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.

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.

Diabetic Retinopathy Screening at the Point of Care (DR SPOC): detecting undiagnosed and vision-threatening retinopathy by integrating portable technologies within existing services.

INTRODUCTION: The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings. RESEARCH DESIGN AND METHODS: This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR. RESULTS: Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m2, HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR. CONCLUSION: There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection.

Type 2 diabetes self-management schemas across diverse health literacy levels: a qualitative investigation.

OBJECTIVE: The aim of this study was to explore how people with diabetes and diverse health literacy levels conceptualise their experience and efforts to engage in self-management behaviours (their self-management 'schemas'). DESIGN: A qualitative design was applied. METHODS: Twenty-six people in Sydney, Australia, took part in semi-structured interviews, which were audio-recorded and coded using Framework analysis. RESULTS: Half the participants (54%) had limited health literacy, whereas 38% adequate health literacy (using Newest Vital Sign). Regardless of health literacy, people described how monitoring increased self-management awareness and signalled periods of low self-management ('lulls'). Accounts of monitoring to sustain motivation were more apparent for participants with adequate health literacy. Most participants described simple and flexible rules (e.g. use artificial sweeteners; eat in moderation). Two schemas related to 'lulls': a 'problem-solving orientation' depicted lulls as inevitable and was associated with varied coping strategies; a 'willpower orientation' attributed lulls to lack of 'willpower,' and described willpower as a main coping strategy. CONCLUSION: There is considerable variation in how people think about their diabetes self-management and the strategies they use. Health literacy may contribute to some of this variation. Self-management interventions could benefit from depicting motivation as fluctuating and challenging ideas about willpower and self-blame.

The effect of an mHealth intervention for titration of insulin for type 2 diabetes: A pilot study.

BACKGROUND: Stabilising blood glucose levels (BGL) after starting or changing insulin and related therapies can be challenging for diabetes services and the patient with type 2 diabetes. Traditionally, a credentialled diabetes educator (CDE) would talk with the patient over the phone to obtain a history of their BGLs over the previous week and provide advice on the insulin dose adjustments as required. This study trialled a smartphone application for sharing BGLs, with the ability to digitally transmit advice back to patients compared with their usual care. AIMS: The aim of this study was to compare desirability, efficiency and ease of use. METHODS: Participants were enrolled in either the traditional (n=50) or Health2Sync (H2S) (n=42) treatment group by patient preference. All insulin stabilisations were conducted by the CDE. Descriptive statistics were used for analysis. RESULTS: The average total time taken to titrate patients was similar in both groups (p>0.05), however there were fewer failure of contacts reported with H2S (p<0.01) and time per interaction was also lower (p<0.01). Sensitivity analysis revealed that, excluding the influence of no contacts, H2S patients had a lower average time for titration (p<0.01). There was no difference in clinical outcomes as measured by HbA1c between the two groups (p=0.75). CONCLUSION: We demonstrated a high acceptance and clinical utility of the H2S application. Clinicians were happy to use H2S and found it easy and convenient for most patients. Importantly, this reduced frequency of contacts with patients, time per interaction and average time for titration (p<0.01). Patient selection for this communication intervention is important.

Implications for GP endorsement of a diabetes app with patients from culturally diverse backgrounds: a qualitative study.

Although many diabetes self-management apps exist, these are not tailored for people from culturally and linguistically diverse (CALD) backgrounds. This study aimed to explore GP perceptions of how diabetes app features could help GPs better support their patients from CALD backgrounds. Twenty-five semi-structured interviews with GPs in Western Sydney explored attitudes towards a proposed app's suitability for CALD patients. Interviews were audio-recorded, transcribed and coded using Framework Analysis. Theme 1 explored the implications of perceptions that patients' health literacy is dependent on the language used. Theme 2 explored the influence of messaging from sources that share the patient's language and culture (including misinformation from community sources). Theme 3 described the suitability of the app platform for CALD patients, and its potential challenges in this group. GPs perceived that a diabetes app could be useful for providing support to patients from CALD backgrounds. Findings suggest app features should be optimised to address existing challenges that GPs face and carefully consider strategies for recruiting CALD patients. It is important that GPs feel comfortable promoting an app to their CALD patients to help increase participation rates by people in the CALD community.

Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study.

BACKGROUND: The health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user's primary care physician (PCP). OBJECTIVE: This study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services. METHODS: Researchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient's primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor. RESULTS: Our analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation. CONCLUSIONS: This study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process.

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.