p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 203–210
Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Evaluation of a community diabetes initiative: Integrating diabetes care Jason Leo Walsh 1 , Benjamin Howell Lole Harris ∗,1 , Aled Wyn Roberts University Hospital of Wales, Cardiff, UK
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: To evaluate the impact of a community diabetes initiative, aiming to improve the
Received 26 September 2014
efficiency of type 2 diabetes (T2DM) care within the Cardiff and Vale Health Board.
Received in revised form
Methods: In 2012, a community diabetes initiative was introduced in Cardiff and Vale. Ten
16 October 2014
National Health Service (NHS) consultant diabetologists and three nurse specialists sup-
Accepted 17 October 2014
ported 69 general practices in this region. Here we evaluate the impact of this initiative
Available online 12 December 2014
by assessing the number and quality of secondary care diabetes clinic referrals before (2011–2012) and after implementation (2013–2014). Referrals pre and post initiative were
Keywords:
audited against Cardiff and Vale T2DM referral guidelines in two 6-month periods.
Community
Results: In the 6-months prior to the initiative, 108 referrals were received, 78 of which were in
Diabetes
line with local guidance. Approximately one year after embarking on the diabetes initiative
Specialist nurse
(2013–2014) there was a 31% reduction (p < 0.01) in the total number of T2DM clinic referrals
Referral
and a 57% reduction (p < 0.01) in referrals outside the guidelines. A decrease in referrals was
Primary care
not seen in the practice noted not to engage with the initiative.
Secondary care
Conclusions: The community diabetes initiative intervention has significantly improved the
E-mail
appropriateness of T2DM referrals from GP practices engaged with the initiative. As a result
Service-based research
we advocate a move towards integrated diabetes care within the community. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Diabetes mellitus (DM) is a chronic condition caused by deficiency or diminished effectiveness of endogenous insulin. This leads to characteristic hyperglycaemia, glycosylation of the vasculature and deranged metabolism, which in turn lead to further pathological problems.
∗
1
DM is becoming an increasing challenge to the global health infrastructure with 4.4% of the world’s population expected to diabetic by 2030 [1]. Due predominantly to the expansion of sedentary lifestyle and increasing life expectancy and the Western obesity epidemic, 90% of DM sufferers will be type 2 (T2DM) [1,2]. In 2013, the prevalence of diabetes in the UK was estimated at 6% [3]. The highest prevalence is in Wales, where ∼7% of the population have been
Corresponding author. Tel.: +44 29 2074 7747x42498. E-mail addresses: [email protected] (B.H.L. Harris), [email protected] (A.W. Roberts). Joint first author.
http://dx.doi.org/10.1016/j.pcd.2014.10.003 1751-9918/© 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
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diagnosed with diabetes [3,4] and in line with the global trend, T2DM is by far the most common type. T2DM prevalence has increased from 3.3% to 4.1% over the 5 years 2004–2009, occasioning an added cost of £649.2million to the NHS in England and Wales [5]. Furthermore, a significant proportion of the population have undiagnosed diabetes [6]. DM and its complications account for 10% of total NHS expenditure today [7], as compared to 6% in 1996 [8]. This increase shows no sign of abating. There is good evidence that early diagnosis and effective management of DM reduces the risk of premature death and complications [9–11]. Given current economic stringency, it is increasingly important that the burden of T2DM and its complications on the NHS are minimised, through patient education and appropriate management. In parallel, the use of existing services must be scrutinised and streamlined, to reduce the strain on already tight purse strings. The treatment of a patient with diabetes is more costeffective if it is kept within a community setting. A study from Cardiff and Vale found that the average cost of managing a T2DM patient within secondary care was £1401 compared with £249 in primary care per annum [12]. Therefore, it appears to be a worthwhile strategy to reduce the burden of T2DM on hospitals. There have been several suggestions in the literature including: (1) Expanding the role of specialist nurses in the community [13], (2) introducing health coaching or similar initiatives into primary care [14,15] and (3) restructuring diabetes services [16–18]. Health coaching or motivational interviewing is a relatively recent concept, which aims to encourage positive behaviour change in disease management via one-to-one support by a peer or professional coach. This support can be face-to-face or via telephone. Health coaching has shown to have positive effects on Hba1c [19] and weight control [20]. Integrating professional health coaches into primary care aiming to optimise diabetic control has been shown to be feasible in Canada [14]. This approach is similar to the DESMOND programme in the UK (delivering diabetes education and self-management for ongoing and newly diagnosed). This consists of a number of registered healthcare professionals being trained as educators. They provide six hours of contact time to newly diagnosed T2DM patients. This approach has been shown to be effective and increased the likelihood of T2DM patients giving up smoking and losing weight [15]. Several strategies involving restructuring of diabetes services have attempted to optimise community diabetes care in the UK. The “super six” diabetes care model created a clear distinction between the roles of primary and secondary care professionals in diabetes management [17]. Having six clear reasons (the “super six”) that justify referral to a secondary care clinic. The model also encourages integration between primary and secondary care, offering telephone, email and face-to-face support from diabetologists to GPs in “complex cases” that fall outside of these six criteria. The role of diabetes specialists in educating primary care professionals is also emphasised. Evaluation of the model showed high GP satisfaction with the service, reduction of episodes of diabetic ketoacidosis, a reduction of hypoglycaemic admissions and a reduction of admissions with hyperglycaemic non-ketotic coma [21].
