Summary
The HSE Midland Diabetes Structured Care Programme (MDSCP) is the longest-established primary care-based diabetes care programme in Ireland, operating in Longford, Westmeath, Laois and Offaly. Established in 1997, currently 82 GPs and 63 practice nurses (30 practices) participate, representing about 60% of all GPs practising across the four Midland counties. To date, 3,797 patients have enrolled. Participating practices receive clinical support via diabetes nurse specialists (DNS), dietetics, podiatry/chiropody, plus educational and administrative support. To be eligible for the MDSCP, practices must have a practice nurse to lead the organisation and co-ordination of the diabetes service, commit to register and regular recall of patients (three review visits per year), and provide space in which to review patients. Funding of the MDSCP is through Heartwatch or reimbursement for practice nurse time.
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Innovation
In Ireland, care delivery can vary regionally, from ad hoc and opportunistic management in primary care, to largely hospital-led management. The MDSCP is a ‘ground-up’, unique programme in Ireland, developed in response to local needs, and combining evidence-based strategies to improve diabetes management (clinical guidelines, patient register and recall, protected time for review visits, ongoing organisation and coordination of care by practice nurses, structured multidisciplinary support and professional and patient education). Over 16 years it has contributed to the evidence base for structured primary care-led diabetes management in Ireland. In 2015 provision of structured management in primary care on a national basis was supported by the introduction of the Diabetes Cycle of Care, which remunerates GPs for routine management and review of patients with type 2 diabetes (T2D) in primary care. This programme, while underpinned by the MDSCP, is distinct. It covers just two review visits per year for medical card and GP visit cardholders. As such, the MDSCP is a more comprehensive solution to improving management in the community.
Method
Over the past 16 years, four audits have been carried out, in 1999, 2003, 2008 and 2016. Since 2003 the MDSCP has collaborated with researchers in the School of Public Health, University College Cork, which provides analysis and audit reports. Data is collected from participating practices by the DNS. Data sources include the patient’s clinical notes (both electronic and paper), together with letters regarding outpatient appointments in acute hospitals, plus referrals to other services, such as dietetics, retinopathy and chiropody/podiatry. Data from the previous 12 months is extracted manually by the DNS. The MDSCP provides insight into the long-term performance and sustainability of a primary care-led approach to diabetes care. Using data from the most recent MDSCP audit (2015/2016), the current analysis aims to assess the quality of care delivered by the programme benchmarked against national guidelines and international performance in diabetes management (National Diabetes Audit [NDA] for England and Wales 2015-2016and the Scottish Diabetes Survey [SDS] 2015).
Results
To examine programme effectiveness and impact over 16 years, data collected in 2016 (1,178 patients) was used in conjunction with data collected for previous audits: 385 patients from ten practices in 1998/1999; 941 from 20 practices in 2003, and 1,071 from 30 practices in 2008. The chi-squared test for trend was used to assess trends in processes and outcomes of care across the four audits. There were statistically significant improvements in process of care recording over time for most indicators for patients with T2D. While the proportion of patients with T2D achieving HbA1c <6.5% remained stable over time (37.6% in 1999 vs. 34.1% in 2016), there was evidence of a significant increase in the proportion of patients meeting the total cholesterol target of <4.5mmol/L (22.9% in 1999 vs. 70.4% in 2016) and triglycerides <2.0mmol/L (46.4% vs. 75.5%). Overall mean ± SD total cholesterol also decreased among patients with T2D, from 5.3 ± 1.2mmol/L in 1999 to 4.1 ± 1.1mmol/L in 2016. While the proportion of patients with blood pressure <130/80mmHg remained stable from 2009 (21.7%) to 2016 (21.1%), there was an increase in the proportion meeting the target between 1999 (7.8%) and 2003 (11.5%). Overall mean ± SD SBP decreased among patients with T2D from 144.7 ± 19.9mmHg in 1999 to 135.1±15.9mmHg in 2016. A sub-analysis of patients followed up from 1998/1999 to 2016 demonstrated a similar pattern of improvement. Recording was comparable with both UK audits across all parameters with the exception of smoking status (78.9%) and BMI (71.3%) which were lower than the NDA (85.2% and 82.7% respectively) and SDS (83.3% and 86.7%, respectively).
Sustainability and Spread
There is ongoing commitment to the MDSCP from GPs, practice nurses and the GP Lead, Dr Velma Harkins. DNS support has continued to develop. Since 2013, new ‘integrated’ DNSs have been recruited across the country. Their time is split between 80% in primary care and 20% in hospital and the MDSCP secured one. Other DNSs supporting the programme have long-standing links with the endocrinologist in Mullingar hospital, which facilitated communication on more complex patients, avoiding hospital outpatient attendances. They have an informal arrangement to work one day/month in Mullingar hospital, which enhances DNSs’ clinical skills by allowing them to work alongside the consultant, participate in joint nurse/dietician clinics, and facilitate integration of primary and secondary care in management of more complex cases in primary care. The findings illustrate the sustainability of the MDSCP over time, suggesting the feasibility of implementing a structured, multifactorial approach to diabetes care in the primary care setting. The MDSCP extended to the wider Midlands area in 1999 and has been critical in persuading successive health ministers that chronic care can be safely delivered in primary care, leading to the national roll-out of the Diabetes Cycle of Care. MDSCP outcomes are communicated widely, through publicly available audit reports. The intention is to continue to invest in, and monitor, the programme.
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