Australian general practitioners' perspectives on integrating specialist diabetes care with primary care: qualitative study.

BACKGROUND: Improving the coordination and integration of health services is recognised nationally and internationally as a key strategy for improving the quality of diabetes care. The Australian Diabetes Alliance Program (DAP) is an integrated care model implemented in the Hunter New England Local Health District (HNELHD), New South Wales (NSW), in which endocrinologists and diabetes educators collaborate with primary care teams via case-conferencing, practice performance review, and education sessions. The objective of this study was to report on general practitioners' (GPs) perspectives on DAP and whether the program impacts on their skills, knowledge, and approach in delivering care to adult patients with type 2 diabetes. METHODS: Four primary care practices with high rates of monitoring haemoglobin A1c (HbA1c) levels (> 90% of patients annually) and five practices with low rates of monitoring HbA1c levels (< 80% of patients annually) from HNELHD, NSW provided the sampling frame. A total of nine GPs were interviewed. The transcripts from the interviews were reviewed and analysed to identify emergent patterns and themes. RESULTS: Overall, GPs were supportive of DAP. They considered that DAP resulted in significant changes in their knowledge, skills, and approach and improved the quality of diabetes care. Taking a more holistic approach to care, including assessing patients with diabetes for co-morbidities and risk factors that may impact on their future health was also noted. DAP was noted to increase the confidence levels of GPs, which enabled active involvement in the provision of diabetes care rather than referring patients for tertiary specialist care. However, some indicated the program could be time consuming and greater flexibility was needed. CONCLUSIONS: GPs reported DAP to benefit their knowledge, skills and approach for managing diabetes. Future research will need to investigate how to improve the intensity and flexibility of the program based on the workload of GPs to ensure long-term acceptability of the program.

"They were all together discussing the best options for me": Integrating specialist diabetes care with primary care in Australia.

Over one-third of diabetes-related encounters with healthcare providers in Australia fail to meet clinical guidelines. Evidence is mounting that care provision within an integrated framework may facilitate greater adherence to clinical guidelines and improved outcomes for patients. The Diabetes Alliance Program was implemented across a large healthcare district to enhance diabetes care capacity at the primary care level through intensive case-conferencing involving the primary care team, patients and visiting specialist team, whole practice performance review and regular diabetes education for practitioners. Here, we provide an in-depth patient assessment of the case-conferencing process and impact on diabetes management. Two practices with high pre-intervention HbA1c monitoring and three practices with low HbA1c monitoring provided the sampling frame. Patients were selected according to their score on the Patient Activation MeasureTM to achieve maximum variation, with up to two patients with high scores and three with low scores, selected from each practice. Patients were sampled until data saturation was achieved and then subjected to thematic content analysis (n = 19). Patients mostly described the model of care as a positive experience, reporting a boost in confidence in diabetes self-management (particularly around nutrition). The program was also seen to be helpful in providing an opportunity to refocus when "life gets in the way". Other valued aspects of the program included the holistic approach to healthcare, reduced travel time, familiarity in environment and clinical care, top-down knowledge transfer as well as mutual learning by the patient and their primary care team. Despite this, difficulties in coping with diabetes and adherence to treatment recommendations remained for a minority of patients. Integrating specialist teams within primary care has the ability to provide efficient healthcare delivery, better patient experience and health outcomes. Investment in such approaches will be critical to navigating healthcare provision in order to meet the demands of an ageing population.

Recent advances in diabetes treatments and their perioperative implications.

PURPOSE OF REVIEW: The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed. RECENT FINDINGS: The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes. SUMMARY: Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.

Burden of paediatric pyoderma and scabies in North West Queensland.

AIM: The study aims to assess the health burden of children admitted with 'scabies' to Mt Isa Hospital, the referral centre for North West Queensland, from 2006 to 2010. METHODS: This is a retrospective chart audit of admissions of children with 'scabies' including age, sex, date, residence, Indigenous status, result of skin swabs and length of stay, and the number of admissions with acute rheumatic fever (ARF) and acute post-streptococcal glomerulo-nephritis (APSGN) in that period. Financial burden was estimated from daily bed costs and transportation. RESULTS: There were 113 admissions with mean age of 23/12: 11% were <2/12 and mean stay was 4.5 days. 19 were admitted twice, 5 thrice and 2 four times. 7 individuals accounted for 25% of admissions. 'Scabies' accounted for 10.1% of medical admissions <5 years of age. Admissions increased from 10 in 2005 to 39 in 2010. The minimum cost per admission was $9584.07. Seventy-one per cent of swabs grew Group A streptococcus, all sensitive to penicillin. Sixty-three per cent of these were accompanied by Staphylococcus aureus, which was the sole organism in 18%. Sixty-four per cent of S. aureus were methicillin resistant. There were 29 admissions for ARF and 23 with APSGN. All children with 'scabies' and ARF and all but three with APSGN were Indigenous. CONCLUSION: Pyoderma and scabies are major health burdens in North West Queensland, requiring organised community-based prevention. The number of repeat admissions emphasises the futility of individual treatment.

Hallucinations in severe, repeated Sydenham's chorea in an Indigenous girl in North-West Queensland.

Sydenham's chorea is a cardinal feature of rheumatic fever. It is known by its dyskinesia and susceptibility to carditis, but associated psychiatric disorder is being recognised. This has included tics and obsessive compulsive disorder, but we report hallucinations in an indigenous girl, suffering her third bout of chorea.