Diabetes Care in General Practice in Galway: initial findings

1. Diabetes Care in General Practice in Galway: initial findings Presented by Dr M�ire O� Donnell On behalf of: Drs David Evans, Emer O Connell, Marita Glacken, Department of Public Health,HSE West Dr Sean Dinneen, Department of Medicine, NUIG Lorna Hurley, Diabetes Day Centre, UCHG Prof. Andrew Murphy, Department of General Practice, NUIG Good afternoon and thank you for attending our session today. My name is M�ire O Donnell and I took up a research position in August this year at the Department of Medicine. I work half time on the NDRP (National Diabetes Research project) which Sean has already mentioned which is exploring the feasability of setting up a national diabetes register in Ireland and the other half of my job which is funded by HSE West is to look at setting up a regional diabetes register in Galway, Mayo and Roscommon. Today I am going to present some findings on a GP survey that was conducted in 2007 in Galway. Although I was not involved in the actual conducting or initial analyses of this survey I have been familiarising myself with the data to get an idea of diabetes care currently delivered in the Galway area. I am presenting some of the preliminary findings from this survey on behalf of those who were involved at various stages of the process. These were Drs David Evans, Emer O Connell and Marita Glacken at the Department of Public Health, HSE West, Dr Sean Dinneen, Department of Medicine, Lorna Hurley, Diabetes Day Centre, and Professor Andrew Murphy at the Department of General Practice. Dr David Evans was primarily involved at the analyses stage of the data. His was not an easy task because of the questionnaire design, something I will touch upon later. Good afternoon and thank you for attending our session today. My name is M�ire O Donnell and I took up a research position in August this year at the Department of Medicine. I work half time on the NDRP (National Diabetes Research project) which Sean has already mentioned which is exploring the feasability of setting up a national diabetes register in Ireland and the other half of my job which is funded by HSE West is to look at setting up a regional diabetes register in Galway, Mayo and Roscommon. Today I am going to present some findings on a GP survey that was conducted in 2007 in Galway. Although I was not involved in the actual conducting or initial analyses of this survey I have been familiarising myself with the data to get an idea of diabetes care currently delivered in the Galway area. I am presenting some of the preliminary findings from this survey on behalf of those who were involved at various stages of the process. These were Drs David Evans, Emer O Connell and Marita Glacken at the Department of Public Health, HSE West, Dr Sean Dinneen, Department of Medicine, Lorna Hurley, Diabetes Day Centre, and Professor Andrew Murphy at the Department of General Practice. Dr David Evans was primarily involved at the analyses stage of the data. His was not an easy task because of the questionnaire design, something I will touch upon later.

2. Firstly some background. A Diabetes Services Advisory Group was formed in Galway in early 2005 and a survey of GPs was undertaken in 2007 as part of a needs assessment exercise and to inform plans for the development of a more integrated approach to diabetes care in the area.Firstly some background. A Diabetes Services Advisory Group was formed in Galway in early 2005 and a survey of GPs was undertaken in 2007 as part of a needs assessment exercise and to inform plans for the development of a more integrated approach to diabetes care in the area.

3. Study Aim To describe diabetes service provision in primary care in Galway city and county The overall aim of the study was to describe diabetes service provision in primary care in Galway city and county. The overall aim of the study was to describe diabetes service provision in primary care in Galway city and county.

4. Methods (1) Postal questionnaire Adapted from a previous UK survey (Williams et al, 2002 ) Ethical approval - ICGP All 103 general practices in Galway city and county 2 reminder letters and follow up phone call This was a postal questionnaire adapted from a previous survey carried out in the UK. Ethical approval for the study was obtained from the Irish College of General Practitioners. The questionnaire was sent to a named GP for all one hundred and three practices in Galway. Two reminder letters and a follow up phone call were used to encourage non-responders to respond. This was a postal questionnaire adapted from a previous survey carried out in the UK. Ethical approval for the study was obtained from the Irish College of General Practitioners. The questionnaire was sent to a named GP for all one hundred and three practices in Galway. Two reminder letters and a follow up phone call were used to encourage non-responders to respond.

5. Methods (2) Closed and open-ended questions Existing diabetes resources Prevalence of diabetes Current delivery of diabetes care Referral to other services The questionnaire consisted of closed and open-ended questions and included questions relating to existing diabetes resources, prevalence of diabetes, current delivery of diabetes care and referral to other services. The questionnaire consisted of closed and open-ended questions and included questions relating to existing diabetes resources, prevalence of diabetes, current delivery of diabetes care and referral to other services.

