Differential shared care for diabetes: does it provide the optimal partition between primary and specialist care?

AIMS: To establish whether a system of differential shared care between general practitioners and specialists is compatible with patients receiving the level of care they require.
METHODS: We sought to trace 200 shared care patients whose care had been kept at the general practitioner level after initial referral and compared them with a group of patients who had been re-referred to the Royal Prince Alfred Hospital Diabetes Centre for specialist review.
RESULTS: There were no significant differences in glycaemic, blood pressure and lipid levels of returned and non-returned patients at initial assessment. However, non-returned patients were less likely to have a history of macrovascular disease or risk factor (adjusted odds ratio (OR) 0.4; 95% confidence interval (CI) 0.2-0.6). Their referral letter was also more likely to emphasize their type and/or duration of diabetes (adjusted OR 4.6; 95% CI 2.5-8.4). Nearly half (47.1%) of the non-returned group changed their doctor in the years following their initial specialist review, increasing their likelihood of not being re-referred five-fold (adjusted OR 5.0; 95% CI 2.9-8.8). At initial assessment, non-returned patients were given less treatment recommendations (adjusted OR 0.5; 95% CI 0.3-0.7). Doctors registered with the Diabetes Shared Care Programme referred more patients than their non-shared care counterparts. However, a higher proportion of these doctors (52.5% vs. 21.3%; chi(2) = 16.5, 1 d.f., P = 0.00005) were selective in whom they re-referred.
CONCLUSION: Differential shared care encourages appropriate referral to specialist services, without compromise to standards of care. Diabet. Med. 18, 554-557 (2001)