Background The increasing prevalence and cost of Type 2 diabetes mellitus (T2DM) has driven the reorientation of diabetes care in recent years. Health systems have moved from reactive, episodic management in the acute setting to greater primary-care-led structured disease management. Structured diabetes management, whereby patients are managed in primary care in a systematic, organised way, with structured specialist support, has been associated with improved patient outcomes. However, there is limited research on the long-term performance. The aim of this study was to examine the quality of care delivered by a primary care-based structured diabetes management programme for T2DM over 10 years.
Methods Data were collected from patients with T2DM (≥18 years) registered with practices participating in the Midlands Diabetes Structured Care Programme. In this programme patients are managed in primary care with support from clinical nurse specialists (CNS), dietetics, ophthalmology, and chiropody. Data were collected by CNS at three time points, 1998/1999, 2003 and 2008, on demographic, clinical, and lifestyle variables, including processes and clinical outcomes. Chi-square tests for trend were used to test differences in the processes and outcomes over time, benchmarked against national guidelines and the English National Diabetes Audit 2012–2013. A p-value of <0.001 was considered statistically significant.
Results Data on 333 patients with T2DM from 10 practices in 1998/1999; 841 from 20 practices in 2003; and 989 from 31 practices in 2008, were available for analysis. BMI, HbA1c, total cholesterol, triglycerides, blood pressure, and creatinine documentation improved significantly over time (p < 0.001), however smoking status remained similar (p = 0.003). In 2008, BMI (73.5%) and smoking status (76.9%) documentation were lower than recorded in the English audit (91.1% and 86.5% respectively), although other processes were comparable. The percentage of patients with T2DM achieving the target blood pressure of ≤140/80 mmHg increased significantly, from 35.7% in 1998/1999 to 57.1% in 2008 (P < 0.001), as did the percentage who achieved the recommended total cholesterol level of <4.5 mmol/L (23.1% vs. 66.6%, p < 0.001), triglycerides ≤ 1.7 mmol/L (37.5% vs. 60.1%, p < 0.001), and HbA1c ≤ 7.0% (55.9% in 1998/1999 vs. 60.8% in 2008, p < 0.001).
Conclusion Over a 10-year period of structured diabetes care, improvements were observed both in process of care documentation and patient outcomes, suggesting that primary-care-led management of diabetes can perform favourably in the long-term. These results are encouraging in light of the new diabetes cycle of care, which will, for the first time in Ireland, remunerate GPs for routine primary care management of T2DM.
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