Primary Care Physicians as point-of-care for Type 2 diabetes

Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice
Original source: BMC Endocrine Disorders 2008, 8:9
Authors: Alejandra Duran, Isabelle Runkle, Pilar Matía, Maria P de Miguel, Sofia Garrido, Emilio Cervera, Maria D Fernandez, Pilar Torres, Tomas Lillo, Patricia Martin, Lucio Cabrerizo, Nuria Garcia de la Torre, Jose R Calle, Jose Ibarra, Aniceto L Charro, and Alfonso L Calle-Pascual (corresponding author)
Publication date: 31 July 2008
DOI (digital document ID): 10.1186/1472-6823-8-9
Requires subscription? No
Publicly-available abstract: Yes

Synopsis:
The investigators looked at diabetes patients with peripheral circulation and capillary circulation issues and sought to find out whether there was any measurable difference in the results whether the patient was treated by a primary care physician (PCP) or an endocrinologist.

One of the issues surrounding diabetes care in Spain is that primary care physicians (PCPs) may not be as aggressive in treating multiple risk factors and signs of complications of diabetes as a hospital-based endocrinology team. A program in which PCPs are trained to address all these factors and to consult with the hospital-based team was instituted. This study attempts to evaluate the effectiveness of this program.

In the "Area 7" section of Madrid, Spain, 126 patients with Type 2 diabetes and peripheral circulation issues were studied over a 30-month period. After an initial three-month period of treatment by the Diabetes team at St Carlos Hospital, the patients were broken up into two groups: one to continue care at St Carlos, the other to return to their program PCPs for diabetes care. Nine patients moved out of district over the period of the study, leaving 117 patients from which to evaluate this program.

The investigators looked at the folloiwng markers as indicators of care effectiveness: HbA1c (%); Total Cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides; blood pressure; albumine-to-creatinine excretion ratio (ACR); body mass index (BMI) and waist circumference (WC); anti-aggregation treatment; and smoking status.

At the end of the follow up, no differences were found between the groups for the following counters:

• more than 37% of diabetic patients achieved a HbA1c <>
• more than 50% a ACR <>
• more than 80% reached low risk values for cholesterol, LDL cholesterol, triglycerides, and diastolic blood pressure
• more than 80% were on aspirin therapy against platelet aggregation
• 12% remained smokers.

On the other hand,

• less than 45% achieved a systolic blood pressure <>
• only 49% of the men and 30% of the women had a waist circumference of low risk.

The largest difference between the groups is that while 23% of the patients cared for by the diabetes care team achieved a BMI less than 25, less than 12% of the patients cared for by family physicians achieved this level. Neither of these results was considered satisfactory and were attributed to focus on risk factors other than overweight.

The investigators concluded that good metabolic control can be achieved at the primary care level, if the PCP coordinates patient care with the endocrinologist. This will result in better results than being treated by an untrained primary care physician without endocrinological support.

Reliability:
The study was small enough that it could be a pilot project -- evaluation of a small-scale implementation before bringing this program to all of Madrid, or to all of Spain. The follow-up time was 2.5 years, which is an intermediate timeframe. Two of the authors work at the St Carlos hospital and clinic; the third is associated with the evaluation of primary care in the "Area 7" section of Madrid. The research was published in a peer-reviewed journal, which suggests a level of reliability to the results.

Practical Applications:
Moving Type 2 diabetes follow-on care out to the primary care practitioner can simplify care delivery from the patient's point of view. It also allows the PCP to do a better job of treating the entire patient, rather than a single aspect of that patient's care. In addition, teaching PCPs more about diabetes, and giving them consultation access to endocrinologists, can improve both initial diagnosis and ongoing diabetes care.


This synopsis was based on the entire article.