Uncomplicated patients should not be in clinics

Dear Editor,

I was very interested to read the interview with Prof Richard Firth (IMT, 19  November, see www.imt.ie/features-opinion/2010/11/tackling-the-diabetes-time-bomb.html) on the topic of diabetes. I agree with much of this article.

The problem of diabetes, especially type II disease, is truly a massive one that  will take intense effort and a truly innovative approach to tackle properly.

There is, however, one important point on which I disagree with Prof Firth.  There is absolutely no need for the average, well-managed, uncomplicated  patient with type II diabetes “to be seen at least once every two years at a hospital for target setting”.

We are all well aware by now of the targets for blood pressure, lipids, smoking, alcohol, vaccination, weight and exercise.

Following the publication of the UKPDS and ACCORD trials, we also have a better understanding of what the glycaemic targets should be. This has all been well documented by the HSE West Diabetes Resource Manual and the ICGP in its recent guidelines on diabetes management.

The Midland Diabetes Structured Care Programme has clearly shown that diabetes can be managed in the community to a very high standard by GPs and their staff.

Similar results have been shown by the Cork-based Diabetes Interest Group and the recently completed Health One electronic diabetes audit.

I have been running a diabetes review clinic in my practice for the last 20 years and my recent audit has also shown comparable results (O’Connor R. ‘Fiche Blian Ag Fas: An Audit of 20 years of Diabetes Care in a Single General Practice.’ Presented at Croi conference Limerick, Oct 2010. In press for Forum – Journal of the ICGP).

Thus, GPs have no difficulty finding their diabetic patients or, indeed, looking after the majority who are uncomplicated if found early and followed up properly. In my own practice, for example, we have had only two foot ulcers in 20 years, one of which also had a partial amputation.

There is no diabetic patient blind or in renal failure. All of my diabetes patients are now screened by the newly established community-based retinopathy screening service.

I also have access to formal diabetes educational programmes such as DESMOND and CODE as well as an excellent, community-based dietetic service.

Sending uncomplicated diabetic patients to hospital clinics is a waste of everyone’s time. We need the hospital for the complex patients, namely:

• All type I patients – it is generally accepted that these patients should have ‘shared care’ with the hospital. Currently, only 10 per cent of my diabetes patients are in this category;

• Type II patients who have persistently elevated sugars on maximum or maximum tolerated doses of metformin and sulphonylurea. At present, there is a lack of clarity as to whether the third step should be a glitazone, an incretin or insulin. These patients also make up a very small percentage of the total number (less than 10 per cent);

• Type II diabetes patients starting on insulin probably need hospital specialist input, although in the Midland Diabetes Structured Care Programme, many of these patients are commenced on insulin in the community;

• Patients with type II diabetes and complications such as painful neuropathy or foot ulcers. Many of these are difficult to manage in the community and would benefit from expert opinion;

• Gestational diabetes.

All of these patients need to be seen in a timely manner (i.e. within two-to-four weeks) by a doctor or nurse with the relevant specialised knowledge once they are referred to the secondary-care services.

By this, I mean a consultant, clinical nurse specialist or specialist registrar. It is highly inappropriate for a patient to travel many miles to a hospital clinic and take a day out of their lives, only to meet a junior hospital doctor who knows less about the disease than the referring GP.

This kind of timely appropriate specialist review (which is the essential element of the ‘shared care’ model) will not happen if the hospital clinics are overrun with hundreds of uncomplicated patients that have no business being there in the first place.

I am delighted to report that we have had such a system successfully in operation with Dr James O’Hare in the Mid-West Regional Hospital in Limerick for many years.

Dr Ray O’Connor,
Kileely, Limerick.