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Diabetes patients do better with more frequent doctor contacts

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Patients with diabetes achieve faster control of A1C, blood pressure and cholesterol targets when they see or have contact with their primary care provider every 2 weeks rather than less frequently, a Massachusetts-based team has shown.

“Encounters every 2 weeks may, therefore, be appropriate for the most severely uncontrolled patients,” the authors conclude. Once diabetes is under control, “the frequency of the encounters may be decreased to alleviate the strain on health care resources and possibly to also reward the patient,” they suggest in their report in the September 26 issue of the Archives of Internal Medicine.

Dr. Alexander Turchin, at Brigham and Women’s Hospital in Boston, and colleagues note that guidelines do not indicate how frequently patients with diabetes should be seen, but several studies have shown generally that patients who see their physician more frequently have better outcomes.

The team therefore retrospectively studied data on 26,496 primary-care patients with diabetes and hyperglycemia, hypertension and/or hyperlipidemia in terms of time to achieve target parameters in relation to physician encounter frequency. “To capture both face-to-face and remote interactions between patients and providers, we defined any note in the electronic medical record (EMR) as an encounter,” the investigators explain.

They found that the time to all treatment targets increased progressively as the interval between encounters lengthened.

For example, for patients not on insulin, the time to achieve a target HbA1c level of <7% was 4.4 months for patients with a mean encounter interval of 1-2 weeks compared to 24.9 months for those seen every 3-6 months.

Similarly, mean times to a blood pressure target lower than 130/85 mm Hg in these same two encounter-interval groups were 1.3 vs 13.9 months, respectively, and corresponding times to reach an LDL level less than 100 mg/dL were 5.1 vs 32.8 months, the report indicates.

“Time to control decreased progressively as encounter frequency increased up to once every 2 weeks for most targets, consistent with the pharmacodynamics of the respective medication classes,” Dr. Turchin and colleagues found.

However, they point out that a causal relationship between encounter frequency and patient outcomes cannot be inferred because the study was retrospective. “A randomized interventional study is, therefore, needed to definitively establish optimal encounter frequency for patients with DM (diabetes mellitus).”

In a related commentary, Dr. Allan H. Goroll with Harvard Medical School and Massachusetts General Hospital, Boston, looks at these findings in terms of physician reimbursement patterns in the US, which are shifting from fees based on volume to payment based on quality of care.

Providers, he notes, “will need to know what evidence-based actions produce the best results,” and the current study provides such information as it pertains to primary care patients with diabetes.

Dr. Goroll points out that evidence-based treatments can have a major effect on morbidity and mortality in conditions such as diabetes, hypertension and hyperlipidemia. “Understanding how best to deliver that care and change patient behavior, especially in primary care settings, is going to be as important as knowing what care to prescribe,” he concludes.

Arch Intern Med. 2011;171:1542-1550.