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Radical rural approach to juvenile diabetes care
A frustration with the challenges faced by rural young people led a Gippsland paediatrician and his team to trial a new private model for diabetes care, with ongoing success. Sam Lawry talks to Dr Peter Goss about their approach.
For young rural people with diabetes mellitus, lack of access to health services can leave them at significant disadvantage, resulting in reduced quality of life, both in terms of physical health, and psychosocial factors1.
In Australia, around 95 per cent of the diabetes found in children is type 1 diabetes. Life expectancy for patients with juvenile diabetes is reduced on average by 15 years, with more than 50 per cent developing severe health complications after 20 years. Significantly, the incidence of juvenile diabetes is increasing at 3.2 per cent a year2.
Despite NHMRC guidelines recommending a multidisciplinary team approach as part of maintaining optimal glycaemic control, there are logistical challenges in rural and regional areas. Funding for the services required for a multidisciplinary team comes from both the state allocation for regional diabetes services (often given to the regional health service) and the federal Medicare budgets for medical and psychological services and some diabetes education. A failure to prioritise the NHMRC recommendations has often led to a disjointed approach to rural child diabetes, meaning patients and their carers need to make multiple appointments with different care providers. In 2007, Gippsland Paediatrics, a private practice in Sale, identified that this approach was not working – glycaemic control was deteriorating and attendance at allied health appointments, including with Credentialled Diabetes Educators (CDEs) was less than ideal.
In response, the practice created a new approach – the RADICAL (Rural Australian Diabetes – Inspiring Control, Activity and Lifestyle) model – hiring both a CDE and a mental health nurse experienced in child, family, behaviour, loss and trauma counselling.
Multidisciplinary diabetes clinics for children and adolescents in the Central and East Gippsland Regions were established, independently of public health services. The practice held six co-located clinics every three months, during which almost 70 patients had appointments with each of the health professionals.
To reduce the burden of disease further, a local charity (the Kate Buntine Children’s Trust) purchased an onsite HbA1c analyser for use at the clinics. At the conclusion of the clinic, the health team with a local dietician met in case conference for each patient to devise strategies and optimise support of the child and family.
In mid-2007 the team commenced an insulin pump (Continuous Subcutaneous Insulin Infusion) program – one of the first of its kind in regional Australia. An insulin pump, which delivers a more physiological regime of insulin including background insulin and food and correction boluses, allows young people and their families greater flexibility and reduces the risk of dangerous fluctuations in blood glucose levels. The Gippsland Paediatrics insulin pump program was supported and encouraged by paediatric endocrinologists who had been consulted by the practice.
The RADICAL model was evaluated and a report published in the international journal, Pediatric Diabetes, in 2010. Dr Peter Goss, Gippsland Paediatrics’ general paediatrician and lead author of the report, and AMA Victoria member, says that their results continue to be equal to or better than most metropolitan centres in Australia. “The results have been consistent now over four years in terms of medical control, patient satisfaction and quality of life. Our region in Gippsland now has the largest percentage (over 80 per cent) of patients in a region using insulin pumps in Australia, even the world, as compared with Germany (70 per cent), the RCH Melbourne (30 per cent) and other parts of country Victoria (less than 5 per cent). It is brilliant equipment that actually works for these rural kids, if supported by an experienced team with appropriate back-up.”
What works for this practice is the team-based approach, where team members share experiences and explore what has worked for individual patients. As Dr Goss explains:
“We listen to each other’s points of view and look for keys to inspire and help the kids and families. The incorporation of the emotional health expertise allows our model to address the whole person in the context of their family and peers and refreshes the approach. You can tweak their dosage, but it makes no difference until you address their emotional health. Many pump programs often do not see sustained improvement, but our results are certainly sustained.”
But running this kind of model from a private practice has had its challenges, including funding the employment of the CDE and counsellor. “It is frustrating; people with type 2 diabetes can rebate up to 16 visits annually with an allied health practitioner but type 1 diabetes patients (that is, most children) only get five. This is despite the NHMRC recommending that patients see at least three different allied health professionals every three months. Psychological care may be rebated for psychologists but not mental health nurses unless you are in a general practice. Some flexibility should be given so these models of care for young people with diabetes can be easily replicated around Australia. The benefits of our model include slashing inpatient admissions from 25 per cent per year to 5 per cent, reducing serious hypoglycaemic reactions, better school support and reducing the risk of long term health issues, such as kidney disease, which places serious demands on the health dollar. Prevention is where the focus should be for all sorts of logical reasons.”
Another challenge was the cost of the IPT pumps for uninsured families. In 2009 the maximum Federal Government subsidy was $2500 for a pump costing approximately $8000. With local charity support and the support of the Shane Warne Foundation, the Gippsland Paediatrics team became the biggest users of the program in Australia, with almost a third of successful applications. Dr Goss then demonstrated3 equivalent benefits of insulin pump therapy in public patients under the RADICAL model with significant improvement in medical control, which provided a strong case for changes to the government program. The Federal Government subsidy now better assists public children, covering up to $6400 of the cost and allowing greater choice for families.
Dr Goss has continued to advocate for the RADICAL model, presenting overseas and locally. This year he was awarded the Murray-Wills Fellowship for Rural Physicians, and travelled to the United Kingdom, to undertake further research, as well as co-authoring a presentation on the effects of changes in atmospheric pressure on insulin delivery from insulin pumps. This research involved studying the physics of insulin pumps during travel up and down elevators at Eureka Tower and on commercial aircraft. He is grateful for the opportunity to undertake postgraduate education in this area.
Dr Goss is passionate about the effectiveness of the model of care with its focus on individual wellbeing, and the improvement in quality of life for their young patients. “We are devising strategies that are individually right for them. Many chronic childhood conditions have appropriate government funding to support the kids. However there are two chronic childhood conditions that need better day-to-day care: cystic fibrosis and diabetes. We know we can make a difference by getting away from the old model of a purely medical approach.”
Frustration can lead to innovation. State and federal governments could look to this successful model, created by one small team, as a potential blueprint for managing rural diabetes care, right across Victoria.
This article was published in the August 2011 edition of vicdoc.
1. Goss PW, Paterson MA, Renalson J, ‘A “radical” new rural model for pediatric diabetes care’, Pediatric Diabetes 2010:11:296-304
2. Juvenile Diabetes Research Foundation, at www.jdrf.org.au
3. Goss PW, ‘Glycaemic control in patients with type 1 diabetes’, Letters, MJA 2010; 192(2): 107-108.
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