Evaluation of the performance and outcomes for the first year of a diabetes rapid access clinic

Diabetes rapid access clinics (DRACs) have been identified by the New South Wales Agency for Clinical Innovation as a key component of an integrated diabetes model of care.1 This cost-effective model provides fast and comprehensive outpatient review and has been shown to circumvent hospital admission, decrease hospital length of stay and improve patient outcomes.2-5 Based on this approach, a nurse practitioner-led DRAC was established in February 2015 at Royal North Shore Hospital (RNSH) in Sydney as a pilot program to assess the suitability of the DRAC for scalability across the Northern Sydney Local Health District (NSLHD).

The DRAC is an outpatient clinic, operating on weekdays, which adopts the principle that high-risk patients who present to the emergency department (ED) could be diverted from hospitalisation if they were well enough for outpatient management of their condition (Appendix). Patients are referred from general practice, the ED or the endocrinologist on call and require rapid review (within 72 hours) of complex diabetes problems, such as an episode (or episodes) of severe hypoglycaemia, recurring mild hypoglycaemia or hyperglycaemia not needing hospitalisation.

We prospectively collected data during the first year since inception of the DRAC, with a particular focus on reasons for referral and cost evaluation. The study was approved by the NSLHD Human Research Ethics Committee (RESP/16/62).

Within the first year of the DRAC pilot program at RNSH, 61 patients attended the clinic. About a quarter of these patients (n = 15) would have been hospitalised had they not been reviewed at the DRAC and they were successfully managed as outpatients. Although these patients met the criteria for admission, they were deemed appropriate for the DRAC by the endocrinologist on call. In addition, 26% of the patients were referred back to general practice, while the remainder required ongoing endocrinologist review. Most patients presented with hyperglycaemia-related problems (n = 40; 66%; Box), including 15 patients with newly diagnosed diabetes. A further 11 patients presented with severe hypoglycaemia. Within 30 days of review at the DRAC, one patient presented to the ED and required hospitalisation.

Using a conservative costing approach, whereby patients were assumed to be uncomplicated with an average length of stay of 2.5 days (based on data from the NSLHD Performance Unit), the cost analysis demonstrated that for 15 patients for whom hospitalisation was avoided, about $46 700 would have been incurred in their inpatient stay. The DRAC was established through a restructure of existing services; however, if nursing costs associated with running the DRAC were included (about $23 400), the analysis showed that the cost of management in the clinic was half the cost of an inpatient stay (Box).

A nurse practitioner-led DRAC was successfully established at a tertiary referral hospital in NSW. Our preliminary evaluation has demonstrated improved patient outcomes and assistance for general practice in managing ongoing outpatient diabetes-related problems. In addition, for a quarter of patients presenting to the DRAC, hospitalisation was prevented. Future directions include the expansion of the DRAC across the local health district and the incorporation of a “hotline” to assist general practitioners with urgent and complex diabetes management.