XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review.

Economic Control of Quality of Manufactured Product.

A systematic review of the epidemiology of gastro-oesophageal reflux disease (GORD) has been performed, applying strict criteria for quality of studies and the disease definition used. The prevalence and incidence of GORD was estimated from 15 studies which defined GORD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period. Data on factors associated with GORD were also evaluated.

An approximate prevalence of 10–20% was identified for GORD, defined by at least weekly heartburn and/or acid regurgitation in the Western world while in Asia this was lower, at less than 5%. The incidence in the Western world was approximately 5 per 1000 person years. A number of potential risk factors (for example, an immediate family history and obesity) and comorbidities (for example, respiratory diseases and chest pain) associated with GORD were identified.

Data reported in this systematic review can be interpreted with confidence as reflecting the epidemiology of “true” GORD. The disease is more common in the Western world than in Asia, and the low rate of incidence relative to prevalence reflects its chronicity. The small number of studies eligible for inclusion in this review highlights the need for global consensus on a symptom based definition of GORD.

The study of the epidemiology of GORD is restricted by the lack of consensus over the basic definition of the disease. To review the global epidemiology of GORD is currently problematic as there is no internationally applied definition, although the need for this has been recognised.1 Gastro-oesophageal reflux manifests as a continuum of symptom frequency and/or severity in the general population. Occasional symptoms are experienced by a large proportion of the population but GORD results from frequent or severe symptoms which are sufficient to impair the individual’s health related quality of life …

https://gut.bmj.com/content/gutjnl/54/5/710.full.pdf

Epidemiology of gastro-oesophageal reflux disease: a systematic review

•The number of domestic graduates from Australian medical schools is set to increase by 81% in 7 years, from 1348 in 2005 to 2442 by 2012. • Including international students, medical school graduates will total almost 3000 by 2012. • Planning must begin now to ensure that the significant flow-on effects of these increases are managed effectively. • Most urgently, postgraduate medical training will require a substantial injection of resources to expand opportunities for clinical training, without compromising quality. • Patterns of career choice by medical graduates and workforce supply levels must be monitored to ensure responsiveness to the effects of substantially larger, and more diverse, graduate cohorts.

Riding the wave: current and emerging trends in graduates from Australian university medical schools.

Background. Over the last 6 years there has been an exponential increase in the publication of medical literature on evidence-based medicine. In Australia, as in many other parts of the world, there have been calls for an increase in the practice of evidence-based medicine. In general practice, two major themes of criticism have been the lack of relevant research evidence in primary care and the failure of evidence-based medicine to take into account the complexity of the consultation. Objective. We aimed to explore the attitudes of Australian GPs to evidence-based medicine. Methods. We conducted a qualitative study using evidence-based guidelines as a model to explore attitudes within focus group interviews. Focus group data were analysed using grounded theory methodology. The study was set in the Australian cities Melbourne, Adelaide and Darwin. The subjects were 27 GPs in five focus groups. Results. Data were used to generate a model illustrating factors affecting the consideration and use of evidence within consultations. Prior beliefs and experience had a strong influence on decision-making. Overall, the GPs had a positive attitude to evidence-based medicine and stated that this could be a helpful strategy for meeting their information needs. These needs arose during the consultation and were frequently generated by patients. The evidence-based approach was regarded as particularly useful when patients required validation of their management or had specific queries. However, the GPs also expressed some concerns, such as the application of evidence from clinical trials to individuals, and the appropriateness of using research evidence with certain patients. They also feared a move away from the ‘art of medicine’. None of the GPs expressed a need for critical appraisal skills. Conclusions. The Australian GPs in this study had mixed views about the increasing profile of evidence-based medicine, and the use of this paradigm in practice. Acceptability was more likely to be influenced by relevance to general practice and local contextual and patient factors than by the strength, or critical quality of the evidence.

/pdf/the-attitudes-of-australian-gps-to-evidence-based-medicine-a-3jwc7q10al.pdf

The attitudes of Australian GPs to evidence-based medicine: a focus group study

Background 

Psychosocial interventions have the potential to enhance relapse prevention in bipolar disorder.

