Diabetes care in general practice: meta-analysis of randomised control trials

BMJ 1998;317:390-396 ( 8 August )

General Practice

Simon Griffin, Wellcome training fellow.

Primary Medical Care Group, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST

Correspondence to: Dr Simon Griffin, General Practice and Primary Care Research Unit, Department of Community Medicine, Institute of Public Health, Cambridge CB2 2SR SJG49{at}medschl.cam.ac.uk

Objective: To assess the effectiveness of care in general practice for people with diabetes.
Design: Meta-analysis of randomised trials comparing general practice and shared care with follow up in hospital outpatient clinic.
Identification: Trials were identified from searches of eight bibliographic and research databases.
Results: Five trials identified included 1058 people with diabetes, overall mean age 58.4 years, receiving hospital outpatient follow up for their diabetes. Results were heterogeneous between trials. In shared care schemes featuring more intensivesupport through a computerised prompting system for general practitionersand patients, there was no difference in mortality between carein hospital and care in general practice (odds ratio 1.06, 95%confidence interval 0.53 to 2.11); glycated haemoglobin tendedto be lower in primary care (weighted difference in means of $-$ 0.28%, $-$ 0.59% to 0.03%); and losses to follow up were significantly lowerin primary care (odds ratio 0.37, 0.22 to 0.61). However, schemeswith less well developed support for family doctors were associatedwith adverse outcomes for patients.
Conclusions: Unstructured care in the community is associated with poorer follow up, worse glycaemic control, and greater mortality than in hospital care. Computerised central recall,with prompting for patients and their family doctors, can achievestandards of care as good as or better than hospital outpatientcare, at least in the short term. The evidence supports provisionof regular prompted recall and review of selected people withdiabetes by willing general practitioners. This can be achievedif suitable organisation is in place.

Key messages

Responsibility for the routine recall and review of people with diabetes has shifted to primary care
Central computerised, prompted recall and review for people with diabetes in primary care can achieve outcomes as good or better than follow up in hospital
The transfer of responsibility for diabetes care to general practitioners without adequate support is associated with adverse outcomes for patients
The cost effectiveness of general practice diabetes care needs longer term evaluation

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Rapid Responses:

Read all Rapid Responses

SUMMATIVE ASSESSMENTS ARE NOT HELPFUL: Ray Jones
bmj.com, 11 Aug 1998 [Full text]
Diabetes in general practice; Resources should follow the patient.: Ian Quigley
bmj.com, 11 Aug 1998 [Full text]
Central registers could coordinate services: Somdutt Prasad
bmj.com, 21 Aug 1998 [Full text]
Like must be compared with like in meta-analyses: Kamlesh Khunti
bmj.com, 7 Sep 1998 [Full text]
Untitled: Kamlesh Khunti
bmj.com, 11 Sep 1998 [Full text]