Effective primary care for people with non-insulin dependent diabetes mellitus: towards earlier detection and better delivery of care in general practice

Griffin, Simon James (1999) Effective primary care for people with non-insulin dependent diabetes mellitus: towards earlier detection and better delivery of care in general practice. University of Southampton, Doctoral Thesis.

Abstract

This thesis is concerned with improving the detection of, and delivery of care to, people with non-insulin dependent diabetes (NIDDM).

Over one year, 41 general practices in Southern England returned data on all newly diagnosed patients. These data were compared with information from the Health Survey for England 1994, then pooled with half the data from the population cross-sectional study, including glucose tolerance testing, to develop a model predicting undiagnosed NIDDM. The model was tested in the remaining half of the population cross-section. Finally, standard systematic review methods with investigation of between-trial heterogeneity, including meta-regression, were used to identify and evaluate trials comparing general practice and hospital care for NIDDM.

The incidence of NIDDM was 1.15/1000 person years. 522 were diagnosed with NIDDM, 84% in general practice. 34% presented with classical symptoms of hyperglycaemia. Mean age at diagnosis was 63 years, men were diagnosis more often and at a younger age than women. New cases were significantly more obese and more likely to be prescribed cardiovascular medication than age-sex matched population controls. A risk score including these and other routinely available data identified NIDDM with 77% sensitivity and 72% specificity. Mortality, glycaemic control and follow up for diagnosed patients in general practice were dependent on the provision of intensive support including a central, computerised system to prompt patients and practitioners to undertake aspects of care.

The systematic review of five trials indicates that once diagnosed, patients can receive standards of care in general practice as good as, or better than, hospital outpatient care, provided that suitable organisation is in place.

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