Aims 

To evaluate a manualised group-based intervention for people with bipolar disorder in a naturalistic setting.

Method 

Eighty-four participants were randomised to receive the group-based intervention (a 12-week programme plus three booster sessions) or treatment as usual, and followed up with monthly telephone interviews (for 9 months post-intervention) and face-to-face interviews (at baseline, 3 months and 12 months).

Results 

Participants who received the group-based intervention were significantly less likely to have a relapse of any type and spent less time unwell. There was a reduced rate of relapse in the treatment group for pooled relapses of any type (hazard ratio 0.43, 95% CI 0.20–0.95; t 343 = –2.09, P = 0.04).

Conclusions 

This study suggests that the group-based intervention reduces relapse risk in bipolar disorder.

/pdf/group-based-psychosocial-intervention-for-bipolar-disorder-4vyy4uh96o.pdf

Group-based psychosocial intervention for bipolar disorder: randomised controlled trial

This is the second of two articles that explore the general practitioner (GP)-specialist relationship. In this article, we explore the nature of the referral process, beginning with referrals frequently made by GPs in Australia and reasons for referral to specialists. In Australia, GPs commonly refer patients to specialists, particularly orthopaedic surgeons, ophthalmologists, surgeons and gynaecologists for a variety of reasons, including diagnosis or investigation, treatment and reassurance (reassurance for themselves as well as reassurance for the patient). GPs will choose a specialist after considering a variety of factors, such as the specialist's medical skill, their previous experience with the specialist, the quality of communication between them, office location and patient preferences. The referral is generally made by telephone or by letter, the latter of which is known to vary significantly in content and quality. The specialist, GP and patient expectations of the referral and the consultation process are also described. Specialists expect the GP to provide information about the problem to be addressed and adequate patient history, GPs expect a clear response regarding diagnosis and management as well as justification for the course of action, and patients expect clear communication and explanation of the diagnosis, treatment and follow-up requirements. When these expectations remain unmet, GPs, specialists and patients end up dissatisfied with the referral process.

Part II. General practitioner-specialist referral process.

Objective To measure the prevalence of somatisation (multiple somatic symptoms and hypochondriasis) among Australian general practice attendees, its recognition by general practitioners, and its relationship with symptoms of depression and anxiety. Design, setting and participants Self-reported questionnaires completed by 10 507 consecutive patients aged > or =18 years attending 340 GPs enrolled in a 6-hour national mental health program of continuing professional development who accepted invitations to participate; audit form completed by GPs for each patient during the period March 2004 to December 2006. Main outcome measures Somatic symptom severity (measured with the 15-item Patient Health Questionnaire [PHQ-15]); hypochondriasis (measured with the Whiteley Index [Whiteley-7]; depression and anxiety (measured by the Kessler Psychological Distress scale [K10]); prevalence of "somatisers" (defined by medium to severe somatic symptom severity and hypochondriasis); GP recognition of somatisation (determined by their responses on audit forms to questions on whether patient's complaints were most likely to have a physical or psychological explanation). Results 18.5% of patients were classified as somatisers and 9.5% as probable cases of depression or anxiety. While 29.6% of somatisers had high anxiety or depression scores, 57.9% of people with anxiety or depression were also somatisers. Sex and age asserted significant but weak effects on psychometric scores. GPs identified somatic complaints as "mostly explained by a psychological disturbance" in 25.1% of somatisers. Conclusions Somatisation is common in general practice, and more prevalent than depression or anxiety. While a minority of somatisers have significant anxiety and depression, most patients with depression and anxiety have a significant degree of somatisation. Recognition of depression and anxiety can be hindered by a somatic presentation and attribution. On the other hand, managing somatisation does not just involve recognising depression and anxiety, but also dealing with the health anxieties that underpin hypochondriasis.

/pdf/somatic-symptoms-hypochondriasis-and-psychological-distress-24dj75wdo0.pdf

Leon Piterman

Papers

Riding the wave: current and emerging trends in graduates from Australian university medical schools.

The attitudes of Australian GPs to evidence-based medicine: a focus group study

Group-based psychosocial intervention for bipolar disorder: randomised controlled trial

Part II. General practitioner-specialist referral process.

Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice.