title: Improving GP diabetes management - A PDSA audit cycle in Western Australia.
abstract: BACKGROUND
  Tight glucose, blood pressure and lipid control in patients with diabetes can reduce morbidity and mortality from macro- and micro-vascular complications. However, treatment targets are not being met in a large proportion of patients. Clinical audit involves cycles of evaluation of current activity against standards. It allows problems to be identified and action to be taken to address them.
  
  
  METHODS
  Annual retrospective audits over 3 years of random samples of up to 20 patient medical records from 13 general practitioners in the midwest region of Western Australia (n=807). Statistical tests compared the second and third audits with the first in regard to completeness of screening, health indicators, and the proportion of patients within The Royal Australian College of General Practitioners and Diabetes Australia guidelines targets.
  
  
  RESULTS
  While there was a significant improvement in lipid monitoring over the study period (p<0.001), monitoring of HbA1c and blood pressure (BP) remained unchanged. Between the first and third audits, a reduction in mean HbA1c (p<0.001), mean total cholesterol (p=0.017), mean LDL cholesterol (p=0.014) and mean systolic BP (p=0.002) was seen. There was an improvement in the proportion of patients achieving cholesterol goals (measured by LDL and reaching a target of HbA1c <7%) between the first and third audits; however the proportion with BP within target declined. In the third audit, 11% of patients on diet alone, 36% on an oral hypoglycaemic agent, 90% on three oral hypoglycaemic agents and 84% of those on insulin were outside the target HbA1c. In the same audit, of those outside target BP, 53% were on no treatment and 65% were only on one type of medication. Eighty-seven percent of patients outside target cholesterol levels had not been prescribed a statin.
  
  
  CONCLUSIONS
  Many of the audited GPs in our study undertreated BP, HbA1c and cholesterol. Improvement in some areas was seen over the study period, which may have been due to the quality assurance activities undertaken. These results reveal a therapeutic opportunity for reducing cardiovascular events in patients with diabetes. More aggressive management of BP and lipids by GPs may see rewards in terms of reducing cardiovascular events in patients with diabetes.
authors.affiliation: Combined Universities Centre for Rural Health, Geraldton, Western Australia. cindyp@cucrh.uwa.edu.au
authors.forename: Cynthia
authors.initials: C
authors.lastname: Porter
authors.forename: Charlie
authors.initials: C
authors.lastname: Greenfield
authors.forename: Ann
authors.initials: A
authors.lastname: Larson
authors.forename: Marisa
authors.initials: M
authors.lastname: Gilles
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D003133:Commission on Professional and Hospital Activities / Q000592:standards* / Q000639:trends; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000453:epidemiology* / Q000628:therapy; D019468:Disease Management; D005194:Family Practice / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D014904:Western Australia / Q000453:epidemiology; D055815:Young Adult