Impact of patient-centred care and population health management on diabetes and hypertension outcomes

BACKGROUND: Type 2 diabetes mellitus (T2DM) and hypertension are prevalent global health concerns associated with increased morbidity, mortality and healthcare expenditure. This study evaluated the effectiveness of patient-centred care (PCC) and population health management (PHM) strategies in improving clinical outcomes and medication adherence among patients with co-existing T2DM and hypertension in Hounslow, UK. STUDY DESIGN: Quantitative intervention study. METHODS: A total of 221 patients were selected from 6000 attendees at West Middlesex University Hospital's pre-assessment clinic. Participants were allocated into three groups. Study 1 was a randomised controlled pilot trial with 40 patients assigned to either a PCC intervention group (n=20) or a usual care group (n=20) over 6 months. Study 2 involved 41 patients receiving a pharmacist/nurse-led collaborative PCC intervention for 6 months. Study 3 included 140 patients enrolled in a 6-month community-based PHM lifestyle programme integrated with PCC. Data collection involved patient questionnaires and hospital records, focusing on clinical and behavioural outcomes. RESULTS: In study 1, the PCC group showed a significant reduction in glycated haemoglobin (HbA1c) (mean decrease 23.2 mmol/mol, 95% CI 4.3 to 42.1) and improved medication adherence compared with controls. The number needed to treat (NNT) was 1.8 (95% CI 1.3 to 7.6). Study 2 participants experienced significant reductions in systolic (27.5 mm Hg) and diastolic (9.1 mm Hg) blood pressure, and HbA1c (23.1 mmol/mol) (all p<0.001). In study 3, 90% of patients with elevated body mass index achieved 5-10% weight loss, and 82% reported an increase in moderate or higher physical activity levels. CONCLUSION: PCC and PHM integration led to substantial improvements in glycaemic control, blood pressure, weight management and physical activity. These findings support the adoption of community-based PCC models to manage chronic conditions effectively and improve public health outcomes.