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

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.

Falling mortality rates in Type 2 diabetes mellitus in the Wirral Peninsula: a longitudinal and retrospective cohort population-based study.

OBJECTIVES: To determine the life expectancy and mortality rates in patients with type 2 diabetes mellitus when compared with the UK general population; to measure the years of life lost. DESIGN: Longitudinal and retrospective cohort study. SETTING: The Wirral Peninsula in the northwest of England. PARTICIPANTS: Total of 13,620 patients with type 2 diabetes mellitus on the Wirral Diabetes Register. MAIN OUTCOME MEASURE: All-cause mortality, from 1 January 2000 to 31 December 2007. RESULTS: Over the 8-year period of the study, there were a total of 16,692.5 person-years lived and 3888 deaths; 2041 (52.5%) males and 1847 (47.5%) females with corresponding mean ages at death of 75.6±10.3 years and 80.2±10.2 years, respectively. Although prevalence rates increased linearly (from 1.06% in 2000 to 4.39% in 2007) a decrease in mortality rates (from 117 to 46 per 1000 population) in both sexes was observed. This coincided with a progressive fall in cardiovascular risk factors in this population. A survival time curve of life lived until death showed that males had 8.0 years reduction in life span and females' life span was reduced by 9.6 years when compared with UK general population. In both sexes, life expectancy was reduced by between 2 and 11 years dependent on the age of diagnosis, with males showing a greater degree of reduction. CONCLUSION: Type 2 diabetes mellitus is associated with a significant reduction in life expectancy, more markedly in men, and in those diagnosed before age 70 years. However, annual mortality rates have fallen progressively in our population and may contribute to longer survival and life expectancy in future years.