Diabetes Care Volume 37, June 2014
e133
Membership in a Diabetes Care Network Improves General Practitioners’ Practices for HbA1c and Microalbuminuria Monitoring: A Cohort Study Among Patients With Type 2 Diabetes
Ludovic Casanova,1,2,3 Aur´elie Bocquier,1,2,4 S´ebastien Cortaredona,1,2,4 St`eve Nauleau,5 Laurent Sauze,5 Vincent Sciortino,6 Patrick Villani,2 and Pierre Verger 1,2,4
Diabetes Care 2014;37:e133–e134 | DOI: 10.2337/dc13-2883
and compared the frequencies of HbA1c and microalbuminuria examinations in these two cohorts. Each patient’s mean annual number of examinations was calculated for his or her study monitoring period; a dichotomous variable (met or did not meet the threshold in the French guidelines) was then calculated for each test. Associations with GP network membership were analyzed by mixed logistic multivariate regression that took the matching design into account and adjusted for patients’ and GPs’ characteristics (Table 1). After matching, GPs’ characteristics were similar in both groups, and the patient cohorts differed only slightly. Mean follow-up was 3.1 years in both cohorts. Monitoring was more frequent for both HbA1c and microalbuminuria in patients of network GPs than nonnetwork GPs, even after adjustment for patients’ and GPs’ characteristics (Table 1). Lack of information about GPs’ reasons for joining a DCN might cause endogenic bias in our study. Including a variable probably related to these motivations (i.e., GPs’ proportion of patients with diabetes) in the propensity score should, however, have limited such bias. Our results concur with those of previous studies of the impact of disease management programs on the frequency
of checkups for type 2 diabetes (2–4). These reports, however, studied only patients belonging to these programs. The strength of the associations between GPs’ membership in a DCN and the frequency of diabetes checkups observed in our study for all patients with diabetes is about the same as that observed in a previous French study of network patients (5). This suggests that GPs belonging to a DCN adhered more closely to guidelines for HbA1c and microalbuminuria monitoring than other GPs for all their patients with diabetes and not only network patients. Despite modest size effects, the impact on public health care may be significant. Further research is needed in other settings to confirm these results, for they may have important implications for the cost-efficiency of DCNs in France and elsewhere.
Acknowledgments. The authors thank the network managers, Drs. C´eline Ohrond (Diabaix) and Ve´ ronique Delorieux (Diabetes Association of Marseille), for their collaboration in this study, and Jo Ann Cahn for reading the letter and improving the English. Funding. This study was conducted with funding from the Provence-Alpes-Cˆote d’Azur Regional Health Agency under the Contrat Pluriannuel d’Objectifs et de Moyens 201222013 (a multiyear funding program for health care). Duality of Interest. No potential conflicts of interest relevant to this article were reported.
1
Observatoire R´egional de la Sant´e Provence-Alpes-Cˆote d’Azur, Southeastern Health Regional Observatory, Marseille, France INSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, France 3 Department of General Practice, Aix Marseille University, Marseille, France 4 Aix Marseille University, UMR_S912, Institut de Recherche pour le D´eveloppement, Marseille, France 5 Department of Studies and Observation, Agence R´egionale de Sant´e Provence-Alpes-Cˆote d’Azur (Regional Health Agency), Marseille, France 6 Regional Bureau of Medical Services, Provence-Alpes-Cˆote d’Azur-Corsica (Direction R´egionale du Service M´edical), National Health Insurance Fund for Salaried Workers, Marseille, France 2
Corresponding author: Aur´elie Bocquier, [email protected]. © 2014 by the American Diabetes Association. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.
