Integrated Care of people with Type 2 diabetes in Western Sydney: A business case for Joint Specialist Case Conference (JSCC) with General Practice

Introduction: Type 2 diabetes is the leading burden of disease in Australia, particularly in Western Sydney, with 960,000 people and one of the fastest growing populations. Approximately 15% of the population have diabetes, 35% are at high risk of diabetes and 50% are overweight/obese.

Western Sydney Diabetes (WSD) initiative was established in 2012 by Western Sydney Local Health District (hospital care) and Western Sydney Primary Health Network (primary healthcare) with a range of partners.

Aim, theory, targeted population and timeline: The business case identified support to primary care through a hospital-led Joint-Specialist Case-Conference (JSCC) service with a focus on prevention and management of patients with diabetes at an individual and practice level.

WSD has run a JSCC service since 2014. A diabetes specialist, resident medical staff, and diabetes nurse educator attend General Practice (GP) to conference with the GP and the patient to develop a management plan. In a session, we see up to 12 patients, 30 minutes each. With four teams doing six sessions a week, JSCC has seen over 1000 patients, and over 150 GPs.

JSCC aims to keep people with diabetes well, with fewer complications and reduce the demand on hospitals. It achieves this by empowering GPs to develop their capacity to manage their patients in the long term after 10 sessions with JSCC.

Highlights: We demonstrated significant benefits for the patient, including (at 3-6 month follow-up) an average HbA1c concentration reduction of 0.87% (95% CI -1.31, -0.44), mean reduction in systolic blood pressure of 6.45mmHg (95% CI -11.48, -1.41) and non-significant reductions in mean weight, total cholesterol and diastolic blood pressure. We also found a significant reduction in hospital waiting times for specialist services, from 12 to 2.5 weeks. These investigations are repeated at the 18 month follow-up.

The JSCC program has high acceptance among GPs. Over 90% of GPs agree/strongly agree that JSCC was useful to their practice to build their capacity to manage patients with diabetes and would recommend it to their colleagues.

The PEN Clinical Audit Tool (PENCAT) was used to track the management of patients with diabetes. Early results indicate that GP practices experienced significant reductions in mean HbA1c of all patients with diabetes (not only those who had been case conferenced) and reductions in BMI, blood pressure and indicators of care integration.

Looking forward; conclusions, sustainability, and transferability: A cost-benefit analysis found that for every dollar spent on JSCC, we would see a return of over A$3. More broadly, across a number of interventions targeting diabetes prevention and management, it found that, over seven years, a $68m investment would deliver a net benefit of $124m.

The flexibility of JSCC and the cultural diversity of Western Sydney (50% of the population born overseas) means the program will be easily transferrable to other primary/tertiary care environs.