medwireNews: The best-performing primary care practices achieve glycemic control in their patients with type 2 diabetes without increasing expenditure on medication, suggest findings from the UK diabetes audit.
Researchers analyzed data from 4038 UK primary care practices in 2013–2014 and 4058 practices in 2014–2015, representing around half of all UK practices, and found an overall 25% increase in spending on diabetes since 2012–2013, accounted for only partly by an increased number of people with diabetes.
Expenditure on medications rose by 7.8% per year, but this was not paralleled by increased glycemic control (glycated hemoglobin ≤58 mmol/mol; 7.5%), which remained stable at around 67%.
The median glycemic control rate among practices in the top 10% based on this measure was 75.4%, and 3.2% of patients in these practices were considered at high risk (>86 mmol/mol; 10.0%), compared with 6.1% overall. Yet these practices actually spent less per patient on diabetes care than poorer-performing practices did.
Adrian Heald (University of Manchester, UK) and study co-authors say this implies more effective lifestyle management “so delaying the move to more expensive injectable treatments in some of their patients.”
Indeed, the top-performing practices achieved better than the overall median on a broad range of measures. For example, they sent more newly diagnosed patients to diabetes education courses, were better at identifying high-risk patients, and more frequently completed eight key diabetes care processes. They also had a higher proportion of patients with target blood pressure and cholesterol levels, and more of their patients with type 1 diabetes achieved glycemic control.
For medication, the top-performing practices made more use of metformin and dipeptidyl peptidase-4 inhibitors and less use of sulfonylureas and glucagon-like peptide-1 agonists, compared with the overall median. These practices had fewer type 2 diabetes patients using insulin, but they handed out more blood glucose monitoring strips.
Heald and team say that if all practices were as efficient as the top 10%, the overall proportion of patients achieving glycemic control would rise by 11%, from 66.8% to 76.9%, and the proportion of high-risk patients would fall by 38%, from 6.1% to 3.8%.
“Even a fraction of this change would benefit tens of thousands of people with diabetes in the longer term,” they write in Diabetes, Obesity and Metabolism, adding: “This would have a very significant impact on the overall consequent health care costs of managing diabetes complications.”
An additional factor contributing to good performance was having a higher proportion of older patients, which the team suggests may be because of the settled routines and available time to devote to diabetes management in this age group.
But they stress that younger patients “carry forward their legacy of poor control into older age” making it critical to focus on glycemic control in these patients.
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