Abstract
Background: Chronic disease patients in Ireland had relied on hospital Out Patient Departments to provide care as General Practitioners (GPs) were not paid for chronic disease management, there were no incentives for early detection and prevention. This Programme incentivises General Practitioners for scheduled visits, with specified care which is evidence based.
Approach: The programme commenced in 2020, there are 3 elements to the programme; Opportunistic case finding of patients at high risk of cardiovascular disease or diabetes or with these undiagnosed conditions. A Prevention Programme for people found at high risk, which includes scheduled visit to the GP and Practice Nurse annually. A Treatment Programme for people diagnosed with cardiovascular disease, chronic respiratory disease or diabetes type 2 which includes 2 scheduled visits annually. All GPs in the Country were invited to contract for the service, GP uptake is 9%, GPs are paid for process they return data on defined scheduled mandatory reviews. A national database is compiled and enables monitoring the system. There was extensive input from GPs to design, evaluate and update the programme, including patient experience surveys, and feedback to GPs and patient feedback to their GPs. Central to the programme is a personal patient centred care plan, developed jointly between the patient and GP.
Results: Analysis of 4 years data showed the programme is well accepted by general practitioners and patients, patient uptake is 80% and 89% in over 65 year olds. A comprehensive set of baseline clinical measurements and multimorbidity was established, e.g. 37% were multimorbid, 4.2% smokers, 32% obese, median BMI 36, mean systolic blood pressure 34 mm/hg.Analysis comparing results at the first visit to the third visit showed lifestyle behaviour, biometric and blood result improvements for substantial numbers of patients; 4% of smokers quit, 4% of obese patients were no longer obese, 44% of hypertensives became normotensive, 45% of diabetics achieved their HbAc, and 34% their LDL cholesterol targets. Over 9% of patients now receive all their routine chronic disease care from their GP.
Implications: The programme demonstrated early detection, prevention and treatment services for patients with chronic ambulatory care sensitive conditions can successfully be provided by General Practice at population scale. This population programme reduces lifestyle and biometric risk factors both at population and individual level. The programme is provided free to the lower income half of the population, this and the acceptability of the programme to patients, results in high uptake rates and equity of geographic and population coverage. The next steps are expansion to include less common high risk CVD conditions.