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Evolution of health professional roles “The Brisbane South Complex Diabetes Service has demonstrated some positive results on reducing waiting time and improving clinical outcome for people with diabetes when advanced skills GPs are employed to provide care.” allied health professionals to provide care to individuals with diabetes who have been referred to the hospital in a community setting. The model contains an element of specialist outreach as the endocrinologist attends the clinic in the community and both the endocrinologist and GPs co-consult with the patient. This service includes insulin initiation and titration. Compared to the hospital clinic, the BSCDS has a waiting time of 4 weeks, their patients have significantly lower HbA 1c at 12 months, there is a reduced number of non-attendees at 12 months compared to that at the hospital, a significantly higher percentage of patients are discharged back to general practice, and care per visit cost is approximately one fifth of that occurring at the hospital outpatient department. This allows for a greater number of follow-up visits whilst still delivering a clinic at a lower cost (Russell et al, 2013). Another initiative exploring the potential for the GPwSI in diabetes role to develop in Australia is the National Faculty of Specific Interests of the Royal Australian College of General Practitioners, which commenced in 2011. Conclusion GPs have been working within areas of special interest for many years in Australia, but in countries such as the UK and Netherlands the role has been formalised. No such GPwSI framework exists in Australia; however, the BSCDS has demonstrated some positive results on reducing waiting time and improving clinical outcome for people with diabetes. n Association of British Clinical Diabetologists (2002) General Practitioners with a Special Interest in Diabetes – a discussion paper. ABCD, Malmesbury, UK. Available at: http://bit.ly/1VgJMNX (accessed 12.02.16) Gerada C, Wright N, Keen J (2002) The general practitioner with a special interest: new opportunities or the end of the generalist practitioner? Br J Gen Pract 52: 796–8 Goenka N, Turner B, Vora J (2011) Commissioning specialist diabetes services for adults with diabetes: Summary of a Diabetes UK Task and Finish Group report. Diabet Med 28: 1494–500 Jackson C, Tsai J, Brown C et al (2010) GPs with special interests impacting on complex diabetes care. Aust Fam Physician 39: 972–4 Jiwa M, Meng X, Sriram D et al (2012) The management of Type 2 diabetes: A survey of Australian general practitioners. Diabetes Res Clin Pract 95: 326–32 Karet B (2007) Intermediate care in diabetes: a rose between two thorns? Practical Diabetes International 24: 389–91 Nocon A, Rhodes P, Wright P et al (2004) Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation. Diabet Med 21: 32–8 Royal College of General Practitioners, Department of Health (2003) Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical Services – Diabetes. DoH, London, UK Russell A, Baxter KA, Askew DA et al (2013) Model of care for the managment of complex type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial. Diabet Med 30: 1112–21 Struijs JN, van Til JT, Baan CA (2010) Experimenting with a bundled payment system for diabetes care in the Netherlands. Centre for Prevention and Health Services Research, Public Health and Health Services Division, The Netherlands Wilkinson D, Dick MLB, Askew DA (2005) General practitioners with special interests: risk of a good thing becoming bad. Med J Aust 183: 84–6 Join the discussion! QDo you think there is a place for the GPwSI in Australia? QAre you a GP with a special interest in diabetes or a health professional working with one? What are your experiences of the role? Should it be formally recognised? QCould the formalised GPwSI role assist in the provision of intermediate care in areas of medical workforce shortage (e.g. rural areas in which access to endocrinologists may be limited)? QAre you a nurse, pharmacist or allied health professional extending beyond the “traditional” role in assisting with the management of diabetes? Tweet @PCDSAus or comment on our LinkedIn page: www.linkedin.com/ primary-care-diabetes-society-of-australia 54 Diabetes & Primary Care Australia Vol 1 No 2 2016
Article Blood glucose: To monitor or not in type 2 diabetes? The practical implications of the Choosing Wisely recommendation John Furler, Jessica Browne, Jane Speight Originating in the USA in 2012 and launched in Australia in 2015, the Choosing Wisely campaign is a professionally driven initiative that aims to encourage clinicians and consumers to question the use of medical tests, treatments and procedures. One of the most widely adopted campaign recommendations focuses on diabetes, and the role of routine self-monitoring of blood glucose. In this article, the authors explain the Choosing Wisely recommendation for self-monitoring of blood glucose in diabetes and put forward their view on how it fits with today’s diabetes environment. They also describe a structured way to use self-monitoring with the ultimate aim of empowering people with diabetes and improving glucose control. Launched in Australia in 2015, the Choosing Wisely campaign is a professionally driven initiative that aims to encourage clinicians and consumers to question the use of medical tests, treatments and procedures. The aim is to eliminate those that are not supported by evidence, that duplicate other tests or procedures, may cause harm and are not truly necessary. Thirteen countries have now implemented locally adapted versions of the Choosing Wisely campaign. One of the most widely adopted campaign recommendations in the US, Canada, UK and Australia focused on diabetes. Developed by the Royal Australian College of General Practitioners (RACGP) through evidence reviews and consultation with members and experts, the Choosing Wisely Australia recommendation was to not advocate routine self-monitoring of blood glucose (SMBG) for people with type 2 diabetes who are only on oral medication (Choosing Wisely Australia, 2015). The recommendation suggested that SMBG may possibly reduce HbA 1c levels by 0.25–0.3% (2.7–3.2 mmol/mol), but this was considered clinically insignificant. SMBG actually increased hypoglycaemia risk, although the reason for this was unclear. The recommendation, therefore, concluded that HbA 1c levels should be used to guide therapy, and promote lifestyle interventions regardless of diabetes control. The recommendation acknowledged that there are exceptions where SMBG is appropriate for people with type 2 diabetes who are on oral medication, such as symptomatic hypoglycaemia; heavy machinery operators on a sulfonylurea; elderly people with renal failure and pregnant women. SMBG may also be appropriate as a possible short-term education tool for how diet influences blood glucose. We believe that such education ought to focus also on the impact of physical activity for regulating glycaemic levels. The concern about SMBG was not only that it may be clinically unhelpful, but also costly. The Choosing Wisely recommendation (2015) noted that, in 2012, $143 million was spent on test strips by the Australian Government, and that people with diabetes who are not on insulin and who use SMBG, on average use 300 test strips a year. While it is worth noting that only 35% of this spend was for those people with non-insulin-treated type 2 diabetes, nevertheless this is not insubstantial. In Australia, type 2 diabetes costs $15 billion annually (Colagiuri Citation: Furler J, Browne J, Speight J (2016) Blood glucose: To monitor or not in type 2 diabetes? The practical implications of the Choosing Wisely recommendation. Diabetes & Primary Care Australia 1: 55–8 Article points 1. The Choosing Wisely campaign is a professionally driven initiative that aims to encourage clinicians and consumers to question the use of medical tests, treatments and procedures. 2. There is concern that selfmonitoring of blood glucose (SMBG) is not only clinically unhelpful, but also costly. 3. Structured SMBG does not duplicate other forms of monitoring but, rather, adds detail and value to what can be learnt from HbA 1c . Key words – Monitoring – Self-care – Type 2 diabetes Authors John Furler is Principal Research Fellow and Associate Professor, Department of General Practice, University of Melbourne, Vic; Jessica Browne is Senior Research Fellow, The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Vic; Jane Speight is Chair at the School of Psychology, Deakin University, Burwood, Vic. Diabetes & Primary Care Australia Vol 1 No 2 2016 55
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