13th November 2018, Dr Chee L Khoo
70-80% of patients with type 2 diabetes (T2D) are managed in primary care in Australia. Patients managed in hospital based outpatients have the advantage of multi-disciplinary team care. They have dietitians, credentialled diabetes educator (CDE), physiotherapists and of course, the endocrinologist in the team. On the other hand, we, as GPs, have the advantage of knowing our patients and their families’ social environment. We can also see them a lot more often. We certainly do the job much cheaper. Does it have to be two separate models? Could we not have a bit of both worlds and have an integrated primary-secondary model. Who does the job better?
A randomised controlled trial conducted in Brisbane recently compared an integrated primary-secondary model of care (“The Beacon” model) with standard hospital based endocrinologist outpatient care. “The Beacon” model consist of a community based general practice comprising of a multi-disciplinary team of one endocrinologist, two GPs with special interest in diabetes (GPwSI) and a Diabetes Nurse Educator (DNE) all co-located within the same premise.
The GPs underwent a 23 hour online advanced diabetes course and attended a one day workshop. The DNE was specifically skilled in case coordination. Consultations with patients were always done with both the endocrinologist and GPs.
Medical reviews, usually 3 monthly, were conducted by the GPwSI and endocrinologist over the course of treatment. Individuals were discharged to their referring GP for ongoing diabetes management once individual clinical targets were deemed to have been met or at 12 months, whichever came first. The participant’s regular GP was advised to continue the usual cycle of care and given guidance about conditions for re-referral.
The primary outcome was HbA1c at 12 months. Secondary outcomes include biochemical endpoints
(total cholesterol, LDL-cholesterol, HDL-cholesterol, TG, serum creatinine and eGFR), BMI and BP. Quality of life and diabetes related quality of life surveys were also collected.
Between Nov 2012 and July 2015, 352 eligible individuals were randomised to either the Beacon model or usual outpatient care. Patients were discharged when they completed the 12 month study protocol or earlier if they have met their clinical targets. The mean age was 55.7 years and the average duration of diabetes was 10 years. Diabetes complications were common, with 17.6% diagnosed with stage 3 or higher kidney disease, 22% with known cardiovascular disorders and 22.9% with retinopathy. Baseline HbA1c was 79.4 mmol/mol (9.4%) in the usual care group and 80.4 mmol/mol (9.5%) in the Beacon group.
There were no significant difference in HbA1c between the groups at completion. The proportion of patients reaching clinical targets were also similar between the groups. There were also no difference between the groups in the secondary outcomes. Participants in the Beacon group were significantly more satisfied than the usual care and reported better self-management support.
This trial demonstrates that “integrated care” in GP is non-inferior to multi-disciplinary outpatient care in achieving clinical outcomes in patients with diabetes. three previous randomised controlled trials of primary–secondary integrated models have been conducted, looking at combining upskilled GPs with practice visits by a DNE ; interdisciplinary diabetes team case discussions ; and a virtual clinic including a diabetes nurse and endocrinologist .
Can these results be replicated in SWS? Can we have “beacons” everywhere?
We already have visiting endocrinologists under the diabetes case conference model. Many of you are already using this service. One of the local endocrinologist will come to your practice to discuss the more challenging cases. GPs get paid for organising the case conference as well as participating in the discussion with the endocrinologist. Read more here.
We don’t have enough DNE to go around and with the limited 5 EPC items, many of our patients run out of EPC sessions to see a DNE. DOMTRU is assisting in training your PN to assist in managing your patients with diabetes. They are also offered the option of completing the online AUS-CDEP course.
To keep GPs upskilled, DOMTRU runs an injectable workshop annually to update GPs on insulin and other injectables. The next one is here. There is an annual diabetes symposium in May to bring the latest in diabetes to general practice. All GPs are also offered the online AUS-CDEP course for free.
The queue to the outpatient for patients with diabetes is long. The queue for a private endocrinologist is equally long (and expensive for many of our patients). The path to improving your skills in diabetes management is simple and convenient. We can look after our patients with T2D as well as the outpatient and at a fraction of the cost to the system as well as to our patient. It can be very satisfying as a clinician to see your patient achieve all their targets. There are already many “beacons” out there.
Anthony W. Russell, Maria Donald, Samantha J. Borg, et al. Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority
randomised controlled trial. Diabetolgia. First published online 3rd Oct 2018.