Family Practice Vol. 18, No. 1, 27-32
© Oxford University Press 2001
Research in Practice |
Inequalities in provision of systematic care for patients with diabetes
Clinical Governance Research & Development Unit, Department of General Practice and Primary Health Care and
a Department of Epidemiology and Public Health, University of Leicester, Leicester, UK.
Correspondence to Dr Kamlesh Khunti, Clinical Governance Research & Development Unit, Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
Khunti K, Ganguli S and Lowy A. Inequalities in provision of systematic care for patients with diabetes. Family Practice 2001; 18: 27–32.
Received 10 December 1999; Revised 9 May 2000; Accepted 5 September 2000.
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Abstract |
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Background. GPs are now playing a greater role in the care of people with diabetes; however, the level of performance in primary care is variable. Practices with a recall system and diabetes mini-clinic have been shown to achieve better outcome of care of patients with diabetes. Systematic care also requires effective community-based diabetes services and access to primary care diabetes teams including dieticians, chiropodists, and optometrists and ophthalmologists.
Objectives. The aims of this study were to determine how services for people with diabetes are organized in primary care and whether there are inequalities in systematic care of people with diabetes.
Methods. A piloted postal questionnaire was sent to all 327 general practices in three health authorities in England serving a population of >2 million people. The three health authorities provided practice-based routine data relating to all general practices.
Results. A total of 264 (80.7%) practices replied; 236 (89.4%) employed a diabetes recall system and 196 (74.2%) reviewed their patients in a diabetes mini-clinic. Multiple regression showed that having a recall system was associated independently with a GP [odds ratio (OR) 6.2; 95% confidence interval (CI) 2.6–14.9] or a practice nurse (OR 3.5; 1.4–8.7) with an interest in diabetes. Having a diabetes mini-clinic was associated independently with a GP with an interest in diabetes (OR 4.1; 2.1–7.8), a practice nurse having attended a diabetes course (OR 2.8, 1.3–6.2), practices with more partners (OR 1.2 per additional partner; 1.0–1.4) and fundholding practices (OR 2.6; 1.2–5.5). One hundred and sixteen (43.9%) practices had a chiropodist present in the practice, and 90 (34.1%) had a practice-based dietician. A chiropodist and a dietician were significantly more likely to be attached in training practices and in less deprived areas. A practice-based dietician was significantly associated with larger practices.
Conclusions. Providing high quality primary care is essential to meeting the government's agenda of reducing inequalities. This study shows high levels of structured diabetes care which are not related to deprivation. However, practices in more deprived areas still lag behind practices in more affluent areas in terms of access to members of the diabetes team. To improve care of people with diabetes in primary care, deficiencies and inequalities highlighted in our survey must be addressed. The results of this survey will be valuable to primary care groups and organizations responsible for commissioning diabetes services.
Keywords. Chiropodists, diabetes mellitus, dieticians, organization of care, primary care.
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Introduction |
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Diabetes is one of the most common chronic conditions managed in primary care, with a prevalence of 2.0%.1,2 GPs are now playing a greater role in the care of people with diabetes. However, the level of performance in primary care is variable,3,4 and previous studies have reported many factors influencing quality of care of people with diabetes.5–8 A recent meta-analysis concluded that structured primary care involving central computerized recall and review of people with diabetes can achieve outcomes as good as or better than hospital care.9 Practices with a diabetes mini-clinic have also been shown to achieve better glycaemic control of their patients with diabetes5 and higher performance of processes of care.10 Systematic care also requires effective community-based diabetes services and access to primary care diabetes teams including dieticians, chiropodists, and optometrists and ophthalmologists.11,12 Farmer and Coulter showed that organized diabetes care including practices with a dietician and a chiropodist was associated with reduced rates of hospital admission.13
In the UK, new national strategies for public health have been drawn up to tackle inequalities with the aim of improving the health of the worst off in society and to narrow the health gap.14 However, little is known about the characteristics of practices that provide systematic care, including recall and specific diabetes clinics, to patients with diabetes. There is also very little information on the provision of diabetes care teams within primary care. We undertook a detailed postal questionnaire survey of three health regions in the UK to determine (i) how services for people with diabetes were organized in primary care and (ii) whether there were inequalities in systematic care of people with diabetes.
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Methods |
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This study was part of a larger study investigating factors associated with quality of care of patients with diabetes. Three health authorities (Leicestershire, Durham and Suffolk) were selected for the main study. Data for the study were obtained by a questionnaire and routinely held health authority data. Ethical approval was granted from all three Ethics Committees, and respondents were assured confidentiality.
