Prompting the clinical care of non-insulin dependent (type II) diabetic patients in an inner city area: One model of community care

Abstract

Objective - To evaluate the effectiveness and acceptability of centrally organised prompting for coordinating community care of non-insulin dependent diabetic patients. Design - Randomised single centre trial. Patients allocated to prompted care in the community or to continued attendance at hospital diabetic clinic (controls). Median follow up two years. Setting - Two hospital outpatient clinics, 38 general practices, and 11 optometrists in the catchment area of a district general hospital in Islington. Patients - 181 patients attending hospital out-patient clinics. Null hypothesis - There is no difference in process of medical care measures and medical outcome between prompted community care and hospital clinic care. Results - 14 hospital patients failed to receive a single review in the clinic as compared with three patients in the prompted group (X2=6̇1, df=1; p=0̇013). Follow up for retinal screening was better in prompted patients than in controls; two prompted patients defaulted as against 12 controls (X2=6̇9, df=1; p=0̇008). Three measures per patient yearly were more frequent.in prompted patients: tests for albuminuria (median 3̇0 υ 2̇3; p=0̇03), plasma glucose estimations (3̇1 υ 2̇5; p=0̇003), and glycated haemoglobin estimations (2̇4 υ 0̇9; p<0̇001). Continuity of care was better in the prompted group (3̇2 υ 2̇2 reviews by each doctor seen; p<0υ001). The study ended with no significant differences between the groups in last recorded random plasma glucose concentration, glycated haemoglobin value, numbers admitted to hospital for a diabetes related reason, and number of deaths. Question-naires revealed a high level of patient, general practitioner, and optometrist satisfaction. Conclusions - Six monthly prompting of non-insulin treated diabetic patients for care by inner city general practitioners and by optometrists is effective and acceptable.