6. Results (1) Response rate (76%) Estimated practice population Range: 100 - 20,000 patients Over 50% of practices: 1000 � 4000 patients Practice manager (35%) Electronic patient consultations (67%) Medicom Dynamic GP (57%) GP Mac (22%) The response rates was 76% Estimated practice population sizes ranged from 100 to 20,000 patients with just over half of the practices reporting estimates of between 1000 and 4000 patients. Over a third (35%) of practices had a practice manager. Electronic patient consultations were maintained by 67% of practices. Of those maintaining electronic patient consultations, 57% reported using Medicom Dynamic GP software and 22% reported using GP Mac.The response rates was 76% Estimated practice population sizes ranged from 100 to 20,000 patients with just over half of the practices reporting estimates of between 1000 and 4000 patients. Over a third (35%) of practices had a practice manager. Electronic patient consultations were maintained by 67% of practices. Of those maintaining electronic patient consultations, 57% reported using Medicom Dynamic GP software and 22% reported using GP Mac.

7. Results (2) Diabetes resources Special interest in diabetes GP(s) (35%) Nurse(s) (33%) Both GP(s) and nurse(s) (19%) Computerised systems (n = 49) Diabetes module (47%) Using diabetes module (50%) Thirty five percent reported that their practice had at least one GP with a special interest in diabetes and a third stated that there had at least one nurse with a special interest in diabetes with 19% of pratices having both. Of those practices with computerised systems, almost half reported that the software had a diabetes module and half of those stated that they used it.Thirty five percent reported that their practice had at least one GP with a special interest in diabetes and a third stated that there had at least one nurse with a special interest in diabetes with 19% of pratices having both. Of those practices with computerised systems, almost half reported that the software had a diabetes module and half of those stated that they used it.

8. Results (3) Diabetes resources Diabetes register (33%) Formal call and recall system (12%) Clinical guidelines (56%) ICGP Clincial Guidelines (37%) HSE West Diabetes Resource Manual (13%) A third of practices reported maintaining a diabetes register with practices that had a GP or nurse with a special interest in diabetes significanlty more likely to do so Twelve per cent of practices reported haivng a formal call and recall system for reviews of Type 2 diabetes patients. Clinical guidelines were used by 56% of respondents. A variety of guidelines were used with the most popular being the Irish College of General Practitioner guidelines which was used by 37% and the Health Service Executive West Diabetes Resource manual which was used by 13%. It is worth noting that the HSE resource manual would have only been circulated to GPs around the same time that the survey was conducted in 2007.A third of practices reported maintaining a diabetes register with practices that had a GP or nurse with a special interest in diabetes significanlty more likely to do so Twelve per cent of practices reported haivng a formal call and recall system for reviews of Type 2 diabetes patients. Clinical guidelines were used by 56% of respondents. A variety of guidelines were used with the most popular being the Irish College of General Practitioner guidelines which was used by 37% and the Health Service Executive West Diabetes Resource manual which was used by 13%. It is worth noting that the HSE resource manual would have only been circulated to GPs around the same time that the survey was conducted in 2007.

9. Results (4) Estimated Prevalence (58 practices) Mean prevalence: 2.8% Range: 0.1 - 9.5% Estimated prevalence of diabetes was calculated for practices that provided estimated numbers for total practice population and number of patients with clinically diagnosed diabetes. The mean prevalence for those 58 practices was 2.8% with a range of 0.1 to 9.5%.Estimated prevalence of diabetes was calculated for practices that provided estimated numbers for total practice population and number of patients with clinically diagnosed diabetes. The mean prevalence for those 58 practices was 2.8% with a range of 0.1 to 9.5%.

10. Results (5) Delivery of diabetes care Specific diabetes clinics (10%, n = 8) Led by pharmaceutical nurse (n = 6) Appointments Doctor/nurse initiated (41%) Patient-initiated or opportunistically (22%) Specific clinics for diabetes patients were reported by 10% of practices. Most clinics were led by a pharmaecutiacal nurse with the remainder being led by the practice nurse and/or GP. Forty one percent of practices reported seeing patients at doctor or nurse initiated appointments and 22% reported seeing patients only at patient-initiated appointments or opportunistically. Specific clinics for diabetes patients were reported by 10% of practices. Most clinics were led by a pharmaecutiacal nurse with the remainder being led by the practice nurse and/or GP. Forty one percent of practices reported seeing patients at doctor or nurse initiated appointments and 22% reported seeing patients only at patient-initiated appointments or opportunistically.

