Introduction
Western Sydney is a diabetes ‘hot spot’ with diabetes and obesity rates higher than the rest of Australia. The Western Sydney Diabetes (WSD) initiative has a broad range of programs including primary prevention and integrated community and hospital diabetes management. WSD conducts JSCC which comprises of an integrated discussion with a diabetes specialist, RMO, diabetes educator, patient and GP. JSCC previously reported benefits for a cohort of 41 patients after 6 months, including reduction in HbA1c and BP.
We aim to evaluate the long term effect of JSCC on patient outcomes, GP and patient satisfaction and the overall impact on practice diabetes management.
Methods
1100 patients, 165 GPs in 53 practices have been involved in JSCC. Data from patients followed up after 6 months was collected again after 3 years using practice management software. The PEN-Clinical-Audit-Tool (PENCAT) was used to track overall diabetes management in 19 practices where JSCC had occurred. 50 Patient satisfaction using a simple questionnaire was used.
Results
31 of the original 41 patients were followed up 3 years after initial JSCC, this data collection is ongoing. 3 were lost to follow-up or deceased. There were sustained significant reductions in HbA1c, weight, and blood pressure after 3 years
90% of patients reported JSCC was useful and GP satisfaction remains high
Aggregate data collected using the PENCAT tool revealed GP practices involved in JSCC experienced significant reductions in mean HbA1c, BMI, blood pressure, improvements in the number of completed diabetes cycle of care billings, and a 10% improvement in the number of patients identified as having diabetes
Discussion
Beneficial effect of JCSS on patient outcomes demonstrated after 6 months is sustained 3 years after the initial intervention. JSCC is an effective method of empowering GPs to provide enhanced diabetes management with emerging evidence that it benefits diabetes management in the whole practice.