Quality of care provided by general practitioners using or not using Division-based diabetes registers

In Australia, general practitioners play an important role in the management of diabetes.1 This involves careful monitoring of behavioural risk factors, blood pressure, glycaemic control and lipids; early detection of complications; and management according to evidence-based guidelines.2,3

There is increasing evidence that care for patients with diabetes in general practice needs to be "structured and systematic".4,5 Having a computerised register,6,7 agreed clinical management guidelines and a system for auditing standards of care generally results in better quality of care.8-10

In Australia, many Divisions of General Practice have established programs with some elements of systematic care in partnership with local diabetes services.11 Program components vary, but a frequent strategy has been to establish a district register, often in collaboration with local diabetes centres. GPs submit data from consenting patients to be entered on a computer register maintained by the Division. The Division then mails reminders to GPs, at various time intervals, to assist in patient recall, and issues audit reports on the GPs' adherence to diabetes management guidelines (Box 1). The participation of GPs and patients in divisional diabetes programs has been shown to increase over time and to be higher in the smaller Divisions.12

The Australian Health Insurance Commission (HIC) maintains a database of medical practitioners and the services they provide. Through its Medicare Benefits Schedule, the HIC remunerates GPs, specialists and pathology service providers for consultations and services.

Using data from HIC records, we sought to determine whether GPs using diabetes shared-care registers had different patterns of practice from GPs not using registers.

Our study was based in the South Western Sydney Area Health Service (SWSAHS), which includes five Divisions of General Practice (Bankstown, Liverpool, Fairfield, Macarthur and Southern Highlands). At the time of our study, the SWSAHS served a population of 793 000 people, of whom 19 826 were expected to have diabetes in 1997.13 All of the Divisions within the SWSAHS had established voluntary shared-care programs using diabetes registers and following NSW Health guidelines.14 The guidelines recommend six-monthly measurement of haemoglobin A1c (HbA1c), blood pressure, lipids and body weight, and checking of feet; yearly testing for microalbuminuria; and two-yearly eye examination and assessment of educational needs.

Our study was carried out over the three-year period 1996–1998. We identified 155 GPs practising within the SWSAHS who were using the diabetes registers and 459 who were not. From the HIC database we obtained information on patients with diabetes attending GPs in either of these two groups in each six-month time period over the three years. A patient with diabetes was identified from HIC data as a patient having at least one test for HbA1c or fructosamine ordered over the time period.

For both "register" and "non-register" GPs in each six-month period, we determined (a) the number of discrete patients with diabetes; (b) the number of attendences by patients with diabetes; and (c) the number of patients having a lipid test, a microalbuminuria test, or an HbA1c test. For each test type, we calculated rates of testing per patient and statistically compared the rates for patients attending register and non-register GPs. Statistical significance was set at α = 0.05.

The average number of patients with diabetes per GP and the average number of attendances by patients with diabetes per GP were higher for register GPs than non-register GPs throughout the study period (Box 2).

For the first two years of the study period, patients of register GPs were more likely to have more than one HbA1c test ordered within a six-month period than patients of non-register GPs (Box 3). They were also more likely to have at least one microalbuminuria test performed in each of the six-month time periods. The rate of lipid testing was low in both groups, and differences between the groups were non-significant in all but one of the six-month periods (Box 3).

The proportion of patients having HbA1c tests rose considerably for both GP groups over the study period, although the level of excessive testing (ie, testing more frequently than once every six months) did not change. This coincided, during 1997 and 1998, with a great deal of education on diabetes care provided to GPs in south-western Sydney based on the introduction of guidelines by the NSW Department of Health.14 By contrast, the frequency of testing for microalbuminuria increased more markedly among register GPs, suggesting that education alone had little effect on this aspect of quality care.

There is a need for further research to evaluate diabetes registers both at Division and practice levels, especially as levels of participation are likely to increase now that the Commonwealth Government has introduced incentives. Since 2001, the government has provided practice incentive program payments to practices using diabetes registers (either at practice or Division levels) and incentive payments for each patient whose care meets certain standards over a 12-month period.15 Our study is consistent with other research that suggests that registers with patient recall and audit feedback to clinicians are associated with improved quality of care.7-9 Reminder systems have been shown to be effective in improving GP compliance with guidelines in diabetes.4,16 Clinical audit and educational feedback to GPs have been shown to produce moderate changes in clinician behaviour.17

Our study and overseas research suggest that rewarding practices who use shared-care register systems to assist in the structured care of their patients with diabetes will reward those who provide better quality of care. The next challenge will be to evaluate whether these incentives give rise to better quality of care across all general practice and associated benefits in terms of health outcomes for patients.

1: Operation of a typical Division of General Practice diabetes register