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Contents lists available at ScienceDirect

Primary Care Diabetes

j o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / p c d

riginal research

iabetes care in Ireland: A survey of general practitioners

heena Mc Hugha,∗, Jo O’Keeffeb, Anne Fitzpatrickb, Anna de Siúnc, Monica O’Mullaneb,van Perrya, Colin Bradleyb, On behalf of the National Diabetes Register Project (NDRP)Department of Epidemiology & Public Health, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, IrelandDepartment of General Practice, University College Cork, IrelandIrish College of General Practitioners, 4-5 Lincoln Place, Dublin 2, Ireland

r t i c l e i n f o

rticle history:

eceived 30 April 2009

eceived in revised form

1 September 2009

ccepted 22 September 2009

vailable online 17 October 2009

eywords:

iabetes

rimary care

epublic of Ireland

eneral practitioners

a b s t r a c t

Aim: To investigate the organisation of diabetes care in general practice in Ireland and

identify areas for future development.

Methods: Survey of a representative sample of 600 general practitioners (GPs). The question-

naire contained closed and open-ended questions addressing 4 topics; characteristics of the

practice, diabetes care delivery, use of services and opportunities for developing diabetes

care.

Results: The response rate was 44% (n = 262). There were an additional 86 responses to a

follow-up shortened version of the survey resulting in a 58% response rate for 9 key ques-

tions. The majority of respondents were from an urban (43%, n = 112) or a mixed area (39%,

n = 101) and 19% of practices were single-handed (n = 66). The reported prevalence in partici-

pating practices was 0.7% for Type 1 diabetes and 2.8% for Type 2 diabetes. Forty-five percent

of GPs maintained a diabetes register (n = 157) while 53% reported using guidelines (n = 140).

A formal call recall system was reported by 30% (n = 78) with a further 20% (n = 54) reporting a

regular if informal approach to calling patients for review. With regard to the use of diabetes

related services 63% reported direct access to a dietician (n = 165), 57% direct access to chi-

ropody services (n = 149) and 89% had direct access to retinopathy screening (n = 234). There

was a significant association between maintaining a diabetes register and other aspects of

care delivery such as engaging in formal recall (p < 0.001), using guidelines (p < 0.001) and a

declared special interest in diabetes (p = 0.001). Of a number of choices 75% of GPs thought

that training was the principal opportunity for improving diabetes care. In response to the

open-ended questions GPs cited lack of resources, time constraints and workload as barriers

to effective care delivery.

Conclusions: Delivery of diabetes care in Ireland remains largely unstructured. Key challenges

to improving diabetes care appear to extend to the system and organisational level of care

delivery.

© 2009 Primary Ca

∗ Corresponding author. Tel.: +353 21 420 5253; fax: +353 21 420 1923.E-mail address: s.mchugh@ucc.ie (S. Mc Hugh).

751-9918/$ – see front matter © 2009 Primary Care Diabetes Europe. Puoi:10.1016/j.pcd.2009.09.002

re Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

blished by Elsevier Ltd. All rights reserved.

e t e s

226 p r i m a r y c a r e d i a b

1. Introduction

Diabetes mellitus is emerging as one of the most significantproblems facing health systems around the world with an esti-mated increase in the worldwide prevalence of diabetes from2.8% in 2000 to 4.4% in 2030 [1]. In Ireland the prevalence isexpected to increase from 4.7% of the population in 2005 to5.6% by 2015 [2]. The rising prevalence and the ever increasingcost of chronic diseases such as diabetes have led to healthservices examining ways to reconfigure services with growingemphasis on the development of primary care services [3].

Consequently general practitioners (GP) are assuminggreater responsibility in the delivery of diabetes care [4]. Carein the community has been found to be as effective as hospitalbased care but only when it is structured and organised [5]. Ithas also been shown that care provided in the primary caresetting can enhance diabetes quality of life without compro-mising quality of care [6]. The first national survey of diabetescare in Ireland in 2003 found that while a significant amountof diabetes care was delivered in general practice, particularlyfor Type 2 patients, this care was largely unstructured. Fewerthan half of the GPs surveyed reported using a register whilejust over half engaged in routine recall [7]. The shift in theIrish system towards primary care management of diabetesis relatively recent compared to the UK where there is alsogreater unity between primary and secondary care servicesand specific policy guidance through the National ServiceFramework for Diabetes [8]. The emphasis placed on quality ofcare in the UK, as evidenced by the implementation of the pay-for-performance incentive scheme the quality and outcomesframework (QOF), has had a positive impact on diabetes careat least in the short-term [9,10].

