Structured care plan from GP practice meets glucose targets

By Gary Culliton

The Bayview Family Practice in Ballyshannon, Co Donegal runs a structured general practice diabetic care programme modelled on the Heartwatch initiative. This type of approach to diabetes care is becoming increasingly common, said Dr Philip Murphy.

There are eight doctors in the practice, including Dr Murphy. A diabetic register was compiled in 2009, covering 394 patients with type II diabetes and 38 people with type I diabetes. Of these, only 49 were attending Sligo General, the local specialist centre.

Most of these were dealt with on an ongoing basis by the GP practice. Some were attending the hospital when they should not have been. They were well-controlled diabetics who had simply not been discharged by the hospital. This is the sort of information that was revealed in the audit – two of which have been conducted over the past six years.

The 2009 audit confirmed the number of people who had been seen and who had HbA1c tests and blood-pressure checks over the previous year. It also established the number of patients who were meeting their targets when it came to managing their diabetes.

The cost to the practice of a structured diabetes programme is about €90,000 per year. One nurse equivalent is employed by the practice throughout the year with regard to this activity. Patients are given a structured plan and are seen every three months.

The practice nurse takes the blood tests and checks the formal parameters: HbA1c, feet, legs, weight and blood pressure (all the cardiovascular risks associated with diabetes). The doctor intervenes, focusing mainly on the targets which are not met (for example, cholesterol or glucose levels).

There has been clear improvement in patients’ diabetes generally since the structured care programme was established in 2004. The first audit was conducted in 2005. A total of 48 per cent of Dr Murphy’s diabetic population have HbA1c levels better than 6.5. A total of 68 per cent were better than 7.1. In all, 76 per cent had a score of better than 7.5. Weight continues to be the most problematic parameter among Dr Murphy’s patients. Smoking is another significant factor.

It emerged in the audit that the patients whose diabetes is not controlled are a disparate group. Some patients simply do not attend for check-up. Others are unlikely to ever be controlled. Nevertheless, with the structured care programme, a very high percentage of patients are now under good control.

Dr Murphy believes some structured funding is needed to encourage every practice to conduct a structured diabetes programme. “If it’s done, it will be effective. But it does need to be incentivised,” Dr Murphy said. “We have shown that it works. We can get a significant number of patients to meet targets. Seventy-six per cent of them are meeting an optimal HbA1c target.”