An audit of structured diabetes care in a rural general practice

Objective: To assess the impact of structured diabetes care in a rural general practice. Design and setting: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor's usual practice. Participants: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003. Main outcome measures: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1(c]) concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk. Results: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, -2.6 cm; blood pressure [systolic, -3 mmHg; diastolic -7 mmHg]; and serum lipid levels [total cholesterol, -0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, -0.4 mmol/L; triglycerides, -0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, -2.2%; proportion with foot lesions, -14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with ideal blood pressure (systolic,

Deregulation, competition policy and intra-professional contests in medical education

This paper investigates how government policy directions embracing deregulation and market liberalism, together with significant pre-existing tensions within the Australian medical profession, produced ground breaking change in the funding and delivery of medical education for general practitioners. From an initial view between and within the medical profession, and government, about the goal of improving the standards of general practice education and training, segments of the general practice community, particularly those located in rural and remote settings, displayed increasingly vocal concerns about the approach and solutions proffered by the predominantly urban-influenced Royal Australian College of General Practitioners (RACGP). The extent of dissatisfaction culminated in the establishment of the Australian College of Rural and Remote Medicine (ACRRM) in 1997 and the development of an alternative curriculum for general practice. This paper focuses on two decades of changes in general practice training and how competition policy acted as a justificatory mechanism for putting general practice education out to competitive tender against a background of significant intra-professional conflict. The government's interest in increasing efficiency and deregulating the 'closed shop' practices of professions, as expressed through national competition policy, ultimately exposed the existing antagonisms within the profession to public view and allowed the government some influence on the sacred cow of professional training. Government policy has acted as a mechanism of resolution for long standing grievances of the rural GPs and propelled professional training towards an open competition model. The findings have implications for future research looking at the unanticipated outcomes of competition and internal markets.