Are general practice characteristics predictors of good glycaemic control in patients with diabetes? A cross-sectional study

In the search for optimal glycaemic control, the cross-sectional study of Esterman and colleagues1 is encouraging. The statistically significant link between annual cycles of care (ACCs) and better glycaemic control points to areas where general practitioners can allocate their resources for effective care.

ACCs have long been important for the prevention of diabetic complications, but as of 2009–10, only 18% of Australians with diabetes had completed an ACC.1,2 While the study acknowledges potentially imperfect information, there is ample cause to advocate for an increased uptake of ACCs.

Chronic disease-focused nurse and diabetes education events for patients are significant factors in completing ACCs. These also direct GPs to concrete ways of achieving glycaemic control among the many options available.

Such measures satisfy five of the six domains of quality identified by the United States Institute of Medicine: safety, effectiveness, timeliness, patient-centeredness and efficiency.3 However, the sixth domain — equity of care — is more problematical as it is borne of geographic and socio-economic disparities.

GPs treating patients with diabetes know the frequent frustration of seeing patients with suboptimal care at irregular intervals. The ability and motivation of patients to learn about their disease, and to assume an active role in its treatment, is long known to be closely related to their particular health beliefs, personality structure and psychosocial situation.4 While patients vary in their capacity to stay vigilant in their care, it is incumbent on the primary care system to integrate evidence-based outcomes such as those identified by Esterman and colleagues into everyday practice.

GPs would be pleased that they do not need to be the only source of cajoling and steering of patients towards glycaemic control, when a chronic disease-focused nurse and well structured diabetes education events can also effectively communicate the message.

To facilitate this, payment policies need to be realigned to change GP and patient behaviour and to remove barriers to quality improvement.3 Pay-for-performance programs for quality improvement are growing rapidly for GPs.5 At present, Medicare pays GPs for completed ACCs. Medicare rebates could be restructured to include incentives to clinics that satisfy the trio of chronic disease-focused nurses, accredited diabetes education events and an agreed percentage of their patients with diabetes completing ACCs. Payment programs for these, emanating from rigorous scientific studies, can complement existing payments. Blended payment systems shift the emphasis away from structures and processes to actual health outcomes.5

The above measures, applied on a larger scale, provide a clearer path for GPs and their patients with diabetes. Declining rates of organ complications thanks to improved glycaemic control and the resulting financial savings speak for themselves.

If such systems could be restructured to address the longstanding inequity faced by many geographically disadvantaged individuals with diabetes in rural Australia, this would be an even better outcome.