The primary care consultation in type 2 diabetes
Type 2 diabetes is a common condition that is associated with high rates of morbidity, mortality and healthcare costs. Multifactorial management has been shown to be effective in preventing complications and inducing remission or cure of the disease. Despite this, the rate of new cases and the overall burden of the disease remains high. There is a need, therefore, to refocus efforts on strategies to prevent complications in type 2 diabetes. Most of the disease in the UK is now managed in primary care consultations and there is increasing emphasis in health policy on ‘making every consultation count’. Accordingly, the overall aim of my thesis is to contribute new knowledge and understanding on the role of the primary care consultation as a strategy in managing and preventing complications of diabetes, with a particular focus on the contribution of patient experiences.
Data from the ADDITION-Cambridge and ADDITION-Plus population-based cohorts were used to quantify associations between experiences of primary care consultations measured with the Consultation and Relational Empathy Measure (CARE), and i) cardiovascular (CVD) risk factors, ii) CVD events, iii) all-cause mortality and iv) remission of type 2 diabetes. This was followed by further observational analyses to examine the role of patient health behaviours as a mediator of these associations. Qualitative analysis of semi-structured interviews with practitioners and patients were carried out to further elucidate theory that might explain how primary care consultations relate to the management of diabetes, and to understand the practicalities and barriers in delivering optimal experiences. Social practice theory was then used as a frame of reference to collate findings and contextualise the primary care consultation in managing and preventing complications of diabetes from a wider social perspective.
The results of the observational analyses suggest that the primary care consultation may have a small impact on CVD risk factors early in the course of illness (higher levels of high-density lipoprotein cholesterol, lower systolic blood pressure and lower diastolic blood pressure). However, these associations are unlikely to be mediated through patient health behaviours. Over the longer term, consultation experience was significantly associated with the incidence of all-cause mortality; a 40% lower risk of mortality was found in patients with type 2 diabetes who reported better primary care consultation experiences compared to those with poor experiences. Similar trends were observed with CVD events but these were not statistically significant. Consultation experiences were additionally associated with remission of diabetes in adjusted models; 2-3% lower odds of remission with better patient-reported experiences of the consultation according to the CARE measure.
The qualitative chapters identified issues around consultation length, relational continuity, face-to-face contact and type of practitioner as important contributors to primary care consultation experience. Moreover, my findings highlighted the difficult balance that needs to be achieved within the consultation between patient experience and disease management, and also between patient-centred and doctor-centred consultations. Further interviews with practitioners emphasised how the wider problems of pressures on the service and increased workloads in primary care are impacting consultation experience. This highlighted competing priorities which could distract from effectively utilising the consultation in diabetes. The final analysis chapter used social practice theory to collate the findings across chapters and suggested that a whole system and societal approach is needed to develop and inform the delivery of effective diabetes strategies. Overall, my thesis suggests that the primary care consultation experience has the potential to be an important strategy in managing and preventing diabetes complications. There are opportunities to more effectively use the consultation in primary care in a way that considers the individual, healthcare system and wider society together. More research is required to establish the causal pathways to explain how these experiences relate to outcomes and to understand what form a future whole system societal intervention might take.
Kinmonth, Ann Louise