11. Results (6) Check up of Type 2 patients Over 97% reviewed medication, smoking status, measured blood pressure and did lipids Urinalysis Dipstick, microalbuminuria, albumin: creatinine ratio tests (41%) Dipstick test only (27%) Nearly all practices reported reviewing medication and smoking status, measuring blood pressure and doing lipids as part of a check up of Type 2 diabetes patients. Forty one per cent of practices (n = 30) reported conducting the 3 urinalysis procedures (dipstick, microalbuminuria and Albumin: creatinine ratio). Twenty seven per cent (n = 20) reported conducting the dipstick test only. Nearly all practices reported reviewing medication and smoking status, measuring blood pressure and doing lipids as part of a check up of Type 2 diabetes patients. Forty one per cent of practices (n = 30) reported conducting the 3 urinalysis procedures (dipstick, microalbuminuria and Albumin: creatinine ratio). Twenty seven per cent (n = 20) reported conducting the dipstick test only.

12. Results (7) Referrals Dietetic services � 91% Chiropody services � 82% Retinal screeening � 68% Ninety one percent of respondents referred patients to dietetic services, 82% to chiropody services and sixty eight per cent for retinal screening.Ninety one percent of respondents referred patients to dietetic services, 82% to chiropody services and sixty eight per cent for retinal screening.

13. Results (8) This table shows the percentage of GMS and non GMS patients referred to public or private dietetic, chiropody or retinal screening services. As you can see referral patterns differed depending on the service. GPs often referred non GMS patients to a HSE dietician (with 59% saying they referred to HSE services) whereas they were more likely to refer non GMS patients privately for chiropody and retinal screening services with 94% saying they referred non GMS patients to a private chiropodist and 61% saying they referred patients privately for retinal screening.This table shows the percentage of GMS and non GMS patients referred to public or private dietetic, chiropody or retinal screening services. As you can see referral patterns differed depending on the service. GPs often referred non GMS patients to a HSE dietician (with 59% saying they referred to HSE services) whereas they were more likely to refer non GMS patients privately for chiropody and retinal screening services with 94% saying they referred non GMS patients to a private chiropodist and 61% saying they referred patients privately for retinal screening.

14. Results (9) Referrals to local hospital specialist team Always referred: Patients with suspected type 2 diabetes (32%) Type 2 diabetes patients requiring transition to insulin (89%) Almost a third of practices reported that they always referred patients with suspected type 2 diabetes to the local hospital specialist team. 89% of respondents reported that they always referred type 2 diabetes patients requiring transition to insulin to the local hospital specialist team.Almost a third of practices reported that they always referred patients with suspected type 2 diabetes to the local hospital specialist team. 89% of respondents reported that they always referred type 2 diabetes patients requiring transition to insulin to the local hospital specialist team.

15. Results (10) Opportunities for developing diabetes care GP/Practice nurse training care (67%) Easier access to specialist advice (63%) Increased access to community services eg chiropody (62%) Over two thirds of practices perceived training in diabetes care for GPs and practice nurses as a key opportunity for developing diabetes care in general practice. Easier access to specialist advice and increased access to communtiy services such as chiropody were also perceived to be important. Over two thirds of practices perceived training in diabetes care for GPs and practice nurses as a key opportunity for developing diabetes care in general practice. Easier access to specialist advice and increased access to communtiy services such as chiropody were also perceived to be important.

16. Results (11) Renumeration When asked how GPs should be remunerated for diabetes care, almost half stated that there should be a mixture of capitation and fee per item and almost a quarter (24%) said that remuneration should be on a fee per patient episode basis. Only 3% selected a capitation grant as a means of renumerating GPs for diabetes care.When asked how GPs should be remunerated for diabetes care, almost half stated that there should be a mixture of capitation and fee per item and almost a quarter (24%) said that remuneration should be on a fee per patient episode basis. Only 3% selected a capitation grant as a means of renumerating GPs for diabetes care.

17. Conclusions GP practices involved in diabetes care to varying degrees Service improvement need to develop more registers Clearer protocols for referral Training of GP/nurses To conclude, the survey shows that many practices are currently involved in diabetes care although to varying degrees. The survey highlights areas for service improvement including a need to develop more registers of patients with diabetes and clearer protocols for referral to secondary care and other support services. GPs themselves identified more training for GPs and nurses in diabetes care as an important factor in improving diabetes care in general practice. To conclude, the survey shows that many practices are currently involved in diabetes care although to varying degrees. The survey highlights areas for service improvement including a need to develop more registers of patients with diabetes and clearer protocols for referral to secondary care and other support services. GPs themselves identified more training for GPs and nurses in diabetes care as an important factor in improving diabetes care in general practice.

