General practice based diabetes clinics. An integration model

Abstract

Background: Diabetes is a common chronic health problem in general practice. The quality of care for patients with diabetes has been shown to depend on many factors involving the patient and the general practitioner (GP) as well as the care environment.

Objective: To measure the benefits of general practice based diabetes clinics that integrate all patient care needs in the one place at the one time.

Methods: General practice based diabetes clinics were conducted in the rooms of 23 practices involving 54 GPs. The clinic team consisted of a diabetes educator, a dietitian and the usual GP. The clinic was conducted in accordance with the NSW Clinical Management of Diabetes Guidelines.

Results: Follow up after 12 months showed a significant drop in the number of patients with very poorly controlled diabetes (HbA1c > 3% of normal range). Management of co-morbidities (hypertension, hyperlipidaemia, microalbuminuria) improved and complication screening for active/high risk feet and diabetic retinopathy were performed.

Conclusions: This coordinated and integrated approach to the management of diabetes improved glycaemic control of the poorly controlled patient with diabetes and improved GPs' management of complication risk factors.