Commentary: Audit of mortality in type 2 diabetes

Abstract

The paper by Allan et al underscores (a) the view that diabetes is a cardiovascular disease and (b) the appropriateness of the management of patients with type 2 diabetes in primary care. Diabetes is the ideal candidate for shared care between the primary and secondary care sectors. In a UK survey carried out in 1991, diabetes care schemes accounted for 48% of all shared care schemes in operation. The practical design varied widely, and about one third had been set up only since 1989. Shared care has been defined as “the joint participation of hospital consultants and general practitioners in the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral notices”. In the case of diabetes, shared care involves input from a range of health care professionals and a collaborative team approach is essential. The forthcoming National Service Framework (NSF) for diabetes in the UK will undoubtedly argue that the most important person in the team is the patient, who must undertake a responsible role in the constant monitoring of their condition. Over the past three decades many types of shared care systems for diabetes have been tried and tested in the UK. Greenhalgh has systematically reviewed the literature, examining more than fifty schemes (over half of which were unpublished). The main findings were as follows: 1 Established shared care schemes of two types, centralised hospital based and consultant led or decentralised, community based and multidisciplinary. 2 A closely knit steering group or enthusiastic key individual, often the consultant diabetologist, could be clearly identified in all of the published successful schemes. 3 Structured care by primary care physicians with an interest in diabetes and supported by an enthusiastic specialist liaison team to produce comparable and occasionally superior levels of care to those provided solely by the hospital diabetes department. Unstructured care was ineffective and wasteful of resources. 4 Three randomised controlled trials showed that successful share care schemes had two common features – a centralised prompting system for recall and a structured check list for the primary care physician. 5 Successful district wide schemes shared three common features A Extensive planning phase when objectives were clearly defined and the facilities, expertise and commitment of primary care were assessed. B Locally developed written guidelines for the management of diabetes. C A well documented outreach system from the hospital by highly trained nurse facilitators who could advise on practical problems, maintain enthusiasm and enable fast tracking of patients for specialist review. The Fife programme incorporated all of these features. Diabetes is recorded as a cause of death on a minority of death certificates for patients with diabetes. Life years lost for patients with diabetes is strongly related to age at diagnosis and is a means of expressing mortality without relying on accurate prevalence data. The light at the end of the tunnel for these patients is careful control of blood pressure down to a level of 130 over 80 and treatment of other risk factors, particularly aggressive lipid lowering.