The Derby model consisted of a partnership between primary and secondary care. Two companies were set up equally owned by Derby Hospital NHS Trust and local primary care organisations (two general practice conglomerates). A multidisciplinary clinical board was established for each institution to oversee the provision of diabetes services. The allocation of resources from within a shared primary and secondary care budget allowed services to be streamlined and improved. The Derby initiative appeared to improve glycaemic control, blood pressure and lipid management for T2DM patients [18]. Here, we also blur the traditional boundaries between primary and secondary care, aiming to integrate diabetes care within the community. In this initiative, we combine DSNs with consultant diabetologist support into a novel community diabetes initiative. Diabetes specialist nurses (DSNs) have been shown to be cost effective [22–25] and improve clinical outcomes in the community [26,27]. Community diabetes specialist nurses deliver educational support to healthcare professionals in primary care e.g. teaching on GLP-1 mimetic initiation whilst consultant diabetologists provide support and specialist advice face to face in the community or via email. Locally, this initiative has been referred to as the Diabetes Integrated Care Service (DICS) model. This study aims to: (1) improve the cost-effectiveness of the diabetes service in the Cardiff and Vale Health Board, (2) improve the quality of referrals to the secondary care diabetes clinics, (3) reduce waiting lists for outpatient diabetes clinics, (4) improve diabetes management in the community and (5) evaluate our community care model, contributing to the evidence-base behind community diabetes management. We used two outcome measures to establish the effectiveness of our intervention. Both the number and quality of referrals were used as surrogate measures of efficient delivery of diabetes care. If the community initiative was effective, we would expect a higher proportion of referrals in line with local referral guidance and potentially a decrease in the total number of referrals. Anecdotal evidence suggests that this approach should be effective, however there have been no systemic validations of approaches that combine DSNs and diabetologist e-support with general practice.
2.
Methods
2.1.
The initiative
The first component of the initiative involves linking individual GP practices to individual consultant diabetologists. Sixty-nine general practices in Cardiff and Vale were divided between 10 consultant diabetologists, according to locality. The named diabetologist for his/her practices visits the assigned practices twice per year to discuss complex and interesting patients. As well as optimising management in the community, this initiative aims to educate primary care workers, contributing towards their professional development. Consultants also provide a decision-making support service by email, giving GPs easy access to specialist advice within five working days of receipt of email. The second component of the initiative comprises the DSNs, who provide educational support to all healthcare
p r i m a r y c a r e d i a b e t e s 9 ( 2 0 1 5 ) 203–210
Box 1: Cardiff and Vale T2DM referral guidelines 1. Failure to reach HbA1c target OR HbA1c >7.0% despite combination therapy. 2. Initiation of insulin therapy in type 2 patients not reaching target HbA1c. 3. Failure to reach BP target OR BP >140/80 despite combination therapy. 4. Failure to reach Total Cholesterol target OR TC >5.0mmol/l despite therapy. 5. Persistent proteinuria (Albumin:Creatinine ratio >35) or haematuria despite therapy. 6. Stage 3 (eGFR 150umol/l. 7. Acute or difficult-to-manage foot/neuropathy symptoms (including acute Charcot joint.) 8. Require assessment of cardiovascular risk profile in order to determine patient specific treatment targets. 9. Recurrent hypoglycaemic episodes.
professionals in primary care. Each practice nurse had a named diabetic nurse mentor, who can be contacted with any concerns pertinent to diabetic management. The 69 practices were divided between the three DSNs. DSN funding was obtained exclusively from pharmaceutical companies (Novo Nordisk, Sanofi, Lilly).
2.2.
Service evaluation
Ethical approval was obtained from Cardiff University School of Medicine Ethics and Research Committee. Before implementation, the number of referrals to the secondary care diabetes clinic was counted in a 6-month period (August–January 2011–2012). All referrals were audited against local referral guidance (Box 1). For each referral, age, weight, sex, BMI, G.P practice and reason for referral were recorded. Confidentiality and anonymity were maintained throughout. One year after implementation, August–January 2013–2014, data collection was repeated to measure the impact of the community diabetes initiative. The total number of referrals was compared before and after the initiative. Referrals were also assessed as falling into, or outside the guidelines (‘referral quality’). The significance of any observed differences was assessed using the chi-squared test.
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Engagement of practices with the community initiative was monitored by the lead diabetiologist. The practices identified as engaging the most and the least were further scrutinised. The referral rate and referral quality were compared before and after the initiative for these individual practices.
3.
Results
3.1.
