Continuity of care in diabetes: to whom does it matter?

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Abstract

The Australian health care system allows patients to move around to seek medical treatment. This may impact negatively on continuity of care. To determine factors associated with continuity of care for persons with diabetes, the profiles of 479 patients attending the Diabetes Centre, Royal Prince Alfred Hospital, Sydney, Australia, were examined. The majority of patients (87.7%) attended only one general practitioner and had been under the care of the referring doctor for a median of 6.2 years. These patients were older (P=0.02), but were comparable with those attending multiple doctors in terms of their type, duration and treatment of diabetes as well as their clinical and complication profile. There was also a relationship between age and the length of time under the care of the referring doctor (P=0.0002). The HbA1c, lipid, blood pressure and treatment profiles of patients attending the referring doctor short, medium or long-term were comparable. However, there was an upward trend in the proportion of patients with a history of cerebrovascular disease, ischaemic heart disease or any complication of diabetes with each incremental increase in length of time under the referring doctor. Appropriately, patients seek continuity of care as they age and their health needs become more complex.

Introduction

Over the past few decades, general practice has changed with the advent of increased competition, more stringent government control and the demand for faster patient throughput to keep general practice economically viable. While general practitioners remain the best placed health professional to take an overall view of the health of person with chronic disease, it takes a great deal of time to care for these patients. These combined factors mean that the provision of best practice medicine is not easy to accommodate within a single appointment. In this pressured environment, continuity of care becomes an important issue. This is especially so for patients with a chronic disease such as diabetes, as they require ongoing monitoring of glycaemic, lipid and blood pressure control and adjustment of medication to deter the development or slow the progression of diabetes complications. A study in our area in the late 1980s found that as many as 31% of people with diabetes attend more than one general practitioner; some attending as many as three or four different practices [1]. We have since taken every opportunity to emphasise to patients the importance of continuity of care. In light of this, it is important to assess the current status. We therefore sought to compare the demographic profile and clinical outcomes of patients attending one versus multiple general practitioners. The profiles of patients who had recently changed their general practitioner, compared to patients under longer term care of their general practitioner were also examined.

Section snippets

Clinical assessment

In the system of diabetes care provided by the Royal Prince Alfred Hospital Diabetes Centre, patients are referred by general practitioners for clinical assessment, including assessment of diabetic complications. For the purpose of this study, all data were collected on a standardised assessment form. Venous blood was taken for measurement of HbA1c, total cholesterol, HDL cholesterol and triglycerides. A spot sample of urine was collected and assayed for urinary albumin and urinary protein. Two

Single versus multiple general practitioners

Most patients (87.7%) attended only one general practitioner and had been under the care of the referring doctor for a median of 6.2 years (IQR: 2.3–12.1). Interestingly, all patients with Type 1 diabetes were under the care of single versus multiple general practitioners (Table 1). As seen in Table 1, patients who reported attending only one general practitioner were older (median of 59.9 years vs 54.0 years; P=0.02) but were comparable with those attending multiple general practitioners in

Discussion

Within the Australian health system patients are relatively free to move around to seek medical care. While some patients like to develop a relationship with their doctor over time, many frequently change their general practitioner or regularly attend more than one general practitioner for the same health problem [4]. The perception that many patients with diabetes shop around for a doctor was confirmed by a study in our area in the late 1980's [1]. The finding from the current study that the

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