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  • want to reduce diabetes rates in a general practice
  • divisions of general practice (Medicare Locals): break a large health area into small manageable chunks
    • integrate GP job with allied health
  • funding comes from commonwealth government and state governments
    • states --> public hospital system
    • commonwealth --> gps and private specialists (through medicare rebates)
    • therefore need coordination at a local level because people are fundamentally part of different organisations. This is the point of medicare local - to plan services that integrate people from each of the 2 systems
  • they have state and commonwealth funding for health, which are separate, so that a "blame game" can be played between the two when the government doesn't want to pay for something (blame the other division, nothing gets done)

St George and Sutherland

  • St George
    • High CALD population
    • Low SES
    • Less GPs
    • Lower prevalence of other chronic illnesses (healthy migrant - better diets etc, health literate; healthy migrant effect goes away with generations)
    • 3 hospitals, big hospitals
  • Sutherland
    • Higher SES
    • Lots of GPs
    • less CALD
    • 2 hospitals; older population; small hospital
  • difficult to achieve consistency in management between different specialists
  • raw fish (Japan) -- gastric cancer
  • more primary care = healthier population; more specialist service = less healthy population
  • T2DM: insulin resistance, later stage there is impaired insulin production
    • hyperglycaemia: polydipsia, polyuria, fatigue, infection
    • 11 random, 7 fasting = glucose cutoffs for glucose. Grey zone for prediabetes: 5.5-6.9.
    • complications = VINES (microvascular, macrovascular)
      • macro = coronary artery disease, stroke, peripheral vascular disease
      • micro = eye, kidney, infection
  • prediabetes (5.5-6.9): impaired glucose tolerance (impaired after bolus of glucose) and impaired fasting glycaemia (high fasting sugar)
    • 30% of those with prediabetes go on to diabetes in 3 years
      • altering diet and exercise is just as effective as medication for prediabetes (30mins exercise a day, reduce saturated fat (get weight down by 7%, more fibre)
      • so reducing from 110kg to 103kg is a big deal.

Australian Type 2 Diabetes Risk Assessment Tool

  • Asians have a higher T2DM risk for a given waist circumference than whites.
  • Look at the form

St George experiment

  • The intervention (exercise and diet) at St George had 1/3 success rate (pretty good over a whole population). Cost is $120 000 over a 3 month period for 250 GPs
    • reduces incidence of retinopathy and nephropathy in these patients - with huge associated costs.

Sutherland experiment

  • SNAP intervention trial
  1. Directory of local services
  2. Training programs for GPs focused on motivational interviewing skills
  3. Patient education materials
  4. Support for practices to establish a patient register recall and reminder system
  5. Involvement of non-GP practice staff in SNAP interventions
  • Shift the whole bell curve of the population TO THE LEFT, because most events occur in the 'non-high risk' part of the population, even though the proportion of people having events is lower in this group -- there are much MORE PEOPLE in the rest of the bell curve
    • This is called epidemiological shift
  • Motivational interviewing/brief intervention - can be done in a few minutes (encourage people to think about change; bring up the point)


  • Offload some of this stuff to non-doctors
  • Australian kids are 2.5kg bigger now than at 15 years old
    • Risk factors for overweight/obesity...
    • "Life - be in it" campaign
    • Could have financial incentives for physical activity, "Life points" etc
    • Tax on fast foods, subsidise healthy food
  • Patients can sue GPs for not referring morbidly obese people for bariatric surgery
    • Shifts responsibility from patient to doctor
  • Majority of the adult population is overweight or obese - how will the health system respond to this? What does the health system need to do to prevent this upcoming epidemic?