Integrated care model offers noninferior diabetes care to gold-standard specialist clinics

A study conducted in Australia found that general practitioners with specialization in diabetes care and subspecialist-led clinics reduced HbA1c levels by similar amounts in patients with complex type 2 diabetes.

A model of integrated care delivered in the community can safely achieve complex diabetes management that is not inferior to that achieved with gold-standard, hospital-based subspecialist outpatient clinics, without harm and with greater patient satisfaction, a recent study found.

To determine whether a Beacon model of integrated care using general practitioners with a special interest in diabetes could achieve similar clinical outcomes to a hospital-based subspecialist diabetes outpatient clinic, researchers conducted a pragmatic, noninferiority, randomized controlled trial that assigned patients with complex type 2 diabetes to a study group or usual care in a 3:1 ratio. The study was done at two hospitals and three intervention sites in Brisbane, Australia.

The Beacon model offers care delivered through a community-based general practice where general practitioners with a special interest in diabetes work alongside an endocrinologist and diabetes nurse educator. Eligible participants were age 18 years or older and had been referred to the hospital by their usual general practitioner. Results were published online Oct. 3 by Diabetologia.

Data from participants' clinical records and questionnaires were collected at baseline and at six and 12 months. The primary outcome was HbA1c at 12 months. Patient-reported outcomes included the 12-item short-form health survey of quality of life (QoL) and the diabetes-related QoL (DQoL-Brief) survey. Participant satisfaction with care was measured at follow-up using the eight-item client satisfaction questionnaire (CSQ-8) and a five-item participant assessment of self-management support.

The mean difference in HbA1c between the two groups at study completion was −0.03% (95% CI, −0.43% to 0.36%) for the per-protocol sample and −0.12% (95% CI, −0.55 to 0.31) for the intention-to-treat sample. The upper limit of the confidence interval fell below the predefined noninferiority margin of 0.4% for both samples. Noninferiority was confirmed at six months.

The authors noted that most improvement in HbA1c was made from baseline through six months of follow-up, and HbA1c reduction was sustained at 12 months for both groups. The proportions of participants meeting clinical targets at 12 months were similar between groups: 23% of the usual care group and 26% of the intervention group achieved an HbA1c of 7.0% or less.

Secondary outcomes were consistent across nonimputed and imputed models. A significantly lower estimated glomerular filtration rate was found in the usual care group (P=0.04). There were no statistical or clinical between-group differences for any other clinical secondary outcome or patient-reported outcome of diabetes-related quality of life or for physical and mental components of the 12-item short-form health survey. “Both groups were mostly satisfied with the treatment received as measured by the CSQ-8, but participants in the Beacon group were significantly more satisfied (mean 28.4, SD 4.9) than the usual care group (mean 25.6, SD 4.9) (P<0.001) and reported better self-management support (P=0.03),” the authors wrote.

“Given the focus on care integration, our innovative model offers a viable alternative to hospital-based specialist care that could make an important contribution to the management of individuals with type 2 diabetes in metropolitan settings,” they added.