James Dunbar

DESPITE a lack of access to medical specialists, a study has shown that people with type 1 or type 2 diabetes living in rural and regional areas do not report worse health or self-care indicators.

The results of the study, of which I was part, suggest that multidisciplinary primary care services in rural areas may be providing additional care for people with diabetes, compensating for poorer access to specialists.

Significant health inequalities between metropolitan and non-metropolitan residents in Australia are well recognised for many health conditions including diabetes. The prevalence of self-reported diabetes is similar among metropolitan and regional and remote populations, yet years of life lost due to diabetes are significantly greater in non-metropolitan areas.

Ensuring optimal diabetes outcomes, regardless of diabetes type, is dependent upon the delivery of a range of evidence-based interventions provided by a multidisciplinary team of health professionals.

People living with diabetes in rural and regional Australia have poorer access to health care compared with those living in metropolitan areas.

In our study, 3338 people with diabetes completed the Diabetes MILES ‒ Australia national survey, funded by the National Diabetes Services Scheme. People were asked about their height, weight, self-care indicators such as frequency of blood glucose monitoring, risk factor management and medication-taking behaviours. There were also asked about their principal sources of diabetes care.

Over half the respondents reported that their GP was their principal diabetes care provider, less than a third reported seeing an endocrinologist, and 8% relied on a diabetes educator. This was regardless of diabetes duration or type of diabetes.

Twice as many metropolitan than rural people reported an endocrinologist or other specialist as their principal diabetes care provider.

People in rural and regional areas were less likely to report consulting an endocrinologist and much more likely to have accessed diabetes educators, dieticians, community or practice nurses for diabetes care. With the exception of foot self-assessment, which was more likely in rural participants, there were no differences in the diabetes self-care indicators between rural and metropolitan people.

This is the first rural–urban comparison of the provision of diabetes-related health care and self-care indicators in Australia.

Living in rural areas is not necessarily associated with worse diabetes self-care indicators.

It appears that endocrinologists are providing care for people living with type 2 diabetes in metropolitan areas, when, arguably a better use of resources would entail care provided by multidisciplinary health care teams. This would release specialists to consult in rural areas, providing better care for complicated cases among children and adolescents for instance, and leading to more equitable outcomes.

The current practice by metropolitan specialists is deskilling metropolitan GPs who should be looking after the large majority of people with type 2 diabetes and is already an unsustainable model of care for the increasing epidemic of type 2 diabetes.

Although rural areas may be performing better in terms of providing GP-coordinated, multidisciplinary team care, there is still much room for improvement in both rural and metropolitan areas in terms of ensuring that all people with diabetes benefit from such comprehensive chronic care models. .

The government needs to consider moving Medicare provider numbers for diabetes specialists from metropolitan to rural locations to equalise the supply of the specialist workforce and allow rural patients to more easily access specialist care.
 

Professor James Dunbar is the director of Greater Green Triangle University Department of Rural Health, Flinders University and Deakin University, Warrnambool, Victoria. Professor Timothy Skinner is head of Psychological and Clinical Sciences at Charles Darwin University, Darwin.

This article was written with assistance from Dr Penny Allen of the Rural Clinical School, University of Tasmania; Dr Elizabeth Peach of the Greater Green Triangle University Department of Rural Health; Dr Jessica Browne and Professor Jane Speight of the Australian Centre for Behavioural Research in Diabetes, Diabetes Australia, and Centre for Mental Health and Wellbeing Research, School of Psychology, Deakin University; and Professor Frans Pouwer of the Department of Medical and Clinical Psychology, Tilburg University, The Netherlands.