Student: Meagan McLeod
Supervisors: Ben Hudson & Maggie Wilson [Dept Public Health & General Practice and Pegasus Health]
Sponsor: Pegasus Health
Diabetes is a major health problem in New Zealand. The number of people with diabetes is predicted to increase substantially in the next 20 years from 115,000 to over 160,000. Type 2 diabetes is the most common form of the disease occurring in about 85% of people with diabetes. About half the people with diabetes are thought to be undiagnosed. Many of these people will not have symptoms.
The main goal in managing diabetes is to control glucose levels. It is well known that lifestyle changes, such as improving diet, weight loss, increasing physical activity and stopping smoking can help reduce glucose levels. As the disease progresses the body's ability to control blood glucose diminishes and most patients with Type 2 diabetes are likely to require glucose lowering medication and eventually insulin treatment.
High blood glucose levels damage blood vessels throughout the body. Keeping blood sugar levels as normal as possible is an important way of preventing serious and expensive health complications including heart disease (heart attacks and strokes), kidney failure, blindness and disabling leg amputations. Limiting the complications of diabetes is one the 13 national health priorities outlined in the New Zealand health strategy.
The patient plays a key role in managing their diabetes by maintaining dietary recommendations and keeping active, complying with medication regimes and regularly visiting their GP. Achieving treatment goals depends on the patient's understanding, social or psychological situation and motivation. However, it is also essential that patients are receiving adequate and appropriate glucose lowering medication.
A recent study in the UK found that nearly half of patients who have poor control of their diabetes might need to have their medication increased or need to consider starting insulin. This study suggests that doctors may not be recognising when more intensive treatment is appropriate.
This summer project sponsored by Pegasus Health IPA had two objectives. First, to determine the proportion of patients not currently taking insulin who have poorly controlled blood glucose levels. Second, this study looked at possible barriers to effective diabetes management in general practice.
11 Christchurch GPs volunteered to participate in this study. A search of the electronic practice records identified patients with Type 2 diabetes and elevated blood glucose levels. These patients were discussed on an individual basis in a follow-up interview with their GP to explore issues around diabetes management and barriers to achieving optimal diabetes control. From these discussions, barriers to effective treatment and starting insulin were identified. Potential ways to improve diabetes management in primary care were also discussed.
In our sample of 382 patients with diabetes who were not taking insulin, 15% of patients had markedly raised blood glucose. Nearly half of the patients with poor diabetes control had already had a recent and appropriate treatment change, although about one third needed increased oral medication and for about one quarter, insulin was considered necessary.
Of the patients who needed changes to their treatment, GPs considered that due to age, social reasons, or other competing health issues, changing the treatment for high blood glucose would be inappropriate for 41%.
According to GPs, the most common barriers to effective management of blood glucose are patient compliance, lack of motivation/responsibility and insulin refusal.
In only 2 cases the GP described their lack of experience and time as a contributing barrier to gaining better blood sugar control.
Improving educational time and resources to help GP teams to better engage with some patients, as well as building doctor confidence through greater exposure to processes around using insulin to treat Type 2 diabetes may contribute to better diabetes management in primary care.