JRSM >
Volume 99, Number 11 >
Pp. 576-581
1 Director, Wandsworth Primary Care Research Centre, London SW11 6HN
2 Specialist Trainee in Public Health, Wandsworth Primary Care Research Centre,
London SW11 6HN
3 Specialist Trainee in Public Health, Department of Primary Care & Social
Medicine, Imperial College Faculty of Medicine, London W6 8RP
4 Professor of Primary Care, Department of Primary Care & Social Medicine,
Imperial College Faculty of Medicine, London W6 8RP
5 Medical Statistician, Medical Statistics Unit, Research & Development
Directorate, University College London Hospitals, London WC1E 5DB
6 Senior Lecturer in Medical Statistics, Medical Statistics Unit, Research &
Development Directorate, University College London Hospitals, London WC1E
5DB
7 Medical Statistician, Department of Statistical Science, University College
London, London WC1E 6BT, UK
8 Senior Lecturer in Medical Statistics, Department of Statistical Science,
University College London, London WC1E 6BT, UK
Correspondence to: Christopher Millett, Specialist Trainee in Public Health, Department of Primary Care & Social Medicine, Imperial College Faculty of Medicine, 3rd Floor, Reynolds Building, St Dunstan's Road, London W6 8RP, UK E-mail: c.millett{at}imperial.ac.uk
 | SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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Design Population-based cross sectional survey using electronic general practice records carried out between June-October 2003.
Setting Thirty-four practices in Wandsworth, South-West London, UK.
Participants 6035 adult patients (
18 years) with diabetes from a
total registered population of 201 572 patients.
Interventions None.
Main outcome measures Success rates for the diabetes quality indicators within the General Medical Services contract for general practitioners.
Results We identified large variations in diabetes management between general practitioner practices with poorer recording of quality care in younger patients (18-44 years). In addition, younger patients had a worse cholesterol and glycaemia profile, although hypertension was more common in older patients. Gender and deprivation did not appear to be important determinants of the quality of care received.
Conclusions There are large variations in diabetes management between general practitioner practices, with care seemingly worse for younger adults. Longitudinal studies are required to determine whether current UK quality improvement initiatives have been successful in attenuating existing variations in care and treatment outcomes.
| INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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Early evidence indicates that these initiatives may have led to better management of diabetes in primary care; although the extent of improvement may have been more modest than that achieved for coronary heart disease.3 In addition, recent studies highlight persisting variations in the quality of diabetes care being delivered. The General Medical Services quality indicators for diabetes have been shown to be less likely to be achieved for certain sectors of the population, for example in areas of high deprivation and high ethnic mix.4 Gender differences have also been identified, with women less likely to have quality care indicators recorded for their diabetes than men.4
Reducing differential access to services and treatments across age-groups is clearly important in improving the management of diabetes in primary care.5 Age inequalities have been identified in the secondary prevention of coronary heart disease, with older patients less likely to receive effective treatments than younger age-groups.6,7 However, few recent studies have examined the relationship between age and the quality of care received for diabetes. We therefore examined associations between age, gender, deprivation and achievement of the General Medical Services quality indicators in adult diabetes patients in one primary care trust in South-West London.
| METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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Since then the programme has established comprehensive diabetes and coronary heart disease registers within two localities in Wandsworth Primary Care Trust. The data collection period for the present study was June-October 2003. Ethical approval for the study was granted by Wandsworth Local Research Ethics Committee.
Setting and participants
The two localities contained 40 practices with a total registered
population of 245 872. Thirty-four practices participated in the 2003
collection round, providing 82% coverage of the registered population. The
population of Wandsworth is younger than that of England and Wales, with 74%
under 45 years. One in five Wandsworth residents (22%) belongs to a non-white
minority ethnic group and the borough has high levels of deprivation relative
to elsewhere in England (index of multiple deprivation
20048 rankings:
overall 128/354, income scale 51/354, employment scale 60/354).
Identification of diabetes patients
The methodology used to develop our disease register for diabetes in
Wandsworth has been described
previously.9 In
brief, all patients with type 1 and type 2 diabetes were identified from
computerized records by searching diagnosis of diabetes (C10) or diabetes care
(66A) Read codes. Patients with repeat prescribing for diabetic medications or
with an HbA1c greater than 7.5% were also included in our sample. Patients
under 18 years and women with gestational diabetes were then excluded. Female
patients who had no other data relating to diabetes apart from metformin
prescribing were excluded on the grounds that they were likely to be receiving
treatment for polycystic ovarian syndrome rather than diabetes. Additional
verification of the diagnosis of diabetes through hand searching of patient
records was not feasible due to the large numbers involved.
Study variables
We examined quality indicators for diabetes from the General Medical
Services contract as they applied to our population between June and October
2003. Each indicator is based on clinical information recorded on the practice
computer within the previous 15 months.
Socio-economic status was assigned to individual patients based on their postcode using the Index of Multiple Deprivation 2004.8 Patients were then grouped into quintiles, with those in quintile one residing in the most deprived areas and five in the least deprived areas.