There is increasing interest in professional and organisa-tional interventions which have led to improvements in themanagement of diabetes patients in primary care, out-patientand community settings. In particular, patient tracking sys-tems and other forms of regular patient follow-up improvedquality at a process level [11]. While electronic patient regis-tration is one of a variety of quality improvement strategies,it is in itself fundamental to the infrastructure of an optimalhigh quality diabetes management system [12]. Before such astrategy can be developed in an Irish context the current levelof diabetes care needs to be assessed.

The organisation and delivery of diabetes services is com-plex and differs between countries involving secondary care,primary care or shared care systems integrating services fromboth settings [13]. Ireland reflects this complexity and ischaracterised by substantial variation in the organisation ofdiabetes care. The aim of this study was to assess the currentlevel of diabetes care delivered to patients in general prac-tice in Ireland and identify areas for future improvement anddevelopment.

2. Methods

2.1. Sampling and data collection

In June 2008 a postal questionnaire and stamped addressedenvelope was sent to a random sample of 600 GPs from the

3 ( 2 0 0 9 ) 225–231

membership database of the Irish College of General Prac-titioners (ICGP). Approximately 2500 GPs are registered withthe ICGP representing 90% of practicing GPs in Ireland. Thesurvey was administered through the ICGP to maintain theanonymity of its members. A second mailing was sent to thosewho had not responded within 2 weeks. Participants werealso provided with a postcard to be returned separately fromthe questionnaire to eliminate responders from subsequentfollow-up. Of the 600 GPs 44% responded (n = 262). A short-ened version of the survey (9 questions) was distributed tothose who had not returned a postcard (n = 338). This resultedin an additional 84 responses, therefore for 9 key questionsthere was a response rate of 58% (n = 346).

2.2. Description of the instrument

The questionnaire was adapted from one used in the UK toassess the level of diabetes care [14]. This questionnaire hasalso been used previously in an Irish setting to assess localservices in the west of Ireland [Evans et al., personal commu-nication] [15]. It was piloted before its use and produced in anoptically scannable format using Teleform software. The sur-vey consisted of closed and open-ended questions addressingpractice characteristics, diabetes care delivery, use of diabetesrelated services and the extent of contact with the local hos-pital based diabetes team and the principal opportunities forimproving diabetes care as well as feedback on current caredelivery.

2.3. Analyses

The obtained responses were scanned, entered automaticallyinto a database and analysed by the Statistical Package forthe Social Science 16.0 (SPSS) software for Windows. Prac-tice size and number of patients with diabetes are describedusing median and interquartile range (IQR) as data wereskewed. Categorical survey responses were analysed usingthe chi square test and supplemented with 95% confidenceintervals around the difference in proportions. The Bonfer-roni correction was used to adjust for multiple comparisons.NVivo software was used to conduct thematic analysis onthe responses to open-ended questions. Inter-coder reliabilitywas conducted on this qualitative data. This ensures internalvalidity of thematic categorisation within the responses [16].

3. Results

3.1. Responders and non-responders

Valid responses were obtained from 262/600 GPs initially (44%).A further 86/338 responses to 9 key questions were obtained inthe non-responders survey. There was only one significant dif-

ference between the groups. Practices with a special interestin diabetes were significantly more likely to have respondedto the initial questionnaire (81% vs. 63%, p < 0.05) but this wasno longer significant after adjustment for multiple testing.

p r i m a r y c a r e d i a b e t e s 3 ( 2 0 0 9 ) 225–231 227

Table 1 – Features of diabetes care delivery.

