Cycle of Care for people with diabetes: an equitable initiative?

Introduction

With rising prevalence and burgeoning healthcare costs, diabetes embodies many of the challenges facing health systems worldwide^1,2. The prevalence of doctor-diagnosed diabetes in Ireland has increased from 2.2% of the adult population in 1998 to 5.2% in 2015³. Among adults aged 50 years and older, the prevalence of type 2 diabetes is 8.5%⁴. Healthcare costs attributable to diabetes in those aged over 50 years are estimated at €89 million per annum with hospital admissions accounting for almost 70% of costs⁵. Out-patient department visits attributable to diabetes cost an estimated €18.5 million per annum.

International consensus exists that structured management of uncomplicated diabetes in primary care with suitable organisational support, constitutes good quality diabetes care. There is growing evidence that primary care led structured diabetes management is associated with improved outcomes for patients^6,7. Structured approaches to diabetes care demonstrate improvements in glycaemic control and cardiovascular risk factors^8,9. Integrated diabetes care has been shown to reduce preventable hospitalisations for diabetes-related complications¹⁰. Recent guidance on integrated care for diabetes in Ireland recommends that patients with uncomplicated type 2 diabetes are managed in primary care and patients with complicated type 2 diabetes are managed between primary and secondary care¹¹. The management of type 1 diabetes remains in secondary care. Patients with uncomplicated type 2 diabetes are defined as patients not on insulin, treated by diet or glucose lowering agents only, controlled HbA1c and no diabetes-related complications¹¹.

In 2015, the diabetes “cycle of care” was introduced. This is the first national initiative to financially remunerate General Practitioners (GPs) for providing structured care for people with type 2 diabetes. GPs are remunerated for providing two structured diabetes review visits per year. The initiative establishes formal requirements for registering, recording and reporting processes of care. However, GPs are only remunerated for patients covered by means-tested public health insurance schemes. We aim to investigate the coverage of the cycle of care and to describe the socio-demographic and clinical profile of the those eligible and non-eligible for the initiative.

Methods

Results

Of the 8,107 participants with complete data, 609 people had type 2 diabetes (7.9% [95% CI: 7.3%, 8.5%]). Table 1 documents that 31.6% (95% CI: 27.8, 35.6) of people with type 2 diabetes, aged 50 years and over, are not eligible for the cycle of care. In 2016, this equates to an estimated 36,567 (95% CI: 32,170, 41,196) people in Ireland, aged 50 years and over, who were not eligible for the initiative.

Table 2 shows the characteristics of the population eligible for the cycle of care and those not eligible. There was a significantly lower proportion of females in the non-eligible population (30.8% compared to 47.2% in the eligible population). The age breakdown between the groups also differed; those not eligible for the cycle of care were younger, with only 4.1% aged over 75 years compared to 34.2% of the eligible population. The prevalence of macrovascular complications in the non-eligible population was 13.4% compared to 17.4% in people who were eligible; however, this was not statistically significant (p=0.2). Similarly, 22.7% of the eligible population had a microvascular complication compared to 28.1% of the non-eligible population (p=0.2). There were statistically significant differences in diabetes management (p<0.001). Among those not eligible for the cycle of care, 9.8% were on insulin compared to 17.4% of those eligible. A higher proportion of non-eligible people reported no medical treatment for their diabetes (27.4% compared to 14.7%).

Discussion

This study describes the proportion, socio-demographic and clinical profile of people with type 2 diabetes according to their eligibility status for the cycle of care initiative. Almost one-third of people over the age of 50 years with type 2 diabetes are not eligible for the initiative. They are more likely to be male, to be younger and to have higher levels of educational attainment than those covered by the scheme.

The aim of the cycle of care is to provide financial remuneration to GPs for providing structured review visits for people with type 2 diabetes in primary care. National guidelines for integrated care identify people with uncomplicated type 2 diabetes as most suitable for management in primary care¹¹. Our findings indicate that most of those currently not eligible for the cycle of care initiative fit the criteria of uncomplicated diabetes and are therefore suitable for primary care management. Almost double the proportion of the non-eligible population managed their diabetes without medication. Furthermore, a significantly lower proportion of the non-eligible population were on insulin. Integrated diabetes care has been shown to reduce preventable hospitalisations for diabetes-related complications¹⁰. Structured approaches to diabetes care demonstrate improvements in glycaemic control and cardiovascular risk factors^8,9. However, if integrated diabetes care is to be clinically effective and cost-effective, it must be provided in the most appropriate setting to all people with diabetes¹⁶.

In Ireland, attendance at out-patient clinics is free at the point of access, creating a perverse incentive for non-eligible individuals to seek routine diabetes care in secondary care. The roll out of the cycle of care to all people with type 2 diabetes would remove the financial barriers that currently exist to managing uncomplicated diabetes at the right time and in the right place. For integrated care to be implemented, the financing must be aligned with the care pathways.

Using a nationally representative sample, we provide robust estimates of the number of people aged 50 years and over who are currently not eligible for the cycle of care. There are some limitations to be noted. Our estimates only include people aged over 50 years and so the total number of non-eligible people is likely to be higher. Self-reported doctor diagnoses may introduce misclassification bias and result in inaccurate estimates. However, a number of studies have demonstrated that self-report is a suitable method to determine the prevalence of diabetes compared to medical records^17,18. The self-reported doctor diagnosis of diabetes may underestimate the true prevalence of diabetes as it does not measure undiagnosed diabetes. However, the prevalence of undiagnosed diabetes has been shown to be low in this cohort¹⁹. As TILDA does not contain information on diabetes-specific health service use, we were unable to explore attendance rates at outpatient departments compared to GP visits for routine diabetes care.

Our findings highlight the inequity of the cycle of care, particularly for younger people with type 2 diabetes. While a welcome initiative and an important step in the implementation of integrated diabetes care in Ireland, eligibility needs to be based on clinical criteria rather than income. It is essential that the provision of the cycle of care be extended to all people with type 2 diabetes in Ireland.

Data availability

The data presented in this report are part of the TILDA study (Wave 1)¹⁸. This is available from the Irish Social Studies Archive (ISSDA) through a system of managed open access. You may find it useful to browse the TILDA Register of Use, which lists all projects that have been approved to use TILDA data.