Team-based co-management of diabetes in rural primary care


Gavin Parker, Ryan Reyes, Stephanie Garies, Cheryl Dolan, Susan Gerber, Beverly Burton, Tracy Burton, Jeff Brockmann, Neil Drummond



Stephanie Garies at



Manuscript Submitted





Variation in the organization and provision of services between individual primary care clinics derives to a large extent from their pursuit of best practice according to the characteristics of their patient populations; however, this also means that much diversity exists in operations and program delivery across the country. One community-based family medicine clinic in rural southern Alberta made a number of specific changes to their service model in an effort to enhance chronic disease prevention and maintenance, particularly among their large diabetic and Aboriginal populations. These included formal, patient-verified panels; selecting their own co-located interdisciplinary health team; more autonomy to allied healthcare professionals; more efficient and accessible referrals to the interdisciplinary team. As the clinic is a member of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), it was possible to evaluate the effectiveness of these organizational and service delivery innovations using patient information extracted from electronic medical records (EMR).


1) to use longitudinal CPCSSN data to explore clinical indicators among diabetic patients in southern Alberta and assess changes over time; 2) to compare diabetic patients attending the reference clinic (RC) to diabetic patients attending the 6 other CPCSSN comparison clinics (CC) in the same region at the time of the study.


Primary care EMR data from CPCSSN were used to evaluate 3 clinical outcomes (blood pressure, glycated hemoglobin, body mass index) in patients with diabetes attending the RC and six CC. For each outcome, the rate of change per year was modeled longitudinally using the means of each of the four annual study periods (2009-2012), creating a slope coefficient for each patient. Clinical outcomes were assessed independently and only those patients who had a measurement in each of the 4 study years were included in each analysis.