New solutions to old problems

Year on YEAR, almost quarter on quarter, we see NSW hospitals breaking new records in terms of hospital presentations and admissions. There is no question we need adequate resourcing of our hospital sector, but we should question how we can optimise the use of resources. Paying for more of the same is a great way to lead to more of the same. Sometimes we don’t need more, we need different.

Western Sydney is a well-known diabetes hotspot, with recent studies showing that 47% of the population in Blacktown-Mt Druitt have HbA1c screening tests in the diabetic or prediabetic range. Amongst admitted patients, every year there is a 1% increase in patients with a diagnosis of type 2 diabetes. A co-morbid diagnosis of diabetes is associated with up to 25% higher total cost per admission and longer bed stays. In my practice, after the age of 35, up to 90% of patients in some deciles are overweight or obese. We diagnose a new case of diabetes on average every three weeks, with almost 12% of our patient population now suffering from diabetes.

Four years ago, the Blacktown Hospital Diabetes Clinic had a wait time of more than nine months when Professor Glen Maberly embarked on a strategy to make a difference. One of the problems was that the clinic was not able to discharge patients and was swamped with referrals. One of the solutions was to improve the capacity to care for patients in the community. While there are many parts to a whole of system, whole of area diabetes strategy, an innovative part of the solution was a partnership program with the Western Sydney Primary Health Network. This allowed endocrinologists and diabetic educators from the hospital to see patients in consultation with their usual GPs and primary care team in general practices. In our practice, our team of our dietitian, pharmacist, nurse and doctors would engage in the case conference – sometimes in person, sometimes using remote video conferencing.

Across the 19 practices involved in the exercise initially, there was an average improvement in HbA1c for each patient seen of almost 0.9% at the six-month mark, and almost 1% at the three-year review. There were significant reductions in lipid profiles and improvements in eGFR. Across the practices, there were improvements in overall diabetic control. Within our practice, the percentage of patients with diabetes with an HbA1c of <8 has continued to increase from 60% in 2014 to 86% in August this year. The wait time at the diabetic clinic reduced to less than a month, with urgent cases being able to be seen in less than a week at a Rapid Access Clinic.

As with all improvements, the reasons are often multifactorial, and treatment of diabetes is more than managing the condition once diagnosed. Community case conferencing is one part of a broader strategy. At a systems level we need to look at primary prevention as well as secondary prevention and management. There needs to be a layered approach to management with support for patients and providers according to needs and experience. What this demonstrates is that integrating hospital and community-based services can show benefits.

We know a 1% reduction in HbA1C can reduce risks of: diabetes-related deaths by 21%; myocardial infarction by 14%; microvascular complications by 37%; and amputation or death by 43%.

The Western Sydney Diabetes Initiative is a partnership program, with partners across the spectrum of community from State Government departments, LHD, PHN down to local practices, universities and community organisations all with a common objective – to reduce the burden and impact of diabetes in the region.

Sometimes we need to do something different.