Feature of care delivery Total, n n (%) 95% CI

Diabetes register 348 157 (45) 40–50Specific clinics 348 78 (22) 18–26

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ated with maintaining a register included engaging in formalrecall (p = 0.000) and the use of guidelines (p = 0.000). Thosewho reported having a diabetes register had greater directaccess to some diabetes related services including a dietician

Formal recall 262Informal recall 262Screening 262Guidelines 262

.2. Practice profile

he median size of the patient list was 4000 (IQR = 2200–6750)nd the median number of diabetes patients in the list was00. The reported prevalence in participating practices was.7% for Type 1 diabetes and 2.8% for Type 2 patients. Thegures for these calculations were predominantly based onhe GPs’ best estimate of diabetes patient figures (n = 171, 72%)ather than actual figures from practice IT systems (n = 66,7%).

The majority of practices had between 2 and 4 doctorsn = 212, 62%) while 19% were single-handed practices (n = 66).espondents were predominantly from an urban area (n = 112,3%) or mixed area (n = 101, 39%) with fewer than 20% from aural area (n = 47, 18%). There was a median of 3 GPs employedn urban and mixed areas compared to a median of 2 GPs inural areas (H = 14.76, df = 2; p = 0.001). Eighty-two percent ofractices employed a practice nurse (n = 286) and over halfad a practice manager (n = 134, 52%). Almost all GPs hadcomputer system (n = 321, 92%). Forty-two percent of GPs

n = 147) had a diabetes module on their system and of those0% reported using such a module (n = 88). Forty percent ofPs declared a special interest in diabetes within the practice

n = 138), most commonly among a GP (n = 81, 31%) or a nursen = 71, 27%). While only 15% of GPs (n = 53) reported no specialnterest in diabetes an additional 45% of respondents did notnswer the question (n = 157).

.3. Diabetes care delivery

eatures of diabetes care delivery present in general prac-ice are presented in Table 1. Around half of respondentseported maintaining a register (n = 157, 45%), engaging in reg-lar recall and review (n = 132, 50%; formal (20%) or informal

30%)) and using guidelines (n = 140, 53%). The most commonlysed guidelines were those developed by the ICGP (n = 59, 23%).ewer than one quarter of GPs held specific clinics for diabetesatients (n = 78) whereas almost all GPs reported screeningatients for diabetes in the practice (n = 243, 93%). Overall 50%f GPs recall stable Type 2 diabetes patients every 1–6 months.pproximately three quarters of Type 2 patients attend for

heir diabetic review (n = 199, 75%). When asked about the con-ent of a routine review the majority of respondents (80–100%)ere in line with the national guidelines on the key compo-ents when reviewing patients with Type 2 diabetes includingedication review [17].

.4. Care pathways

en percent of GPs reported having a formal shared proto-ol with his/her local hospital based specialist diabetes team

78 (30) 25–3654 (20) 15–25

243 (93) 90–96140 (53) 47–59

(n = 26). Similarly only 10% reported having ever had a jointmeeting with the hospital based team (n = 25) while 3% hadregular meetings with the hospital based team (n = 7). Sixty-three percent of GPs had direct access to a dietician (n = 165).Fewer GPs reported direct access to chiropody services (n = 149,57%). The majority of GPs had access to a practitioner whocould provide an ophthalmic exam for retinopathy screening(n = 234, 89%). In over half the cases retinopathy screening wasprovided through a combination of 2 or more practitioners(n = 127, 54% of those with access). The most common wait-ing time for all three services was 1–3 months (Fig. 1). Overone third of GPs had access to a systematic population basedretinal screening programme (n = 91, 35%).

3.5. Factors associated with maintaining a diabetesregister

There was no association between the practice profile andwhether or not a practice maintained a diabetes register; num-ber of GPs employed (p = 0.09), number of patients (p = 0.53) andnumber of diabetes patients in the practice (p = 0.084). Therewas also no significant association between location of thepractice and maintaining a register (p = 0.07). However main-taining a diabetes register was associated with a number offeatures of care delivery (Table 2). Factors significantly associ-

Fig. 1 – Waiting times for diabetes related services asestimated by GPs.

