Hospitalisation among patients with diabetes associated with a Diabetes Integrated Care Initiative: a mixed methods case study

Abstract

Integrated care has been postulated to result in improvements to diabetes outcomes, including reduced hospitalisation. The Diabetes Integrated Care Initiative (DICI) aimed to integrate primary, secondary and community diabetes care in East Cambridgeshire and Fenland (ECF). The aims of this study were to describe changes in care and hospitalisation rates over the first 3 years of the initiative, 2009-2012. The evaluation involved a mixed-methods approach, including a before-after design with controls from adjacent geographical areas and from patients without diabetes, alongside a 30-month ethnographic study including interviews with patients and health professionals. Over the three years, admission rates among patients with diabetes in the intervention area continued to grow. In fact, the increases in admissions in ECF were 7.4% (95% CI 5.2-9.2) and 45.5% (95% CI 42.5-48.5) greater than in the neighbouring areas of Huntingdonshire and Greater Cambridge, respectively. The rates of increase in diabetic foot, non-elective or other hospital admissions were not reduced. In summary, the DICI was not associated with improved diabetes care or reduced diabetes hospitalisation over the 3 years studied, despite substantial investment. While the principle of integration remains an ideal, linking different providers in ECF, especially those that are positioned between primary and secondary care, created barriers rather than bridges to better diabetes outcomes.

Keywords: Diabetes; HbA1c hypophysitis; encephalopathy; hospital admission; integrated care.

Fig 1.

Components of the DICI. ^†Neuropathy, vascular impairment and/or deformity with heavy callus, advanced in-growing toenails and/or previous foot ulceration. *Most of the 17 general practices already had a lead -GP and/or practice nurse trained in diabetes management. ^‡ Under the Sustainable Health Partnership (2010–2011 www.sustainablehealthcambs.nhs.uk/Workstreams/Diabetes.htm accessed 10/4/2013). DAFNE = dose adjustment for normal eating; DCT = diabetes care technician; DEP = diabetes education programme; DICI = Diabetes Integrated Care Initiative; DSD = diabetes specialist dietician; DSN = diabetes specialist nurse; DSP = diabetes specialist podiatrist; LES = Local Enhanced Service.

Fig 2.

Hospitalisations (number/week) among those with and without diabetes over the five years by area. Each plot is fitted with a LOWESS fit line.

Fig 3.

Monthly percentage change in hospital admission rate (monthly hospital admission rate before and after each month) across areas for all patients and for non-elective patients. The plots on the left show all-caused hospitalisation; those on the right show non-elective hospitalisations. The black (upper) plots represent percentage change in hospital admissions for those with diabetes. The grey (lower) plots represent percentage change in hospital admissions for those without diabetes. Figures above 0% indicate that the mean monthly hospitalisation rate after the index month is greater than the mean hospitalisation rate before the index month. 95% confidence intervals are shown for each month.