Pre-initiative
108 T2DM patients were referred to the secondary care diabetes clinic in August 2011–January 2012 (Fig. 1). Approximately one third (30/108) were not in line with referral guidance (Fig. 2). The mean age of the sample was 57.4 years, the male:female ratio was 48:60 and mean BMI was 32.3 (although BMI was not recorded in 35% of patients). Fig. 2 shows the reasons for referral in those patients referred under the guidelines. The majority of appropriate such referrals result from high HbA1c levels. No patients were referred under criterion 5 (persistent proteinuria). One caveat in viewing this data is that the proportions in the pie chart are expressed relative to the number of reasons for referral (87), which is larger than the number of patients (78) as several patients had more than one appropriate reason for referral. Fig. 3 shows the reasons for referral in those patients referred outside the guidelines. Compliance-related issues (31%) were the single most significant cause although other major contributors were changes in regime (e.g. during pregnancy, changes in drug therapy) or a perceived lack of specialist knowledge in the GP practice.
3.2.
Post-initiative
In August 2013–January 2014, one year after the initiative had been introduced, 75 T2DM patients were referred to the secondary care diabetes clinic (Fig. 4). Approximately 10% (9/75) were not in line with referral guidance (Fig. 6). The mean age of the sample was 58.1 years, the male:female ratio was 38:37 and mean BMI was 35 (although BMI was not recorded in 40% of patients). High HbA1c levels despite adequate combination therapy were the predominant reason for referral within the guidance (Fig. 5), with initiation of insulin therapy a second major contributor. The total number of reasons for referral within the guidelines was 80.
Fig. 1 – T2DM referrals to the Cardiff and Vale secondary care diabetes clinic at Univerisity Hospital of Wales (UHW), pre-initiative.
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Fig. 2 – Reasons for referral in line with the referral guidelines pre-initiative (n = 78).
Fig. 3 – Reasons for referral outside the referral guidelines pre-initiative (n = 30).
As previously, compliance-related issues (22%) were the major reason for referral outside the guidelines, but patient request (15%) became the second most significant cause for referral outside of the guidelines.
3.3.
Comparison
The total number of referrals to the secondary care diabetes clinic fell from 108 to 75 referrals. This equates to a ∼30% decrease in the volume of referrals post-initiative. In view of the fact that the number of T2DM patients is likely to have risen during this period, this represents a promising change following the initiative.
Of these 75 referrals, only nine were identified as being outside the guidelines. The proportion of referrals outside of the guidelines had thus fallen from 28% before the initiative to 12% after its introduction, giving a 57% reduction (p < 0.01) (Fig. 7). Again, this represents a promising change following the initiative, Comparing Figs. 3 and 6, we can see other noteworthy differences following the initiative. These include:
• A reduced proportion of referrals for recurrent hypoglycaemia (9% to 3%).
Fig. 4 – T2DM referrals to the Cardiff and Vale secondary care diabetes clinic at Univerisity Hospital of Wales (UHW), post-initiative.
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Fig. 5 – Reasons for referral in line with the referral guidelines post-initiative (n = 66).
Fig. 6 – Reasons for referral outside the referral guidelines post-initiative (n = 9).
• A lower number of patients referred for GLP-1 agonist initiation (13% to 7%). • An overall reduction (31% to 22%) in compliance issues, although these remain the major reason for referrals outside the guidelines.
Figs. 2 and 5 show that, following the initiative, an increased proportion of insulin initiation took place in secondary care (13% to 29%). Although not given in the above data, there was also a marked improvement in waiting times for a secondary care
Fig. 7 – The proportion of referrals in line vs referrals not in line with the referral guidelines pre and post initiative.
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Fig. 8 – Referral rates for individual practices in Cardiff and Vale, pre and post-initiate. Green arrow indicates “most engaged surgery” (Practice F) and yellow arrow indicates “least engaged surgery” (Practice DD).
appointment after the initiative. Waiting lists for a diabetes clinic were 6 months pre-initiative, whereas post-initiative there was no waiting list and patients were seen within 2 weeks.
3.4.
Breakdown by GP surgery
A breakdown of all referrals amongst Cardiff and Vale surgeries pre and post initiative is given in Fig. 8. Particularly noticeable is the change in referrals at Practice F, from the highest number pre-initiative to the (equal) lowest postinitiative. To test the hypothesis that this change might be the result of the initiative, practices were assessed by the lead diabetologist as regards their engagement in this exercise. Practice F was noted by the lead diabetologist to most engage with the initiative, whereas Practice DD did not engage. Referrals by Practice F dropped post-implementation by around 90% (from 17 to 2), and the proportion of inappropriate referrals at Practice F dropped from ∼30% to 0%. In contrast, over the same period, referrals for T2DM by Practice DD increased from 5 to 10. The proportion of referrals outside the guidelines at Practice DD remained unchanged (data not shown).
4.
