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| Journal of the New Zealand Medical Association,
25-October-2002, Vol 115 No 1164
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Diabetes care by general practitioners in South Auckland:
changes from 1990 to 1999
Tim Kenealy, Helen Kenealy, Bruce Arroll, David Scott,
Robert Scragg and David Simmons
Concern about an ‘epidemic’ of diabetes led New
Zealand to develop a national strategy for diabetes in
1997.1,2 The implementation of the national
strategy, including free annual checks, could further increase the role of
general practice (particularly practice nurses) in diabetes care.
However, during the 1990s the health system in New Zealand
underwent major changes3 with unpredictable
effects on the ability of general practice to deliver the systematic and
continuous care needed by diabetic patients. Community services cards probably
improved access to GPs for poorer patients. Increased educational requirements
to maintain vocational registration, mandated by the Medical Council and
supported by the Royal New Zealand College of General Practitioners (RNZCGP) and
the Independent Practitioners Associations, may have increased GP skills and
confidence in diabetes care. On the other hand, short-lived patient charges for
community laboratory glucose tests and outpatient visits may have altered
diabetes screening practices and referral practices; decreased practice nurse
subsidies may have interfered with their role; and the exit of GPs from
obstetric practice has reduced continuity of care. Furthermore, in the cities,
‘accident and medical’ clinics took over most after-hours primary
care and later an increasing amount of ‘during hours’
care.
Meanwhile, there were major developments in the management
of diabetes. Publication in 1993 of the Diabetes Control and Complications
Trial,4 and later the United Kingdom
Prospective Diabetes Study series of
papers,5–7 greatly strengthened the
evidence base confirming the value of vigorous treatment of diabetes.
Postal questionnaires sent to all GPs and practice nurses in
South Auckland formed part of a major study of diabetes in the area in
1990.8,9 In repeating the questionnaires, the
aim of this study was to compare self-reported practices and preferences for
diabetes care by GPs in South Auckland between 1990 and 1999.
MethodsThe questionnaires were
developed locally and piloted with small groups of GPs. The 1990 questionnaire
consisted of 42 closed and open questions. For 1999, questions were eliminated
if no longer relevant or the information could be obtained from another source,
and new questions addressed topical concerns in implementing national diabetes
guidelines. The final 1999 questionnaire contained 67 closed and open questions,
including 38 of those asked in 1990.
In 1990, a list of all GPs known to work in South Auckland was compiled from Auckland Area Health Board records and by telephoning each practice. The questionnaires were mailed in June 1990. The responses were anonymous but tagged with a temporary identification code to track non-responders who were followed up by letter and then by telephone. The non-responding doctors came from the full range of practice sizes and localities. In 1999, the list of GPs was obtained from a commercial mail-list company, and supplemented by phoning those in the current Telecom telephone directory but not on the commercial list. The questionnaires were posted in November 1999. We attempted to contact non-responders by phone, a second letter and a second phone call. The questionnaires were not anonymous. To improve response rates, the questionnaires were kept as short and relevant as possible, multiple contacts were made by more than one method, and reply-paid envelopes were provided.10,11 In addition, the 1999 questionnaire used coloured paper and offered a prize draw.12 SPSS 9.0 software was used for analysis. Means are compared by t-test for continuous data. Proportions of categorical data are compared with chi-square and ordinal data with Mann-Whitney U. Percentages reported are the proportion of valid responses only. Statistical significance is cited at p ≤0.05, and all tests are two-tailed. Ethics approval was given by the Auckland Area Health Board Ethics Committee in 1990 and the Auckland University Human Subjects Ethics Committee in 1999. ResultsIn 1990, 226 ‘GPs’ were
identified; 41 were unavailable (due to maternity or prolonged leave,
retirement, having moved from the area, or not being a GP) leaving 185 GPs
eligible. In 1999, 273 ‘GPs’ in 149 practices were identified; 27
were unavailable for the same reasons, leaving 245 GPs eligible. The commercial
list identified 72.2% of eligible GPs. The response rate in 1990 was 88.1% (163
in 101 practices), and was not significantly different from the 1999 rate of
75.9% (186 in 107 practices) (p = 0.3). Almost half the 1999 respondents (49%)
had worked in South Auckland for 10 or more years, so would have received the
1990 questionnaire.
GPs were asked which one method they use most often to
screen for diabetes, shown in Table 1. Twenty six GPs in 1999 and one in 1990
nominated multiple methods so are not included in the analysis for Table
1.