Questionnaire development
A questionnaire was developed and piloted in eight practices. The pilot results led to a small number of minor alterations to the wording of the questionnaire. The self-administered questionnaire consisted of 20 questions. The questionnaire sought details of the presence of a diabetes register, a diabetic mini-clinic, a recall system and a glucometer, and availability of members of a practice diabetes team. The questionnaire also sought information on GPs' and practice nurses' self-declared interest in diabetes and educational courses attended for diabetes. The majority of questions required a closed-ended response.
The questionnaire was sent in 1997 to all practices for which the three health authorities were responsible. Addresses of the GPs were obtained from the respective health authorities. The questionnaire was addressed to the practice manager or practice nurse with instructions that some data would need to be obtained from the GP. Non-responders were sent a reminder letter after 3 weeks and then telephoned.
Data relating to practices
The three health authorities provided data relating to 1996 for all the general practices including data on list size, number of partners, fundholding status, Jarman score, Townsend score, presence of a computer, training status and the number of whole time equivalent (wte) nurses. For two health authorities, the Jarman score was calculated using a weighted average of the percentage of registered patients in each practice according to the enumeration district in which they lived. For the third health authority, the Jarman score was calculated at ward level.
Data collection and analysis
Data were analysed using SPSS for Windows (version 8). All questionnaires were entered twice by SG. Associations between variables were sought using a standard chi-squared test for categorical variables and t-tests for continuous variables. Odds ratios (ORs) were calculated and, because many of the factors examined in the univariate analysis are correlated, such as list size and number of doctors in a practice, logistic regression was employed to determine which practice characteristics were associated independently with having a recall system and diabetes mini-clinic. Variables were included if there was a significant association in univariate analysis at a significance level of 0.05 or if they were likely confounders. Explanatory variables were tested in a forward stepwise regression analysis.
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Results |
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The three health authorities were responsible for 327 practices (number of practices in each health authority: 87, 88 and 152) of which 264 responded (mean response rate 80.7%; 70.1%, 81.2% and 90.8%). The practices in the three health authorities served a population of >2 million people. Two practices refused to participate and 61 failed to reply. Table 1
shows the comparison between responders and non-responders.
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Recall system and diabetes mini-clinic
Of the responders, 251 (95.1%) practices had a register of patients with diabetes. A recall system was employed by 236 (89.4%) practices, 196 (74.2%) reviewed their patients in a diabetes mini-clinic and 65 (24.6%) reviewed their diabetic patients in routine clinics or surgeries. Nearly all (97.6%) practices were approved for the chronic disease management programme.15 Table 2
shows results of univariate analysis and multiple logistic regression of factors associated with having a recall system. Practices with a diabetes mini-clinic were significantly more likely to have a recall system than those without [93.9% versus 76.4%; OR 4.7, 95% confidence interval (CI) 2.1–10.6]. Having a recall system was associated independently with the presence of a GP or a practice nurse with an interest in diabetes. The adjusted R2 for having a recall system with these two variables was 20.0%. Table 3 shows the results of univariate analysis and multiple logistic regression of factors associated with having a diabetes mini-clinic. The presence of a diabetes mini-clinic was associated independently with a GP with an interest in diabetes, a practice nurse having attended a diabetes course, practices with more partners and fundholding practices. The adjusted R2 for having a diabetes mini-clinic with these four variables was 25.2%.
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A glucometer was available in 82.0% (214/261) of practices. Practices possessing a glucometer were larger [mean list size (1000s): 7.3 versus 4.9; OR 1.2; 1.1–1.3] and had a lower Jarman score (mean 2.5 versus 8.2; P < 0.05) and Townsend score (mean 0.4 versus 1.7; P < 0.05). Practices with a diabetes mini-clinic were also more likely to have a glucometer (OR 2.6, 1.3–5.0).
Diabetes multidisciplinary team
In 175 (67.8%) practices, there was at least one partner who had an interest in diabetes, and in 69.2% (162/234) practices at least one partner had been on a diabetes course. A nurse with an interest in diabetes was present in 226 (85.6%) practices and a nurse had been on a diabetes course in 225 (85.2%) practices. In 80.6% (125/155) of practices, a partner had been on a diabetes course in the last 3 years, and in 90.6% (192/212) a nurse had been on a course in the last 3 years. Table 4 shows other members of a diabetes team either based at the practice or referred to outside the practice. Table 5 shows the characteristics of practices having a practice-based chiropodist or dietician.
