Objectives: To investigate whether General Practice Management Plans (GPMPs), Team Care Arrangements (TCAs) and reviews of these improve the management and outcomes of patients with diabetes when supported by cdmNet, a web-based chronic disease management system; and to investigate adherence to the annual cycle of care (ACOC), as recommended in diabetes guidelines.
Design, participants and setting: A before-and-after study to analyse prospectively collected data on 577 patients with type 1 or 2 diabetes mellitus who were managed with a GPMP created using cdmNet between June 2008 and November 2012.
Main outcome measures: Completion of the clinical tests in the ACOC (process outcome) and values of six of these clinical measurements (clinical outcomes).
Results: Significant improvements were seen after creation of a GPMP in the proportion of ACOC clinical tests completed (57.9% v 74.8%, P < 0.001), total cholesterol level (P < 0.01), low-density lipoprotein (LDL) cholesterol level (P < 0.001) and body mass index (BMI) (P < 0.01). Patients using GPMPs and TCAs also improved their glycated haemoglobin (HbA1c) level (P < 0.05). Patients followed up with irregular reviews had significant improvements in the proportion of ACOC clinical tests completed (59.2% v 77.6%, P < 0.001), total cholesterol level (P < 0.05), and BMI (P < 0.01), but patients with regular reviews had greater improvements in the proportion of ACOC clinical tests completed (58.9% v 85.0%, P < 0.001), HbA(1c) level (57.7 v 53.0 mmol/mol, P < 0.05), total cholesterol level (4.8 v 4.5 mmol/L, P < 0.05), LDL cholesterol level (2.8 v 2.4 mmol/L, P < 0.01) and diastolic blood pressure (76.0 v 74.0 mmHg, P < 0.05).
Conclusion: There were significant improvements in process and clinical outcomes for patients on a GPMP or a GPMP and TCA, particularly when these were followed up by regular reviews. Patients using cdmNet were four times more likely to have their GPMP or TCA followed up through regular reviews than the national average.