228 p r i m a r y c a r e d i a b e t e s 3 ( 2 0 0 9 ) 225–231

Table 2 – Association between maintaining a diabetes register and features of diabetes care delivery.

Feature of care delivery Register, n (%) No register, n (%) %Difference 95% CI p

Computer system 148 (96) 169 (91) 5 −0.7 to 10 0.15Diabetes module 96 (74) 49 (50) 24 11–36 0.000†

Specific diabetes clinic 64 (41) 13 (7) 34 25–43 0.000†

Formal recall 65 (54) 12 (9) 45 35–56 0.000†

Guidelines 91 (78) 49 (36) 42 31–53 0.000†

Special interest 72 (84) 62 (61) 23 11–36 0.001†

Screening 113 (95) 128 (93) 2 −4 to 7 0.08Formal shared protocol 18 (15) 8 (6) 9 2–20 0.03Regular joint meetings 6 (5) 1 (0.7) 4 0.1–8 0.86Access to dietician 95 (79) 67 (49) 30 19–41 0.000†

Access to chiropodist 81 (67) 68 (50) 17 5–29 0.009Access to ophthalmic exam 114 (95) 118 (88) 7 0.2–14 0.82Access to pop. based retinal screening programme 56 (48) 35 (26) 22 10–33 0.001†

† Significant after Bonferroni correction.

cipal

Fig. 2 – Percentage of GPs selecting the prin

(p = 0.000) and to population based retinal screening (p = 0.001).Eighty-four percent of those with a register also expressed aspecial interest in diabetes (n = 72) compared to 61% of thosewithout a register (n = 62) (p = 0.001).

3.6. Developing diabetes care

GP responses to options for developing diabetes care areshown in Fig. 2. Three quarters of GPs consider training tobe the most important opportunity for improving diabetescare (n = 196, 75%). Almost two thirds of GPs also consideredgreater access to specialist advice (n = 166, 63%) and greateraccess to community services as principal opportunities forimprovement (n = 160, 61%). These themes were reiteratedin the open-ended responses (n = 46, 18% of total sample)where issues such shared care arrangements (n = 11, 4%), dieti-cian access (n = 8, 3%) and ophthalmology access (n = 5, 2%)emerged. Many GPs felt they are not being recognised for their

work in primary care and remuneration was suggested as ameans of developing care (n = 7, 3%). Most GPs (n = 136, 52%)felt a mixture of capitation and fee for patient would be themost suitable method of remuneration.

opportunities for developing diabetes care.

In the open-ended questions GPs were also asked for theirinsights into diabetes care and ways to improve its deliveryin Ireland. Over one third of the total sample made sugges-tions and comments on diabetes care (n = 93, 36%). The mostcommon responses were categorised into facilitators and bar-riers to delivering care. Facilitators to the improvement of careincluded incentives and remuneration (n = 24, 9% of respon-dents), supportive specialist community services (n = 20, 8%)and co-operative secondary care services (n = 18, 7%). Expand-ing and building on existing shared care arrangements wassuggested as more efficient use of resources in addition toimproving patient care (n = 22, 8%). Lack of resources (n = 20,8% of respondents), time constraints (n = 14, 5%) and workload(n = 14, 5%) were cited as the most common barriers to develop-ing care delivery. Unmanageable workloads were felt to havea negative impact on the quality of diabetes care provided.

4. Discussion

The present study assessed the level of diabetes care deliv-ered in general practice in Ireland and identified areas for

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urther development. We found limited evidence of a struc-ured approach to diabetes care. The survey showed that fewerhan half of GPs maintained a diabetes register while only halff GPs operated some form of call/recall system for reviewingatients, whether formal or informal. These findings are con-istent with the first national survey of diabetes care in generalractice in 2003 where 43% of GPs reported using a registernd 51% recalled patients for regular review [7], suggesting lit-le progress has been made in organising the delivery of care.he findings also echo regional level results from a survey in

he West of Ireland in which one third of GPs reported usingregister while far fewer engaged in formal recall (12% vs.

