Improving diabetes care and management in Torres Strait remote primary health care settings

Abstract

Background: Torres Strait Islanders (TSI) have the highest prevalence of Type 2 diabetes in Australia with about a third of the adult population affected; the incidence of Type 2 diabetes and other co-morbid conditions are also extremely high at around 3%. A review in 2005 noted that newer diabetes cases were younger, more obese and had poorer glycaemic control compared to 6 years previously. Clinicians report anecdotally that many patients are prescribed insulin therapy; however, it is unknown if patients are collecting their medication from local primary health care centres. Diabetes is associated with significant depression, which can result in poorer clinical outcomes, including increased mortality. Little is known about the prevalence of depression among TSI adults with diabetes. Models of chronic disease management in the Torres Strait region remains an ongoing discussion that supports better self-management of diabetes amongst patients. Study Aims: The overall aim of this thesis is to provide epidemiological evidence to support the development of community level interventions to address the most important risk factors associated with the health of Torres Strait Islanders with Type 2 diabetes. 1. Review patient level factors on behavioural aspects of diabetes management and care including psychological insulin resistance and depression. 2. Review health service factors that impact on diabetes management and care. Methods / Design: Study 1: 29/197 adults with poorly controlled diabetes who have refused insulin treatment, were interviewed using validated instruments Insulin Treatment Appraisal Scale (ITAS) and Barriers to Insulin Treatment Questionnaire (BITQ). Study 2: A descriptive cross-sectional survey in 2013 and 2014, Interviews with 188/197 adults with diabetes in five remote Torres Strait Islands using the Patient Health Questionnaire (PHQ)-9. Study 3: A Retrospective clustered cohort study of the impact of the intervention on care processes, intermediate clinical outcomes in 285 adults with known diabetes. At baseline 197 participants from five remote Torres Strait Island communities (mostly the Eastern group of Islands) consented to be enrolled in the survey. A further 88 records from the western group of islands were audited from 2012 - 2015 and serves as a comparator group. Target population: Adults diagnosed with Type 2 diabetes located in the remote Island communities of the Torres Strait region with primary health care services provided by Queensland Health. Results: Study 1: Thirty- four percent (n=197) had poor glycaemic control. Compared to those with HbA1c 8.5% and taking insulin (n=37), the 29 insulinnaive participants were more obese, more likely to smoke and drink alcohol, have lower mean HbA1c and fewer years with diabetes. Among the insulinnaive group, those reporting higher 'barriers' (BITQ scores) were older and with lower formal education than those reporting fewer barriers. TSI participants consistently scored low on 'knowledge' items in the ITAS, especially those which would guide insulin initiation (insulin improves glucose control and prevents complications). Study 2: Ninety – five percent (n=197) completed PHQ-9 interviews. The median PHQ-9 score was 5.5 (IQR 0-7); 42% of respondents scored 0-4 (noneminimal), 46% scored 5-9 (mild) and 12% scored10+ (moderate –severe). Mean Hba1c was 8.3% (67.4 mmol). HbA1c was not related to PHQ-9 scores (β=0.20, Ρ = 0.323), however exercise in hours (β =0.34, Ρ < 0.001) and screen time in hours (β = 0.11, Ρ < 0.001) were significant predictors of depression after adjusting for other study variables. Study 3: At baseline, overall (n=285), 61% were women, 75% were aged over 50, 67% were obese (Body Mass Index (BMI), higher in the comparator group), 65% were poorly controlled (Hba1c>8.5%) and 18% were smokers (lower in comparator group). At baseline (2012) GP management plans (GPMP) and team care arrangements (TCA) were more likely to be completed in the eastern group 93% vs. 39% with 90% referred to a dietician, diabetes educator or podiatrist. However, in 2015 a decrease in the GPMP from 93% vs. 20% in the eastern group. It appeared that participants in the eastern group had better glycaemic control than those in the western group (34% had hba1c> 8.5% compared to 39% in the eastern group) and this difference persisted through to 2015. Conclusion: Improving patient level factors on behavioural characteristics of diabetes care requires better communication between service providers and clients, taking consideration of local cultural contexts and beliefs. Simple health promotion activities could improve mental health and general well-being in this population. Understanding patient behaviour can assist service providers to deliver appropriate service delivery that involves clients' input. Overall, patients with Type 2 diabetes are hesitant to commence insulin therapy, mild depression scores were evident that do not appear to have an effect on glycaemic control. However, care planning, referrals, and other clinical measures important to diabetes care, and actual numbers of consultations appeared to decline dramatically between 2012 and 2015 in all sites. This suggests that a more systematic approach to population-level diabetes care is required.