Statistical analyses
We examined variation between general practitioner practices in achievement
of each of the quality indicators for diabetes by calculating median values
and 10th and 90th centiles. Logistic regression was undertaken to determine
odds ratios, with 95% confidence intervals, for each quality indicator with
age, gender and deprivation as the independent variables. We used robust
standard errors to take account of the clustering of patients within general
practices.10
Statistical analyses were performed using STATA 9.1.
| RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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18 years) were identified as having diabetes in
the 34 participating practices: 3118 were men and 2917 were women. The
European age-standardized prevalence of diabetes per 1000 population in all
age-groups was 34.5 for females and 38.1 for males. Nearly 70% of patients
were aged 55 years or older (18-44 years [16.6%], 45-54 years [15.2%], 55-64
years [24.7%], 65-74 years [26.6%], 75+ years [16.9%]).
The median practice achievement for blood pressure and haemoglobin A1c
(HBA1c) recording were 83.6% and 73.0%, respectively. However, practice
achievement of treatment targets was much lower, at 46.2% for HbA1c <7.5
and 58.3% for blood pressure 
145/85. Considerable between practice
variation was evident in the achievement of quality indicators
(Table 1).
|
Age
Process measures of quality care (Tables
2 and
3) were significantly less
likely to be recorded in young adult patients (18-44 years) than in older
age-groups. Patients aged 18-44 years were significantly less likely to meet
the General Medical Services treatment targets for cholesterol and HbA1c but
had better blood pressure control than older patients (Tables
4 and
5).
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Gender
Recording of quality care indicators was broadly similar in men and women.
However, women were significantly more likely to be asked about their smoking
status than men, but less likely to receive cessation advice if they were
smokers.
Women were significantly more likely to have cholesterol levels above 5 mmol/L but there was no significant difference between women and men in terms of meeting General Medical Services targets for HBA1c control and blood pressure.
Deprivation
Recording of quality care indicators was similar in patients within the
most and least deprived groups in our sample. Patients in the most deprived
group were less likely to meet the General Medical Services target for blood
pressure control and more likely to have HbA1c >10% than those in the least
deprived groups. However, these differences did not attain statistical
significance.
| DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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Strengths and weaknesses of this study
We identified considerable patient group and practice level variation in
the achievement of the General Medical Services quality indicators. Some of
this variation may be due to differences in recording practice, rather than
the actual differences in the quality of care received. Variations in
recording practice in primary care should be gradually eliminated now that the
General Medical Services contract has been implemented and general practices
are being paid based on the information they are recording.
Patients with diabetes were identified from computerized records using algorithms based upon diagnostic and diabetes care codes. We have previously shown that computer searches based on diagnostic Read codes for diabetes alone have a low sensitivity, as they may miss up to a third of cases.9 We used a more comprehensive search strategy to compensate for this under-recording of diabetes. All but six general practitioner practices within the study area participated in our survey. Hence our findings provide a comprehensive and typical picture of the care provided in this diverse, inner city location.
Comparison with previous studies
Few recent studies have examined the relationship between age and the
quality of overall diabetes care received. Our findings confirm previous
research which has shown that ageing is associated with improved glycaemic
control,11-13
but an increased likelihood of
hypertension.14,15
Our findings are also consistent with the recent National Diabetes Audit in
England,16 which
suggested that older patients may be more likely to achieve cholesterol
treatment targets. These differences may reflect tighter management policies
for older patients within practices and better treatment compliance amongst
this patient group. Patients aged 75+ years did not appear to receive poorer
quality care when compared to younger patients. This finding contrasts with
recent evidence of persistent age inequalities in the secondary prevention of
coronary heart
disease.6,7
Our findings confirm recent research which suggests that glycaemic control may be similar in women and men,4,11 but that women with diabetes are more likely to have poorly controlled cholesterol.4 Intermediate treatment outcomes were not significantly different amongst participants living in deprived areas compared with those living in more affluent areas. Existing evidence on the association between socio-economic status glycaemic control is mixed4,11,17 but may be influenced by definitions used as well as the choice of measurement tool.18 Our findings differ from that of Hippisley-Cox et al.,4 who found that women and patients living in deprived areas may receive less comprehensive care for their diabetes. The comprehensive diabetes disease management programme being implemented in Wandsworth and the regular monitoring of practice performance may have helped to attenuate gender and socio-economic differences in the quality of care for diabetes in this locality.
The European age-standardized prevalence of diabetes per 1000 population in all age-groups was 34.5 for females and 38.1 for males, which is higher than that reported in previous population based surveys.16,19 This is not unexpected given that our study population was characterized by a relatively high proportion of individuals from minority ethnic and deprived groups, who are known to experience elevated rates of diabetes.2
| CONCLUSIONS AND FUTURE RESEARCH |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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| Footnotes |
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Competing interests None declared.
| REFERENCES |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONS AND FUTURE RESEARCHREFERENCES |
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