Background
Diabetes mellitus is a chronic condition primarily characterised by elevated levels of plasma glucose due to a lack of insulin. Diabetes is a risk factor for a number of acute and chronic complications and is associated with significant morbidity and mortality, the risks and impact of which may be modifiable through high-quality primary care. This thesis examines the relationship between the quality of primary care and emergency admissions, readmissions and mortality.
Methodology
Associations between primary care quality and clinical outcomes for people with diabetes were assessed at the practice and patient level. Practice-level analyses, utilising Quality and Outcomes Framework (QOF) and Hospital Episodes Statistics (HES) data, modelled the impact of practice achievement of thematically-grouped QOF indicators on standardised emergency admission rates, controlling for characteristics of the practice, the socioeconomic environment and the patient population. Patient-level analyses utilised a Clinical Practice Research Datalink (CPRD-HES) dataset linking primary care activity with hospitalisations. Modelling examined associations between QOF target-based indicators and National Diabetes Audit (NDA) care processes and rates of emergency admissions, readmissions and the odds of death.
Results
In practice-level analyses, QOF indicators pertaining to processes of care and availability of appointments were most consistently associated with reduced emergency admission rates. For patient-level analyses, a number of NDA processes were consistently associated with reduced emergency admission and readmission rates and reduced odds of death across follow-up periods ranging from one to five years. Associations with QOF targets were less consistent. Across all practice- and patient-level analyses, deprivation was strongly associated with changes in admission rates and odds of death.
Conclusions
High-quality primary care has the potential to meaningfully improve outcomes for people with diabetes; the effects of socio-economic deprivation remain sizeable even after adjustment for primary care quality.