The impact of point of care testing on diabetes services along Victoria's Mallee Track: Results of a community-based diabetes risk assessment and management program

Abstract

In the State of Victoria in Australia, diabetes is considered one of the top 10 health problems for people living in the rural Mallee Track region (which is centred on the town of Ouyen and extends west to the border with South Australia). A project entitled 'Diabetes Management Along the Mallee Track' was conducted through a Rural Chronic Disease Initiative (RCDI) program grant from the Australian Government's Department of Health and Ageing, Canberra, with the aim of improving the delivery of diabetes services in this region. The project's aims were achieved through the implementation of a community risk assessment program and the establishment of an integrated, multidisciplinary 'one-stop' service for the management of people with diabetes. The use of on-site point-of-care (POC) pathology testing equipment was the key component of both arms of the project. Community risk assessment sessions were held in seven towns across the Mallee Track region using a local settings approach. Risk assessment included POC pathology testing for glucose and lipids, as well as blood pressure, age, personal and family history of diabetes, smoking status, and self-assessed weight and level of exercise. The multidisciplinary 'one-stop' service for the management of people with diabetes involved having a single appointment with their local GP, during which time they met the local diabetes educator and podiatrist as well as the GP, and on-site POC testing (POCT) performed for haemoglobin A1c (HbA1c), urine albumin : creatinine ratio (ACR), lipids and glucose. A written survey was conducted among patients with diabetes, local GPs and local health professionals to assess the level of satisfaction with the project and the use of POCT, and to assist policy development for the future planning and development of diabetes services along the Mallee Track region. Risk assessment: 320 adults were assessed for their risk of diabetes during community sessions (representing approximately 20% of the adult population of the region). Two-thirds of people tested had equivocal random blood glucose levels (5.1-11.0 mmol/L), while hypertension and high cholesterol were found in more than one-third. Management of established diabetes: 49 people with known, established diabetes were initially entered into a Central Diabetes Register (with 5 more joining the register since). These diabetes patients (n = 54) have now been monitored by POCT for a mean of 10 months (range 3-18 months). Since the introduction of the 'one-stop shop', the percentage of persons achieving optimal glycaemic control (HbA1c <7%) has increased by 30% (from 33% to 63%), the percentage achieving controlled glycaemia (HbA1c < 8%) has increased by 32% (59% to 91%), while the number exhibiting poor control has reduced by 7% (13% to 6%). The mean HbA1c has fallen from 7.6% at the commencement of the program to 7.1% (p = 0.03, paired t-test). Falls in cholesterol and blood pressure were also observed. Satisfaction with new management services for diabetes: 36 patients with diabetes (73% of all known diabetes patients in the region at the time) completed satisfaction questionnaires. There was overwhelming support within this group for the use of POCT as part of their management, because it was convenient, encouraged self-management and enhanced doctor-patient relationships. The proportion of patients with diabetes who were satisfied/very satisfied with the available diabetes services was significantly greater following the introduction of the project (before: n = 18 (64%), after: n = 29 (91%), chi2 = 6.10, p = 0.01). Doctors agreed that the immediate availability of POCT results at the time of consultation was convenient for them, contributed positively to patient compliance and improved their relationship with the patient. Health professionals felt confident in using the POC analysers and believed the program had raised community awareness about diabetes and enhanced community ownership. Point-of-care pathology testing has enabled the introduction of a community-friendly risk assessment program for diabetes and provided a convenient and rapid service for monitoring the control of diabetes in people with established disease in the Victorian Mallee Track region. The number of diabetes patients accessing diabetes services has more than doubled since the introduction of the program. All community and health professional groups surveyed agreed that the POC model delivered as part of this project should be available to all people throughout the Mallee Track region. The model, although conducted in a small rural community, has the potential to form a suitable template for the broader introduction of POCT services for diabetes in rural and remote communities across Australia. As an independent measure of the success of the program, the Australian Government's Department of Health and Ageing selected the Diabetes Management Along the Mallee Track project as one of three demonstration projects from the RCDI grants for showcasing to all rural health services in Australia through the production of an education resource called 'Building Healthy Communities'.