1-e20. [PMID: 34763822 DOI: 10.1016/j.ecl.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School; Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System; Department of Health Behavior and Health Education, School of Public Health, University of Michigan.
| | - David Simmons
- School of Medicine, Western Sydney University, Sydney, Australia; Macarthur Clinical School, Campbelltown Hospital, Therry Road, Campbelltown, New South Wales 2560, Australia
| | - Gretchen A Piatt
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan; Department of Learning Health Sciences, University of Michigan Medical School, 1111 E. Catherine Street, Victor Vaughan Building, Room 225, Ann Arbor, MI 48109, USA
| |
Collapse
|
9
|
Zarora R, MacMillan F, Piya MK, Fernandes B, Simmons D. Effectiveness of a locality-based integrated diabetes care service on clinical outcomes. Intern Med J 2021; 52:975-981. [PMID: 33471370 DOI: 10.1111/imj.15211] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Reetu Zarora
- Doctor of Philosophy student, School of Medicine, Western Sydney University.,Diabetes Obesity and Metabolism Translational Research Unit.,Macarthur Clinical School, Campbelltown, New South, Wales.,Western Sydney University, Locked Bag 1797, Penrith, New South Wales, 2751, Australia
| | - Freya MacMillan
- Diabetes Obesity and Metabolism Translational Research Unit.,Western Sydney University, Locked Bag 1797, Penrith, New South Wales, 2751, Australia.,Senior Lecturer, School of Health Science.,The Translational Health Research Institute.,Western Sydney University, Campbelltown, New South, Wales
| | - Milan K Piya
- Diabetes Obesity and Metabolism Translational Research Unit.,Macarthur Clinical School, Campbelltown, New South, Wales.,Western Sydney University, Locked Bag 1797, Penrith, New South Wales, 2751, Australia.,Senior Lecturer in Diabetes, School of Medicine, Western Sydney University
| | - Brunelle Fernandes
- Diabetes Obesity and Metabolism Translational Research Unit.,Registered Nurse/Credentialed Diabetes Educator.,Campbelltown Hospital, Campbelltown, New South Wales, 2751, Australia
| | - David Simmons
- Diabetes Obesity and Metabolism Translational Research Unit.,Macarthur Clinical School, Campbelltown, New South, Wales.,Western Sydney University, Locked Bag 1797, Penrith, New South Wales, 2751, Australia.,The Translational Health Research Institute.,Professor of Medicine, School of Medicine, Western Sydney University
| |
Collapse
|
10
|
Challenges to Introducing Integrated Diabetes Care to an Inner-Regional Area in South Western Sydney, Australia. Int J Integr Care 2020; 20:6. [PMID: 32405283 PMCID: PMC7207248 DOI: 10.5334/ijic.4692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
Collapse
|
11
|
Acharya S, Philcox AN, Parsons M, Suthers B, Luu J, Lynch M, Jones M, Attia J. Hunter and New England Diabetes Alliance: innovative and integrated diabetes care delivery in general practice. Aust J Prim Health 2019; 25:219-243. [PMID: 31221243 DOI: 10.1071/py18179] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/22/2019] [Indexed: 02/28/2024]
Abstract
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.
Collapse
Affiliation(s)
- Shamasunder Acharya
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia; and School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia; and Corresponding author
| | - Annalise N Philcox
- Department of Medicine, Calvary Mater Hospital, Edith Street, Waratah, NSW 2298, Australia
| | - Martha Parsons
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia
| | - Belinda Suthers
- Clinical Research Design and Statistical Support Unit, Hunter Medical Research Institution, Lot 1, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Judy Luu
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia; and School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Margaret Lynch
- Smith Street Medical Centre, 28 Smith Street, Charlestown, NSW 2290, Australia
| | - Mark Jones
- Clinical Research Design and Statistical Support Unit, Hunter Medical Research Institution, Lot 1, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - John Attia
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305, Australia; and Clinical Research Design and Statistical Support Unit, Hunter Medical Research Institution, Lot 1, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| |
Collapse
|
12
|
Bishay RH, Meyerowitz-Katz G, Chandrakumar D, Jayaballa R, Hng TM, Mclean M, Punchihewa D, Jeyaprakash M, Burgess D, Riskallah J, Maberly GF. 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. Diabetol Metab Syndr 2018; 10:90. [PMID: 30564287 PMCID: PMC6295105 DOI: 10.1186/s13098-018-0393-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/11/2018] [Indexed: 01/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ramy H. Bishay
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
- School of Medicine, Western Sydney University, Sydney, NSW Australia
- School of Medicine, University of Sydney, Sydney, NSW Australia
- Metabolic and Weight Loss Program, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
- Department of Endocrinology, Clinical School Building, Level 3, Western Sydney University Blacktown Campus, Blacktown Hospital, Marcel Crescent, Blacktown, NSW 2148 Australia
| | - Gideon Meyerowitz-Katz
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
| | - David Chandrakumar
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
| | - Rajini Jayaballa
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
| | - Tien-Ming Hng
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
- School of Medicine, Western Sydney University, Sydney, NSW Australia
- Department of Endocrinology, Clinical School Building, Level 3, Western Sydney University Blacktown Campus, Blacktown Hospital, Marcel Crescent, Blacktown, NSW 2148 Australia
| | - Mark Mclean
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
- School of Medicine, Western Sydney University, Sydney, NSW Australia
| | - Dilini Punchihewa
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
| | - Maiyoori Jeyaprakash
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
| | - David Burgess
- School of Medicine, Western Sydney University, Sydney, NSW Australia
- Department of Cardiology, Blacktown Hospital, Blacktown, NSW Australia
| | - John Riskallah
- Department of Cardiology, Blacktown Hospital, Blacktown, NSW Australia
| | - Glen F. Maberly
- Western Sydney Diabetes, Integrated and Community Health Directorate, Department of Endocrinology and Diabetes, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW Australia
- School of Medicine, Western Sydney University, Sydney, NSW Australia
- School of Medicine, University of Sydney, Sydney, NSW Australia
| |
Collapse
|