Discussion
Our key findings are that, following the introduction of the community diabetes initiative, the number of referrals of T2DM patients to the Cardiff and Vale secondary care diabetes clinic reduced, and the proportion of high quality referrals increased. The reduced volume and enhanced quality of referrals may have several implications:
1) Cost-effectiveness of our local diabetes service may have improved. Local data suggests that management of diabetes in primary care is significantly cheaper, although it is difficult accurately to estimate the actual savings [12]. Additionally, the initiative itself is cost-neutral to the NHS, with DSNs funded by the pharmaceutical industry and consultant support provided by existing employees. 2) T2DM patients requiring secondary care review are now seen faster (waiting lists reduced from 6 months to 2 weeks). 3) Primary care diabetes management appears to have improved, with DSN education and consultant support. This view is supported by the 6% reduction of referrals for both GLP-1 agonist initiation (Figs. 3 and 6) and for recurrent hypoglycaemia (Figs. 2 and 5). The reduction in GLP-1 initiation referrals suggests either more initiation in the community or a reduction in their use. Reduction in recurrent hypoglycaemia referrals implies more appropriate glycaemic control. 4) This community diabetes initiative model appears effective. Indeed, a surgery notably engaging with the initiative showed the largest absolute reduction in total number of referrals (17 to 2) and all referrals post-initiative were in line with guidance. Conversely, a surgery noted not to be engaging with the initiative showed no improvement in its volume of referrals. 5) Reducing the number of referrals will free up specialist time, allowing them to work more in the community.
Although the results are encouraging, there are several limitations to this study. Firstly, confounding factors may have played a role in the change in referral pattern (e.g. GP education not via the initiative, and changes to staffing in primary
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care). However, there were no other major community diabetes initiatives implemented during the course of this study. Quality of referrals was determined by auditing against local referral guidance. However, some more complex referrals may have been appropriate, but did not fit the referral criteria. Several other methods could also be used to evaluate the impact of the community diabetes initiative. This could include analysing several other parameters pre and postinitiative, such as: patient satisfaction, GP perception of the initiative, clinical parameters of patients (e.g. HbA1c levels), whether primary care diabetes management targets are achieved [3] and effect on consultant diabetologist workload. Further work needs to be done to elucidate the specific benefits of integrated community care models. We assert that integrating care within the community is likely to reduce costs and workload for healthcare professionals. However, it may be that this workload and cost is simply shifted. Finally, the dramatic effects on Practice F (Fig. 8) may, in part, be related to the fact that, at the start of the study, this surgery was something of an outlier in diabetic treatment and that change might have been more easily achieved here. The practice size did not account for the high level of referrals (data not shown).
4.1.
Future prospects
This study is limited to one health board in Wales. This study suggests that such initiatives would be useful in similar contexts (e.g other health boards in the UK). Further validation would be required to determine the effectiveness of this type of initiative in other healthcare systems. The success of this initiative depends upon cooperation between primary and secondary care healthcare professionals and their desire to engage with the initiative. This is clearly seen when comparing referral patterns of Practice F (engaged) and Practice DD (not-engaged). Our financial model depends on obtaining funding from the pharmaceutical industry for the DSNs. We accept this may not be possible in all settings, however, on the basis of the promising results from this study, national health organisations (e.g. the NHS), may be willing to provide public funding. Several alternative methods may have been used to evaluate the impact of the community diabetes initiative. This could include analysing several other parameters pre and post-initiative, such as: patient satisfaction, GP perception of the initiative, clinical parameters of patients (e.g. HbA1c levels), whether primary care diabetes management targets are achieved [3] and effect on consultant diabetologist workload. This study raises several questions. It is unclear how generalisable our method is. We suggest trials of this method in other areas, and continued monitoring of the impact of the initiative in Cardiff and Vale. The effect of changing parameters within the model could be tested, e.g. optimal number of DSNs per capita for maximal impact. A formal cost-effectiveness analysis could be carried out to establish an accurate estimate of savings to the health service. This initiative may impact on clinical practice in both primary and secondary care. DSN-led education and
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case-based discussions with consultant specialists should improve knowledge and understanding of diabetes management by primary care professionals. When complex cases are discussed, GPs gain expertise which then can be applied to subsequent similar cases without consultant input. By reducing referral rates, this initiative allows consultant diabetologists to focus their attention on patients most requiring secondary care input. Our model allows for integration of primary and secondary care teams, allowing care to be shared/allocated without duplication. By having a named diabetologist for a practice, patients receive improved continuity of care as the same physician can give remote advice and see the same patient in outpatient clinic (if needed). Furthermore, reduced referrals to secondary care mean that patients can visit their GP rather than having to attend hospital outpatient clinics.
5.
Conclusion
The community diabetes initiative appears to be effective, reducing referral rate and improving referral quality. This model is a feasible approach to optimise diabetes management in the community and increase the efficiency of secondary care diabetes services. We would encourage trials of this method in other areas to further assess its effectiveness and generalisablity.
Conflict of interest The authors state that they have no conflict of interest.
