Download factors that contribute to plan formation

Medicine, Nursing and Health Sciences
Care plans for patients with type 2 diabetes:
factors that contribute to plan formation
Wickramasinghe LK1, Schattner P1, Enticott J2,3, Georgeff M1,4, Russell G2,3, Piterman L5
1 Department of General Practice, School of Primary Health Care, Monash University, 2 School of Primary Health Care, Monash University,
3 Southern Academic Primary Care Research Unit (SAPCRU), Australia, 4 Precedence Health Care, Melbourne,
5 Office of the Vice-Chancellor, Monash University.
Aims & rationale
Australian governments encourage care planning for
patients with chronic disease by providing incentives for
general practitioners (GPs) to develop General Practice
Management Plans (GPMPs) and, when multidisciplinary
care is required, Team Care Arrangements (TCAs).
However, approximately 20% of patients with chronic
disease who have a GPMP do not have a TCA [1, 2].
cdmNet [6, 7] is a web-based chronic disease management
tool developed in Australia to assist GPs and other
healthcare providers to optimise care management for
patients with chronic disease. cdmNet creates GPMPs and
TCAs, manages Reviews, and assists adherence to a care
plan by the patient and the care team.
Though patient factors such as BMI > 25kg/m2, smoking
status and comorbidity had an association with the creation of
a TCA, they had a minimal effect. The only predictor, BMI >
25kg/m2, had a very small odds ratio.
The major determinant of TCA creation could be the
complexities in managing TCAs [8, 9] rather than patient
factors. Compared to national Medicare data in the
corresponding period (TCA/GPMP ratio of 79%), the results
indicate that users of cdmNet create half the number of GPMP
only care plans (11%) than non-users (21%). cdmNet may
reduce process complexities and thus enable a more efficient
creation and management of TCAs.
Given the importance of TCAs in managing patients with
diabetes [3, 4], this study aimed at investigating patient
factors associated with the creation of a TCA as a care
planning item in addition to a GPMP.
Methods
Large practices were likely to create more TCAs than small
practices. The reason could be that large practices place more
emphasis on adhering to systematic care procedures
compared to small practices. These practices may possibly
have taken a practice-wide approach to the use of cdmNet in
managing their patients with chronic disease.
Design
A cross-sectional analysis of prospectively collected data
from cdmNet.
Setting
Discussion
Participants
The analysis could be enhanced if for each practice the
percentages of GPs who use cdmNet were known. However,
as the results indicate that larger practices perform more
TCAs, these practices may be engaged in greater
collaboration with the health care team.
The sample included de-identified data of 1417 patients for
whom a GPMP was created by 148 GPs within 77 practices
from September 2008 to January 2012.
Conflicts of interest
The cohort of interest was cdmNet patients with care plans
for diabetes mellitus type 1 or type 2.
•
•
•
Electronically sends the TCA to allied health providers
Shares patient information across the care team
Facilitates collaboration
Professor Georgeff is the CEO of Precedence Health Care
that developed cdmNet. However, the views expressed in this
paper are those of the authors and should not be taken to
represent the views of Precedence Health Care.
Measurements
Patient factors included:
1. Demographics: age, gender and marital status
2. Clinical measures: glycosylated haemoglobin (HbA1c),
body-mass index (BMI), blood pressure (BP), high-density
lipoprotein (HDL), low-density lipoprotein (LDL) and total
cholesterol (TC)
Acknowledgement
3. Lifestyle: smoking status and alcohol consumption
4. Comorbidity
Demographics and lifestyle factors were coded as
categorical variables. Clinical measures were dichotomised
based on ‘best practice’ management targets as given in
Australian diabetes management guidelines.
Comorbidity was dichotomised based on the existence (yes)
or non-existence (no) of one or more chronic conditions
(beyond diabetes).