0% reported in this survey) [Evans et al., personal commu-ication] [15]. Most GPs in this survey reported screening foriabetes. While it is vital to detect diabetes before the onsetf complications, these results raise the issue of introducingore patients into an unstructured system of care delivery.The survey showed that the majority of GPs did not have

formal shared protocol with the local hospital based spe-ialist diabetes team and had little formal contact with thisetting. This contrasts with results from the UK survey ofare provision where 39% reported a formal protocol and 14%ad regular joint meetings with the hospital based specialistiabetes team [14]. However GPs in this survey did express

nterest and enthusiasm for integrated care arrangementsith shared care emerging as one of the suggested oppor-

unities for developing diabetes care. There are a number oftructural, resource and practice implications arising fromhese findings such as the development of communicationathways between settings and patient tracking systems toacilitate the integration of these settings.

Our survey found that approximately half the sample useduidelines for care, with fewer than one quarter of GPs refer-ing to the national guidelines produced by the Irish Collegef General Practitioners. According to the recently updateduidelines for diabetes care in Ireland, three of the key com-onents of a comprehensive diabetes service are patientegistration, recall and regular review [17]. A patient regis-ration system could facilitate the latter two components ofntegrated diabetes management as it allows patients to beecalled for review or referral at appropriate intervals basedn evidence-based guidelines as well as facilitating the audit-

ng of care and outcomes for quality improvement [18]. Thisual relationship is supported by the significant associationsetween maintaining a diabetes register and other aspects ofiabetes care delivery demonstrated in this study. Among oth-rs there was a significant association between maintaining aegister and having a diabetes module on the practice IT sys-em as well as engaging in formal recall. Thus other aspects ofiabetes care may facilitate or be facilitated by the presencef a register.

It seems likely that maintaining a diabetes register is alear marker of a greater interest among practices in qual-ty improvement activities overall [12]. There was a significantssociation between having a special interest in diabetes andaintaining a register however the substantial proportion of

issing data on the former variable should be taken into

ccount. This study highlights the need for further explorationf the attitude towards quality improvement. A follow-upualitative study with GPs will explore issues such as the pos-

( 2 0 0 9 ) 225–231 229

sibly iterative relationship between having a special interest indiabetes and employing quality improvement strategies suchas maintaining a register. Health professionals are key playersin the success or failure of quality improvement programmesdepending on their willingness to learn, accept and adapt tochanges in practice [19].

The main barriers to developing care, lack of resources,time constraints and workload, concur with other studiesand reflect published primary care concerns around provid-ing diabetes care in general practice [7,20]. Our study extendsprior results on barriers to care by also highlighting the prin-cipal opportunities for diabetes care improvement. Trainingfor GPs or practice nurses was the most important opportu-nity according to GPs again reflecting an enthusiasm amongthose surveyed for improving care. Further investigation iswarranted as to how this special interest translates into prac-tice.

Improving links with specialist community services suchas dieticians and ophthalmologists was cited as one of thedominant facilitators to developing care delivery in GPs’ openresponses. Access to foot-care was particularly low with justover half of the GPs reported direct access to chiropody ser-vices. While access to retinopathy screening was high (89%),it was commonly delivered through a combination of two ormore sources. This reflects the variability of care character-istic of Ireland. The last 10 years has seen the introductionof specific structured or shared care programmes for dia-betes in Ireland [13,21], however some of these initiativeshave not been sustained due to lack of funding and resources.The recent report from the Expert Advisory Group on Dia-betes (2007), which was subsequently accepted as the HealthService Executive policy on diabetes care, recommendedan integrated model of care emphasizing the importanceof equivalent standards of care in all locations through astructured and multidisciplinary approach [17]. Responsibil-ity for the implementation of this model has been handedto local Diabetes Service Implementation Groups in order toadapt care arrangements to local circumstances. The currentembargo on recruitment in the health service and the empha-sis on saving rather than spending are likely to slow progressin this area.

