Diabetes care: the effectiveness of systems for routine surveillance for people with diabetes

Abstract

Background: There is wide variation in the extent of general practice involvement in diabetes care.

Objectives: To assess the effects of involving primary care professionals in the routine review and surveillance for complications of people with established diabetes mellitus compared with secondary care specialist follow up.

Search strategy: We searched the Cochrane Diabetes Group specialised register, The Cochrane Library, MEDLINE (January 1966 to December 1996), EMBASE (to December 1996), Cinahl (to December 1996), National Research Register (to December 1996), PsycLIT (to December 1996), HealthSTAR (to December 1996), CRIB (to December 1996), Dissertation Abstracts (to December 1996), and reference lists of articles.

Selection criteria: Randomised trials in which people with diabetes were allocated to a system of review and surveillance for complications by primary care professionals. Outcomes included mortality, metabolic control, cardiovascular risk factors, quality of life, functional status, satisfaction, hospital admissions, costs, completeness of screening, and development of complications.

Data collection and analysis: The reviewer assessed trial quality and extracted data. Analysis was on an intention to treat basis. General practice care was categorised into routine or prompted care and a stratified analysis undertaken.

Main results: Five trials involving 1058 people were included. Results were heterogeneous between trials. In those schemes featuring more intensive support through a prompting system for general practitioners and patients, there was no difference in mortality between hospital and general practice care (odds ratio 1.06, 95% confidence interval 0.53 to 2.11), HbA1 tended to be lower (a weighted difference in means of -0.27%, 95% confidence interval -0.59 to 0.03) and losses to follow up were significantly lower (odds ratio 0.37, 95% confidence interval 0.22 to 0.61) in primary care. However, schemes with less well-developed support for family doctors were associated with adverse outcomes for patients. Quality of life, cardiovascular risk factors, functional status and the development of complications were infrequently assessed.

Reviewer's conclusions: Unstructured care in the community is associated with poorer follow up, greater mortality and worse glycaemic control than hospital care. Computerised central recall, with prompting for patients and their family doctors, can achieve standards of care as good or better than hospital outpatient care, at least in the short term. The evidence supports provision of regular prompted recall and review of people with diabetes by willing general practitioners and demonstrates that this can be achieved, if suitable organisation is in place.