Why type 2 diabetes patients should shift from secondary to primary care
The benefits of moving patients to primary care were covered at the recent EASD 2022 meeting. Lisa Buckingham reports.
A wealth of evidence was presented in ‘Integrated care models: benefit beyond expectation’, a presentation by Samuel Seidu, clinical professor of primary care diabetes and cardiometabolic medicine at the Diabetes Research Centre, University of Leicester.
There are barriers to left-shifting patients with type 2 diabetes from secondary care to primary care if it’s not done properly, he said, such as software systems not being integrated properly (causing a bottleneck), patients not wanting to be managed by their GPs after having received specialist care (although this is not the norm – patients generally like to be managed closer to home), data protection issues where departments can’t share data across, or a practice not being well enough equipped to deal with the complexities of diabetes care.
It is rare for a person with type 2 diabetes to have diabetes alone, so having someone look at a patient’s conditions all together therefore offers an advantage. He highlighted a study showing the co-morbidities of the top 10 most common conditions. For example, it showed that 54% of patients with diabetes have hypertension and 23% have coronary heart disease. Only 17.6% have diabetes only. If you’re over 65, your mean number of conditions is 6.5; if you’re under 65, it’s 2.9.
The problem, he said, is that the medical specialisation system we have does not encourage doing a lot for the patient in one setting. In the past two decades, we have seen people super-specialising in certain areas and it’s rare to find a consultant physician. He showed recently published research from the Leicester Diabetes Centre showing the drop in GP consultation rates for people type 2 diabetes and cardiovascular disease in the past 20 years. It’s declined by 40% for those with type 2 diabetes alone and 50.5% for those with diabetes and cardiovascular disease. Meanwhile, in the secondary care setting, consultations for diabetes and CVD increased by 33% and for those with diabetes alone, it was 54.4%.
This means that GPs are getting fewer chances to work with diabetes patients, said Professor Seidu, but with diabetes being a condition with a lot of other chronic conditions clustered around it, we need to change this.
More research from his group looked at patients with heart failure. For patients with diabetes and heart failure, there has been a decline in the trend for hospitalisations by 24% in the past two decades. However, when you add chronic kidney decease into the mix, this decline is attenuated. In fact, there has been an increase of 26% in the one-year rate of all-cause hospitalisations in these patients. Life expectancy in patients with all three conditions has decreased by 2.2 years.
GPs in the middle
My favourite approach, Professor Seidu said, is integrating diabetes care around a primary care team because when you talk about integration of care, it is very difficult to get a multi-disciplinary team to work together seamlessly. You will never get them all in the same room. Post-COVID-19, there has been more talk of digital integration, where a consultant logs in digitally when a patient is with the GP, but this is logistically complicated.
The suggestion that his team has come up with is to get the GP in the middle with the patient to do the integration of care, along with the nurses and healthcare assistants in that setting. This is because the primary care physician is the person who has all the data on the patient, maintains continuity of care from birth to death and has responsibility for their long-term condition, as well as knowing all about the patient’s biopsychosocial history. Managing patients closer to home is also more cost-effective and usually preferred by the patient.
He moved on to discuss a model they use in Leicester, where they equip primary care teams to be able to carry out an integrated model. He showed research from his group that did a cost-comparison between these ‘enhanced practices’ (GPs with an interest in diabetes being supported by a multi-disciplinary primary care team) and ‘core practices’ (standard GPs that provided standard care supported by integrated specialist diabetes care services in the community). Some patients were excluded due to being too complex to be managed in primary care, such as patients on dialysis or those using insulin pumps, children and adolescents.
Empowering primary care teams
So how do you empower primary care teams to operate as an enhanced practice? You train them up, Professor Seidu said – GPs see a big picture, but they need training for the specifics to safely look after a diabetes patient. This was done in Leicester through an MSc in diabetes or updating diabetes knowledge through a locally accredited programme (Effective Diabetes Education Now). They were then supported to repatriate stable patients from secondary care back to the practice, with monthly clinical engagement meetings to discuss complex cases, audits and feedback to compare data with other practices, and care planning for people with HbA1c of 8% or more, patients with multi-morbidities and those who were housebound.
For the core practices, basic diabetes care was provided as usual by a primary care physician (PCP), but in order to prevent a two-tier system, they were supported by diabetes specialist nurses, dietitian and podiatrists, working under the supervision of diabetes specialists in the secondary care units in an integrated way.
The results were impressive, said Professor Seidu. For first-year trends in outcomes, there was a large decrease in non-elective bed days for the enhanced practice group, compared with an increase in the core practice group. For hospital admission with diabetes complications, there was a significant decrease in the enhanced practice group compared with a trend towards an increase in the core practice group.
This was followed by a cost-comparison analysis, which found an annual cost saving of £83 per patient in the enhanced practices, which would equate to a saving of £276,200,000 if it was delivered across all practices in the UK.
He moved on to discuss models in other countries, with Australia being a top performer. In a model in Brisbane in which GPs with a specialist interest are supported by consultant colleagues (the Beacon model), they showed improvements in HbA1c, LDL cholesterol and blood pressure, and combined treatment targets for all of these. The cost saving per patient was A$365 versus the gold-standard hospital care model.
Lastly, he covered digital integration and drew attention to a review of 22 studies from across the world on the effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes. The effect on reduction in HbA1c was statistically significant. Quality of life was also improved.
In summary, well-established primary care teams can provide safe and good quality care. Primary care physicians also have the advantage of managing patients throughout their lives, providing continuity of care and having knowledge of other factors such as their social situation.
He addressed the issue of funding in the post-presentation questions, stating that the funding needs to follow the patient. When patients are shifted from secondary care to primary care, the money needs to go with them.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.