18. Methodological issues (1) Too many open-ended questions Wide variety of responses Coding at analyses stage As I mentioned at the beginning of this talk there were a number of issues relating to questionnaire design that were not ideal. One of the main issues with this particular questionnaire was the over usage of open ended questions. This allowe respondents to provide a whole range of responses that had to be then coded at the analyses stage. As I mentioned at the beginning of this talk there were a number of issues relating to questionnaire design that were not ideal. One of the main issues with this particular questionnaire was the over usage of open ended questions. This allowe respondents to provide a whole range of responses that had to be then coded at the analyses stage.

19. Methodological issues (2) Q13a �Do you refer to chiropody services?� Yes/No Q13b �If yes, where do you refer the GMS patient AND how long do these patients have to wait for an appointment?� ............................................................... Q13c �If yes, where do you refer the non-GMS patient AND how long do these patients have to wait for an appointment?� ............................................................... On this slide is an example of one question format relating to referrals that caused a number of problems. The question relates to referrals to chiropody services. A similar format was used for referrals to dietetic and retinal screening services. The first part of the question had a Yes/No response. If respondents reponded Yes they were meant to go on to the second and third parts of the question. The second and third parts of the question are classic examples of double barreled questions (where you ask 2 questions in one) which should be avoided when designing a questionnaire. In this case respondents were asked where they referred patients and how long patients had to wait. One of the consequences of using these double barrelled questions was that it affected the response rates with some respondents filling out only the first part of the question about where they referred but not answering the second part of the question about waiting times. As a result the response rates for waiting times were low with a 30% response rate for GMS patients and a 27% response rate for non GMS patients. Coding was also a problem because of the use of open ended questions with some respondents providing very vague responses as to where they referred such as �to the clinic� whereas others provided actual names of practitioners which then had to been coded at the analyses stage. As you saw in a previous slide we ended up coding this question as whether GPs referred to HSE services, to private practitioners or both which in hindsight could have been provided as possible responses to this question if that was the way it was thought this data would be presented. Another coding issue with this particular question was that in some cases respondents answered No to first part of question (do you refer) but then proceeded to go on and give a response to where they referred patients and how long it took. In this case a decision has to be made whether to recode the first part of the question to a yes or exclude responses to second part of the question as missing. This would all depend on their responses and how confident we were that their responses definitely indicated they were chiropody referrals and they had not misinterpreted this second part of the question to mean referrals in general for example. On this slide is an example of one question format relating to referrals that caused a number of problems. The question relates to referrals to chiropody services. A similar format was used for referrals to dietetic and retinal screening services. The first part of the question had a Yes/No response. If respondents reponded Yes they were meant to go on to the second and third parts of the question. The second and third parts of the question are classic examples of double barreled questions (where you ask 2 questions in one) which should be avoided when designing a questionnaire. In this case respondents were asked where they referred patients and how long patients had to wait. One of the consequences of using these double barrelled questions was that it affected the response rates with some respondents filling out only the first part of the question about where they referred but not answering the second part of the question about waiting times. As a result the response rates for waiting times were low with a 30% response rate for GMS patients and a 27% response rate for non GMS patients. Coding was also a problem because of the use of open ended questions with some respondents providing very vague responses as to where they referred such as �to the clinic� whereas others provided actual names of practitioners which then had to been coded at the analyses stage. As you saw in a previous slide we ended up coding this question as whether GPs referred to HSE services, to private practitioners or both which in hindsight could have been provided as possible responses to this question if that was the way it was thought this data would be presented. Another coding issue with this particular question was that in some cases respondents answered No to first part of question (do you refer) but then proceeded to go on and give a response to where they referred patients and how long it took. In this case a decision has to be made whether to recode the first part of the question to a yes or exclude responses to second part of the question as missing. This would all depend on their responses and how confident we were that their responses definitely indicated they were chiropody referrals and they had not misinterpreted this second part of the question to mean referrals in general for example.

20. Lessons learnt Avoid opened ended questions where possible Avoid double-barrelled questions When piloting questionnaire ask respondents to describe their understanding of questions Document coding decisions so the process is transparent From the problems encoutered at the analyses stage a number of lessons have been learnt. These include: avoiding opened ended questions where possible and avoiding double barrelled questions at all costs. In addition it is useful during the pilot stage to ask respondents to describe their understanding of questions to avoid ambiguities and at the coding stage to document coding decisions so that the process is transparent to others.From the problems encoutered at the analyses stage a number of lessons have been learnt. These include: avoiding opened ended questions where possible and avoiding double barrelled questions at all costs. In addition it is useful during the pilot stage to ask respondents to describe their understanding of questions to avoid ambiguities and at the coding stage to document coding decisions so that the process is transparent to others.

21. Any questions?