Diabetes care in general practice: meta-analysis of randomised control trials Commentary: Meta-analysis is a blunt and potentially misleading instrument for analysing models of service delivery

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Abstract
Objective : To assess the effectiveness of care in general practice for people with diabetes. Design : Meta-analysis of randomised trials comparing general practice and shared care with follow up in hospital outpatient clinic. Identification : Trials were identified from searches of eight bibliographic and research databases. Results : Five trials identified included 1058 people with diabetes, overall mean age 58.4 years, receiving hospital outpatient follow up for their diabetes. Results were heterogeneous between trials. In shared care schemes featuring more intensive support through a computerised prompting system for general practitioners and patients, there was no difference in mortality between care in hospital and care in general practice (odds ratio 1.06, 95% confidence interval 0.53 to 2.11); glycated haemoglobin tended to be lower in primary care (weighted difference in means of 0.28%, 0.59% to 0.03%); and losses to follow up were significantly lower in primary care (odds ratio 0.37, 0.22 to 0.61). However, schemes with less well developed support for family doctors were associated with adverse outcomes for patients. Conclusions : Unstructured care in the community is associated with poorer follow up, worse glycaemic control, and greater mortality than in hospital care. Computerised central recall, with prompting for patients and their family doctors, can achieve standards of care as good as or better than hospital outpatient care, at least in the short term. The evidence supports provision of regular prompted recall and review of selected people with diabetes by willing general practitioners. This can be achieved if suitable organisation is in place. Objective : To assess the effectiveness of care in general practice for people with diabetes. Design : Meta-analysis of randomised trials comparing general practice and shared care with follow up in hospital outpatient clinic. Identification : Trials were identified from searches of eight bibliographic and research databases. Results : Five trials identified included 1058 people with diabetes, overall mean age 58.4 years, receiving hospital outpatient follow up for their diabetes. Results were heterogeneous between trials. In shared care schemes featuring more intensive support through a computerised prompting system for general practitioners and patients, there was no difference in mortality between care in hospital and care in general practice (odds ratio 1.06, 95% confidence interval 0.53 to 2.11); glycated haemoglobin tended to be lower in primary care (weighted difference in means of 0.28%, 0.59% to 0.03%); and losses to follow up were significantly lower in primary care (odds ratio 0.37, 0.22 to 0.61). However, schemes with less well developed support for family doctors were associated with adverse outcomes for patients. Conclusions : Unstructured care in the community is associated with poorer follow up, worse glycaemic control, and greater mortality than in hospital care. Computerised central recall, with prompting for patients and their family doctors, can achieve standards of care as good as or better than hospital outpatient care, at least in the short term. The evidence supports provision of regular prompted recall and review of selected people with diabetes by willing general practitioners. This can be achieved if suitable organisation is in place.