Among this sample of GPs remuneration was cited as animportant factor for the development and integration of dia-betes care. A mixture of capitation and fee per patient wasproposed as the most suitable method of payment. The impactof the pay-for-performance incentive scheme introduced inthe UK (QOF) appears to have reached a plateau in terms ofquality improvement in diabetes care [22]. Taking the ceilingeffects into account, the rate of improvement in diabetes careis equivalent to the rate before the scheme was introduced.There may be credence in linking remuneration to the threepillars of effective integrated diabetes care; registration, recalland review. A comparable strategy has been proposed by theObama administration in the U.S where bonus payments willbe given to physicians who adopt and use electronic healthrecords effectively [23].

This study has some limitations because of the relativelylow response rate however the profile of the sample in termsof urban/rural breakdown is broadly comparable with thenational profile [24]. Given the self-selecting nature of sur-

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vey research and thus the inevitable bias towards GP with aninterest in diabetes one would expect to have found a biastowards optimal care delivery in this sample. Therefore giventhe significant deficits in the level and organisation of diabetescare documented in this study it is arguable that the prob-lems highlighted here have been understated. With regard tostrengths of this study, the survey instrument has also beenused to assess service provision in the UK [14] and adaptedand used previously in an Irish setting [Evans et al, personalcommunication] [15].

The results of this survey have been compared primar-ily to findings of a similar survey from the UK where moredata is available. However, the challenges facing diabetes careprovision in Ireland are possibly more similar to other Euro-pean countries with weaker primary care systems on whichthere is much less data available. For example, Ireland likeGreece is severely lacking quality assurance systems and per-formance indicators to monitor and improve diabetes care[25]. We believe the development of a standardized informa-tion system for diabetes would facilitate the integration ofcare and increase the utility of information being collected. Inaddition, there is need to foster and encourage the interest ofhealth care providers perhaps through further education andtraining opportunities. An investment of additional resourcesor a redeployment of resources to primary care if properlytargeted would also encourage further improvements.

In conclusion, this study provides an important benchmarkof the level of diabetes care in general practice in Ireland.The findings suggest limited progress towards more organ-ised care delivery since 2003. Maintaining a diabetes registeris associated with other quality improvement efforts and itis likely that a register is a reliable marker of enthusiasm andinvestment in quality improvement for patients with diabetes.Despite the focus on improving diabetes care in recent years,considerable gaps in care remain suggesting that the prob-lems and solutions extend beyond clinician engagement tosystems level interventions addressing service design, caredelivery and remuneration.

Conflict of interest

None.

Acknowledgements

This study was supported by the Health Research Board grantNo. HS/2006/14. The project was approved by the Ethics Com-mittee of the Irish College of General Practitioners. SheenaMc Hugh is a PhD Scholar of the Health Services ResearchInstitute—the Irish Health Research Board’s Cross-InstitutionPhD Scholar Programme in Health Services Research.

e f e r e n c e s

[1] S. Wild, G. Roglic, A. Green, R. Sicree, H. King, Globalprevalence of diabetes: estimates for the year 2000 andprojections for 2030, Diabetes Care 27 (May (5)) (2004)1047–1053.

3 ( 2 0 0 9 ) 225–231

[2] Institute of Public Health in Ireland, in: Department ofHealth and Children (Ed.), Making Diabetes Count: WhatDoes the Future Hold?, Institute of Public Health in Ireland,Belfast, 2006.

[3] A. Nocon, P.J. Rhodes, J.P. Wright, J. Eastham, D.R.R. Williams,S.R. Harrison, et al., Specialist general practitioners anddiabetes clinics in primary care: a qualitative anddescriptive evaluation, Diabet Med 21 (1) (2004) 32–38.

[4] S. Griffin, Diabetes care in general practice: meta-analysis ofrandomised control trials, Br Med J 317 (August (7155)) (1998)390–396.

[5] S. Griffin, A.L. Kinmonth, Systems for routine surveillancefor people with diabetes mellitus, Cochrane Database SystRev (1998) 1 (Art No.: CD000541).

[6] M.M. Collins, T. O’Sullivan, V. Harkins, I.J. Perry, Quality oflife and quality of care in patients with diabetesexperiencing different models of care, Diabetes Care 32(April (4)) (2009) 603–605.

[7] T. O’Sullivan, S. Smith, National survey of diabetes care ingeneral practice, Ir Med J 99 (April (4)) (2006) 104–106.

