Over the past 20 years, diabetes care has moved from the more traditional specialist hospital clinic to a process of integrated care between specialist and GP. The long-awaited National Service Framework (NSF) for diabetes is likely to put even more emphasis on care for people with diabetes in primary care.
Some fundamental issues of concern regarding the primary/secondary care interface are communication and, to a lesser degree, shared prescribing and disease management.1 One of the busiest areas of data transfer is between hospital and general practice, but the quality of such communication is often far from ideal.2
One way to address this issue is through the use of a shared care patient-held booklet. This idea is not new: patient-held shared care records have been widely and successfully used in a number of different patient groups, e.g. obstetric care3 and child health surveillance.4, 5 The Oncology units at Great Ormond Street and Birmingham Children's Hospital also use shared care cards for children with malignant disease on chemotherapy. Studies suggest that this approach to shared care is of great benefit to all involved.6
The literature contains very little information on the use of shared care management plan booklets for people with diabetes. However, there are references to the use of cooperation cards in the shared care management of people with diabetes7–9 and to a diabetic passport system devised in Glasgow.10
It is widely believed that patient compliance can be increased by persuading patients to participate in their own care. It has been shown that increasing patient education about diabetes can help improve metabolic control and quality of life for many patients.11
However, patient education is not a one-off event. It should be an ongoing process, dealing with changes in treatment as they occur, and equipping patients with the information they need in order to cope with situations such as intercurrent illness or pregnancy, and to prevent the complications of diabetes, and thus promote better health.
There are now evidence-based data which clearly show that achieving optimal treatment targets in people with diabetes reduces the risk of heart disease, stroke and death from other diabetes-related diseases as well as diabetic eye disease and early kidney damage.
The findings of the UK Prospective Diabetes Group (UKPDS)12 and the Diabetes Control and Complications Trial (DCCT) Research Group13 indicate that the optimal treatment targets for glycaemic control are:
- Glycosylated haemoglobin (HbA1c) <7%
- Fasting blood glucose 4-7mmol/l
- Self-monitored blood glucose before meals 4-7mmol/l
- Blood pressure <=140/80mmHg.
There are similar evidence-based recommendations for lipid-lowering treatment,14 and more recently the use of aspirin.15 With these treatment targets and aims in mind, a study was set up as detailed below.
- To ascertain whether knowledge of diabetes control and other treatment targets could be improved by the use of a 'Filofax' system.
- To provide a central record and source of communication to enable seamless care of diabetes between primary and secondary care.
A Filofax-style plan was constructed, taking into account the shared care, management plan and patient education information, together with the evidence-based data for treatment aims and targets.16
It was put together by a multi-disciplinary team comprising diabetes consultants, GPs, diabetes nurse specialists (DNSs), diabetes dietitians and diabetes podiatrists.
It included sections for:
- Education (Figure 1, below)
- Clinical information, with special sheets for:
- diabetes annual review
- blood test results (Figure 2, below)
- full medical history
- Drug treatment
- Diabetes monitoring (Figure 3, below)
- Treatment targets (Figure 4, below)
- Patients' rights and responsibilities
- Information on Diabetes UK.
|Figure 1: 'Filofax' page with explanation of HbA1c|
|Figure 2: 'Filofax' page for most recent laboratory test results|
|Figure 3: 'Filofax' page for summary of diabetes annual review|
|Figure 4: 'Filofax' page for individual treatment targets (completed for each patient)|
The 'Filofax' was designed to allow pages to be inserted and removed as required, and to be small enough to be carried easily in a pocket or handbag, to encourage patients to use it.
Once the 'Filofax' had been constructed, a pilot study was undertaken.
A questionnaire was devised to assess patients' knowledge regarding treatment aims and targets as set out by the Leicestershire Evidence Based Guidelines.17
Three hundred patients were selected at random in the diabetes outpatient department and given the questionnaire to complete as a baseline for the study. Of these, 150 were randomly given the 'Filofax' and 150 were not.
After 6 months, a second identical questionnaire was sent out to all patients in both groups.
In the control group, 139/150 patients (93%) returned the baseline questionnaire, and 88/150 (59%) returned the postal questionnaire sent out after 6 months. In the 'Filofax' group, 150/150 patients (100%) returned the baseline questionnaire, and 93/150 (62%) returned the postal questionnaire sent out after 6 months. The response rate was slightly higher in the 'Filofax' group, but was still comparable to that in the control group.
The chi-squared test was used to indicate statistically significant results (where P<0.05 is significant). Analysis of the questionnaires returned showed the following:
- Blood sugar levels aimed for
In the control group, the range of blood sugar levels aimed for at baseline was 1-18mol/l, improving to 4-14mmol/l after the 6-month study period. Clearly, blood sugar levels >10mmol/l indicate poor control. In the 'Filofax' group, the range of target blood sugar levels aimed for at baseline was 1-12mol/l, improving to 4-10mmol/l after 6 months. There was a significant improvement over the 6-month period in both groups, but particularly in the 'Filofax' group.