Close to half the GPs in each year say they routinely refer
those with newly diagnosed Type 2 diabetes for additional assessment or
education (Table 2). Referrals in both years are almost exclusively to one or
more public services, but it was not possible to determine which components of
care would be provided. GPs in each year estimated that they provided sole
medical care for diabetes glucose control over the previous two years for about
half their Type 2 diabetic patients, ie with no specialist physician or
specialist nurse input.
Table 1. Method most used for screening (results are
percentages of valid responses)
*Chi-square for individual comparisons. Overall 1990 vs
1999, excluding questions not asked in 1990, p
<0.0001 Mann-Whitney U
Table 2. GP education, skills, confidence and preferred
care arrangements (results are percentages of valid responses unless stated
otherwise)
*includes a median of five patients with Type 1, and 30
with Type 2 diabetes
In 1999, 61.8% of GPs were recording their clinical notes on
computer; of these, 61.2% reported that computerised clinical notes helped their
diabetes care, 33% said it made no difference, and 5.8% said the computer
hinders care.
Thirty seven respondents (22.7%) in 1990 were women, as were
60 (32.4%) in 1999 (p = 0.04). The only difference found between women in 1990
and in 1999 was the number of patients with diabetes for whom they cared; median
10 in 1990, and 25 in 1999 (p = 0.002). However, the number of diabetic patients
also increased for men (who saw significantly more in each year, data not shown)
and for women and men combined (Table 2). The difference between women and men
each year is probably a reflection of the greater number of women working part
time. Data on ‘tenths’ were not requested in 1990, but in 1999,
53.3% of women worked fewer than eight ‘tenths’, compared with 8.1%
for the men (p = 0.001). This data is also consistent with the number of total
patients seen per doctor (data not shown).
There were, however, several differences between women and
men GPs in each year and when both years were combined. Women GPs were much more
likely than men to refer all newly diagnosed diabetic patients to a secondary
service (68.0% women, 42.8% men, p <0.001, years combined), and were much
more likely to prefer routine shared care (74.7% women, 58.7% men, p = 0.007,
years combined). Data were collected only in 1999 for women’s position in
the practice (principal/partner, employee, locum or other). The preference of
women in 1999 for shared care was not statistically related to either tenths or
position in the practice. Routine referral was not significantly related to
position in practice but was significantly related to tenths; those preferring
referral worked a mean of 7.3 (SE 0.41) tenths, while those not referring worked
mean 5.9 (SE 0.56) tenths (p = 0.049).
DiscussionThis study found that, compared
with 1990, GPs in 1999 provided regular care for more people with diabetes and
seemed more confident managing diabetes. Most GPs in both years felt confident
to monitor insulin and detect complications (with a significant increase from
1990 to 1999). Fewer GPs preferred routine hospital clinic follow up. Probably
more GPs in 1999 are confident to start insulin in patients with Type 2
diabetes, although the questions in 1990 and 1999 were not directly comparable.
The number of GPs using fasting capillary glucose to screen for diabetes
increased. There were differences in practice preferences between women and men,
but these did not change from 1990 to 1999. Women were more likely than men to
refer to secondary care patients with newly diagnosed diabetes, and to prefer
shared care for long-term patient management.
The high response rates of 89% and 76% are a strength of
this study, as validity can be limited by low response
rates.13 Our response rates are in line with
other New Zealand general practice mail
surveys,14–16 and compare favourably with
the average response rate of 61% in one British
journal.10 GPs are less likely to reply to
surveys if they are older or are not active in the area of
study,10,12 though it was not possible to
confirm these factors in this study. Postal surveys may be less susceptible to
social desirability bias than interviews,10 but
do not overcome the known differences between self-reported and observed
activity. Nevertheless, GP self perceptions of attitudes and behaviour are an
important component of their willingness to learn and change their
practice.
The number of diabetic patients per doctor has increased
substantially from median estimates of 20 in 1990, to 33 per doctor in 1999. New
diagnostic criteria for diabetes were published in New Zealand early in
1999.17 While these criteria increase the
number of people classified with diabetes,18
the change was too late to explain the increased numbers of diabetic patients
reported by GPs in 1999 compared to 1990. The number of people with diabetes is
known to be climbing at an alarming
rate.19,20
It is interesting to note that the GPs estimate they provide
sole medical care for glucose control for about half their Type 2 diabetes
patients. The only figure previously available is that they provide sole care
for just over 60%, across all ethnic groups.21
This later figure was obtained by analysis of sources from which patients were
identified for a study in South Auckland in 1990–1, and is probably more
objective than the GP estimates.
