Primary care docs deliver in insulin management.
SAN FRANCISCO--Adults with diabetes who started insulin achieved similar levels of glycemic control within 6 months whether they were managed by primary care physicians or specialists, according to a post hoc analysis of data on 17,374 patients.
Primary care physicians had more face-to-face visits and phone contacts with patients and took more time to train patients on insulin use, compared with specialists, which may be why patients seen by primary care physicians had more insulin dose adjustments and were less likely to develop hypoglycemia, Dr. Louise Faerch reported at the annual scientific sessions of the American Diabetes Association.
The data were collected prior to starting insulin and at 12 and 24 weeks after insulin initiation in the 10-country observational SOLVE (Study of Once-Daily Levemir) study (Diabetes Obes. Metab. 2012;14:654-61), which primarily studied the timing of starting insulin.
Hemoglobin [A.sub.1c] (Hb[A.sub.1c]) levels decreased by a mean of 1.3% in the 13,230 patients managed by specialists and by 1.2% in the 4,144 patients seen in primary care. Fasting blood glucose levels decreased by a mean of 3.1 mmol/L in the specialist group and by 2.9 mmol/L in the primary care group, reported Dr. Faerch of Novo Nordisk, Soborg, Denmark.
Patients seen by primary care providers were 25% less likely to have a hypoglycemic episode after starting insulin, compared with the specialist group, a difference that was significant, she said. The incidences of minor or severe hypoglycemia fell insignificantly in the primary care group, compared with before insulin initiation. In the specialist group, the incidence of minor hypoglycemia increased significantly and the incidence of severe hypoglycemia decreased significantly, compared with before insulin initiation.
The starting dose of insulin increased by 24 weeks in both groups but significantly more in the primary care group than in the specialist group, by a difference of 0.06 units/kg, after adjustment for the effects of confounding characteristics.
Patients in the primary care group lost a mean of 1.1 kg, compared with 0.4 kg in the specialist group, and had a 7% greater odds of losing at least 1 kg than did the specialist group, a significant difference.
Rates of office visits or phone contacts and the number of insulin dose changes were significantly higher in the primary care group at the 12- and 24-week follow-ups, she reported. The insulin dose was adjusted a mean of five times within 12 weeks and three times in the next 12 weeks in the primary care group, compared with three adjustments within 12 weeks and another two adjustments by 24 weeks in the specialist group.
Primary care physicians spent an average of approximvvately 18 minutes in training each patient on self-injection, 13 minutes on dose adjustments, and 22 minutes on other aspects of insulin treatment (such as diet and glucose monitoring), while specialists spent approximately 14 minutes on self-injection, 11 minutes on dose adjustment, and 16 minutes on other aspects of treatment.
Clinicians followed the guidelines for diabetes treatment in their countries. Other than that, treatment choices were at the discretion of each physician, Dr. Faerch said.
The study controlled for the effects of confounders including age, duration of diabetes, body mass index, history of hypoglycemia or macrovascular disease, number of oral antidiabetic drugs being taken at baseline, change in the number of oral antidiabetics used, time of insulin initiation, Hb[A.sub.1c] levels at baseline, and insulin dose.
Dr. Faerch works for Novo Nordisk, which funded the study and markets diabetes medications.
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|Publication:||Internal Medicine News|
|Date:||Jul 1, 2014|
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