Clinical outcomes audit in a primary care setting

The diabetes project in Enfield commenced in 2005 with a mandate to provide a comprehensive and systematic model of care for people with diabetes living in the borough. The model chosen was a nurse-led intermediate diabetes service (IDS) that would link closely with the hospital-based service and fully support the general practices. 

The aim of the IDS was to provide a high-quality pathway of care for diabetes management, which offered education, support and advice for people with diabetes and their carers, as well as healthcare professionals. The changes and developments of the service have been outlined in two articles (Hicks and McAuley, 2006; 2008), with another in press. 

Although the nursing team had undertaken patient satisfaction surveys, there was no clinical evidence of good health outcomes for the people who attended the IDS. An audit proposal was developed to provide information on the effectiveness of the IDS to sit alongside the patient satisfaction survey data.

Aim
The main aim of this audit was to assess the efficacy of the IDS. Data collected from several patient satisfaction surveys have shown that the people who access the service are happy with it, for example 100% of people being seen within 15 minutes of their appointment time, as well as feeling that the quality of care received was either good or very good. We decided that it was essential to see if we had been as successful at making a difference to the patients’ clinical picture as we had been at improving their experience.

Methods
A clinical outcomes audit was undertaken between June and September 2009. Administrative and DSN time was allocated. Case notes of 361 people referred to level 3 diabetes care (for more information on the model of care see NHS Enfield web page: http://bit.ly/9i4oyF) were examined and retrospective details entered onto a Microsoft Excel spreadsheet. 

Results
Referral data: the highest number of referrals (53.7%) came from Edmonton. This area has the largest proportion of single-handed practices as well as indicators that show that this area has a diverse ethnic mix and is socially deprived with a high level of unemployment.

Number of consultations: face-to-face consultations averaged 4.3 per person and telephone contacts averaged 3.9 per person. An average of 1.2 dietetic appointments was attended for each episode of care.

HbA_1c: The mean HbA_1c level at time of referral was 9.3% (78 mmol/mol; range 4.5–16.4% [26–156 mmol/mol]). The final mean taken at the time of data collection was 8.2% (66 mmol/mol), a reduction of 1.1 percentage point within the audit period.

Total cholesterol (TC): A drop from a mean TC of 5 mmol/L to a final mean result of 4.4 mmol/L was observed.

Blood pressure (BP): the audit of BP was found to be too problematic to analyse. The results for BP were therefore omitted from this audit.

Conclusion
The IDS in Enfield has been shown to be effective in improving clinical outcomes while maintaining a high degree of patient satisfaction. We have learnt much about the audit process, data collection and analysis from this exercise. We are pleased to note that this information demonstrates that our service is making a significant difference to improving the health of people with diabetes living in Enfield.

A full article discussing this audit will be available shortly.