Care delivery variation affects glycemic control for type 1 diabetes patients
medwireNews: If all UK primary care practices operated to the standards of the top-performing centers there would be a marked nationwide increase in the proportion of patients with type 1 diabetes achieving glycemic control, say researchers.
The findings from the UK’s National Diabetes Audit are in line with those the team reported for management of type 2 diabetes, earlier this year. The current analysis, which focuses on type 1 diabetes patients, highlights the apparent influence of technology update, report Adrian Heald (University of Manchester, UK) and study co-authors in Diabetic Medicine.
One of the factors associated with improved glycemic control was insulin pump use (inferred from prescriptions of rapid-acting insulin), which gave a number needed to treat of 11 to result in one patient achieving glycated hemoglobin (HbA1c) levels of 7.5% (58 mmol/mol) or below or moving out of the high-risk category (HbA1c >10%; 86 mmol/mol). Practices in the top 10% in terms of type 1 diabetes patients meeting HbA1c targets had 36% of their type 1 diabetes patients using pumps, compared with an overall average of 16%.
The number of blood glucose monitoring strips given per 50 units of insulin was also a marker of better glycemic control.
The author of an accompanying commentary, Peter Hammond (Harrogate District Hospital, UK), cautions that pump use may be a marker of better general care, such as improved patient education, rather than a direct cause of improved glycemic control. But he adds that “we should not be surprised that increased use of insulin pump therapy and greater use of blood glucose monitoring results in improved glycaemic outcomes.”
The other service-related markers of good glycemic control among type 1 diabetes patients were better control and higher insulin use among patients with type 2 diabetes, and good control of cholesterol levels among type 1 diabetes patients.
Overall, if all practices performed as well as the top 10% did on these modifiable measures, the proportion of patients achieving glycemic control across the UK would increase from 29% to 36% and the proportion at high glycemic risk would fall from 15% to 10%. About half of the improvement would be realized through service improvements and half through medication and technology changes.
“This has significant implications for the potential to improve the longer-term outcomes of people with Type 1 diabetes, given the close link between glycaemia and complications in such individuals,” say the researchers.
But Hammond notes: “The challenge is how to improve performance at general practice level to bring all practices up to the level of the top 10%.”
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