eLETTERS – OBSERVATIONS
To prevent complications of diabetes, clinical practice guidelines recommend specific frequencies of several checkups. Following these guidelines can decrease all-cause mortality and cardiovascular morbidity (1). France, like other countries, has sought to improve diabetes management, specifically by establishing diabetes care networks (DCNs) that coordinate care, provide continuing medical education for health care professionals, and educate network patients. Nonetheless, less than 5% of all patients with type 2 diabetes participate in these networks. Our aim was to study whether general practitioners (GPs) belonging to a DCN adhered more closely to guidelines for diabetes monitoring than GPs not belonging to a DCN for all their patients with type 2 diabetes and not only those in a DCN. Analyses focused on orders for two diabetes-specific examinations: HbA1c and microalbuminuria testing. Using health insurance reimbursement databases in southeastern France, we included 468 GPs in two networks and 468 nonnetwork GPs in the same geographical area, matched one to one by propensity scores (Table 1). We followed their patients treated with oral hypoglycemic agents who were aged 18–79 years from 2008 through 2011 (n 5 11,832 and 10,976, respectively)
e134
Diabetes Care Volume 37, June 2014
Diabetes Care Networks and Diabetes Management
Table 1—Associations between GPs’ membership to a DCN and the indicators of diabetes monitoring Adherence to guidelines* Indicators of diabetes monitoring
Mean annual number of examinations (6 SD)
%
aOR†
95% CI†
HbA1c Matched‡ nonnetwork GPs Network GPs
1.91 6 1.16 2.04 6 1.19
20.1 23.9
1 1.37
1.27–1.47
Microalbuminuria Matched‡ nonnetwork GPs Network GPs
0.26 6 0.51 0.38 6 0.56
10.3 15.7
1 1.96
1.77–2.16
*At least three HbA1c or at least one microalbuminuria examination(s) a year. Only the examinations prescribed by the GPs to whom the patients were linked were included. †Adjusted odds ratio (aOR) and 95% CI from a mixed logistic model adjusted for 1) patient variables (age, sex, Complementary Universal Health Insurance [CMUC] [proxy for low income level], incident oral hypoglycemic agent [OHA] treatment, chronic illness status for type 2 diabetes, chronic illness status for cardiovascular disease, intensity of treatment [one OHA, two OHA or more, at least one insulin claim], mean yearly visits to the GP, endocrinologist visits), and 2) for the six variables for matching‡ physicians and for the density of private physicians in the municipality of the physician’s practice. ‡Network GPs and nonnetwork GPs in the study area were matched by the propensity score method (one-to-one matching with the nearest neighbor without restriction). The propensity score was calculated from the following characteristics: age, sex, patient volume, proportion of the physician’s patients with type 2 diabetes treated with medications, proportion of patients receiving CMUC, Carstairs index of deprivation for the municipality where the physician practices.
Author Contributions. L.C. researched data, performed statistical analysis, and wrote the manuscript. A.B. researched data and wrote the manuscript. S.C. performed statistical analysis. S.N., L.S., and V.S. provided data and reviewed the manuscript. P.Vi. reviewed the manuscript. P.Ve. designed the study and reviewed and wrote the manuscript. P.Ve. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
References 1. Giorda C, Picariello R, Nada E, et al. The impact of adherence to screening guidelines and of diabetes clinics referral on morbidity and mortality in diabetes. PLoS One 2012;7:e33839 2. Norris SL, Nichols PJ, Caspersen CJ, et al. The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002;22(Suppl.):15–38 3. McEwen LN, Hsiao VC, Nota-Kirby EM, Kulpa GJ, Schmidt KG, Herman WH. Effect of a managed care
disease management program on diabetes care. Am J Manag Care 2009;15:575–580 4. Egginton JS, Ridgeway JL, Shah ND, et al. Care management for type 2 diabetes in the United States: a systematic review and meta-analysis. BMC Health Serv Res 2012;12:72 5. Boyer L, Ohrond C, Fortanier C, et al. Qualite´ , coˆut et impact de la prise en charge coordonne´ e des patients diabe´ tiques de type 2 dans un re´ seau de sante´ . Pratiques et Organisation des Soins 2007;38:111–117
