medwireNews: People with type 2 diabetes receiving care from a general practitioner (GP) with low adherence to recommended follow-up procedures have higher risk for cardiovascular disease (CVD) and poor glycemic control than those registered with high-performing GPs, suggest results from the ROSA 4 study.
The total estimated average 10-year CVD risk according to the NORRISK 2 score was 12.3% among the 6015 Norwegian participants (aged 18–75 years) without CVD at baseline, while the modifiable CVD risk – calculated by omitting age, sex, and ethnicity from the score – was 3.3%.
For the study, Kjersti Nøkleby (University of Oslo, Norway) and fellow authors calculated the average GP process performance from 0% to 100%, based on the proportions of their patients with diabetes receiving the following six processes of care: measurements of glycated hemoglobin (HbA1c), low-density lipoprotein cholesterol, albuminuria, and blood pressure; recorded foot examination in the past 15 months; and recorded eye examination in the past 30 months. The 275 GPs included in the study were divided into five quintiles based on their performance average to categorize them from best (quintile 5; n=55) to worst performance (quintile 1; n=54).
In a multivariate analysis, patients of GPs in quintile 1 (n=1174) had a 1.88-percentage point higher total risk for CVD compared with patients of GPs in quintile 5 (n=1224), which represents a relative mean adjusted difference of 16.6%.
The team also found that having a GP in quintile 1 was associated with a 1.78-percentage point higher modifiable CVD risk compared with having a GP in quintile 5, with a relative adjusted mean difference of 74.8% between both groups. These results were consistent irrespective of whether high-density lipoprotein cholesterol was included as a modifiable risk factor.
Patients with a GP in quintile 1 were also more likely to have HbA1c levels above 69 mmol/mol (8.5%) than those with a GP in quintile 5, at an adjusted odds ratio of 1.77.
“[Ο]ur findings that type 2 diabetes patients of GPs delivering high-quality processes of care have reduced risk are probably relevant/generalizable to other contexts and health care systems,” comment Nøkleby et al in Diabetic Medicine.
“Quality improvement strategies adapted to the worst-performing GPs are called for,” they say, and conclude that “[f]urther studies with a longitudinal design are needed to explore if GP factors influence morbidity and mortality, preferably also including more detailed information about patient comorbidities, socioeconomic status and place of residence.”
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Diabet Med 2021; doi:10.1111/dme.14586