Assessing the Impact of Primary Care-Led Optimisation Clinics in the Management of Type 2 Diabetes: A Service Redesign Pilot Study

Abstract

Background Many individuals diagnosed with type 2 diabetes (T2D) in the London Borough of Waltham Forest, treated solely with oral hypoglycaemic medications (OHAs), exhibit increased levels of glycated haemoglobin (HbA1c). While specialised community and secondary care clinics are at full capacity, a gap exists for dedicated diabetes optimisation services at the primary care level. This study aimed to launch a remote Primary Care Network (PCN)-based clinic during the coronavirus disease 2019 (COVID-19) pandemic to enhance the management of OHAs, introduce motivational interviewing, and incorporate patient empowerment strategies in tandem with a secondary care endocrinologist. The primary objective was to evaluate the impact on HbA1c levels and other metabolic parameters. Concurrently, the "behaviour change model" served to measure patient engagement. Methodology We recruited 43 patients in this study, each undergoing a 30-minute consultation focused on diabetes management. A dedicated administrator ensured patient engagement and a three-month follow-up with repeat metabolic profile testing. Sustained, high-quality care was upheld through bimonthly remote consultations, receiving expertise from an endocrinology consultant. Results Of the pilot's 38 patients managed solely with OHAs, 31 achieved an HbA1c reduction of more than 11 mmol/mol. The overall median reduction for the entire cohort was significant (initially 88 mmol/mol versus 70 mmol/mol, p < 0.0001). Triglyceride levels also saw a notable median decline (1.56 mmol/L down to 1.20 mmol/L, p = 0.0247). Of the 38 completing the pilot, 14 had behavioural stages recorded both initially and at follow-up. Employing motivational interviewing led to significant diabetes-related behavioural changes in 11 of the 14 patients. Conclusions A PCN-based optimisation clinic, augmented with active recall strategies, was a cost-effective method to boost awareness, self-management, and glycaemic control among individuals with T2D. These PCN-led clinics orchestrated by primary care clinicians offer a streamlined solution for achieving treatment benchmarks even amid the challenges of the COVID-19 pandemic.

Keywords: behaviour; clinics; diabetes; general practice; gp; optimisation; pcn; primary care; primary care network; type 2.

Figure 1. Comparison of age and initial pre-pilot HbA1c across three practices.

HbA1c: glycated haemoglobin

Figure 2. Comparison of the engagement with the pilot study across three practices.

HbA1c: glycated haemoglobin

Figure 3. Duration of diabetes diagnoses among study participants.

Figure 4. Oral hypoglycaemic burden.

Figure 5. Comorbidities of the cohort (excluding hypertension, obesity, and dyslipidaemia).

ASCVD: atherosclerotic cardiovascular disease; SMI: serious mental illness; AF: atrial fibrillation; CKD: chronic kidney disease; LD: learning difficulty; BMI: body mass index

Figure 6. Pre- and post-optimisation pilot mean HbA1c results.

HbA1c: glycated haemoglobin

Figure 7. Ladder plot of pre- and post-optimisation pilot HbA1c results.

HbA1c: glycated haemoglobin

Figure 8. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention HbA1c results.

HbA1c: glycated haemoglobin

Figure 9. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention systolic BP results.

BP: blood pressure

Figure 10. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention diastolic BP results.

BP: blood pressure

Figure 11. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention triglyceride results.

Figure 12. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention cholesterol ratio results.

Figure 13. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention total cholesterol results.

Figure 14. Box plot representation and Wilcoxon signed-rank test of pre- and post-intervention BMI results.

BMI: body mass index

Figure 15. Intervention recorded after the initial optimisation clinic consultation.

SGLT2: sodium-glucose co-transporter-2 inhibitor; HTN: hypertension; MODY: maturity-onset diabetes of the young

Figure 16. Theoretical model of behaviour change showing strategy used to encourage progress.

Figure 17. Study participants’ progress through the cycle of behaviour change.