Acknowledgements Novo Nordisk UK Research Foundation, Sanofi and Lilly for supplying funding for the community diabetes specialist nurses. The authors acknowledge Professor David Anselm Harris and Ms Di Croft for their useful comments on the manuscript.
references
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Evaluation of a community diabetes initiative: Integrating diabetes care Jason Leo Walsh 1 , Benjamin Howell Lole Harris ∗,1 , Aled Wyn Roberts University Hospital of Wales, Cardiff, UK
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: To evaluate the impact of a community diabetes initiative, aiming to improve the
Received 26 September 2014
efficiency of type 2 diabetes (T2DM) care within the Cardiff and Vale Health Board.
Received in revised form
Methods: In 2012, a community diabetes initiative was introduced in Cardiff and Vale. Ten
16 October 2014
National Health Service (NHS) consultant diabetologists and three nurse specialists sup-
Accepted 17 October 2014
ported 69 general practices in this region. Here we evaluate the impact of this initiative
Available online 12 December 2014
by assessing the number and quality of secondary care diabetes clinic referrals before (2011–2012) and after implementation (2013–2014). Referrals pre and post initiative were
Keywords:
audited against Cardiff and Vale T2DM referral guidelines in two 6-month periods.
Community
Results: In the 6-months prior to the initiative, 108 referrals were received, 78 of which were in
Diabetes
line with local guidance. Approximately one year after embarking on the diabetes initiative
Specialist nurse
(2013–2014) there was a 31% reduction (p < 0.01) in the total number of T2DM clinic referrals
Referral
and a 57% reduction (p < 0.01) in referrals outside the guidelines. A decrease in referrals was
Primary care
not seen in the practice noted not to engage with the initiative.
Secondary care
Conclusions: The community diabetes initiative intervention has significantly improved the
appropriateness of T2DM referrals from GP practices engaged with the initiative. As a result
Service-based research
we advocate a move towards integrated diabetes care within the community. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Diabetes mellitus (DM) is a chronic condition caused by deficiency or diminished effectiveness of endogenous insulin. This leads to characteristic hyperglycaemia, glycosylation of the vasculature and deranged metabolism, which in turn lead to further pathological problems.
∗
1
DM is becoming an increasing challenge to the global health infrastructure with 4.4% of the world’s population expected to diabetic by 2030 [1]. Due predominantly to the expansion of sedentary lifestyle and increasing life expectancy and the Western obesity epidemic, 90% of DM sufferers will be type 2 (T2DM) [1,2]. In 2013, the prevalence of diabetes in the UK was estimated at 6% [3]. The highest prevalence is in Wales, where ∼7% of the population have been
Corresponding author. Tel.: +44 29 2074 7747x42498. E-mail addresses: [email protected] (B.H.L. Harris), [email protected] (A.W. Roberts). Joint first author.
http://dx.doi.org/10.1016/j.pcd.2014.10.003 1751-9918/© 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
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diagnosed with diabetes [3,4] and in line with the global trend, T2DM is by far the most common type. T2DM prevalence has increased from 3.3% to 4.1% over the 5 years 2004–2009, occasioning an added cost of £649.2million to the NHS in England and Wales [5]. Furthermore, a significant proportion of the population have undiagnosed diabetes [6]. DM and its complications account for 10% of total NHS expenditure today [7], as compared to 6% in 1996 [8]. This increase shows no sign of abating. There is good evidence that early diagnosis and effective management of DM reduces the risk of premature death and complications [9–11]. Given current economic stringency, it is increasingly important that the burden of T2DM and its complications on the NHS are minimised, through patient education and appropriate management. In parallel, the use of existing services must be scrutinised and streamlined, to reduce the strain on already tight purse strings. The treatment of a patient with diabetes is more costeffective if it is kept within a community setting. A study from Cardiff and Vale found that the average cost of managing a T2DM patient within secondary care was £1401 compared with £249 in primary care per annum [12]. Therefore, it appears to be a worthwhile strategy to reduce the burden of T2DM on hospitals. There have been several suggestions in the literature including: (1) Expanding the role of specialist nurses in the community [13], (2) introducing health coaching or similar initiatives into primary care [14,15] and (3) restructuring diabetes services [16–18]. Health coaching or motivational interviewing is a relatively recent concept, which aims to encourage positive behaviour change in disease management via one-to-one support by a peer or professional coach. This support can be face-to-face or via telephone. Health coaching has shown to have positive effects on Hba1c [19] and weight control [20]. Integrating professional health coaches into primary care aiming to optimise diabetic control has been shown to be feasible in Canada [14]. This approach is similar to the DESMOND programme in the UK (delivering diabetes education and self-management for ongoing and newly diagnosed). This consists of a number of registered healthcare professionals being trained as educators. They provide six hours of contact time to newly diagnosed T2DM patients. This approach has been shown to be effective and increased the likelihood of T2DM patients giving up smoking and losing weight [15]. Several strategies involving restructuring of diabetes services have attempted to optimise community diabetes care in the UK. The “super six” diabetes care model created a clear distinction between the roles of primary and secondary care professionals in diabetes management [17]. Having six clear reasons (the “super six”) that justify referral to a secondary care clinic. The model also encourages integration between primary and secondary care, offering telephone, email and face-to-face support from diabetologists to GPs in “complex cases” that fall outside of these six criteria. The role of diabetes specialists in educating primary care professionals is also emphasised. Evaluation of the model showed high GP satisfaction with the service, reduction of episodes of diabetic ketoacidosis, a reduction of hypoglycaemic admissions and a reduction of admissions with hyperglycaemic non-ketotic coma [21].
