Hull Sally, Chowdhury Tahseen A, Mathur Rohini, Robson John
Centre for Primary Care and Public Health, Queen Mary, University of London, , London, UK.
BMJ Qual Saf. 2014 Feb;23(2):171-6. doi: 10.1136/bmjqs-2013-002008. Epub 2013 Sep 3.
Structured diabetes care can improve outcomes and reduce risk of complications, but improving care in a deprived, ethnically diverse area can prove challenging. This report evaluates a system change to enhance diabetes care delivery in a primary care setting.
All 35 practices in one inner London Primary Care Trust were geographically grouped into eight networks of four to five practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary team developed a 'care package' for type 2 diabetes management, with financial incentives based on network achievement of targets. Monthly electronic performance dashboards enabled networks to track and improve performance. Network multidisciplinary team meetings including the diabetic specialist team supported case management and education. Key measures for improvement included the number of diabetes care plans completed, proportion of patients attending for digital retinal screen and proportions of patients achieving a number of biomedical indices (blood pressure, cholesterol, glycated haemoglobin).
Between 2009 and 2012, completed care plans rose from 10% to 88%. The proportion of patients attending for digital retinal screen rose from 72% to 82.8%. The proportion of patients achieving a combination of blood pressure ≤ 140/80 mm Hg and cholesterol ≤ 4 mmol/L rose from 35.3% to 46.1%. Mean glycated haemoglobin dropped from 7.80% to 7.66% (62-60 mmol/mol).
Investment of financial, organisational and education resources into primary care practice networks can achieve clinically important improvements in diabetes care in deprived, ethnically diverse communities. This success is predicated on collaborative working between practices, purposively designed high-quality information on network performance and engagement between primary and secondary care clinicians.
结构化糖尿病护理可改善治疗效果并降低并发症风险，但在贫困、种族多样的地区改善护理可能具有挑战性。本报告评估了一项系统变革，以加强初级保健机构中的糖尿病护理服务。
伦敦市中心一个初级保健信托基金的所有35家医疗机构按地理位置划分为8个网络，每个网络由4至5家医疗机构组成，每个网络由一名网络经理、文书工作人员和一项教育预算提供支持。一个多学科团队制定了一套2型糖尿病管理的“护理套餐”，并根据网络目标的达成情况给予经济激励。每月的电子绩效仪表盘使各网络能够跟踪和改善绩效。包括糖尿病专科团队在内的网络多学科团队会议支持病例管理和教育。改善的关键指标包括完成的糖尿病护理计划数量、接受数字视网膜筛查的患者比例以及达到多项生物医学指标（血压、胆固醇、糖化血红蛋白）的患者比例。
2009年至2012年间，完成的护理计划从10%增至88%。接受数字视网膜筛查的患者比例从72%增至82.8%。血压≤140/80毫米汞柱且胆固醇≤4毫摩尔/升的患者比例从35.3%增至46.1%。平均糖化血红蛋白从7.80%降至7.66%（62-60毫摩尔/摩尔）。
将财政、组织和教育资源投入到初级保健实践网络中，可以在贫困、种族多样的社区实现糖尿病护理方面具有临床意义的改善。这一成功基于各医疗机构之间的协作、针对性设计的高质量网络绩效信息以及初级和二级保健临床医生之间参与。