- Knowledge of last HbA1c
In the control group at baseline, 31% of patients knew their last HbA1c result, improving to 43% after the 6-month study period. In the 'Filofax' group, at baseline 29% of patients knew their last HbA1c result, improving to 57% after the 6-month study period. The percentage improvement was 12% in the control group vs 28% in the 'Filofax' group (P<0.0001) (Figure 5, below).
|Figure 5: Knowledge of last HbA1c|
- Knowledge of target blood pressure
In the control group, at baseline 11% of patients knew their target blood pressure, improving to 15% after the 6-month study period. In the 'Filofax' group, at baseline 9% of patients knew their target blood pressure, improving to 38% after the 6-month study period. The percentage improvement was 4% in the control group vs 29% in the 'Filofax' group (P<0.0001) (Figure 6, below).
|Figure 6: Knowledge of target blood pressure|
- Knowledge of name of DNS
In the control group, at baseline 38% of patients knew the name of their DNS, improving to 44% after the 6-month study period. In the 'Filofax' group, at baseline 29% of patients knew the name of their DNS, improving to 52% after the 6-month study period. The percentage improvement was 6% in the control group vs 23% in the 'Filofax' group (P<0.0001) (Figure 7, below).
|Figure 7: Knowledge of name of diabetes nurse specialist|
- Knowledge of contact number for advice
In the control group, 28% of patients knew the telephone number to call for advice on the day-to-day management of their diabetes at baseline, compared with 49% after the 6-month study period. In the 'Filofax' group, 35% knew the advice contact number at baseline, improving to 69% after the 6-month study period. The percentage improvement was 21% in the control group vs 34% in the 'Filofax' group (P<0.0001) (see Figure 8, below)
|Figure 8: Knowledge of contact number for advice|
- Knowledge of target HbA1c
This was good at baseline for all patients in the study, as indicated in Table 1 (below).
Table 1: Knowledge of target HbA1c
|Average target HbA1c|
|Control group before||6.50|
|Control group after||6.61|
|Filofax group before||6.49|
|Filofax group after||6.59|
The pilot study showed that patients who received the 'Filofax' showed a greater percentage improvement in:
- Blood sugar level aimed for
- Knowledge of last HbA1c
- Knowledge of target blood pressure
- Knowledge of name of their DNS
- Knowledge of contact number for advice.
Knowledge of target HbA1c was good in all patients throughout the study.
Patients' knowledge of their last blood pressure reading improved in both groups, but the difference between the groups was not statistically significant. Similarly, patients' knowledge of the name of their diabetes consultant also improved in both groups, but the difference between the groups was not statistically significant.
The pilot study shows that the use of a patient-held record in people with diabetes improves their knowledge of core treatment targets as well as providing a worthwhile source of information and education. Improving knowledge of core treatment targets may help to improve metabolic control and so reduce the risk of long-term complications from diabetes.
The 'Filofax' provides a central record, carried by the patient, which can be updated by both the hospital physician and GP to enable seamless care of diabetes between primary and secondary care providers (thus addressing one of the most fundamental issues of concern – communication).
The 'Filofax' design means that information contained therein can be updated on a regular basis in line with latest evidence-based data, or any new evidence-based targets.
Its small size will encourage patients to carry it to all consultations in the primary and secondary care sectors, enabling changes in drug treatment and new diagnoses to be updated, and facilitating communication between all care providers even if there is a delay in correspondence by letter.
The 'Filofax' is an efficient way of following up patients, continuing their education and maintaining a watch for diabetes complications. It acts as a focus for all those involved in the patient's management, and enables GPs to become more involved in and informed about the management of their diabetes patients, thus promoting best practice.
- Hampson JP, Roberts RI, Morgan DA (1996) Shared care: a review of the literature. Fam Pract 1996; 13(3): 264-75.
- Penney TM. Delayed communication between hospitals and general practitioners: where does the problem lie? Br Med J 1988; 297: 28-9.
- Draper J, Field S, Thomas Hare MJ. Should women carry their antenatal records? Br Med J 1986; 292: 603.
- British Paediatric Association. Parent-held and Professional Records used in Child Health Surveillance. London: British Paediatric Association, 1993.
- Macfarlene A. Personal child health records held by parents. Arch Dis Child 1992; 67(5); 571-2.
- Muir KR, Parkes SE, Boon R et al. Shared care in paediatric oncology. J Cancer Care 1992; 1(1): 15-17.
- Watkins PJ, Drury P, Howell SL. Diabetes and its Management. 5th edn. Oxford: Blackwell Science, 1996: 274-5.
- Tattershall RB, Gale EAM. Diabetes: Clinical Management. Edinburgh: Churchill Livingstone, 1990: 105.
- Hill RD. Community care service for diabetics in the Poole area. Br Med J 1976; i: 1137-9.
- Paterson KR, McDowell JA. Passport to improved diabetes care. Diabet Med 1988; 5(3): 285-7.
- Vinicor F, Swanton S, Duckworth W, Clarke C. A randomized trial of the effects of the physician and/or patient education on diabetes patient outcome. J Chronic Dis 1987; 40: 345-56.
- UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risks of complications in patients with type 2 diabetes. Lancet 1998; 352: 837-53.
- Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993, 329: 977-86.
- Pyorala K, Pedersen TR, Kkekhus J et al. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease: a subgroup analysis of the Scandanavian Simvastatin Survival Study (4S). Diabetes Care 1997; 20: 614-20.
- Antiplatelet Trialist Collaboration. Collaborative overview of randomised trials of antiplatelet therapy 1: Prevention of death, myocardial infarction and stroke by prolonged antiplatelet therapy in various categories of patient. Br Med J 1994; 308: 81-106.
- Quinn M, Davies MJ, Needles L et al. Handheld patient monitoring and management plan Filofax for people with diabetes. Diabetic Med 2001; 18 (Suppl 2): Abstract A11.
- Leicestershire Evidence Based Management Guidelines for Diabetes. Leicestershire Health Authority, 1998.