Copyright of Diabetes Care is the property of American Diabetes Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
e133
Membership in a Diabetes Care Network Improves General Practitioners’ Practices for HbA1c and Microalbuminuria Monitoring: A Cohort Study Among Patients With Type 2 Diabetes
Ludovic Casanova,1,2,3 Aur´elie Bocquier,1,2,4 S´ebastien Cortaredona,1,2,4 St`eve Nauleau,5 Laurent Sauze,5 Vincent Sciortino,6 Patrick Villani,2 and Pierre Verger 1,2,4
Diabetes Care 2014;37:e133–e134 | DOI: 10.2337/dc13-2883
and compared the frequencies of HbA1c and microalbuminuria examinations in these two cohorts. Each patient’s mean annual number of examinations was calculated for his or her study monitoring period; a dichotomous variable (met or did not meet the threshold in the French guidelines) was then calculated for each test. Associations with GP network membership were analyzed by mixed logistic multivariate regression that took the matching design into account and adjusted for patients’ and GPs’ characteristics (Table 1). After matching, GPs’ characteristics were similar in both groups, and the patient cohorts differed only slightly. Mean follow-up was 3.1 years in both cohorts. Monitoring was more frequent for both HbA1c and microalbuminuria in patients of network GPs than nonnetwork GPs, even after adjustment for patients’ and GPs’ characteristics (Table 1). Lack of information about GPs’ reasons for joining a DCN might cause endogenic bias in our study. Including a variable probably related to these motivations (i.e., GPs’ proportion of patients with diabetes) in the propensity score should, however, have limited such bias. Our results concur with those of previous studies of the impact of disease management programs on the frequency
of checkups for type 2 diabetes (2–4). These reports, however, studied only patients belonging to these programs. The strength of the associations between GPs’ membership in a DCN and the frequency of diabetes checkups observed in our study for all patients with diabetes is about the same as that observed in a previous French study of network patients (5). This suggests that GPs belonging to a DCN adhered more closely to guidelines for HbA1c and microalbuminuria monitoring than other GPs for all their patients with diabetes and not only network patients. Despite modest size effects, the impact on public health care may be significant. Further research is needed in other settings to confirm these results, for they may have important implications for the cost-efficiency of DCNs in France and elsewhere.
Acknowledgments. The authors thank the network managers, Drs. C´eline Ohrond (Diabaix) and Ve´ ronique Delorieux (Diabetes Association of Marseille), for their collaboration in this study, and Jo Ann Cahn for reading the letter and improving the English. Funding. This study was conducted with funding from the Provence-Alpes-Cˆote d’Azur Regional Health Agency under the Contrat Pluriannuel d’Objectifs et de Moyens 201222013 (a multiyear funding program for health care). Duality of Interest. No potential conflicts of interest relevant to this article were reported.
1
Observatoire R´egional de la Sant´e Provence-Alpes-Cˆote d’Azur, Southeastern Health Regional Observatory, Marseille, France INSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, France 3 Department of General Practice, Aix Marseille University, Marseille, France 4 Aix Marseille University, UMR_S912, Institut de Recherche pour le D´eveloppement, Marseille, France 5 Department of Studies and Observation, Agence R´egionale de Sant´e Provence-Alpes-Cˆote d’Azur (Regional Health Agency), Marseille, France 6 Regional Bureau of Medical Services, Provence-Alpes-Cˆote d’Azur-Corsica (Direction R´egionale du Service M´edical), National Health Insurance Fund for Salaried Workers, Marseille, France 2
Corresponding author: Aur´elie Bocquier, [email protected]. © 2014 by the American Diabetes Association. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.
