The inexorable rise of primary care diabetes over the past 10 years, with a mass transfer of patients from hospital clinics and the creation of community diabetes medical and nurse consultants may now be demonstrating a down-side.
A summary of the National Diabetes Inpatient Audit (NaDIA 2011) in England was recently published, this being the third snapshot of inpatient care for people with diabetes. NaDIA 2011 was carried out by diabetes teams in 188 acute sites on a nominated day in October, resulting in data on 11,866 inpatients.
People in hospital with diabetes were older than other patients (median age of 75 years vs. 65 years for all patients), more likely to be admitted as an emergency (84.5% vs. 80.8%) and had a longer median length of stay (8 nights vs. 5 nights).
41.1% of diabetes inpatients were insulin treated with over 80% of these being people with type 2 diabetes (T2DM).
So who is looking after these elderly, acutely unwell diabetes patients on complex anti-diabetes therapies? Well not, apparently clinicians with a special interest in the condition. 69.1% of sites had no specialist inpatient dietetic provision for people with diabetes, 30.9% had no diabetes inpatient specialist nurses and diabetes consultants were spending only 11.6% of their time on inpatient care. Perhaps this partly accounts for 32.4% of patients experiencing at least one medication error and 65 patients (0.6%) developing diabetic ketoacidosis as an inpatient?
It is of note that less than 10% of patients were admitted specifically for management of their diabetes, perhaps implying that a shift in resource from secondary to primary care will not affect the high admission rates (as might be anticipated in other chronic diseases such as COPD or congestive cardiac failure, where acute exacerbations of the disease typically leads to an emergency review).
Of those patients admitted specifically for management of their diabetes, 47% were admitted with active foot disease. This is especially relevant to the decline in inpatient diabetes personnel since the NICE guidance for ‘Inpatient management of diabetic
foot problems March 2011’ recommends referral to the multidisciplinary (MDT) foot care team within 24 hours of the initial examination of the patient’s feet and transfer of responsibility of care to a consultant member of the MDT foot care team. In this context, the MDT foot care team ‘should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist and a tissue viability nurse’. In the NaDIA 2011, only 22.4% of patients had a documented foot examination within 24 hours of admission…
Is a lack of adequate inpatient diabetes care, a price worth paying for the inevitable benefits of the beefing up of primary care provision? Well, perhaps those benefits are not quite as obvious as one might imagine. The Audit Commission’s publication ‘Costing Care Pathways: Understanding the cost of the diabetes care pathway’ in 2011 concluded that ‘community and outpatient care data are not good enough’ and commented that ‘moving care out of hospitals and into the community might be intuitively better for patients, but it has so far proven very difficult to cost or measure’.
Back to the drawing board?
Professor Steve Bain