A comparison of two models of general practice care of patients with diabetes
The presumption that diabetes is a disease treated in hospital that cannot be trusted to primary care has shifted in favour of a view that diabetes care should be shared between hospital specialists and general practice. Greenhalgh concedes that there may be some patients for whom the specialist has only a limited role to play. Pereira Gray, however, identifies structured versus unstructured care in general practice as the key issue. This study compares these two approaches in terms of process measures, clinical outcomes, service utilisation and costs. Methods. A retrospective review of general practice and hospital records of patients with type II diabetes (n = 709) was conducted in ten urban practices. In 5 practices care of diabetes was structured around the concept of an identified period of "protected time" - a 'mini-clinic'. In the other 5 the style of care was more traditional. Practices were compared in terms of frequency of measurement of various parameters including body mass index, random blood glucose, blood pressure, glycosylated haemoglobin (HbA1) or fructosamine, and fundoscopy. The extent of hospital involvement in care and the economic implications of the two modes of care delivery were also assessed. Results. In terms of metabolic parameters the two models of care were broadly comparable. Measures of process of care indicated that required monitoring was more likely to have been carried out in patients under the care of mini-clinic practices and that within other practices there was both under and over recording of disease parameters. The most striking difference, however, was in the extent of hospital utilisation with the 353 patients in mini-clinic practices generating only 75 hospital visits over a 2 year period versus 288 visits generated by 356 patients looked after in non-mini-clinic practices. This difference was statistically significant (p < 0.05) and was associated with (and the main cause of) an estimated £ 46 (£ 163 versus £ 116) greater cost over 2 years for the care of patients not being care for under the mini-clinic model. Conclusions. This study suggests that the bulk of diabetes care can be managed in primary care and, if properly structured, can achieve comparable metabolic outcomes at a greatly reduced cost.