Bites

November 2009

Research

Improving GP diabetes management

A PDSA audit cycle in Western Australia

Volume 38, No.11, November 2009 Pages 939-944

Cynthia Porter

Charlie Greenfield

Ann Larson

Marisa Gilles

Background

Tight glucose, blood pressure and lipid control in patients with diabetes can reduce morbidity and mortality from macro- and micro-vascular complications. However, treatment targets are not being met in a large proportion of patients. Clinical audit involves cycles of evaluation of current activity against standards. It allows problems to be identified and action to be taken to address them.

Methods

Annual retrospective audits over 3 years of random samples of up to 20 patient medical records from 13 general practitioners in the midwest region of Western Australia (n=807). Statistical tests compared the second and third audits with the first in regard to completeness of screening, health indicators, and the proportion of patients within The Royal Australian College of General Practitioners and Diabetes Australia guidelines targets.

Results

While there was a significant improvement in lipid monitoring over the study period (p<0.001), monitoring of HbA1c and blood pressure (BP) remained unchanged. Between the first and third audits, a reduction in mean HbA1c (p<0.001), mean total cholesterol (p=0.017), mean LDL cholesterol (p=0.014) and mean systolic BP (p=0.002) was seen. There was an improvement in the proportion of patients achieving cholesterol goals (measured by LDL and reaching a target of HbA1c <7%) between the first and third audits; however the proportion with BP within target declined. In the third audit, 11% of patients on diet alone, 36% on an oral hypoglycaemic agent, 90% on three oral hypoglycaemic agents and 84% of those on insulin were outside the target HbA1c. In the same audit, of those outside target BP, 53% were on no treatment and 65% were only on one type of medication. Eighty-seven percent of patients outside target cholesterol levels had not been prescribed a statin.

Discussion

Many of the audited GPs in our study undertreated BP, HbA1c and cholesterol. Improvement in some areas was seen over the study period, which may have been due to the quality assurance activities undertaken. These results reveal a therapeutic opportunity for reducing cardiovascular events in patients with diabetes. More aggressive management of BP and lipids by GPs may see rewards in terms of reducing cardiovascular events in patients with diabetes.

In the management of type 1 and 2 diabetes, it is clear that tight glucose, blood pressure (BP) and lipid control can reduce morbidity and mortality from macro- and microvascular complications.1–6 Best practice recommended biological targets are constantly under re-evaluation and change. Current consensus guidelines suggest the following:7

  • glycated haemoglobin (HbA1c <7%)
  • BP (<130/80 mmHg), and
  • total cholesterol (<4.0 mmol/L).

Despite the known benefits of managing these parameters appropriately, targets are not being met in a large proportion of patients with type 2 diabetes mellitus (T2DM).8,9 Better screening alone does not improve health outcomes;10 however there is evidence of improved lipid levels with active clinical management.6

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Correspondence afp@racgp.org.au

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