The Derby model consisted of a partnership between primary and secondary care. Two companies were set up equally owned by Derby Hospital NHS Trust and local primary care organisations (two general practice conglomerates). A multidisciplinary clinical board was established for each institution to oversee the provision of diabetes services. The allocation of resources from within a shared primary and secondary care budget allowed services to be streamlined and improved. The Derby initiative appeared to improve glycaemic control, blood pressure and lipid management for T2DM patients [18]. Here, we also blur the traditional boundaries between primary and secondary care, aiming to integrate diabetes care within the community. In this initiative, we combine DSNs with consultant diabetologist support into a novel community diabetes initiative. Diabetes specialist nurses (DSNs) have been shown to be cost effective [22–25] and improve clinical outcomes in the community [26,27]. Community diabetes specialist nurses deliver educational support to healthcare professionals in primary care e.g. teaching on GLP-1 mimetic initiation whilst consultant diabetologists provide support and specialist advice face to face in the community or via email. Locally, this initiative has been referred to as the Diabetes Integrated Care Service (DICS) model. This study aims to: (1) improve the cost-effectiveness of the diabetes service in the Cardiff and Vale Health Board, (2) improve the quality of referrals to the secondary care diabetes clinics, (3) reduce waiting lists for outpatient diabetes clinics, (4) improve diabetes management in the community and (5) evaluate our community care model, contributing to the evidence-base behind community diabetes management. We used two outcome measures to establish the effectiveness of our intervention. Both the number and quality of referrals were used as surrogate measures of efficient delivery of diabetes care. If the community initiative was effective, we would expect a higher proportion of referrals in line with local referral guidance and potentially a decrease in the total number of referrals. Anecdotal evidence suggests that this approach should be effective, however there have been no systemic validations of approaches that combine DSNs and diabetologist e-support with general practice.
2.
Methods
2.1.
The initiative
The first component of the initiative involves linking individual GP practices to individual consultant diabetologists. Sixty-nine general practices in Cardiff and Vale were divided between 10 consultant diabetologists, according to locality. The named diabetologist for his/her practices visits the assigned practices twice per year to discuss complex and interesting patients. As well as optimising management in the community, this initiative aims to educate primary care workers, contributing towards their professional development. Consultants also provide a decision-making support service by email, giving GPs easy access to specialist advice within five working days of receipt of email. The second component of the initiative comprises the DSNs, who provide educational support to all healthcare
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Box 1: Cardiff and Vale T2DM referral guidelines 1. Failure to reach HbA1c target OR HbA1c >7.0% despite combination therapy. 2. Initiation of insulin therapy in type 2 patients not reaching target HbA1c. 3. Failure to reach BP target OR BP >140/80 despite combination therapy. 4. Failure to reach Total Cholesterol target OR TC >5.0mmol/l despite therapy. 5. Persistent proteinuria (Albumin:Creatinine ratio >35) or haematuria despite therapy. 6. Stage 3 (eGFR 150umol/l. 7. Acute or difficult-to-manage foot/neuropathy symptoms (including acute Charcot joint.) 8. Require assessment of cardiovascular risk profile in order to determine patient specific treatment targets. 9. Recurrent hypoglycaemic episodes.
professionals in primary care. Each practice nurse had a named diabetic nurse mentor, who can be contacted with any concerns pertinent to diabetic management. The 69 practices were divided between the three DSNs. DSN funding was obtained exclusively from pharmaceutical companies (Novo Nordisk, Sanofi, Lilly).
2.2.
Service evaluation
Ethical approval was obtained from Cardiff University School of Medicine Ethics and Research Committee. Before implementation, the number of referrals to the secondary care diabetes clinic was counted in a 6-month period (August–January 2011–2012). All referrals were audited against local referral guidance (Box 1). For each referral, age, weight, sex, BMI, G.P practice and reason for referral were recorded. Confidentiality and anonymity were maintained throughout. One year after implementation, August–January 2013–2014, data collection was repeated to measure the impact of the community diabetes initiative. The total number of referrals was compared before and after the initiative. Referrals were also assessed as falling into, or outside the guidelines (‘referral quality’). The significance of any observed differences was assessed using the chi-squared test.
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Engagement of practices with the community initiative was monitored by the lead diabetiologist. The practices identified as engaging the most and the least were further scrutinised. The referral rate and referral quality were compared before and after the initiative for these individual practices.
3.
Results
3.1.