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Discussion |
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This paper reports on a survey of differences between practices that offer systematic care to patients with diabetes and those that do not. Systematic diabetes care requires good organization and co-operation between members of the primary health care team. This survey of 264 practices in three different health regions shows that many practices are well organized in providing systematic diabetes care. Some factors associated with the provision of systematic diabetes care were not unexpected. However, there are variations between practices that provide systematic care and those that do not.
Limitations
The response rate of >80% for a general practice questionnaire is excellent; however, there are some limitations to this survey. The practices generally were representative except for the number of partners. Practices with three or more partners had a significantly higher response rate than those with one to two partners (84.4% versus 74.4%; chi-squared 4.8, P < 0.05). Furthermore, some of the responses to the questionnaire were self-reported, for example interest in diabetes by a GP or a practice nurse. In addition, we did not determine the content of the courses attended by the GPs or the nurses or confirm attendance. Although only two health authorities supplied enumeration district level data, separate analysis did not determine any differences. The data supplied by the health authorities related to 1996 while the questionnaire was distributed in 1997; however, the differences are unlikely to be large.
Diabetes recall and mini-clinic
Our study is in agreement with the survey of 45 practices in Poole4 and shows that many general practices are now organized to provide systematic diabetes care. Payment for chronic disease management15 may have influenced the increase in numbers of practices providing a diabetes mini-clinic and recall system. A key obstacle to the provision of systematic diabetes care in general practice is the lack of organization.16,17 Larger practices and practices with GPs or nurses with an interest in diabetes are more likely to have organized routine recall and to operate diabetes mini-clinics. However, deprivation is not a barrier to providing structured diabetes care. The models used in this study explained only a small part of the variation in practices possessing a recall system or a diabetes mini-clinic. Variations are therefore likely to be due to other unmeasured factors.
Multidisciplinary diabetes team
Previous studies have shown that one major barrier to providing comprehensive care to people with diabetes was the lack of specific skills.18–20 This study shows that many practices do not have readily available access to dieticians, chiropodists and optometrists.
Only a few (14%) practices in our study had practice-based access to ophthalmological services. Because lack of time and expertise are barriers to diabetic retinopathy screening,18–20 other methods of improving screening in primary care may include providing easy access for retinopathy screening by practice-attached ophthalmological services or an annual retinal photography service.21 Practices with access to dietetic services have been shown to have better glycaemic control than those without,5,20 however, fewer than half the practices provided practice-based chiropody and dietetic services. Practices with a practice-based chiropodist or dietician were larger, better organized and in less deprived areas. The perceived need for involvement of diabetes specialist nurses was low, a finding similar to that of a previous study.22
Any team caring for people with diabetes must receive annual continuing medical education in diabetes.12 Structured educational programmes involving all professionals can lead to improved clinical care for people with diabetes.23 Pringle and colleagues found that doctors who professed a special interest in diabetes acheived better glycaemic control and suggested that diabetic care should be concentrated on partners with a special interest in diabetes.5 In our study, just over two-thirds of GPs but 85% of nurses professed an interest in diabetes and had been on a diabetes course. Our study also shows that GP or nurse interest influenced provision of systematic care. The recent report Continuing Professional Development in General Practice proposes practice-based education.24 This would give an opportunity to focus on developing all aspects of diabetes care with emphasis on education with a multidisciplinary practice diabetes team.
Conclusion
Providing high quality primary care is essential to meeting the government's agenda of reducing inequalities.14 Recent studies25,26 have also confirmed the existence of an inverse socio-economic mortality gradient in people with diabetes. One of the major barriers to the provision of diabetes care in general practice is the lack of organization. This study shows high levels of structured diabetes care which are not related to deprivation. However, practices in more deprived areas still lag behind those in more affluent areas in terms of access to members of diabetes teams. This study has identified key factors associated with service delivery and systematic organization of care of patients with diabetes. To improve care of patients with diabetes in primary care, the deficiencies and inequalities highlighted in our survey must be addressed. The results of this survey will be valuable to primary care groups and organizations responsible for commissioning diabetes services.
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Acknowledgments |
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We thank the Leicestershire, Durham and Suffolk Health Authorities who provided the practice data and the three respective primary care groups for providing a list of practices that participated in the multipractice audit of diabetes. The Clinical Governance Research & Development Unit is an integral part of the Department of General Practice and Primary Health Care, University of Leicester. It is an independent research unit core funded by Leicestershire Health Authority. This study was funded by the Scientific Foundation Board of the Royal College of General Practitioners.
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