Editorial |
Improving care for patients with diabetes: the role of simple reminders
a Honourable Reader in Medical and Social Care Education, University of Leicester
b Consultant Director of Chronic Disease Management, Heart of Birmingham Teaching Primary Care Trust, Diabetic Care, Carver Street, Hockley, Birmingham B1 3AS, UK
Correspondence to AC Felix Burden, Heart of Birmingham Teaching Primary Care Trust, Diabetic Care, Carver Street, Hockley, Birmingham B1 3AS, UK; Email: felix.burden{at}hobtpct.nhs.uk
It is now accepted that the correct place for routine management of the person with diabetes is in primary care with supporting services from specialists; various models of such care have been recently described.1
The paper describing a ‘logistics support service’ by Marianne Meulepas et al.2 suggests that simple recall of patients for blood and annual review checks improves diabetic control, with an HbA1c improvement of 0.7% when compared with the control. The intervention was simple: phoning the patient to remind them of the need to have an investigation, for example laboratory testing, foot examination, fundus photography or appointments with dietician or diabetes nurse; the patient was asked to make an appointment at the surgery to discuss results.
The intervention did not provide any patient care itself. The results of the tests were sent directly to the GP. Phone call prompts are used widely in secondary care to encourage patients to attend appointments but this study appears to be the first used in primary care.
Seventy-eight practices were included in the study, were they representative of practices in the Netherlands and elsewhere? In terms of practice size and prevalence of diabetes, the average list size was 2653 in the intervention practices and 2827 in the control practices: not dissimilar to many parts of the UK. The prevalence of diabetes was 2.2% (control practice) and 2.6% (intervention practice) similar to that quoted elsewhere3 and not dramatically different from the prevalence in many other countries. In that article, the authors present further details confirming the representativeness of these 78 practices. For inner city areas of the UK, though, where the prevalence of diabetes is about 5% and where additional funding is available from the ‘Quality Framework’,4 the recall system could be based in the practice itself.
The primary outcome was change in Hba1c, which was 0.7% lower in the intervention group at the end of the study, a statistically significant effect, and clinically significant. Of the other variables studied, all improved, and for systolic blood pressure, total cholesterol and triglycerides did so statistically significantly. This is an impressive effect, which can be translated into about 30% less retinopathy or nephropathy.5 The difference is similar to the differences found between the United Kingdom Prospective Diabetes Study (UKPDS) ‘intensive’ group when compared with the controls.6 It is also similar to values seen with education as in the X-PERT trial7 and with empowering the patient with counselling options.8 It is as effective in lowering HbA1c as a single oral hypoglycaemic drug.9
This study would appear to be generalizable elsewhere. Many programmes less rigorously studied using phone contact are already in place: in the Birmingham, UK, region, we have increased the uptake of retinal screening by phoning people who had not been screened; Pfizer and NHS Direct are counselling patients with long-term conditions, to take their medication.
The authors in the discussion continue some commonly held fallacies about the results of the UKPDS. One is that blood pressure control might be more advantageous than glycaemic control in preventing complications. The blood pressure trial was of a prevalent cohort, whereas the glycaemic trial was of an incident cohort. When both blood pressure and HbA1c are studied in an observational study, then both are shown to be important.5,10 The other is that glycaemic control inevitably worsens (as happened in the control group of this study). In the UKPDS, the protocol demanded intensive use of monotherapies. Additional therapies were not allowed unless the fasting glucose was more than 15 mmol/l or there were symptoms. Outside the confines of a research study, and in the glucose 2 UKPDS substudy,11 additional therapy can be added when HbA1c reaches a set ceiling, such as HbA1c of 6.5%.
Finally, this study did not empower people with diabetes. In particular, the results of investigations were not given directly to the patient but a further appointment had to be made to find out the results and receive additional therapy. Most people with long-term conditions such as diabetes expect better care that this. It would be useful to study the effects of this intervention coupled with empowerment and education of people with diabetes, possibly with a matrix design. This may show even greater effects on HbA1c and blood pressure.
Declaration
Funding: None.
Ethical approval: Not applicable.
Conflicts of interest: None declared.
Notes
Burden ACF. Improving care for patients with diabetes: the role of simple reminders. Family Practice 2007; 24: 1–2.
References
1 Burden AC. (2006) Shift in diabetes care: theory and practice of integrated care. Pract Diabetes Int 23:Suppl, 1–19.
2 Meulepas MA, Braspenning JCC, de Grauw WJ, et al. (2007) Logistic support service improves processes and outcomes of diabetes care in general practice. Fam Pract 24:20–25.
3 Ubink-Veltmaat LJ, Bilo HJ, Groenier KH, Houweling ST, Rischen RO, Meyboom-de Jong B. (2003) Prevalence, incidence and mortality of type 2 diabetes mellitus revisited: a prospective population based study in the Netherlands (ZODIAC-1). Eur J Epidemiol 18:8793–800.[Web of Science][Medline]
4 http://www.bma.org.uk/ap.nsf/Content/qof06 (accessed on January 1, 2007).
5 UKPDS Group. (2000) UKPDS 35: association of glycaemia with macrovascular and microvascular complications of type 2 diabetes: prospective observational study. Br Med J 321:405–412.
6 UKPDS Group. (1998) UKPDS 33; intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 352:837–853.[CrossRef][Web of Science][Medline]
7 Deakin TA, Cade JE, Williams R, Greenwood DC. (2006) Structured patient education: the diabetes X-PERT programme makes a difference. Diabet Med 23:944–954.[CrossRef][Web of Science][Medline]
8 Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. (1988) Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 3:5448–457.[Web of Science][Medline]
9 NICE Technology Appraisal Guidance 63. Guidance on the Use of Glitazones for the Treatment of Type 2 Diabetes http://www.nice.org.uk/page.aspx?o=ta063 (accessed on January 18, 2007).
10 UKPDS Group. (2000) UKPDS 36: association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes: prospective observational study. Br Med J 321:412–419.
11 Wright A, Burden ACF, Paisey RB, Cull CA, Holman RR. (2002) UKPDS 57 sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the UK prospective diabetes study. Diabetes Care 25:330–336.
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