[8] National Service Framework for Diabetes: Standards[Database on the Internet], Department of Health, 2001[cited 10.09.2009]. Available from:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 4002951.

[9] M. Gulliford, M. Ashworth, D. Robotham, A. Mohiddin,Achievement of metabolic targets for diabetes by Englishprimary care practices under a new system of incentives,Diabet Med 24 (5) (2007) 505.

[10] A. Tahrani, M. McCarthy, J. Godson, S. Taylor, H. Slater, N.Capps, et al., Diabetes care and the new GMS contract: theevidence for a whole county, Br J Gen Pract 57 (539) (2007)483.

[11] C.M. Renders, G.D. Valk, S. Griffin, E. Wagner, J. Eijk, W.Assendelft, Interventions to improve the management ofdiabetes mellitus in primary care, outpatient andcommunity settings, Cochrane Database Syst Rev (2000) 4[serial on the Internet].

[12] K.G. Shojania, S.R. Ranji, K.M. McDonald, J.M. Grimshaw, V.Sundaram, R.J. Rushakoff, et al., Effect of qualityimprovement strategies for type 2 diabetes on glycemiccontrol: a meta-regression analysis, JAMA 296 (July (4)) (2006)427–440.

[13] S. Smith, G. Bury, M. O’Leary, W. Shannon, A. Tynan, A.Staines, et al., The North Dublin randomized controlled trialof structured diabetes shared care, Fam Pract 21 (1) (2004)39–45.

[14] D.R. Williams, H.S. Baxter, C.M. Airey, S. Ali, B. Turner,Diabetes UK funded surveys of the structural provision ofprimary care diabetes services in the UK, Diabet Med 19 (July(Suppl. 4)) (2002) 21–26.

[15] D.S. Evans, E. O’Connell, M. O’Donnell, L. Hurley, M. Glacken,A. Murphy, et al., The Provision of General Practice DiabetesServices in Galway City and Country: A Survey of GeneralPractice, 2009.

[16] J. Ritchie, J. Lewis, Qualitative Research Practice: A Guide forSocial Science Students & Researchers, Sage Publications,Thousand Oaks, 2003.

[17] V. Harkins, in: Irish College of General Practitioners, HealthService Executive, Irish Endocrine Society (Eds.), A PracticalGuide to Integrated Type 2 Diabetes Care, Health ServiceExecutive, Dublin, 2008.

[18] D. Penn, J. Burns, A. Georgiou, P. Davies, M. Harris, Evolutionof a register recall system to enable the delivery of better

quality of care in general practice, Health Inf J 10 (3) (2004)165.

[19] D. Berwick, A. Enthoven, J. Bunker, Quality management inthe NHS: the doctor’s role—II, Br Med J 304 (6822) (1992) 304.

e s 3

p r i m a r y c a r e d i a b e t

[20] G. Agarwal, M. Pierce, D. Ridout, The GP perspective:problems experienced in providing diabetes care in UKgeneral practice, Diabet Med 19 (s4) (2002) 13–20.

[21] C. Brennan, V. Harkins, I. Perry, Management of diabetes inprimary care: a structured-care approach, Eur J Gen Pract 14

(3) (2009) 117–122.

[22] S.M. Campbell, D. Reeves, E. Kontopantelis, B. Sibbald, M.Roland, Effects of pay for performance on the quality ofprimary care in England, N Engl J Med 361 (July (4)) (2009)368–378.

( 2 0 0 9 ) 225–231 231

[23] P.C. Tang, T.H. Lee, Your doctor’s office or the Internet? Twopaths to personal health records, N Engl J Med 360 (March(13)) (2009) 1276–1278.

[24] T. O’Dowd, M. O’Kelly, F. O’Kelly, Trinity College Dept. ofPublic Health & Primary Care, Structure of General Practice

in Ireland: 1982–2005, Department of Public Health andPrimary Care, Trinity College Centre for Health Sciences[and] Irish College of General Practitioners, Dublin, 2006.

[25] C. Lionis, A. Papathanasiou, Primary care diabetes in Greece,Prim Care Diabetes 2 (2) (2008) 97–99.