The effect of specialist care within the first year on subsequent outcomes in 24,232 adults with new-onset diabetes mellitus: population-based cohort study.

Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Quality and Safety in Health Care (Impact Factor: 2.16). 03/2007; 16(1):6-11. DOI: 10.1136/qshc.2006.018648
Source: PubMed

ABSTRACT Although specialty care has been shown to improve short-term outcomes in patients hospitalised with acute medical conditions, its effect on patients with chronic conditions treated in the ambulatory care setting is less clear.
To examine whether specialty care (ie, consultative care provided by an endocrinologist or a general internist in concert with a patient's primary care doctor) within the first year of diagnosis is associated with improved outcomes after the first year for adults with diabetes mellitus treated as outpatients.
Population-based cohort study using linked administrative data.
The province of Saskatchewan, Canada. Sample: 24 232 adults newly diagnosed with diabetes mellitus between 1991 and 2001. Method: The primary outcome was all-cause mortality. Analyses used multivariate Cox proportional hazards models with time-dependent covariates, propensity scores and case mix variables (demographic, disease severity and comorbidities). In addition, restriction analyses examined the effect of specialist care in low-risk subgroups.
The median age of patients was 61 years, and over a mean follow-up of 4.9 years 2932 (12%) died. Patients receiving specialty care were younger, had a greater burden of comorbidities, and visited doctors more often before and after their diabetes diagnosis (all p< or =0.001). Compared with patients seen by primary care doctors alone, patients seen by specialists and primary care doctors were more likely to receive recommended treatments (all p< or =0.001), but were more likely to die (13.1% v 11.7%, adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.08 to 1.27). This association persisted even in patients without comorbidities or target organ damage (adjusted HR 1.16, 95% CI 1.01 to 1.34).
Specialty care was associated with better disease-specific process measures but not improved survival in adults with diabetes cared for in ambulatory care settings.

  • [Show abstract] [Hide abstract]
    ABSTRACT: To investigate the frequency and predictors (diabetes care and treatment, comorbidity) of documented hypoglycaemia in primary care patients with insulin-treated type 2 diabetes. Data from 32,545 patients (mean age: 70 (SD 11) years, 50.3% males) from 1072 practices were retrospectively analyzed (Disease Analyzer database Germany: 09/2011-08/2012). Logistic regression (≥1 documented hypoglyemia) was used to adjust for confounders (age, sex, practice characteristics, diabetes treatment regimen). The prevalence of patients (12 months) with at least one reported hypoglycaemia was 2.2% (95% CI: 2.0-2.4%). The adjusted odds of having hypoglycemia were increased for renal failure (OR; 95% CI: 1.26; 1.16-1.37), autonomic neuropathy (1.34; 1.20-1.49), and adrenocortical insufficiency (3.08; 1.35-7.05). Patients with mental disorders including dementia (1.49; 1.31-1.69), depression (1.24; 1.13-1.35), anxiety (1.18; 1.01-1.37), and affective disorders (1.80; 1.36-2.38) also showed an increased odds of having hypoglycemia. Location of the practice in an urban area was associated with a lower odds ratio (0.74; 0.68-0.80). Both individual patient characteristics (e.g. comorbidity) and regional factors (practice location) have a substantial impact on hypoglycaemia in primary care patients with insulin therapy.
    Primary care diabetes. 10/2013;
  • [Show abstract] [Hide abstract]
    ABSTRACT: To review the proportion of diabetic patients reaching recommended therapeutic goals, as reported in intervention trials and observational studies, and to analyse the factors associated with success or failure in achieving these targets. A systematic review and meta-analysis through a Medline and Embase search for "diabetes" and "HbA1c" has been performed between 1 January 1995 and 1 March 2012 on randomised clinical trials and observational studies on type 1 (T1DM) or type 2 diabetes (T2DM) enrolling at least 200 patient*year. Out of 169 patient groups in RCTs with results available for analysis, the overall proportion of patients reaching HbA1c ≤7 % was 36.6 (34.1-39.1) %. Of these, 8 groups included T1DM subjects [proportion at target (PAT) 27.2 (22.7-32.3) %] and 161 T2DM patients [PAT 37.1 (34.5-39.7) %]. In patients with T2DM on oral agents, at multivariate analysis, higher success rate was associated with higher age and body mass index (BMI), lower duration of diabetes, lower proportion of Caucasians and more recent publication year. Among the insulin treated, only duration of diabetes retained a significant association with success rate. Among 41 groups from cross-sectional studies, 6 and 22 were composed of patients with T1DM and T2DM, respectively, and the remaining 13 included both types. Patients at target for HbA1c were 19.8 (12.4-30.1), 36.1 (31.5-41.0), and 39.0 (32.9-45.3) %, respectively. Higher age, lower BMI, shorter duration of diabetes and a higher proportion of males and Caucasians were associated with a higher success rate. Available data show that a wide distance remains between recommended targets and actual achievements in routine clinical practice.
    Journal of endocrinological investigation 04/2014; · 1.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND & AIMS: the development of ascites in patients with cirrhosis is associated with a high rate of health care utilization. New models of specialized caregiving support are necessary to optimize its management. The aim of the study was to evaluate the efficacy and financial sustainability of the "Care management check-up" as a new model of specialized caregiving support based on a series of diagnostic facilities performed in real time and on the integrated activity of consultant hepatologists at the hospital unit for outpatients, dedicated nurses, physicians in training and primary physicians, compared to standard care in outpatients with cirrhosis and ascites. METHODS: 100 cirrhotic patients admitted to our hospital were allocated, after discharge, to the "Care management check-up" group (group 1), or to the "Standard outpatient care" group (group 2), and followed prospectively as outpatients up to death or for at least 12 months. Patients of the two groups could also access to a "Day hospital" when an invasive procedure was required. In group 1 the "Care management check-up" and the "Day hospital" taken together defined the "Care management program". RESULTS: twelve-month mortality was higher in group 2 than in group 1 (45.7% vs 23.1%, p<0.025). The rate of 30-day readmission was also higher in group 2 (42.4% vs 15.4%, p<0.01). The global cost attributable to the management per patient-month of life was lower (1479.19±2184.43 Euros) in group 1 than (2816.13±3893.03 Euros) in group 2 (p<0.05). CONCLUSIONS: the study suggests that this new model of specialized caregiving reduces 12-month mortality in patients with cirrhosis and ascites as well as the global health care costs for their management.
    Journal of Hepatology 03/2013; · 9.86 Impact Factor

Full-text (2 Sources)

Available from
May 20, 2014