Measuring and Improving the Quality of Diabetes care in General Practice. Dr M Grixti. Dr C Scalpello, Dr C Mercieca, Dr P Mangion, Dr T O Sullivan

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1 Measuring and Improving the Quality of Diabetes care in General Practice Dr M Grixti. Dr C Scalpello, Dr C Mercieca, Dr P Mangion, Dr T O Sullivan

2 Outline of presentation Statistics Diabetes care,as the model for chronic diseases management Shared care project Clinical Audit report Summary Conclusions Recommendations

3 International Diabetes Federation Europe General Assembly Together We Are Stronger St Julian's, Malta 9- September 8 Diabetes currently affects approximately 8.6% of the adult population of the European Union -around million people across the current 7 EU Member States. Individual country prevalence rates range from 4% in the United Kingdom to.8% in Germany. The IDF Diabetes Atlas 6 estimates that the diabetes prevalence rate in Malta is 9.7% of the adult population, representing 8,6 people. The Atlas forecasts a rise in prevalence to.6% by 5. Data from IDF and FEND Audit Report 6

4 International Diabetes Federation Europe General Assembly Together We Are Stronger St Julian's, Malta 9- September 8 MALTA - Key Statistics IDF Atlas IDF Atlas 6 Estimated National diabetes prevalence (% of total population aged -79) Estimated number of people with diabetes 9.% 5,8 9.7% 8,6 Estimated cost of diabetes National Plan Not Available No Data from IDF and FEND Audit Report 6

5 International Diabetes Federation Europe General Assembly Together We Are Stronger St Julian's, Malta 9- September 8 The National Diabetes Association (Ghaqda Maltija Kontra id-dijabete) states that there are over, diagnosed persons with diabetes in Malta. They expect this number to double by. Furthermore, 84% of people with diabetes in Malta are either overweight or obese. Deaths from DM : 9.% of deaths from all causes in Malta are attributable to DM. Diabetes atlas 4 th Ed 9 National Diabetes Association, http;//www.dibetesmalta.org/profile.php WHO, World Health Statistics 7, Diabetes in Malta: Current findings and future trends, Malta Medical Journal, Vol. 7: (March 5), 4.pdf

6 International Diabetes Federation Europe General Assembly Together We Are Stronger St Julian's, Malta 9- September 8 "DIABETES The Policy Puzzle: Is Europe Making Progress?" The 8 report provides the latest evidence of the spiraling diabetes epidemic in Europe Diabetes prevalence rates in Europe continue to rise and are predicted to reach an average of.% of the EU population by 5 a burden which national healthcare systems will find hard to bear. The international Diabetes Federation European Region ( IDF Europe) and the Federation of European Nurses in Diabetes ( FEND) announce the publication of the second edition of their pan European diabetes policy audit.

7 The burning questions Why involve general practice & primary care? Does general practice need to adapt to provide effective diabetes care? Can primary care perform? Does shared care add value? Can we influence psycho-social well-being?

8 Why involve general practice and primary care? Diabetes is a complex multisystem metabolic disorder characterized by raised blood glucose levels associated with inadequate insulin production or inefficient insulin utilisation. Diabetes is usually a lifelong condition from the time of diagnosis. People with type diabetes have an increased risk of depression, which is consistent with the association between increased frequency of depression among people with other chronic diseases. People with diabetes therefore need long-term care that is consistent, offers continuity and holistic support, is accessible and is delivered in context with their changing life styles and with other medical conditions, preferably in a convenient local setting. Hence it is an ideal condition for general practitioner based care.

9 Organization of Diabetes care Type diabetes is gradually progressive, requiring frequent reassessment and modification of treatment Diabetes treatment is lifelong, but its organization should be tailored to the individual in terms of age, education, support and experience of the condition Patient education and involvement to motivate significant lifestyle change are as important as clinical examination and prescribing. Diabetes competes with other priorities, and patient motivation will fluctuate As a basic standard of care, people with diabetes should have regular access to a doctor, nurse and dietician. The objectives of care include controlling the symptoms of diabetes, prolonging life and preventing the long-term complications of the condition, while preserving quality of life.

10 Diabetes care models Structured care organised, planned care characterised by registration, recall & regular review Shared care planned care jointly delivered by teams in primary and secondary care with enhanced communication

11 Anatomy of shared care ( ECAD) Community-based nurse & dietician Liaison group Agreed targets Protocols eg insulin Training Regular reports Type patients GP visits Annual review in hosp Complication screening Audit

12 Is shared Care the answer to the problem of diabetes? Pilot project of shared care involving primary care team at Gzira Health Centre and Specialists at Mater Dei Hospital Dr Mario Grixti PHC/MCFD

13 Diabetes Shared Care Program for the Maltese Islands This shared care model shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.