The unchanged and relatively low numbers of those who
reported having ‘postgraduate education’ in diabetes appears
anomalous in light of increasing diabetes-related activities. This could reflect
inconsistent interpretations of the term – many GPs probably interpret
postgraduate education as meaning formal university courses. We note that over
three quarters of GPs in 1999 feel they need to learn more about diabetes
(despite a statistically significant decrease from 1990 to 1999). During the
1990s, many GPs increased their participation in continuing medical education,
facilitated by the Maintenance of Professional Standards (MOPS) programme of the
RNZCGP, to meet the requirements for vocational registration with the Medical
Council. However, topic choice was uncoordinated and learning on a specific
topic was usually voluntary. We advocate a ‘compulsory’ component in
the MOPS programme, covering developments in important areas such as diabetes,
especially as GPs are not always good at ‘knowing what they do not
know’.22
The differences in preferred practice style between men and
women are related to known differences in consultation
style.23 Women develop experience and expertise
in different areas of medicine24 and in one
study women felt less prepared in some areas than men (though this did not
include diabetes).25 Gender rates of patient
referral to other services were not reported in the only study we located on GP
referral patterns in New Zealand.15 Male/female
practitioner differences may have implications for future planning of primary
and secondary care integration as the proportion of women GPs continues to
increase. We have reported elsewhere on the implications of our surveys for
continuity of care, especially those due to changes of practice composition and
male/female GP differences.26
Practical recommendations for diabetes screening in New
Zealand have recently been published.27 When
GPs request a laboratory test for either fasting or random glucose, they rely
for interpretation on automated comments returning from the laboratory along
with the glucose result. These comments were not standardised across the country
at the time of these questionnaires. For example, in the year 2000 the upper end
of the ‘normal’ random glucose reference range varied around the
country from 7.5 to 9.5 mmol/l.2 Furthermore,
many GPs were screening for diabetes using meters that are principally designed
for patients to self-monitor. However, these meters are arguably too inaccurate
for routine screening purposes, and the new recommendations discourage their
use. It is also interesting to note that fructosamine use had largely
disappeared by 1999 without being replaced by
HbA1c to screen for diabetes.
The apparent decrease in screening for gestational diabetes
is confounded by a change in obstetric supervision, in which few of the GPs
managing obstetric patients now have primary responsibility for pregnancy care
in late second trimester when most screening is performed. Nevertheless, a South
Auckland audit in 1994–5, which did not distinguish between care
providers, confirmed screening rates for gestational diabetes were
inappropriately low.28
The reason for asking GPs whether they thought that using
computer records helped or hindered diabetes care was because of anecodotal
concerns about increased difficulty of providing systematic care for diabetes
patients when recording notes on computers without specific diabetes modules,
compared with using available paper
systems.29,30 It is reassuring that few GPs
thought the computers hindered care compared with whatever methods they
previously used.
The GPs report a marked increase in availability of recall
systems, which parallels their increased computerisation. In late 1999, 95% of
GPs in South Auckland had a computer in the practice (personal communication, T
Kenealy, 2002). For most of these practices, the diabetes registers were formed
initially by the audit nurses from the Diabetes Care Support
Service.9 Given that registers are an essential
first step to audit, and audit is a key part of the continuous
quality-improvement cycle, the practices are in a much stronger position to
improve quality of care than they were in 1990.
Yet more changes are currently facing primary care,
including Primary Health Organisations and rearranged funding. It will be
important to periodically monitor the impact of changes on the diabetes care
provided by GPs and practice nurses.
Author information:
Tim Kenealy, HRC Training Fellow; Helen Kenealy, Medical Student; Bruce
Arroll, Associate Professor of General Practice, Division of General Practice
and Primary Health Care, University of Auckland; David Scott, Physician and
Diabetologist, Auckland; Robert Scragg, Senior Lecturer, Department of Community
Health, University of Auckland; David Simmons, Professor of Rural Health,
Department of Rural Health, University of Melbourne, Shepparton, Victoria,
Australia
Acknowledgements:
The Health Research Council of New Zealand funded the 1990 study and in 1999
supported Tim Kenealy with a Training Fellowship and Helen Kenealy with a Summer
Studentship. Thanks to Alistair Stewart for statistical advice.
Correspondence:
Dr Tim Kenealy, Department of General Practice and Primary Health Care,
University of Auckland, Private Bag 92019, Auckland. Fax: (09) 373 7006; email:
t.kenealy@auckland.ac.nz
References:
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