Multi-disciplinary care of T2D – does it work in primary care?

April 2018, Dr Chee L Khoo

Multi-disciplinary care (MDC) is often hailed as THE comprehensive management for patients with type 2 diabetes (T2D). We refer these patients to podiatrists, exercise physios, dietitians, diabetes educators and sometimes, endocrinologists. Now, that is MDC, isn’t it? We are part of the MDC team. Do we see the benefit that is often hailed from MDC?

I was recently asked to speak to our allied health colleagues about how care of patients with T2D is so much better if we all worked as a MD team. The more research I did into the subject, the more I realised that MDC in primary care is actually a different beast from the MDC cited in studies.

The Ontario Medical Advisory Secretariat commissioned an evidence based review of successful management of diabetes in 2008. It reviewed 22 randomised controlled trials and concluded that MDC lead to “statistically and clinically significant reduction in HbA1c and some reduction in SBP”.

Two recent RCTs, one in HK and one in Saudi Arabia both confirmed that MDC lead to significant improvement in clinical outcomes and saves money. Both were in a diabetes centre type setting and not primary care.

In Australia, you may remember the Diabetes Care Project (DCP) a few years ago. Three groups were compared:

  1. Standard GP care
  2. Intervention 1 – GPs given online training  and
  3. Intervention 2 – GPs given online training but funding provided for care coordination.

Only the Intervention 2 group resulted in clinical improvements. Patient outcomes improved but the additional funding was deemed financially unsustainable.

Does MDC in primary care lead to clinical improvement? Diabetes centre type MDC has the following characteristic which is not normally present in primary care setting:

  • Clinical Leadership
  • Clinical Expertise amongst team members
  • Clinician Autonomy
  • Effective Communication between clinicians
  • Shared data
  • Management provided in an evidence based clinical framework
  • Shared Decision Making and often, joint consultation
  • Team Education & Training
  • Clinical Audit/Benchmarking

In order for MDC to achieve patient outcomes in primary care, we need a clinical leader. That naturally, is the GP but that GP needs to be up to date, switched on and be on top of his game. In other words, we need to lead with knowledge. We need our AHP colleagues to be equally switched on and be experts in their own field. This will require joint education sessions on a regular basis.

There needs to be effective communication between the team members so that everyone is on the same page providing consistent messages to patients. This has been shown to improve patient outcomes. Patient management needs to occur in an evidence based clinical framework which is propagated amongst the team members. We need shared data (not myhealthrecord) amongst the clinicians which, not only facilitate the achievement of clinical outcomes but also allow clinical audit and benchmarking to be conducted. Benchmarking means comparing practices with national benchmarks and this will facilitate quality improvement.

Patients with T2D who receive care from different clinicians may not necessarily benefit from MDC. They need integrated care led by a switched on GP leader. We need to lead with knowledge.

DOMTRU is hosting the largest diabetes symposium in SWS on May 18-19, 2018. Many of our allied health professional and university colleagues will be attending and provide a great networking opportunity for all the members of the diabetes team. For details, click here.