Practice factors included:
Figure: TCA/GPMP ratio vs number of GPs in a practice
Table: Significant patient factors
Patient factor
BMI > 25kg/m2
Smoking status
Comorbidity
N (patients)
1114
1315
1417
Significance (p)
< 0.05
< 0.05
< 0.05
Effect size
small
small
small
1.Number of GPs who use cdmNet
Results
2.Practice location: Australian Standard Geographical
Classification - Remoteness Area (ASGC-RA) [5].
Patient factors
Outcomes
Out of 1417 patients, 1257 (89%) had both a GPMP and a
TCA, and 160 (11%) had a GPMP only care plan.
1.Patient factors: GPMP associated with TCA (yes) or GPMP
not associated with TCA (no).
Significant factors for having a TCA (see Table)
2.Practice factors: The proportion of GPMPS with TCAs
(TCA/GPMP ratio) for each GP in the practice.
Analysis
1. Chi-square test for independence - to examine any
association between each patient factor and the output
variable.
2. Binary logistic regression test - to determine whether any
significant variables identified in analysis (1) are predictors
for the creation of TCAs.
3. Pearson product-movement correlation - to explore any
association between the TCA/GPMP ratio and the number of
GPs in a practice who use cdmNet.
4. One-way between-groups analysis - to examine any
association between the TCA/GPMP ratio and practice
location.
This work is supported by funding from the Victorian
Government under the Victorian Science Agenda program and
the Australian Government under the Digital Regions Initiative.
Precedence Health Care (www.precedencehealthcare.com)
was the lead partner. We thank the GPs who provided consent
to their cdmNet data being analysed.
•
BMI > 25kg/m2
•
Smoker
•
Comorbidity
Predictors for having a TCA
•
BMI > 25kg/m2 with an odds ratio of 1.84
Practice factors
A positive correlation between the TCA/GPMP ratio and the
number of GPs in a practice who use cdmNet (see Figure)
• a large variation in the TCA/GPMP ratio for small practices
with number of GPs ≤ 5 (SD = 0.35);
• compared to small practices, a consistent ratio for large
practices with number of GPs > 5 (SD = 0.05); and
• higher mean TCA/GPMP ratio for large practices compared
with small practices (mean = 0.94 vs 0.74 respectively).
References
1. Medicare Item Reports.
https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
2. Adaji A, Schattner P, Jones K, Beovich B, Piterman L. Care
planning and adherence to diabetes process guidelines: Medicare
data analysis. Australian Health Review (accepted)
3. Zwar N, O. and Comino, E.J. and Shortus, T. and Burns, J. and
Harris, M. Do multidisciplinary care plans result in better care for
patients with type 2 diabetes? Aust Fam Physician. 2007;36(1/2):85-9
4. Zwar N, Hasan I, Hermiz O, Vagholkar S, Comino E, Harris M.
Multidisciplinary care plans and diabetes-benefits for patients with
poor glycaemic control. Aust Fam Physician. 2008;37:960-2
5. Australian Standard Geographical Classification - Remoteness
Area (ASGC-RA).
http://www.health.gov.au/internet/otd/publishing.nsf/Content/ra-intro
6. Georgeff, M., et al., CDM-Net: a broadband health network for
transforming chronic disease management. Final report, Precedence
Health Care (2010)
7. Jones, K., Dunning, T., Costa, B., Fitzgerald, K., Adaji, A.,
Chapman, C., Piterman, L., Paterson, M., Schattner, P. and Catford,
J. (2012). ‘The CDM-Net Project: The Development, Implementation
and Evaluation of a Broadband-Based Network for Managing Chronic
Disease.’ International Journal of Family Medicine. DOI.
10.1155/2012/453450
8. Hartigan PA, Soo TM, Kljakovic M. Do team care arrangements
address the real issues in the management of chronic disease. Med J
Aust. 2009;191(2):99-100
9. Kirby SE, Chong JL, Frances M, Powell-Davies G, Perkins DA,
Zwar NA, et al. Sharing or shuffling - realities of chronic disease care
in general practice. Med J Aust. 2008;189:77.
Contact:
[email protected]