14 Audit approach (4) docs patients items Structure Process first Outcomes Intermediate End-point Docs compared with: Each other Gold standard Irish colleagues What explains differences? Organisation Attention Rigour Access

15 Patient No Eyes screened (=yes, =no) Record complications (=yes, =no) No. Reviews attended (number) No. HbAIc records (number) No. BP records (number) No. Weight records (number) No. BMI records (number) No. Foot exams (number) Smoking status (=yes, =no) No. Dietician reviews (number) Most recent HbAc record (%) Most recent Systolic BP (mmhg) Most recent Total Chol. (mmol/l) Most recent BMI (kg/m²) No. BP Medications (number) Aspirin use (=yes, =no) No. OHA's (number) Insulin added/increased (=yes, =no) CVD events 8 (number) New Foot Ulcers 8 (=yes, =no) Death 8 (=yes, =no)

16 Summary of data Total patients 67 had eyes screened (68%) 56 had a record of complications (5%) 898 had smoking status recorded (9%) 89 reviews attended (mean.9 visits per patient) 96 HbAc records Mean HbAc 6.8, Max.8 Mean Systolic BP 6 Mean total cholesterol 5.5, range.-9.5 Mean BMI 8.9, Range patients (4%) were on aspirin 4 (.6%) had insulin added or altered during the year 84 BP records 887 weight records 54 BMI records 67 foot exams 6 dietician visits 9 CVD events (.9%) 6 foot ulcers deaths

17 Eyes Screened Count of GP No Eyes screened GP No Record of complications Count of GP No 5 5 Record of complications GP No It is a concern that between ¼ and ½ of patients do not have a record of retinopathy screening, and most do not have the presence or otherwise of complications recorded

18 Number of reviews attended Count of GP No 5 5 No of reviews attended GP No No of HbAc results Count of GP No 5 5 No of HbAcrecords GP No All patients attended for diabetes reviews, which is encouraging, and most are having HbAc tests at least once a year. Ideally this should rise to -4 times depending on treatment changes during the year

19 No of BP readings Count of GP No 5 5 No of BP records GP No No of weight records Unsurprisingly, most patients have several BP readings, but it is gratifying that most also have more than weight record.

20 No of BMI records No of foot examinations Transferring weight to BMI involves height recording, and undertaking the calculation although GP software systems sometimes do this automatically. The lack of a record of foot examination in / of the group is a concern, reflecting time constraints and patient and provider reluctance.

21 Smoking status recorded? Number of dietician reviews Smoking status is very well-recorded, while access to dietetic care is clearly inadequate.

22 Mean HbAc (%) Total Mean Systolic BP Total Glucose and BP control is very adequate in this sample, with room for improvement in one group.

23 Mean Total Cholesterol Total... 4 Mean BMI Total Similarly, lipid and weight control is consistent between groups and generally across international norms

24 Mean number of BP medications (an indicator of intensive treatment) Total Number on Aspirin Total Compared with other studies, numbers receiving aspirin is low (perhaps under current evidence we shouldn t do anything about that) and BP prescribing is also low (indicating less intensive BP reduction or a population with less tendency to metabolic syndrome and high BP)

25 Mean number of oral hypoglycaemics Total No of patients with Insulin added or adjusted Total In contrast, glycaemic treatment is quite intensive, particularly with regard to insulin initiation. Insulin Initiation is a common barrier in general practice.

26 Summary data for entire group Total patients 67 had eyes screened (68%) 56 had a record of complications (5%) 898 had smoking status recorded (9%) 89 reviews attended (mean.9 visits per patient) 96 HbAc records 84 BP records 887 weight records 54 BMI records 67 foot exams 6 dietician visits Mean HbAc 6.8, Max.8 Mean Systolic BP 6 Mean total cholesterol 5.5, range.-9.5 Mean BMI 8.9, Range patients (4%) were on aspirin 4 (.6%) had insulin added or altered during the year 9 CVD events (.9%) 6 foot ulcers deaths The summary data confirms the generally good control, while some areas of process will be improved with investment of simple resources into community-based diabetes care.

27 Comparison with Ireland( ECAD) Measure % having HbAc Mean HbAc result % having a chol Mean tot chol % seeing a dietician % taking aspirin % having CVD events % having foot ulcers Proportion dying Ireland 9 % % 4.47 mmol/l % 7 % 8.6 %.4 %.4 % Malta 79 % % 5.5 mmol/l 6 % 4 % 9. % 4.4 %. %

28 Conclusions Diabetes is a major threat to health Investment in more effective care Numbers overwhelm system Primary care offers an immediate solution GP participation is cost effective Shared, not shifted care Resource all sectors adequately Needs of patients st priority Support integration Collect comparable data Use EU experiences

29 Recommendations Joint treatment of patients between the family physician and the diabetes specialist, may be a proposed model to improve diabetes control. This model of treatment should be checked in a prospective study. Good care of the diabetic patient reduces the incidence of long-term complications. Treatment should be interdisciplinary; in the last decade a debate has raged over how to optimize treatment and how to use the various services efficiently. We are recommending a shared care program with the secondary care specialists and we have produced an audit which shows that shared care is possible and that quality of care delivered to diabetic patients by General Practitioners with a special clinical interest in diabetes does work and could be the way forward in this country for other chronic disease management.

30 Thank You World Diabetes day 4 th November 9 Diabetes education and prevention Acknowledgement Dr D Vella Baldacchino Prof S Fava Dr T O Sullivan Mrs M Dimech Director Primary Care Director Dept of Diabetes and endocrinology at MDH Director East Coast Area Diabetes shared care program Nurse i/c of Diabetes Clinic at GHC

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