Pre-initiative
108 T2DM patients were referred to the secondary care diabetes clinic in August 2011–January 2012 (Fig. 1). Approximately one third (30/108) were not in line with referral guidance (Fig. 2). The mean age of the sample was 57.4 years, the male:female ratio was 48:60 and mean BMI was 32.3 (although BMI was not recorded in 35% of patients). Fig. 2 shows the reasons for referral in those patients referred under the guidelines. The majority of appropriate such referrals result from high HbA1c levels. No patients were referred under criterion 5 (persistent proteinuria). One caveat in viewing this data is that the proportions in the pie chart are expressed relative to the number of reasons for referral (87), which is larger than the number of patients (78) as several patients had more than one appropriate reason for referral. Fig. 3 shows the reasons for referral in those patients referred outside the guidelines. Compliance-related issues (31%) were the single most significant cause although other major contributors were changes in regime (e.g. during pregnancy, changes in drug therapy) or a perceived lack of specialist knowledge in the GP practice.
3.2.
Post-initiative
In August 2013–January 2014, one year after the initiative had been introduced, 75 T2DM patients were referred to the secondary care diabetes clinic (Fig. 4). Approximately 10% (9/75) were not in line with referral guidance (Fig. 6). The mean age of the sample was 58.1 years, the male:female ratio was 38:37 and mean BMI was 35 (although BMI was not recorded in 40% of patients). High HbA1c levels despite adequate combination therapy were the predominant reason for referral within the guidance (Fig. 5), with initiation of insulin therapy a second major contributor. The total number of reasons for referral within the guidelines was 80.
Fig. 1 – T2DM referrals to the Cardiff and Vale secondary care diabetes clinic at Univerisity Hospital of Wales (UHW), pre-initiative.
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Fig. 2 – Reasons for referral in line with the referral guidelines pre-initiative (n = 78).
Fig. 3 – Reasons for referral outside the referral guidelines pre-initiative (n = 30).
As previously, compliance-related issues (22%) were the major reason for referral outside the guidelines, but patient request (15%) became the second most significant cause for referral outside of the guidelines.
3.3.
Comparison
The total number of referrals to the secondary care diabetes clinic fell from 108 to 75 referrals. This equates to a ∼30% decrease in the volume of referrals post-initiative. In view of the fact that the number of T2DM patients is likely to have risen during this period, this represents a promising change following the initiative.
Of these 75 referrals, only nine were identified as being outside the guidelines. The proportion of referrals outside of the guidelines had thus fallen from 28% before the initiative to 12% after its introduction, giving a 57% reduction (p < 0.01) (Fig. 7). Again, this represents a promising change following the initiative, Comparing Figs. 3 and 6, we can see other noteworthy differences following the initiative. These include:
• A reduced proportion of referrals for recurrent hypoglycaemia (9% to 3%).
Fig. 4 – T2DM referrals to the Cardiff and Vale secondary care diabetes clinic at Univerisity Hospital of Wales (UHW), post-initiative.
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Fig. 5 – Reasons for referral in line with the referral guidelines post-initiative (n = 66).
Fig. 6 – Reasons for referral outside the referral guidelines post-initiative (n = 9).
• A lower number of patients referred for GLP-1 agonist initiation (13% to 7%). • An overall reduction (31% to 22%) in compliance issues, although these remain the major reason for referrals outside the guidelines.
Figs. 2 and 5 show that, following the initiative, an increased proportion of insulin initiation took place in secondary care (13% to 29%). Although not given in the above data, there was also a marked improvement in waiting times for a secondary care
Fig. 7 – The proportion of referrals in line vs referrals not in line with the referral guidelines pre and post initiative.
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Fig. 8 – Referral rates for individual practices in Cardiff and Vale, pre and post-initiate. Green arrow indicates “most engaged surgery” (Practice F) and yellow arrow indicates “least engaged surgery” (Practice DD).
appointment after the initiative. Waiting lists for a diabetes clinic were 6 months pre-initiative, whereas post-initiative there was no waiting list and patients were seen within 2 weeks.
3.4.
Breakdown by GP surgery
A breakdown of all referrals amongst Cardiff and Vale surgeries pre and post initiative is given in Fig. 8. Particularly noticeable is the change in referrals at Practice F, from the highest number pre-initiative to the (equal) lowest postinitiative. To test the hypothesis that this change might be the result of the initiative, practices were assessed by the lead diabetologist as regards their engagement in this exercise. Practice F was noted by the lead diabetologist to most engage with the initiative, whereas Practice DD did not engage. Referrals by Practice F dropped post-implementation by around 90% (from 17 to 2), and the proportion of inappropriate referrals at Practice F dropped from ∼30% to 0%. In contrast, over the same period, referrals for T2DM by Practice DD increased from 5 to 10. The proportion of referrals outside the guidelines at Practice DD remained unchanged (data not shown).
4.