eLETTERS – OBSERVATIONS
To prevent complications of diabetes, clinical practice guidelines recommend specific frequencies of several checkups. Following these guidelines can decrease all-cause mortality and cardiovascular morbidity (1). France, like other countries, has sought to improve diabetes management, specifically by establishing diabetes care networks (DCNs) that coordinate care, provide continuing medical education for health care professionals, and educate network patients. Nonetheless, less than 5% of all patients with type 2 diabetes participate in these networks. Our aim was to study whether general practitioners (GPs) belonging to a DCN adhered more closely to guidelines for diabetes monitoring than GPs not belonging to a DCN for all their patients with type 2 diabetes and not only those in a DCN. Analyses focused on orders for two diabetes-specific examinations: HbA1c and microalbuminuria testing. Using health insurance reimbursement databases in southeastern France, we included 468 GPs in two networks and 468 nonnetwork GPs in the same geographical area, matched one to one by propensity scores (Table 1). We followed their patients treated with oral hypoglycemic agents who were aged 18–79 years from 2008 through 2011 (n 5 11,832 and 10,976, respectively)
e134
Diabetes Care Volume 37, June 2014
Diabetes Care Networks and Diabetes Management
Table 1—Associations between GPs’ membership to a DCN and the indicators of diabetes monitoring Adherence to guidelines* Indicators of diabetes monitoring
Mean annual number of examinations (6 SD)
%
aOR†
95% CI†
HbA1c Matched‡ nonnetwork GPs Network GPs
1.91 6 1.16 2.04 6 1.19
20.1 23.9
1 1.37
1.27–1.47
Microalbuminuria Matched‡ nonnetwork GPs Network GPs
0.26 6 0.51 0.38 6 0.56
10.3 15.7
1 1.96
1.77–2.16
*At least three HbA1c or at least one microalbuminuria examination(s) a year. Only the examinations prescribed by the GPs to whom the patients were linked were included. †Adjusted odds ratio (aOR) and 95% CI from a mixed logistic model adjusted for 1) patient variables (age, sex, Complementary Universal Health Insurance [CMUC] [proxy for low income level], incident oral hypoglycemic agent [OHA] treatment, chronic illness status for type 2 diabetes, chronic illness status for cardiovascular disease, intensity of treatment [one OHA, two OHA or more, at least one insulin claim], mean yearly visits to the GP, endocrinologist visits), and 2) for the six variables for matching‡ physicians and for the density of private physicians in the municipality of the physician’s practice. ‡Network GPs and nonnetwork GPs in the study area were matched by the propensity score method (one-to-one matching with the nearest neighbor without restriction). The propensity score was calculated from the following characteristics: age, sex, patient volume, proportion of the physician’s patients with type 2 diabetes treated with medications, proportion of patients receiving CMUC, Carstairs index of deprivation for the municipality where the physician practices.
Author Contributions. L.C. researched data, performed statistical analysis, and wrote the manuscript. A.B. researched data and wrote the manuscript. S.C. performed statistical analysis. S.N., L.S., and V.S. provided data and reviewed the manuscript. P.Vi. reviewed the manuscript. P.Ve. designed the study and reviewed and wrote the manuscript. P.Ve. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
References 1. Giorda C, Picariello R, Nada E, et al. The impact of adherence to screening guidelines and of diabetes clinics referral on morbidity and mortality in diabetes. PLoS One 2012;7:e33839 2. Norris SL, Nichols PJ, Caspersen CJ, et al. The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med 2002;22(Suppl.):15–38 3. McEwen LN, Hsiao VC, Nota-Kirby EM, Kulpa GJ, Schmidt KG, Herman WH. Effect of a managed care
disease management program on diabetes care. Am J Manag Care 2009;15:575–580 4. Egginton JS, Ridgeway JL, Shah ND, et al. Care management for type 2 diabetes in the United States: a systematic review and meta-analysis. BMC Health Serv Res 2012;12:72 5. Boyer L, Ohrond C, Fortanier C, et al. Qualite´ , coˆut et impact de la prise en charge coordonne´ e des patients diabe´ tiques de type 2 dans un re´ seau de sante´ . Pratiques et Organisation des Soins 2007;38:111–117
Copyright of Diabetes Care is the property of American Diabetes Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
