Sharing the care of diabetic patients between hospital and general practitioners: does it work?

A randomized controlled trial was conducted to compare three forms of diabetes follow-up: (1) general practitioner care, (2) a system of care shared between the general practitioner (GP) and clinic and (3) conventional clinic care. Two hundred and six diabetic patients without significant diabetes-related or other medical complications were randomized to one of these follow-up systems. Metabolic control and blood pressure improved significantly and equally in all three groups (p < 0.05). The shared care group performed as well as or better than either of the other two groups in all other outcome measures. In particular, final attendance rates were 72% for shared care compared with only 35% for GP care and 53% for clinic care. Data collection rates for shared care were comparable with the clinic group for random blood glucose (88.9% vs 95.1%), weight (93.5% vs 98.3%), and blood pressure (94.8% vs 92.7%). Only in the case of glycosylated haemoglobin did shared care have poorer data collection (66.0% vs 98.4%). In all these parameters, except blood pressure, shared care out-performed the GP group. We conclude that with adequate support from and communication with hospital-based diabetes services, GPs are capable of providing care appropriate to the needs of uncomplicated diabetic patients.

Interaction between diabetic patients, their general practitioners and a hospital diabetic clinic.

OBJECTIVE: The aim of this study was to examine the sociodemographic data of diabetic patients referred to our clinic and to correlate these with characteristics of their individual general practitioners. How these factors affect the interaction between patients, general practitioners and a hospital diabetic clinic was evaluated. DESIGN: Prospective recruitment of consecutive referrals. SETTING: The diabetic clinic of a teaching hospital located in the inner city suburbs of Sydney. PATIENTS: Two hundred and forty-six patients with diabetes (10% insulin dependent), aged 20-86 years, participating in our Shared Care Project, a randomised controlled study on various methods of following up diabetic patients. INTERVENTIONS: Data for the study were gathered by interview and questionnaire during first assessment at the clinic. MAIN OUTCOME MEASURES: Clinical and sociodemographic characteristics of patients; the location of general practitioners, their diagnostic equipment and type of practice; and the level of detail recorded in referral letters from general practitioners. RESULTS: Diabetic patients of migrant background who cannot speak English are older and have less formal education. They see their doctors more often and seek out general practitioners who speak their language, even if it means travelling longer distances. Patients referred from 24 hour medical centres are younger, more educated and have less contact with their doctors both in duration and frequency of visits when compared with patients whose general practitioners operate in conventional sole or partnership practices. Many patients have more than one general practitioner, making communication with hospitals difficult. In their referral letters, general practitioners usually concentrate on hypertension, hypercholesterolaemia and metabolic aspects of diabetes, but under-emphasise diabetic complications; they make insufficient use of measurement of the glycosylated haemoglobin level to assess diabetic control while over-using glucose tolerance testing in making the diagnosis. The referral letter often does not contain enough information to help clinical decision making. CONCLUSIONS: Demography of patients and characteristics of general practitioners are important factors which can affect their interaction with public hospitals. Bearing in mind the work load of general practitioners and the diverse nature of patients, hospitals must implement systems which make it easier for general practitioners and patients to interact with them.

Anti-smoking programme for diabetic patients: the agony and the ecstasy.

It is generally accepted that people with diabetes should be encouraged to abstain from smoking but there are few data on the best strategy to implement this. In a preliminary survey of our diabetic patients, knowledge of the general and specific health effects of smoking was poor. In a prospective study of 70 diabetic smokers, only 50% agreed to participate in an anti-smoking programme, and the drop-out rate was high irrespective of whether the content of the programme was general or specific for diabetes. The enrollment rate was best 2 months after the diagnosis of diabetes and the drop-out rate was highest in patients recruited immediately following diagnosis. According to self-reported data, cigarette consumption fell after the first session of the anti-smoking programme but this could not be verified by the measurement of plasma cotinine. It is concluded that an anti-smoking counselling programme based on provision of information, within the context of a specialized diabetes centre, is not cost-effective.

The compliance of diabetic patients: relationship between subjective assessment by physicians and objective measurement of patient performance.

During a survey period of 9 months, diabetic patients attending an outpatient clinic were asked routinely by the nursing staff to produce their home urine/glucose monitoring charts and diet charts. If they could not do so, the importance of bringing these charts was explained and they were instructed to bring their charts at subsequent visits. In addition, the individual responses of 109 consecutive patients were monitored as index cases. The physicians of these 109 patients were asked to grade each patient according to their estimate of the patient's compliance. This subjective rating was correlated with the actual performance of the patients in bringing charts. During the survey the overall number of patients attending the clinic who brought urine/blood charts increased from 31% to 59%. The corresponding figures for diet charts were 6% and 21%. Before intervention, the group rated "high compliance" was more likely than the "low compliance" rated group to bring urine/glucose charts. However, after adjustment for this baseline difference the subsequent performances of the high and low rated groups were comparable. These two groups of patients also performed similarly with respect to diet charts. It is concluded that patients judged subjectively to have poor compliance were able to modify their behaviour similarly to those assessed as having good compliance.