Discussion
Our key findings are that, following the introduction of the community diabetes initiative, the number of referrals of T2DM patients to the Cardiff and Vale secondary care diabetes clinic reduced, and the proportion of high quality referrals increased. The reduced volume and enhanced quality of referrals may have several implications:
1) Cost-effectiveness of our local diabetes service may have improved. Local data suggests that management of diabetes in primary care is significantly cheaper, although it is difficult accurately to estimate the actual savings [12]. Additionally, the initiative itself is cost-neutral to the NHS, with DSNs funded by the pharmaceutical industry and consultant support provided by existing employees. 2) T2DM patients requiring secondary care review are now seen faster (waiting lists reduced from 6 months to 2 weeks). 3) Primary care diabetes management appears to have improved, with DSN education and consultant support. This view is supported by the 6% reduction of referrals for both GLP-1 agonist initiation (Figs. 3 and 6) and for recurrent hypoglycaemia (Figs. 2 and 5). The reduction in GLP-1 initiation referrals suggests either more initiation in the community or a reduction in their use. Reduction in recurrent hypoglycaemia referrals implies more appropriate glycaemic control. 4) This community diabetes initiative model appears effective. Indeed, a surgery notably engaging with the initiative showed the largest absolute reduction in total number of referrals (17 to 2) and all referrals post-initiative were in line with guidance. Conversely, a surgery noted not to be engaging with the initiative showed no improvement in its volume of referrals. 5) Reducing the number of referrals will free up specialist time, allowing them to work more in the community.
Although the results are encouraging, there are several limitations to this study. Firstly, confounding factors may have played a role in the change in referral pattern (e.g. GP education not via the initiative, and changes to staffing in primary
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care). However, there were no other major community diabetes initiatives implemented during the course of this study. Quality of referrals was determined by auditing against local referral guidance. However, some more complex referrals may have been appropriate, but did not fit the referral criteria. Several other methods could also be used to evaluate the impact of the community diabetes initiative. This could include analysing several other parameters pre and postinitiative, such as: patient satisfaction, GP perception of the initiative, clinical parameters of patients (e.g. HbA1c levels), whether primary care diabetes management targets are achieved [3] and effect on consultant diabetologist workload. Further work needs to be done to elucidate the specific benefits of integrated community care models. We assert that integrating care within the community is likely to reduce costs and workload for healthcare professionals. However, it may be that this workload and cost is simply shifted. Finally, the dramatic effects on Practice F (Fig. 8) may, in part, be related to the fact that, at the start of the study, this surgery was something of an outlier in diabetic treatment and that change might have been more easily achieved here. The practice size did not account for the high level of referrals (data not shown).
4.1.
Future prospects
This study is limited to one health board in Wales. This study suggests that such initiatives would be useful in similar contexts (e.g other health boards in the UK). Further validation would be required to determine the effectiveness of this type of initiative in other healthcare systems. The success of this initiative depends upon cooperation between primary and secondary care healthcare professionals and their desire to engage with the initiative. This is clearly seen when comparing referral patterns of Practice F (engaged) and Practice DD (not-engaged). Our financial model depends on obtaining funding from the pharmaceutical industry for the DSNs. We accept this may not be possible in all settings, however, on the basis of the promising results from this study, national health organisations (e.g. the NHS), may be willing to provide public funding. Several alternative methods may have been used to evaluate the impact of the community diabetes initiative. This could include analysing several other parameters pre and post-initiative, such as: patient satisfaction, GP perception of the initiative, clinical parameters of patients (e.g. HbA1c levels), whether primary care diabetes management targets are achieved [3] and effect on consultant diabetologist workload. This study raises several questions. It is unclear how generalisable our method is. We suggest trials of this method in other areas, and continued monitoring of the impact of the initiative in Cardiff and Vale. The effect of changing parameters within the model could be tested, e.g. optimal number of DSNs per capita for maximal impact. A formal cost-effectiveness analysis could be carried out to establish an accurate estimate of savings to the health service. This initiative may impact on clinical practice in both primary and secondary care. DSN-led education and
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case-based discussions with consultant specialists should improve knowledge and understanding of diabetes management by primary care professionals. When complex cases are discussed, GPs gain expertise which then can be applied to subsequent similar cases without consultant input. By reducing referral rates, this initiative allows consultant diabetologists to focus their attention on patients most requiring secondary care input. Our model allows for integration of primary and secondary care teams, allowing care to be shared/allocated without duplication. By having a named diabetologist for a practice, patients receive improved continuity of care as the same physician can give remote advice and see the same patient in outpatient clinic (if needed). Furthermore, reduced referrals to secondary care mean that patients can visit their GP rather than having to attend hospital outpatient clinics.
5.
Conclusion
The community diabetes initiative appears to be effective, reducing referral rate and improving referral quality. This model is a feasible approach to optimise diabetes management in the community and increase the efficiency of secondary care diabetes services. We would encourage trials of this method in other areas to further assess its effectiveness and generalisablity.
Conflict of interest The authors state that they have no conflict of interest.
Acknowledgements Novo Nordisk UK Research Foundation, Sanofi and Lilly for supplying funding for the community diabetes specialist nurses. The authors acknowledge Professor David Anselm Harris and Ms Di Croft for their useful comments on the manuscript.
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